Pallimed: A Hospice and Palliative Medicine Blog

The Prognostic Frame of Healthcare for Older Adults (and Everyone Else)

2012-01-16T15:00:00.000-06:00

I have a 1 in 542 chance of dying in the next year. In other words, for every 542 men who are the same age as me, one will die in 2012. For those of us who survive until 2017, the probability of death during that year will be 1 in 364. This probability will increase fairly predictably over the years. Gompertz Law of human mortality suggests that the rate doubles every eight years. Supposedly, this law stands the test of time and across populations.

I'm certain actuarialists routinely figure out probabilities that a man my age will become seriously ill or disabled as well. Statistics put mathematical meat onto a mild, chronic anxiety about dying or becoming ill. It's something that most of us feel and I don't trust people who say that they don't have any anxiety about it.

Source: Meandering Through Mathematics

What does one do with that anxiety? Prepare. Prepare for the "worst case" scenarios. Name a surrogate. Talk to that surrogate about theoretical scenarios and make sure they know what you value most. Put it in writing. Get life insurance. Learn to respond to the anxiety you have. If you make it through this next year, the chances are lower that you'll make it through the subsequent year, so you might as well get ready.

Don't be superstitious. Acknowledging death does not make it happen.

Live your life. There is a 99.8% chance that you'll live through the next year if you are my age and your life expectancy going forward is an additional 40 years. Save for retirement. Anticipate being around to pay for your kids' college education. Exercise. Eat well. Seek appropriate preventative healthcare. Find what you love to do and do it. Breathe.

And if you live long enough, you'll likely develop a chronic disease. People are remarkably resilient and can adjust, so don't worry about this too much. With illness, you'll likely develop a greater awareness of your own mortality. Hopefully, you've prepared. If not, it's never too late.

But you'll go to your doctor with the expectation that he'll help improve your quality of life in the face of the chronic disease and also that he'll know what to do to help you avoid death. You've seen the ads on TV for such and such a pill which will improve your vigor. You'll look ten years younger than the average person with your condition, be able to win the stuffed animal for your grandkid, and the lights will go off in your bedroom a full 30-45 minutes before you plan on going to sleep. You imagine it to be so perfect that if a life-threatening condition arises and your doctor doesn't have a pill to fix the problem, you'll think, "This is the year 20XX, why don't they have a pill for this?"

This is the generic frame for the typical clinic visit for patients in the early 21st century. You know that doctors can't fix everything. Your doctor knows she can't fix everything. Both facts frequently go unspoken between the four walls of the clinic room as both sides labor to prevent a "premature" death. It's a noble and worthy goal but Gompertz Law remains. It occasionally crosses your mind: What would it be like to get sick, what type of interventions will you have to go through, what will happen if you become ill and don't have enough support to remain at home? It's crossed your doctor's mind, too. She's seen others go through it, but it's easier to talk about A1C's, LDL's, and holiday plans so concerns go unspoken. Advance care planning in the office remains challenging for multiple reasons, but the frame of the visit does not easily permit acknowledgement of death or other difficult outcomes.

Enter ePrognosis. Researchers from UCSF (including colleagues from Geripal) reviewed prognostic indices for older adults in JAMA last week. The research and the slick new ePrognosis website with easy to use prognostic indices has been widely publicized (all the way around Le Monde!). Their review identified several indices for predicting prognosis in community dwelling, hospitalized, or nursing home bound older adults. The indices aren't perfect. For instance, most need more testing for validity in heterogeneous populations. (See Ken Covinksy's wise analysis at Geripal.) If you're looking for an "expiration date" (who would do that?), then don't hold your breath. We can look at actuarial data or Gompertz Law to get a general sense of prognosis. The tools on ePrognosis sharpen the lens based on variables related to disease state, functional status, etc.

I've written about the importance of framing for discussions about code status in hospitalized patients. In that setting, it's helpful for the patient and doctor to have a common understanding of the patient's prognosis before discussing the code status decision. The same principle applies to the outpatient setting in a non-terminally ill population. My hope is that ePrognosis will help providers prepare the frame for the advance care planning discussion. As Carol Levine points out in her comment below Ken's Geripal post, ePrognosis may unintentionally turn into a "parlor game" for the general population. Even though ePrognosis is intended for provider use, I'm not convinced that use amongst the general population is a bad thing. It may be quite the opposite, as long as you can go "talk to your doctor" about it!

It's always appropriate to prepare for multiple scenarios. Explicit discussion of prognosis, while not an absolute prerequisite, can serve as an entree to discuss the possible scenarios. The healthy young man looks at his probability of death and buys life insurance but prepares at the same time for life as a 50, 60, and 70 year old. In old age, it's still appropriate to prepare for multiple scenarios. If you are an 80 year old with a Mazzaglia Index score is 3, then you have an 8% chance of dying in the next 15 months and a 30% risk of being hospitalized, it makes sense to do some preparation for those events. However, you also have a 92% chance of NOT dying in the next 15 months. What then? What will it take for you to age in place? What happens if frailty or other circumstances make this impossible? Prepare for the most likely and worst case scenarios. It should be your expectation that your healthcare team can help you prepare.

In the JAMA article, the authors suggest using the indices to guide discussions about preventative care (such as whether to pursue a screening colonoscopy in a woman with advanced COPD and comorbidities). This use of the indices makes sense. Colonoscopy, while generally safe, is not without risk of complications, especially in older adults with comorbidities. It's appropriate for physicians to use the indices along with their clinical judgment to guide their recommendations. This has brought about accusations of bedside rationing, which is really a separate discussion. Medicare covers screening colonoscopy once every ten years. I wouldn't anticipate physicians refusing to order a colonoscopy for a non-terminally ill elderly patient based on a prognostic score.

It remains to be seen whether ePrognosis will increase awareness of prognosis in non-terminal, older adults or whether this will impact clinical decisions. I think it will. Time will tell.

(See also this recent NEJM perspective piece and related Geripal commentary.)

The Alignment of HPM and Oncology: Palliative Care Influence on Chemotherapy Use in Metastatic NSCLC

2012-01-02T11:20:00.000-06:00

We continue to learn more from the landmark randomized controlled trial conducted by Temel et al from NEJM which demonstrated that outpatient palliative care consultation for patients with newly diagnosed Stage IV lung cancer improves quality of life and may also improve survival by a few months.

Although the survival advantage was a secondary outcome in the original NEJM study, it remains the headliner outcome. For many who were stuck in an old paradigm of considering palliative medicine as the option of last resort after all other therapies have failed, there was a strong association (mentally, not scientifically) with an idea that hospice and palliative care for patients with cancer meant “letting go of the rope” (i.e. stopping chemotherapy) and that when the transition was made, the patient would go into a free fall towards their death as a result of “letting go.” Although some lesser quality studies had already suggested that hospice and related interventions might not shorten life and may even prolong it, it was still pleasantly surprising (and for some, inexplicable) when this randomized controlled trial demonstrated a survival advantage for patients seen by a palliative care team.

"Aikido" from
Wikimedia Commons

As with any result in a clinical trial, it helps to have a plausible mechanism of action to explain the result. Since this was a “bundled” intervention, it may be difficult to tease out the exact reason why palliative care patients lived longer. Many explanations have been proposed. Chemotherapy definitely has a role for life-prolongation but has side effects. Could it be that palliative care helps patients with those side effects, allowing them to receive more of it? Conversely, could palliative care “protect” patients from toxic chemotherapy near the end of life when chemo may do more harm than good? Alternatively, is there something intrinsic to palliative care which prolongs life irrespective of chemotherapy?

Last week, the Journal of Clinical Oncology released a secondary analysis of the data from the initial NEJM study data which further elucidates the differences in chemotherapy utilization between the palliative care and standard groups to try to help answer some of these questions. The authors also reexamined healthcare utilization at the end of life. Here are some bottom lines. The palliative care wing did not appear to receive more chemotherapy. The two groups did not differ with respect to initial anti-cancer therapy (and only one patient…in the standard care wing, incidentally.... didn’t receive anti-cancer therapy at the onset of the trial). They examined the use of multiple lines of chemotherapy (first, second, third, fourth, and beyond). Once again, there was no difference between the groups nor was there any difference in how much time it took for the groups to arrive at the next line of chemo.

How did the two groups differ, then?

Days between last IV chemotherapy dose until death (Palliative care group median 64 days vs. Standard Care median 40 days, p=.02). For oral chemo, the results were 27 days and 17 days respectively but this was not statistically significant.
Chemotherapy use in last 60 days of life (Palliative care group 52.5% vs. 70% in the Standard Care group, p=0.05). A trend towards less chemo use in last 30 and last 14 days of life as well but not statistically significant.
Hospice utilization: While there was no difference between groups with respect to the percentage of patients utilizing hospice, the palliative care group received hospice services longer (median of 24 days vs. 9.5 days in the standard care group). In the palliative care group, 60% of patients received hospice >7 days before death compared to 33% in the standard care group. (More on this below.)

When examining location of death, a slightly greater proportion of the palliative care group died at home compared to an inpatient hospice, hospital, or nursing facility, but this was not statistically significant.

It should be noted that the study was not powered to look at many of these outcomes such as chemo use in the last month and 14 days of life as well as location of death. For instance, with a larger sample size, it’s possible that the increased incidence of home death in the palliative care group might have risen to statistical significance. However, the lack of statistically significant difference here is not surprising. While hospital based palliative care can prepare patients/families for the challenges which may come near the end of life, the provision of adequate care within the home to ensure a peaceful death involves many factors which may be outside the purview of the intervention described in the study (e.g. the development of unpredictable symptoms which are difficult to manage at home, capability of caregivers, capacity of the home hospice, etc).

