So as I am getting closer to needed to choose a specialty I am confused at what I want to do. I know you can get a residency in Family Med then do a hospice fellowship or the same with Internal med. I am really interested in doing Hospice but am also really leaning toward Emergency Medicine. Are there any options after an EM residency to pursue a career in hospice? and would it even be practical to say work part time in each. Any info you have would be appreciated.
EM and Hospice?
- Thread starter Jondoetag
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Hospice and palliative care is an accredited EM fellowship (that was sponsored along with American Board of Internal Medicine, the lead and administrative board; American Board of Anesthesiology, American Board of Family Medicine, American Board of Obstetrics and Gynecology, American Board of Pediatrics, American Board of Physical Medicine and Rehabilitation, American Board of Psychiatry and Neurology, American Board of Radiology, and American Board of Surgery).
So, you see a wide range there (like radiology and EM). However, at the same time, I kinda scratched my head when I first heard about this with EM, as we only see these patients when either a frazzled family member/POA revokes the hospice status, or there's a breakthrough, and that is still a quandary because the regimens used get very precise and specific as each patient moves ahead in their progression. There's not a lot of hospice/pal care that is applicable on a regular old shift in the ED.
However, it's there if you want it. You'll just be doing extra time outside the full-time shifts in the ED. If you can find a group that will support that, that's optimal. Otherwise, it's one of several options - less in the ED to do the hospice time, full time in the ED plus extra in hospice, or month by month blocking. Also, though, if a patient needs you while you're in the ED, if it's not a block situation, I'm not sure how that is managed.
So, you see a wide range there (like radiology and EM). However, at the same time, I kinda scratched my head when I first heard about this with EM, as we only see these patients when either a frazzled family member/POA revokes the hospice status, or there's a breakthrough, and that is still a quandary because the regimens used get very precise and specific as each patient moves ahead in their progression. There's not a lot of hospice/pal care that is applicable on a regular old shift in the ED.
However, it's there if you want it. You'll just be doing extra time outside the full-time shifts in the ED. If you can find a group that will support that, that's optimal. Otherwise, it's one of several options - less in the ED to do the hospice time, full time in the ED plus extra in hospice, or month by month blocking. Also, though, if a patient needs you while you're in the ED, if it's not a block situation, I'm not sure how that is managed.
Yea I guess what I was getting at is I want to provide hospice care in the community because I love it but still want to work as an EM doc too. I was thinking cutting hours in the ER and picking those up in hospice work in the community or in the hospice centers that are located around town. I just wasn't sure if you could work "part time EM" and "part time hospice doc".
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Yes, I personally know of two doctors who do this and very much enjoy it.
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Are they EM?
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Yes, sorry, both are part time EM/part time hospice docs.
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I've considered it.
I see so many bad deaths, that it's a privilege to walk a family through a good one.
I see so many bad deaths, that it's a privilege to walk a family through a good one.
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I am an EM trained doc and have done fellowship in HPM. I do occasional shifts in the ED, run an inpatient/outpatient Palliative care service and do hospice. There is far more overlap in the specialties than you would think. The hours and lifestyle for HPM are far more humane than EM, I haven't missed any of my kids events and haven't worked an overnight shift since I switched.
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Please, expand on this. I ask because, being a practicing EP, I have not seen many opportunities that I feel I was underprepared to see or undertrained to handle.
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How many times have you seen the same contracted old dementia patient brought in from the nursing home for sepsis? Worse yet how many times have you intubated this guy and admitted him to the unit? How many times have you told the family members he "needs the ventilator" to stabilize him ignoring the fact he is at the end of life and all we are doing is prolonging his dying by artificial means. We kid ourselves we are saving lives in these cases. When patients and families are told the truth about these events they choose more appropriate therapies. I work shifts in a major tertiary referal center. When I tell the families this is what the end of life looks like for their disease and cpr/mechanical ventilation/artificial nutrition and hydration are not likely to be helpful they tend to have realistic expectations and make good decisions. Before fellowship I would admit 3 patients a shift to the ICU, now usuall one to the unit and 2 to the palliative floor. The patient still dies but does so with comfort and family around, not on a vent.(most hospital deaths are on vents and most patients say they would never want that if they were told it was likely)
Most ED docs are uncomfortable talking about it with families and most don't even know Medicare has hospice criteria that can help back up the fact these are dying patients with six month or less life expectancy. Most ED docs are uncomfortable calling it what it is.
