Hospice & Palliative Medicine Fellow -- AMA

[Frazier]

Hello Lionhearts,

I'm excited for your arrival into medicine, keep up the energy as you continue on your journey! It's a tough road, you already anticipate it, especially with everything going on today. But you know what? Dare I say it's well worth it!

I started on SDN about a decade ago as a nontrad business major interested in the idea of returning to school for the pre-med things. 10 years is a long time ago. MCAT, STEP 1, STEP 2CK, STEP 3, specialty boards, you guys will go through a lot of change as you know... And in retrospect it will be very much a whirlwind.

There have been an excellent variety of AMA's done over the years in these forums, in fact one now ongoing by our colleague in urology; however, I don't recall seeing any initiated by hospice & palliative medicine folks. So here I am. 😀

I can appreciate how this field might be unknown to you before diving into medical school rotations (a time when, even if you don't do a formal HPM rotation, rest assured that one [hopefully many] of your teams will consult us along the way). Truth be told, it wasn't on my radar as a pre-med either.

If you have any questions about the subspecialty (who, why, what) or about medical school, residency, fellowship, being an attending, life in general, etc. go right ahead and ask away. I'm happy to provide you with my n=1.

PS: Feel free to visit us in our SDN sub-forum for more information, if you feel so inclined!

Hospice and Palliative Medicine

Hospice and Palliative Care Medicine discussion forum.

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[RocuROMANium]

I’ll start with the basics.

What is your day-to-day like? What drew you to HPM?

 

[premedanon16]

Hi! I'm a current undergraduate junior really interested in hospice and palliative medicine. I'm about to start working as a hospice volunteer (currently going through training) and I also do research on Advance Care Plan/MOLST utilization in ERs. What was your path to this subspecialty like? When did you know you wanted to go into it? Did you do a residency in hospice/palliative medicine specifically, or did you go into the field from anesthesiology/internal medicine/geriatrics or something like that? Thanks so much!

 

[Frazier]

What is your day-to-day like?

To tackle this question, we need to appreciate that HPM lends to a wide variety of opportunities -- everything from practicing one's primary specialty and just using the tools/knowledge from fellowship training to further enhance practice as a full-time surgeon/internist/EM doc/etc, to working as a part-time hospice medical director, to working as a full-time inpatient palliative medicine doc.

As you know, each of these folks would have vastly different day-to-day schedules. So, let me approach your question as is written -- what is MY schedule like now?

As a fellow, it depends largely on which service I'm on for the month. The standard rotations in HPM fellowship are palliative consults, inpatient hospice, outpatient hospice, inpatient palliative unit, pediatric palliative care, interventional pain medicine, a longitudinal clinic experience, and various electives unique to the various programs.

Throughout the year, I'm scheduled for clinic one day per week. We have a daily cap of 4 patients with the option to add-on 1 if we wish. I typically choose to have that add-on when someone needs frequent checks/close monitoring (think opioid naïve patient with H&N cancer starting a course of radiation). If the options are to either be seen by me as an add-on, or not be seen and to suffer until my next regular slot opens up, I'm going to put them as an add-on and stay later in the day, so be it.

Speaking of clinic, I have 2 types of appointment windows -- 90 minute intakes and 45 minute follow-ups (so, yes, plenty of time for patients/families and plenty of time to chart, collaborate with oncology/surgery/etc without having to stay late).

Clinic days go from 8-5p. One hour lunch. However if your schedule ends at 4p and you're done with your tasks at 4p -- great, go home at 4.

When I'm on the palliative consult service, I typically carry about 6 patients per day. Days start at 8a and end around 4pm. One hour lunch. A consult could be on anything from complex symptom management, to goals of care, to terminal extubation, to LVAD-assessment (think cardiac clearance from a palliative standpoint), to palliative sedation, to just offering support to our colleagues on the service that consulted us. There is a pretty wide variety. You will work with nearly every service in the hospital. I get consults from the ED, from IM, from ortho, from neurosurgery, from bariatrics, from Pulm/Crit, everyone. One thing that is consistent: everyone highly values our help. I never heard such appreciative surgeons until entering this field. It is really nice. If a patient and team is doing well, we sign off. If we continue to be needed, we continue to follow the patient daily during their hospitalization.

When on the inpatient palliative unit, you are in charge of the census -- it is a budding program in its infancy -- so that is usually 3-6 patients at any given time. One hour lunch. Often these are patients familiar to our service via clinic and are requiring intensive symptom management or are at end-of-life (and for them dying at home is not concordant with their goals). You are more likely to be managing the 48-year old with Stage 4 colon cancer c/b peritoneal carcinomatosis and now opioid-refractory pain crisis and dehydration 2/2 recalcitrant nausea/vomiting... than you are to find a full-code 75-year old with COPD exacerbation (more likely to find this on the typical IM service). If you patient needs a procedure, say therapeutic paracentesis for dyspnea, and if you are credentialed to do it, go ahead and do your own procedures as you wish, or ship off to IR -- depends on the doc.

