Frazier

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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!
 
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So refreshing to read this post. I am currently a PGY2 in EM and can honestly already say I don't see myself doing EM for the rest of my life, if at all after residency. HPM is the only fellowship I would even consider, but given that it is mostly pursued by FM and IM folks, I don't feel like I can really get good feedback from my colleagues. Also, no one from my institution has ever pursued it as far as I know. I hear people saying over and over again that you end up taking a big paycut doing straight HPM; but the older I get, the more and more I have come to value quality and not quantity. Do you plan on doing full-time HPM after fellowships or a little of both?
 
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Frazier

Palliative Emergentologist
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So refreshing to read this post. I am currently a PGY2 in EM and can honestly already say I don't see myself doing EM for the rest of my life, if at all after residency. HPM is the only fellowship I would even consider, but given that it is mostly pursued by FM and IM folks, I don't feel like I can really get good feedback from my colleagues. Also, no one from my institution has ever pursued it as far as I know. I hear people saying over and over again that you end up taking a big paycut doing straight HPM; but the older I get, the more and more I have come to value quality and not quantity. Do you plan on doing full-time HPM after fellowships or a little of both?

Glad to hear you are considering it. I was also the first EM resident who has pursued it from my program as well. Most attendings had no idea it was a viable fellowship in EM. A number were largely unhelpful in that they were under the erroneous, albeit common, impression that HPM is "all about death" and "how depressing".

Quite the opposite! HPM is all about living... Living with the best quality of life achievable... Living in a way concordant with one's personal goals and values. To see the appreciation and hope on so many of our patient's faces -- it can often make the work inspiring.

I can appreciate your sense of heading out into uncharted territory.

The juxtaposition of HPM and EM in the lens of pay is real with the scale going both ways. I'll quote myself from another thread since applicable here too:

"The loss of potential overall income with fellowship is not exactly true, if the subspecialty is one that you are willing to do for a substantially longer time (ie actually enjoy it).

For example, with palliative, say one makes 230k per year (average) compared to EM at 350k (likely going to be going down further unfortunately)...

EM let's be generous and say the person "looking to get out" can muster up 10 years if they really have to do so, then retire completely because they are burnt to a complete crisp doing what they don't like for a decade.

3,500,000 lifetime income before taxes.

Now let's compare with pallimed, which pays less than pain, let's say 230k. the schedule and lifestyle are very doable and you have a passion for the work. You enjoy the patient population and going onto service every day. You make a 30 year career out of it.

6,900,000 lifetime earnings before taxes.
Number even higher with other subspecialties.

If you need to get your money fast and dont like the practice of modern day medicine itself, EM is better option. If you like the crux of being a physician and are okay with coming out far ahead via the marathon instead of a sprint -- become a subspecialist. That said, palliative in particular should only be pursued if you have an actual passion for the field and patient population/families."

My original plan was to do a little of both. However, with how the actual daily experience of HPM has been, I cannot imagine myself going back to working EM shifts. I am however interested in helping to bridge the two fields for our patients -- so I will always have some EM exposure, but hopefully not much (any?) in regard to grinding out shifts.
 
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Glad to hear you are considering it. I was also the first EM resident who has pursued it from my program as well. Most attendings had no idea it was a viable fellowship in EM. A number were largely unhelpful in that they were under the erroneous, albeit common, impression that HPM is "all about death" and "how depressing".

Quite the opposite! HPM is all about living... Living with the best quality of life achievable... Living in a way concordant with one's personal goals and values. To see the appreciation and hope on so many of our patient's faces -- it can often make the work inspiring.

I can appreciate your sense of heading out into uncharted territory.

The juxtaposition of HPM and EM in the lens of pay is real with the scale going both ways. I'll quote myself from another thread since applicable here too:

"The loss of potential overall income with fellowship is not exactly true, if the subspecialty is one that you are willing to do for a substantially longer time (ie actually enjoy it).

For example, with palliative, say one makes 230k per year (average) compared to EM at 350k (likely going to be going down further unfortunately)...

EM let's be generous and say the person "looking to get out" can muster up 10 years if they really have to do so, then retire completely because they are burnt to a complete crisp doing what they don't like for a decade.

3,500,000 lifetime income before taxes.

Now let's compare with pallimed, which pays less than pain, let's say 230k. the schedule and lifestyle are very doable and you have a passion for the work. You enjoy the patient population and going onto service every day. You make a 30 year career out of it.

6,900,000 lifetime earnings before taxes.
Number even higher with other subspecialties.

If you need to get your money fast and dont like the practice of modern day medicine itself, EM is better option. If you like the crux of being a physician and are okay with coming out far ahead via the marathon instead of a sprint -- become a subspecialist. That said, palliative in particular should only be pursued if you have an actual passion for the field and patient population/families."

My original plan was to do a little of both. However, with how the actual daily experience of HPM has been, I cannot imagine myself going back to working EM shifts. I am however interested in helping to bridge the two fields for our patients -- so I will always have some EM exposure, but hopefully not much (any?) in regard to grinding out shifts.

Thank you for your response. I definitely have such a tremendous appreciation for the field of HPM and what you guys do. To quote what you said earlier: "HPM is all about living... Living with the best quality of life achievable... Living in a way concordant with one's personal goals and values. To see the appreciation and hope on so many of our patient's faces -- it can often make the work inspiring." This resonates very strongly with me and I couldn't agree with you more. I can see a future in this rather than the grind that is EM. I would much rather make less money doing what I love rather than making more money and being unsatisfied with the work even if it pays the bills quicker.

Unfortunately, I won't have any time left this year to do an HPM elective, so I will plan on doing one during my third year. I hope if I do it early enough (i.e., July) it will not be too late to obtain a LOR. Do you plan on working strictly in the hospital setting after completing fellowship? Any general advice on the application process as a whole would be greatly appreciated.
:)
 

WilcoWorld

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@visceral0775 - Doing an elective at the beginning of PGY-3 is perfectly acceptable. What's really essential is to get some time on a Palliative service to make sure your experience aligns with your expectations. As long as you aren't severely limiting yourself geographically and you apply to a decent # of programs I expect you to match.

