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Early this week I was getting really bummed because I was thinking I had nothing to write about for Pallimed, and then BOOM! it all came at me at once. Enjoy!

1) The NOLA case against a physician (Dr. Anna Pou) and 2 nurses (Lori Budo and Cheri Landry) being charged with murder/euthanasia is currently getting ready to go to the Grand Jury investigation. The jury was selected but the trial was delayed by Mardi Gras. (Seriously.)

Interestingly the coroner submitted the deaths as 'undetermined' early in February, and said there was not enough evidence for homicide after consulting with leading forensics experts. Apparently this has not deterred the District Attorney, and the Grand Jury will proceed.

One connection to a previous Pallimed post was that there was an outcry by supporters of Pou, Budo, and Landry before the airing of the Boston Legal episode. They felt that since the doctor to be found guilty (based on leaked information, sorry to give the ending away), and the trial had not started yet, that it would unfairly influence the public.

Wish I could show you some key scenes from the show, but all I could find was this promo clip. I had it on DVR but it got erased somehow, so now I cannot invite all of you to my house.

2) KPBS in San Diego headlined an article with:

Leading Hospice Organization Drops Opposition to Doctor-Assisted Suicide.

Pretty shocking headline. Let's read a little bit further. What the AAHPM (the organization) did was take a position of neutrality. Which is technically 'dropping opposition', but basically the statement moves to at least support health care providers in states where physician-assisted death* is legal (Oregon only, although multiple other states have tried and failed). With headlines like this, and knowing that few people actually read the article, I wonder how this play when it hits more papers, and talk show radio? I encourage all members of the field to read the AAHPM statements as they are well written and have been re-vamped in the past few weeks.

*the AAHPM's choice of terms for more neutrality...although it does make the distinction between euthanasia and physician assisted suicide more murky, a point we have belabored here before. And interestingly the link to the physician-assisted death position statement is to 'suicide.html' (I feel like such a sleuth!)

3) I get some pretty interesting searches when I look for materials for the blog, but business and economics hits for 'hospice' are pretty rare. But I found this very interesting stock market analysis of Chemed the parent company of VITAS and Rotorooter** (thus the Chem I presume?). No plan to debate the for-profit versus non-for-profit here, but it does make for interesting reading.

Some of the more interesting quotes (I don't read business-ese, but they sound pretty bullish on hospice & palliative medicine, kind of like us here at Pallimed):

While the relatively low absolute capital requirements represent a low barrier to entry, the regulatory complexity associated with establishing a Medicare-licensed hospice location remains a significant barrier.

AND also...

This industry has benefited in the last few years from favorable demographic trends and expanded Medicare reimbursements. There have been several notable disasters in this industry recently (ironically, due to issues with Medicare reimbursements). However, a favorable pricing environment, with tiered benefit plans and double-digit premium increases, coupled with stable inflation, should result in estimated earnings growth of 15% to 20% for the industry over the medium term. Medical care organizations will benefit from continued volume growth, innovative plans designed to moderate cost increases (along with higher consumer co-payments), better claims handling (leading to improved reimbursements from insurers), and expanded Medicare coverage and reimbursements.

I guess no one told them Bush is planning to cut Hospice Medicare Reimbursements.

** Super side note and obscure reference here (thanks Wikipedia!): From the show Futurama, a ad jingle: "Call robo-rooter if you flush a towel. We can also help with that impacted bowel."

4) Some short entries:

Business and HPM again: The folks at the Freakonomics Blog (Very interesting read by the way) actually posted about the JAMA Grief article we just posted about here.

HospiceGuy with some great posts! If you have not been reading HospiceBlog by Hospice Guy, he is making some great posts over there. Especially his very interesting and well written take on different payment levels for home hospice versus nursing home hospice.

Hospice and the lottery. An interesting way to fund hospice programs in the UK. Hope it does not come to that here in the US.

I got a Drew style heavy duty analysis post coming up by the end of this week, for those who read Pallimed for the articles.

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Two from the latest JAGS and one from Journal of Medical Ethics...

