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Episode 8 - The past, present, and future of palliative care in emergency medicine – Tammie Quest, MD
32 Plays1 month ago
A trailblazer in bringing palliative care into emergency medicine, Tammie Quest, MD, joins the PalliEM Podcast for our first-ever video podcast episode. She reflects on her career at the forefront of EM/palliative care integration and highlights necessary aspects of resident education that will help prepare future EM clinicians for the increasing needs for palliative care in the emergency department.
This episode was previously released in January of 2023
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Transcript
Introduction to Pallium Podcast
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Speaker
This is the Pallium Podcast, a production of pallium.org at the intersection of palliative and emergency medicine.
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I'm your host, Justin Bruton.
Meet Dr. Tammy Quest
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Today on the PallyM Podcast, I'm joined by Dr. Tammy Quest.
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Dr. Quest has had a tremendously influential career in the field of palliative medicine and has been at the forefront of improving the integration of palliative care and emergency medicine.
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In 2017, Dr. Quest was recognized by her peers in the American Academy of Hospice and Palliative Medicine as one of the 30 most influential leaders in hospice and palliative care.
Dr. Quest's Career Highlights
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She is currently the Montgomery Chair in Palliative Medicine and Professor in the Department of Family and Preventative Medicine
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and the Department of Emergency Medicine at the Emory University School of Medicine.
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She is the Chief of Palliative Medicine for the Division of Palliative Medicine in the Department of Family Medicine.
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She is the past president of the American Academy of Hospice and Palliative Medicine and director of the Emory Palliative Care Center for Emory's Woodruff Health Sciences Center.
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Dr. Quest, it's a pleasure to have you on the podcast and it's especially fitting that this is also our first ever video podcast.
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Thank you so much for joining me today.
Journey into Leadership
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Thank you, Justin.
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I have the perfect face for radio and was hoping that that's what we were going to have today, but I'm willing to roll with the punches because I'm a team player.
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So excited to be here and thank you for having me.
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So looking back on the different roles you've had through the years, what surprised you the most about your career trajectory?
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Thanks, Justin, for that.
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light reflective moment.
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So, you know, I really think in thinking about, I'm in my 24th year being faculty, which is just almost impossible to believe.
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I think that I've been surprised by two things.
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One is really leadership.
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I never went into medicine to really be a leader, to be honest with you.
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I went into medicine to take care of patients and
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was inspired to be an emergency physician through mentors that I saw who were in service of others.
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And so I went into Madison to be in service of others.
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I never thought, I think in my wildest dreams, that I would end up directing anything.
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And...
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I thought it was bad enough to be chief resident at Highland to make the schedule.
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I thought that was really probably about the end of it for me with leadership.
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And it just really, I think, is surprising to me that I've had the opportunity to lead some really incredible things.
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I think that the other piece of that leadership is,
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I've certainly worked in leadership here in my own organization, but the ability to serve our field in emergency medicine and in palliative medicine through various leadership roles, I don't think that I would have ever dreamed that a aspiring emergency physician would be able to be president of the academy.
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It just never would have been anything I would have thought of.
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And so,
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I've just been really fortunate to have, I think, a servant heart over the years and been able to step up when asked and answered the call.
Daily Inspirations from Patients
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So I think I've been really surprised by the calls that I've had over the years and really graced by the opportunities.
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Where do you find your inspiration?
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So I am really quite blessed and lucky to say that after many, many, many years in medicine, I guess now, of course, there are people who have many more than I do, but I am really...
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not in a place of compassion fatigue, thank God, and burnout.
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And that inspiration comes from the fact that every single day, the patients that I think of and that we take care of with serious illness
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are all having a worse day than me.
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So even on my absolute worst day where I'm thinking I'm having a bad day, I'm not facing serious illness.
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And I can, I'm just inspired every day to say that's the reason that we get up in the morning.
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That's what this field is about.
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I was always drawn to distress and suffering, which is
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I actually liked that aspect in the emergency department of being able to meet people in their distress.
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And I am inspired every day to try to figure out a way to either deliver service or think about how to grow programs.
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And along the way, somehow, you know, almost gotten an MBA, if you will, and trying to be able to figure out how to fiscally sustain the programs that I've led.
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But I will say that
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Even in my darkest of days and my worst budget meeting, it's never as bad as the kinds of things that our patients and families have to face every day.
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So they are my inspiration.
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Yeah, that's an excellent point.
