Our Integrative Approach to Palliative Care

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest, innovative research and clinical advances in the field of oncology. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase I and Sarcoma Programs. Today, I'm happy to be joined by Dr. Cory Chevalier, a hospice and palliative care specialist at the Taussig Cancer Institute. He's also director of wellness and wellbeing for the graduate medical education program here at Cleveland Clinic and to the Cleveland Clinic Lerner College of Medicine. So welcome, Cory. Maybe you can tell us a little bit about your role here at Cleveland Clinic as we get started.

Cory Chevalier, MD: Absolutely. And thank you for having me on Dale. So, I've been a hospice and palliative care physician at Cleveland Clinic for about five years now. Prior to that, I've actually done all my training here as well. So, it's a place that I've loved to train and work as well. I do a lot primarily with the oncology patient population. Most of the time when I'm working with patients, I'm actually on service in our in-patient side taking care of our cancer patients on the solid tumor oncology service. And I can tell you a little bit more about that a little bit later, but that's an integrated service and it's oncologist and palliative physicians working together.

Outside of that, when I'm not taking care of patients, I do a lot with wellness and wellbeing in the education sphere. So, within the GME, and more specifically internal medicine, I focus on a lot of the things actually that palliative medicine focuses on, quality of life and helping the residents to have their best life and to thrive as much as possible during their training, and something very, very similar during the medical school as well with our Cleveland Clinic Lerner College of Medicine,

Dale Shepard, MD, PhD: So, essentially palliation of the pain that can come from residency?

Cory Chevalier, MD: Yes, very much so.

Dale Shepard, MD, PhD: So, I think we have a pretty unique model in how we have integrated palliative medicine into our solid tumor oncology service. And it's been an evolution. It seems to work pretty well, but maybe you can tell us a little bit about the services that you can provide our patients and how this all works.

Cory Chevalier, MD: Yeah, thank you for asking. So, I agree. It's a very unique model. We actually are integrated... I'll talk a little bit more about the oncology service solid tumor where I spend most of my time, but we're integrated in multiple different oncology services. So, we have our solid tumor oncology integration. We have our BMT, bone marrow transplant, and leukemia integration as well. And we are housed in Taussig Cancer Center. So, as far as our clinic and our patient follow-up, once they leave the hospital or even getting those referrals prior to coming in the hospital, we are 100% integrated using the same social workers, using the same psychologists. When you're seeing a cancer doctor at Cleveland Clinic, if there's a need for palliative medicine you can follow up with palliative medicine in clinic that same day as well. And we try and keep it that way, make it as simple as possible for our patients.

Dale Shepard, MD, PhD: How often do you encounter patients in the hospital setting that maybe haven't been provided palliative care and the hospitalization itself provides a good opportunity to start those services?

Cory Chevalier, MD: So, I would say it's something that we see a lot. A lot of times when people are admitted to the hospital, that's one of the first times. If it's an early admission for them during their cancer treatment, that they're starting to have some symptoms, they may be admitted with uncontrolled pain, they may be admitted for uncontrolled nausea related to their disease, related to their treatment. And so actually our model, if it's okay if I take you through a little bit, kind of what a day might look like when I'm on service.

Dale Shepard, MD, PhD: Sure.

Cory Chevalier, MD: Every single day, when we're on the... I'll talk about the solid tumor oncology service. There's always one staff physician on from palliative medicine that's helping to take care of that service. We start the day by actually reviewing every single patient, and I get a list of all the patients that are on our oncology service. And I go through one by one and just sort of say, "What's going on with this patient? Do they have metastatic disease? Do they have any uncontrolled pain looking at their pain scores throughout the last 24 hours? Are they admitted for uncontrolled nausea or any other symptoms?" And that's something for every single patient every single day that we look through and see. Is there a way that we can help this patient?

After that, I have some time to get out there, start seeing some new patients, some follow-up patients. But as early in the day as possible, communicating with the team and just touching base and saying, "Hey, I noticed that this patient is having seven out of 10 pain scores. What's going on? What have we been using? How can we be helpful?" And trying to help as many patients as we possibly can, as early as we can.

