Transcript
Speaker: This is the Pallium Podcast, a production of pallium.org at the intersection of palliative and emergency medicine.
Speaker: I'm your host, Justin Bruton.
Speaker: Today on the PallyM Podcast, I'm joined by Dr. Tammy Quest.
Speaker: 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.
Speaker: 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.
Speaker: She is currently the Montgomery Chair in Palliative Medicine and Professor in the Department of Family and Preventative Medicine
Speaker: and the Department of Emergency Medicine at the Emory University School of Medicine.
Speaker: She is the Chief of Palliative Medicine for the Division of Palliative Medicine in the Department of Family Medicine.
Speaker: 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.
Speaker: 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.
Speaker: Thank you so much for joining me today.
Speaker: Thank you, Justin.
Speaker: 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.
Speaker: So excited to be here and thank you for having me.
Speaker: So looking back on the different roles you've had through the years, what surprised you the most about your career trajectory?
Speaker: Thanks, Justin, for that.
Speaker: light reflective moment.
Speaker: So, you know, I really think in thinking about, I'm in my 24th year being faculty, which is just almost impossible to believe.
Speaker: I think that I've been surprised by two things.
Speaker: One is really leadership.
Speaker: I never went into medicine to really be a leader, to be honest with you.
Speaker: I went into medicine to take care of patients and
Speaker: was inspired to be an emergency physician through mentors that I saw who were in service of others.
Speaker: And so I went into Madison to be in service of others.
Speaker: I never thought, I think in my wildest dreams, that I would end up directing anything.
Speaker: And...
Speaker: I thought it was bad enough to be chief resident at Highland to make the schedule.
Speaker: I thought that was really probably about the end of it for me with leadership.
Speaker: And it just really, I think, is surprising to me that I've had the opportunity to lead some really incredible things.
Speaker: I think that the other piece of that leadership is,
Speaker: 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.
Speaker: It just never would have been anything I would have thought of.
Speaker: And so,
Speaker: 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.
Speaker: So I think I've been really surprised by the calls that I've had over the years and really graced by the opportunities.
Speaker: Where do you find your inspiration?
Speaker: 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...
Speaker: not in a place of compassion fatigue, thank God, and burnout.
Speaker: 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
Speaker: are all having a worse day than me.
Speaker: So even on my absolute worst day where I'm thinking I'm having a bad day, I'm not facing serious illness.
Speaker: And I can, I'm just inspired every day to say that's the reason that we get up in the morning.
Speaker: That's what this field is about.
Speaker: I was always drawn to distress and suffering, which is
Speaker: I actually liked that aspect in the emergency department of being able to meet people in their distress.
Speaker: And I am inspired every day to try to figure out a way to either deliver service or think about how to grow programs.
Speaker: 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.
Speaker: But I will say that
Speaker: 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.
Speaker: So they are my inspiration.
Speaker: Yeah, that's an excellent point.
Speaker: 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.
Speaker: Didn't just show up, but that was such a big piece of it.
Speaker: 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.
Speaker: Yeah.
Speaker: Well, I will say when I look back, 1998 was the pivotal year.
Speaker: It was the year that I was looking for a job after residency.
Speaker: And there was a lot of no.
Speaker: I wanted to do this thing called, it turns out back then we called it end-of-life care.
Speaker: The word palliative care was actually being, being,
Speaker: coined in its vernacular of being able to be used on a regular basis.
Speaker: But essentially, this thing that I wanted to do fell in this area of ethics then and end-of-life care.
Speaker: And there was not a lot of energy or enthusiasm or support for a faculty career in that way.
Speaker: And really, there were a lot of doors that were closed.
Speaker: And I started looking.
Speaker: I knew I wanted to do academic medicine.
Speaker: I started looking further and wider than I had wanted to.
Speaker: And happened upon Arthur Kellerman by chance at Emory who said that this was an amazing idea to work in this area.
Speaker: Nobody else was doing that.
Speaker: and he would support me.
Speaker: 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.
Speaker: So I would say that in the early days, it was a lot of no.
Speaker: 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.
Speaker: And so surrounding yourself with people who are going to support your dreams is never a bad idea.
Speaker: And it didn't fail me.
Speaker: And a lot of doors open as a result of that kind of support really early in my career.
Speaker: 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.
Speaker: 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.
Speaker: And it really
Speaker: I think made the difference between, you know, things happening and not was that I believed it when other people didn't.
Speaker: 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.
Speaker: 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?
Speaker: 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,
Speaker: 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.
Speaker: And, okay, I guess they were inspired by that level of tenacity, if nothing else.
Speaker: And that was really very pivotal in my career.
Speaker: So I will say that a lot of doors opened as a result of just simply believing it more than anybody else.
Speaker: And it's just so wonderful now that other people believe it.
