Podcasts about aahpm

Dr. Mellar Davis discusses the joint guideline from MASCC, ASCO, AAHPM, HPNA, and NICSO on opioid conversion in adults with cancer. He reviews the limited evidence, and the formal consensus process used to develop the guideline. He shares the key recommendations on pre-conversion assessment, how opioid conversion should be conducted, including opioid conversion ratios, and post-conversion assessment. We touch on gaps and questions in the field and the impact of these new recommendations.  Read the full guideline, “Opioid Conversion in Adults with Cancer: MASCC-ASCO-AAHPM-HPNA-NICSO Guideline” at www.asco.org/supportive-care-guidelines. TRANSCRIPT This guideline, clinical tools, and resources are available at http://www.asco.org/supportive-care-guidelines. Read the full text of the guideline in the Supportive Care in Cancer, https://link.springer.com/article/10.1007/s00520-025-09286-z   Brittany Harvey: Hello and welcome to the ASCO Guidelines podcast, one of ASCO's podcasts delivering timely information to keep you up to date on the latest changes, challenges and advances in oncology. You can find all the shows, including this one at asco.org/podcasts. My name is Brittany Harvey and today I'm interviewing Dr. Mellar Davis from Geisinger Medical Center, lead author on “Opioid Conversion in Adults with Cancer: Multinational Association of Supportive Care and Cancer, American Society of Clinical Oncology, American Academy of Hospice and Palliative Medicine, Hospice and Palliative Nurses Association, Network Italiano Cure di Supporto and Oncologia Guideline.” Thank you for being here today, Dr. Davis. Dr. Mellar Davis: Thank you. I'm glad to be here. Brittany Harvey Before we discuss this guideline, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO Conflict of Interest Policy is followed for each guideline. The disclosures of potential conflicts of interest for the guideline panel, including Dr. Davis, who has joined us here today, are available online with the publication of the guideline, which is linked in our show notes. So then, to dive into the content here, Dr. Davis, can you provide an overview of both the scope and purpose of this guideline on opioid conversion in people with cancer? Dr. Mellar Davis: This is an important topic in management of cancer pain and this topic came up as a result of a survey that MASCC had done, which involved 370 physicians in 53 countries. They were queried about how they change or convert one opioid to another, which is a common practice, and we found that there was quite a divergence in opioid conversion ratios. To step back a little bit, about two thirds of patients with advanced cancer have moderate to severe pain and most of the time they're managed by opioids. But about 20% or 40% require a switch either because they have an adverse reaction to it or they don't respond to it, or the combination of both. Rarely, it may be that they need a route change, perhaps because they have nausea or vomiting. So, the opioid conversion works basically because of the complexity of the new opioid receptor which has at least four exons to it as a result of that non-cross tolerance between opioids. As a result of the survey, we convened a group of specialists, 14 international specialists, to look to see if we could develop an international guideline. And we did a systematic review which involved viewing 21,000 abstracts and we came up with 140 randomized trials and 68 non-randomized trials. And after reviewing the data, we found that the data was really not strong enough to provide a guideline. As a result, ASCO, MASCC, the AAHPM, the HPNA and the Italian Group formed a supportive network that allowed us then to do a Delphi guideline based upon ASCO modified criteria for doing Delphi guidelines. And so we then involved 27 additional international experts informing the guideline to it. And this guideline is then the result of the Delphi process. It consists basically of a pre-conversion ratio recommendations, conversion ratios, which is actually a major contribution of this guideline, and then what to do after converting someone to another opioid. Our target audience was not only oncologists, but also we wanted to target nurses, pharmacists, hospitalists, primary care physicians, patients and caregivers. Brittany Harvey: I appreciate that background information, particularly on the evidence that is underpinning this and the lack of quality of evidence there, which really transformed this into a formal consensus guideline. We're glad to have all of these organizations coming together to collaborate on this guideline. So then next I'd like to review the key recommendations. So starting with, what is recommended for pre-conversion assessment? Dr. Mellar Davis: In regards to pre-conversion, physicians and clinicians need to be aware of pain phenotypes. That is, there are pains that are more opioid refractory than others, such as neuropathic pain, hence, they may be more resistant to the opioid that you're converting to. One needs to be aware of the fact that patients may not be compliant, they're either afraid of opioids not taking what was prescribed, so it's important to query patients about whether they are taking their opioid as prescribed. Occasionally, there are patients who will divert their medication for various reasons. Pain may be poorly controlled also because of dosing strategies that are poorly conceived, in other words, giving only ‘as needed' opioids for continuous cancer pain. And there are rare circumstances where an opioid actually induces pain and simply reducing the opioid actually may improve the pain. The other issue may be cancer progression. So that poorly controlled pain or rapidly increasing pain may actually be a result of progressive cancer and changing treatment obviously will be important. And you need to assess the pain severity, the quality of the pain, the radiating localizing effects, which does require not only a physical exam but also radiographic examinations. But the other thing that's very important in opioid conversions are pain scales with function. A significant number of patients don't quite understand a numerical scale which we commonly use: 0 to 10, with 10 being severe pain and 0 being no pain. They may in fact focus more on function rather than on pain severity or pain interference with daily activities or roles. Sometimes patients will say, “Oh, my pain is manageable,” or “It's tolerable,” rather than using a numerical scale. Choices of opioids may be based on cost, drug-drug interactions, organ function, personal history or substance use disorder so that one will want to choose an opioid that's safe when converting from one to another. And obviously social support and having caregivers present and understanding the strategy in managing pain will be important. Brittany Harvey: Thank you, Dr. Davis, for reviewing those pre-conversion assessment considerations and particularly the challenges around some of those. So, following this pre-conversion assessment, what are the recommendations on how opioid conversion should be conducted? Dr. Mellar Davis: Opioid conversions are basically the safe dose. People have used the term ‘equianalgesia', but the panel and the consensus group felt that that would be inappropriate. So a conversion ratio is the dose at which the majority of patients will not experience withdrawal or adverse effect. It would be the safe dose. Thereafter, the dose will need to be adjusted. So, in converting, that's only the first step in managing pain, the doses need to be adjusted to the individual thereafter. There are a significant number of conversions that are done indirectly, that is that there has not been a study that has looked at a direct conversion from one opioid to another in which one needs to convert through another opioid. We call that a ‘morphine equivalent daily dose'. So, most of the time a third opioid is used in the conversion. It allows you then to convert when there hasn't been a direct study that has looked at conversion between those two opioids, but it is less accurate and so one has to be a little bit more careful when using morphine daily equivalents. We found, and I think this is the major advantage to the guideline, is that commonly used opioids - oxycodone, morphine, hydromorphone - we did establish conversion ratios to which we found in the MASCC guideline they were widely divergent and hope that actually, internationally, they will be adopted. We also found some conversion ratios for second-line opioids. However, we felt also that an opioid like methadone, which has a unique pharmacology, should be left to experts and that experts should know at least several ways of converting from morphine usually to methadone. There is what appears to be a dose-related increased potency of methadone relative to morphine, which makes it more difficult, particularly at higher doses, to have an accurate conversion ratio. Most patients will have transient flares of pain. We came up with two suggestions. One is using a 10 or 15% of the around-the-clock dose for the breakthrough dose, but we also realized that there was a poor correlation between the around-the-clock dose and the dose used for transient flares of pain. And so the breakthrough dose really needs to be adjusted to the individual responses. There was also a mention of buprenorphine. One of the unique things about buprenorphine is that if you go from high doses of a drug like morphine to buprenorphine in a stop-start dosing strategy, you can precipitate withdrawal. And so one has to be careful and have some experience in using buprenorphine, which can be an effective analgesic. Brittany Harvey: Yes, I think that the conversion ratios that you mentioned that are in Table 3 in the full guideline are a really useful tool for clinicians in practice. And I appreciate the time that the panel and the additional consensus panel went through to develop these. I think it's also really key what you mentioned about these not being equianalgesic doses and the difficulties in some of these conversions and when people need to really look to specialists in the field. So then, following opioid conversion, what assessments are recommended post-conversion? Dr. Mellar Davis: Post-conversion, probably the cardinal recommendation is close observation for response and for toxicity. And I think that probably summarizes the important parts of post-conversion follow up. So assessment should be done 24-48 hours after conversion and patients followed closely. Assessment scales should include patient personalized goals. Now, it used to be in the past that we had this hard stop about a response being below 4 on a 0 to 10 scale, but each patient has their own personal goals. So they gauge the pain severity and their function based upon response. So a patient may function very well at “a severity of 5” and feel that that is their personal goal. So I think the other thing is to make sure that your assessment is just not rote, but it's based upon what patients really want to achieve with the opioid conversion. The average number of doses per day should be assessed in the around-the-clock dose so those should be followed closely. Adverse effects can occur and sometimes can be subtle. In other words, a mild withdrawal may produce fatigue, irritability, insomnia and depression. And clinicians may not pick up on the fact that they may be actually a bit under what patients have or they're experiencing withdrawal syndrome. It's important to look for other symptoms which may be subtle but indicating, for instance, neurotoxicity from an opioid. For instance, visual hallucinations may not be volunteered by patients. They may transiently see things but either don't associate with the opioid or are afraid to mention them. So I think it's important to directly query them, for instance, about visual hallucinations or about nightmares at night. Nausea can occur. It may be temporary, mild, and doesn't necessarily mean that one needs to stop the second opioid. It may actually resolve in several days and can be treated symptomatically. Pruritus can occur and can be significant. So close observation for the purposes of close adjustments are also necessary. As we mentioned, you want to start them on an around-the-clock of breakthrough dose, but then assess to see what their response is and if it's suboptimal then you'll need to adjust the doses based both upon the around-the-clock and the breakthrough dose or the dose that's used for breakthrough pain. Also looking at how patients are functioning, because remember that patients frequently look at pain in terms of function or interference with their roles during the day. So, if patients are able to do more things, that may, in fact, be the goal. Brittany Harvey: Thank you for reviewing all of these recommendations across pre-conversion assessment, how opioid conversion should be conducted, including conversion ratios, and what assessments are recommended after opioid conversion. I think it's really important to be watching for these adverse events and assessing for response and keeping in mind patient goals. So, along those lines, how will these guideline recommendations impact both clinicians and people with cancer? And what are the outstanding questions we're thinking about regarding opioid conversion? Dr. Mellar Davis: I think it's important to have a basic knowledge of opioid pharmacology. There's, for instance, drugs that are safer in liver disease, such as morphine, hydromorphone, which are glucuronidated. And there are opioids that are safer in renal failure, such as methadone and buprenorphine, which aren't dependent upon renal clearance. I think knowing drug-drug interactions are important to know. And sometimes, for instance, there may be multiple prescribers for a patient. The family physician's prescribing a certain medication and the oncologist is another, so being aware of what patients are on, and particularly over-the-counter medications which may influence opioid pharmacokinetics. So complementary medications, for instance, being aware of cannabis, if patients are using cannabis or other things, I think, are important in this. There are large gaps and questions and that's the last part of the guideline that we approach or that we mentioned that I think are important to know. And one is there may be ethnic differences in population in regards to clearance or cytochrome frequencies within communities or countries, which may actually alter the conversion ratios. This has not been explored to a great extent. There's opioid stigmata. So we are in the middle of an opioid crisis and so people have a great fear of addiction and they may not take an opioid for that reason, or they may have a relative who's been addicted or had a poor experience. And this may be particularly true for methadone and buprenorphine, which are excellent analgesics and are increasingly being used but may in fact have the stigmata. There are health inequalities that occur related to minority groups that may in fact not get the full benefit of opioid conversions due to access to opioids or to medical care. Age, for instance, will cause perhaps differences in responses to opioids and may in fact affect conversion ratios. And this may be particularly true for methadone, which we have not really explored to a great extent. And finally, the disease itself may influence the clearance or absorption of an opioid. So for a sick patient, the opioid conversion ratio may be distinctly different than in a healthy individual. This is particularly seen with transdermal fentanyl, which is less well absorbed in a cachectic patient, but once given IV or intravenously has a much longer half life due to alterations in the cytochrome that clears it. And so conversion ratios have frequently been reported in relatively healthy individuals with good organ function and not that frequently in older patient populations. So just remember that the conversion ratios may be different in those particular populations. Brittany Harvey: Yes. So I think a lot of these are very important things to consider and that managing cancer pain is key to quality of life for a lot of patients and it's important to consider these patient factors while offering opioid conversion. I want to thank you so much for your work to review the existing literature here, develop these consensus-based recommendations and thank you for your time today, Dr. Davis. Dr. Mellar Davis: Thank you. Brittany Harvey: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast. To read the full guideline, go to www.asco.org/supportive-care-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app available in the Apple App Store or the Google Play Store. If you have enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe so you never miss an episode.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.  