On the other hand, doing EM for a few years and then going back to fellowship is another viable option. It's what I did ;)
 
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How this wisdom continues to evade so many is beyond me.
I think many people have the idea during medical school that it's all about money and prestige. I think you quickly realize when you get out into the real world that this couldn't be further from the truth. I'm glad you can appreciate this as well. I can't tell you how many people told me to pursue EM (vs another field I was considering during med school) and they often listed more money as the reason for this. Unfortunately higher salary doesn't = less burnout and greater satisfaction.
 
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@visceral0775 - Doing an elective at the beginning of PGY-3 is perfectly acceptable. What's really essential is to get some time on a Palliative service to make sure your experience aligns with your expectations. As long as you aren't severely limiting yourself geographically and you apply to a decent # of programs I expect you to match.

On the other hand, doing EM for a few years and then going back to fellowship is another viable option. It's what I did ;)
Thank you. Do you continue to do EM as well or are you strictly practicing HPM?
 

Frazier

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Thank you for your response. I definitely have such a tremendous appreciation for the field of HPM and what you guys do. To quote what you said earlier: "HPM is all about living... Living with the best quality of life achievable... Living in a way concordant with one's personal goals and values. To see the appreciation and hope on so many of our patient's faces -- it can often make the work inspiring." This resonates very strongly with me and I couldn't agree with you more. I can see a future in this rather than the grind that is EM. I would much rather make less money doing what I love rather than making more money and being unsatisfied with the work even if it pays the bills quicker.

Unfortunately, I won't have any time left this year to do an HPM elective, so I will plan on doing one during my third year. I hope if I do it early enough (i.e., July) it will not be too late to obtain a LOR. Do you plan on working strictly in the hospital setting after completing fellowship? Any general advice on the application process as a whole would be greatly appreciated.
:)

I imagine working in a hospital setting for my palliative hat as the complex symptom management is hard to beat -- perhaps working up to a department director role, but would also be interested in serving with a community hospice in a medical directorship role part-time as another hat.

Tips:
Apply broadly but no need to over-do it.
Know what you are looking for in a program, because they will ask during interviews (things like exposure to different hospital types, hospice exposures, program size, research availability, etc)
Make sure your application answers why HPM.
Really ensure that your LOR's are handpicked to focus on the skill set and fit of HPM (EM docs writing that you have a great ability to move the meat and amazing procedural skills isn't going to wow anyone in the HPM arena -- make sure they know what to write about since most EM docs have a poor understanding of HPM in my experience at least).
 
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I imagine working in a hospital setting for my palliative hat as the complex symptom management is hard to beat -- perhaps working up to a department director role, but would also be interested in serving with a community hospice in a medical directorship role part-time as another hat.

Tips:
Apply broadly but no need to over-do it.
Know what you are looking for in a program, because they will ask during interviews (things like exposure to different hospital types, hospice exposures, program size, research availability, etc)
Make sure your application answers why HPM.
Really ensure that your LOR's are handpicked to focus on the skill set and fit of HPM (EM docs writing that you have a great ability to move the meat and amazing procedural skills isn't going to wow anyone in the HPM arena -- make sure they know what to write about since most EM docs have a poor understanding of HPM in my experience at least).

Great thank you again, I appreciate the feedback :)
 

TheOther

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Can you highlight how the medicine looks in HPM? I'm an FM PGY-2 somewhat interested in HPM, but from what I've looked into about it, it seems to be about the "art of medicine" in developing the skills to navigate conversations with patients and family members.

I'm curious what the day to day practice of medicine looks like.

I'll be honest, I haven't looked very deeply into the HPM sub-forum so I'll also be doing that.
 

Frazier

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Can you highlight how the medicine looks in HPM? I'm an FM PGY-2 somewhat interested in HPM, but from what I've looked into about it, it seems to be about the "art of medicine" in developing the skills to navigate conversations with patients and family members.

I'm curious what the day to day practice of medicine looks like.

I'll be honest, I haven't looked very deeply into the HPM sub-forum so I'll also be doing that.

As a brief summary...

Communication is a huge part of the field, you are absolutely correct.
There is also plenty of management depending on the sort of position you seek out.

Some SYMPTOMS we manage with the goal of improving care and quality of life for our patients include those such as:
Acute pain / Chronic pain (across the spectrum of somatic, visceral, neuropathic, etc)
Total pain
Dyspnea
Nausea+vomiting
Delirium/agitation
Constipation
Diarrhea
Excess secretions
Pruritis
Fatigue
Loss of appetite
Hiccups
Depression
....

You do anything from prescribing standard tylenol to managing methadone PCA's.
You do anything from aromatherapy for nausea to initiating and managing palliative sedation.

(Keep in mind there is a wide net of underlying conditions that might be causing these things -- which you will thereby be playing a role in managing/understanding as well -- so it helps to be familiar with various regimens spanning surgery, chemo, radiation, etc. It doesn't instill confidence when a patient has questions about their underlying diagnoses and you have zero idea, it is good to have at least ballpark answers and can defer to colleague specialists for very intricate things.)

Depending on your practice you might be doing some procedures such as therapeutic thora's and para's.

Of course there is also plenty of emotional, psychological, social, and spiritual management to be had as well -- which can be tasks shared with your IDT depending on resources.

The above describes clinic and inpatient consult settings where you are not primary team.

If you are working in an inpatient palliative unit, you are primary team and need to manage everything as such -- in addition to the symptoms that landed the patient in the IPU, you will be managing their diabetes, blood pressure, etc.

Your relationship could be a one-time pot shot goals of care visit in the hospital -- or for years longitudinally until their death or culminate in transitioning them onto hospice.

With that said, hospice is an additional arena.