The other area of overlap is expertise in pain and symptom control. How many of patients are there because something hurts?
I now longer intubate dying patients at the end of life without discussing it with the family if possible. II am emboldened by the concept of appropriateness/futility. Patients are getting care that is medically appropriate for their disease.
Most ED docs are uncomfortable talking about it with families and most don't even know Medicare has hospice criteria that can help back up the fact these are dying patients with six month or less life expectancy. Most ED docs are uncomfortable calling it what it is.
The other area of overlap is expertise in pain and symptom control. How many of patients are there because something hurts?
I now longer intubate dying patients at the end of life without discussing it with the family if possible. II am emboldened by the concept of appropriateness/futility. Patients are getting care that is medically appropriate for their disease.
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From what you've said, I guess I don't have to do a fellowship, because all of what you've said, I do. I even have a pat speech - "We can do everything, and, if you say yes or nothing, we will do it, but, in a word, it is barbaric. What we do to the body of your loved one, for just another 2 or 3 days, maybe, I would not do for my family. It is up to you, but I can guide you. You are not alone during these terrible times."
This, though:
Really? What do you do for the "fibromyalgia" people? "Hospice and Palliative Care" clearly states end of life care; palliation is not improving or trying to correct, but making the best of what is left. Or how does HPM handle nonspecific abdominal pain? I am being completely sincere.
I am not dinging you. Even in parts of specialties that I think are BS, you would be hard pressed to find anyone whom I have derided that are bona fide trying to do the right thing. I shall plainly admit I'm a thief (or appropriator, as I don't actually "take" something that you can no longer use), and, if I get some good stuff from here, for example, I'll integrate it into my practice and use it.
Thank you.
This, though:
Really? What do you do for the "fibromyalgia" people? "Hospice and Palliative Care" clearly states end of life care; palliation is not improving or trying to correct, but making the best of what is left. Or how does HPM handle nonspecific abdominal pain? I am being completely sincere.
I am not dinging you. Even in parts of specialties that I think are BS, you would be hard pressed to find anyone whom I have derided that are bona fide trying to do the right thing. I shall plainly admit I'm a thief (or appropriator, as I don't actually "take" something that you can no longer use), and, if I get some good stuff from here, for example, I'll integrate it into my practice and use it.
Thank you.
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If that is your "pat speech" than the OP indeed has a wide open career in academics helping people in EM learn more effective ways of communicating. I would be horrified if a physician approached me in a time of crisis with words like the ones you did above, and I would imagine a Hospice Palliative Care trained EM provider would be better equipped to lead the discussion.
The reality is that the overwhelming majority of EM providers are NOT comfortable having the conversation, and those that ARE comfortable do it in a woefully poor fashion (see example above). There is a tremendous need for more training in this in our field.
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Really? Really? Should I show you the letters thanking me for not "terrorizing" family members? Are you really "horrified"? All I know is, is that, for people in crisis with family members, they thank me, not curse me, and for you to say it is "woefully poor fashion" is unsubstantiated and poorly thought out (if at all).
To use your mentality, clearly, you have never had the "do everything" talk with a family member. Your withering perspective as a minimally experienced post-grad, versus psychologically challenged family member in crisis, yields little value - no, no value.
Or, if you are saying that intubation and CPR is NOT barbaric, then you are simply screwed up.
If you want "horrifying", I can refer you back to a post I put up in response to someone else stating something else was horrifying: "'Horrifying is raped with a broken stake. Horrifying is shot in the face with a shotgun over a drug deal. Horrifying is a 4 year old child starved to death by parents, who insist "she's faking it"."
Or maybe it's just in the way I say it. "Your father is very ill. He is near death, but he is not dead yet. I am wondering if he had any wishes about times like this, towards the end of life. If you want us to do everything, or you don't say anything, we will do everything we can to try and save him. However, we might not be able to save him, and the things we do, if you saw it, you might very likely think are barbaric. I would not do it for my family. It is up to you, but I can guide you. You are not alone during these terrible times."
That is about the gist of what I've said, every time. Now, if you find that 'horrifying', the only thing I can tell you is you REALLY haven't done it yet (because you've always had backup), or you can just kiss my ***, because the lay public, anecdotally, does not agree with you.