In today's podcast we were delighted to be joined by the presenters of the top scientific abstracts for the Annual Assembly of the American Academy of  Hospice and Palliative Medicine (AAHPM) and the Hospice and Palliative Medicine Nurses Association (HPNA).  Eric and I interviewed these presenters at the meeting on Thursday (before the pub crawl, thankfully).  On Saturday, they formally presented their abstracts during the plenary session, followed by a wonderful question and answer session with Hillary Lum doing a terrific job in the role of podcast host moderator. Our three guests were Marie Bakitas, who conducted a trial of tele/video palliative care for Black and White inpatients with serious illness hospitalized in the rural south; Yael Shenker, for a trial of patient-directed Prepare-for-your-care vs. facilitated Respecting Choices style advance care planning interventions; and, Na Ouyang, who studied the relationship between prognostic communication and prolonged grief among the parents of children who died from cancer.  From just the abstracts we had so many questions. We covered some of our questions on the podcast, others you can ponder on your own or in your journal clubs, including: Marie's tele/video palliative care intervention was tailored/refined with the help of a community advisory board. Does every institution need to get a community advisory board to tailor their rural tele-palliative care initiative (or geriatrics intervention) to the local communities served?  Who would/should be on that board? How to be sensitive to the risks of stereotyping based on recommendations from the few members of the board to the many heterogeneous patients served? Advance care planning has taken a beating. For the purposes of a thought exercise, no matter what you believe, let's assume that there are clear important benefits. Based on the results of Yael's study, should resources be allocated to resource intensive nurse facilitated sessions (Respecting Choices), which had significantly better engagement, or to low resource intensive patient-facing materials (Prepare), which had significantly less engagement but still plenty of engagement (e.g. 75% vs 61% advance directive completion)? One interpretation of Na's study is that clinicians can lean on the high levels of trust and high ratings of communication to engage with parents of children with cancer about prognosis.  Another interpretation is that clinicians avoided telling the parents prognosis in order to bolster their ratings of trust and communication quality.  Which is it? Bonus: Simon says he composed the song Sounds of Silence in a dark echoing bathroom about his concerns that people had stopped listening to each other in the 1960s (still resonates, right?).  Garfunkel says Simon was writing about Garfunklel's friend and college roomate Sandy, who was blind.  Who's got the right of it?   Enjoy! -Alex Smith   

