Fellowship has so far proven to be the most enjoyable experience of my medical career. Granted it is still early in the year, learning the subspecialty day-by-day has been IMMENSELY rewarding. The clinical approach, the medications, the tailored regimens, the communication techniques et al are vastly different than in the ED. I feel the dedicated year to learn in becoming a board-certified subspecialist is warranted. My chief year in EM specifically was also very rewarding in many ways but rolling the dice to pursue the fellowship has absolutely proven to be the correct choice for me.
To frame things a bit more, I knew heading into EM residency that HPM was going to be on the radar and I in no way regret my primary specialty choice. I'd choose my EM residency program again 10 times out of 10.
For people on the fence this cycle, I experienced minimal "discrimination" by programs applying as an EM resident. (If you look at old threads, this was a concern of mine back then.) I say minimal in the sense that -- despite ACGME, ABMS, and AAHPM all acknowledging that EM residency is a perfectly fine pathway into HPM -- there were still a few programs that were not interested solely due to me not being IM/FM.
There are 3 of us at my program now. One is IM, one is FM, and I round out the trio with EM... I feel this is an excellent mix as we all bring new experiences, strengths, and goals to the year. We all learn from each other in ways which wouldn't have materialized if we were out of the same primary specialty.
For my EM residents, the lifestyle and daily routine is vastly different than in the pit. I'm at one of the more rigorous academic HPM fellowship programs, with a M-F, 8a-5p, Q3 week overnight call schedule for the entire year -- then add on top of that studying during evenings. Call has been very valuable for education. Additionally, you are learning and getting to practice a field that you love, so this isn't a bad thing. After all, you are doing what you sought to do. One year is a short amount of time to take it all in, so don't fret about "working hard". With that said, overall, a day on service is much less stressful than an ED shift (depending on the person). If you're exploring this field as an option, you likely enjoy talking with patients, prefer not being rushed, wish to relieve suffering, and highly value advocating for your patient's wishes. I'm happy to say that you will do all those things to the nth degree in HPM. Additionally, it was a twilight-zone moment discovering that consultants are happy when you call them back and grateful for your help -- they are the ones consulting you now. Coming out of the ED, this was pretty entertaining to see.
You will have the opportunity to still do some procedures depending on your patients, their primary team, and department culture. Procedures like paracentesis and thoracentesis could be doable for symptom management. On the other hand, you likely won't be intubating or doing chest tubes much anymore.
Patients and families are, as a whole, extremely grateful for your expertise, time, and attention. This is satisfying and a nice cherry-on-top to be appreciated.
Additionally, the team-based nature of the service is amazing. While much of healthcare delivery is now a "team sport", I can't think of many other specialties where that is more true than HPM. Much time is spent in IDT, where literally, you have numerous highly-trained and caring folks putting their minds together to achieve a common goal: make things better for the patient. While the practice of EM is also a team sport, in that the department would crumble without nurses, respiratory, etc... the culture and spirit is just completely different in HPM.
Long story short: if you are interested in being the essence of a physician, striving to relieve suffering in the sick/dying with confirmed pathology, and being part of the squad that gets called when ish hits the fan (in a sense similar to EM in that regard) consider looking more into subspecializing in HPM!
Happy to answer any questions you might have in the future!
It has been a bit over a year now since starting this thread.
Wanted to pop back in and update, esp since there are not a lot of resources out there for EM residents looking towards HPM as a subspecialty.
Fellowship, during the time, and now in the rearview, was phenomenal. I was just talking to my wife this week about something and somehow it came up where she pointed out: "there wasn't a day that year that you came home irritated or complained about something at the hospital". That was powerful to hear. And in retrospect, it was true. Regardless of the service, the team, or the venue -- every day was rewarding.
I hope that carries on as a general trend in my attending job!
Still getting settled in, but for your reference on the type of medicine you can practice coming out of EM residency as an attending if you dedicate 1 extra year to your training (i.e. fellowship):
I work at a large academic center with 50+ residency and fellowship programs, including an EM residency and HPM fellowship (I serve as faculty for the latter).
Depending on the week, I am either working on the inpatient consult service, the inpatient palliative unit, or in our palliative clinic.
Consult service functions for both complex symptom management and assistance with complicated decision-making/goals of care conversations. The team consists of attending, fellow, NP/PA, and any residents or med students that happen to be on the service. It runs M-F and days are flexible in that it is 830-900 to 4-5PM. Weekend coverage for acute consult needs is covered by whoever is the inpatient palliative unit doc for the weekend.
The inpatient palliative unit is for patients with a clear delineation in their desired care and are either transferred to our service or direct admit. We function as the primary team so are in charge of everything -- from high-level palliative sedation decisions -- to placing diet/ambulating orders. Given the circumstances of their disease process and admission status, the mortality rate for the unit is understandable at >50%. We also have some hospice patients on our unit when they need to be admitted for GIP level care. The census is very doable typically ranging between 3-8 pts at any given time. This is a 7-days per week service, so when you are on you're on for 7 days. We are available for overnight calls during this week, but first call goes to the fellow/NP/PA and we are their back-up as needed. It works out to being on home-call about every 5-6 weeks.
Clinic is where we see out folks... you guessed it... in the outpatient clinic. You can have everything from new consults to quick check-ins with patients you have been following for years. Note, however, that even the quick check-ins feel luxurious as there are only 2 types of time slots for bookings: either 60 minutes or 30 minutes. There are no 10-minute bookings or double-booking. Our clinic has a cap of 10 patients per day. It is eye-opening seeing how some PCP colleagues have to see 30+ patients per day. I feel spoiled with a cap of 10, but given the complexity and needs of our patients/families, it is still a day's hard work. The schedule is M-F 830-4 PM. We could have fellows and residents in the clinic any given day, in which case they take on some of those aforementioned 10 patients scheduled for the day.
Benefit-wise, they are quite generous with what works out to be essentially 7-8 weeks PTO. There is a CME fund and a 403b+457 plan with guaranteed employer contributions which work out to about 15k per year extra by the institution. I think I mentioned previously that current compensation hovers around 300. Every day regardless of service I have at least a 1-hour lunch. No complaints really.
Given my background in EM, I have been asked to get involved or eventually spearhead the workflow/protocols with our ED. I haven't taken this on yet, but will perhaps once I get my feet under me. I can see how the background lends to more understanding from the ED doc side of things than perhaps if an IM/FM trained palliative doc was sitting in the same seat.
Many of the folks in EM like to work with "sick" -- let me tell you that you will be working with often times the sickest of the sick. While you won't be focusing on resuscitative emergencies anymore -- there is still a surplus of daily symptomatic emergencies to tend to which given the values and goals of our patients are just as high acuity/importance to manage. Improve things for your patient. Find meaning in your work. Do a good job.
So if HPM is a field where the essence captures your interests and passion, this sort of a career is available to you coming from EM residency. My day to day life is 0% resembling work in the ED, for whatever that is worth. Still would have chosen EM as my primary specialty!
Anyway, I get many PM's about palliative and the EM/HPM mix on here -- please feel free to post those questions or comments on here instead of PM so that those that come after you can benefit from our discussions.