And, again, you are right -- the art of medicine and skillful intentional communication permeates any and every encounter (in addition to the tasks above).
 
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As a brief summary...

Communication is a huge part of the field, you are absolutely correct.
There is also plenty of management depending on the sort of position you seek out.

Some SYMPTOMS we manage with the goal of improving care and quality of life for our patients include those such as:
Acute pain / Chronic pain (across the spectrum of somatic, visceral, neuropathic, etc)
Total pain
Dyspnea
Nausea+vomiting
Delirium/agitation
Constipation
Diarrhea
Excess secretions
Pruritis
Fatigue
Loss of appetite
Hiccups
Depression
....

You do anything from prescribing standard tylenol to managing methadone PCA's.
You do anything from aromatherapy for nausea to initiating and managing palliative sedation.

(Keep in mind there is a wide net of underlying conditions that might be causing these things -- which you will thereby be playing a role in managing/understanding as well -- so it helps to be familiar with various regimens spanning surgery, chemo, radiation, etc. It doesn't instill confidence when a patient has questions about their underlying diagnoses and you have zero idea, it is good to have at least ballpark answers and can defer to colleague specialists for very intricate things.)

Depending on your practice you might be doing some procedures such as therapeutic thora's and para's.

Of course there is also plenty of emotional, psychological, social, and spiritual management to be had as well -- which can be tasks shared with your IDT depending on resources.

The above describes clinic and inpatient consult settings where you are not primary team.

If you are working in an inpatient palliative unit, you are primary team and need to manage everything as such -- in addition to the symptoms that landed the patient in the IPU, you will be managing their diabetes, blood pressure, etc.

Your relationship could be a one-time pot shot goals of care visit in the hospital -- or for years longitudinally until their death or culminate in transitioning them onto hospice.

With that said, hospice is an additional arena.

And, again, you are right -- the art of medicine and skillful intentional communication permeates any and every encounter (in addition to the tasks above).

In your fellowship, do you receive training in a variety of different environments such as hospice, nursing homes, etc? Or are your primarily in a hospital setting?
 

TheOther

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Mar 2, 2015
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As a brief summary...

Communication is a huge part of the field, you are absolutely correct.
There is also plenty of management depending on the sort of position you seek out.

Some SYMPTOMS we manage with the goal of improving care and quality of life for our patients include those such as:
Acute pain / Chronic pain (across the spectrum of somatic, visceral, neuropathic, etc)
Total pain
Dyspnea
Nausea+vomiting
Delirium/agitation
Constipation
Diarrhea
Excess secretions
Pruritis
Fatigue
Loss of appetite
Hiccups
Depression
....

You do anything from prescribing standard tylenol to managing methadone PCA's.
You do anything from aromatherapy for nausea to initiating and managing palliative sedation.

(Keep in mind there is a wide net of underlying conditions that might be causing these things -- which you will thereby be playing a role in managing/understanding as well -- so it helps to be familiar with various regimens spanning surgery, chemo, radiation, etc. It doesn't instill confidence when a patient has questions about their underlying diagnoses and you have zero idea, it is good to have at least ballpark answers and can defer to colleague specialists for very intricate things.)

Depending on your practice you might be doing some procedures such as therapeutic thora's and para's.

Of course there is also plenty of emotional, psychological, social, and spiritual management to be had as well -- which can be tasks shared with your IDT depending on resources.

The above describes clinic and inpatient consult settings where you are not primary team.

If you are working in an inpatient palliative unit, you are primary team and need to manage everything as such -- in addition to the symptoms that landed the patient in the IPU, you will be managing their diabetes, blood pressure, etc.

Your relationship could be a one-time pot shot goals of care visit in the hospital -- or for years longitudinally until their death or culminate in transitioning them onto hospice.

With that said, hospice is an additional arena.

And, again, you are right -- the art of medicine and skillful intentional communication permeates any and every encounter (in addition to the tasks above).
Fantastic. Thanks for taking the time to respond and sharing insight into the field!
 

Frazier

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In your fellowship, do you receive training in a variety of different environments such as hospice, nursing homes, etc? Or are your primarily in a hospital setting?

Great question.

Every ACGME accredited program has required exposures and experiences. So you will always have inpatient exposure, clinic exposure, hospice exposure.

One thing that is more variable is IPU exposure, as not every hospital has an inpatient palliative unit.

At my program, we have rotations including inpatient consults, inpatient palliative unit, inpatient hospice, outpatient hospice, longitudinal clinic, pain management, peds, and electives.

Historically there was a nursing home/senior living rotation, however that got cut for now due to COVID risk mitigation.

It is good variety to explore.
 
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Great question.

Every ACGME accredited program has required exposures and experiences. So you will always have inpatient exposure, clinic exposure, hospice exposure.

One thing that is more variable is IPU exposure, as not every hospital has an inpatient palliative unit.

At my program, we have rotations including inpatient consults, inpatient palliative unit, inpatient hospice, outpatient hospice, longitudinal clinic, pain management, peds, and electives.

It is good variety to explore.
Thank you. More questions soon from me :)
 
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Great question.

Every ACGME accredited program has required exposures and experiences. So you will always have inpatient exposure, clinic exposure, hospice exposure.

One thing that is more variable is IPU exposure, as not every hospital has an inpatient palliative unit.

At my program, we have rotations including inpatient consults, inpatient palliative unit, inpatient hospice, outpatient hospice, longitudinal clinic, pain management, peds, and electives.

Historically there was a nursing home/senior living rotation, however that got cut for now due to COVID risk mitigation.

It is good variety to explore.

I’m currently a pgy-2 EM resident interested in Palli.

What are some projects or QI interventions I can undertake in my current ED to move the objectives of palliative care forward and get more experience in the field?
 

Frazier

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I’m currently a pgy-2 EM resident interested in Palli.

What are some projects or QI interventions I can undertake in my current ED to move the objectives of palliative care forward and get more experience in the field?