Boca Raton Regional Hospital of Baptist Health South Florida hosted a symposium, "Caring for Jewish Patients and Families at End of Life," on December 4, 2024. The keynote speaker was Dr. Barry Kinzbrunner, with responses from Dr. Claudio Kogan, Dr. Jessica Eichler and Rabbi Ed Bernstein. Dr. Barry Kinzbrunner, MD, FACP, is Former Chief Medical Officer, VITAS Healthcare. He is board certified in Internal Medicine, Medical Oncology, and Hospice and Palliative Medicine and he was ordained as an orthodox rabbi in Jerusalem, Israel in 2002. Dr. Kinzbrunner's publications include a textbook entitled “20 Common Problems in End of Life Care,” a second edition of which, under the title “End of Life Care: A Practical Guide” was published in January, 2011. As a pioneer in the development of the role of the Hospice Medical Director for Vitas, as well as for the hospice industry in general, Dr. Kinzbrunner had the opportunity to author and publish a monograph entitled “Medical Director Model” for the American Academy of Hospice and Palliative Medicine (AAHPM) in 2004. He also was an editor in a more recent AAHPM publication for Hospice Medical Directors entitled “The Hospice Medical Director Manual.” Dr. Kinzbrunner is a member of Neshama: Association of Jewish Chaplains. Dr. Claudio Kogan, MD, MBE, M.Ed.,  is Director of Bioethics for Baptist Health South Florida.  Dr. Kogan is a native of Buenos Aires, Argentina. He attended the University of Buenos Aires Medical School where he received his M.D. Dr. Kogan received his Masters of Hebrew Letters and his rabbinical ordination at the Hebrew Union College-Jewish Institute of Religion and his Master of Education from Xavier University, in Cincinnati, Ohio. He also received his Master of Medical Ethics from the University of Pennsylvania Medical School. Rabbi Kogan served on the Human Investigation Committee at Yale University.Rabbi Kogan served 26 for years multiple Jewish congregations in Buenos Aires, Michigan, Ohio, South Dakota, Kentucky, Florida and Texas. He is also a Mohel (certified to perform circumcisions) and a firm believer that Medicine and Religion are two sides of the same coin. Dr. Kogan is a strong advocate to combine Science and Spirituality and an activist who has traveled around the world promoting interfaith dialogue.Dr. Jessica Eichler, MD,  is Chief Hospice and Palliative Care Specialist for Boca Raton Regional Hospital. She also serves as the Associate Medical Director for Trustbridge Health and as an Assistant Professor for Florida Atlantic University, teaching all internal medicine residents on palliative care service at Boca Raton Regional Hospital. Dr. Eichler earned her medical degree at Universidad Iberoamericana School of Medicine, Santo Domingo, Dominican Republic. She completed her hospice and palliative care medicine fellowship at the University of Miami Miller School of Medicine. She serves on the ethics committee of Boca Raton Regional Hospital. Rabbi Edward Bernstein, BCC, serves as Chaplain at Boca Raton Regional Hospital of Baptist Health South Florida. He is a member of the Board of Neshama: Association of Jewish Chaplains. About our host:Rabbi Edward Bernstein, BCC, is the producer and host of NeshamaCast. He serves as Chaplain at Boca Raton Regional Hospital of Baptist Health South Florida. He is a member of the Board of Neshama: Association of Jewish Chaplains. Prior to his chaplain career, he served as a pulpit rabbi in congregations in New Rochelle, NY; Beachwood, OH; and Boynton Beach, FL. He is also the host and producer of My Teacher Podcast: A Celebration of the People Who Shape Our Lives. NeshamaCast contributor Rabbi Katja Vehlow was ordained at the Jewish Theological Seminary and is Director of Jewish Life at Fordham University. She trained as a chaplain at Moses Maimonides Medical Center in New York. Previously, she served as Associate Professor of Religious Studies at University of South Carolina. A native German speaker, she is planning a forthcoming German-language podcast on the weekly Torah portion with a focus on pastoral care. Support NeshamaCast and NAJC with a tax deductible donation to NAJC. Transcripts for this episode and other episodes of NeshamaCast are available at NeshamaCast.simplecast.com and are typically posted one week after an episode first airs. Theme Music is “A Niggun For Ki Anu Amecha,” written and performed by Reb-Cantor Lisa Levine. Please help others find the show by rating and reviewing the show on Apple Podcasts or other podcast providers. We welcome comments and suggestions for future programming at NeshamaCast@gmail.com. And be sure to follow NAJC on Facebook to learn more about Jewish spiritual care happening in our communities.

The AANHPI tent covers Asian immigrants from more than 70 nations. Despite the wide spread of cultures, Asians are severely underrepresented within the Association community.In this episode of Associations Thrive, host Joanna Pineda welcomes back a returning guest in Wendy-Jo Toyama, CEO, of the American Academy of Hospice and Palliative Care (AAHPM). Wendy-Jo discusses:The four focus areas of AAHPM.How they have increased both voice and vote for interdisciplinary team members.How AI is changing healthcare, and how it is going to add some risks and take away other risks.How hospice is changing to shift towards at-home care.How associations are going to be operating in an increasingly competitive environment because there are so many places where people can belong.How associations must offer comprehensive value to members structured around education, access, and community.The risks to associations that don't take advantage of AI models that help to catch mistakes and improve data analysis.How and why she came to work for an association management company.While looking for her first CEO job she led with her values and selected a firm with a culture aligned with her values.How AMC is doing a lot of things right regarding diversity, including having a DEI week every year and a DEI advisory group, as well as housing a number of ERGs (employee resource groups).How May is Asian American, Native Hawaiian, and Pacific Islander Heritage Month (AANHPI).How AANHPI is an incredibly diverse community, encompassing people from various ethnic, cultural, and socioeconomic backgrounds. She explains the issues that are overlooked due to the sheer size of the communityHow Asian Americans have some of the highest income communities across the nation as well as communities among the lowest.How Wendy is a chair of ASAEs AANHPI Advisory Group, which aims to create a community for execs in the association space, alongside attracting more Asian Americans to the field.How Wendy urges listeners to visit the ASAE AANHPI LinkedIn page and collaborate community.How we need to use our voices to raise people up, spread awareness, and move the community forward.References:AAHPMAMCWendy-Jo's Previous EpisodeAANHPI Association Community LinkedIn PageAANHPI Collaborate Community

PediPal goes on the road! Dan brings his microphone to Phoenix, AZ, for the 2024 Annual Assembly of Hospice and Palliative Medicine, ambushing unsuspecting guests with that classic PediPal question, "What are your take-home points?" Sarah, unable to attend the conference, shares her take-homes from home.Major thanks to AAHPM and all our enthusiastic participants: Tyler Badding, Gabe Daniels, Kelstan Ellis, Rachel Kentor, Jen Hwang, Matt McEvoy, Jennifer Salant, Alexis Santos, Meghna Singh, and Claire Slusarz, as well as #1 Fan Jared Rubenstein and #1 Fan Conrad Williams.