Hospice typically 2-7 patients on census. One hour lunch. In many ways similar to the inpatient palliative unit, however these folks are sicker and more likely at the end-of-life (i.e. admitted for GIP [general inpatient hospice]).

I spend as much time as I want with the patients on inpatient settings, no one is sitting there timing me. But try to remain mindful that consults might be building up, or there might be other patients with more acute needs -- so I don't get too reckless with time.

I take q4 call (week-long stretch). This is overnight call from home. Calls range from 0-8 per night. There is the possibility that you need to physically go into the hospital overnight if there is an extremely compelling reason. This is rare, maybe a few times per year. I go in and round on patients/see emergent consults on Sat and Sun during call weeks.

A glimpse at the anticipated schedule for my HPM faculty job: large academic institution with med students/residents/fellows, slated for 80% inpatient, 20% clinic, no hospice currently anticipated. 8-5 standard, M-F service. Call Q6 weeks (the fellows and PA/NP will take first call and I'll serve as backup call during those weeks). In many ways it will mirror fellowship, but now captain of the ship and enjoying 5x the salary --which of course will be nice.

Let me know if you have any other questions about the day-to-day schedule. I'll take on your next question soon.

 

[oncology2021]

how much does a hospice internist make? in the community

 

[Frazier]

What drew you to HPM?

It was a dash of serpentine and a cup of serendipity.

Between 2010 and 2015, I flipped all over the place... between RadOnc, Ophthalmology, NeuroSurg, Rad, Psych, EM, GI, OBGYN, Sleep, HemOnc, Addiction, Pain... my assigned faculty advisor day 1 of medical school happened to be a HPM doc. Funny enough, I didn't explore HPM during those first few years of medical school while making the rounds through every other field in medicine it seemed 🙂

As you can get a sense, I liked a lot about a lot of the different fields. I had a passion for patients dealing with serious illness and intense symptoms -- whether physical, functional, psychological, or spiritual. I also enjoyed equally the ability to perform interventions with my words, just as much as with my hands or prescription pad. The concept of quality of life has been a long-time research interest of mine dating back to 2009.

Okay great! ...So why HPM?

Around 2016 I realized that none of those early fields I mentioned captured everything I wanted out of my career. The road to becoming a physician is long and arduous, laced with sacrifice and ongoing dedication. Call me selfish -- but I decided I wasn't willing to settle. Fortunately, I did a rotation in HPM, at recommendation of that assigned advisor that was a palliative doc, and it was phenomenal. I knew it was going to be in my future in some capacity, but it is a subspecialty -- I would need to choose a primary specialty first. So as you could imagine, I chose a residency where you do a little bit of everything for all populations and all acuities: EM. I went on to serve as chief resident and loved my residency program; I'd choose the same path again 10/10. It gave me a further appreciation for HPM and enriched my perception of what really matters in a career. I also gained an appreciation for treating patients with known pathology and not being rushed (two things somewhat incompatible with a career in EM). I appreciated knowing a little about a whole lot, but missed not also having that specialist-level knowledge about a given subject (granted one could easily argue EM docs are specialists in resuscitation, otherwise you know what I mean). EM did provide me with a level of comfort with recognizing "sick", interpretation of imaging, procedural skills, and building rapport quickly with all sorts of folks... not bad tools to keep in the kit for today's modern HPM doc. One interest that grew out of the 3 years of residency was how palliative services would be effectively integrated into the ED to better serve both patients and the clinical team (note: this would end up being a facet of my attending job next year). So I continued on my anticipated path to HPM fellowship.

Overall, I choose this field because providing subspecialty-level palliative care to patients battling known serious illness, or at end-of-life, is an extremely rewarding endeavor that is overwhelmingly appreciated by the patient, their family, and their consulting team. You literally relieve palpable suffering for a living every day. How wonderful is that? Never have I left an encounter and felt "I have nothing to offer this patient" because there is always something to improve. I imagine sometimes surgeons, GI docs, heme/onc docs, you name it, might all feel that way regarding the bread-and-butter services intrinsic to their field. I know I absolutely felt that way often times in the ED. It is rewarding being able to improve things for the person sitting across from you on a consistent basis -- I believe this is artifact of the subspecialty covering so many domains of existence. I still get exposure on a longitudinal basis to all those fields I found interesting during pre-med/MS1/MS2/MS3... except now they are consulting me to help with their patient and through that we get to talk shop. I learn about other fields all the time -- from neurosurgery to bariatrics to interventional cards. I review advanced imaging daily to help understand etiology and guide management. I have a close relationship with our interventional pain colleagues. In palliative medicine, you enter the room and might be faced with all sorts of pain, nausea, dyspnea, fatigue, sleep problems, sexual problems, emotional/existential/spiritual suffering et al. and my team will be happy to tackle it if it will potentially improve quality of life for the patient.

