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I am mailing out the Pallimed Street team kits in time for the AAHPM/HPNA Annual Assembly on Tuesday, so if you want to help out let me know soon by shooting me an email at ctsinclair@gmail.com. Right now we have over 20 people who have volunteered to hand out Pallimed 'P' Stickers at the assembly to wear on your name badge.

In case you forgot what the kit includes:

• A set of 20 Pallimed 'P' Stickers
• A set of 20 Pallimed business cards
• 2 5x7" mini posters
• A Pallimed Prize Pledge sheet
• A special treat for you (non-edible)

The support has been great so far! Thanks for making our advertising budget stretch further than it ever could.

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In 2009, the Annual Assembly of the American Academy of Hospice and Palliative Medicine (AAHPM) and the Hospice and Palliative Nurses Association (HPNA) became the first demonstration of multi-user use of Twitter at a major medical conference.  Part of this was a nice coincidence of events: Twitter was growing in popularity in early 2009, I had just become more comfortable with Twitter after a few months of use, smartphone apps for Twitter became more powerful allowing for non desktop use of the platform.


Some basic stats from 2009's AAHPM/HPNA Annual Assembly: 

• Tweets During the Conference (Tue 3/24-Sat 3/28 using #AAHPM tag): 224
• Unique users tagging Tweets with #AAHPM: 30
• Average number of followers: 220
• Median number of followers: 70
• Minimum number of followers: 5
• Maximum number of followers: 1,424
• Total number of followers for the 30 Tweeple: 6,621 (not checked for redundancy)

Hopefully this year we can surpass those numbers as we hopefully have more people familiar with Twitter.  To help boost those numbers and spread the word of the good information on hospice and palliative medicine I hope you will join the effort.


So if you:
1. Own a smartphone or laptop with wi-fi AND
2. Are coming to the AAHPM/HPNA Annual Assembly (or wish you could) AND
3. Care about hospice and palliative medicine issues

Then you should be tweeting at the conference.

With over 2000 people in attendance if even 10% of us could be tweeting about this we could make a big impact and create an ongoing network of HPM twitter users and become leaders in communication beyond the bedside.

So this is what you need to do soon so you can start building your Twitter network (if you don't have an account yet or only your brother-in-law is following you). First:
Read the previous post on Twitter for Health Care Professionals.
Read the post on lessons learned from the previous Assembly.

Pre-conference
1. Post a tweet using the hashtag (#) of #AAHPM so that other people going can start finding and following you (forming a network of attendees).  Example: "I am excited to meet a lot of my friends at the #AAHPM Annual Assembly next month"
2. Follow my Twitter list of 2010 AAHPM/HPNA Attendees (I will continue to update this list through the conference) and my Twitter list of A-list Tweeters in HPM
3. Feel free to follow the other HPM related Twitter lists in the right hand column of my profile.
4. Try to grow your number of followers by searching interests outside HPM so that you start to be bridge between different networks (say Red Sox fans and HPM or Cheese Lovers and HPM)
5. Post interesting thoughts about HPM leading up to the conference. (Avoid tweeting about patient issues: "I just made someone a DNR!" Bad form and legally dumb)
6. Tweet from your phone and your computer to get use to using both


At the conference
1. Save the search term #AAHPM so that it is easy for you to find other people tweeting from the conference
2. Don't forget to add #AAHPM to every conference related tweet
    2a. If using a computer with wi-fi then use a web based program like TweetChat to automatically add #AAHPM to every tweet.
3. If you don't like tweeting during a talk, write down interesting things to tweet about and tweet at night or in between sessions
4. Start replying to other people on Twitter about the conference
5. RT good tweets with #AAHPM hashtags.

And don't forget to come to the Social Media Workshop Friday AM and you can meet other Twitter users face to face!

Good luck Tweeting!

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Twitter really had a big year in 2009, but some of the shine may appear to be wearing off.  Sure you have seen it on your preferred 24/7 news channel and everyone and every organization seems to want you to follow them on Twitter (or be a fan on Facebook).  But Twitter is still a important force in information dissemination and therefore medical professionals and organizations need to be aware of how this tool can work best for one's information gathering and disseminating practices.