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One of the things I enjoyed discussing when we had a chance to talk previously was just how you feel like you had a passion for this and opportunities just sort of showed up as a result of it.
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Didn't just show up, but that was such a big piece of it.
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So tell me about how kind of the opportunities that have happened throughout your career have just surprised you and how that's taken your passion for the patients and for the care has taken you through that.
00:05:56
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Yeah.
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Well, I will say when I look back, 1998 was the pivotal year.
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It was the year that I was looking for a job after residency.
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And there was a lot of no.
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I wanted to do this thing called, it turns out back then we called it end-of-life care.
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The word palliative care was actually being, being,
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coined in its vernacular of being able to be used on a regular basis.
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But essentially, this thing that I wanted to do fell in this area of ethics then and end-of-life care.
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And there was not a lot of energy or enthusiasm or support for a faculty career in that way.
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And really, there were a lot of doors that were closed.
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And I started looking.
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I knew I wanted to do academic medicine.
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I started looking further and wider than I had wanted to.
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And happened upon Arthur Kellerman by chance at Emory who said that this was an amazing idea to work in this area.
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Nobody else was doing that.
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and he would support me.
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And so being able to take that chance, uproot your life, and the people that you love to take that chance that something good might happen, really as a result of no.
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So I would say that in the early days, it was a lot of no.
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And I came to Emory and found Emory and have stayed at Emory because the answer's always been yes, that this wasn't a bad idea.
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And so surrounding yourself with people who are going to support your dreams is never a bad idea.
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And it didn't fail me.
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And a lot of doors open as a result of that kind of support really early in my career.
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of being able to say, this is something that I dream that emergency clinicians around the world will be able to support patients and families in the midst of distress.
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And I just never gave up that idea that we were not smart enough or capable enough or insightful enough to be able to do it.
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And it really
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I think made the difference between, you know, things happening and not was that I believed it when other people didn't.
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And very early in my career, when I applied for some things, people on a routine basis told me that I was crazy and that this was not something that should be done in the emergency department.
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And I remember applying as a Soros scholar way back when, and I had to go interview in New York, and I remember coming out of the interview because there were lots of challenges at the table of why is this important in emergency medicine?
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And I just got kind of fired up with the group, and I walked out, and I remember calling my husband in front of the OSI office,
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the Institute there, and just telling them, well, that didn't go well because I think I gave them a piece of my mind about emergency medicine and sort of where that was.
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And, okay, I guess they were inspired by that level of tenacity, if nothing else.
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And that was really very pivotal in my career.
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So I will say that a lot of doors opened as a result of just simply believing it more than anybody else.
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And it's just so wonderful now that other people believe it.
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And those few of us in the very beginning had to have support groups.
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So people like Rob Zielinski and Susan Stone were really pivotal, Knox Todd, people like that early, early in trying to motivate and support one another that this wasn't a bad idea.
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You know, it's interesting you you reflect on that because I think about sort of the sideways looks I got when I told people I was interested in palliative and emergency medicine.
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But that was coming at a time where it was it had it had at least gained traction and really the the the traction you had to gain.
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I mean, that was all that was all uphill because it was such a new concept.
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And it's it's interesting because it's so intuitive to me that we need to know these things as emergency clinicians because sick people come to us.
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But just this idea of trying to integrate the two was so foreign at one time.
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And now it's now it's starting to become much more commonplace and residency programs are talking about and recognizing this is a need.
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So you just you you laid a lot of that foundation, which is which is awesome.
00:10:41
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It's hard to probably say to pick one thing in the midst of all of the different things you've been able to do, but with the impact you've had in emergency and palliative care, what accomplishment has been most significant for you personally?
Epic Emergency Medicine Project
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So I get guests privileged to have a tie.
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So I get two.
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How about that?
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And they're a tie.
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Fair enough.
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So I would say that working on the Epic Emergence Medicine Project.
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And so in 2005, I had, remember I was on this, had this vision, maybe in the desert somewhere, right?
00:11:17
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And went to the National Cancer Institute and asked for a grant to train patients.
00:11:22
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emergency clinicians in core palliative care skills.
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And by happenstance, I'd gone to this conference called Epic back then and saw somebody stand up in the crowd and I was just really impressed.
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I said, I think we could do this for emergency clinicians.
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This might be the way, train the trainer, that we could build a cadre of emergency clinicians in
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in this nation who can teach and can teach this because I probably can't do this by myself.