The study still doesn’t definitively answer the survival mechanism of action question, it only suggests that aggressive chemo at the end of life is not the reason. The median survival advantage in the original study was about 2.7 months. In this study, patients receiving the palliative care intervention were free from IV chemo 24 days longer at the end of life and received 14 days more of hospice which doesn’t add up to 2.7 months. Avoidance of toxic chemo near the end of life and provision of supportive hospice likely play a role, but in the shadows, there appears to be a survival benefit which is unrelated to chemo avoidance or hospice. Improved symptom control and psychological well-being, perhaps? In Temel et al, the primary outcome was improved QOL 12 weeks after initiation of the intervention.

While we are talking about the study being underpowered, I do have to point out that there was a statistically insignificant trend towards the palliative care group having a longer time from first to second line and from second to third line chemo (0.8 months longer in each case). This result came about only when participants were censored at time of analysis--when the numbers were crunched censoring participants at either date of death or date of analysis, there was no difference between groups in time to next line of chemo. I'm not sure which method is better for detecting a difference between groups, but this does suggest that with greater power, the study might have detected a statistically significant difference. In other words, we still can't rule out the possibility that palliative care helped patients receive more chemo early on in the course of their cancer therapy.

It was never my hypothesis that palliative care helped patients receive more chemo, thus resulting in the survival advantage. I've always thought that the benefits of excellent symptom/psychosocial support and avoidance of chemo near the end of life were more plausible explanations. Don’t confuse this with a bias against chemotherapy for patients with advanced lung cancer. I fully embrace the role for chemotherapy in advanced lung cancer and the palliative care practitioners in this study were obviously not chemotherapy obstructionists. I am familiar enough with oncology clinical trials (without being an oncologist) to know they lend more guidance to oncologists regarding when to start the agents and less guidance regarding when to stop. While sometimes the decision to stop is clear cut (patient has catastrophic complication or documented progression of disease on imaging with performance status slipping to ECOG 3), there are other times when the decision is more arbitrary.

For example, consider a patient in the middle of third line chemo who is experiencing more fatigue whose ECOG slips from 1 to 2 where everyone is suspecting progression but it may be just as easy to continue with the status quo until the next scan or until a complication comes up. At this point, many patients may be thinking that pushing forward with chemo isn't worth it to them, but what's next? That question is often wrought with fear. Palliative care might help “tip the scales” towards discontinuation in this circumstance a couple of ways. Through advance care planning discussions, "what next" becomes clearer: The role of hospice may be better understood and end of life fears already addressed. Even if hospice isn’t initiated immediately, palliative care is already part of the status quo, perhaps enabling either the oncologist or the patient to be more proactive with saying “hey, this (chemo) doesn’t seem like it’s working” with less of a feeling that they are “giving up.”

One of the most frequently noted caveats to this study is the fact that it's a single institution. Other institutions vary with respect to patient population, oncology practice, and palliative care team practice. The palliative care intervention brought the median hospice length of stay just above the national median (21.1 days in 2009) and 60% of the palliative care patients received hospice >7 days which is below the national rate of 65%. (Source: NHPCO Facts and Figures). It's worth remembering that the palliative care intervention followed guidelines from the National Consensus Project for Quality Palliative Care. Adherence to those guidelines at other institutions should also mean that patients will see many of the same benefits even if the results of Temel et al and the present study couldn't be exactly replicated.

It’s notable that the American Society of Clinical Oncology (ASCO) is looking carefully at the quality of end of life care within oncology programs (quote from present study):

“With accumulating evidence for the benefits of earlier referral to hospice for patients with terminal cancer, leaders in oncology have established guidelines for quality end-of-life care. The American Society of Clinical Oncology Quality Oncology Practice Initiative has delineated several key metrics for determining high-quality treatment near death, such as no chemotherapy within the last 2 weeks of life, referral to hospice, and enrollment in hospice care more than 1 week before death. Palliative care clinicians, who are accustomed to practicing within a multidisciplinary team, are ideally suited to support oncology providers, patients, and families in discussing and planning for such treatment at the end of life. To date, to our knowledge, no studies have shown the utility of these services for altering the quality of end-of-life care.”

The QOPI measures are worth reviewing. As palliative care programs track metrics and achieve TJC certification, it's only natural that we should work with our oncology colleagues to help with the end of life QOPI metrics as well. The results of this study indicate that our work helps oncologists with those measures.

Lastly, a friendly editorial which accompanies the study is also worth a read.

Christopher Hitchens: Dying as an Atheist

2011-12-16T06:00:00.000-06:00

Image credit: Wikipedia

Christopher Hitchens, noted author and philosopher died December 15, 2011 leaving behind many essays, books, and other writings as well as contributing to several lectures, ethics/religion debates, and TV talk shows. His acerbic style often ruffled feathers as he attacked religious dogmatism.

As one of the most famous outspoken atheists of this era, his thoughts on being diagnosed with an incurable disease would be a powerful insight into how atheists might approach illness and death. Where others might retreat from the public spotlight, Hitchens attacked his cancer through writing.

As a doctor caring for patients facing their own mortality, understanding their spirituality becomes an important part of caring for the whole person. I have seen many caring family members and friends inquire to me if their was enough time to get the appropriate clergy to help a patient convert or be saved. A person dying as an agnostic/atheist or even not the right religion becomes a very important focus for some people. Some have asked me or chaplains if we have ever seen any 'deathbed conversions' or someone who died without being saved. I never really expected this before I became a palliative medicine fellow.

What surprises me about the inside peek that Hitchens gives us with his writings is that many of his feelings, thoughts and experiences are really about the human condition and I have seen and heard similar things from religious patients as well. In reading his articles it helps me understand that despite all our differences we are all human and as we die our experience is both unique and universal.

I wanted to share a few choice quotes from his articles here. Any one of them would be a good review for your team or learners on discussing the different approaches to dying that our patients experience.

The quotes come from the following Vanity Fair articles:
Unanswerable Prayers - Oct 2010
Miss Manners and the Big C - Dec 2010
Unspoken Truths - June 2011
Trial of the Will - January 2012 (published posthumously)

On stories about any possible deathbed conversions:

In which case, why not cancer of the brain? As a terrified, half-aware imbecile, I might even scream for a priest at the close of business, though I hereby state while I am still lucid that the entity thus humiliating itself would not in fact be “me.” (Bear this in mind, in case of any later rumors or fabrications.)

On holding hope and realism:

The absorbing fact about being mortally sick is that you spend a good deal of time preparing yourself to die with some modicum of stoicism (and provision for loved ones), while being simultaneously and highly interested in the business of survival.

On losing his voice:

Now, if I want to enter a conversation, I have to attract attention in some other way, and live with the awful fact that people are then listening “sympathetically.” At least they don’t have to pay attention for long: I can’t keep it up and anyway can’t stand to.

On sharing stories about other people's cancer:

...your narrative may fail to grip if you haven’t taken any care to find out how well or badly your audience member is faring (or feeling).

On a false cliche (What doesn't kill you makes you stronger.):

After all, if it were otherwise, then each attack, each stroke, each vile hiccup, each slime assault, would collectively build one up and strengthen resistance. And this is plainly absurd. So we are left with something quite unusual in the annals of unsentimental approaches to extinction: not the wish to die with dignity but the desire to have died.

On pain:

It’s probably a merciful thing that pain is impossible to describe from memory. It’s also impossible to warn against. If my proton doctors had tried to tell me up front, they might perhaps have spoken of “grave discomfort” or perhaps of a burning sensation. I only know that nothing at all could have readied or steadied me for this thing that seemed to scorn painkillers and to attack me in my core.

Palliative Drug Shortages

2011-12-16T02:10:00.004-06:00

There was a time when I heard about chemo shortages, and I thought that must really force some tough choices for patients and physicians. But thankfully (I thought) drug shortages for generic non cutting edge medications that have been around for a long time like the ones commonly used for symptom control would probably be relatively immune.

But in the past 2 weeks I began hearing rumblings from our pharmacists about a possible shortage of IV lorazepam. As I researched this more it appears to be a much bigger problem. It wasn't just local or even regional but national. Thanks to the American Society of Health System Pharmacist (ASHP) website I could find out lots of info that is up to date on the supply chain of key meds for hospice patients. They have a drug shortage page which a pharmacist (Mick Schroeder) turned into an app for iPhone and Android.

Quick quiz: How many medications do you think are on the current drug shortage list? (Answer at the end of the post)

But the thing about the lorazepam shortage is that the other benzodiazepines you might consider for conversion are also involved in this shortage. The reasons for the shortage are (via ASHP):

Bedford discontinued lorazepam in May, 2011 to concentrate on the manufacturing of other products.
West-Ward acquired Baxter’s lorazepam injection products in May, 2011. The company cannot provide a reason for the shortage.
Hospira states lorazepam vials are on shortage due to increased demand. The 1 mL iSecure syringes were discontinued in September 2011.

Converting patients to other benzos seems appropriate but midazolam and diazepam are also listed as having drug shortages on ASHP. And even if you do have them in your pharmacy supply chain, without injectable lorazepam there is bound to be a run on these other two injectables thereby increasing the strain.

