The PalliEM Podcast:
Episode 8 – Dr. Tammie Quest, MD  

Episode 8 Production:

Podcast Guest:
Dr. Tammie Quest, MD
Link to Dr. Quest’s Bio

Podcast Host:
Dr. Justin Brooten, MD

Podcast Editing & Production:
Michelle C. Brooten-Brooks

Podcast Transcript:  

00:00:00:03 – 00:00:22:08
Dr. Justin Brooten, MD

This is the PalliEM podcast, a production of  PalliEM.org, at the intersection of palliative and emergency medicine. I’m your host, Justin Brooten. Today on the PalliEM podcast, I’m joined by Dr. Tammie Quest. 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 in emergency medicine.

00:00:22:19 – 00:00:42:15
Dr. Justin Brooten, MD

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. She is currently the Montgomery Chair in Palliative Medicine and professor in the Department of Family and Preventative Medicine in the Department of Emergency Medicine at the Emory University School of Medicine.

00:00:43:04 – 00:01:05:03
Dr. Justin Brooten, MD

She is the Chief of Palliative Medicine for the Division of Palliative Medicine in the Department of Family Medicine. 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. 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.

00:01:05:11 – 00:01:08:11
Dr. Justin Brooten, MD

Thank you so much for joining me today.

00:01:08:18 – 00:01:23:01
Dr. Tammie Quest, MD

Thank you, Justin. 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 am a team player so excited to be here and thank you for having me.

 

00:01:24:17 – 00:01:33:00
Dr. Justin Brooten, MD

So, looking back on the different roles you’ve had through the years, what surprised you the most about your career trajectory?

 

00:01:33:05 – 00:02:11:04
Dr. Tammie Quest, MD

Thanks, Justin, for that light. reflective moment. So, you know, I really think…in thinking about it, I’m in my 24th year being faculty which is just almost impossible to believe. I think that I’ve been surprised by two things. One is really leadership. I never went into medicine to really be a leader, to be honest with you. I went in to medicine to take care of patients, and I was inspired to be an emergency physician through mentors that I saw who were in service of others.

00:02:11:13 – 00:02:31:07
Dr. Tammie Quest, MD

And so, I went into medicine to be in service of others. I never thought, I think in my wildest dreams, that I would end up directing anything. And I thought it was bad enough to be chief resident at Highland to make the schedule. I thought that was really probably about the end of it for me with leadership.

 

00:02:32:04 – 00:03:12:21
Dr. Tammie Quest, MD

And it just really, I think is surprising to me that I’ve had the opportunity to lead some really incredible things. I think that the other, the other piece of that leadership is, 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 an aspiring emergency physician would be able to be president of the academy.

 

00:03:12:21 – 00:03:41:20
Dr. Tammie Quest, MD

It just never would have been anything I would have thought of. And so, 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. So, I think I’ve been really surprised by the by the calls that I’ve had over the years and really graced by the opportunities.

 

00:03:42:01 – 00:03:43:15
Dr. Justin Brooten, MD

Where do you find your inspiration?

 

00:03:45:02 – 00:04:23:13
Dr. Tammie Quest, MD

Yeah, so I am really quite blessed and lucky to say that after many, many, many years in medicine, I guess now of course, many people have many more than I do, but I am really not in a place of compassion fatigue, thank God, and burnout. 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 are all having a worse day than me.

 

00:04:24:01 – 00:04:50:13
Dr. Tammie Quest, MD

So even on my absolute worst day, where I’m thinking I’m having a bad day, I’m not facing serious illness, and I can, I’m just inspired every day to say that’s the reason that we get up in the morning. That’s what this field is about. I was always drawn to distress and suffering, which I actually liked that aspect in the emergency department of being able to meet people in their distress.

 

00:04:50:13 – 00:05:25:12
Dr. Tammie Quest, MD

And I am inspired every day to try to figure out a way to either deliver service or think about how to grow programs and along the way, somehow 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. But I will say that 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.

 

00:05:25:12 – 00:05:27:02
Dr. Tammie Quest, MD

So, they are my inspiration.

 

00:05:27:18 – 00:05:44:23
Dr. Justin Brooten, MD

Yeah, that’s an excellent point. 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 the opportunities just sort of showed up as a result of that. Didn’t just show up, but that was such a big piece of it.