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The sad thing is that there is nothing that I will be able to say in response will change your holier-than-thou attitude. I am open to learning more effective ways of communicating with families and patients in crisis, it sounds like you are not. Training in the field of HPM has much to offer for those of us willing to be receptive to changing our practice patterns instead of sitting with our arms crossed saying "I don't need that, I am good enough" (and then demonstrating the example of how NOT to communicate).
Do you offer the same level of condescension towards our other subspecialties? Do you argue that advanced training in ultrasound is unnecessary because you "already know everything" about that field? What makes HPM (a subspecialty recognized by ACEP) less worthy of your respect?
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I'll just call you "hypocrite".
Let's recap: I said what I do. You vilify me - your subjective opinion - and say I'm wrong. I say that it works, and my evidence is anecdotal, but it is evidence. It works, in reality, versus your abstract, unsupported statement. You go with acrimony from the outset (which I did not do while questioning the EM/HPM guy - I was only cordial and polite), so I return tit for tat.
Then, you say I am closed-minded and can't learn anything new. Huh? First, let's recap again - what I say works for me, irrespective of your opinion. If it works, why should I change? Do you have a better way? No, you don't - you, instead, use the opportunity you have for more criticism (again, based on something you made up out of whole cloth), and hew very closely to the line of Burnett's Law. Your criticism is not constructive - it's just you complaining. And the hypocrisy? You call me condescending, when that just drips from both of your posts (and you condescended first).
And ultrasound has a LOT more bearing on EM than HPM. But I'm not a concrete thinker or a splitter, as you sound like - if I could learn the U/S I needed, then I wouldn't need the fellowship. But where did I say HPM was a total loss? (That's the concrete thinking - black and white, no grey, throw the baby out with the bathwater.) I didn't. I just wanted to know how this would apply to patients we see very often in the ED. That would be a chance for me to expand my practice (irrespective of your bloated sense of self worth, equating mine with a 'holier-than-thou' attitude - if ANYONE has that, it's you, buddy), yet, for some reason, which sounds like it comes from emotion, you take to be an indictment of HPM in total.
So, if you can actually state something constructive, like why you think my DNR speech (which, from your posting, it sounds like you haven't given yet) fails (even though it doesn't, where the rubber meets the road), instead of just that it sucks. Maybe you haven't heard the adage (or, "horrifyingly", you did, but choose to ignore it) "Don't tell me I suck. Tell me why I suck."
You had opportunity for a teaching moment, from your perspective, at least, but you squandered that just to complain and sound like an effete prig.
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First off, I don't think palliative care is specifically end of life. Hospice is but palliative care encompasses "life-limiting" disease but does not specify wether the limitations are length of life or functional limitations. I have lots of folks in my practice with scleroderma-they arent't dying today but they are suffering. I see plenty of errors taking place with cancer pain management from the ED just because we aren't taught pharmacology of pain meds. Someone with bone mets on methdone for pain is going to little relief from 2 vicodin yet I see it done all the time.
Going back to your original question about where there is overlap in HPM and EM, I'm glad you are comfortable having the end of life discussion. It does not need to be done perfectly but it does need to be done. I'm not criticizing your approach because I'm sure it is quite appropriate in the moment. I have found knowing the typical outcomes and having more familiarity with what happens downstream from the ED makes me much more thoughtful and rational with my decisions and recommendations when I'm in the ED.
I don't have much for the fibromyalgics and the chronic abdominal pain patients in the ED but when they come in on 300mg a day of oxycodone(as outpatients) and have a compartment syndrome I know how to get their pain under control.
Going back to your original question about where there is overlap in HPM and EM, I'm glad you are comfortable having the end of life discussion. It does not need to be done perfectly but it does need to be done. I'm not criticizing your approach because I'm sure it is quite appropriate in the moment. I have found knowing the typical outcomes and having more familiarity with what happens downstream from the ED makes me much more thoughtful and rational with my decisions and recommendations when I'm in the ED.
I don't have much for the fibromyalgics and the chronic abdominal pain patients in the ED but when they come in on 300mg a day of oxycodone(as outpatients) and have a compartment syndrome I know how to get their pain under control.
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I find that interesting that you do what sounds like pain medicine (the not terminal pts). How does HPM compare and contrast with fellowship trained (i.e. not just anesthesiologists, but GSx, neurology, PM&R, IM, and others) pain docs?