Congrats! It has been a phenomenal journey so far on this end!

The opportunities are broad... especially depending on the stature of HPM in your hospital already. There was much room for improvement at my residency program's hospital... so basically anything I thought of wasn't done already and therefore on the table. YMMV.

Undertakings are limited only by creativity really...from doing an actual investigation about XYZ to moving ahead towards actually pushing through policy which you already KNOW is a shortcoming without requiring the formal research process.

Some various topics which would be relatively easy to collect data and/or assess for policy improvement would be:

Palliative-focused order sets (pain, dyspnea, consults, comfort, etc)... do they exist? Utilization rate?
Status of contacting hospices (enrollment or notifications)... is there a process? Streamline it further? Education needed?
Eval of processes for code status assessment in ED.
Palliative care/hospice patient flags on ED tracker.
Time to being seen when known hospice pt (ie are they getting put on the back burner more than non-hospice pts)
Time to being seen for CHF with dyspnea
Time to being seen for COPD with dyspnea
Time to med for known malignancy in pain crisis
Time to med for nausea in known chemo
Time to med for comfort care pt
Education materials that can be given to pts about HPM
Education materials that can be given to pts about symptoms pertinent to their disease
... or something quite specific like Eval of how often pts at end-of-life on hospice show up for difficult to control pain/dyspnea (ie panicking family brings them to ES) and are automatically given 1L IV fluids -- or worse an entire sepsis bundle -- by triage provider.

Etc
Etc

It depends also on your patient population.

...Things can range from educational, to EMR, to actual orders, to communication.

Overall, what is important, if you choose to go down that road, is that you are striving to advocate for the unique needs of our patients. It is also nice to be advancing the presence/awareness of HPM.

If you have any specific ideas juggling around in your head and want to bounce them of us here or me via PM -- happy to do so!
 
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WilcoWorld

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As stated by @Frazier HPM is a lot more than just talking. Now, I'll admit that the therapeutic value of LISTENING is incredibly important in HPM, but that's not all we do.

I considered myself a bit of a Tox-curious PharmaGeek during my over 10 years as an ED attending...and then I did an HPM fellowship. In that one year I more than tripled my knowledge of pharmacology.

In addition to that, HPM will sharpen your history taking abilities with respect to symptom management. The first step in managing a symptom is to elucidate its cause. Your patient has nausea - 95% of docs will prescribe Zofran. In HPM you'll explore the nausea to determine if the etiology is vestibular, obstructive, psychogenic, infectious or toxicologic and then you'll select the best treatment (which is rarely Zofran).

In fellowship my attendings ran the gamut from super touchy-feely types to almost robotic scientific types. Contrary to popular belief, being emotionally expressive is not a necessary condition for HPM. The necessary condition is being able to sit with discomfort rather than running away from it.
 
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I am a current 4th year going into EM who is also interested in HPM. I was wondering what your thoughts were about going into fellowship straight out of residency vs. practicing as an attending for some number of years and then completing the fellowship. I've gotten different advice from different people (none of whom are HPM docs) about doing it straight after because you won't have to eat the fellow pay level after practicing as an attending for a while vs. practicing as an attending to develop your clinical skills and practice style and then doing fellowship.

Also, what is your peds experience like? Is peds palliatative care reserved for pedatric specific docs and you stick with adult HPM when you go into practice? Just from googling it seems most programs have about one month of a peds rotation
 

Frazier

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I am a current 4th year going into EM who is also interested in HPM. I was wondering what your thoughts were about going into fellowship straight out of residency vs. practicing as an attending for some number of years and then completing the fellowship. I've gotten different advice from different people (none of whom are HPM docs) about doing it straight after because you won't have to eat the fellow pay level after practicing as an attending for a while vs. practicing as an attending to develop your clinical skills and practice style and then doing fellowship.

Also, what is your peds experience like? Is peds palliatative care reserved for pedatric specific docs and you stick with adult HPM when you go into practice? Just from googling it seems most programs have about one month of a peds rotation

My own experience was going straight through to fellowship. There is no universally correct route, rather just the right route for the individual.

I think a large part can be framed through your long term goals to help guide at the individual-level. If you plan on dedicating a significant portion of your monthly time to EM shifts throughout your career, working for XYZ years after residency can help (as you mentioned) to solidify your competence as an emergency physician, to start to identify your weaknesses, to learn about what you can do better or are uncomfortable with in the realm of being solo (compared to having the safety net of residency)... This is in opposition to basically getting rusty during a year-long hiatus (i.e. an IM fellowship) away from your primary specialty (okay, maybe sprinkle on some moonlighting shifts). I can certainly see how gaining a few years time of practice in the pit will make you all the stronger during and after dedicated sub-specialty training. On my interviews there was likely a 50/50 split among EM applicants that were PGY3 versus attending.

Additionally, as you wisely noted, it is much harder to go from 300k back down to 60k than it is to go from 55k to 60k. I can appreciate how this can be a big psychological and functional block for folks that have been practicing attendings before starting fellowship.

On the flip-side, if you plan on practicing almost completely -- or entirely -- as a sub-specialist, then why wait another second? Assuming no familial/financial situation that requires a bolus of cash right after finishing residency, then proceeding straight into fellowship so that you can arrive at your chosen destination makes all the sense in the world. This was essentially my route. I knew early PGY1 that I was going to do HPM fellowship, by early PGY3 I knew my future career would be very likely exclusively the practice of HPM -- so it made little sense to delay a second longer nor practice EM for a few years prior to fellowship. While I'm loving my time as a fellow, I certainly also look forward to getting out there and serving my patients and colleagues as a subspecialist in 2021 (not 2022 or 2023).

What are your thoughts?

Regarding pediatric training, every program is going to have some exposure. This most often ranges between 2-4 weeks, with outliers. One could gain more experience if they want to dedicate their elective time to peds training. At my program we have 2 weeks.