1)
First is a mortality follow-back study on advance directives and quality of terminal care. I have expressed skepticism about AD's on this blog before--wondering whether they really improve end of life care etc.--and I'm happy to report that here is a bit of data proving me wrong. The study was a typical, solid Teno mortality follow-back survey of ~1500 bereaved family members. About 70% of patients had AD's before they died; those with AD's were more likely to be older, female, and white. AD's were definitely associated with 'better' terminal care:

"For decedents with written ADs, the last place of care was most likely to be a nursing home. Those with an AD used less life-sustaining treatment in the last month of life, because they were less likely to die in an intensive care unit (11.8% vs 22.0%), to be on a respirator (25.6% vs 36.7%), or to be using a feeding tube (17.3% vs 26.8%) in the last month of life. Family members of decedents with ADs were not more likely to report that the decedent did not receive enough life-sustaining treatment."

In multivariate analysis, having an AD was associated with improved communication with physicians about decision making and better family preparation for death. I would interpret these findings with caution (as do the authors of the article)--they argue that having an AD is associated with 'better' EOL care; this doesn't mean that the AD lead to the better care & in fact in this study those with ADs were significantly different than those without. It could be used, however, as an argument that AD completion is a valid quality marker for EOL care--that debate however is a whole other story....

2)
There's a study looking at pain and how it attenuates recovery from depression in elderly veterans. It does (well, maybe--it's a complicated study which I'm not going to belabor here--it's an interesting read for those of you interested in the topic).

3)
Journal of Medical Ethics has an article proposing a conceptual framework for medical futility. This is a rather erudite treatise which references Hume liberally, as well as has a dash of Schrodinger's cat, and frankly it lost me frequently. That being said its thesis seems to be rather straight-forward: that the futility of a medical intervention can only be evaluated if the goal of the medical intervention is established, but that, you know, there's often disagreement about what a reasonable goal is, and who gets to decide what the goal is anyway...? If there's anything more subtle going on in this paper that I've missed please comment and let me know.

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JAMA published an excellent, ground-breaking study in to the actual testing of the stage theory of grief (apparently this is a full-text free article) this week. You may have seen this brought up in some of the media outlets over the past few days, but we here at Pallimed will break down the study for you in ways those health care reporters cannot.

Maciejeski, Zhang, Block, and Prigerson followed 233 bereaved people up to 24 months post-death of their loved ones. They were interviewed in 3 different periods after their loss (1-6, 6-12, and 12-24 mos). The stages of grief assessed were a combination of Kubler-Ross' (Denial, Anger, Bargaining, Depression, and Acceptance) and Bowlby & Parkes' (Shock-Numbness, Yearning-Searching, Disorganization-Despair, and Reorganization) stages of grief. The study stages were as follows:

Disbelief -> Yearning -> Anger -> Depression -> Acceptance

Now it should be said these items do not have to happen in any particular order, nor does any one stage have to be completed before the other can begin. In fact what is great about this study is that it demonstrated that these various stages do have peaks, and do largely overlap each other. I wish I could post the figure that demonstrates this, but JAMA has some strict terms of use. The article is free so go get it. The graphs would be very helpful in any talk on grief and bereavement. The discussion is very well formed in this article and should be a must read for any SW or counselor dealing with the bereaved or soon to be bereaved.

The ones sentence that really makes the study is this one:

Within each period, acceptance is greater than disbelief, yearning, anger, and
depression; yearning is greater than disbelief, anger and depression; and
depression is greater than anger.

It does give support to the resilience of the human spirit in times of great adversity. I hope to see more studies on grief based off of this one. Maybe ones that track people closer to the time of loss? In this study the mean time to first interview was 6.3 months post-loss. Hopefully with active bereavement groups in hospices this could be started a little earlier. The authors do comment on the difficulty in obtaining IRB for bereavement studies out of fear of causing harm in discussing loss.

It should also be noted that this study excluded those who met criteria for complicated grief and the the majority of participants were white (97%), females (71%) over 65 (54%) who lost their spouse (84%). So your mileage may vary with your population that you see. Obviously A 24yo Laotian father who loses his son may not have the same sort of grief. Which brings up the point to study the stage theory of grief in vastly different populations to see if it is the humanity that gives us a commonality or if our cultures really separate our emotional experiences.

(Thanks to Scott L. for the heads-up)

2) Coming home from the AAHPM, I had a layover in Denver and got to read a whole Newsweek. (Man it has been a long time since I have done that.) The My Turn piece (not yet avail online) was written by a father who lost his son 13 years ago and is still distressed over the junk mail he receives for his son. Graduation pictures, military recruitment ads, etc. I thought it was bad when my dog got a credit card application (Spot Sinclair, c'mon?!), but this has too be very difficult as Gary Weiner writes very well in his editorial. I have already written a letter to the editors to bring light on the UK solution with the bereavement register that we posted here on Pallimed. Do you think the Bereavement Register would work here in the US? Or would direct mailers oppose it fiercely, and funeral home directors balk at more data collection? It might save a lot of heartache...