In our podcast with palliative care pioneer Susan Block, she identified the psychological/psychiatric aspects of palliative care as the biggest are of need for improvement.  As she said, when you think about the hardest patients you've cared for, in nearly all cases there was some aspect of psychological illness involved.  That rings true to me. Today we talk with two psychologists who are deeply invested in addressing psychological aspects of care for people living with serious illness. Elissa Kozlov, a geropsychologist and director of a new population aging MPH at Rutgers, surveyed AAHPM members, and found that doctors reported major shortcomings in level of comfort and knowledge caring for patients with psychological illness. She conducted a systematic review and meta-analysis of 38 palliative care trials, finding that many excluded people with serious illness, and a lack of impact on psychological outcomes.  Analyzing the Health and Retirement Study, she found 60% of older adults screened positive for depression in the last year of life (related study here). Des Azizoddin is a psychologist at the University of Oklahoma primarily focused on pain for people with cancer. Des delivered a plenary at this year's National Palliative Care Research Center's Foley retreat. She began by asking, “Raise your hand if you think there is a psychological component to cancer pain.” All hands go up.  Then, “Keep your hand up if you frequently refer patients with cancer pain to a psychologist?” All hands go down.  Unfortunately, we lack the financial structures to reimburse psychologists that would incentivize widespread inclusion on palliative care teams.  Because we live in the world as it is, not as it should be, Des has helped develop an app (link to pilot trial hot off the press!) to help people with cancer pain engage in cognitive behavioral therapy in bite sized 3-4 minute sessions (there are other apps available now developed in the VA, who have been leaders in the psychology/palliative care space).  Des additionally studied stigma associated with opioid use among patients with cancer in the context of the opioid epidemic;  depression, pain catastrophizing, recent surgery and opioid use among people with cancer. And, we talk about these issues and more (with far more nuance than I can include in this post).  Kudos and credit to my son Renn, age 15, for the guitar on Heartbeats (hand still broken at time of recording).

There's a saying, “never let a crisis go to waste.”  The pandemic was horrific in many ways.  One positive change that came about was the lifting of restrictions around the use of telemedicine.  Clinicians could care for patients across state lines, could prescribe opioids without in person visits, could bill at higher rates for telemedicine than previous to the pandemic.  Many patients benefited, not only those isolating due to covid, but also patients in rural areas, patients who are homebound, and many others.  So now that the emergency response has ended, what's to be done?  In this podcast, Joe Rotella, Chief Medical Officer of the American Academy of Hospice and Palliative Medicine, Brook Calton, Palliative Care doc at Massachusetts General Hospital and Medical Director at Devoted Health, and Carly Zapata, Palliative Care doc at UCSF and fellowship director, talk about the importance of maintaining access to telehealth for the good of patients with serious illness.  This DEA is taking 6-months to consider how to move forward vis a vis restrictions and requirements for telehealth in a post-pandemic world.  Now is the time to act, dear listeners!  You can: Write an Op-Ed to your local paper as Carly Zapata and colleagues did.  Start with a story as Carly did in her Op Ed.  Stories trump data. Write to your congressperson. See the AAHPM Legislative Action Center https://www.votervoice.net/AAHPMORG/home Write to the DEA, with guidance from AAHPM's comments to the DEA March 2023. Advocate for the CONNECT for Health Act, which would permanently expand access to telehealth for Medicare beneficiaries: https://www.schatz.senate.gov/imo/media/doc/connect_for_health_act_2023_summary1.pdf Much more on this podcast, including puzzling out who the characters in Space Oddity by David Bowie might represent in an extended analogy to telehealth.  Enjoy! -@AlexSmithMD

How do you define your leadership values and how do you ensure they guide everything you do, from job hunting, to developing programs, recruiting members, and managing your staff? In this episode of Associations Thrive, host Joanna Pineda interviews Wendy-Jo Toyama, CEO of the American Academy of Hospice and Palliative Medicine (AAHPM). Wendy-Jo introduces AAHPM, talks about her journey to becoming CEO, then discusses what AAHPM is doing differently to thrive. She discusses:What hospice and palliative care are, the settings they are provided in, and the professionals who provide this care.Wendy-Jo's leadership values of creativity, courage, service, justice and family.What it means to be an interdisciplinary association.How associations are never going back to what life was like before the pandemic.How AAHPM just had their two highest membership months ever.The importance of AAPHM's communities, which are meeting virtually and in person.AAHPM's four innovations: Being Interdisciplinary, Focus on Philanthropy, DE&I, and Data Analytics.How AAHPM gave interdisciplinary members voice and vote, including two new Board members who are interdisciplinary.Wendy's work with ASAE to increase the number of AAPI individuals in the association profession.References:AAHPM HomepageAAHPM Diversity, Equity & InclusionAAHPM Giving CenterReasons To Give – includes donor stories and Impact ReportsMedicare.gov provides some background on finding hospice careMusic from #Uppbeat (free for Creators!); https://uppbeat.io/t/paul-yudin/quiet-flight; License code: KJRRI6GHC7WKCLDT

We have a special extra podcast this week.  During the last AAHPM - HPNA meeting in Montréal, we went around asking attendees what one thing that they are most worried about and one thing they are most hopeful for when thinking about the future of our field.  We couldn't fit everyone's responses in but came up with the big themes for questions and edited them into this weeks podcast / YouTube video.  Eric and Alex   DISCLAIMER While we filmed in Montreal during the Annual Assembly, all opinions expressed in this podcast are independent of AAHPM and HPNA, or the Annual Assembly.  Furthermore, direction to external websites is not an endorsement from AAHPM or HPNA, or the Annual Assembly.  Palliative Care the Next Generation: How the Service May Grow and Evolve https://hospicenews.com/2023/04/14/palliative-care-the-next-generation-how-the-service-may-grow-and-evolve/ AccentCare, a portfolio company of private equity firm Advent International, is another example. The company has expanded its palliative care services through partnerships with hospitals and other managed care providers, according to AccentCare CEO Stephan Rodgers. “We've got a very large palliative care practice,” Rodgers told PCN. “What we've seen to make it really work is you either have to be in the hospital, where we've taken over palliative care in the hospital, or you have to be contracted with managed care and get it at some kind of risk, because community-based palliative care is very difficult to make operate right now from a profitable [perspective].”  

In November of 2022, Ava Kofman published a piece in the New Yorker titled “How Hospice Became a For-Profit Hustle.”  Some viewed this piece as an affront to the amazing work hospice does for those approaching the end of their lives by cherry picking stories of a few bad actors to paint hospice is a bad light. For others, this piece, while painful to read, gave voice to what they have been feeling over the last decade - hospice has in some ways lost its way in a quest of promoting profit over care. On today's podcast, live from the American Academy of Hospice and Palliative Medicine Annual Meeting, we invite two thought leaders in the field, Ira Byock and Joseph Shega, to discuss among other things: Is hospice losing its way? Is there a difference between for-profit and not-for-profit when it comes to quality of care? What is our role as hospice and palliative care providers in advocating for high-quality hospice care? If you are interested in signing the position statement “Core Roles and Responsibilities of Physicians in Hospice Care”, click here. For a deeper diver into these issues, check out some of the following links:     Ira's Stat new article “Hospice care needs saving” GeriPal's episode on the growing role of private equity in hospice care Acquisitions of Hospice Agencies by Private Equity Firms and Publicly Traded Corporations. JAMA IM 2021 Hospice Acquisitions by Profit-Driven Private Equity Firms. JAMA Health Forum. 2021 Association of Hospice Profit Status With Family Caregivers' Reported Care Experiences.  JAMA IM 2023 A shout-out to my NPR episode on 1A titled the “State of Hospice Care”   DISCLAIMER While we filmed in Montreal during the Annual Assembly, all opinions expressed in this podcast are independent of AAHPM and HPNA, or the Annual Assembly.  Furthermore, direction to external websites is not an endorsement from AAHPM or HPNA, or the Annual Assembly.    ---------------------------  