You nailed it -- typically folks which practice as pediatric palliative docs have completed a dedicated pediatric palliative fellowship -- which itself requires typically completion of a pediatrics residency, CA psych fellowship, etc.
 
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My own experience was going straight through to fellowship. There is no universally correct route, rather just the right route for the individual.

I think a large part can be framed through your long term goals to help guide at the individual-level. If you plan on dedicating a significant portion of your monthly time to EM shifts throughout your career, working for XYZ years after residency can help (as you mentioned) to solidify your competence as an emergency physician, to start to identify your weaknesses, to learn about what you can do better or are uncomfortable with in the realm of being solo (compared to having the safety net of residency)... This is in opposition to basically getting rusty during a year-long hiatus (i.e. an IM fellowship) away from your primary specialty (okay, maybe sprinkle on some moonlighting shifts). I can certainly see how gaining a few years time of practice in the pit will make you all the stronger during and after dedicated sub-specialty training. On my interviews there was likely a 50/50 split among EM applicants that were PGY3 versus attending.

Additionally, as you wisely noted, it is much harder to go from 300k back down to 60k than it is to go from 55k to 60k. I can appreciate how this can be a big psychological and functional block for folks that have been practicing attendings before starting fellowship.

On the flip-side, if you plan on practicing almost completely -- or entirely -- as a sub-specialist, then why wait another second? Assuming no familial/financial situation that requires a bolus of cash right after finishing residency, then proceeding straight into fellowship so that you can arrive at your chosen destination makes all the sense in the world. This was essentially my route. I knew early PGY1 that I was going to do HPM fellowship, by early PGY3 I knew my future career would be very likely exclusively the practice of HPM -- so it made little sense to delay a second longer nor practice EM for a few years prior to fellowship. While I'm loving my time as a fellow, I certainly also look forward to getting out there and serving my patients and colleagues as a subspecialist in 2021 (not 2022 or 2023).

What are your thoughts?

Regarding pediatric training, every program is going to have some exposure. This most often ranges between 2-4 weeks, with outliers. One could gain more experience if they want to dedicate their elective time to peds training. At my program we have 2 weeks.

You nailed it -- typically folks which practice as pediatric palliative docs have completed a dedicated pediatric palliative fellowship -- which itself requires typically completion of a pediatrics residency, CA psych fellowship, etc.

Thanks for your reply! I am leaning more towards splitting time between a palliative care service and the ED with the eventual likelihood of transitioning most time/full time into palliative care when I'm older (50/60+) and reach the point where I want a more reasonable schedule, am slowing down clinically, want to be less burntout, but still want to practice medicine, etc. I am also looking into applying to the 5 yr EM/Peds combined programs, and potentially doing an HPM fellowship afterwards and doing some combination of those jobs, hence the pediatric specific question. Don't know how reasonable this is, I've heard from attendings that think its too many different departments to be involved with as an attending, so still figuring some things out.
 
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What is the job market like for palliative care doctors? It is typical/doable to work in multiple settings? I.e., hospital setting, nursing home, hospice?
 

tealeafexplorer

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Just started a thread, but I will ask some of those questions here.

What is your day to day like? How many patients do you see/ how much time do you spend with each patient/family?

What is the call like?
 

Frazier

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What is the job market like for palliative care doctors? It is typical/doable to work in multiple settings? I.e., hospital setting, nursing home, hospice?

Great question! It is good... at baseline.

There is currently a bit of a shortage compared to regular years due to many large hospitals being on hiring freezes.

Often you can work in multiple settings pending your employer contract stipulations. Otherwise, many large robust practices actually have inpatient, hospice, and community presence -- so it is not rare to find positions that have split responsibilities across practice settings while still staying under the umbrella of the same institution.

Not a lot of data on the forum regarding salary, which I found unfortunate in the past engaging in my own due diligence. There is a wide range between 160k-300k in total comp being seen (to use MGMA's approach). Average is around 225k.

I've signed for an academic position on the east half of the US. 80% inpatient, 20% clinic. Q6-7 week call. 7 weeks pto. My faculty position will put me around 300k.

Quite good for the field, granted I could make more staying in my primary specialty -- but that was never the goal. The goal was to practice what I love and with this subspecialty, I've found it.

The field is very broad with many sorts of opportunities. The patients and families are great. Consultants appreciate our expertise. The work itself is rewarding. My wife and kids are happy to have me home during nights, weekends, and holidays.

Very pleased with my decision to subspecialize.
 
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Great question! It is good... at baseline.

There is currently a bit of a shortage compared to regular years due to many large hospitals being on hiring freezes.

Often you can work in multiple settings pending your employer contract stipulations. Otherwise, many large robust practices actually have inpatient, hospice, and community presence -- so it is not rare to find positions that have split responsibilities across practice settings while still staying under the umbrella of the same institution.

Not a lot of data on the forum regarding salary, which I found unfortunate in the past engaging in my own due diligence. There is a wide range between 160k-300k in total comp being seen (to use MGMA's approach). Average is around 225k.

I've signed for an academic position on the east half of the US. 80% inpatient, 20% clinic. Q6-7 week call. 6 weeks pto. My faculty position will put me around 290k.

Quite good for the field, granted I could make more staying in my primary specialty -- but that was never the goal. The goal was to practice what I love and with this subspecialty, I've found it.

The field is very broad with many sorts of opportunities. The patients and families are great. Consultants appreciate our expertise. The work itself is rewarding. My wife and kids are happy to have me home during nights, weekends, and holidays.

Very pleased with my decision to subspecialize.
Thank you for your response :)
Do you foresee any issues with the field being taken over by midlevels?
 

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Thank you for your response :)
Do you foresee any issues with the field being taken over by midlevels?

Taken over? No. NP's and PA's are very much part of the team however -- just as are social workers, chaplains, RN's, pharmacists, music therapy, fellows, residents, and med students.