3) Time magazine has an opinion piece by Scott Haig [link fixed 2/25] (an emergency room doctor I presume, although his credentials are not listed) about the value of the human mind in assessing other people’s pain. The discuss the poor efficacy of the Visual Analog Scale in the ED comparing a stoic man who denies pain to a recent female MVA patient who seems to be embellishing her pain in the desire to get Percocet.

While I agree that the VAS can be of limited usefulness and that patients sometimes rebel against it, or become confused by it, we should not abandon the VAS. It remains a critical tool for assessing impact of therapies in reducing a patient’s pain. All of us have different thresholds for pain and to imagine that we can walk in another shoes and feel their pain is ludicrous. I gave a talk a few months ago about assessing pain, and I asked the audience to assess my pain by looking at me. They all said 'Zero.' Well I rated my pain at a 6 because I just played hockey last night and my back was killing me from a accidental body check in my no-check league (Honestly, I did not see the guy coming. I didn't mean to knock him over.)

The professional skill comes in taking the VAS applying it to the clinical situation and using it as part of a comprehensive examination. Never should a policy say, "for pain of X give a morphine dose of Y." That makes our professional skills take a back seat. So while the general point of the article (our minds are still useful in medicine) was good, I think the gist is that 'people may deceive' and 'the VAS is worthless.' It all depends on how you use the tools provided.

PS for those of you wanting the talks at the AAHPM , check out Rollin' Recordings for the MP3's they have there. I got to talk to Lou at the meeting and he is a great guy. And you can listen to the talks in your car.

-CTS

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1)
Internal Medicine Journal has an article about anger in palliative care. It is a qualitative & narrative article reviewing anger in palliative care and is based at least on part on interviews with palliative care clinicians (docs, nurses). It's an issue which isn't frequently written about specifically--usually conflict in general is addressed--and for those of you who follow these things it might be interesting. It has this quote near the beginning:

In cancer care, despite being considered a normal reaction, anger is often seen as a negative emotion, which is tolerated, as it may presage a future, more constructive response.

I was hoping when I read this that the article was going to thoroughly de-pathologize anger, but it didn't really.

2)
Journal of Clinical Oncology has kept my inbox busy as of late...

First are a couple of articles about complementary and alternative therapies in cancer care. One is a randomized trial of aromatherapy massage (which is exactly what it sounds like) for depression and anxiety in cancer patients. It was a multi-center non-blinded trial in which 288 cancer patients were randomized to four one-hour sessions of AM or 'usual care.' How these patients were identified is unclear, they apparently met 'modified criteria' for 'clinical anxiety/depression' according to DSM-IV criteria. I don't have a DSM in front of me but the last time I checked 'clinical anxiety' or 'clinical depression' weren't diagnoses in the DSM--GAD, major depressive disorder, adjustment disorder etc--but not 'clinical anxiety.' This sort of stuff worries me when I see it in an article. Their primary outcome was depression and anxiety symptoms at 10 weeks post-randomization and intention to treat analysis was used. (After reading the article a couple of times I'm still a little fuzzy on how they actually defined anxiety and depression). They found modest improvements in anxiety and depression 6 weeks post-randomization (2 weeks after the intervention was done) in the AM group; no differences in anxiety/depression between the AM & usual care group at 10 weeks (this was the primary outcomes); and no differences at any times between the groups regarding pain, fatigue, nausea, or global quality of life.

Problems aside (and, frankly, supportive cancer/symptom trials tend not to be of the highest quality in most instances), this was the best designed and executed CAM trials I've seen for a while, and I commend the authors for publishing its severely underwhelming findings. In their discussion they noted some of the difficulties in undertaking the trial--typical stuff about patients getting sick etc.--but they also mentioned how none of the study sites actually had infrastructure supporting research into supportive cancer research which was a problem for them. This is the real story here.