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And that was really very pivotal at the time.
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We held the first training conference in November of 2007.
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We had about 40 people show up, which was absolutely a shocker.
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What we did, Arthur Kellerman was incredible.
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He helped me get all the chairs and the SAM Council of Chairs
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to try to send somebody from their program.
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And I think without that initiative to get a groundswell to bring people together, it was even more pivotal because we didn't have any teachers.
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We didn't have any emergency clinicians that actually knew palliative care.
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So Frank Ferris and
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in all of his incredible fervor as a teacher, actually brought together and agreed to mentor a group of emergency physicians to actually teach us palliative care at the Epi-Analgesic Dosing Table, goals of care conversations, all of those things
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we really spent time to try to train people who were actually going to do this conference.
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So when that conference launched in 2007, it was like a dream come true.
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I didn't think it was like having a wedding that you sort of thought nobody was going to show up to.
00:13:10
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And people showed up, and it was incredible.
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Sangeeta Lamba, who she and I have collaborated so many times over the years, met at that conference.
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And
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I just, I felt like, you know, my world was changed because there were other people that finally showed up and had this idea that maybe this wouldn't be so bad.
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So I think that really changed the landscape because it went from one person saying, guess what, you know, I'd love to teach these things to trying to build a out of the box curriculum.
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The whole concept of Epic Emergency Medicine is that it's just out of the box.
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You can tailor, you do the slides, you can change the background, I don't care.
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But here's the material because we were never taught that as emergency clinicians.
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And so the idea of how you're gonna actually get people to know palliative care who have no access to it at that time, it was really pivotal.
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So I will say that without that cadre of individuals who showed up at those conferences in those early years, I don't think
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that we as a field would be where we are now.
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So that's one thing.
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The second thing that I think is most pivotal and what I'll say is that we've had Epic Emergency Medicine every single year except for during COVID.
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And we'll be having our course this fall in October and hoping that people will want to join that.
00:14:45
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And the second most important thing, I think, was the being a part of helping lead the effort for the American Board of Medical Subspecialties for the ABEM to sign on to the subspecialty track to be able to allow emergency physicians to become board certified in hospice and palliative medicine.
00:15:10
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That, I think, probably ties with the Game Changer Award in our field.
00:15:16
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I believe that if, at that time, emergency medicine didn't sign on as one of the boards where you could become board certified, I think we would have been shut out of emergency medicine.
00:15:28
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of this incredible field.
00:15:30
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We have seen that happen in other specialties, and I was hellbent that that was not going to happen.
00:15:36
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And I remember bringing together a group of people.
00:15:41
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We had a wiki page.
00:15:43
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Knox Todd introduced me to that idea.
00:15:45
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And we got the ABM at that time said, why do you think this is important for emergency clinicians?
00:15:55
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We created a groundswell of people to be able to state why we thought this was important.
00:16:02
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And I remember writing the white paper and sending it, hitting send to the ABM and saying, this is really important.
00:16:10
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If we don't do this, we're going to be shut out.
00:16:13
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This is not going to be good.
00:16:15
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The future of our field is at stake here to be able to have people who want to not only be
00:16:23
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clinicians in emergency medicine, but also clinicians and experts in palliative medicine.
00:16:29
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And so every time I see an emergency medicine clinician who is doing a fellowship, it warms my heart.
00:16:41
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And I also know how close we came to not, that not being a reality.
00:16:48
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And so I would say that the two things in my life that I know that I played a pivotal role in, that I will always be grateful that I was at the right place at the right time with the right thought, with people putting wind in the sails, were those two things.
00:17:05
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So that's my tie.
00:17:08
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Yeah, that's well put.
00:17:10
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And I'm definitely one of the beneficiaries of that because I was doing medical school between 2010 and 2014, and I was in the midst of deciding what I was going to do and what residency I was going to pick.
00:17:22
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And palliative care was a big piece of it.
00:17:24
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So was emergency care.
00:17:25
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I wanted to take care of sick people.
00:17:27
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But if that hadn't been an option, there's a good chance I would have probably gone like a critical care route or something else, or like an internal medicine route.
00:17:36
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But I got to have my cake and eat it too and do EM and get to do palliative still.
00:17:41
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So I'm definitely the beneficiary of that.
00:17:43
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This year we have both of our fellows at our program at Wake are both emergency medicine trained.
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So that's really awesome.
00:17:52
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It's actually really fascinating to hear about the pieces coming together.
