NP's & PA's : Will Palliative Medicine be taken over by midlevels, APP's, extenders, XYZ? Click to find out!

[Frazier]

Hopefully, the title catches search results for those looking for answers. This is a hot topic clearly on many individual minds. I see the sentiment about other specialties on different social media platforms. I see it in other subforums. I personally get asked this question on SDN about once per week. While that might not sound like a ton -- another way of looking at it: I answer the same thing 50 times per year. My answer tends to be relatively comprehensive. For the sake of time and my copy and paste buttons, I will include my answer here. For current readers and future readers wondering about the reality of NP and PA folks in palliative medicine, see my thoughts below:

Will the subspecialty of palliative medicine be taken over? No. But palliative medicine is much unlike any other field in medicine with the utilization of an interdisciplinary team. NP's and PA's are very much part of that team, however -- just as are our social workers, chaplains, RN's, pharmacists, music therapists, fellows, residents, and med students.

One point to make early, is that if a hospital or program wishes to have its palliative program certified by the joint commission, it needs to have physicians who are trained in palliative medicine. For example, HR.01.02.07, EP10, which states that physicians need to be in the IDT. For the new crowd of readers, IDT stands for the interdisciplinary team and the entity which serves patients as a unit -- many members might see the same patient focusing on different facets of their needs.

There are too many millions of patients needing care for a 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 workforce -- others wouldn't get off the ground in the future. For example, this week, there was an attending, fellow, resident, nurse navigator, and two NP's with my team... in addition to a chaplain, pharmacist, social worker, and music therapist. We had 4 new consults on any given day, 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 often 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 medical care. 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/learners/XYZ. 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 they see? The fellow and resident can't -- they are learning the subspecialty, taking time with patients, savoring the medicine. The attending can't easily do it -- as it would take away from the physician trainees' oversight and teaching. 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? Ahhhh, Who is paying for that? Read on...

Financially, palliative isn't a big revenue-generator (surprise). Historically it is often framed as "cost-saving." So you can typically justify a physician salary and PA/NPs salaries and remain well within net "cost-saving". However, if you make an army of only physicians, all of which are 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 many "costs" can be "saved."

That is not to say we do not provide a valuable service. Ask any patient, family, and doc that places a consult -- and you will find that we offer a very valuable service indeed. Current reimbursement just doesn't capture it fully.

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 an excellent service to patients and their families -- as well as to the physicians. They bring a different viewpoint to the table regarding the idea of whole-person care, given that their training is inherently different than the physician. What this does is benefit the patient. It is all about the patient.

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. That is rather hard to do at baseline in palliative medicine. This isn't psychiatry where you can post an ad, rent an office, and you're off to the races. Palliative medicine is typically a hospital-based practice tied to hospitals with close ties to cancer treatment centers. Additionally, these folks 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. Oncologists are rather protective of their patients. Surgeons are rather protective of their patients. Hematologists are rather protective of their patients. They aren't going to refer out to, or consult, someone they don't trust.

One important take away is that, at least in this field of medicine -- NP and PA 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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[InvestingDoc]

I love the detailed and well thought out post.

I do have a question though.... I have 3 friends that are palliative care docs in Texas each with a different program who tell me that things are a bit different that what you say. I know it might be hard to give an answer, but do you see a shift occurring as there are less physician owned practices around to hire midlevels instead of palliative care doctors to save money? I feel like this is a perfect storm to crash the market for palliative care doctors. Those that are well established will probably do well, but I don't know if I could tell a new graduate that I personally would feel confident if it were me delaying one year of attending salary to do fellowship in palliative care with the possible squeeze in the job market.

The one friend I have in Houston was told that a PA would be taking her role in the hospital and that this PA was also taking the role of another palliative care doctors with her group. My friend who is a board certified palliative care doctor told me that she was offered a part time gig to stay on as admin + seeing patients on the side at about a 40% reduction in salary. She opted to say "no thanks" and is a stay at home mom now.

The other two friends in Texas, one was employed at HCA facility, and that group let him go due to a NP taking over the role for inpatient and nursing home hospice consults. He shifted over to another group now and tells me that he landed with his feet on the ground making more money than before. Almost the same story for the other friend but with a non HCA group.

I know my sample size is small, but I only have 4 close friends that I know who are palliative care and 3 of them in the past 2 years had to change jobs after their job was replaced by a NP/PA.

Maybe what you are saying is location dependent?

 

[Frazier]

I love the detailed and well thought out post.

I do have a question though.... I have 3 friends that are palliative care docs in Texas each with a different program who tell me that things are a bit different that what you say. I know it might be hard to give an answer, but do you see a shift occurring as there are less physician owned practices around to hire midlevels instead of palliative care doctors to save money? I feel like this is a perfect storm to crash the market for palliative care doctors. Those that are well established will probably do well, but I don't know if I could tell a new graduate that I personally would feel confident if it were me delaying one year of attending salary to do fellowship in palliative care with the possible squeeze in the job market.

The one friend I have in Houston was told that a PA would be taking her role in the hospital and that this PA was also taking the role of another palliative care doctors with her group. My friend who is a board certified palliative care doctor told me that she was offered a part time gig to stay on as admin + seeing patients on the side at about a 40% reduction in salary. She opted to say "no thanks" and is a stay at home mom now.

The other two friends in Texas, one was employed at HCA facility, and that group let him go due to a NP taking over the role for inpatient and nursing home hospice consults. He shifted over to another group now and tells me that he landed with his feet on the ground making more money than before. Almost the same story for the other friend but with a non HCA group.

