For this week's faculty spotlight, we talk to Dr. James A. Tulsky about the history and future of palliative care, patient-provider communication, and fly fishing.
How long have you been at Duke? How long have you been at the Division? I have been at Duke since 1993, when the Division was MUCH smaller--maybe fewer than 25 faculty members.
What does a typical day for you at the Division look like? My job is split between doing research and running Duke Palliative Care, where I oversee a Health System wide clinical program. I'm not so good at compartmentalizing, so my typical day is anything but typical. I go to a LOT of meetings - about patient care delivery, budgets, personnel, faculty and staff concerns, etc. We are a rapidly growing program, so I've spent a lot of time on hiring, setting up administrative systems, and clinical service dissemination. I also have lots of research meetings - following recruitment, overseeing analyses, planning papers and grants, and so forth. Finally, I'm involved with a number of activities outside of Duke. So, too often, a typical day includes a ride on an airplane. Somewhere in the middle of all that, I try to find time to write - although that tends to be a late-night activity.Your research focuses on palliative care at the individual and system levels. How are the challenges and opportunities different than providing palliative care at the individual level?
Most of my research has focused on the individual patient experience, whether that is how they cope with serious illness, or how they speak with their provider about it. We are currently in the middle of a clinical trial (PAL-HF) in which we are looking at the effect of palliative care on the quality of life of patients with advanced heart failure.
My work at the system level is less research and more implementation. The major challenges to improving palliative care at the system level are overcoming cultural barriers (e.g., "my patient isn't ready for palliative care"), a significant workforce shortage and, of course, cost.
The opportunities are huge - the possibility of improving care transitions, enhancing quality of life and the experience of living with serious illness, and saving money while doing so. This is one of those places in medicine where we may be able to truly achieve high value: better care at lower cost.How has palliative care changed over the past decade? Ten years ago palliative care was not a formally recognized discipline. Only 45% of U.S. hospitals had palliative care services, and there was a meager evidence base. Today, palliative medicine is an ABMS-certified medical specialty. Eighty-four percent of hospitals have palliative care services, robust academic programs exist, and research funding and publications have increased dramatically.
Where palliative care going in the next 10 years? We can expect to see further growth in the availability of palliative care services, particularly in outpatient and community settings, as well as the integration of palliative care quality measures into clinical practice. Perhaps most importantly, under the Affordable Care Act, health systems will increasingly turn to palliative care to help them achieve greater integration of services, decreased transitions of care, and higher patient and family satisfaction.
In addition to palliative care, your research has also focused on patient-physician communication. How have you brought that knowledge into your individual practice? My work in patient-physician communication has made me acutely aware of everything that is happening during a medical encounter. I experience an uncanny sense as if I am watching both myself and the patient from a third perspective - almost like watching myself on TV.
Now, when I sit down with a patient, I accept that there are three of us in the room: the patient, me, and “mini-me,”—the mini-me hovering over the encounter, observing and providing feedback, like a favorite uncle. And while mini-me may not always keep big-me from sticking my foot in my mouth, he’s often helped me extract it before I leave the room. What advice do you have for other physicians looking to improve their patient-provider communication? The only way to learn to improve one's communication is to be observed, receive feedback, to practice one's new found skills, and then to repeat the process. There are many ways to do this - through communication courses, asking colleagues (or learners) to observe you and give feedback, or to audio-record encounters and review them yourself or with a colleague. In the future, we hope to have self-guided modules in which one can upload their audio-recorded conversations, have them analyzed by a computer, and receive feedback directly. Until then, if people are interested in courses or educational resources like handouts and videos, I highly recommend our new VitalTalk website (www.vitaltalk.org).What’s one thing that you enjoy doing while you’re not at Duke? I love fly fishing. Standing in the middle of a stream, preoccupied by wily trout is the one place that I completely forget about everything else in my life and find total peace.