First let's get a few things out of the way

• Saying Twitter, Tweet, Re-Tweet, Tweeple or Tw-(insert word here) sounds stupid. It will never sound cool, I agree. That doesn't mean you should dismiss it. You would still order a PET scan if you found it helpful right?
• Privacy and legal concerns for medical staff abound, but that doesn't mean you have to be a tight-lipped recluse and never share your knowledge. You can be smart about it.
• You are a busy person.  Lots of people are busy, but a few clicks on your smartphone while waiting for an elevator may not be too much to ask.
• Using social media to publicly discuss medical issues with patients or families is not a smart idea, despite what idealistic futurists might think.

So if you are willing to at least agree with my points above let's continue.


Phil Baumann (@PhilBaumann (follow him on Twitter!) ) posted a often shared post of 140 Health Care Uses for Twitter which is great for sparking ideas, but after using Twitter frequently for a year I have found the list to not be so exhaustive.  My list has a slightly different context as it is viewed from the professional side and not from the patient side.  So here are my 11 reasons a medical professional should use Twitter:

Networking (with people you do and do not know)
1. Network with medical professionals in their discipline (doctors and doctors)
2. Network with medical professionals outside their discipline (doctors and pharmacists)
3. Network with medical professionals within one's specialty (ER nurses and ER nurses)
4. Network with medical professionals outside one's specialty (ER  nurses and hospice nurses)

Learning:
5. Following search terms related to your field to see what people are saying
6. Finding media reports about one's field to find what your patients might be reading

Supporting:
7. Extending the reach of topics important to you
8. Giving words of support to those in your Twitter network


Influence:
9  Posting journal articles, news, blog posts, conference highlights from others supporting your cause

Educating:
10. Posting links or quotes to talks, articles, blog posts written by you or your team
11. Posting links or quotes to talks, articles, blog posts written by others

Some key aspects of getting to know Twitter is to use it frequently from your phone and your desktop over two weeks and you will start to see how the culture moves.  Here is a simple 9 step list on how to become an intermediate Twitter user.

1. Open a Twitter account
2. Enter all the information in your profile accurately and truthfully including your real name and picture. (Social media thrives on authenticity)
3. Use Twitter search to start following key medical organizations and journals for your discipline/specialty
4. Use Wefollow.com to pick influential twitter users in your discipline/specialty
5. Follow people that follow you if their tweets or profile seem to match your interest
6. Follow Twitter lists of people/orgs that are relevant to your field
6. Get whatever Twitter app for your smartphone is best (just Google Twitter + "your smartphone type")
7. Tweet at least 3 different times during the day, 2-4 tweets each time.
8. Reply to people via twitter using the '@' symbol
9. Retweet other people's content if it is good (and you have actually read it yourself)
Bonus step: Follow me @ctsinclair

For further reference see the Mashable.com Twitter Guidebook

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Can't always get to a computer to get to Pallimed?  Well now iPhone (and iTounch and iPad) users have an option to read Pallimed and Pallimed: Arts and Humanities (including comments to both blogs) with the very first Pallimed FREE iPhone app.

by Pixel 196,5

Simple, well thought-out, a great way to keep up with the latest information in palliative care. I've never read this blog before but I'll be following it regularly now! Thank you for doing this.

You are welcome Pixel 196,5!

If you have an iPhone we encourage you to get the FREE Pallimed iPhone app and review it.  Maybe it will rise in the standings and more Pallimed naive people may get the app and learn more about hospice and palliative medicine issues.

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The AAHPM has a blog!  The AAHPM has a blog! 

www.aahpmblog.org

This has been in the works for a while and I am very glad to see it!  I am hoping this will be a great new way for the Academy to interact with members and non-members to help grow awareness about hospice and palliative medicine.  Go over and say hello!

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As we get closer to the AAHPM/HPNA Annual Assembly in Boston (March 3-6, 2010), we will again be calling on Pallimed readers to help spread the word about Pallimed and medical blogging.  Believe it or not there are some people out there who think blogs are just for political slams, celebrity gossip, and watching videos of my kids performing magic tricks.  But as you know a blog can be a place for serious discussions about vital issues to good clinical practice, public opinion of hospice and palliative medicine and occasionally a funny quip.

This offer is open to any Pallimed reader who wants to grow the knowledge of hospice and palliative medicine professionals. A street team kit will be sent out free of charge to any Pallimed reader who requests one.  If you are so enthusiastic that you would like more than one kit just ask.