3)
Second is another CAM study. This one looked at the use of complementary and alternative therapies in cancer patients starting phase I trials. About 200 patients were interviewed at the University of Chicago as they were enrolling in phase I trials about their CAM use. Their most interesting findings, although not surprising I guess, is that CAM use seemed to increase with decreasing quality of life and increasing certainty of death (it was much more common in patients who thought they were likely to die within the year).

4)
Third in JCO is a study looking at advanced cancer patients' religiousness & spiritual support & how it relates to quality of life and end of life treatment preferences. This was another interesting article to come out of the Coping with Cancer Study (a multi-institutional U.S. study of advanced cancer patients and their caregivers). 230 patients were interviewed about spirituality, religion, and sundry other things. Not surprisingly most patients felt like the medical system provided inadequate spiritual support; more surprising was that almost half of patients reported their own religious communities provided inadequate support. This finding was attenuated for African-Americans & Hispanics. Spiritual support was associated with improved quality of life (this finding survived multivariate analysis). In multivariate analysis increased religiousness was associated with wanting all possible measures to extend life 'even if you were going to die in a few days' but not decreased rates of advance directive completion. Being 'non-white' was associated with decreased completion of advance directives and a DNR order (being in the Northeast was also associated with not having a DNR order--no comment on that). Most of these findings are consistent with previous ones. What was striking to me was how, it seems, patients felt like their spiritual needs were not being met by either the medical system or their own religious communities--perhaps part of the progressive isolation many patients undergo as they become increasingly disabled?

(Supporting editorial by Betty Ferrell here.)

5)
Fourth and finally is a randomized controlled trial to help advanced cancer patients ask their physicians about prognosis. Basically a bunch of cancer patients were given a booklet with potential questions to ask their physician about, among other things, prognosis, what to expect in the future, support services, etc. The booklet intervention did seem to raise the number of questions patients asked and topics discussed, although in the long run it's not clear it significantly improved the amount or quality of info patients got. The physicians didn't seem to mind the intervention too much, although I did find this quote notable:

However, five of 13 physicians stated they had some reservations; namely, fear that the patient may not be ready to discuss end-of-life issues, and concern that it may put the onus on the patient to ask questions rather than on the physician to respond to patients' cues.

Because, as we all well know, physicians are the ones who should be deciding when it's time to discuss end of life concerns, and are famous for our ability to pick up on patients' cues, particularly when it comes to discussing uncomfortable information.

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1) Did anyone else miss the Pope talking about palliative care last weekend (Feb. 11)? Where was I?

I work at a Catholic hospital, so any pronouncement about health care by the Pope usually draws some attention. For those of you who also work with Catholic health care systems, you may want to read some of this and tie it in to your palliative care education. Maybe it will help with the administration supporting your efforts? I give you a few choice quotes from the article:

“There is a need to promote policies which create conditions where human beings can bear even incurable illnesses and death in a dignified manner,” he said, pointing to the need for more palliative care centers.

While the Catholic Church has always sought to follow the “example of the Good Samaritan” in showing “particular concern for the infirm,” the pope urged that Catholic health-care professionals, pastoral ministers, volunteers and family members to continue to “stand alongside the suffering and to attend to the dying striving to preserve their dignity at these significant moments of human existence.”

2) An interesting set of letters to the editor (link may expire) in the LA Times in response to a favorable article about San Diego Hospice:

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Thanks to all of you who said Hi at AAHPM and came to the happy hour. It was a good few days, although I'm ecstatic to be home with my boy. In the interim many articles have been piling up and here they are... (JCO has published a spate of interesting articles in the last 2 weeks and I'll try to get to them by the end of the week.)


1)
Annals of Internal Medicine has a study examining the effects of an educational intervention to patients to help them understand medical risk. Patients were given a booklet/primer explaining medical risk. Basically they found it was helpful and higher socioeconomic status patients did better than lower socioeconomic status patients. Unfortunately you can't actually access the primer online and so you tell if it would be helpful for a palliative care population (one assumes it'll be made commercially available at some point). It's an interesting idea and certainly understanding risk is important for decision making for, say, chemotherapy for advanced cancer.

2)
Medscape is reporting that hydromorphone is a minor metabolite of morphine and can be positive in urine drug tests for people taking morphine only (not hydromorphone). The story is from a presentation from the recent AAPM meeting and cannot be otherwise vetted. (Medscape articles are available for free if you sign-up).