Buprenorphine.  It's been around for a long time but is acting like the hot new kid in town.  Just look at this year's AAHPM meeting, where it felt like every other session was talking about how hot buprenorphine is right now.  But does this drug really live up to the hype? On today's podcast we talk with three experts on buprenorphine on why, when, and how to use it in serious illness. Our experts include Katie Fitzgerald Jones (palliative nurse practitioner and doctoral student at Boston College), Zachary Sager (palliative care physician at the Boston VA and Dana-Farber Cancer Institute), and Janet Ho (physician at UCSF in addiction medicine and palliative care). We try to cover a lot in a 45 minute podcast, but if there is one take-away, it's that all of us who prescribe opioids should learn how to use buprenorphine and that we should all sign up for a DEA X-waiver at www.getwaivered.com or at www.buprenorphine.samhsa.gov (now you can treat up to 30 patients without completing the additional educational training, so signing up takes about 5 minutes).  And if you want to learn more about buprenorphine from these amazing palliative care clinicians and others, check out of some of these articles: Learn more about caring for those with substance use disorder:  Adapting Palliative Care Skills to Provide Substance Use Disorder Treatment to Patients With Serious Illness  Learn about using the low dose buprenorphine patch:  Low-Dose Buprenorphine Patch for Pain - Fast Fact Learn about how to initiate buprenorphine:  Sublingual Buprenorphine Initiation: The Traditional Method  - Palliative Care Network of Wisconsin Low Dose Initiation of Buprenorphine: A Narrative Review and Practical Approach Good review on buprenorphine for pain Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion  

In this podcast Chris interviews Dr. Janet Bull whom he  has worked with throughout much of his career at Four Seasons.  In this podcast Dr. Bull reviews innovations, she is most proud of and what she learned from them throughout her illustrious career in hospice and palliative care.  Dr. Bull also shares a creative thinking framework:  Ideation, Inspiration, and Implementation which all of us can use.   Finally,  Dr. Bull takes our listeners through a visualization exercise with a look towards the future.  You will enjoy this one so please join us.  Dr Janet Bull's BioJanet Bull, MD, MBA, FAAHPM is the Chief Medical Officer Emerita/Chief Innovations Officer at Four Seasons Compassion for Life and holds a consultant assistant professorship at Duke University Medical Center. She is a Fellow of the AAHPM, board certified in hospice and palliative medicine and holds a hospice medical director certification.  Janet has authored or coauthored several papers on  palliative care operations, telehealth, billing issues, and quality data reporting. She helped develop the QDACT (Quality Data Assessment Collection Tool), co-directed the Global Palliative Care Quality Alliance, and is on the board of the Palliative Care Quality Collaborative. She directs the research department at Four Seasons and has served as the Principal Investigator on over 45 clinical trials in hospice and palliative medicine. She is Program Director of the Palliative Care Immersion Course and a principal of Four Seasons Consulting Group, which offers consulting services in hospice, palliative care, and research.  Janet was the recipient of the Sharon O. Dixon Award in 2007, the Cuniff-Dixon Hastings Award in 2012, and the Josephino Magno Distinguished Physician Award in 2013. In 2014, she was recognized as one of the Top 30 Visionaries in the Field award by the American Academy of Hospice and Palliative Medicine (AAHPM) and served as Principal Investigator on the 2014-17 Center of Medicare Innovations Grant demonstrating the value of palliative care.  She was President of the American Academy of Hospice and Palliative Medicine (AAHPM) in 2017 and was as a core team member on the development of the Alternative Payment Model for Serious Illness Care for AAHPM..  

Sunil Aggarwal, MD, PhD, FAAPMR is a Board-Certified Physician in Hospice and Palliative Medicine and Physical Medicine and Rehabilitation and Medical Geographer and serves as the Past Chair of the American Academy of Hospice and Palliative Medicine (AAHPM) Integrative Medicine Special Interest Group and an inaugural member of the Safe Use in Psychedelic-Assisted Therapies Forum. He was recently named as a Top 20 Emerging Leader by the AAHPM. He is an Affiliate Assistant Clinical Professor in Rehabilitation Medicine at the University of Washington School of Medicine, an Affiliate Assistant Professor in the Department of Geography, and an Affiliate Clinical Faculty with Bastyr University. He completed his MD and PhD degrees at the University of Washington and Residency and Fellowship at Virginia Mason Medical Center, NYU Langone Health, and the NIH Clinical Center. He is a Co-founder, Co-director and practitioner at the Advanced Integrative Medical Science (AIMS) Institute in Seattle, a multispecialty teaching clinic and research institute offering cutting edge care in oncology, psychiatry, neurology, rehabilitation, pain, and palliative care. He also serves as an Associate Hospice Medicine Director and On-Call Palliative Physician for MultiCare Health System. He has published over three dozen peer-reviewed article and book chapters that have been cited over 800 times per Google Scholar. 8:32 Dr. Aggarwal describes the unique cancer care at the Advanced Integrative Medical Science (AIMS) Institute in Seattle. 13:50 Dr. Diva's take on how this approach is revolutionary compared to the standard of cancer care. 18:48 How AIMS Institute's approach translates to treating chronic conditions beyond cancer. 21:24 Dr. Aggarwal's approaches to psycho-spiritual healing. 27:05 Dr. Aggarwal explains his utilization of ketamine-assisted therapies, and his legal efforts to expand patients' access to other psychedelics including psilocybin. 32:58 Dr. Aggarwal's perspective on how psychedelic therapies assist in overall healing and wellbeing. 36:59 The power of psychedelics as psychoplastogens—and the psychology of awe. 41:10 Discussing dosages for ketamine-assisted therapy. 44:13 The ongoing efforts to track how AIMS' integrative approach compares to the current standards of care. 48:17 Contact info, and how to utilize the services of the AIMS Institute. Links mentioned in this episode: https://www.aimsinstitute.net/ (AIMS Institute Website) https://www.facebook.com/aimsinstitutepllc/posts_to_page/ (Facebook) https://www.instagram.com/aimsinstituteseattle/ (Instagram) This episode is sponsored by http://www.getchews.com/ (TotumVos Collagen Chews). You can find TotumVos at www.getchews.com. *Use code DRDIVA for an additional 10% off your first order.