Included in the Pallimed Street Team kit:

• A set of 20 Pallimed 'P' Stickers
• A set of 20 Pallimed business cards
• 2 5x7" mini posters
• A Pallimed Prize Pledge sheet
• A special treat for you (non-edible)

So how do you make the best use of the Pallimed Street Team kit?

Stickers: The 'P' stickers are great additions to any name tag while at a conference to help you find other readers of Pallimed thereby creating a bigger sense of community. And when someone asks you about the 'P' you can tell them about Pallimed.  They were a great hit at the 2009 conference.  I ran out of mine!

Business Cards: The Pallimed cards are great to hand out to members of your hospice or palliative care team or peers you see at regional and national meetings. They are especially helpful if you run out of Pallimed 'P' stickers or are too embarrassed to wear a 'P' sticker on your badge.  (Why would you be embarrassed? They were very popular last year!)

Mini Posters: Great to hang up at bulletin boards around conferences or at tables with lots of stuff to pick up.  (But don't be rude and steal someone's push pin or sweep flyers off a table just to make room!)

Pallimed Prize Pledge Sheet:  Sign up people to pledge any amount towards the Pallimed Prize announced last month to encourage hospitals to support Palliative Care teams through advertising.  This obviously will take a little more gumption on your part.  Instructions on how to best make use of this will be included as well as discussed in an upcoming blog post. 


Special Treat: I have not yet decided on what this will be but it will be a collectors item.  But if you are signing up for the Pallimed Street Team just to get this, you have to re-examine your priorities!


If you want them before the AAHPM Annual Assembly email me (ctsinclair@gmail.com) by Monday February 23rd so I can get them in the mail to you.  I will have a few kits on hand at the assembly, but they won't have the special treat, so let me know soon.  If you are going to any other medical conferences or just would like to spread the word locally, you can also request a kit, it just might come a little later.

Why use these viral or guerilla marketing techniques? Our biggest growth has always come from word of mouth from our readers which is so appreciated. And we have never and will never take any advertising so we have no budget! If you want to help...great! If this is not your gig, then that is OK too!

A special thanks to members of 2009's Pallimed Street Team:
Heather O.
Jane B.
Judy G.
Karla S.
Keri H.
Kristina N.
Leigh F.
Lynda S.
Melinda H.
Susan N.
Risa D.
And a very shy and reluctant Drew R.

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Since Drew is taking a little time off to play HGTV, I wanted to welcome our first guest blogger, Brian McMichael, MD, a Physical Medicine and Rehabilitation resident with a keen interest in palliative medicine.  He has spent some quality time crafting wonderful comments to Pallimed and GeriPal, so we decided to invite him to guest post on Pallimed.

If you are interested in posting on an occasional basis to Pallimed, please email Drew and Christian (our emails are all over this blog) and we will fill you in on the requirements/details.  If you have read Pallimed you understand the basic approach and topics we like to cover.  Academic yet conversational reviews of palliative care and hospice related articles (preferably from non-core palliative medicine journals) are our bread and butter but if you have a great topic feel free to shoot us a line.  Advertisements or endorsements of programs, organizations, blogs, etc is not what we are looking for.  We will continue to maintain our no-ad policy.

If you become a regular guest here we can always let you in on the inner workings and make you a contributor, which comes with a nice benefits package. (i.e. a Pallimed coffee mug)

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For those of you who do not stray to far from the main blog, here is a quick summary of the posts from January 2010 Pallimed: Arts & Humanities blog by Amy Clarkson, MD and Amber Wollesen, MD.

Death and Harry Potter
Amber reviews the multiple themes around death in the popular series of the boy wizard.

I Still Do: Loving and Living with Alzheimer's Dementia
Amy discusses a writer/photographer's first hand account of watching her husband succumb to Alzheimer's.  The author even commented on the post!

Iris
Amber talks about the 2001 film and palliative care themes around the sense of time in a chronic illness.


Unclaimed
In this post, the story of an unclaimed body is something we occasionally encounter in hospice and palliative care.  Amy explores how different groups have addressed this challenge.