3)
BMJ has a news story about a woman in the UK seeking permission from a court to get enough morphine to relieve her pain which, apparently, will kill her. She's a 30 year old woman with end stage Eisenmenger's syndrome (ineligible for heart-lung transplant) and chronic pain. It's unclear from the article, because it's probably unclear to many involved, whether the woman is asking for terminal sedation (with morphine as the primary agent god help us), or for some sort of assisted death like euthanasia. Or, is she asking for simple pain relief and it just happens that she, apparently, only responds to morphine but unfortunately the amount she would need would, in the estimation of her physician, kill her (sound unlikely? I agree). This last scenario seems to be being invoked by the patient herself although what seems to be being talked about is a terminal sedation scenario. Anyway it's another example of coverage of end of life issues that abut hastened death that is confusing.

4)
Annals of Pharmacotherapy has published a review looking at opioid conversions (both PO to IV and between different agents). It's one of the better pieces I've read on the subject and I'd highly recommend it for the teaching file. It is relatively concise, discusses the difficulties of defining rigid conversion ratios, and argues for different ratios depending on which direction you're going ( e.g. morphine to hydromorphone using 3.7:1 vs. hydromorphone to morphine of 1:5). One caveat stems from this paragraph about fentanyl and morphine:

A potential error that is especially dangerous with fentanyl can occur when a conservative ratio for conversion in one direction is reversed, resulting in a liberal conversion in the opposite direction. For example, converting 100 μg of fentanyl to 1 mg of morphine, using a conservative ratio of 100:1, is substantially different from converting 1 mg of morphine to 100 μg of fentanyl.

By my math 100mcg of fentanyl = 0.1mg of fentanyl & by using a 100:1 ratio that would be 10mg of morphine. 1mg of morphine divided by 100 is 0.01mg = 10mcg fentanyl. So
A) I'm not really sure what their point is, and
B) The fact that they made this error in an article about opioid conversions is disquieting. If I'm wrong here, feel free to comment and publicly humiliate me.

Back to their point though--being conservative with these ratios, especially with those we know the least about, is of course prudent, provided the patient has access to sufficient ad lib meds or attentive dose titration, but I'm not sure specifically what their point is here about fentanyl.

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Well the American Academy of Hospice and Palliative Medicine put on another great Assembly this year in Salt Lake City. (Next year it will be in Tampa.) There were some great presentations, and of the four presentations I was involved with they all went pretty well, although I would have loved to see more people at the Professionals-in-Training Case Conference Saturday morning, because honestly the cases presented there touched on some of the great things about our field (educationally, intellectually, socially and more). And nowhere at the Assembly can you really hear about focused cases (you get some of this in the paper sessions but that is more research oriented, and the poster session doesn't have the same feel as a 15 minute case review).

I wanted to comment on the sessions that I really felt were outstanding. The first one being the Heaven & Hell session. Dr. Boal covered the major Eastern and Western Religions view of the afterlife, and made some good points about approaching patients that are having difficulty reconciling issues and concerns about the after life. For a non-chaplain, he did a good job and answered some questions well about the other Christian denominations he did not have time to touch on. A gentleman sitting in front of me at that session, made a fine point afterwards: "If we enter the patients room with a sense of humility and understanding that we DO NOT ALWAYS have to know the answer, we will serve our patients well." (That was paraphrased but fairly close to what he said). (Heaven and Hell: Understanding Your Patient’s View of the Afterlife (304) James Scott Boal, MD, Angela Hospice)

I was interested to find out there is some data from the laboratory that bone pain may have a neuropathic component and that we should consider anti-neuropathic pain medications when treating bone pain. (Cancer Pain: From the Laboratory to the Clinic (313) Pat Mantyh, PhD JD, University of Minnesota)

There was a lot of information at the conference that was important to the continuation of our field, in particular the issues around moving to the ACGME for fellowship training, and moving from the ABHPM to the ABMS. Most of the information you may need can be found on the respective websites, but it was good to hear what is coming down the pipeline from the people who are preparing this transition.

One of the better sessions I went to (although it did run a bit long, because she had so much to cover) was Care of the Dying Infant: Before and After Birth (423) by Jeanne G. Lewandowski, MD FAAHPM, Hospices of Henry Ford. Please see her handout on the CD for more information. Palliative care really has a lot of work to do in the pediatric world. This is really tip of the iceberg stuff.