00:17:56
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And I like when you said that you were held bent on getting that in front of them and helping them see how important it was.
00:18:04
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So one of the things I was going to ask about was we've made headway in emergency medicine and palliative care integration.
00:18:09
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It sounds like a big piece of that.
00:18:10
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It's really been education, getting curriculum developed, getting programs developed, and also obviously getting the fellowship pathway.
00:18:18
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Where do you think the field is headed?
00:18:21
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Yeah.
00:18:22
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So, wow, it's just so incredible.
Integrating Palliative Care in Emergency Departments
00:18:26
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I think a sign of success, while I was there in the early days with some other really incredibly committed people, a sign of success is that you don't need to be in the room for all of the incredible things that are happening.
00:18:38
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So I'm always really excited when I hear about something brand new that's happened.
00:18:43
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that we're doing in emergency medicine and palliative care and I had nothing to do with it.
00:18:46
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It's fabulous because that means that we've actually gotten critical mass and everything doesn't revolve around one or two or five or seven people.
00:18:58
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That's really incredible.
00:19:00
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So I do think that there have been some incredible movers and shakers in our field.
00:19:07
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And advancing the science, Corita Gredson has done incredible work advancing the science and all the people who are working now to work on the largest randomized control clinical trial for looking at models of care.
00:19:22
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And
00:19:24
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So I think that we've just gone from, you know, a teeny five articles or something to hundreds and hundreds now.
00:19:32
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I do think that we have work to do on models of care and what is the
00:19:39
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the right dose of palliative care in the emergency department, is there a dose that is appropriate and that we can standardize from a quality perspective, that it's not just dependent on one or two people to do this or to have those
00:19:58
Speaker
those skills, but what are the standards of care?
00:20:00
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What can we work into for standards of care like aspirin and acute myocardial infarction?
00:20:06
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What is the palliative care piece of that?
00:20:08
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So I think that we have not yet come up with the model of care that we can disseminate and replicate across the field of emergency medicine.
00:20:22
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And with that, I think that one of the biggest gaps, the biggest nets that we have not cracked is really moving away from just academic centers and emergency medicine and palliative care.
00:20:35
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And so community models, what are the community practice models that become the standard of care?
00:20:42
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Is that going to end up tied to, it's always great if you can get somebody to do something with a carrot, but sometimes you need a stick.
00:20:50
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and what sort of things are going to move the entire practice of emergency medicine at its core.
00:20:58
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Not so much just you happen to be at an academic center with Justin or Tammy or Kay or you pick, right?
00:21:07
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All the people in our field, and I could rattle off 20, 30 names of people that I've mentored and supported and who've changed our field as innovators.
00:21:19
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And yet, if I go to a community emergency department today, there's no guarantee if I have a palliative care need that it will be met.
00:21:28
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And so while I think we've made great advances in academic centers, I worry that we have not actually moved the needle on really the fundamental quality indicators in an emergency department that drive it, that drive it fiscally, that drive it operationally,
00:21:49
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And so I think that that is something that needs to be, that we need to crack that net some kind of way.
00:21:55
Speaker
And then lastly, while education, and that's always one of the things in Epic Emergency Medicine, we were always very clear, the first lecture of Epic EM is about palliative care integration, is that education is only a first step.
00:22:11
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Education alone will not change programs or practice, but without education and that spark,
00:22:18
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in the mind, it's hard to get to the next level until we actually have it fundamentally true that every emergency medicine resident that finishes any program in the nation actually gets core palliative care skills.
00:22:35
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Not one skill, but a suite of skills, right?
00:22:39
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They need to know death disclosure.
00:22:40
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They need to know equianalgesic dosing.
00:22:42
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They need to know how to control nausea and vomiting.
00:22:45
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They need to know best evidence for dyspnea management.
00:22:48
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They need to know how to break bad news.
00:22:50
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They need to know how to have a goals of care conversation.
00:22:53
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They need to know how to take care of a patient who's in hospice care who comes in their emergency department.
00:23:00
Speaker
They need to be able to refer somebody to hospice.
00:23:03
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How do we ensure that for every resident?
00:23:09
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And I actually do not think that we have a qualified teacher at every program in the nation.
00:23:16
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Why is that?
00:23:17
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Because I still get asked to speak in emergency medicine programs, and residents are telling me that they are not getting these skills.
00:23:25
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They're not getting the things that they need.