While home hospice patients may do fine with PO/SL lorazepam, inpatient units and hospitals may depend more heavily on injectable benzos. I am curious to see what other hospice and palliative clinicians are doing to handle this shortage that apparently is expected to last until February or March. Please share your thoughts in the comment section.

(Related: Outcome Resources blog has a post on the lorazepam injection shortage as well.)

(H/T to @HospiScript and Outcome Resources aka @HospicePharmacy)

Quick Quiz Answer: Approximately 210 drugs are listed as currently being in short supply. I thought it was going to be 30. Yikes!

Engage With Grace 2011: Occupy With Grace

2011-11-23T21:14:00.001-06:00

For the past few years at Thanksgiving, Pallimed donates a blog post to Engage With Grace, a movement to encourage a new tradition of using the family time during this American fall tradition to get families talking about what is important to them. This is a movement you can easily get behind in person if you are an advocate for good patient centered health care, which you likely are if you are reading this blog. So donate your blog, Facebook update, Twitter account (#EWG) to Engage With Grace this holiday weekend. And then put your money where your mouth is and bring it up yourself while your family is together.

Here is the this year's post from the Alexandra Drane and the Engage With Grace Team:

----------------------------------------------------------------------

Occupy With Grace

Once again, this Thanksgiving we are grateful to all the people who keep this mission alive day after day: to ensure that each and every one of us understands, communicates, and has honored their end of life wishes.
Seems almost more fitting than usual this year, the year of making change happen. 2011 gave us the Arab Spring, people on the ground using social media to organize a real political revolution. And now, love it or hate it - it's the Occupy Wall Street movement that's got people talking.

Smart people (like our good friend Susannah Fox) have made the point that unlike those political and economic movements, our mission isn't an issue we need to raise our fists about - it's an issue we have the luxury of being able to hold hands about.

It's a mission that's driven by all the personal stories we've heard of people who've seen their loved ones suffer unnecessarily at the end of their lives.
It's driven by that ripping-off-the-band-aid feeling of relief you get when you've finally broached the subject of end of life wishes with your family, free from the burden of just not knowing what they'd want for themselves, and knowing you could advocate for these wishes if your loved one weren't able to speak up for themselves.

And it's driven by knowing that this is a conversation that needs to happen early, and often. One of the greatest gifts you can give the ones you love is making sure you're all on the same page. In the words of the amazing Atul Gawande, you only die once! Die the way you want. Make sure your loved ones get that same gift. And there is a way to engage in this topic with grace!

Here are the five questions, read them, consider them, answer them (you can securely save your answers at the Engage with Grace site), share your answers with your loved ones. It doesn't matter what your answers are, it just matters that you know them for yourself, and for your loved ones. And they for you.

We all know the power of a group that decides to assemble. In fact, we recently spent an amazing couple days with the members of the Coalition to Transform Advanced Care, or C-TAC, working together to channel so much of the extraordinary work that organizations are already doing to improve the quality of care for our country's sickest and most vulnerable.

Noted journalist Eleanor Clift gave an amazing talk, finding a way to weave humor and joy into her telling of the story she shared in this Health Affairs article. She elegantly sums up (as only she can) the reason that we have this blog rally every year:

For too many physicians, that conversation is hard to have, and families, too, are reluctant to initiate a discussion about what Mom or Dad might want until they're in a crisis, which isn't the best time to make these kinds of decisions. Ideally, that conversation should begin at the kitchen table with family members, rather than in a doctor's office.

It's a conversation you need to have wherever and whenever you can, and the more people you can rope into it, the better! Make this conversation a part of your Thanksgiving weekend, there will be a right moment, you just might not realize how right it was until you begin the conversation.

This is a time to be inspired, informed - to tackle our challenges in real, substantive, and scalable ways. Participating in this blog rally is just one small, yet huge, way that we can each keep that fire burning in our bellies, long after the turkey dinner is gone.

Wishing you and yours a happy and healthy holiday season. Let's Engage with Grace together.

To learn more please go to www.engagewithgrace.org. This post was developed by Alexandra Drane and the Engage With Grace team.

A Better Kind of Care

2011-11-16T15:18:00.015-06:00

Paul White, shown here at a chemotherapy session with his daughter Laurie Alexander.

(Essdras M Suarez/Globe Staff)

In a July 24th article, A Better Kind of Care, The Boston Globe journalist Kathleen Burge introduced readers to Paul White, a successful owner of an engineering and manufacturing business, a man with a wife, two adult daughters, five granddaughters, and stage IV renal cell carcinoma. He had beat the odds repeatedly, having survived over seven years since the discovery of metastases. Despite availing himself of surgery, every new advancement in chemotherapy and participating in a clinical trial, his cancer was implacably progressing. Contemplating starting on what might be the last chemotherapeutic agent, he had also started seeing Dr. Vicki Jackson, Director of the Palliative Care Unit at Massachusetts General Hospital.

IMHO, the article did a terrific job of fleshing out the concerns, dilemmas, and ambivalence of patients, family members and healthcare providers in the uncertain, lurching and insidious territory of life-limiting/life-threatening illness and its treatments. It also did a great job of featuring and explaining palliative care, and its role upstream from hospice care. Here are the published letters to the editor on the story.

This morning I read in the Globe that Mr. White died on November 5th.

We have posted here before at the passing of patients with variously documented life-limiting/life-threatening illnesses, e.g., here, here and here. I thought I would respectfully post this retrospective with gratitude to the many patients who allow us to glimpse some of the most difficult situations in hopes of connecting to, and of helping, others.

"I Am a Doctor Working in Palliative Care. Ask Me Anything."

2011-11-15T16:00:00.004-06:00

The social news website Reddit advertises itself as the "Front Page of the Internet." The site might as well be called "Procrastination Grand Central" (based on my experience).

For those unfamiliar with the site, Reddit relies on a simple upvote/downvote system which brings popular stories/posts to the top of the page. Once you click on a post, you will notice many comments which are once again ordered based on popularity. One can also search the site based on keywords.

A lot of the stuff posted on the site is, well, junk... but there is enough good stuff to keep you occupied if you aren't not careful.


by Eva B

One of the "subreddits" on the site is entitled "IAMA," which doubles for "I am a" and "ask me anything." Several posts strike me as notable. For instance, see "IAmA terminally ill man with ALS, AMA" or "IAMA 20 something that supports his two disabled/terminally ill parents about to deal with his 2nd eviction. AMA."

The "subreddit" has a verification system which doesn't seem to be applied to every post. Veracity issues aside, it's curious to watch public interactions among (mostly anonymous) people attempting to grapple with these issues.

Of note, an anonymous Australian palliative care physician recently posted an "IAMA" which turned out to be fairly popular. Many excellent questions were asked, such as:

Several people didn't ask questions but merely thanked the physician for his or her work.

This is yet another example of how social media can be used to educate the public, although it needs to be done carefully. For instance, the doctor was not transparent in the introduction about the fact that he or she is from Australia- this fact was buried in the comments in the thread of replies. While there are many commonalities in the practice of palliative care around the world, some practices are system-specific so one could see the potential for misunderstanding. The doctor does seem to mention this a few times when it may be relevant. And, as always, one should stay away from providing consultation regarding specific issues which may create a liability concern. (Consult your institution's social media policy if they have one.)

Furthermore, the physician's response to the last question listed above (when should I be looking at palliative care, if at all?) leaves much to be desired. The response starts out appropriately: "I think the best person to determine when you should be considering palliative care would be your main treating physician" but then unravels very quickly when the physician suggests that being "minimally responsive" to treatment would prompt consideration of a palliative care referral. We know by now that earlier palliative care consultation for this patient may be appropriate. I'd be interested in the Australian perspective on the NEJM study to help us understand if system differences change the relevance of the study.

Predictably, the poster with Stage IV lung cancer responds to the physician's comments, "Thank you for your response! Knowing when to seek out palliative care certainly helps! I hate to say it, but I'm going to do my best to never have to meet you in a professional setting!"

I've written an additional response to the question. If you have comments you wish to make, it takes about 10 seconds to sign up for an anonymous account (no email address required).

See some other relevant "IAMA"s:

What do you think of this use of social media? Should the hospice palliative care community actively monitor sites like this for opportunities to educate?

REMS education comment period

2011-11-11T08:30:00.011-06:00

The FDA has opened a comment period, closing December 7, on it's just-released draft "Blueprint for Prescriber Continuing Education Program." The accompanying request-for-comment states that "The central component of the Opioid REMS program is an education program for prescribers and patients." If you've missed the previous discussion of opioid REMS, see Drew's blogs here and here and especially Stew Leavitt's extensive analysis last April.

The actual REMS stuff that has come out so far has not been as draconian as some had feared when first announced. The education Blueprint is pretty benign and pretty much (what should be) standard of care for almost any medication: the prescriber should know about the medications' potential negative effects, take them into consideration in prescribing and in teaching/counseling patients, and systematically monitor effects. Naturally, there is a fair amount about managing the risk of intentional misuse. The content outline provided by FDA to educational providers states that education must include information on: (1) weighing the risks & benefits of opioid therapy; (2) choosing patients appropriately; (3) managing and monitoring patients; (4) counseling patients on the safe use of these drugs; (5) information on how to recognize evidence of or the potential for opioid misuse, abuse, and addiction.