Other than that, I enjoyed getting to see old friends, work with members of the Professionals in Training Special Interest Group (SIG) and the Fellowship Directors SIG in forming the foundation of education for our field. It was also great getting feedback from all the Pallimed readers and matching up names with some of the people who make comments, like Tom and Marachne (not maraschino). I also found out there are a lot more of you readers out there who don't comment. Please feel free to and if the technology is inhibiting you or the fear of repercussion exists, use an alias or comment anonymously. We can build a great community here that can make an impact on the field through sharing of knowledge, opinions and experience.

And to all our first time readers or those that have rediscovered us, WELCOME! (You may want to look at this beginners guide to Pallimed post.)

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I likely won't be posting again until next week after AAHPM. A lighter topic until then....

Archives of Internal Medicine has released a study about a subject near and dear to many of us: the role of the consultant. They posit the study as an update of the famous 1983 article about the 10 commandments of consultation.

The current study is from a survey of academic internists, family medicine docs, & general, orthopedic, and ob-gyn surgeons about what they want from consultants. The findings are illustrative but not, I guess, surprising. In general: surgeons (particularly orthopedic surgeons) were much more likely than family docs/internists to want a "co-management" model from their consultants--much more likely to say that it was ok for the consultants to write orders and to not restrict themselves to a narrowly defined question. 60% of surgeons wanted co-management whereas less than a quarter of non-surgeons did. Everyone wanted verbal communication from the consultant about her/his recs.

They go on to update the 1983 commandments. E.g. "thou shalt not covet thy neighbors turf" has been modified to "thou may negotiate joint title to thy neighbor's turf. The first commandment, which I strongly endorse and am glad they kept it as the first (although the wording is a little weird) is "determine your customer." That is, know thy consultee. This is much more important than the differences between orthopods and internists. Everyone wants something different from you....

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This is the sixth and final post in a series previewing the sessions at the American Academy of Hospice & Palliative Medicine's Annual Assembly.

You can see all the posts in the series below:
2/14 - Pre-conferences
2/15 - AM Sessions
2/15 - PM Sessions
2/16 - AM Sessions
2/16 - PM Sessions
2/17 - AM & PM Sessions

Click here for the AAHPM Annual Assembly Brochure 2007 (pdf)

Register soon if you have not already!

Saturday, February 17th - AM Sessions

7-7:45am - SIG meetings
Pick one that you are interested in and go. These are great ways to meet peers who share your concerns and get involved with the AAHPM. I will plan on being at the PIT-SIG meeting as I think this will be my last year actively supporting the PIT-SIG as it is time to pass the torch to the next batch of upstarts who want to get some recognition for fellow within the Academy and field.

8-9am & 9:15-10:15am
Now if you are a reader of this blog, I sincerely hope that you come to the Professionals in Training Case Conference - Part 1 and Part 2. This will be the third year in a row for the case conference which has allowed palliative medicine fellows to present at the national meeting. Typically in a year long fellowship, you have no chance to submit a talk to the national meeting because the submission deadlines are not friendly to the academic year. If you do present it is likely as a generous tag along with a senior faculty member as I did my first year at the AAHPM. I learned so much from presenting at the AAHPM in 2004. I gave a talk on methadone to over 500 people. Ever since then talking in front of people has not been difficult at all, although the Harvard PCEP course did help as I mentioned before. So I and a rotating group of faculty have made an agreement with the AAHPM to allow this case conference to have later deadlines so fellows can submit. This case conference does not get much publicity because it misses a lot of printing deadlines, no one knows what the PIT Case Conference is, or what the PIT-SIG is, or what cases will be presented.

But this case conference is critical to ongoing involvement of the next generation of leaders of the AAHPM. Please come out and support them and see their cases, and ask great questions. Especially if you know them or are part of their program. (Ahem Fellowship Directors!)