Speaker: And those few of us in the very beginning had to have support groups.
Speaker: 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.
Speaker: 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.
Speaker: 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.
Speaker: I mean, that was all that was all uphill because it was such a new concept.
Speaker: 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.
Speaker: But just this idea of trying to integrate the two was so foreign at one time.
Speaker: 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.
Speaker: So you just you you laid a lot of that foundation, which is which is awesome.
Speaker: 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?
Speaker: So I get guests privileged to have a tie.
Speaker: So I get two.
Speaker: How about that?
Speaker: And they're a tie.
Speaker: Fair enough.
Speaker: So I would say that working on the Epic Emergence Medicine Project.
Speaker: And so in 2005, I had, remember I was on this, had this vision, maybe in the desert somewhere, right?
Speaker: And went to the National Cancer Institute and asked for a grant to train patients.
Speaker: emergency clinicians in core palliative care skills.
Speaker: 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.
Speaker: I said, I think we could do this for emergency clinicians.
Speaker: This might be the way, train the trainer, that we could build a cadre of emergency clinicians in
Speaker: in this nation who can teach and can teach this because I probably can't do this by myself.
Speaker: And that was really very pivotal at the time.
Speaker: We held the first training conference in November of 2007.
Speaker: We had about 40 people show up, which was absolutely a shocker.
Speaker: What we did, Arthur Kellerman was incredible.
Speaker: He helped me get all the chairs and the SAM Council of Chairs
Speaker: to try to send somebody from their program.
Speaker: 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.
Speaker: We didn't have any emergency clinicians that actually knew palliative care.
Speaker: So Frank Ferris and
Speaker: 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
Speaker: we really spent time to try to train people who were actually going to do this conference.
Speaker: So when that conference launched in 2007, it was like a dream come true.
Speaker: I didn't think it was like having a wedding that you sort of thought nobody was going to show up to.
Speaker: And people showed up, and it was incredible.
Speaker: Sangeeta Lamba, who she and I have collaborated so many times over the years, met at that conference.
Speaker: And
Speaker: 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.
Speaker: 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.
Speaker: The whole concept of Epic Emergency Medicine is that it's just out of the box.
Speaker: You can tailor, you do the slides, you can change the background, I don't care.
Speaker: But here's the material because we were never taught that as emergency clinicians.
Speaker: 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.
Speaker: So I will say that without that cadre of individuals who showed up at those conferences in those early years, I don't think
Speaker: that we as a field would be where we are now.
Speaker: So that's one thing.
Speaker: 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.
Speaker: And we'll be having our course this fall in October and hoping that people will want to join that.
Speaker: 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.
Speaker: That, I think, probably ties with the Game Changer Award in our field.
Speaker: 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.
Speaker: of this incredible field.
Speaker: We have seen that happen in other specialties, and I was hellbent that that was not going to happen.
Speaker: And I remember bringing together a group of people.
Speaker: We had a wiki page.
Speaker: Knox Todd introduced me to that idea.
Speaker: And we got the ABM at that time said, why do you think this is important for emergency clinicians?
Speaker: We created a groundswell of people to be able to state why we thought this was important.
Speaker: And I remember writing the white paper and sending it, hitting send to the ABM and saying, this is really important.
Speaker: If we don't do this, we're going to be shut out.
Speaker: This is not going to be good.
Speaker: The future of our field is at stake here to be able to have people who want to not only be
Speaker: clinicians in emergency medicine, but also clinicians and experts in palliative medicine.
Speaker: And so every time I see an emergency medicine clinician who is doing a fellowship, it warms my heart.
Speaker: And I also know how close we came to not, that not being a reality.
Speaker: 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.
Speaker: So that's my tie.
Speaker: Yeah, that's well put.
Speaker: 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.
Speaker: And palliative care was a big piece of it.
Speaker: So was emergency care.
Speaker: I wanted to take care of sick people.
Speaker: 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.
Speaker: But I got to have my cake and eat it too and do EM and get to do palliative still.
Speaker: So I'm definitely the beneficiary of that.
Speaker: This year we have both of our fellows at our program at Wake are both emergency medicine trained.
Speaker: So that's really awesome.
Speaker: It's actually really fascinating to hear about the pieces coming together.
Speaker: 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.
Speaker: So one of the things I was going to ask about was we've made headway in emergency medicine and palliative care integration.
Speaker: It sounds like a big piece of that.
Speaker: It's really been education, getting curriculum developed, getting programs developed, and also obviously getting the fellowship pathway.
Speaker: Where do you think the field is headed?
Speaker: Yeah.
Speaker: So, wow, it's just so incredible.
Speaker: 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.
Speaker: So I'm always really excited when I hear about something brand new that's happened.
Speaker: that we're doing in emergency medicine and palliative care and I had nothing to do with it.