Later on in the morning, we always do our case management and care management rounds together. And when we talk about working together as a team, multidisciplinary care, that's what I think of. Right now it's primarily virtual, but the oncology team, the residents, the nurses, the care managers, the social workers, the nutrition team, palliative medicine, everyone sitting down, maybe in different rooms right now, but together talking through patients one by one and seeing, "Okay, yeah, we all have different angles, we all have different lenses, but how can we come together as a team and help these patients?"

And then the majority of the rest of the day is continuing to help the patients that we've identified, continue to talk with the team, work with the team. And since we have residents on the team, provide education so that if I'm not there, if it's 2:00 AM in the morning, and there may be residents who are there although we're always on call, sometimes they want to manage some things on their own and they want to get some medication started, they've had that education, they've had that initial experience about, "Okay, well, what do we use for first-line cancer pain? What do we use for first-line cancer related nausea?" So, truly, it's an integration in how we're working together on a day-by-day basis. And then the next day, the same cycle repeats.

Dale Shepard, MD, PhD: And that's the best part is that it really is an integration. It's not sort of pulling in some outside group to help manage the patients. You guys are great at being embedded in the team and really as much of the team as anyone else. So, that's great. What has been in the impact? So, as you mentioned, oftentimes patients come in from the symptoms of their disease, the symptoms of their treatment, they may or may not have had palliative care in the outpatient setting. Has this been shown to have an impact on length of stay, on readmission rates, on urgent visits, those sorts of things? So, are we helping patients from that standpoint?

Cory Chevalier, MD: We absolutely are. It's incredibly important that we're involved as early as possible. So, that way, we can help people as early as possible. Things like length of stay, involving palliative medicine early and often has been shown to definitely decrease length of stay when people are admitted to the hospital. And getting that integration, getting that additional resource for when people are discharged, and then we're able to follow up on an outpatient basis and we're able to be part of the team that when people are saying they're having an uncontrolled symptom where there's something new going on, instead of just coming immediately to the emergency room, instead of maybe turning that into admission, maybe we can help those patients to stay out of the hospital. So, they'll give us a call. We're on call 24/7, and whether it's helping them over the phone, whether it's setting up a virtual visit, whether it's setting up a same-day appointment, we've definitely shown that we're able to decrease readmissions as well with that.

Another really important thing that we've actually been showing, in addition to those two different things, is focusing and helping people fill out their advanced directive forms also. And that's just making sure that if somebody were to get very, very sick, who do they want making decisions for them? And having that on file, especially when our patients do get very sick, helps prevent a lot of major issues downstream. And the majority of our patients actually now have medical power of attorneys on file, whether it's from doing it in the hospital, whether it's from doing in clinic. And that's another thing that can help with all of the things that we already talked about.

Dale Shepard, MD, PhD: You talked a little bit about here the integration on the in-patient side, how has palliative care integrated effectively into the clinical setting?

Cory Chevalier, MD: So, on the clinic side, we've actually grown quite substantially with that. As I mentioned, we have our palliative medicine colleagues that are taking care of our cancer patients in the clinic. What our goal and our aim, just since we've been talking about in-patient medicine, is to see them as quickly as possible when they're leaving the hospital. So, if somebody is admitted, they're discharged, we want to see them within five days of them being discharged. Not only does that help make sure that they're doing well, but like we mentioned before, it helps keep people out of the hospital. But we have a very large network of physicians that can continue to follow up people when they're outside of the hospital and to keep them well, keep the focus on how can we help this person thrive, focus on their quality of life. And it's not just physicians, it's physicians, advanced practice practitioners, social workers. And not just in our cancer center as well. We have people in multiple of our regional hospitals. So, no matter where somebody is living, they'll have somebody that's near them.