00:23:29
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I've been so graced over the years here at Emory, and the leadership has
00:23:35
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really embraced palliative care.
00:23:38
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We've been doing palliative care education since the day that I got here in 1998, because they said, if you come, this is going to be good.
00:23:46
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And we started with death disclosure, and then we went to a foundational palliative care skills, knowledge and skills-based curriculum.
00:23:55
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simulation and now a rotation.
00:23:59
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And so that's great that we can have that here.
00:24:01
Speaker
Isn't that fabulous that we can have that here?
00:24:03
Speaker
But that's not good enough, right?
00:24:05
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Because it's not everywhere.
00:24:06
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So the fact that it's good in my spot or is better, it's probably not the best.
00:24:12
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I'm sure somebody else out there is doing even more than we're doing.
00:24:16
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but it's never gonna be right until every program has that and every emergency medicine resident that is trained is able to do that.
00:24:27
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And we also have a retraining problem because we always have the old dogs, new tricks
00:24:33
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And I'm one of those old dogs, so it's really hard when we come up with a new thing in the ED.
00:24:38
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I'm like, no.
00:24:39
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But so I do think that foundationally we've got to really ensure that everybody in every emergency medicine program has a qualified teacher.
00:24:51
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And that is the starting place, is that every program needs a qualified teacher, and I don't believe that we have that universally.
00:25:00
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That is a really excellent overview of kind of the mission moving forward, I think.
00:25:05
Speaker
And you're right, I think the first, being able to have people that are trained in emergency medicine and palliative care is a big step to that, to having a qualified person in each department.
00:25:14
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And then as the
00:25:17
Speaker
as people get training, there still is that trickle down process in the community.
00:25:21
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Because you're right, I can see where even here, you know, implementing things in an academic center, you have some momentum for it, but then being able to change practice in the community, that's a, it takes time.
00:25:32
Speaker
And people have to see a priority for it too.
00:25:35
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Because it, you're asking people to invest time on the front end and how to communicate and
00:25:40
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something they're going to add to the care of somebody in the emergency room, and they've got to see the benefit of that on the flip side.
00:25:46
Speaker
You know, the time that I invest in that difficult conversation, is that going to help?
00:25:50
Speaker
Is that going to get them, you know, where they want, where we think they should be as clinicians, but also in managing a department in a community setting, you're investing time that you're having to take away from trying to manage the flow of the department to take care of those situations.
00:26:04
Speaker
So how do you implement resources in a way that's going to work with their workflow?
00:26:08
Speaker
But that's a really excellent overview of kind of the mission ahead.
00:26:14
Speaker
And this next question, this is kind of a broad question.
00:26:18
Speaker
that really could be multiple parts.
00:26:21
Speaker
You've already done work, obviously, in education in so many areas of palliative care and ED integration.
00:26:28
Speaker
You've worked to examine and address care inequity and disparities, and you spearheaded efforts to improve how we study, disseminate knowledge, and deliver palliative care from the standpoint of race, equity, inclusion, and diversity.
00:26:40
Speaker
So what are your thoughts on how an REID focus informs our approach to palliative care and emergency medicine in the greater sphere of palliative care now
Addressing Disparities in Care
00:26:48
Speaker
and in the future?
00:26:48
Speaker
Yeah.
00:26:51
Speaker
Thanks, Justin.
00:26:51
Speaker
So one of the reasons that I went into emergency medicine was because I absolutely loved the fact that everybody gets care when they arrive, irrespective of if you can pay, what you look like,
00:27:10
Speaker
And also, I think no emergency department would be complete without the snack fridge or the brown paper bags or whatever it is, because we actually feed the hungry as well.
00:27:20
Speaker
And so when we...
00:27:24
Speaker
So working in an emergency department, almost without exception, you are going to take care of vulnerable patients.
00:27:33
Speaker
Yes, even the most swank emergency department will take care of vulnerable patients.
00:27:41
Speaker
So I think that fundamentally we have to be true to our mission that the emergency department is the funnel of all disparity.
00:27:52
Speaker
It's the final common pathway.
00:27:55
Speaker
And so one of the worst days you can have in the emergency department is actually diagnosing metastatic cancer in somebody who's had back pain, who has gone from having that symptom a year ago and not able to get care for whatever reason or accessing care, but not being worked up because nobody wanted to do the MRI or whatever that is.
00:28:22
Speaker
And so when we see those kinds of things, we ought to be thinking about and reminding ourselves how much of advocates we are.