Episode 35: Palliative Care and HospiceCOVID-19 vaccines and USPSTF recommendations. Palliative care and hospice briefly explained by Dr Tu. Pyogenic granuloma is defined. Feliz Navidad, and jokes._________________Hepatitis B screening in adolescents and adultsFirst, on December 15, 2020, the USPSTF recommended to offer screening for Hepatitis B virus infection to all adolescents and adults at increased risk for infection, regardless of their immunization status[1]. Some examples of patients at increased risk are:Those coming from countries with HepB prevalence above 2% (for example, most countries in Africa and Southeast Asia, South Korea, Italy, Colombia, Ecuador, and Peru, among others). Also, US-born children if they did not receive the HepB vaccine as infants AND their parents come from countries with a prevalence above 8% (check the list online).Other groups include: IV drug users, MSM, HIV, even household contacts of persons known to have POSITIVE HepB surface antigen. Remember to order the right test for screening: HepB surface antigen. As a reminder, Hep B screening in pregnant women at the first prenatal visit is a USPSTF “A” recommendation. Screening for high blood pressure in children and adolescentsOn November 10, 2020, the USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for high blood pressure in children and adolescents. This is a Grade I recommendation[2]. When screening, clinicians should consider risk factors, such as obesity, family history of hypertension, and ethnicities such as African-American or Hispanic. The grade I recommendation means that more research is needed. Maybe you guys can use that as a research idea.Announcement of Coronavirus VaccinesOn December 11, 2020, the FDA granted an Emergency Use Authorization for tozinameran or the BNT162b2 vaccine, manufactured by Pfizer-BioNtech, becoming the first coronavirus vaccine approved in the USA. A week later, on December 18, 2020, the mRNA-1273 vaccine, manufactured by Moderna, was also approved for emergency use. The two vaccines are being administered as we speak to front-line health care providers across the nation. The two vaccines have an efficacy above 90%, and consist of two doses: 3 weeks apart for Pfizer, and 4 weeks apart for Moderna. They seem to reduce the risk of severe COVID-19.Reported side effects include: injection site pain, fatigue, headache, muscle pain, and joint pain. Some people may experience fever. Side effects are more common after the second dose; younger adults, who have more robust immune systems, reported more side effects than older adults. Staggering vaccinations among staff is recommended.The vaccines have not been tested in children or pregnant women yet. The American College of Obstetricians and Gynecologists (ACOG), recommends that COVID-19 vaccines should not be withheld from pregnant individuals who meet criteria for vaccination based on ACIP-recommended priority groups. ACOG recommends that pregnant individuals should be free to make their own decision in conjunction with their clinical care team. Efforts across the globe are being made to find a vaccine and medications to treat COVID-19. Sputnik V was a vaccine created in Russia and being distributed in allied countries; the Soberana 1 and Soberana 2 were created in Cuba and are under investigation; and in October, a “molecule” called DR-10 was announced in Venezuela that reportedly neutralizes 100% of SARs-CoV-2. There is so much to say about this topic, and the conversation may go beyond just science, but we invite you to follow the news from trustworthy sources as they continue to evolve. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA and it is sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.“You matter because you are you. You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but to live until you die.”Dame Cicely Mary SaundersEnd-of life care may be challenging but also very rewarding. You get to take care of people during this critical time or their lives. Some people think it’s the end of a life, some people see it as a period of your existence, a passage to a “better life” or whatever your belief is about it. As doctor, we consider seriously the principle of sanctity of life vs quality of life.  Today, we have Dr Tu, who previously talked about wound care, and now he comes with a new topic to discuss. Welcome again Dr Tu.1.  Question #1: Who are you? Presently I am a second-year family medicine resident.  And I recently finished my palliative care-hospice elective 2 weeks ago with Dr. Warren Wisnoff.  And I had a wonderful and full of learning experience during this rotation.  And I really want to share some of those experiences with you. 2.  Question #3: What did you learn this week? Just like what I said I recently finished my elective KM with Dr. Wisnoff for palliative care and hospice.  I learned the difference between palliative care and hospice and the different services that are involved in this specialty. Palliative care and hospice service also known as end-of-life care and focuses more on comfort care and quality of life. Difference between palliative care and hospice   I am not an expert on palliative care and hospice but based on my recent elective and previous experience working in hospice care as a registered nurse there are overlapping similarities but also significant differences in terms of services being offered in palliative care and hospice. Palliative care Palliative care service is not reimbursable under CMS regulation.  Palliative care focuses on improving quality of life for patients with serious illness in their families.  This approach may include providing relief from pain and or other distressing symptoms, integrating psychological and spiritual aspects of care, assisting with difficult decision making, and supporting patients and families.   Another main difference of palliative care from hospice is specialty services that patient can still benefit from chemotherapy and other specialty visits. History The specialty of palliative medicine arose as a direct result of the hospice movement.  Palliative medicine incorporates the holistic care developed by hospice, focusing on symptom management, supporting and assisting with communication, and providing such care to avoid a group of patients including those who are not dying or who cannot receive or choose not to receive hospice services.  Palliative care aims to relieve suffering and no stages of disease and is not limited to end-of-life care. Type of services offered by palliative care service Assessment and treatment of physical symptoms most especially pain.  Around 80% of cancer patient patients will complain of severe pain.  Or patient will also complain of breathlessness especially patients with congestive heart failure.  Symptom assessment and management are necessary not only to provide diagnosis but also to help in controlling these symptoms.  The symptoms are a big burden to patient's quality of life and there are management available to address these symptoms.  Pain management is critical and cancer patient and opiate management in patients with breathlessness. Psychological, social, cultural, and spiritual aspect of care. Attention to the psychological, social, cultural, and social needs of patients and families is an important part of good medical care.  Symptoms of depression, anxiety, social and financial stressors, and caregiver burden are, and serious illnesses.  Patient's and family's approach of serious illness, death, and dying, and spiritual needs are often heightened near the end of life.  All clinicians who care for patients with serious illness need basic skills to recognize and treat uncomplicated depression and anxiety, recommending appropriate social supports, and eliciting and respecting cultural traditions since with well preferences. Serious illness communication skills.  Basic serious illness communication skills include communicating bad news, eliciting patient preferences, establishing goals of care, identifying a surrogate decision maker, deciding about future CPR and mechanical ventilation and providing emotional support.  These skills are required routinely in the care of seriously ill patients and should therefore be familiar to all clinicians who provide palliative care. Care coordination.  Basic care coordination in serious illness means of ensuring the transfer between healthcare settings are timely and reflect patient/family needs and goals.  Primary team must also have basic knowledge about how to refer patients for hospice care.  Hospice care is a model and philosophy of care that focuses on providing palliative care to patients with life limiting illness, focusing on palliating patient's pain and other symptoms, attending to their and their family's emotional and spiritual needs and providing support for their caregivers. Candidates for hospiceHospice is appropriate when patients are entering the last week to months of life and patients and their families decide to forego disease modifying therapies with curative/life-prolonging intent in order to focus on maximizing comfort and quality of life.  In the United States guidelines from Medicare are available to help in the determination of terminal status for hospice qualification.  Commonly if the patient meets the indication for an estimate of 6-month life expectancy using a decline in clinical status. The hospice team Registered hospice nurse: Primary case manager and is responsible for skilled nursing care and coordination of other members of the interdisciplinary team. Hospice physician: They have medical and administrative roles, they may be board-certified in the specialty of hospice and palliative medicine.  Some hospice physicians visit patients at home particularly if the patient does not have an involved attending physician.  Hospice physician also acts as a liaison with attending clinicians and can assist with symptom management. Primary attending physician or referring physician: They are encouraged to remain involved in the care of their patients after referral to hospice, unfortunately for the continuity of the doctor-patient relationship, this does not occur often. Ideally, the primary attending physician works directly with the hospice nurse and also in collaboration with the hospice medical director to monitor symptoms in order intervention such as medications or skilled nursing care. Social worker: They provide psychological support for patients and families including counseling, bereavement support, burial/funeral planning, and/or referrals to other support systems. Chaplain: He or she oversees the spiritual needs of patients and families.  