There are explicit statements that the educational basics outlined in the Blueprint do not have to be part of required education for licensing of prescribers, although apparently the FDA will approve these basic educational offerings. They estimate the basics can be presented in 2-3 hours. The industry consortioum has submitted suggested supplemental content that could take 10x that amount of time or more. FDA explictly says they will not require nor review supplemental educational content. The other explicit exclusion is Patient-Provider Agreements (these have been called opioid contracts in the past). FDA says content about these as a managment option should be included, but will not be required as a standard for pain practice. Industry is expected to provide grants to CE providers to develop and present these courses free of charge to prescribers. ACCME standards are to be maintained.

My main concern, both viscerally and cognitively, is the generally negative tone. All the emphasis is on negative effects/risks with nothing at all said about how valuable and effective opioids are when prescribed and used as intended. There are statistics presented about the misuse, abuse, and non-medical use of opioids, but nothing at all about the prevalence of pain, as described in (competing?) government publications such as the "Special Feature: Pain" chapter in the CDC report Health, United States, 2006 and the IOM 2011 report Relieving Pain in America. See Stew Leavitt's discussion on the use/misuse of statistics in government publications on the prescription drug abuse "epidemic."

The Blueprint is really not about managing pain--it's about prescribing and monitoring opioid analgesics. The target audience is probably primary care practitioners, but there are plenty of specialists who use opioids poorly, if at all. An educational emphasis on safe prescribing of these agents is probably not a bad thing, although the tone could reinforce the prevalent perspective that these medications are too dangerous to prescribe.

Patient-centered care

2011-11-08T14:26:00.004-06:00

I started to blog about two new reports from the Institute of Medicine (IOM). Both relate to patient-centered care, a major area of interest for the IOM in the past decade. But then I got distracted by some headlines that seem somehow related: The first was a New York Times piece, "The Downside of Doctors Who Feel Your Pain." The article, written by a young physician who considers herself to be empathetic and likable, wonders aloud if the current emphasis on improving the doctor-patient relationship is just a fad. Furthermore, she wonders if the adage her father introduced to her, "competence is inversely proportional to how much patients like" the physician, might have some truth to it. Appropriately, she questions how one measures the impact of improved interpersonal skills in overall healthcare quality and cost. Of course, palliative care was a little ahead of the curve in emphasizing interpersonal skills. Billings & Block at Harvard; Tulsky's pioneering research; Back, Arnold, Tulsky & company's Oncotalk training; ELNEC and EPEC (and EPEC-O); and family meeting as a bedrock "procedure" of palliative care are all examples.

"The Virtual Nurse Will See You Now" and "Friending Your Doctor Online" are recent offerings in the online newspaper, Technology Review. I was surprised to read that patients found the virtual nurse, "Elizabeth," a computer simulation, was likeable and effective. Patients are reported to resonate with the empathic responses of Elizabeth and to respond well to her instructions and coaching. [I wonder how well she would get along with Siri?] A physician-prescribed social network designed by a startup called Wellaho is in clinical trials in San Diego. It differs from other health-related social networks by including clinicians and by being integrated with the electronic health record. Might this improve coordination across disciples and care sites? Could it reduce hospital readmissions through improved monitoring and communication?

Back to the IOM: Patient-Clinician Communication: Basic Principles and Expectations is the inaugural IOM Discussion Paper, a new IOM series. Patient-Centered Cancer Treatment Planning: Improving the Quality of Oncology Care is the report of a workshop (Feb 28 – Mar 1, 2011) jointly sponsored by the National Coalition for Cancer Survivorship and IOM. Both of these publications grew out of the IOM emphasis on patient-centered care that was highlighted in the 2001 consensus report, Crossing the Quality Chasm: A New Health System for the 21st Century. In that report patient-centeredness was identified as one of six key characteristics of quality care.

Patients are the “ultimate stakeholders” in an increasingly complex delivery system, often with poor coordination and unclear roles. “The effectiveness of patient-clinician communication can be as important as that of a diagnostic or treatment tool.” Basic principles of patient-clinician communication are enumerated: mutual respect, harmonized goals, a supportive environment, appropriate decision partners, the right information, transparency and full disclosure, and continuous learning. In cancer care the last point might be illustrated by the follow-up/reassessment visit before the next in a series of treatments, the transition visit between treatment modalities or at the end of treatment, or the reassessment following a family meeting or after introducing a treatment for a bothersome symptom.

"Patient-Clinician Communication" is short, pretty straightforward, and appropriate for use in an introductory education offering in improving communication skills. It is, after all, a discussion paper, and is likely to spark substantive discussion in classroom and workshop settings.

Applying these principles to cancer treatment planning is a challenge. 80% of cancer patients are treated in the community where fragmentation of services is inherent, but even academic medical centers are subject to communication hurdles (I know many of your are astounded to read that). The average cancer patient sees three specialists who may each be in a different location and has multiple treatments across time and space. Imaging and blood tests might also be in different locations. Each setting and even different departments within an institution may have documentation systems that don’t link with each other. Tumor Boards, designed to improve multidisciplinary care, may not insert their conclusions into the patient record and don’t include the patient in the discussion of treatment recommendations. Meanwhile, patients may access information from friends or the Internet that adds further complexity and confusion, despite the availability of high-quality Web sites. Many patients lose touch with their primary care practitioner during the acute treatment phase.

The major recommendations of the conference were that a shared decision-making model be used and that each patient be given a written treatment plan. Shared decision-making includes an active partnership between patient and physician in which shared treatment goals are agreed, risks and benefits of various alternatives are discussed, and the values and preferences of each are honored. A written treatment plan includes collaborative input from each discipline and specialty involved, incorporates patient preferences, and identifies the responsible clinician(s) for each phase of care. The treatment plan is organic and may need to be revised as the patient progresses through treatment. The treatment plan then becomes the basis for the treatment summary and survivorship care plan, documents advocated by a previous influential IOM report, From Cancer Patient to Cancer Survivor: Lost in Transition. A good summary of the treatment planning publication can be found in the Oct 10 issue of Oncology Times.

The cancer treatment planning conference did not limit itself to the acute treatment phase of care. It also covered advance care planning, survivorship planning, and planning care for advanced disease. Despite the splash made by Jennifer Temel's early palliative care study in late 2010, it was mentioned only once in this report, in the context of advanced care planning. Discussants included Tom Smith, Betty Ferrell, and others well-known to the palliative care community.

The cancer-planning document is not a peer-reviewed report, like "From Cancer Patient to Cancer Survivor." None-the-less, it is meaty and the discussants are all well-known and influential. I suspect (and hope) that it will become the basis for numerous discussions around the country about improving the process of treatment planning at all phases of cancer care.

[IOM products are available for purchase in hard copy, can be viewed free on the IOM web site, and many, including those mentioned here, can be downloaded in free in PDF format].

Serious vs. Chronic vs. Life-limiting vs. Advanced vs. Terminal

2011-11-04T22:31:00.000-05:00

by adaphobic

A 50 -year-old woman calls the palliative care office requesting an outpatient evaluation. She says that she was diagnosed with rheumatoid arthritis approximately one year ago. She has gained benefit from initiation of disease modifying anti-rheumatic drugs yet she is still left with residual pain that has caused her to cut back on her work schedule. She reports over the phone that she has stopped going to church because she has a hard time sitting through long early morning church services and she's also developed depression. She read about palliative care on a website and decided to give the clinic a call to request an evaluation.

Is this a scenario which you have been encountered previously ?

I ran across a blog post the other day ("Palliative Care: The Pal for Every RA Patient") from an enthusiastic advocate for patients with rhematoid arthritis who suggested that palliative care might have a role in this type of patient.

Let's review some generally accepted "criteria" for "early" involvement of palliative care:

Does the patient have a serious illness? No one can argue the fact that rheumatoid arthritis is very serious.
Does the patient have a burden of symptoms? It certainly seems so. Check.
Does the patient had significant psychosocial and spiritual concerns? Yes indeed.

I think it is flattering that palliative care would be considered an option in this type of scenario. It means that our field's message is truly getting across to a wider audience and that our philosophy is resonating with that audience. The biopsychosocial model which underpins palliative care also applies very well to care of patients with rheumatoid arthritis. If an expert palliative care inter-disciplinary team is to see patients as described above, though, we are going to need to bring our sleeping bags into work.

The recent CAPC Public Opinion Survey suggested that we should say that we see patients who have "serious" illness rather than "advanced," "life-limiting," or "terminal" diseases (see Christian's post about the survey here). I have found this to be helpful as I describe our services to new patients/families. If we want to see patients at an appropriate point in their illness course, create appropriate demand amongst patients/families, and ensure they will embrace us from the start, then using "serious illness" does seem to be a more sensitive approach (for finding cases which may be appropriate for palliative care).

We'll likely never find an ideal 1-2 word adjective to describe the type of patients we think we can benefit most. Most of the terms above represent general statements regarding prognosis but still leave a lot for interpretation (eg when in the does one become "terminally ill"?) "Serious" tells you even less regarding prognosis- it's only a vague conception of how a patient or family perceives their illness. We need to accept that while "serious illness" is more sensitive than other terms , it probably isn't as specific. As we try to maximize the number of appropriate early referrals, we'll continue to be challenged to determine what our role is for patients as described above.

Intersections between palliative care and rheumatology do definitely exist, though. The author of the blog post does refer to a journal article which describes some cases where palliative care is most certainly appropriate. This article is worth a glance and I have encountered some similar issues in my clinical work.

Certainly I do not discourage this type of advocacy. I remember from my residency being exposed to several rheumatologists who practiced medicine using a biopsychosocial philosophy. I'm sure that many of them would welcome greater interdisciplinary involvement. Perhaps palliative care's greatest benefit for these patients would be more indirect than seeing every patient. System-wide educational and quality improvement palliative care initiatives may be where the value is for these patients.