00:28:33
Speaker
And while particularly after pandemic conditions and all of the compassion fatigue that we are experiencing,
00:28:45
Speaker
And it really, it's imperative that we remember why we're there in the emergency department.
00:28:52
Speaker
And so as you see patients that are either suffering with serious illness or being diagnosed with new serious illness that they didn't even know they had before, remembering that we're still advocates.
00:29:03
Speaker
I'd like to sort of think a little bit about the patient that comes to the emergency department who's under hospice care.
00:29:13
Speaker
And the first thing somebody might say is, well, why are they here?
00:29:16
Speaker
Well, actually, hospice care in America is broken, newsflash.
00:29:21
Speaker
The Medicare hospice benefit does not cover much of what people need, which includes caregivers and 24-hour support.
00:29:33
Speaker
that is needed.
00:29:35
Speaker
Medicare doesn't cover long-term care.
00:29:38
Speaker
And so when you have vulnerable patients who are coming to an emergency department and they're suffering this serious illness and their caregivers still have to work because somebody has to put food on the table and they don't have
00:29:54
Speaker
Medicaid or private pay to be able to get long-term care and the Medicare hospice benefit, it's getting more stringent for inpatient days.
00:30:03
Speaker
That dying is not a reason to go to inpatient hospice and caregiver breakdown is not a such thing in hospice care anymore for inpatient hospice.
00:30:12
Speaker
the inability to access the kind of services that they need.
00:30:19
Speaker
Hospice care works really well if you have caregivers and if you have a roof over your head and you have, you know, and it's not dependent on every member of the family having to work to
00:30:31
Speaker
to keep you from being homeless.
00:30:34
Speaker
And so whenever I see patients who are in hospice care and they're in the emergency department, I try very, very hard not to go to that deep, dark place of like, oh, they don't get it.
00:30:47
Speaker
actually you don't live in their house and you don't know what it's like and the hospice agency may not have actually responded.
00:30:57
Speaker
I'm still looking for hospice response times by neighborhood because I'm not always convinced that every neighborhood gets the same response time.
00:31:06
Speaker
And so, which
00:31:10
Speaker
which patients are going to be more phone managed versus the nurse is going to be right out there.
00:31:15
Speaker
And if you're at home and it's three in the morning and there's a hospice agency and you live in a bad neighborhood and they don't want to come do a visit and they're trying to manage shortness of breath over the phone and your family member looks like they're dying and you call 911 and you end up in Justin's emergency department,
00:31:34
Speaker
you know, yeah, it looks like, well, maybe they didn't get it, you know, but maybe there's a little bit more to that story.
00:31:41
Speaker
And so I think being able to unpack more some of the reasons that people access emergency care at end of life, I don't always think that it's on them.
00:31:54
Speaker
I think that we often blame the patient for being in the emergency department at end of life.
00:31:58
Speaker
And what I can tell you
00:32:00
Speaker
is that if we peel that onion back, just one or two layers, if we're going to live true to diversity, equity, inclusion, we need to think about all the things that patients who are vulnerable have to face.
00:32:15
Speaker
And those things only get harder as you start dying.
00:32:18
Speaker
And so being able to really move the needle
00:32:25
Speaker
in advocacy for what patients need as opposed to making them the problem, the fact that they call 911, that is a really important first step, I think, to diversity, equity, inclusion, and justice.
00:32:40
Speaker
That is, no, that's a great way of articulating that.
00:32:43
Speaker
And one thing that we've been looking into, I've been involved with several others looking into this, is the use of EMS and being able to help give EMS protocols because they are, like you said, they are gonna be in the bad neighborhood.
00:32:55
Speaker
They are gonna be in the neighborhoods
00:32:56
Speaker
where there's maybe a longer hospice response time, and hopefully they can bolster that symptom management or do something on the scene that doesn't necessarily lead to an emergency department transfer if that's not really what the patient needs.
00:33:10
Speaker
But you're absolutely right.
00:33:11
Speaker
And I think
00:33:13
Speaker
You're saying the same things I say a lot of times in that, you know, this person had something, their family didn't know how to deal with it.
00:33:20
Speaker
They're scared, they're terrified, the patient's uncomfortable.
00:33:24
Speaker
Exactly what they're gonna do is call 911.
00:33:26
Speaker
And you also wanna make sure you're empowering your emergency workers to be able to handle those situations with the broadest scope they can to hopefully help keep the patient at home if that's what they want.
