My colleague Dr. Earl Quijada just wrote a blog about the top three lessons he learned at the national meeting in hospice and palliative care. As I evaluated the sessions for CME credit, I am embarrassed to admit that I spent lots of time in the hallways, and all four evenings listening to music.
Here are my top three:
1. Teach with small incremental tasks: I live (or should I say lived?) in terror of having a learner spoil or blow a sensitive goals of care conversation with a patient and family. You remember the feeling… when you were a second year resident and had to go and start the IV after the medical student and intern had tried two to three times each. So I rarely let a learner perform the sensitive discussions. Drs. Back, Arnold and Tulsky have given me a technique of discussing the meeting ahead of time to identify challenges and let the learner know that I am going to step in when the learner gives me the signal, and follow the meeting with a debriefing.
We practiced their technique many times over that preconference. We even got a technique for debriefing with colleagues. I will make it a standard of my care that I always include a learner in patient interactions. Why waste the teaching moment?
2. Thousand (uncelebrated ) Points of Amazingness: I attended two SIG meetings-one for Program Chiefs and the other for Fellowship Directors. I stand in admiration at the depth and breadth of our scholarship, our reach for excellence, our sense of equity to incoming fellows, our commitment and our cunning (using the Joint Commission Advanced Certification to get what we need for the program).
I did hear some specialty physicians get thrown under the bus: surgeons, among them. The irony is that palliative medicine started with surgeons. (Think mastectomy, Billroth, Whipple). My 2nd take away is to enjoy the variety of PC docs (big fish and little fish) and the routes we have taken. When I am tempted to roll my eyes about a colleague-I will first seek to understand.
3. Duke nailed it: Duke’s Solid Tumor oncology service is staffed by oncologists and palliative care physicians. After a patient is admitted, the teams decide if the patient is better served with the palliative care physician as primary (high symptom burden of pain, nausea, dyspnea) or with the oncologist as primary (more disease directed care required). The entire team meets 3 times a day with the other disciplines. Outcomes are decreased LOS, decreased 7/30 day readmission rate, and decreased visits to the ED.
I will respond to the sentiment that advance care planning can be done too soon. I live in a community that is trying to reproduce the Lacrosse Wisconsin/ Bud Hammes Respecting Choices model. In our version, HONORING YOUR WISHES, the document is about values first, then about medical interventions that are appropriate to the stage of life. Since I am 56 years old, the only medical intervention decision that my family will need to make is about a sudden event. I have covered this in my advance care planning document. Nursing home patients fill out an IPOST, and people with chronic disease will fill out another document. Building a culture of informed consent around end of life cannot be a “just in time” affair. All the generations need to participate. At least that is what we are hoping for in Iowa City.
What is Soloman Group anyway? I thought WE brought stories to life!