With a lot of the changes that have been going on with the pandemic, we actually have an extensive virtual visit system now. So, if somebody is feeling too weak, if they're not feeling well enough to even get out of their house, we can make sure that they're getting an appointment and that they're getting help when they need it. And a lot of the integration, a lot of the working together in the clinic doesn't involve just physicians, doesn't involve just our clinical team, it also involves a lot of our support services, our 4th Angel Mentoring Program, our art therapy, our meditation room, the massage that we have in-house, reflexology, music therapy, the list goes on, and how we will refer out and make recommendations to help support our patients not just in their physical wellbeing and how they're doing but their mental well-being, their emotional wellbeing, all the different things that we can help support them with as they're going through what can be a very, very challenging time.

Dale Shepard, MD, PhD: So, to those that are listening that might not have this integration, what do you think is the biggest barrier? Do you think it's the doctors not referring to their palliative medicine colleagues? Do you think it's the patients maybe being scared to go see someone else and even just thinking that palliative medicine sounds scary? What do you think are the biggest barriers to integration into other systems?

Cory Chevalier, MD: I think you hit on it, and I think there's a couple of different barriers. Definitely I do think that there's somewhat of a stigma, a feeling that palliative medicine is just for end-of-life care or just for patients who are getting substantially sick. And from both the patient side and also from the physician side, I think what I want to put out there is we want to be there for all phases of care, all phases of treatment. When somebody is having issues with their nausea on their very first-line chemotherapy, who has non-metastatic disease, we want to help. And by doing that, we're building relationships with the patient as early as possible. They're not having that stigma with us anymore. They're making sure that they know that we're just part of the team. We're helping them to get through their treatments and thrive and get cured and make sure that that's maintaining the focus.

The nice side from that as well is the more that we're integrated and the more that we're working with the different oncologists and physicians, the more that they're comfortable with us. I mean this is a two-way street. Our goal is to build relationships and have continuity with not just the patients but with the oncologists as well. I mean you and I have been working together for years now. I think having that continuity and having that relationship built in, there's a huge level of trust that's put in there as well. I think as an oncologist, you don't want just anybody that you've never met coming in and talking to your patients and caring for them. You want that team that you're familiar with. You want those people that you've had experience with. And having us involved early, having us involved often, builds those relationships from many different angles and helps break down those barriers.

Dale Shepard, MD, PhD: You guys have a great service. I always describe to the patients that I'm trying to control your tumor growth and control your symptoms and make you live longer. And, "Hey, I have a group that can really help out with that make you feel better part."

So, maybe switch gears really quickly. Tell us a little bit about the things you're doing for wellness with the trainees and how we're keeping them as healthy as possible from a wellbeing standpoint.

Cory Chevalier, MD: Oh my goodness. Thank you so much for asking about that. So, I think trainee GME medical student wellbeing has always been a challenge. It's a very difficult shift in their life. They're going from students to being physicians at this point. So, it's a time where we need to focus and make sure that all of the different things are accounted for. A lot of what we do is make sure that all of the resources that are there are things that are there to support them such as their emotional wellbeing. We have multiple different services that we integrate and introduce early. We're not building a safety net, we're not building things that are there in case they have issues. We're building ongoing education, we're building ongoing didactics, we're building ongoing relationships so that we can reach out, we can make sure that we're asking them how they're doing, we can be proactive in helping them rather than being reactive after the fact, focusing on a lot of the other things as well, focusing on their physical wellbeing.

A lot of people don't even know the resources that exist, especially here. We're such a big program. A lot of people don't know that there's multiple different fitness centers around campus that they have free and easy access to. So, we actually take them, we bring them there, we get them signed up. We make sure that they know how to access it, how do they bring their spouses, what happens with their kids. I think one of the most important things though is just bringing the resources down to their level and communicating in a way that they communicate. I've noticed over time that no matter what we're building, whether it's building emotional resources, whether it's building physical fitness resources, mental health, social wellness, a lot of it is just how do we tell 1,500 people about these resources? How do we get that information out there?