How would you recommend that a palliative care team handle this type of request for an evaluation? Here are some possible options:

I would schedule the patient for an appointment with a plan to provide a single evaluation, sending recommendations back to the rheumatologist and primary care physician.
I would be open to the possibility of comanaging this patient over time alongside the patients rheumatologist and primary care physician.
I would consider taking over this patient's primary care as the palliative care clinician.
I would not schedule an evaluation of the patient.
Outpatient palliative care clinic? We're barely keeping our heads above water seeing patients in the hospital!
Other.

Most Days I Clamor for POLST

2011-10-30T22:33:00.000-05:00

Helen Kao at Geripal recently wrote a thoughtful post which highlights some of the flaws in the California POLST form. It's worth a read and I agree with her comments. (And even though I use "POLST" here, I agree with her thoughts on using "POST" instead.)

For jurisdictions which are considering the establishment of POLST, it is important to consider the experience of other states as new forms are designed and legislation is drafted. I live in one of the many states which is in the process of developing a program. In spite of the weaknesses of forms currently in use in other places, PO(L)ST/MO(L)ST remains a very helpful tool with new research continuing to back its utility. For instance, consider a recent study published in the Journal of the American Geriatrics Society which demonstrated high consistency between treatments provided to nursing facility residents and orders recorded on POLST forms. The study found that overall, POLST orders were consistent with treatments provided 94% of the time. Consistency rates were especially high for resuscitation orders. Consistency rates were slightly lower for antibiotic use and much more modest for feeding tubes use.

Reasons for inconsistencies between orders and treatments should be evaluated further. It's unclear that improving the form itself would reduce these inconsistencies. Patients' preferences sometimes change and sometimes patients want their surrogate to have the leeway to change orders after the patient loses capacity (perhaps using a "best interest" standard of decision-making at that time rather than a pure "substituted judgment" standard).

I hope that my state will "get it right the first time" taking into account the experiences of others. However I know that it is impossible to get it completely right the first time. Therefore, I hope that any legislation approved will include a process for modification of the forms which does not require the wheel to be reinvented down the road.

The Death of Steve Jobs: In Medias Res

2011-10-30T22:15:00.000-05:00

The illness and death of the iconic Steve Jobs have stimulated much conversation both online and off. I won't rehash that now.

In case you missed it, NYT published the eulogy delivered by Steve's sister, Mona Simpson, who is a novelist and English professor.

"One time when Steve had contracted a tenacious pneumonia his doctor forbid everything — even ice. We were in a standard I.C.U. unit. Steve, who generally disliked cutting in line or dropping his own name, confessed that this once, he’d like to be treated a little specially.

I told him: Steve, this is special treatment.

He leaned over to me, and said: “I want it to be a little more special.”

Intubated, when he couldn’t talk, he asked for a notepad. He sketched devices to hold an iPad in a hospital bed. He designed new fluid monitors and x-ray equipment. He redrew that not-quite-special-enough hospital unit. And every time his wife walked into the room, I watched his smile remake itself on his face.

For the really big, big things, you have to trust me, he wrote on his sketchpad. He looked up. You have to.

By that, he meant that we should disobey the doctors and give him a piece of ice."

A remarkable blending of the mundane with the extraordinary. He put his two pant legs on and wanted his ice chips just like everyone else.

Oh, how I'd love to see those drawings.

The eulogy hints at how Jobs' illness and treatments interacted with his goals of care (which I'm guessing he was able to clearly define) and quality of life. Given the amount of discussion in our society which surrounded his illness and death, how special might it be to know how he went about making various decisions related to his health care? That could be a beautiful contribution to our society. There is no doubt that limitless financial resources played a role in the care which he received, but he wasn't in the ICU or even the hospital when he died.

"We all — in the end — die in medias res. In the middle of a story. Of many stories."

Innovation Advisors Program

2011-10-28T20:01:00.000-05:00

Attention! Palliative Care advocacy opportunity!

Do you want to get palliative care on the health care agenda? Are you interested in healthcare innovations? Please consider applying for the Innovation Advisors Program with the Center for Medicare and Medicaid Innovations (CMMI). Deadline for applications November 15, 2011. Check it out!!!

http://innovations.cms.gov/innovation-advisors-program/

What caught my eye in Twitter this week (10/28/11)

2011-10-28T20:00:00.000-05:00

(From http://www.thedesignwork.com/)

What follows are a few of the things of the interesting things that went by me on Twitter this week (most recent on top). If you don't tweet, no worries, I removed the hashtags (those pesky # signs). I did leave in the @ signs for those of you who do tweet so you can see who the tweets came from and to give proper credit, but I included who they are in parentheses if it wasn't really obvious. Let me know if you like having the tweets cherry-picked for you. (Disclaimer: I don't read all the tweets in Twitter, so you are getting some of the select few I found interesting enough to retweet/repeat.)

Congrats to Dr. Anthony Back of Seattle Cancer Care Alliance for Sojourns Award! http://bit.ly/tAnzWU

*Well-deserved!!! Check out the ONCOTalk website at http://www.oncotalk.info. A great resource for improving communication skills and teaching communication. In my opinion, if you haven’t looked at it, you should. Thanks for the link @rabob (Bob Arnold), @jfclearywisc (Jim Cleary), @renee_berry (Renee Berry), and @RegenceWA (Regence Blue Shield - Washington)!

New@lifebeforedeath (LIFE Before Death) Short Film 'Together We Are Stronger' online: http://bit.ly/sveCLp

@lifebeforedeath (LlFE Before Death) awarded Best of Show in the Best Shorts Competition - film for social change. http://on.fb.me/pcvWEJ

*Two this week about this great series about the global pain crisis. One is the latest released short, the other is ANOTHER award for the project. See previous Pallimed posts about this work here and here. Thanks for the links @lifebeforedeath!

Mindfulness training for doctors: http://nyti.ms/sUgO13

*NY Times article on mindfulness for physicians. See previous Pallimed post about mindfulness here. Thanks for the link @Robert_Fried (Bob Fried)!

Nurse and Doctor describe their own experiences with cancer http://t.co/koRQdPMc

*Two stories about how personal experience with breast cancer has changed how a nurse and a physician approach patient care. Makes me think of a quote, “We are all healers who can reach out and offer health, and we are all patients in constant need of help.”- Henri Nouwen. Thanks for the link to the article @hastingscenter and @CNN!

The promise and pitfalls of palliative care http://lat.ms/mUeprR

The costs of palliative care teams http://lat.ms/ojEoNH

*Two stories in the LA Times featuring palliative care. Important to see what the public sees about our field. Thanks to @suzanakm (Suzana Makowski) and @AAHPM for the links!

Dr. James Tulsky, innovative researcher in Palliative Medicine, named to NINR Advisory Council. http://1.usa.gov/qjxtXL

*Another well-deserved honor! Congrats!!! Thanks @geri_doc (Ken Covinsky) for the link!

What does Siri know about hospice and palliative care? http://bit.ly/n9jVHW

*Hilarious post from @EWidera (Eric Widera) at @Geripal. Thanks @donaldhtaylorjr (Don Taylor) for the link!

Oncology Patients in the Emergency Department

2011-10-19T23:35:00.014-05:00

by john cowper

Dusting off the Blogger account and checking in......

JCO published a population-based snapshot that looks at the characteristics of patients with cancer who visited emergency departments in North Carolina during 2008. Lung cancer was the most common cancer identified in visits by a significant margin while breast, prostate, and colorectal cancer were each identifed in a smaller number of visits. Patients with lung cancer were more likely to be admitted to the hospital with a total of 63% of all ED visits for patients with cancer resulting in an admission. The top three complaints included pain, dyspnea, and gastrointestinal complaints. More ED visits occurred during night and weekend hours than regular office hours.

Few brief thoughts/questions to ponder:

What percentage of the ED visits were preventable? What systems could be introduced to prevent the visits? (Urgent clinic availability, telemedicine, enhanced home health, etc)
Would these system changes result in a more timely manner and would that result in reduced need for hospital admissions?
As a palliative care clinician, it's not a surprise to see lung cancer disproportionately represented. One of the results of the Temel et al study regarding palliative care involvement from the time of metastatic NSCLC diagnosis was reduced hospital admissions/ED visits. It's not clear what the "mechanism of action" is, but improved access to a team that can help with the top symptoms certainly is one plausible hypothesis.
What is the "right number" of appropriate ED visits/hospital admissions? Hard to say, but palliative care as a field should actively work to help our oncology colleagues to push the numbers as low as possible. As much as I like my ED colleagues, the ED is not a fun place to be.

The New Language of Medicine

2011-10-19T23:32:00.000-05:00

NEJM published a perspective piece where the author briefly describes recent evolution of certain terms within medicine which may resonate with you.

"Patients are no longer patients, but rather “customers” or “consumers.” Doctors and nurses have been transmuted into “providers.” These descriptors have been widely adopted in the media, medical journals, and even on clinical rounds. Yet the terms are not synonymous. The word “patient” comes from patiens, meaning suffering or bearing an affliction. Doctor is derived from docere, meaning to teach, and nurse from nutrire, to nurture. These terms have been used for more than three centuries."

"The words “consumer” and “provider” are reductionist; they ignore the essential psychological, spiritual, and humanistic dimensions of the relationship — the aspects that traditionally made medicine a “calling,” in which altruism overshadowed personal gain."