Spiritual care is offered to patients with both formal and unstructured religious beliefs. Home health aides: Home health aides and other direct care workers help the patient and caregivers in the home, including personal care, food preparation, and shopping. Bereavement counselors: They are available to provide support to bereave once of hospice patients for the 13 months after patients that. Community volunteers: Volunteers are a mandatory component of hospice care and received training and support for their work. They will provide extra support for patients and families such as reading to patients, visiting, and assisting with errands.  Managing common symptoms during end-of-life careClinician should follow certain guiding principles when prescribing medication for symptoms management at the end of life.  Medication should be used to treat the primary etiology of these symptoms.  For example, if the patient is anxious because of shortness of breath, treatment should focus on the dyspnea to alleviate the primary symptom and the resulting anxiety.  Medication should generally start at lower doses a titrate up or down until you get desired effect.  The dosing should initially be as needed (prn) and then transition to a standing dosage or long-acting medication for symptom management. Whenever possible, proactive regimens that prevent symptoms should be used, because it is generally easier to prevent than treating an acute symptom. Pain: It is a common symptom occurring in approximately 50% of person in the last month of life.  It is important to recognize the patient's total pain which includes not only physical symptoms but also the psychological, social, and spiritual components of distress. Some medications include fentanyl, hydromorphone, morphine, oxycodone, and hydrocodone. Dyspnea: Although dyspnea is common in patients with end-stage pulmonary and cardiac disease, it is also regularly observed in patients with cancer, CVA, or dementia. Opiates are the medications of choice for the management of breathlessness and end-of-life care, especially morphine. Delirium and agitation: Patients often experience delirium and agitation in the last days and weeks of life.  Symptoms that do not cause the patient distress can be managed conservatively without medication.  It is essential to assess reversible or treatable causes of delirium such as medication adverse effects, uncontrolled pain or discomfort, constipation, or urinary retention. Medications: antipsychotics such as haloperidol and risperidone are effective in the treatment of delirium and agitation at the end of life.  Dosing for delirium tends to be significantly lower than for psychosis and schizophrenia.  Benzodiazepine should be used with caution for the treatment of agitation and delirium because they can potentially provoke increased symptoms in older patients.  However, benzodiazepines can effectively treat anxiousness and agitation in the last hours and days of life because of the potentially sedating effects. Nausea and vomiting: These are common symptoms during the end of life. Multiple receptor pathways in the brain and in the gastrointestinal tract mediate nausea and vomiting. Medications that target dopaminergic pathways are effective like haloperidol, risperidone, metoclopramide, and prochlorperazine.  Constipation: Effective management of constipation is critical because constipation can lead to pain, vomiting, restlessness, and delirium. Common causes of constipation are low oral intake of food and fluids and adverse effects of opiates. Medications: stimulant laxative like senna, stool softener like docusate, and polyethylene glycol. Oropharyngeal secretions: It is common for patients to lose the ability to manage oropharyngeal secretions as they progressed through the dying process.  This can result in noisy breathing pattern, sometimes referred to as death rattle. Medications: hyoscyamine, atropine sulfate, glycopyrrolate, and scopolamine. Fever: Treatment of fever at the end of life is based on the patient's life expectancy and goals of care. Medication: acetaminophen, NSAIDs, corticosteroids. Common end-of-life medications (hospice comfort kit):  Effective management of symptoms at the end of life is challenging but often can be achieved with fewer than 4 or 5 key medications which are commonly found in hospice comfort kit in the patient's home. The kit is composed of antipsychotics, antipyretics, benzodiazepines, opiates, and secretion medication. Question #3: Why is that knowledge important for you and your patients?There are significant number of patients that during the end of life still suffer significantly whether it is from pain, nausea and vomiting, severe dyspnea, or constipation. Hospice care provides medical care and support services that focus on quality of life rather than life prolongation or cure. Hospice philosophy seems to help patient achieve comfort and quality of life until they die with dignity, and the care and treatment provided are based on the patient and family goals and values.  As of 2015 and estimated 1.38 million Americans yearly are being served by hospice programs around the country, and around 50% of Medicare patients utilize hospice at some point in their care. Question #4: How did you get that knowledge?Before getting accepted in the residency program I worked as an RN case manager both in home health and hospice here in Bakersfield, and recently I finished an elective at Kern Medical with Dr. Warren Wisnoff. My other sources include the American Academy of Palliative and Hospice Medicine book, up-to-date, and the American Academy Family Physician website.____________________________Speaking Medical: Pyogenic Granuloma by Muhammad Suleman, MS4 I’m going to present to you a case and then I’ll explain our Medical word of the week. Just imagine you have a patient who is an 8-year-old child with no significant past medical history. He comes to the clinic with a concern of a red ball-like mass on his lower lip. The mother states it started as a small pimple and has progressively gotten bigger over the last 2 weeks. It is mildly tender, nothing makes it better or worse. Patient denies trauma, recent sick contact, or infections, or weight loss. Skin lesion is a friable, pedunculated mass on right side of lower lip, beefy red, moist, with no purulent discharge. It measures 1 cm x 1cm. What do you think it is? This is a pyogenic granuloma (PG). Not to be confused with the other PG Pyoderma gangrenosum (another type of PG). Pyogenic granuloma is a benign vascular tumor of the skin or mucous membranes characterized by rapid growth and friable surface. Pyogenic granuloma occurs at any age, although it is seen more often in children and young adults. In children, most common in age 6-10 years old. Trauma can be a trigger of PG. It may also be drug induced (antineoplastic agents). It may also be found in chronic inflammation in ingrown toenails. PG is usually solitary but can be disseminated. Sizes rarely exceed 1cm. PG may be pedunculated or sessile. The base is often surrounded by thick ring of epidermis. In pregnant women 2-3 trimester, we can see PGs in the oral cavity, which tends to regress after birth.  PG usually regresses but can be treated with surgical treatments, such as full-thickness excision or cryotherapy) and topical and intralesional therapies. So, remember the medical word of the week: Pyogenic granuloma (PG). Espanish Por Favor: Feliz Navidadby Yosbel Martinez, MDAs residents, we always want to have a good relationship with our patients. That is what we call rapport. Rapport is all we need to have a bidirectional conversation. Having a harmonious relationship with your patient will allow you to collect a more comprehensive history, perform an effective physical exam, discuss treatments and have a more enjoyable patient encounter. The ideal doctor-patient relationship should be one full of trust, accountability, and respect. This Christmas, if you have a Spanish-speaking patient, an easy way to break the ice may be telling them “Feliz Navidad”. We wish everyone of you a Merry Christmas and a Happy New Year from our Rio Bravo Family. ____________________________For your Sanity: Christmas Jokesby Julia Peters, MS3, and Jennifer Amezcua, MAResident 1: What do you get when you cross a snowman with a vampire?Resident 2: A mean, flying snowman? I don’t know. Resident 1: A Frostbite!Resident 1: What do you get if you cross Santa with a detective?Resident2: Santa Holmes?Resident 1: Good thought: Santa Clues!Resident 1: What do you call Santa when he's got no money?Resident 2: Saint-NICKEL-less!Resident 2: What do elves post on social media?Resident 1: Elf-ies!Resident 2: Someone must be mad at Frosty the Snowman.Resident 1: Why?Resident 2: Because they gave him two black eyesNow we conclude our episode 35, “Palliative Care and Hospice.” We gave you an update on the USPSTF screening guidelines, and gave you the long-waited news about the coronavirus vaccines. Yes, we are full of excitement and hope. Then, Dr Tu explained the importance of providing palliative and hospice services to our chronically-ill and terminally-ill patients. Our patients deserve special care during those critical moments of their lives. Moe explained pyogenic granuloma, a small growth that can be alarming for patients but easily treated in office. Dr Martinez reminded us of the holidays by wishing us “Feliz Navidad”, and Jenni and Julia made us laugh with their silly jokes about Santa. May you enjoy the holidays!This is the end of Rio Bravo qWeek. If you have any feedback about this podcast, send us an email to RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Ariana Lundquist, Manual Tu, Xeng Xiong, Yosbel Martinez, Julia Peters, and Jennifer Amezcua. Audio edition: Suraj Amrutia. See you soon!  References:Screening for Hepatitis B Virus Infection in Adolescents and Adults, December 15, 2020, U.S. Preventive Services Task Force(USPSTF), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-b-virus-infection-screening. High Blood Pressure in Children and Adolescents: Screening, November 10, 2020, U.S. Preventive Services Task Force(USPSTF), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/blood-pressure-in-children-and-adolescents-hypertension-screening#bootstrap-panel--6. “Your questions about the coronavirus vaccine, answered”, The Washington Post, https://www.washingtonpost.com/health/2020/11/17/covid-vaccines-what-you-need-to-know/?arc404=true , accessed on December 21, 2020. “Venezuela Developed A Drug That Eliminates The Coronavirus 100 Percent”, The Venezuelan Journal, https://thevenezuelanjournal.com/maduro-bivenezuela-developed-a-drug-that-eliminates-the-coronavirus-p2791-155.htm, accessed on November, 12, 2020. Ross H. Albert, MD, PhD, End-of-Life Care: Managing Common Symptoms, Am Fam Physician. 2017 Mar 15;95(6):356-361. https://www.aafp.org/afp/2017/0315/p356.html, accessed on November 9, 2020. Thompson Ruth M., Chirag Rajni Patel, and Kate M. Lally, Essential Practices in Hospice and Palliative Me, 5th edition, Unipac 1, Medical Care of People with Serious Illness, AAHPM. Dawn A. Marcus, M.D., Treatment of Nonmalignant Chronic Pain, Am Fam Physician. 2000 Mar 1;61(5):1331-1338. https://www.aafp.org/afp/2000/0301/p1331.html.    

