175 000 Blue Chairs

Abstract

Shirley Roberson has been living with stage 4 cancer for many years. A while back, she had an appointment to go over some frustrating test results. As she waited for her oncologist to arrive, Shirley could think of only one thing. What will these results mean for me and my future? In came a young resident who, skipping formalities, launched into the data at hand, explaining the test results. This speech continued until ... “Stop,” Shirley said, pointing to the chair in the corner. “What I want you to do is stop talking and go sit in that blue chair. While sitting in the blue chair you must not talk. You must listen. I get to talk. Do you understand what I am asking you to do?” The resident, shocked, quickly nodded and took a seat. “Now what you should’ve done was ask me how I’m doing and what I want to discuss,” continued Shirley. That resident is one of the more than 175 000 clinicians who Back et al estimate to be in need of communication training. This figure was reached by examining the number of physicians practicing in specialties that involve patients with serious illness, which they defined as cardiology, hematology-oncology, geriatrics, nephrology, hospital medicine, neurology, pulmonary and critical care, and general internal medicine. This comes to a total of 185 000 physicians. To reach a conservative estimate, Back et al posited that 50% of those physicians, a total of 92 500, could benefit from training. The group then examined the total numbers of practicing nurse practitioners and physician assistants in the United States, 248 000 and 115 000, respectively. Assuming that 25% of all nurse practitioners and physician assistants could benefit from training, Back et al reached a total of 62 000 nurse practitioners and 28 750 physician assistants. Adding these figures to their estimated number of physicians who could be trained, they reached a total estimate of more than 175 000 clinicians. That’s a lot of blue chairs to fill (as illustrated in Figure 1)! The authors note that, even with the integration of training into undergraduate and graduate clinician training, it would be over a decade before we trained a full workforce. A decade. Can we get there faster? I am hopeful we can, by way of three strategies that the Coalition to Transform Advanced Care (C-TAC) and our members are taking on to ensure that people like Shirley get the care that they want, when and where they want it. First, we all have stories about how serious illness has affected us. The question is whether or not we will use them strategically. Shirley is using her story of the blue chair to raise awareness of the challenge and point to a solution— empowerment of people living with serious illness and their family to call for better patient-clinician communication. Clinicians, as well as patients, often have personal and professional experience with serious illness. These stories offer insight that clinicians can use to provide compassionate care for those living with serious illness, from discussions of end-of-life wishes to pain and symptom management. Second, we need to spread promising community partnerships to reach students. For instance, recently, all four medical schools in Massachusetts—Harvard, Tufts, Boston University, and the University of Massachusetts—have agreed to develop standards for end-of-life medical training. These practices even involve role-playing scenarios with actors, offering students the chance to practice discussing end-of-life care. The program, backed by the Massachusetts Coalition for Serious Illness Care, is the first of its kind in the United States. “A lot of us in the medical profession look at death as a failure,” said Dr. Majid Yazdani, subinternship program director at the University of Massachusetts, to the Boston Globe, “but to be there for people in that transition, and to understand their wishes in the time they have left, that’s part of what we do.” It is not just physicians who need training, as the authors point out. Programs like Respecting Choices offer tools for the development of advance care planning programs with nurses in the lead. This training is being piloted in schools of nursing, and early results look promising. While specific data from schools are not yet available, Respecting Choices has found that long-term care and adult memory care facilities have been eager to work with students certified in this training because they are much more comfortable when engaging residents and interdisciplinary teams. The Center to Advance Palliative Care and the California State University Institute for Palliative Care also offer online training for nonphysician members of the team. Third, we need to change public policy. Several pieces of current federal legislation would address the challenges facing our healthcare workforce while empowering patients to take charge of their own care. The C-TAC–supported Palliative Care and Hospice Education and Training Act (PCHETA), which passed in the US House of Representatives earlier this year, would establish palliative care and hospice workforce training programs and support research aimed at improving palliative care This commentary comments on the article by Anthony Back et al.