 

00:05:45:00 – 00:05:55:19
Dr. Justin Brooten, MD

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?

 

00:05:56:07 – 00:06:23:14
Dr. Tammie Quest, MD

Yeah, well, I will say when I look back, 1998 was the was the pivotal year. It was the year that I was looking for a job after residency. And there was a lot of, now I wanted to do this thing,  turned out back then we called it end of life care. The word palliative care was actually being coined in its vernacular of being able to be used on a regular basis.

 

00:06:23:14 – 00:06:51:20
Dr. Tammie Quest, MD

But essentially, this this thing that I wanted to do felt in this areas of ethics then and end of life care. And there was not a lot of energy or enthusiasm or support for faculty career in that way. And really, there were a lot of doors that were closed and I started looking. I knew I wanted to do academic medicine to start looking further and wider than I had had wanted to.

 

00:06:51:20 – 00:07:18:16
Dr. Tammie Quest, MD

And I happened upon Arthur Kellerman, MD, by chance at Emory, who said that this was an amazing idea to work in this area. Nobody else was doing that. And he would support me. 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.

 

00:07:18:16 – 00:07:42:23
Dr. Tammie Quest, MD

So, I would say that in the early days it was a lot of no. And I came to Emory and found Emory and stayed at Emory because the answer’s always been yes that this wasn’t a bad idea. And so, surrounding yourself with people who are going to support your dreams is never a bad idea. And it didn’t fail me.

 

00:07:43:16 – 00:08:09:18
Dr. Tammie Quest, MD

And a lot of doors open as a result of that kind of support really early in my career 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. 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.

 

00:08:09:18 – 00:08:30:15
Dr. Tammie Quest, MD

And it really, I think, made the difference between, you know, things happening and not that I believed it when other people didn’t. 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.

 

00:08:31:13 – 00:09:09:00
Dr. Tammie Quest, MD

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? 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, like the institute there, and just telling him, 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.

 

00:09:09:00 – 00:09:30:18
Dr. Tammie Quest, MD

And okay, I was I guess they were inspired by that, that level of tenacity, if nothing else. And that was really very pivotal in my career. So, I will say that a lot of doors opened as as a result of just simply believing it more than anybody else. And it’s just so wonderful now that other people believe it.

 

00:09:30:18 – 00:09:56:01
Dr. Tammie Quest, MD

And those the few of us in the very beginning had to have support groups. So people like Rob Zelinsky and Susan Stone were really pivotal… people like that early in trying to motivate and  support one another that this wasn’t a bad idea.

 

00:09:56:01 – 00:10:12:19
Dr. Justin Brooten, MD

You know, it’s interesting 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,  but that was coming at a time where it had at least gained traction. And really that, the traction, you had to gain.

 

00:10:12:19 – 00:10:34:09
Dr. Justin Brooten, MD

I mean, that all uphill. But because it was such a new concept and 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. But just this idea of trying to integrate the two was so foreign at one time and now, it’s starting to become much more commonplace. And residency programs are talking about it and recognizing this is a need.

 

00:10:34:09 – 00:10:53:13
Dr. Justin Brooten, MD

So you’ve just laid a lot of that foundation which is awesome. It’s hard to probably say that 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 medicine, in palliative care – what accomplishment has been most significant for you personally?

 

00:10:55:02 – 00:11:24:21
Dr. Tammie Quest, MD

So, I get guest privileged to have a tie, so I get two how about that? And they are a tie.

 

Dr. Justin Brooten, MD

Fair enough.

 

Dr. Tammie Quest, MD

Well, I would say that working on the Epic Emergency Medicine Project. So in 2005, I had, remember I was on this, I had this vision maybe in the desert somewhere. Right? And went to the National Cancer Institute and asked for a grant to train emergency clinicians in core palliative care skills.

 

00:11:24:21 – 00:11:52:08
Dr. Tammie Quest, MD

And by happenstance, I’d gone to this this conference called Epic back then and saw somebody stand up in the crowd. And I was really impressed. I said, I think we could do this for emergency clinicians. This might be the way, we train the trainer, that we could build a cadre of emergency clinicians in this nation who can teach, and can teach us, because I probably can’t do this by myself.