So, we've built wellness apps that now we have on multiple different levels within the medical school, within GME, to focus on that digital realm. And whether it's Twitter, whether it's Instagram, these are the resources and the platforms that people who are in training are using. So, that's another thing that we've been doing is promoting, using sources that they're already using so that they can hear the information.

Dale Shepard, MD, PhD: So, a lot of the people listening in may be associated with training programs and think that this is something that would be of value to their program. So, any advice to how to get buy-in, how to get these services in place in a setting where time is valuable and budgets are tight? And how do we address this in the most efficient way possible?

Cory Chevalier, MD: I think everyone has the understanding that this is incredibly important. When we look at wellness and how wellness and supporting physicians, supporting students, relates to burnout, we know that there's a strong relationship there. And when we look at the burnout rates that have been going on, we know that there's a lot of people who are actually leaving their jobs and leaving the profession because of a lot of the issues that are going on and because of the mindset shift that we need to have. And I think currently, the last paper that I saw, the business case for this is it can cost up to a million dollars to replace a single physician when that does happen. So, definitely in some ways, it's hard to afford not to make sure that we're making some of these changes and focusing on supporting our trainees and our students.

It's incredibly important. I also say it doesn't take much. It doesn't take a lot of resources to do these things. Sometimes it's about being present, about putting in the effort, putting in the time. One of the things that we do here and one of the things that I do once a week is I do wellness rounds. I'll go from floor to floor in the hospital, every single floor in a very big hospital, takes a couple of hours at the most, and just being present, touching base with all of our trainees, the students, when I see them and just saying, "How are things going? How can we help? What's going on?" I always bring a bag of snacks with me, so that way they're more likely to see me. But that's one way where we can do almost like a walking about management style, popularized by Toyota, and just say, "We're being present. We're here. We care." It's a very different optic than sending links for yoga and having a more passive approach. And it adds to that more proactive approach.

A lot of these things we're doing already, a lot of these things already exist, but making sure that it's coming from a proactive place and that there's a structure that's built that's very specific for focusing on all these different domains. So, that way, things don't get lost and that way residents and medical students don't get lost as well.

Dale Shepard, MD, PhD: So, it sounds like putting the effort in while they're enthusiastic trainees will keep them from being better at some later point in time.

Cory Chevalier, MD: And being vulnerable ourselves. When we talk with the residents, I mean I'm open about my own emotions when I'm on service and we have a very difficult discussion with the patient and family. That's something that we share and that's something that we debrief on, and I think it all interlinks. It'd be hard for me to have my wellness role and try and have an authentic relationship with people when I'm not doing that when I'm caring for patients. So, I think they're both incredibly important.

Dale Shepard, MD, PhD: Well, it sounds like you've come up with an interesting integration of working with patients and trainees, so kudos for that. It sounds like you've been able to find a way to be helpful across the board. So, some really good insights. Any additional comments?

Cory Chevalier, MD: I think that one of my biggest takeaways from years of doing this and years of being integrated with our cancer center is something I mentioned earlier, just building those strong relationships. And I think that's something that can't be overstated when it comes to helping our patients. Me being able to give somebody a call on their cell phone and say, "Hey, your patient's admitted. This is what's going on," is so important. Calling the oncologist, calling our oncologic orthopedists, and giving them a call and saying, "Hey, this person is having really uncontrolled pain because of X, Y, Z. What can we do to help them?"

It is such a different dynamic than I'm sending an email and a couple of days later I get a response while somebody is sitting there and they're having some issues that maybe aren't being addressed. So, those relationships are key to, I think, providing the best care. And that's one of the things that has honestly kept me here for the past decade is just the relationships that I've built and how that's allowed me in palliative medicine and wellness for our cancer patients to just make sure we're taking the best care of our patients possible.

Dale Shepard, MD, PhD: That's outstanding. Well, thank you very much for being with us today.

Cory Chevalier, MD: Oh no, thank you for your time. And thank you for the invitation.

Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget, you can access real-time updates from Cleveland Clinic's cancer center experts on our Consult QD website at consultqd.clevelandclinic.org/cancer. Thank you for listening. Please join us again soon.