AAHPM responds to COVID: Serving patients, providers and communities - Dr. Joe Rotella, Chief Medical Officer of AAHPM, shares how the Academy has stepped up to the plate during this pandemic, providing valuable resources to the community. http://aahpm.org/education/covid-19-resources

Accurate diagnosis and prognosis are crucial in determining a patient’s plan of care. Many look at a prognosis as an “event” – a moment in time when a prediction about a patient’s illness trajectory is made – when it’s really an ongoing process that typically changes over time.Especially because of these changing dynamics, how can clinicians be more accurate about prognoses? Christian Sinclair, MD, AAHPM, provides intriguing information and considerations about the impact of prognoses – particularly on hospice and palliative care – and offers suggestions on improving prognoses going forward.In this conversation with host Stan Massey of Transcend, Dr. Sinclair discusses some of the challenging factors that go into making a highly accurate prognosis. He also talks about the need for unified research and prediction technology present in other businesses to be applied in improving the accuracy of clinical prognoses. In addition, the discussion explores the role of big data in the future of prognoses, along with the importance for clinicians to apply more tangible metrics to their observations.Dr. Sinclair is Associate Professor of Internal Medicine at University of Kansas Medical Center. He is the organizer of a popular weekly TweetChat on hospice and palliative care (#hpm), as well as editor-in-chief of Pallimed, a widely read hospice and palliative medicine blog. His deep expertise and passion for hospice and palliative medicine makes listening to this episode time well invested.

Do you struggle with board engagement and notice that leaders are often zoned out, checking e-mails or on social media during board meetings? If so, you’ll want to listen to my interview with Steve Smith of the American Academy of Hospice and Palliative Medicine to hear how his board uses generative discussions to enhance engagement. Poorly designed agendas often lead to board disengagement, but AAHPM’s agenda starts off with high-level, directional conversations setting the tone for the board meeting that follows. Listen for ideas on how to use generative discussions and where to find ideas to launch them with your board. © 2019 Mary Byers Find out more at MaryByers.com Join the conversation on our social sites: @MaryByers on Twitter Mary on Facebook Mary on LinkedIn Produced by Podcast Prowess

Joanne Lynn, a geriatrician and palliative care physician who leads Altarum’s work on eldercare, wrote a recent JAGS editorial titled The “Fierce Urgency of Now”: Geriatrics Professionals Speaking up for Older Adult Care in the United States” which is very much a call to action for those who care for older adults. We talk with Joanne about this article and some meaningful things clinicians in both geriatrics and palliative care can do to be advocates for a growing population of older adults. One way I would like to plug to better advocate for our patients is through our national societies. To learn more what both AAHPM and AGS are doing to improve care for older adults and those with serious illness, and to learn how you can help lead change, check out the following links: - AAHPM’s advocacy page - http://aahpm.org/advocacy/overview - AGS’s Health in Aging Advocacy Center - http://cqrcengage.com/geriatrics/ So check out the podcast and pick one thing that you can do to better advocate for older adults or those living with serious illness. Eric (@ewidera)

While we still don’t know many of the specifics that will be part of the alternative payment models, there is still much providers can do to be proactive. Jon R. sits down with Lori Bishop and Dr. Phil Rogers who was the architect of the proposal submitted by AAHPM and worked in collaboration on the C-TAC proposal. Hear the background on this issue and how that shaped the proposals.

For this weeks podcast, we talk all about prognostication with Christian Sinclair. Christian is a palliative care physician at University of Kansas Medical Center, past president of AAHPM, recent AAHPM "Visionary" awardee, and Pallimed social media guru. We go over a lot of topics at the heart of prognostication in hospice and palliative care including: - The importance that prognostication plays in daily practice, especially in goals of care discussions - Helpful tools and skills to estimate prognosis - How prognosis changes the way we think about prescribing opioids - How to think about prognosis when it comes to hospice eligibility and why it may be that one of the most important tools used for prognostication in the hospice setting, the hospice eligibility guidelines, were last updated over two decades ago. So we have a ton to talk about and we would love for you to continue this discussion in the comment section of this blog, on Facebook or on twitter.

Most of us will eventually reach a point where medical intervention is outmatched by advanced age, illness, or both. It is at this point where meaningful conversations between physicians, patients and their families are crucial. Why then do medical schools and residencies offer their trainees little to no formal guidance on how to facilitate end of life conversations What steps should we all consider taking now to make our end of life wishes clear to our family and loved ones What legislative changes are taking place to ensure that our wishes are carried through Board certified in internal medicine, geriatrics, and hospice and palliative care, Dr. Susan Nelson is making real change in helping patients and their families at end of life. Join Arian as she and Dr. Nelson explore the collaborative challenges physicians, patients, and their loved ones face when death is imminent. Helpful links LaPOST website http www.La POST.org or http www.LHCQF.org LaPOST http www.palliativedoctors.org Hospice and Palliative Medicine professional organization http www.AAHPM.org Louisiana Conference of Catholic Bishops https www.lhcqf.org page flip The Final Journey Deborah Grassman s book Peace at Last http www.opuspeace.org Atul Gawande s book Being Mortal http www.atulgawande.com book being mortal