 

00:11:53:03 – 00:12:30:03
Dr. Tammie Quest, MD

And that was really very pivotal at the time. We held the first training conference in November of 2007. We had about 40 people show up, which was absolutely a shocker. What we did, Arthur Kellerman, MD, was incredible. He helped me get all the chairs and the SRM Council chairs to try to send somebody from their program 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, we didn’t have any emergency clinicians that actually knew palliative care.

 

00:12:30:14 – 00:13:04:16
Dr. Tammie Quest, MD

So, Frank Harris and 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, the analgesic dosing table for care conversions, all of those things we really spent time to try to train people who are actually going to do this conference. So, when that conference launched in 2007, it was like a dream come true.

 

00:13:05:11 – 00:13:35:01
Dr. Tammie Quest, MD

I didn’t think it was like having a wedding that you sort of thought nobody was going to show up to and people showed up and it was incredible. Sangeeta Lamba, MD, who she and I have collaborated so many times over the years, met at that conference. And I just I felt like, you know, my world was changed because there were other people that finally showed up and have this this idea that maybe this wouldn’t be so bad.

 

00:13:35:01 – 00:13:52:19
Dr. Tammie Quest, MD

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 an out of the box curriculum. The whole concept of Epic emergency medicine is that it’s just out of the box. You can tailor.

 

00:13:53:03 – 00:14:21:15
Dr. Tammie Quest, MD

But here’s the material because we were never taught that as emergency clinicians. And so, the idea of how you’re going to actually get people to know palliative care, who you have no access to it at that time, it was really pivotal. So, I will say that without that cadre of individuals who showed up at those conferences, as in those early years, I don’t think that we as a field would be where we where we are now.

 

00:14:22:01 – 00:15:08:15
Dr. Tammie Quest, MD

So that’s one thing. The second thing that I think is most pivotal and we’ll see is that we’ve had Epic emergency medicine every single year except for during COVID. And we’ll be having our course this fall in October. And I’m hoping that people will want to join that. 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 team to sign on to the subspecialty track, to be able to allow emergency physicians to become board certified in hospice and palliative medicine.

 

00:15:09:18 – 00:15:36:05
Dr. Tammie Quest, MD

That  I think probably ties with the game changer award in our field. 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 this incredible field. We have seen that happen in other specialties. And I was hellbent that that was not going to happen.

 

00:15:36:05 – 00:16:02:02
Dr. Tammie Quest, MD

And I remember bringing together a group of people. We had a wiki page introduced me to that idea and we got the… at that time said What? Why, why do you think this is important for emergency clinicians? And we created a groundswell of people to be able to state why we thought this was important.

 

00:16:02:02 – 00:16:29:07
Dr. Tammie Quest, MD

And I remember writing the white paper and hitting send to the ABM and saying, this is really important. If we don’t do this, this is where we’re going to be shut out. This is not going to be good. That are, are few. The future of our field is at stake here to be able to have people who want to not only be clinicians in emergency medicine, but also clinicians and experts in palliative medicine.

 

00:16:29:07 – 00:17:04:15
Dr. Tammie Quest, MD

And so every time I see a emergency medicine, a clinician who is doing a fellowship, it warms my heart. And I also know how close we came to not that not being a reality. And so I would say that the two things in my life that I 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 fight with people putting one in the sales were those two things.

 

00:17:04:21 – 00:17:06:08
Dr. Tammie Quest, MD

So that’s my tie.

 

00:17:07:17 – 00:17:31:15
Dr. Justin Brooten, MD

Yeah, that’s, that’s well-put. And, and I’m definitely one of the beneficiaries is 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. And palliative care was a big piece of it. So as emergency care, I wanted to take care of sick people, but if that hadn’t been an option, there’s a good chance I would have probably gone like.

 

00:17:31:19 – 00:17:47:19
Dr. Justin Brooten, MD

Like a critical care route or something else, or like an internal medicine route. But I got to have my cake and eat it too, and get to do palliative, still. So, I’m definitely the beneficiary of that. And also, this year we have both of our fellows at our program at Wake are both emergency medicine trained.

00:17:48:04 – 00:18:09:07
Dr. Justin Brooten, MD

So that’s really awesome. It’s actually really fascinating to hear about the pieces coming together. And I like when you said that you are hell bent on getting that in front of them and helping them see how important it was. So, one of the things I was going to ask about was, we’ve made headway in emergency medicine and palliative care integration.