The terms "providers" and "consumers" do strike me as "health care industry"-centered terms which have served to frame the discussion in a way that is favorable to said industry. Hopefully, the terms (especially "consumers") don't advance any further in the lexicon and maybe more feedback needs to be given to media sources regarding better terms to use.

Oligometastatic Lung Cancer

2011-10-19T23:30:00.000-05:00

NEJM presents a case of a man found to have a primary lung cancer and a solitary brain metastasis. The discussion regarding management of the patient is noteworthy, especially the possible role of surgery and a brief discussion regarding the use of tyrosine kinase inhibitors.

The palliative care consultant should be aware of the available case series which suggest that a minority of patients might have a longer survival than what is usually expected in patients with brain mets. (See Table 1 in the article.) In the case series, patients received aggressive surgical intervention for the brain met and aggressive attempt at locoregional control of the primary cancer.

The article provides some guidance for selection of appropriate patients for aggressive disease-based management. No particular quality of life outcomes are mentioned related to aggressive surgical management.

The bottom line dilemma: This is a scenario where multidisciplinary/multimodality management may give a small number of patients a chance at longer term survival. The approach may be worthwhile to some, but talking about prognosis on multiple levels (survival, anticipated quality of life/burden of procedures) is essential. I cannot remember encountering this scenario recently, but a palliative care consult would be appropriate in any patient with Stage IV lung cancer. It's possible that the complexities of therapy and communication surrounding prognosis may only increase the usefulness of palliative care in this scenario.

NPR Series on Aging and End of Life: Hospice and Palliative Care in Prison Population

2011-10-19T23:25:00.000-05:00

The NPR show Tell Me More has a week long series on issues surrounding aging and end of life.

Today, the show highlighted the documentary Serving Life about care provided to inmates at Angola Penitentiary in Louisiana. The documentary aired this summer on the Oprah Winfrey Network.

Also, see this recent perspective piece from Annals of Internal Medicine which addresses the issue of compassionate release of prisoners near the end of life.

Pallimed has featured stories on palliative care in prisons previously (see search results for "prison" here).

The Fellowship Quest With No Match, or O Brother, Where Are We?

2011-08-01T11:53:00.003-05:00

Update: In the vast palliative care social media echo chamber, Eric Widera over at the GeriPal has provided the 2 to a 1-2 post combination on the problems of applicant/learners in the current state-of-the-fellowships. Please be sure to pop on over and check it out.
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Eric Widera over at GeriPal posted in April about changes in the National Resident Matching Program (NRMP) timeline for medical subspecialty fellowships, and the implications for Hospice & Palliative Medicine (HPM) and Geriatrics.

I'd like to talk about our Match-less HPM fellowship application process, from one applicant's perspective.

Photography by Ken Goldberg. From “Tele-Twister” CC 2004. Some rights reserved.

So, there I am minding my own business, I've interviewed at five impressive programs, with two more interviews scheduled. Then unexpectedly, I get an offer for a position from a stellar institution (I rather awkwardly ask for time to interview more fully before making a decision, which was granted). This is followed a week later by another offer from a great program. One is closer to my family, but culturally less vibrant, with an academic practice pattern and team culture to my liking; the other is farther from my family, but in a more culturally robust area, with a strong clinical program offering high volume and challenging cases. My wife is a professional musician and music journalist, so the cultural milieu where I train, and may wind up practicing in, is an important factor. Then an interview opportunity comes in from another great program in a great town an hour away from my wife's family.

Photography by Ken Goldberg. From “Tele-Twister” CC 2004. Some rights reserved.

Perhaps one might say, "I should be so lucky." My reaction is actually more like panic. The opportunity costs is high assuredly, but determining which I should choose and which I should forego is excruciatingly difficult. I still have 10 applications out (OK maybe too many applications. But, who knows at the outset how one is going to fare?). All of those programs are very interesting to me, for location, institution and program faculty, etc.

So, I ask for and get extensions of the offers. I interview at the program close to my wife's family. When I meet with the program director, I'm told their decision about my cohort of applicants will likely be made after my other offer extensions are up. I also get what is probably a generic invitation to contact the program if I needed an early decision to clarify matters. So, back to the offering programs to update them and ask for more time, which they graciously grant. I then ask for, but did not get, an early decision, which means I was still in the running. So, I am being pulled now in at least three ways, with irons still in the fire.

Interviewing is expensive, especially on a resident's salary, and doing this all during residency, with long hours while taking care of patients and collateral responsibilities, and having to use vacation time is all very stressful. As this is all going on interview offers continue to trickle in. I begin to turn down interview offers, even canceling interviews I already have scheduled, thinking I am likely to take one of these positions. At the same time, I am anxious about eliminating interviews out here in the Wild, Wild West because something could go wrong and my birds in the bush could fly the coop, and the whole thing could come down like a house of cards leaving me in the cold, and empty-handed.

The last few days start ticking down. Out of the blue, I get a contingent offer from a program that is very strong clinically and highly academic, in a culturally vibrant town, not too terribly far away from my family. They are working on getting approval for another Accreditation Council for Graduate Medical Education (ACGME) slot, versus perhaps another candidate may turn down an offer they have already made. At this point I make criteria for being "drawn and quartered," now being pulled in four different directions. The opportunity costs mount!

The way it felt, both as it was happening and in retrospect, was something like an uncertain, perilous and epic quest. It reminded me of my favorite epic, The Odyssey. Odysseus was struggling to get home after many long years away, but one problem after another cropped up to thwart him: the whim and malice of gods and goddesses, the threats of monsters, the thrall of enchantments, the lure of comfortable captivities, the sirens' call, tempestuous storms and even more monsters. It is at this point that imagery from the Odyssey wells up: Odysseus caught between the gorging and belching vortex of Charybdis on the one hand and the rapacious heads and voracious mouths of Scylla on the other, with no way out but through.

By luck and craftiness Odysseus barely averts disaster again and again, and by holding to the course, he finally achieves his quest and arrives home, travel-weary, older, perhaps wiser… but also with an unnecessary case of PTSD. To reason that since the hero survives and achieves the quest, the arduous and circuitous course he was made to take is justified is, in my opinion, a rationalization.

In the end, I secured a position and I am very happy with my outcome. I am however very unhappy with the process. Thank goodness for the Electronic Resident Application System (ERAS) where one's application, CV, personal statement, letters of recommendation, are uploaded into the electronic ERAS cloud once, and then are electronically submitted to one's desired programs (except for the programs that don't participate in ERAS and require old-fashioned paper applications, thus duplicating work for interested applicants and their recommenders). Having ERAS in place prevented the process from being even more labor-intensive and chaotic.

The diversity among programs in their respective timelines for application review, interviewing, and how and when to do what about making offers is frankly stunning. My process was cut short by a spoils-to-the-swift ethic. Because of the asynchronous timelines, I had to decline interview offers from programs I was very interested in. Given the inherent power disparity in the roles and the dynamics involved, I did not believe I had the latitude to walk away from offers from great programs in order to "explore my options" further. Perhaps my issue, but I doubt mine alone.

If there wasn't already an existing, simple, validated, large-scale, low-cost system to regulate and standardize behavior and decision-making among applicants and programs then one would be pragmatically stuck with the status quo. Luckily for us the kinks and bugs have already been worked out and a process is readily available for us to plug into. I'm speaking of course of the NRMP, or more simply "the Match."

Having been through an NRMP Match, and now this Matchless Meet Market, I find the latter is wholly unsavory and unsatisfactory. Rather than feeling like I've come through a fair process conducted on an even playing field to arrive at an optimized placement to advance my learning and professional development and to staff the houses of programs with the best they can attract, instead I feel like I just bought a house in today's market; I've closed the best deal I could, but I really would not want to do that over again.

Furthermore, I believe I was extremely lucky; my timelines were generous and fluid. I just think about those souls out there who are waiting for an interview in their preferred program, near their family, but get an acceptance from another program with a one week deadline to accept the offer (not an uncommon demand). Yes, I feel lucky for how it turned out in the end, but I also feel like I've been through the wringer unnecessarily, and I resent that.

My conclusion is that for the sake of learners (and I actually believe in the interests of most programs) HPM needs to align with the leaders in GME and participate in The Match on the same timeline as the other medical specialties. Incidentally, moving the process into applicants' final year of specialty training would bring it in line with the fellowship application process in other specialties, at least with Physical Medicine & Rehabilitation and Emergency Medicine.

If you have a war story, please feel free to add it. I would suggest de-identifying the data for the sake of human subjects protection, if you get my drift.

Call for Submissions to the 3rd Annual AAHPM Interactive Educational Exchange!

2011-07-25T06:00:00.053-05:00

If you are a med ed geek like me, you L-O-V-E the Interactive Educational Exchange which has been a fun and exciting part of the Americal Academy of Hospice and Palliative Medicine (AAHPM) Annual Assembly for the past two years. It's not your ordinary concurrent session. No! Instead, you listen to a quick overview of the different presentations and then you zip around to learn more about the ones that you find most intriguing. I have always come away with at least one interesting idea to try or tweek to fit my teaching style and audience. So... if you're students are yawning, you can A) buy them coffee or B) go to the Interactive Educational Exchange on March 9th, 2012 from 3:30 to 5:00 pm.

If you've got an exciting way to teach palliative medicine to any discipline, please do share! Submit it for the 2012 Interactive Educational Exchange at the AAHPM Annual Assembly in Denver! Hurry! Submissions are due by 5 pm PST August 2, 2011! Heck! They make it easy by even giving you previous year's submission examples.