I know my sample size is small, but I only have 4 close friends that I know who are palliative care and 3 of them in the past 2 years had to change jobs after their job was replaced by a NP/PA.

Maybe what you are saying is location dependent?

This is a phenomenal addition to the conversation. I hope to respond fully tonight!

 

[Frazier]

I love the detailed and well thought out post.

I do have a question though.... I have 3 friends that are palliative care docs in Texas each with a different program who tell me that things are a bit different that what you say. I know it might be hard to give an answer, but do you see a shift occurring as there are less physician owned practices around to hire midlevels instead of palliative care doctors to save money? I feel like this is a perfect storm to crash the market for palliative care doctors. Those that are well established will probably do well, but I don't know if I could tell a new graduate that I personally would feel confident if it were me delaying one year of attending salary to do fellowship in palliative care with the possible squeeze in the job market.

The one friend I have in Houston was told that a PA would be taking her role in the hospital and that this PA was also taking the role of another palliative care doctors with her group. My friend who is a board certified palliative care doctor told me that she was offered a part time gig to stay on as admin + seeing patients on the side at about a 40% reduction in salary. She opted to say "no thanks" and is a stay at home mom now.

The other two friends in Texas, one was employed at HCA facility, and that group let him go due to a NP taking over the role for inpatient and nursing home hospice consults. He shifted over to another group now and tells me that he landed with his feet on the ground making more money than before. Almost the same story for the other friend but with a non HCA group.

I know my sample size is small, but I only have 4 close friends that I know who are palliative care and 3 of them in the past 2 years had to change jobs after their job was replaced by a NP/PA.

Maybe what you are saying is location dependent?

I wish those incidents didn't happen! It sounds like a huge headache, to say the least -- I am very glad to hear that most ended up coming out ahead once getting their feet back under them in a new job. I would be curious to know a bit more about their prior positions.

Slight tangent, to be truthful, much of what is labeled as "palliative care" by some hospital systems (say, HCA) and small hospitals is not a really and truly complete palliative care offering...at least in my opinion. [Not the rule! Again, not always the case!] But, I have described in an earlier post above what my definition partly entails -- many ways similar to the joint commission -- in that true palliative care is offered via an IDT -- led by subspecialty-trained physicians -- to best serve the multidimensional needs of the patient. On the other hand, I've heard of, seen advertisements, and discussed with recruiters positions for a solo clinician to come to a hospital and "offer palliative care" -- or to join a tiny team of, say, one doc and one NP/PA -- how this actually materializes is another story.

Nevertheless, a significant proportion of those positions do not follow a robust care model with truly active management of complex symptom burden. Again, that is NOT to say the above describes your friends' circumstances. Rather it is what I have seen myself.

Were any of these locations academic centers? How big were the palliative departments -- or did they even have a palliative department? What was the makeup of the IDT? Were the programs certified by the joint commission? What was their role in the hospital and the positioning of care delivery in the hospital? Was there an inpatient palliative unit they lead? Did they take call? Did they see patients across the full range of services (ED, med/surg, MICU, SICU, NICU, cards, onc, GI, etc)? Did they actively manage or, at minimum, frequently get consulted for recommended treatments for complex symptoms, or were they all basically goals of care discussions? Was their compensation in any way tied to RVU's?

These many questions do not need answers out of both respect for your time and honor the privacy of your friends' situations. Rather these are questions on my mind, which potential answers describe situations where perhaps a subspecialty-trained physician is not best utilized to the full breadth of expertise/training.

Long story short -- I cannot deny the experiences of your friends. I do not have an explanation for it. It sounds like a significant portion of the pool of HPM folks you know have been impacted by this concern. My experience has been quite different. As you allude to, however, I am not in Texas. Those incidents happened, and they will continue to happen in the future. I am confident it will remain the exception and not the rule, however. Perhaps most of all, it is important for our readers today to recognize that-- just as with most specialties -- you should always aim to make yourself indispensable. Also, be wary of the position you accept and the risk you might be taking.

Below are two job descriptions:

1) Full-time position with the palliative medicine department at an academic center. Function as core faculty for established hospice & palliative medicine fellowship, as well as teach residents and medical students. Lead our well-developed IDT consisting of six physicians, three NP's, two social workers, two nurse navigators, a chaplain, and a pharmacist. We are well-respected across the hospital and get over 2,000 consults annually with a 60/40 ratio between symptom management/goals of care consults. Split your responsibilities between leading our 12-bed dedicated inpatient palliative unit, hospital consults, and seeing your patients in the palliative clinic. We ensure 24/7/365 coverage for our patients and consulting services, therefore call is required and split across providers. Professional interest in growing a relationship with our emergency department is considered a plus. Compensation is salary-based. Board-eligible, or board-certified in HPM required.

2) Internal medicine chair is seeking full-time palliative medicine practitioner in a wonderful community hospital. Join a growing team with one well-experienced NP. Have your expertise greatly appreciated with goals of care assistance by the intensive care service and medical wards. Nearly 400 consults annually. NO call, NO weekends, NO holidays. Enjoy an excellent quality of life. No outpatient services currently, but considering development in the future. Benefit from a competitive compensation package tied to RVU's and quality metrics. Palliative medicine experience is preferred but not required.

For readers, between those two (both very much characterizing actual openings), which would you feel makes better use of your training and offer a sense of having more job security from outsiders or administrators [who VERY often have little to no idea of what we actually do or are trained to do]?