 

00:18:09:07 – 00:18:19:16
Dr. Justin Brooten, MD

It sounds like a big piece of that. It’s really been education, getting curriculum developed, getting programs developed, and also, obviously getting the fellowship pathway. Where do you think the field is headed?

 

00:18:20:11 – 00:18:44:20
Dr. Tammie Quest, MD

Yeah, so wow. It’s just so incredible. 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. So I’m always really excited when I hear about something brand new that’s happened that we’re doing in emergency medicine and palliative care and I had nothing to do with it.

 

00:18:44:20 – 00:19:22:04
Dr. Tammie Quest, MD

It’s fabulous because that means that we’ve actually gotten critical mass in there. Just everything doesn’t revolve around one or two or five or seven people. That’s really incredible. So, I do think that there have been some incredible movers and shakers in our field and advancing the science-created medicine is doing incredible work. Advancing the science and all the people who are working now to work on the largest random, randomized controlled clinical trial for looking at models of care.

 

00:19:22:16 – 00:19:58:04
Dr. Tammie Quest, MD

And so I think that we’ve just gone from, you know, a teeny five articles or something to hundreds and hundreds. Now, I do think that we have work to do on models of care and what is 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 skills.

 

00:19:58:04 – 00:20:35:01
Dr. Tammie Quest, MD

But what are the standards of care? What can we work into for standards of care, like aspirin in acute myocardial infarction? What is the palliative care piece of that? 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. And with that, I think that one of the biggest gaps that the biggest nuts that we have not cracked is really moving away from just academic centers and emergency medicine and palliative care.

 

00:20:35:01 – 00:20:57:05
Dr. Tammie Quest, MD

And so community models, what are the community practice models that become the standard of care? 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. And what sort of things are going to move the entire practice of emergency medicine at its core?

 

00:20:57:21 – 00:21:27:00
Dr. Tammie Quest, MD

Not so much just you happen to be at an academic center with Justin or Tammy or Kay or you pick right all the people in our field. And I could rattle off 20, 20, 30 names of people that I’ve mentored and supported and who changed our field as innovators. 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.

 

00:21:27:14 – 00:21:54:12
Dr. Tammie Quest, MD

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. And so, I think that that is something that needs to be that we need to crack that net some kind of way.

 

00:21:54:20 – 00:22:34:01
Dr. Tammie Quest, MD

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 M is about palliative care. Integration is that education is only a first step. Education alone will not change programs or practice, but without education and that spark 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.

 

00:22:34:08 – 00:22:53:09
Dr. Tammie Quest, MD

Not one skill, but a suite of skills, right? They need to know death disclosure. They need to know equianalgesic dosing. They need to know how to control nausea and vomiting. They need to know best evidence for dyspnea management. They need to know how to break bad news. They need to know how to have a goals of care conversation.

 

00:22:53:09 – 00:23:25:06
Dr. Tammie Quest, MD

They need to know how to take care of a patient who’s in hospice care, who comes in their emergency department. They need to be able to refer somebody to hospice. How do we ensure that for every resident? And I actually do not think that we have a qualified teacher at every program in the nation. Why is that? Because I still get asked to speak in emergency medicine programs and residents are telling me that they are not getting these skills.

00:23:25:06 – 00:23:57:15
Dr. Tammie Quest, MD

They’re not getting the things that they need. I’ve been so graced over the years here at Emory and the leadership has really embraced palliative care. 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. And we started with death disclosure and then we went to a foundational palliative care skills, career skills, knowledge and skills-based curriculum simulation and now a rotation.

00:23:58:09 – 00:24:26:08
Dr. Tammie Quest, MD

And so that’s great that we can have that here. Isn’t that fabulous that we can have that here? But that’s not good enough, right? Because it’s not everywhere. So, the fact that it’s good in my spot or is better, it’s probably not the best. I’m sure somebody else out there is doing even more than we’re doing, but it’s never going to be right until every program has that and every emergency medicine resident that is trained is able to do that.

 

00:24:26:08 – 00:24:50:06
Dr. Tammie Quest, MD

And we also have a retraining problem because we always have the old dogs new tricks. And I’m one of those old dogs. So, it’s really hard when we come up with a new thing in the head, I’m like, Noooo… So I do think that foundationally we’ve got to really ensure that everybody in every emergency medicine program has a qualified teacher.