"The Exchange provides a structured, interactive, and hands-on forum for palliative care educators from all disciplines to present, share and exchange materials and methods from model educational initiatives, including curricula, program development, educational process, assessment tools, online materials, and research in teaching and evaluation." (via the Educational Exchange Session Faculty: Laura Morrison, MD; Elise Carey, MD; Barbara Jones, MSW, PhD; Pamela Fordham, RN, DSN, CNRP)

Hope to see you there!!!

Photo by Elizabeth Thomsen via Flickr

LIFE Before Death Short Films - Week 10 of 50!

2011-07-25T05:59:00.001-05:00

Each week for 50 weeks, there will be a short documentary film about the international crisis in untreated pain. We've already made it through the first 10 weeks so far! This is a part of a larger project entitled LIFE Before Death which includes a full-length documentary film as well (see Christian’s earlier post Movie Trailer Premiere: LIFE Before Death).

Whether you are interested in watching about Opiophobia or debate the question of Torture in Health Care, you can catch up at TreatThePain.com. You can also download the videos for advocacy and training work at the Life Before Death website (the topic of two previous Pallimed posts here and here).

If you are interested in some blog posts on individual short films, Dr. James Cleary, Director of the Pain Policy Studies Group (PPSG), has been faithfully writing about the episodes on the PPSG blog.

So what is the big deal? It may not seem like there is such a big problem if you live in the US or Canada, but there is. With all the concern about the morbidity and mortality of prescription drug abuse, we still have a major issue of untreated pain right here at home which is obvious to the average American. Many people who live in the US continue to suffer significant pain because of low doses or poor access to opioids.

A case in point from my non-work life, I was in the ED waiting room keeping a friend company while she waited to be seen, when the woman on the other side of me (who had been waiting for more than 4 hours) loudly threatened to lift up her shirt to show the triage nurse her breast cancer so that she could get some pain relief. Needless to say, they finally got her some medication, but it took threatening public tumor nudity to get it. Yes, we have education/policy/access issues too. Undoubtedly, if you travel internationally you will see the same issues, only amplified. See my earlier post about World Opioid Consumption and Christian's post about the International Pain Crisis.

Education is needed for safe use of anything, from opioids to a lawn mower. Just because you have the drugs doesn't mean you know how to prescribe them safely and effectively. Proper policy is also necessary so that medications can be safely and simply prescribed by those who are caring for people who suffer from pain and other symptoms. Drug availability is a critical and central issue, with 80% of countries using very small amounts of opioids for symptom control.

As we often tell you on Pallimed, you can get involved easily. It only takes a few minutes of your time. Follow the LIFEBeforeDeathMovie channel on YouTube, comment, like it, post it to your Facebook, tweet it, tell your med students, your mom, AND your nosy neighbor about it. Spread the word locally, nationally, internationally. It is through the collective efforts of all of us that we can help major media efforts promoting good palliative care get noticed across the US and around the world. Social media and on-the-ground action can lead to significant change... just look Egypt. Keep your eyes out for the next short film coming out this week! Thank you for not being silent!

Video credit: LIFE Before Death short film "Conspiracy of Silence

Photo credits: Stills from LIFE Before Death short films "We All Belong" and "Demand and Supply".

Denosumab, palifermin, and the costs of supportive cancer care

2011-07-19T22:30:00.001-05:00

I've been following the emergence of denosumab as a preventive therapy for skeletal related events in patients with bone metastases, and thought I'd write about it. Denosumab is a monoclonal antibody therapy which binds RANK-ligand, leading to osteoclast inhibition, decreased bone turnover, and presumably its salutary effects in preventing fractures and other skeletal related events (this glowing editorial on denosumab gives a nice/brief overview of its mechanism of action - the image is from this editorial.)

There have been several publications the last half-year in Journal of Clinical Oncology (breast cancer study here; myeloma & non-breast, non-prostate cancer study here) all showing that denosumab is non-inferior to zoledronic acid in preventing skeletal related events. (SREs are a composite research outcome which combines pathologic fracture, hypercalcemia, and need for surgery/radiotherapy due to bone mets.) I'd noted the abstracts, and already seen a few patients receiving it, but finally gave the research a closer look the last couple weeks.

What struck me, as I read the paper for the myeloma/non-breast/prostate one, was their power calculation: they calculated needing 1700 patients to demonstrate noninferiority of denosumab to zoledronic acid given monthly. That's a pretty high number for a supportive cancer trial, I thought to myself, Why? Well the answer is obvious, and borne out by the study results. The benefits of denosumab, compared to zoledronic acid, are marginal, and you'd need a lot of patients to minimally prove statistical significance: denosumab met their non-inferiority definition; the median time to first on-study SRE was 20.6 months for denosumab vs 16.3 months for zoledronic acid (this difference did not achieve statistical significance). There was some expected differences in side effects: more flu-like symptoms and renal problems with zoledronic acid, some more hypocalcemia with denosumab. That's about it. The breast cancer study had similar findings, a little more positive (by 27 months 50% of patients in the zoledronic acid group had had an SRE whereas only 40% of of the denosumab group had - this met their superiority criteria). The paper doesn't present its data in a way that allows one to calculate this exactly, but by eye-balling a figure (2a) my conclusion is that the number needed to treat to prevent 1 SRE over 27 months is 10 (you'd have to give denosumab to 10 patients to further prevent a single SRE over 27 months compared to what you would have prevented with zoledronic acid).

This is a modest enough improvement that the investigators needed 2000 patients in the breast cancer study to demonstrate it actually is, and not noise. I want to be clear: I think the research supports that denosumab is as good as zoledronic acid, and for breast cancer patients it is better. I don't doubt that. That's what the N of 2000 showed. The issue is, as a clinician, I have become more and more inclined over the years to think that the bigger N you need to show something, chances are that something is of a magnitude that is small enough, or of a frequency that is rare enough, that it's an intervention that is likely to help any given patient in theory only. The 'better' of denosumab is probably barely worth it, at least for most patients (it may be worth it for patients with significant chronic kidney disease, but that's it).

Part of this is then re-learning what was beaten into me when I was younger, which is that bigger trials are better. They probably are better if the outcome you're interested in is a small improvement, or rare event (and there are some outcomes for which that's appropriate - stroke prevention, for instance), but if the outcome you're interested in is anything else, including symptom control, you want something better than a small, barely statistically demonstrable, improvement.

Another way of looking at this are the costs involved. I tried finding out more about this, and found a couple cost-effectiveness analyses (here, here - both from 2011 ASCO), dishearteningly brought to us by Novartis, the maker of zoledronic acid. Yep. You can see Amgen (the maker of denosumab, and palifermin) & Novartis glowering at each other across the aisle at the poster session of ASCO. Both suggest that denosumab costs an additional $640,000 dollars per quality-adjust life year gained in breast cancer. More for prostate cancer. Denosumab's acquisition cost is $1650/dose vs $887/dose for zoledronic acid. Ignoring arguments about QALYs (I'm not the biggest fan either), the magnitude of the dollar figure here gives you some sense of how marginal the improvement denosumab is bringing. One wonders about all the ways one could use that money to help our patients in ways that will be actually helpful to them.

Which brings me to palifermin to prevent oral mucositis. A recent JCO published the results of two (related, and Amgen funded, and randomized, double-blinded, placebo controlled) trials of weekly palifermin times 7 doses during definitive radiochemotherapy for head and neck cancer: here & here. Palifermin is a recombinant human keratinocyte growth factor, and is approved for the prevention of oral mucositis for patients undergoing stem cell transplants. Revisiting my prior discussions, both studies estimated they needed ~200 patients to be adequately powered to demonstrate superiority of palifermin over placebo in preventing the incidence of severe oral mucositis (200 patients - now that's a study which is probably measuring something!).. Rates of severe OM were reduced by ~15% (absolute risk reduction - NNT of 6.7). Secondary outcomes suggested a (dramatic but apparently non-statistically significant) trend in one study and a statistically significant reduction in the other of duration of severe OM by two weeks. Acknowledging that that's a sort of 'wow' outcome that gets one excited, I have to remind myself it was a secondary outcome. Going through definitive radiochemotherapy for head and neck cancer has got to be one of the harshest medical interventions around, and reducing the most severe OM by a couple weeks seems huge. Notably, however, they didn't look at health related quality of life, and one wonders if this was a missed opportunity. I've tried to identify cost effectiveness analyses for palifermin, but haven't found any for radiochemotherapy. The stem-cell transplant literature suggests it's cost effective in that setting.

Increasing Palliative Care Awareness - the 2011 CAPC Public Opinion Research

2011-06-29T22:11:00.002-05:00

Palliative Care still befuddles many people when they first hear the term. Even after seeing it people may feel like the many blind scientists touching different parts of an elephant. Historically we have described to people what palliative care is on our terms as the experts who provide it. Looking at many organizations definition of palliative care they have not been made based on public opinion and understanding.

The Center to Advance Palliative Care (CAPC) with support from the American Cancer Society Action Network commissioned a study of public opinions on palliative care, but now the question is what can we do with this new information.

Before I get any further on my opinion of the key findings, I need to tell you to take 15 minutes and read the actual report. Then go talk to your team and your leadership about this. It needs to be discussed and understood widely by all stakeholders. Do it, I mean it (and then come back here abnd post what you talked about so we can all learn).