00:33:35
Speaker
But you're right, there's all those things that people deal with get harder if they're dealing with dying.
00:33:41
Speaker
Sometimes the way I would think about that also is that an ED visit at end of life, we see that as a failure.
00:33:51
Speaker
In fact, I think that in and of itself, the fact that we have marked emergency department visits at end of life
00:34:01
Speaker
as a failure in vulnerable populations, I think we need to actually relook at that.
00:34:07
Speaker
If they were given optimal resources and the same resources, as opposed to blaming the patient or blaming the system, if you will, but just, you know, looking at the human condition and having some, not only just grace for why that is happening, but also when we think of systemic racism,
00:34:30
Speaker
We think of financial disparity.
00:34:34
Speaker
We think about all of the inequities in health and access to care, which many of those things in this country are tied to financial resources.
00:34:46
Speaker
And so I just think we need to think deeper about these issues.
00:34:53
Speaker
And I think stopping at
00:34:55
Speaker
having an ED visit being a negative mark on either the patient or the family or even the hospice agency at times can be really, I think, short-sighted.
00:35:09
Speaker
Yeah, I think that's a great point.
00:35:10
Speaker
And I agree with you.
00:35:11
Speaker
I think it, assuming it's a negative, I think if we take it as our field of, you know, we're going to see sick people, we're going to see sick, we're going to see people with symptoms at end of life that are difficult to manage.
00:35:23
Speaker
And they're going to call 911 and they're going to need an emergency physician to help address those things sometimes in the, in the,
00:35:29
Speaker
abruptness and the emergent nature of it.
00:35:31
Speaker
That's one of the things I love about emergency medicine too.
00:35:34
Speaker
I like that universality of it and the fact that it's just, you see so many different people in so many different situations and it really opens up your world.
00:35:43
Speaker
I was at EMS in Georgia and I'd go into homes that you'd literally had somebody living in a shed with an extension cord powering it, a space heater.
00:35:51
Speaker
And that was their existence.
00:35:54
Speaker
you'd see some things that you just would not expect to see in the United States.
00:35:58
Speaker
You'd expect to see it on a medical mission trip.
00:36:01
Speaker
Yeah, and for the way that many of my patients live, most of us probably could not live a night like that.
00:36:09
Speaker
And so being able to be in a space.
00:36:11
Speaker
And, you know, patients clean it up right for us and their families.
00:36:15
Speaker
And so EMS is a real window.
00:36:18
Speaker
And even, you know, I think I've done all the jobs in the
00:36:23
Speaker
in hospice and palliative care.
00:36:25
Speaker
I've been a hospice medical director.
00:36:26
Speaker
I've done home visits.
00:36:27
Speaker
I've done all those things.
00:36:29
Speaker
And I would always be amazed when I go into homes what sort of challenges people are dealing with, right?
00:36:37
Speaker
So keeping the electricity on to keep the concentrator going
00:36:42
Speaker
is not a small point.
00:36:43
Speaker
And so having to go to the hospital or wait, well, there's no inpatient bed and your concentrator is off because there's no electricity.
00:36:53
Speaker
I mean, these are just really fundamental kind of root cause analysis of like, well, why is this person in the emergency department?
00:37:01
Speaker
I mean, you know, because they don't have anybody to pay their electricity bill, that's why, so.
00:37:07
Speaker
What gaps do you think still exist in our training and preparation of future clinicians in emergency medicine and palliative care who are going to continue to address these needs in emergency settings?
00:37:18
Speaker
Yeah.
Comprehensive Training in Emergency Medicine
00:37:19
Speaker
So I think the gap really is that
00:37:25
Speaker
you can't just do one thing and feel like you're done in education, in emergency medicine, residency and training.
00:37:36
Speaker
So you can't just know the equi-homes using dosing table and feel like, oh boy, oral IV morphine three to one, yay.
00:37:46
Speaker
Being able to actually get an entire skillset is really important.
00:37:52
Speaker
You can't just be able to break bad news.
00:37:55
Speaker
It's just not good enough.
00:37:57
Speaker
And so what I think we're lacking in many emergency medicine training programs is wraparound skillset.
00:38:10
Speaker
which is why when we first created Epic Emergency Medicine, we were very, very intent on making sure that there were symptom modules in there, that while communication is important, Kathy Foley, one of the legends in our field, always said to me that if you can't manage pain, there's nothing to talk about.
00:38:33
Speaker
And that stuck with me, okay?