 

00:24:51:03 – 00:24:58:06
Dr. Tammie Quest, MD

And that that is the starting place is that every program needs a qualified teacher. And I don’t believe that we have that universally.

 

00:25:00:03 – 00:25:27:18
Dr. Justin Brooten, MD

That is a really excellent overview of kind of the mission moving forward. I think 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. And then as the as people get training, there’s still is that trickle down process in the community because you’re right, I can see where even here, you know, implementing things in an academic center, you have some momentum for it.

 

00:25:27:18 – 00:25:45:05
Dr. Justin Brooten, MD

But then being able to change practice in the community, that’s a it takes time and people have to see a priority for it too because it you’re asking people to invest time on the front end and how they communicate and 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…

 

00:25:45:05 – 00:26:04:03
Dr. Justin Brooten, MD

On the flip side, you know, the time that I invest in that difficult conversation, is that going to help? Is that going to get them, you know, where they want, where we think they should be as clinicians? But also we 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 the department to take care of those situation.

 

00:26:04:03 – 00:26:25:04
Dr. Justin Brooten, MD

So how do you implement resources in a way that’s going to work with their workflow? That’s a really excellent overview of kind of the mission ahead. And this next question, this is kind of a broad question that that really could be multiple parts.

 

00:26:26:07 – 00:26:53:16
Dr. Justin Brooten, MD

You’ve already you’ve done work, obviously, in education in so many areas of part of current EDI integration. 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. So what are your thoughts on how an REID focus informs our approach to point of care in emergency medicine in the greater sphere of palliative care now and in the future?

 

00:26:54:19 – 00:27:25:16
Dr. Tammie Quest, MD

Yeah. Thanks, Justin. So one of the reasons that I went into emergency medicine was because I absolutely loved the fact that every everybody gets care when they arrive, irrespective of if you can pay, what you look like. 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.

 

00:27:25:16 – 00:27:56:22
Dr. Tammie Quest, MD

And so working in an emergency department, almost without exception, you were going to take care of vulnerable patients. Yes, even the most swank emergency department will take care of vulnerable patients. So I think that fundamentally, we have to be true to our mission, that the emergency department is the funnel of all disparity.

 

00:27:57:10 – 00:28:25:09
Dr. Tammie Quest, MD

It’s the final common pathway. And so one of the 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, you know, 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.

 

00:28:27:05 – 00:28:57:07
Dr. Tammie Quest, MD

And so, when we see those kinds of things, we ought to be thinking and reminding that we thinking about and reminding ourselves how much of advocates we are. And while particularly after pandemic conditions and all of the compassion fatigue that we are experiencing and it really, it’s imperative that we remember why we’re there in the emergency department.

 

00:28:57:07 – 00:29:20:20
Dr. Tammie Quest, MD

And so as you see patients that are either suffering with serious illness or being diagnosed with new stories, illness that they didn’t even know they had before, remembering that we’re still advocates, I’d like to sort of think a little bit about the patient that comes to the emergency department who’s under hospice care. And the first thing somebody might say is, why are they here?

 

00:29:20:20 – 00:30:02:03
Dr. Tammie Quest, MD

Well, actually, hospice care in America is broken. Newsflash, the Medicare hospice benefit does not does not cover much of what people need, which includes caregivers and 24-hour support that is that is needed. Medicare doesn’t cover long-term care. And so, when you have vulnerable patients who are coming to an emergency department and they’re suffering with serious illness, and their caregivers still have to work because somebody has to put food on the table and they don’t have Medicaid or private pay to be able to get long-term care.

 

00:30:02:03 – 00:30:25:10
Dr. Tammie Quest, MD

And the Medicare hospice benefit, it’s been even more it’s getting more stringent for inpatient days 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. And so, the inability to access the kind of services that they that they need, hospice care works really well.

 

00:30:25:10 – 00:30:51:16
Dr. Tammie Quest, MD

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 keep you from being homeless. 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.

 

00:30:52:04 – 00:31:18:23
Dr. Tammie Quest, MD

Actually, you don’t live in their house, you don’t know what it’s like. And you know that hospice agency may not have actually responded. I’m still looking for hospice response times by neighborhood because I am not always convinced that every neighborhood gets the same response time and so which patients are going to be more phone  managed versus the nurse is going to be right out there.