The key findings:

Concerns for quality of care for patients with serious illness, which include:

treatment choices not offered
lack of physician collaboration
lack of confidence in plan after leaving the clinic or hospital
lack of control
lack of time
lack of listening

Perfect! These are all the things palliative care is good at changing. Could we be a model for other ways to deliver health care effectively? Take the time and listen to patients, give them a chance at real informed consent of all options after talking to other physicians and effectively communicate the plan to patients. That is what palliative care does! You can see where this is headed...

People do not know what palliative care is. 78 % of people said they were 'not at all knowledgeable or don't know' when asked about palliative care. Frustrating I am sure to those of you who beat the drum everyday but at least it is not being wholly defined and understood without us (yet).

Physicians equate palliative care with hospice or end of life care.
Well think about it...many in the field nearly always refer to hospice AND palliative medicine, (although I think this is changing a bit and read to the end for more) so isn't that like peanut butter and jelly? They have to go together right? (H/T @aliciabloom)

Think about palliative care consults in the hospital which is where most docs are exposed to palliative care. What does a palliative care team get asked to do? Consults for goals of care discussion when other options have been exhausted, even though palliative care wants and could be involved much further upstream and some institutions are successful at doing this. So of course many docs would consider palliative care 'brink of death' care. Which leads people to think 'hospice in the hospital' which I have heard whilst cringing too many times...

'Serious Illness' is perceived as less about 'being terminal' than 'Advanced Illness' (18% v 36%)
So who is your palliative care team looking to serve...those with serious or advanced illness. Whichever it is, I think we need to have consistency across the board. Our two major representative organizations are on the same page at least. (HPNA did not mention patients, but focused more on support of nurses in their mission statement)

AAHPM's Core Purpose:
To improve the care of patients with life- threatening or serious conditions through advancement of hospice and palliative medicine.

NHPCO's Vision:
A world where individuals and families facing serious illness, death, and grief will experience the best that humankind can offer.

Are all of our member organizations and constituents using similar language? Is uniformity a important goal? I think so.

Palliative Care should be made available to patients with serious illness.
Once informed there were high rates (in the 90's) believing there should be access to pallaitive care for their loved ones, regardless of political affiliation (although there were some differences). To get patients access to quality palliative care, we need to be able to create a consumer demand especially if physicians are reluctant to consult. After we do that we need to quickly figure out the workforce issues. (Another blog post...)

Language Matters.
Now for the tricky part that really started me thinking about the conjoined twin nature of Hospice and Palliative Care. They took what was termed an 'old' definition (source unclear - must ask @DianeEMeier) and compared it to a new version (also source unclear). Italics highlight the new portions:

OLD: Palliative care is the medical specialty focused on improving the quality of life of people facing serious illness. Emphasis is placed on pain and symptom management, communication and coordinated care. Palliative care is appropriate from the time of diagnosis and can be provided along with curative treatment

NEW: Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment

Nothing totally revolutionary in the definitions except for the outcomes when they compared the acceptance/favorable rate for the two definition. Mean Rating Score (Scale of 100) improved from 63 to 74 and the % scoring it in the 75-100 range increased from 36% to 60%.

Personally I think the 'new' one is too long for saying in a clinical setting compared to the first, but maybe better for brochure language. Also to get people who refer to palliative care to introduce you to the family using the second definition will be pretty hard. Instead they are likely looking for something easy to say and memorable...like 'hospice in the hospital.' (which is not accurate for those of you with that misconception.)

But the part that got me thinking is this new definition really made me look at the 'can be provided with curative treatment' phrase. I have said it a million times, but now looking at it makes me think that hospice is becoming less of a type of palliative care since it has the emphasis on time via prognostic qualifications per the Medicare Hospice Benefit. I know the lumping or splitting the terms of hospice and palliative care is a topic of great debate in the field, so I want to let you know that these are my opinions and not those of the AAHPM board. But I really think we need to keep this as a open debate for our field. I don't think we are served by splitting the terms, but lumping is causing confusion.

So how will you use this research?

And a big kudos to the American Cancer Society Action Network for supporting this. The ACS is really working well with our key leadership orgs. Now if we could only get the NIH, NCI, and others to...

The New York Times Takes on the Issue of Rising Hospice Costs

2011-06-29T21:17:00.002-05:00

This week the New York Times talks about the rising costs of providing hospice care in America with a particularly juicy hook about a nearly $25 million whistle-blower settlement against an Alabama hospice. From there it talks about the focus of some hospices to seek patients who are likely to have longer lengths of stay, like dementia and stroke. One research analyst even goes as far to say "It's a lucrative business, at least under the current reimbursement system." They also feature an inspector general report that documentation for hospice patients in nursing homes was lacking.

Not a good start from a newspaper that has actually been quite kind to hospice in the past. The rest of the article goes on to discuss the various fixes including every hospice medical director's new task: the face to face certification visit. (We have not yet dedicated a blog post to face-to-face home visits for certification, but one is in the works so we can has that out at a later date.)

But the article leaves out a lot and I feel it is pretty one-sided. Apparently Don Schumacher, head of the NHPCO, has found some flaws in the article too as he is communicating with the NYT editorial board. There is relatively little about potential changes to the payment structure to focus greater reimbursement during the first 7 and last 7 days of service when need is thought to be the greatest. The article does not talk about or reference the article by another NYT reporter from 2007 with the title "In Hospice Care, Longer Lives Mean Money Lost" about the aggregate cap. Nor did it quote the Duke Study that found hospice care saved Medicare an average of $2,300 per beneficiary (OPEN ACCESS PDF), calling hospice “a rare situation whereby something that improves quality of life also appears to reduce costs.” Yeah, they missed some stuff.

Which is not to say we need to look closely at fraud issues. Good oversight is important for a multi-billion part of the health care system, but we have to realize that every problem started out as the solution to another problem. The system is perfectly designed for the outcomes it gets. So let your legislators know about what hospice means to you. Talk to your organizations and actually answer the advocacy emails that moment instead of promising to get back to them later.

As the NYT usually does there is no ability to comment on the article but there is a linked blog post at "The New Old Age" which allows for comments. As of this writing there are 64 comments. Here are a few I thought stood out:

It is amusing and annoying to be complaining about the costs of hospice care, when in fact hospice patients are forgoing the ER visits, hospitalizations, specialists' visits, procedures, and many medications that Medicare would instead be covering if not for the patient making a decision to pursue comfort care only. So, what was the cost SAVINGS to Medicare by having these people on hospice, even though they stayed on longer than usual? Alot.- ras

I don't even believe desperate old people are gaming the system via hospice. But if they are, it's because this country has utterly failed them, taken payroll deductions for a lifetime in exchange for medical care in old age, and then only given the kind of medical care 70-year-olds need, not 90-year-olds. Shame on us. - jane gross

Hospice is a critical service that is offered to all. It is necessary, compassionate, and well run. So, if we discontinue it or cut services, we are a nation without merit and compassion. We will not only be third world, we should not be in this world. - Julie

The article disingenuously ignores this broader care issue while it exploits an example of an Alzheimer's patient. Please, NY Times, get perspective on the bigger picture. Help the US face its fear of dementia that keeps us in denial and prevents us from preparing to fight a huge healthcare tidal wave. Take more leadership and make a difference. - Suzanne

So it's too expensive to have an MD check on hospice patients once every six months? The health care industry has become even more shamelessly and barbaricly greedy than I thought. - Cowboy Marine

TAYLOR JR, D., OSTERMANN, J., VANHOUTVEN, C., TULSKY, J., & STEINHAUSER, K. (2007). What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Social Science and Medicine, 65 (7), 1466-1478 DOI: 10.1016/j.socscimed.2007.05.028

Photo credit: Flickr user: castle79

"I'm taking care of him...but not really." - The dying patient in intensive care

2011-06-19T21:21:00.000-05:00

The Happy Hospitalist, a long time blogger and purveyor of fine absurdist humor with the creation of multiple 'animated bear' videos (aka Xtranormal videos) has created a video focused on the dying patient in the intensive care unit...but not really. Not really in the fact the video is not patient-centered at all, and that is the point. HH skewers the system that so readily places orders for tests, scans and procedures before even talking or touching the patient. For anyone in hospital based palliative care I am sure there are many witnessed experiences in the self-declared hyperbole of the video.

Here is the video (link to original post):

Below are some of my favorite lines/segments because they emphasize the frustrating weaknesses of our current approach to care of the critically ill:

"His functional score is -2, which means death within minutes."
'The cardiologist who orders a stat echo, EKG Q1 hour, and a iTunes enhanced pacemaker so he can bill for music therapy.'
"'Everyone deserves to die with a normal BMP."

There are other little gems I don't want to spoil that will make sense to anyone who has worked in the hospital, and for the non health care professionals reading this post I think anyone who has had a loved one critically ill will recognize some of these absurd situations that divorce the care of the numbers from the care of the patient. This point is highlighted in my favorite line of the video which is repeated over and over again from both the hospitalist and the ICU nurse:

"I'm taking care of him...but not really."

Listen all the way to the end to get a sense of what HH really thinks about palliative care in the hospital. He has been a big supporter of palliative care and he gets the fact that palliative care should be far upstream from just dying patients in the ICU. For examples see some of his other posts:
Barriers to Palliative and Hospice Care: Denied by the Nursing Home
End of Life Care Discussion Should Occur Before Death
The Power of Love: Going to Dialysis Hell and Back

Leave your thoughts here but also go to Happy Hospitalist's blog and leave comments there because it is pretty popular and our thoughts might get to people outside our normal blogging circles