Also, along those lines, how much do you overlap with the other specialties (like onc for the cancer pts or rheum for the PSS, for example)? I might think that HPM would get some of the growing pains like EM did 30+ years ago, as HPM, like EM, is synthetic across fields (or, looks at patients from a different direction), and there could be conflict between the HPM and the "old guard" of the individual specialties.
(And I thought that the treatment for compartment syndrome pain is fasciotomy! - but, if there's something else besides Dilaudid for acute compartment pain, I'm all ears.)
This is all news to me, and, you being an EM doc, there is a perspective we (or at least I) find to which I can relate. Thanks!
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Palliative medicine is not end of life care. Palliative medicine is medicine aimed at easing pain and suffering. It's something every physician practices and it begins at the time of diagnosis. It's everything from Tylenol, Zofran, and informed consent to advanced directives, hospice, and the kind of lengthy patient education that is becoming increasingly rare.
Palliative care specialists are just stepping in when the patient requires a greater amount of time or experience than the non-specialists can provide the same way a cardiologist steps in when the primary finds himself out of his comfort zone. The exact domain of palliative specialists is going to vary from place to place (just as every other specialty does) but the belief that palliative care is only for those on their death bed causes consistent delays in appropriate consults...
What I find confusing is that people in a specialty as broad as EM find it difficult to imagine how someone could carve a niche specializing in one of the many facets of the field. Someone wants to do Interventional Cardiology and Fertility Medicine? Sure, I can see skepticism. But I can't think of many fields that don't have at least some overlap with emergency medicine.
To me the overlap is pretty obvious. Emergency medicine is full of patients dealing with end-of-life issues, patient who can only be offered symptomatic treatment, and patients in desperate need of some medical education. Having a local pediatrics expert or ultrasound guy or toxicology girl wouldn't even raise an eyebrow but I'd wager there are just as many, if not more, patients who would benefit from some palliative care expertise...
Edit:
Maybe my opinion has been biased by an unusually strong palliative care program. if anything, however, I think that just represents where palliative medicine is heading. Just as emergency medicine pulled itself away from "glorified triage nurses and burnt-out family physicians", palliative medicine is pulling itself away from "hospice doctors".
Palliative care specialists are just stepping in when the patient requires a greater amount of time or experience than the non-specialists can provide the same way a cardiologist steps in when the primary finds himself out of his comfort zone. The exact domain of palliative specialists is going to vary from place to place (just as every other specialty does) but the belief that palliative care is only for those on their death bed causes consistent delays in appropriate consults...
What I find confusing is that people in a specialty as broad as EM find it difficult to imagine how someone could carve a niche specializing in one of the many facets of the field. Someone wants to do Interventional Cardiology and Fertility Medicine? Sure, I can see skepticism. But I can't think of many fields that don't have at least some overlap with emergency medicine.
To me the overlap is pretty obvious. Emergency medicine is full of patients dealing with end-of-life issues, patient who can only be offered symptomatic treatment, and patients in desperate need of some medical education. Having a local pediatrics expert or ultrasound guy or toxicology girl wouldn't even raise an eyebrow but I'd wager there are just as many, if not more, patients who would benefit from some palliative care expertise...
Edit:
Maybe my opinion has been biased by an unusually strong palliative care program. if anything, however, I think that just represents where palliative medicine is heading. Just as emergency medicine pulled itself away from "glorified triage nurses and burnt-out family physicians", palliative medicine is pulling itself away from "hospice doctors".
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I didn't mention the definative treatment for compartment syndrome but you are correct it is fasciotomy. Dilaudid is a good choice but typically someone like this would require a dose higher than most are willing to give in order to acheive an effect. Usuall start with an equianalgesic dose of dilaudid for 10-20% of their daily scheduled dose. You can repeat at point of maximal effect if some effect or double if none. Peak effect is in 15 minutes for hydromorphone. 1mg of dilaudid IV equals 15-20mg oxycodone. You may start with 2mg and can go to giving another 4mg in 15 minutes if no effect. My ED nurses won't give this, they would make me push the meds.
I don't think my practice in non-malignant, non-terminal pain is all that different from the other boarded pain specialists, in fact my state(Ohio) defines me as specialty trained in pain with HPM certification. I routinely diagnose RA and other rheum diseases in my workups and routinely find meds in my spinal mris. I use interventional treatments like a typical pain physician, epidurals, nerve blocks(easy as can be if you have and skills as an EM physician) I refer for PT/OT and psych. I'm not too worried about the old guard of pain, they haven't really held on to it very tightly and there are far too many patients for them to service those in need.