 

00:31:19:19 – 00:31:39:15
Dr. Tammie Quest, MD

And if you are if you’re at home and it’s three in the morning and there’s hospice agency and you live in a bad neighborhood and they don’t want to come to 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, you know?

 

00:31:40:02 – 00:32:03:07
Dr. Tammie Quest, MD

Yeah, it looks like well, maybe they didn’t get it, you know, but maybe there’s a little bit more to that story. And so, I think the being able to unpack more, some of the reasons that people access emergency care, end of life, I don’t always think that it’s on them. I think that we often blame the patient for being in the emergency department at end of life.

 

00:32:03:07 – 00:32:43:01
Dr. Tammie Quest, MD

And what I can tell you 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. And those things only get harder as you start dying. And so being able to really move the needle of an advocacy for what patients need as opposed to making them the problem, the fact that they called 911, that is a really important first step, I think, to add diversity, equity, inclusion and justice.

 

00:32:44:18 – 00:33:04:19
Dr. Justin Brooten, MD

That is, you know, that’s a that’s a great way of articulating that. And one thing that we’re 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 going to be in the bad neighborhood. They are going to be in the neighborhoods where there’s maybe a longer hospice response time.

 

00:33:04:19 – 00:33:25:12
Dr. Justin Brooten, MD

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. But you’re absolutely right. And 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.

 

00:33:25:12 – 00:33:46:13
Dr. Justin Brooten, MD

They’re scared, they’re terrified, the patient is uncomfortable. Exactly what they’re going to do is call 911. And you also want to make sure you’re empowering your emergency workers to be able to handle the situations with a broader scope they can to hopefully help keep the patient at home if that’s what they want. But you’re right, there’s all those things that people deal with get harder if they’re there dealing with dying.

 

00:33:47:09 – 00:34:16:05
Dr. Tammie Quest, MD

And I will say, you know, here, sometimes the way I would think about that also is that an ED visit at end of life, we see that as a failure. In fact, I think that in and of itself, the fact that we have marked emergency department visits at end of life as a failure in vulnerable populations, I think we need to we need to actually re-look at that.

 

00:34:16:23 – 00:34:55:14
Dr. Tammie Quest, MD

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, we think of financial disparity, we think about all of the inequities in health and access to care, which many, many of those things in this country are tied to financial resources.

 

00:34:56:08 – 00:35:19:01
Dr. Tammie Quest, MD

And so, I just think we need to think deeper about these about these issues. And I think stopping at 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.

 

00:35:19:01 – 00:35:36:23
Dr. Justin Brooten, MD

Yeah, I think that’s a great point. And I agree with you. 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 people with symptoms that end of life that are difficult to manage. And they’re going to call 911 and they’re going to need an emergency physician to help address those things.

 

00:35:36:23 – 00:36:09:23
Dr. Justin Brooten, MD

Sometimes in the in the abruptness and the emergent nature of it. So now I agree with you. I think we shouldn’t look at that as a as a as a negative. And I’m and I’m very much on board with you. I felt like that’s one of the things I love about emergency medicine, too, is just that the office is open, you know, it’s it hopefully it’s something that, you know, hopefully it’s not a stubbed toe at two in the morning but it’s going to be that, I agree, I like that 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.

 

00:36:09:23 – 00:36:27:11
Dr. Justin Brooten, MD

And I saw that in EMS to you. You’d go to some homes that, you know, because I was in 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 and a space heater. And that was, that was their existence, you know.

 

00:36:27:11 – 00:36:38:18
Dr. Justin Brooten, MD

And you’d see some you’d see some things that you just would not expect to see in the United States. You’d expect to see it on a on a medical mission trip. But we have patients that live like that every day.

 

00:36:39:09 – 00:37:02:19
Dr. Tammie Quest, MD

Yeah. And I for the way that many of my patients live, most of us probably cannot live a night like that. And so being able to be in a space and, you know, patients clean it up, right. For us so and their families. And so EMS is a real window and even, you know, I think I’ve done all the jobs in in hospice and palliative care.

 

00:37:02:20 – 00:37:39:18
Dr. Tammie Quest, MD

I’ve been a hospice medical director. I’ve done home visits. I’ve done all those things. And I would always be amazed when I go into homes what sort of challenges people are dealing with. Right? So keeping the electricity on to keep the concentrator going is not a small point. And so having to go to the hospital or wait the new inpatient bed and your concentrator is off because there’s no electricity, I mean, these are just really fundamental kind of root cause analysis of like, why is this person in the emergency department?