Speaker: 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.
Speaker: That's really incredible.
Speaker: So I do think that there have been some incredible movers and shakers in our field.
Speaker: 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.
Speaker: And
Speaker: So I think that we've just gone from, you know, a teeny five articles or something to hundreds and hundreds now.
Speaker: I do think that we have work to do on models of care and what is the
Speaker: 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
Speaker: those skills, but what are the standards of care?
Speaker: What can we work into for standards of care like aspirin and acute myocardial infarction?
Speaker: What is the palliative care piece of that?
Speaker: 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.
Speaker: 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.
Speaker: And so community models, what are the community practice models that become the standard of care?
Speaker: 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.
Speaker: and what sort of things are going to move the entire practice of emergency medicine at its core.
Speaker: Not so much just you happen to be at an academic center with Justin or Tammy or Kay or you pick, right?
Speaker: 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.
Speaker: 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.
Speaker: 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,
Speaker: And so I think that that is something that needs to be, that we need to crack that net some kind of way.
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.
Speaker: Education alone will not change programs or practice, but without education and that spark,
Speaker: 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.
Speaker: Not one skill, but a suite of skills, right?
Speaker: They need to know death disclosure.
Speaker: They need to know equianalgesic dosing.
Speaker: They need to know how to control nausea and vomiting.
Speaker: They need to know best evidence for dyspnea management.
Speaker: They need to know how to break bad news.
Speaker: They need to know how to have a goals of care conversation.
Speaker: They need to know how to take care of a patient who's in hospice care who comes in their emergency department.
Speaker: They need to be able to refer somebody to hospice.
Speaker: How do we ensure that for every resident?
Speaker: And I actually do not think that we have a qualified teacher at every program in the nation.
Speaker: Why is that?
Speaker: Because I still get asked to speak in emergency medicine programs, and residents are telling me that they are not getting these skills.
Speaker: They're not getting the things that they need.
Speaker: I've been so graced over the years here at Emory, and the leadership has
Speaker: really embraced palliative care.
Speaker: 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.
Speaker: And we started with death disclosure, and then we went to a foundational palliative care skills, knowledge and skills-based curriculum.
Speaker: simulation and now a rotation.
Speaker: And so that's great that we can have that here.
Speaker: Isn't that fabulous that we can have that here?
Speaker: But that's not good enough, right?
Speaker: Because it's not everywhere.
Speaker: So the fact that it's good in my spot or is better, it's probably not the best.
Speaker: I'm sure somebody else out there is doing even more than we're doing.
Speaker: 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.
Speaker: And we also have a retraining problem because we always have the old dogs, new tricks
Speaker: And I'm one of those old dogs, so it's really hard when we come up with a new thing in the ED.
Speaker: I'm like, no.
Speaker: But so I do think that foundationally we've got to really ensure that everybody in every emergency medicine program has a qualified teacher.
Speaker: And that is the starting place, is that every program needs a qualified teacher, and I don't believe that we have that universally.
Speaker: That is a really excellent overview of kind of the mission moving forward, I think.
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.
Speaker: And then as the
Speaker: as people get training, there still is that trickle down process in the community.
Speaker: 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.
Speaker: And people have to see a priority for it too.
Speaker: Because it, you're asking people to invest time on the front end and how to communicate and
Speaker: 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.
Speaker: You know, the time that I invest in that difficult conversation, is that going to help?
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.
Speaker: So how do you implement resources in a way that's going to work with their workflow?
Speaker: But that's a really excellent overview of kind of the mission ahead.
Speaker: And this next question, this is kind of a broad question.
Speaker: that really could be multiple parts.
Speaker: You've already done work, obviously, in education in so many areas of palliative care and ED integration.
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.
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 and in the future?
Speaker: Yeah.
Speaker: Thanks, Justin.
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,
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.
Speaker: And so when we...
Speaker: So working in an emergency department, almost without exception, you are going to take care of vulnerable patients.
Speaker: Yes, even the most swank emergency department will take care of vulnerable patients.
Speaker: So I think that fundamentally we have to be true to our mission that the emergency department is the funnel of all disparity.
Speaker: It's the final common pathway.
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.
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.
Speaker: And while particularly after pandemic conditions and all of the compassion fatigue that we are experiencing,
Speaker: And it really, it's imperative that we remember why we're there in the emergency department.
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.
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.
Speaker: And the first thing somebody might say is, well, why are they here?
Speaker: Well, actually, hospice care in America is broken, newsflash.
Speaker: The Medicare hospice benefit does not cover much of what people need, which includes caregivers and 24-hour support.
Speaker: that is needed.
Speaker: Medicare doesn't cover long-term care.
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
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.
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.
Speaker: the inability to access the kind of services that they need.