Here are the cases for Part 1 & Part 2 (And Drew will be there as well, facilitating):

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Professionals-in-Training Case Conference - Part 1
8-9am

Choreoathetosis in a frail elderly female hospice patient taking low dose trazodone: a case report
Charina Gayomali, MD
Summa Health System
Akron, OH

Communication challenges in a Puerto Rican gentleman with oropharyngeal cancer
Winnie Suen, MD, MSc
Massachusetts General Hospital
Boston, MA

Communication challenges in a patient with multiple myeloma and developmental delay
Cindy Lien, MD
Dana Farber Cancer Institute
Boston, MA

Professionals-in-Training Case Conference - Part 2
9:15-10:15am

It’s never too late
Kelly Ryder Letsinger, MD
VCU Medical Center
Richmond, VA

Communication challenges: denial, language and cultural barriers
Sarah E. Harrington, MD
VCU Medical Center
Richmond, VA

ICU as a comfort measure: treating the anxiety of a lung transplant patient who has survived it all
Lise Taylor Barbour, MD
Medical College of Wisconsin
Milwaukee, WI

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No comments on other sessions during this slot although I do admit there are some interesting talks. Especially the one in which my partner Ann Allegre receives an award from the American Academy of Hospice & Palliative Medicine and the Project on Death in America for Palliative Medicine Community Leadership. She really deserves it for what she has accomplished in the Kansas City area with Kansas City Hospice & Palliative Care.

10:45-11:45am
Couple of good talks here. Bruera and Fatigue should be good, although I don't know how much of a sea change there is, unless he is announcing something spectacular. I don't know if we have had a talk solely devoted to updated legal issues, although this one may be good to follow as hospice and palliative medicine becomes more ubiquitous it will be hard to keep up the great press and high expectations because of all the different programs growing out there. Medical futility and religion is a very good topic as this can be a huge barrier/opportunity to finding consensus. No big comments on the speakers although there are some big names in this time slot.

Noon-1:30pm

Now as some longtime readers may know, I am not a huge fan of pharma sponsored activities. I have been underwhelmed with these presentations in the past, and so last year did not sign up for it and was relieved to find that there were many people that I was excited to run into and have lunch with. It allowed for some great networking and catching up. This may be your last chance before the end of the conference to catch up with people.

1:45-2:45pm

Another candidate for intriguing but leave me guessing title is "A Complex Case Awaits Your Input." Picking titles is key to getting your talk accepted, so I hope the abstract was what they focused on, so this might be a gem. But I guess you could say the same thing about the PIT Case Conf being enigmatic as well.

Another talk during this time is about research papers, which is a good sign I hope of trying to improve the caliber of research done in our field. I would love to do some research but it somehow never finds the time to reach my desk and get completed. I have a ton of great questions as I am sure most HPM providers do.

Other than that, not much that thrills me at this time.

3–4:15 pm
Plenary Session
State of the Science
Daniel Fischberg, MD PhD, The Queen’s Medical Center
Nathan E. Goldstein, MD, Mount Sinai School of Medicine

This has been a great talk the last two years I have been to it. Goldstein and Fischberg do an excellent job of going through the key articles in our field with humor and insight. Get to this talk if you do nothing else. That being said, I will miss it. I have to catch a earlier flight home to be there for my twins first birthday. I think Goldstein and Fischberg would understand.

And with that I am done. Leave any thoughts if you would like. ( I decided not to review the paper cases. Not enough time. I got to prepare for my 4 talks!)

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Not going to any of the special interest group meetings at AAHPM? Christian and I will be having a clandestine "Blogging SIG" meeting on Thursday and all are welcome!

To be precise, Christian and I will be talking/drinking/socializing/philosophizing at Kristauf's Martini Bar starting ~6:45ish after Thursday's program is finished. It will be super-informal and casual. If anyone wants to come, talk about Pallimed, medical blogging, how one can try to rationally sip from the apocalyptic deluge of medical information we constantly find ourselves under, or anything else--please stop by. If not CS & I will have a fine time alone. CS, knowing him, will likely be drunk by 6:45pm anyway**, so it promises to be a worthwhile evening.

Map is here (I think it's mere blocks from the conference).
I've changed the photo on my profile temporarily and will invite CS to do the same so you can recognize me/us.

**For the record that was a joke. He'll be tipsy by noon. To (mis)quote Arrested Development, the only thing CS usually has in him is a bottle of vodka and an estrogen pill. This was also a joke.

CS Here...Umm...I am not sure how to respond to Drew's allegations of my vices, for he has only been to lunch with me, and I had a club sandwich and a soda. But his post reminds me of what a social worker was telling me about this week. Something about projecting the image of yourself onto others. Something like that. And for the record, I am not planning on drinking heavily. Coming to hang out with us does not have to be about alcohol if that is not your scene. Binge drinking, joke or not, can be dangerous to your health and generally does not impress people, or so Drew has told me.

I have changed my profile pic temporarily. I may or may not have a goatee at the conference.