There are too many millions of patients needing care for palliative physician to do everything from the standpoint of both time and money. Many current well-developed teams around the country would crash without the manpower -- others wouldn't get off the ground in the future. For example with my team this week, there was an attending, fellow, resident, nurse navigator, and two NP's. On any given day we had 4 new consults and our census hovered around 20. In broad strokes, fellow carried 6, resident 4, each NP carried 5. Why can't the fellow and resident just see more patients? Because that isn't good palliative care. Back in my EM days, I would see 2 patients per hour for about 20 total per shift. In that world it's colloquially called moving the meat. You can move the meat and still provide excellent emergency medicine services. When it comes to excellent palliative medicine services, there is no moving the meat -- those ideals do not mix in any universe. Oil and water.

Coming back to our fellow/resident, typically the more medically complex, symptom management consults go to the physician trainees and the goals of care-focused consults (with maybe some symptom overlap) go to our NP colleagues. The attending oversees the team and is the boss. If there were no NP's on the team, who would do the heavy lifting each day regarding those 10 patients? The fellow and resident can't -- they are learning the subspecialty, taking time with patients, savoring the medicine. The attending can't as it would take away from the oversight and teaching of the physician trainees. Plus, doing everything for those 10 patients would be more than enough to fill a day by itself. Add 1-2 more attending physicians instead? Who is paying for that?

Financially, palliative isn't a big revenue-generator. Historically it is often framed as "cost-saving". So you can typically justify a physician salary and PA/NPs salaries, and still remain well within net "cost-saving" -- however, if you make an army of only physicians all demanding to be full-time and expecting physician level reimbursement, well, the teams are going end up as a skeleton crew of burnt out folks providing patients with less than ideal palliative services because they are stretched too thin.

It isn't an easy solution of "oh, just train more palliative medicine physicians" (versus say dermatologists) because we don't generate revenue and only so much "costs" can be "saved".

Furthermore, much of what our PA/NP colleagues do is not exactly the desire of the doc on the team. Again, the palliative doc leads the team and steers the ship whether in IDT meetings, on the floor, or in hospice. So it works out great. They provide a great service to patients and their families -- as well as to the physicians.

From everything I've seen the PA/NP folks aren't militant or trying to take over/hang a shingle, or striving to practice outside their scope. They were drawn to palliative medicine -- a very specific field -- for a reason. Much more often than not, that reason is rather altruistic and in line with doing what's best for the patient. Even if they wanted to go run off and be independent -- there would be no IDT, so it wouldn't work so great.

One important take away is that, at least in this field of medicine -- they are a huge asset. And if one doesn't want to work with NP's or PA's, it likely isn't a great fit.
 
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“From everything I've seen the PA/NP folks aren't militant or trying to take over/hang a shingle, or striving to practice outside their scope. They were drawn to palliative medicine -- a very specific field -- for a reason. Much more often than not, that reason is rather altruistic and in line with doing what's best for the patient. Even if they wanted to go run off and be independent -- there would be no IDT, so it wouldn't work so great“

With a few exceptions, this has been my experience as well.
 
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EM physician here. I have heard of ER docs going to practice in hospice without doing fellowship. Do you know anything about what these jobs involve? I have heard the pay for these jobs is lower than palliative care, but any idea how much lower? My situation is that I want to do a fellowship in a few years, but will be geographically limited due to family reasons. Ill be in the Detroit area at that time, so there are multiple programs, but I am trying to figure out what other options there might be if I don't get into fellowship the first time I apply. Im practicing full time EM now, and I like EM, but the night shifts are just getting harder and harder with time, and I know Im not going to want to continue doing EM for more than a few more years for that reason. Also, getting away from a "move the meat" mindset and being able to spend a little more time with patient's sounds pretty amazing to me at this point.
 

Frazier

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EM physician here. I have heard of ER docs going to practice in hospice without doing fellowship. Do you know anything about what these jobs involve? I have heard the pay for these jobs is lower than palliative care, but any idea how much lower? My situation is that I want to do a fellowship in a few years, but will be geographically limited due to family reasons. Ill be in the Detroit area at that time, so there are multiple programs, but I am trying to figure out what other options there might be if I don't get into fellowship the first time I apply. Im practicing full time EM now, and I like EM, but the night shifts are just getting harder and harder with time, and I know Im not going to want to continue doing EM for more than a few more years for that reason. Also, getting away from a "move the meat" mindset and being able to spend a little more time with patient's sounds pretty amazing to me at this point.

I think there are a lot of potential job positions with ranges likely between 40k-300k.

On one end would be a part-time hospice doc or a rather hands-off medical director role for a small hospice. The other end would be a full-time medical director of a giant hospice system.

Detroit has great programs. Henry Ford, et al. You will match on your first try, no doubt, assuming that you check all the app boxes and put the requisite effort into your app to paint a clear picture of "why HPM".

You might want to touch bases with SDN's very own @dchristismi and @WilcoWorld as they might have further insight for your concerns -- both are EM.

Congrats on considering HPM. You won't regret it. No one ever does. ;)
 
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Frazier

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EM physician here. I have heard of ER docs going to practice in hospice without doing fellowship. Do you know anything about what these jobs involve? I have heard the pay for these jobs is lower than palliative care, but any idea how much lower? My situation is that I want to do a fellowship in a few years, but will be geographically limited due to family reasons. Ill be in the Detroit area at that time, so there are multiple programs, but I am trying to figure out what other options there might be if I don't get into fellowship the first time I apply. Im practicing full time EM now, and I like EM, but the night shifts are just getting harder and harder with time, and I know Im not going to want to continue doing EM for more than a few more years for that reason. Also, getting away from a "move the meat" mindset and being able to spend a little more time with patient's sounds pretty amazing to me at this point.

To give you idea about the standard in clinic settings regarding being able to spend time with patients/families... my upcoming clinic schedule as attending books only 2 types of visits: 60 minute intakes and 30 minute follow-ups.

When I'm in fellow clinic, I'll just be supervising them and not seeing my own pts solo.