00:38:37
Speaker
And like very young mind was, Kathy said, if you can't manage pain, there's nothing to talk about.
00:38:44
Speaker
And so I would just ruminate on that is not being able to manage pain in an emergency department.
00:38:53
Speaker
And it's really interesting.
00:38:55
Speaker
I feel like the opiate crisis that we have experienced
00:39:02
Speaker
in our field and in our nation has really, I think, negatively impacted the care of seriously ill patients with respect to things like rapid dose escalation and things that people really need to get out of pain.
00:39:17
Speaker
And being able to do that skillfully and confidently like we do other things is as important as what you say and also being able to understand systems of care.
00:39:32
Speaker
It's fascinating when I just ask emergency clinicians to explain hospice care to me and they don't really understand it.
00:39:43
Speaker
They don't understand that it's a package and that the hospice is a care manager
00:39:48
Speaker
And, you know, all of these things and how the insurance works and what's in and what's out.
00:39:52
Speaker
I mean, those kinds of things, it seems like a small point, but when you are caring for patients, you have to have this core knowledge and skills.
00:40:01
Speaker
And I think what's really missing for most emergency medicine patients
00:40:08
Speaker
I don't actually have this nationwide data, but I will just say, anecdotally, it's just the wraparound package that you get the symptom management, you get the communication skills, you get the systems of care.
00:40:21
Speaker
But you get all of those things reliably and consistently.
00:40:26
Speaker
We would never let an emergency medicine resident now leave the emergency department without, or emergency medicine training program without ultrasound training.
00:40:39
Speaker
That's just standard of care now, right?
00:40:42
Speaker
In training.
00:40:43
Speaker
And so what do we do?
00:40:44
Speaker
We hire ultrasound
00:40:46
Speaker
education directors, right, to be able to do that.
00:40:49
Speaker
And while we may not need that level of intensity, we do need that level of expertise, and programs need to endow and support the teachers that are going to have that wraparound curriculum and give them the curricular time to do it.
00:41:08
Speaker
and maybe take a week off of another rotation that they think is so incredibly critical to their development for them to be on a palliative medicine service or to have a hospice rotation or something.
00:41:23
Speaker
And so we just haven't, I think that's just a gap.
00:41:26
Speaker
I think that we're, you know, programs are doing pieces, bits and pieces here, but it's not, you can't just do communication skills.
00:41:33
Speaker
You can't just do symptom management.
00:41:36
Speaker
You gotta have wraparound
00:41:38
Speaker
education that is reliable, predictable, and tested in the way in which we test in our field, on our board exams, and including all of those aspects of care.
00:41:52
Speaker
And I'm so glad that there are people in our field who are working to actually go to the point of certification exams, including palliative care content.
00:42:05
Speaker
But I do believe that that's probably the single biggest thing we can do in emergency medicine to improve at least education is to ensure that we have a wraparound education in all the domains to ensure there's skill and competency.
00:42:22
Speaker
Excellent.
Conclusion and Appreciation
00:42:23
Speaker
Well, this has just really been enlightening.
00:42:25
Speaker
I've enjoyed just hearing your experiences and your perspective.
00:42:30
Speaker
And there's just a lot of shared appreciation, not just for this field, but for emergency medicine and how we apply palliative care principles in the emergency setting.
00:42:39
Speaker
And also, just thank you for being a trailblazer, because people like me get to do what we do, partly because you helped lay a lot of that foundation that helped us get a leg up.
00:42:48
Speaker
and continue to pass along those principles.
00:42:51
Speaker
And I agree with what you said.
00:42:52
Speaker
You know that something's really taken off where you don't have to be the center cog for it to work.
00:42:59
Speaker
You're disseminating the information.
00:43:00
Speaker
Other people are picking it up and running with it.
00:43:02
Speaker
So I've really enjoyed this, and thanks so much for joining me for this podcast.
00:43:09
Speaker
Thanks, Justin.
00:43:09
Speaker
Thanks everyone out there for believing in this as much as I do.
00:43:14
Speaker
And I've just been really graced to be able to be at the forefront with a lot of other really wonderful people to believe in something when others didn't.
00:43:24
Speaker
So we're all here because we know it's the right thing to do.
00:43:29
Speaker
So I appreciate everybody.
00:43:33
Speaker
Thank you.
00:43:34
Speaker
For more information on current topics in the fields of palliative and emergency medicine, please visit pallium.org.