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
Speaker: to keep you from being homeless.
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.
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.
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.
Speaker: And so, which
Speaker: which patients are going to be more phone managed versus the nurse is going to be right out there.
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,
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.
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.
Speaker: I think that we often blame the patient for being in the emergency department at end of life.
Speaker: And what I can tell you
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.
Speaker: And those things only get harder as you start dying.
Speaker: And so being able to really move the needle
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.
Speaker: That is, no, that's a great way of articulating that.
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.
Speaker: They are gonna be in the neighborhoods
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.
Speaker: But you're absolutely right.
Speaker: And I think
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.
Speaker: They're scared, they're terrified, the patient's uncomfortable.
Speaker: Exactly what they're gonna do is call 911.
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.
Speaker: But you're right, there's all those things that people deal with get harder if they're dealing with dying.
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.
Speaker: In fact, I think that in and of itself, the fact that we have marked emergency department visits at end of life
Speaker: as a failure in vulnerable populations, I think we need to actually relook at that.
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,
Speaker: We think of financial disparity.
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.
Speaker: And so I just think we need to think deeper about these issues.
Speaker: And I think stopping at
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.
Speaker: Yeah, I think that's a great point.
Speaker: And I agree with you.
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.
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,
Speaker: abruptness and the emergent nature of it.
Speaker: That's one of the things I love about emergency medicine too.
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.
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.
Speaker: And that was their existence.
Speaker: you'd see some things that you just would not expect to see in the United States.
Speaker: You'd expect to see it on a medical mission trip.
Speaker: Yeah, and for the way that many of my patients live, most of us probably could not live a night like that.
Speaker: And so being able to be in a space.
Speaker: And, you know, patients clean it up right for us and their families.
Speaker: And so EMS is a real window.
Speaker: And even, you know, I think I've done all the jobs in the
Speaker: in hospice and palliative care.
Speaker: I've been a hospice medical director.
Speaker: I've done home visits.
Speaker: I've done all those things.
Speaker: And I would always be amazed when I go into homes what sort of challenges people are dealing with, right?
Speaker: So keeping the electricity on to keep the concentrator going
Speaker: is not a small point.
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.
Speaker: I mean, these are just really fundamental kind of root cause analysis of like, well, why is this person in the emergency department?
Speaker: I mean, you know, because they don't have anybody to pay their electricity bill, that's why, so.
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?
Speaker: Yeah.
Speaker: So I think the gap really is that
Speaker: you can't just do one thing and feel like you're done in education, in emergency medicine, residency and training.
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.
Speaker: Being able to actually get an entire skillset is really important.
Speaker: You can't just be able to break bad news.
Speaker: It's just not good enough.
Speaker: And so what I think we're lacking in many emergency medicine training programs is wraparound skillset.
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.
Speaker: And that stuck with me, okay?
Speaker: And like very young mind was, Kathy said, if you can't manage pain, there's nothing to talk about.
Speaker: And so I would just ruminate on that is not being able to manage pain in an emergency department.
Speaker: And it's really interesting.
Speaker: I feel like the opiate crisis that we have experienced
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.
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.
Speaker: It's fascinating when I just ask emergency clinicians to explain hospice care to me and they don't really understand it.
Speaker: They don't understand that it's a package and that the hospice is a care manager
Speaker: And, you know, all of these things and how the insurance works and what's in and what's out.
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.
Speaker: And I think what's really missing for most emergency medicine patients
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.
Speaker: But you get all of those things reliably and consistently.
Speaker: We would never let an emergency medicine resident now leave the emergency department without, or emergency medicine training program without ultrasound training.
Speaker: That's just standard of care now, right?
Speaker: In training.
Speaker: And so what do we do?
Speaker: We hire ultrasound
Speaker: education directors, right, to be able to do that.
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.
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.
Speaker: And so we just haven't, I think that's just a gap.
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.
Speaker: You can't just do symptom management.
Speaker: You gotta have wraparound
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.
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.
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.
Speaker: Excellent.
Speaker: Well, this has just really been enlightening.
Speaker: I've enjoyed just hearing your experiences and your perspective.
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.
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.
Speaker: and continue to pass along those principles.
Speaker: And I agree with what you said.
Speaker: You know that something's really taken off where you don't have to be the center cog for it to work.
Speaker: You're disseminating the information.
Speaker: Other people are picking it up and running with it.
Speaker: So I've really enjoyed this, and thanks so much for joining me for this podcast.
Speaker: Thanks, Justin.
Speaker: Thanks everyone out there for believing in this as much as I do.
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.
Speaker: So we're all here because we know it's the right thing to do.
Speaker: So I appreciate everybody.
Speaker: Thank you.
Speaker: For more information on current topics in the fields of palliative and emergency medicine, please visit pallium.org.