There are no 10-minute visits. No double booking patients. A lot of the stress our colleagues in IM and FM might feel regarding clinic days is removed.

This is still much faster than fellowship where our intakes are 90-min and follow-ups 45 min slots... but we need that time as fellows to take time and learn the subspecialty. It isn't a race. No moving the meat.

I've yet to have a negative patient encounter or confrontational consulting doc call me up -- several months into training. It is really quite remarkable. I'm sure they are going to be out there, but the frequency is exponentially lower than in the ED.

n=1
 
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WilcoWorld

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EM physician here. I have heard of ER docs going to practice in hospice without doing fellowship. Do you know anything about what these jobs involve? I have heard the pay for these jobs is lower than palliative care, but any idea how much lower? My situation is that I want to do a fellowship in a few years, but will be geographically limited due to family reasons. Ill be in the Detroit area at that time, so there are multiple programs, but I am trying to figure out what other options there might be if I don't get into fellowship the first time I apply. Im practicing full time EM now, and I like EM, but the night shifts are just getting harder and harder with time, and I know Im not going to want to continue doing EM for more than a few more years for that reason. Also, getting away from a "move the meat" mindset and being able to spend a little more time with patient's sounds pretty amazing to me at this point.
@dchristismi is better suited to tell you what going straight from EM-->hospice medical director is like.

@Frazier has posted extremely useful info above about fellowship/inpatient palliative practice, so I won't try to improve.

I'll just say that if more time with patients is your goal, an HPM fellowship is a great way to get there!
 
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Very much appreciate the info. 60 and 30 min appointments? Sounds pretty amazing to me. Sounds alot better than what I am currently doing at work, running around like a chicken with my head cut off trying to get all my ED's super sick patient's what they need, while the whole time I have people trying to pull me out to the waiting room to appease patient's who are not sick at all because they are tired of waiting.
 

Frazier

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Very much appreciate the info. 60 and 30 min appointments? Sounds pretty amazing to me. Sounds alot better than what I am currently doing at work, running around like a chicken with my head cut off trying to get all my ED's super sick patient's what they need, while the whole time I have people trying to pull me out to the waiting room to appease patient's who are not sick at all because they are tired of waiting.

It is indeed a drastically different world and experience of practicing medicine than in the ED. You will be pleased.
 
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Very much appreciate the info. 60 and 30 min appointments? Sounds pretty amazing to me. Sounds alot better than what I am currently doing at work, running around like a chicken with my head cut off trying to get all my ED's super sick patient's what they need, while the whole time I have people trying to pull me out to the waiting room to appease patient's who are not sick at all because they are tired of waiting.
I completely understand what this feels like. Couldn't have said it better.
 

Frazier

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When applying for fellowships, how many LOR did you get from HPM docs?

Zero.
My hospital didn't have a traditional HPM presence at the time.
Fortunately, I knew about the field from med school -- or else I might have missed it!

I imagine having at least 1 LOR from HPM would be nice, however it was far from a dealbreaker.

My LOR's were ED PD, ED APD, ED attending, ED attending.
 
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Zero.
My hospital didn't have a traditional HPM presence at the time.
Fortunately, I knew about the field from med school -- or else I might have missed it!

I imagine having at least 1 LOR from HPM would be nice, however it was far from a dealbreaker.

My LOR's were ED PD, ED APD, ED attending, ED attending.
Great thanks!
 
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An HPM doc recently said to me that this field is considered a "higher burnout" one; I was very surprised bc this is the first time I am hearing this. I suppose any job certainly can be depending on the job itself, especially in medicine. Also advised to be careful looking for jobs after fellowship as many agencies are RVU-based, which is of course low in HPM. My goal is to avoid working for an institution that places such intense focus on production. Any thoughts?
 
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Frazier

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An HPM doc recently said to me that this field is considered a "higher burnout" one; I was very surprised bc this is the first time I am hearing this. I suppose any job certainly can be depending on the job itself, especially in medicine. Also advised to be careful looking for jobs after fellowship as many agencies are RVU-based, which is of course low in HPM. My goal is to avoid working for an institution that places such intense focus on production. Any thoughts?

You know, that is an excellent conversation to have and reflect upon. The following point is not in reference to that doc, I don't know their status or circumstances. However, if someone is to pick HPM for the wrong reasons, then it can absolutely be a high risk of burnout. In addition to dealing with immense physical suffering, sometimes recalcitrant to everything you do, there are heavy loads of emotional, spiritual, and existential suffering as well.

Thinking of the average medical student, there is a quite notable proportion that don't like working with patient emotions, don't like tackling existential questions, don't favor the idea of having to use therapies without great evidence behind them, and don't like death.

Of course, whatever specialty they end up choosing might have some of those things mixed in occasionally -- but if one is that type of person where their patient's death takes a toll (i.e. they take it personally)... then HPM will be a huge burnout regardless of hours.

In regard to the lifestyle angle of burnout, it is all about where you work. If you are at a moderate sized hospital, the HPM team consists of only you and an NP/PA, and administration wants you to build protocols to increase services offered to cardiology, nephrology, and the ED (in addition to everyone else you serve) -- that is going to stretch the HPM super thin and skyrocket the risk of burnout. You might be on Q2 call to boot. It is a recipe for dissatisfaction.

Your compensation, specifically how it is determined, can be another source of distress. As you alluded to, RVU based compensation in HPM is setting the stage for failure. You will see job postings out there. Typically it is a sign that the hospital/recruitment doesn't really understand what HPM does. HPM earns its keep via cost-saving just as much if not more than it does via RVU-generation. To base compensation off of RVU's like we are a procedural subspecialty is preposterous. Solution? Make sure there is a base salary and that you are okay with that number -- if there is RVU bonuses, okay, but don't count on hitting major quotas.