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• Greater ICU use in the last 6 months of life
• Larger size, and
• For-profit ownership vs government ownership

Teno JM, Mitchell SL, Gozalo PL, Dosa D, Hsu A, Intrator O, & Mor V (2010). Hospital characteristics associated with feeding tube placement in nursing home residents with advanced cognitive impairment. JAMA : the journal of the American Medical Association, 303 (6), 544-50 PMID: 20145231

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NEJM has a paper which pushes the last several years' worth of fMRI studies in patients in the PVS or MCS (persistent vegetative state; minimally conscious state) to the next level. (See here for other blog postings about this.) There have been a handful of reports in the last few years of patients clinically diagnosed as being in a PVS, who have some fMRI evidence of cortical activity (e.g. have 'normal' responses to hearing their name spoken, demonstrate normal cortical responses to instructions such as imagining they are playing tennis - by normal I mean show responses similar to healthy controls in that the appropriate areas of the motor cortex show increased activity, etc.). This study is builds on that, and the authors describe identifying one subject who could answer yes/no questions via fMRI.

Let me explain. First, the proof of principle. They had 16 healthy subjects imagine either playing tennis or walking around a familiar environment imaging what they'd see: reliably in these subjects these tasks would cause predictable, and predictably different, activity seen on fMRI (e.g. in the supplemental motor cortex for the motor task and in the parahippocampal gyrus for the spatial task). Then they told the subjects that they were to answer yes/no questions by, for instance, imagining the motor task for Yes and the spatial task for No. The healthy subjects could do this, and essentially they demonstrated you could use this technique to have people answer Y/N questions simply by having them imagine different things.

Next they tried the imaging tasks on 54 patients who were diagnosed as being in the PVS or MCS. 5 of them could do the imagining task (get results similar to the healthy subjects). Then they chose one patient to test the Y/N answering protocol (it is unclear to me why this specific patient was chosen or why they didn't investigate or didn't report their findings on the other four), and found that this patient could in fact give accurate Y/N answers to biographical questions (name of his father, etc.). He did this for 5/6 questions, repeatedly. This patient, a young man over 3 years out from a traumatic brain injury, was considered to be in a PVS (although the authors indicate some ambivalence about this - there seems to be some question if he was in a MCS: regardless, he was profoundly brain injured and would likely be considered by most to be in a PVS).

My thoughts on this: I think there is no doubt that the previously-established clinical diagnoses of PVS and MCS are going to be modified by this sort of information, and it seems apparent that a small percentage of patients diagnosed as being in a PVS actually have some cortical activity and awareness (on some level, in some way - see below). The sort of idea of the PVS being a 'clean,' homogeneous diagnostic and phenotypic category (no 'higher' cortical activity, no awareness of surroundings) clearly is wrong (at least for a few patients - this study would suggest 2-9%). However, until any of this translates into improved prognostic data (the ability to predict who, if anyone, has a chance of some recovery) or effective therapies are developed (perhaps aided by this technique to identify those patients like to benefit), the clinical situation hasn't really changed. And, as we've discussed on the blog before, the idea that there might be people misdiagnosed as being in the PVS doesn't change in any fundamental way the ethics of giving, withholding, or withdrawing life-prolonging medical treatments in these patients. The fundamental question remains would the patient her/himself want to be prolonged, with medical treatments, in such a state with such a prognosis, and allowing that that patient may have some awareness doesn't necessarily change one way or the other the decision-making. It might for some families/individuals, but not predictably. If you believe in the 'clean' PVS then you can argue that at least they're not suffering so why not continue; if you don't, then you have the added dilemma of a patient truly locked-in, unable to communicate thirst, pain, hunger, love, etc. and that's not necessarily 'better' than being 'vegetative.'

As perplexing and challenging as this research is, I think we have to keep this perspective at the forefront as these sorts of responses are inevitable. This research is important, and it might change things, but not in the way some automatically assume.

Of course the logical extension of this technology is The Captain Pike scenario (for those few 'PVS' patients who can respond); those patients, if felt to be sufficiently decisional, could theoritically communicate their own wishes.

How one would determine that - and the gulf between answering 5 biographical Y/N questions and establishing that a patient is 'conscious,' is discussed in an associated editorial, which has a more detailed exploration of how we really don't know what any of this means yet.

The mind is an emergent property of the brain and cannot be "seen" in images. The article by Monti et al is provocative; however, physicians and society are not ready for "I have brain activation, therefore I am." That would seriously put Descartes before the horse.

(Image via Memory-Alpha.org, which uses a Creative Commons share-alike license.)
(Eric Widera at Geripal has also posted about this article; he has a nice summary of some of the media reporting, such as it is, about this paper.)