It is also worth noting that providing a person at end-of-life with a graceful experience of death is one of the best gifts which can be given to a patient and their loved ones -- you get to do that all the time in this profession. As often said, "with death, there are no re-do's." Also as alluded to earlier, managing pain, true pain, is a great gift for patients and their QoL...as well as for their families. Helping one to regain function and live their life in the best way they can with the time they have left is extremely fulfilling and I'd trade it for no other field in medicine.

Maybe a little cheesy, but to put it all another way with a quote: "You treat a disease, you win, you lose– but you treat a person, I guarantee you, you’ll win, no matter the outcome" (Patch Adams).

Lastly, HPM docs and our IDT tend to be extremely friendly and happy folks on average. The positivity tends to rub off on each other and that isn't a bad thing when it comes to long-term satisfaction in the workplace.

If you have any questions about anything above, just let me know to clarify further -- it felt like a bit of a stream of consciousness!

 

[RocuROMANium]

Wow, thank you for that wealth of information! It truly sounds like a rewarding career. I need to check it out.

 

[oncology2021]

thank you so much!
I am applying to hospice, what is the salary you can make after fellowship?

 

[Frazier]

Hi! I'm a current undergraduate junior really interested in hospice and palliative medicine. I'm about to start working as a hospice volunteer (currently going through training) and I also do research on Advance Care Plan/MOLST utilization in ERs. What was your path to this subspecialty like? When did you know you wanted to go into it? Did you do a residency in hospice/palliative medicine specifically, or did you go into the field from anesthesiology/internal medicine/geriatrics or something like that? Thanks so much!

Hello and thanks for your interest!

I'm thrilled to hear that you are interested so early. Your current and continued research efforts for the field will be remarkable. My path was somewhat unique, I went into that quite a bit above, so I won't bore you with saying it all again. That said, HPM is only achievable via fellowship in the US. There is no residency in HPM. As you alluded to, I completed residency first and then proceeded into the subspecialty training. My primary specialty is emergency medicine.

AAHPM lays out the following approximations on specialty-breakdown for board-certification within HPM (as of 2020):

Internal Medicine	4751
Family Medicine	1931
Pediatrics	346
Emergency Medicine	176
Psychiatry & Neurology	144
Anesthesiology	136
Surgery	80
Obstetrics & Gynecology	80
Radiology	69
Physical Medicine & Rehabilitation	59
Preventive Medicine	7

Great questions! Let me know what else you have!

 

[premedanon16]

Thank you @Frazier !!! All of your information on this thread is so helpful. I'll be sure to pm you in the future or continue on this thread if I can think of any other questions! Thank you again!!

 

[Frazier]

thank you so much!
I am applying to hospice, what is the salary you can make after fellowship?

A very reasonable question, especially in the time of blossoming medical school tuition and debt!
Of course, similar to basically all fields, one shouldn't subspecialize in HPM unless passionate about its essence. That said, in regard to salary we do okay for physicians, great for US population, and phenomenal for world inhabitant!

Not a lot of data out on the forum regarding salary -- or on the internet for that matter... which I felt was unfortunate in the past while performing my own due diligence. Essentially it boils down to this: there is a wide range between 160k-300k+ in total comp being seen (to use MGMA's approach).

Average across the country for all sorts of set-ups is around 225k.

On the one hand, everyone should be reimbursed more in medicine -- at the same time, I feel well-compensated for the intensity of work life and the satisfaction I get. Three points important for longevity.

My own position is academic on the east half of the US. 80% inpatient, 20% clinic. Q6 week call. 7 weeks pto. To be transparent, the faculty position will put me around 300k.

The field is very broad with many sorts of opportunities. The patients and families are great. Even the most proud neurosurgeon appreciates our expertise and support when needed. 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.

In regard to hospice specifically, 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 large hospice system.

 

[deleted1041221]

Thank you so much for all this information! It's really cool to see this all concretized -- I took a course at my undergrad institution last spring that was all about hospice and palliative care. I have a question that I think you partially answered earlier, but I just want to clarify -- it seems like you can choose to specialize into HPC after completing a residency in a variety of fields...once you do enter and finish your fellowship, can you continue to practice in the field in which you trained for residency, while also doing work with HPC? For example, could one be an OB/GYN-trained HPC physician and spend a good amount of time in the OR/L&D while also doing some work with perinatal hospice, or once you finish fellowship is your work necessarily centered around palliative care? Or is it up to the person?

 

[oncology2021]

thank you so much!