Another point could be the patient population. I personally find utilization of translators frustrating more often than not -- and that was back in the ED. Often things get lost in translation, and when words mean the world, I need to know EXACTLY what is being said (not paraphrasing by the translator taking liberties). At my EM residency I hated having to use translator services for anything beyond straight forward complaints for that reason -- I felt I wasn't serving my patient to the best of my ability. I cannot imagine having to use a translator regularly for something like HPM. For some folks, I'm sure they don't mind it. For me, it would be HUGE point of irritation and dissatisfaction. More about this later.

Hospital culture is also relevant. I've heard stories about how the primary team might say something like "here comes the grim reaper" or "morphine doc has arrived" in reference to HPM -- I imagine it could be frustrating to work in an environment where there is such a gross misrepresentation of what we provide. Across the several hospitals I've been at historically, that has been the case at zero. In fact it has been the opposite and everyone appears to hold HPM in high esteem. But it was accounts I've read about before -- so I will assume it to be true, and disheartening!

So what can you do? Reflect on what the job of offering excellent HPM services entails. Does it match your values and passions? When looking for your first position, pay attention to the hospital culture -- how is HPM viewed? Are the revered and teams exalt us with "so happy you're here, thanks for your help with this patient" -- or do they say "oh grim reaper has arrived"? What is the lifestyle going to be like -- is it a large team in place or is it a position described as "exciting new opportunity to build the practice from scratch" (read: get ready to work hard, lone wolf, and be on call constantly). Are you provided a respectable base salary or is it all "RVU-based"? Are there pet peeves (such as the translator thing) which need to be kept in mind when job searching?

My experience has been that HPM docs are highly satisfied, can work into old age if they wish (and often do out of choice), and are not really burned out... (I've seen some really burned out docs in other specialties to frame things off of). But I am n=1, and the doc you mentioned counters that as another n=1. In all likelihood reality is somewhere in-between.
 
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Frazier

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One other point... an often cited 2016 study out of Duke claimed to discover a large prevalence of burnout in HPM.

Perhaps the doc you mentioned is referencing this exact paper...

That study was actually retracted (by the authors - HONORABLE) in May 2020 for serious methodology flaws which had resulted in grossly inflated rates of burnout.
 
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WilcoWorld

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I think @Frazier points out something important by stating that EVERY field of medicine must deal with uncertainty, while HPM is nearly unique in embracing uncertainty

that’s not for everyone, it’s not even for most
 
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You know, that is an excellent conversation to have and reflect upon. The following point is not in reference to that doc, I don't know their status or circumstances. However, if someone is to pick HPM for the wrong reasons, then it can absolutely be a high risk of burnout. In addition to dealing with immense physical suffering, sometimes recalcitrant to everything you do, there are heavy loads of emotional, spiritual, and existential suffering as well.

Thinking of the average medical student, there is a quite notable proportion that don't like working with patient emotions, don't like tackling existential questions, don't favor the idea of having to use therapies without great evidence behind them, and don't like death.

Of course, whatever specialty they end up choosing might have some of those things mixed in occasionally -- but if one is that type of person where their patient's death takes a toll (i.e. they take it personally)... then HPM will be a huge burnout regardless of hours.

In regard to the lifestyle angle of burnout, it is all about where you work. If you are at a moderate sized hospital, the HPM team consists of only you and an NP/PA, and administration wants you to build protocols to increase services offered to cardiology, nephrology, and the ED (in addition to everyone else you serve) -- that is going to stretch the HPM super thin and skyrocket the risk of burnout. You might be on Q2 call to boot. It is a recipe for dissatisfaction.

Your compensation, specifically how it is determined, can be another source of distress. As you alluded to, RVU based compensation in HPM is setting the stage for failure. You will see job postings out there. Typically it is a sign that the hospital/recruitment doesn't really understand what HPM does. HPM earns its keep via cost-saving just as much if not more than it does via RVU-generation. To base compensation off of RVU's like we are a procedural subspecialty is preposterous. Solution? Make sure there is a base salary and that you are okay with that number -- if there is RVU bonuses, okay, but don't count on hitting major quotas.

Another point could be the patient population. I personally find utilization of translators frustrating more often than not -- and that was back in the ED. Often things get lost in translation, and when words mean the world, I need to know EXACTLY what is being said (not paraphrasing by the translator taking liberties). At my EM residency I hated having to use translator services for anything beyond straight forward complaints for that reason -- I felt I wasn't serving my patient to the best of my ability. I cannot imagine having to use a translator regularly for something like HPM. For some folks, I'm sure they don't mind it. For me, it would be HUGE point of irritation and dissatisfaction. More about this later.

Hospital culture is also relevant. I've heard stories about how the primary team might say something like "here comes the grim reaper" or "morphine doc has arrived" in reference to HPM -- I imagine it could be frustrating to work in an environment where there is such a gross misrepresentation of what we provide. Across the several hospitals I've been at historically, that has been the case at zero. In fact it has been the opposite and everyone appears to hold HPM in high esteem. But it was accounts I've read about before -- so I will assume it to be true, and disheartening!

So what can you do? Reflect on what the job of offering excellent HPM services entails. Does it match your values and passions? When looking for your first position, pay attention to the hospital culture -- how is HPM viewed? Are the revered and teams exalt us with "so happy you're here, thanks for your help with this patient" -- or do they say "oh grim reaper has arrived"? What is the lifestyle going to be like -- is it a large team in place or is it a position described as "exciting new opportunity to build the practice from scratch" (read: get ready to work hard, lone wolf, and be on call constantly). Are you provided a respectable base salary or is it all "RVU-based"? Are there pet peeves (such as the translator thing) which need to be kept in mind when job searching?

My experience has been that HPM docs are highly satisfied, can work into old age if they wish (and often do out of choice), and are not really burned out... (I've seen some really burned out docs in other specialties to frame things off of). But I am n=1, and the doc you mentioned counters that as another n=1. In all likelihood reality is somewhere in-between.
Thank you for your insight, I appreciate it :)
 

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  7. This thread is locked.
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