 

00:37:39:18 – 00:37:44:13
Dr. Tammie Quest, MD

I mean, you know, because they’re they don’t have anybody to pay their electricity bill. That’s why so.

 

00:37:45:08 – 00:38:07:00
Dr. Justin Brooten, MD

Absolutely. My last question. I mean, I feel like we’ve covered a lot and it’s been really just fascinating to hear your perspective and all the different experiences you’ve had. What gaps do you think still exist in our training and preparation of future clinicians and emergency medicine and palliative care who are going to continue to address these needs in emergency settings?

 

00:38:07:12 – 00:38:41:13
Dr. Tammie Quest, MD

Yeah. So, I think the gap really is that you can’t just do one, one thing and feel like you’re done in education of an emergency medicine residency and training. So, you can’t just, just know the testing table and feel like, you know, oh, boy, you know, oral I.V. morphine, 3 to 1 year. Being able to actually get an entire skill set is really important.

 

00:38:41:13 – 00:39:21:05
Dr. Tammie Quest, MD

You can’t just be able to break bad news. It’s just not good enough. And so what I think where we’re lacking in in many emergency medicine training programs is, is wraparound skill set, 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.

 

00:39:22:03 – 00:40:06:09
Dr. Tammie Quest, MD

And that was that’s that stuck with me. Okay. And like very young mind was, Kathy said, if you can’t manage pain, there’s nothing to talk about. And so, I would just ruminate on that. You know, not being able to manage pain in an emergency department. And it’s really interesting. I feel like the opioid crisis that we have experienced in our 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.

 

00:40:06:09 – 00:40:41:14
Dr. Tammie Quest, MD

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 if it’s fascinating when I just ask emergency clinicians to explain hospice care to me and they don’t really understand it. They don’t understand that it’s a package and that the hospice is a care manager and, you know, all of these things and how the insurance works and what’s in and what’s out.

 

00:40:41:22 – 00:41:15:18
Dr. Tammie Quest, MD

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. And I think what’s really missing for most emergency medicine residents, I don’t actually have this nationwide data, but I will just say anecdotally, it’s just the wrap-around package that you get, the symptom management, you get the communication skills, you get the systems of care that you get all of those things reliably and consistently.

 

00:41:16:01 – 00:42:06:10
Dr. Tammie Quest, MD

We would never let an emergency medicine resident now leave the emergency department without, or emergency medicine training program, without ultrasound training. That’s just standard of care now, right? In training. And so, what do we do? We hire ultrasound education directors, right? To be able to do that. And while we may not need that level of intensity, we do 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. And, maybe take a week off for another rotation that they think is so incredibly critical to their development.

 

00:42:06:20 – 00:42:52:18
Dr. Tammie Quest, MD

For them to be on a palliative medicine service or to have a hospice rotation or something. And so, we just haven’t, I think that’s just a gap. I think that work programs are doing pieces, bits and pieces here that it’s not, you can’t just do communication skills, you can’t just do symptom management. You got to have wraparound 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 and I’m so glad that there are people in our field who are working to actually go to the point of certification or certification exams and palliative care content.

 

00:42:54:10 – 00:43:11:22
Dr. Tammie Quest, MD

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 wraparound education in all the domains to ensure their skill and competency.

 

00:43:11:22 – 00:43:40:18
Dr. Justin Brooten, MD

Excellent. Well, this has just really been enlightening. I’ve enjoyed just hearing your experiences and your perspective 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. 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 and continue to pass along those, those principles.

 

00:43:40:18 – 00:43:57:09
Dr. Justin Brooten, MD

And like and I agree with what you said. You know, you know that something’s really taken off where you don’t have to be the center cog for it to work. You’re disseminating the information. Other people are picking it up and running with it. So I’ve really enjoyed this. And thanks so much for joining me for this podcast.

 

00:43:58:07 – 00:44:22:08
Dr. Tammie Quest, MD

Thanks, Justin. Thanks everyone out there for believing in this as much as I do. 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. So, we’re all here because, because we know it’s the right thing to do. So, I appreciate everybody.

 

00:44:22:08 – 00:44:32:02
Dr. Justin Brooten, MD

Thank you. For more information on current topics in the fields of palliative and emergency medicine, please visit PalliEM.org.