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I didn't mention the definative treatment for compartment syndrome but you are correct it is fasciotomy. Dilaudid is a good choice but typically someone like this would require a dose higher than most are willing to give in order to acheive an effect. Usuall start with an equianalgesic dose of dilaudid for 10-20% of their daily scheduled dose. You can repeat at point of maximal effect if some effect or double if none. Peak effect is in 15 minutes for hydromorphone. 1mg of dilaudid IV equals 15-20mg oxycodone. You may start with 2mg and can go to giving another 4mg in 15 minutes if no effect. My ED nurses won't give this, they would make me push the meds.
I don't think my practice in non-malignant, non-terminal pain is all that different from the other boarded pain specialists, in fact my state(Ohio) defines me as specialty trained in pain with HPM certification. I routinely diagnose RA and other rheum diseases in my workups and routinely find meds in my spinal mris. I use interventional treatments like a typical pain physician, epidurals, nerve blocks(easy as can be if you have and skills as an EM physician) I refer for PT/OT and psych. I'm not too worried about the old guard of pain, they haven't really held on to it very tightly and there are far too many patients for them to service those in need.
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From the "Eligibility Criteria For Certification and Recertification":
"...is designed to recognize excellence among physicians who are specialists in the care of seriously ill and dying patients with life-limiting illness. The field of hospice and palliative medicine is based on expanding scientific knowledge about symptom control when cure is not possible and appropriate care during the last months of life. The major competencies of subspecialist-level hospice and palliative medicine fall under the broad patient-centered goals of:
•
relieving suffering and improving the quality of life for patients and families with life-threatening illness,
•
helping patient and family cope well with loss and engage in effective grieving,
•
comprehensive interdisciplinary team management of the physical, psychosocial, social and spiritual needs of patients and their families,
•
managing and coordination of the array of challenging problems associated with end-of-life care, including the management of the immediately dying patient, and,
•
promoting closure and the possibility of growth at the end of life."
and specifics of a pal care team:
"To qualify, interdisciplinary hospice or palliative care teams must have all of the following characteristics:
(a) provide active clinical care,
(b) hold regular meetings,
(c) have regular membership of a physician, nurse, and at least one other professional from a psychosocial
discipline, and
(d) operate in a context in which a substantial number of the team's patients are near the end of life. It is expected that multidisciplinary team members will be appropriately trained and ultimately certified in Hospice and Palliative Medicine."
So, actually, it seems that pal care IS end of life care, or at least the majority. I applaud those that are dedicated to such; who was it that said "how we die is indicative of how we live"? To pull away from "hospice docs" seems to superimpose on pain docs (who, as I said, are drawn from all sorts of specialties, crossing all sorts of lines), and, if "HPM" is going towards "hPM", how does that differ from pain medicine? Or, in other words, if the HPM subspecialist certified is treating a panel of patients that are not going to die from their condition or illness, how does the HPM doc differ from the pain medicine doc (who, I believe, might refer to HPM if their patients were to find themselves dying)? Axehandler's described skill set seems to be substantially similar to that of a pain medicine certified doc.
I'm going to ask the pain medicine docs the same thing.
Wayne State Univ has a Division of Palliative Emergency Medicine in its Department of Emergency Medicine.
http://emergencymed.med.wayne.edu/palliative_care.php
http://emergencymed.med.wayne.edu/palliative_care.php
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Yes, the field of "Hospice AND Palliative Medicine" involves terminal illness. That doesn't change the definition of palliative care. OB-GYN heavily emphasizes pregnancy but that doesn't negate the broad spectrum of non-pregnant gynecologic issues.
Yes, there's overlap between palliative care and pain medicine just like there is overlap between family practice and pediatrics. Pain medicine focuses on really mastering the treatment of physical pain. Palliative care spreads itself over a larger set of symptoms and (when combined with hospice medicine) includes care in situations where increased mortality is not an absolute contraindication...
Yes, there's overlap between palliative care and pain medicine just like there is overlap between family practice and pediatrics. Pain medicine focuses on really mastering the treatment of physical pain. Palliative care spreads itself over a larger set of symptoms and (when combined with hospice medicine) includes care in situations where increased mortality is not an absolute contraindication...
