Pal Q

[clement]

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What percentage of pall care fellowships are open to psychiatrists? I know some are specifically designed for psychiatrists, but in general, aren't most open to FM and IM?

 

[splik]

i have not heard of any good hpm fellowships specifically for psychiatrists, however most fellowships are generally open to pretty much all clinical specialties. The exceptions maybe the more medically intense ones such as harvard and ucsf and even then there are probably ways round it. i am interested in going the hospice and palliative medicine route, and hope my additional IM experience (albeit not in the US) will help. obviously if you do HPM through psychiatry you are not going to be draining malignant ascites (not that its difficult) but probably focussing on pain management, delirium, dementia, anxiety/depression at the end of life, grief, family systems problems, capacity, and so on. lots of psychotropic drugs e.g. benzos, antipsychotics, ritalin etc. so psychiatry has lots of expertise of many end-of-life issues.

palliative medicine is not very competitive because there is no money in it. like geriatrics you may end up making less than without the fellowship (?large medicare population).

 

[clement]

hmmm really? no it seems even places that i don't imagine to be "super hard core" have their preferenes...maybe it's a geographical culture at some programs...nyc: take for example monte and mt sinai...both seem to cater to fm and im (well monte even specifies that they'd be ok with neuro as well)...granted i don't know how stringent they are with what specialties they'll consider regardless of what their websites states, perhaps the creamier of the crop can be more selective?

 

[splik]

mt sinai deffo will look at psychiatry applicants into their palliative medicine program and they actually have quite strong palliative care services. The problem is of course that few psychiatrists pursue palliative medicine. This might be because your earning potential is less in palliative medicine than general psychiatry, so why would you spend an extra year with low salary for a lower opportunity cost unless you were really passionate about, in which case you might have elected for a primary specialty where you'd be a 'real doc' to begin with etc.

 

[notdeadyet]

hmmm really? no it seems even places that i don't imagine to be "super hard core" have their preferenes..

I was considering this route and asked palliative care faculty at my home program. The word I got was that many programs do not take psychiatrists. When I inquired at a few programs I was interested in, they verified this. I was told that a large emphasis of the program is medical management of the patient, for which they preferred applicants with a stronger broad/basic/physical medical background than most psychiatrists have.

Look at the current residents and faculty at the palliative care fellowships you're interested in. If you see now psychiatrists as fellows or faculty, that should probably be a pretty good clue.

 

[clement]

You echo my assumptions and what I had heard from IM people...However true this might be, the IM folk are biased, remember...I have a feeling, just a feeling, that a decent percentage of palliative fellowships are psych-friendly (randomly stumbled across the cleveland clinic, for example).
I'd be curious to someday see an excel sheet with data on psych-friendly programs. I realize a lot of pall care involves medical management, but oh so much of it also overlaps with psych. And I don't think they do the sort of elaborate medical management that a psychiatrist can't be trained to do in fellowship, though having a medical background in residency I'm sure helps. I think it's more a matter of the culture of specific programs and who runs them. The same is true of other multidisciplinary fields like preventative medicine, occupational medicine or sleep medicine. Their openess to a particular field depends on who runs the fellowship, somewhat more so than whether any one specialty might actually be more capable in practice.

 

[sunlioness]

I really don't see how us maybe needing some extra training in certain medical stuff is all that different that what someone from another specialty might need in terms of managing depression, anxiety and delirium or determining capacity. *shrug*. There's a lot of overlap and it seems silly to prioritize some skill sets over others. Which doesn't mean that it doesn't happen, of course.

I may yet do palliative/hospice someday. Maybe.

 

[clement]

I really don't see how us maybe needing some extra training in certain medical stuff is all that different that what someone from another specialty might need in terms of managing depression, anxiety and delirium or determining capacity. *shrug*. There's a lot of overlap and it seems silly to prioritize some skill sets over others. Which doesn't mean that it doesn't happen, of course.

I may yet do palliative/hospice someday. Maybe.

I dunno. I kind of got the vibe the programs run by IM are the ones that are more hesistant to have psych applicants? Not trying to stir the pot, but I saw at least one program that said, "neuro, IM, and FM" are qualified to apply. Who knows if they're really strict about that. Are these spots really filling THAT competitively that they can limit to a few specialties? I know neurologists do 6-8 months of medicine during prelim year, but...As you say, we are kind of a natural fit for this. I think at least a few people where I'm at practically essentially do palliative w/o having done a fellowship.

 

[DebDynamite]

Also, consider looking into openings after the programs have not filled. I am envisioning that these fellowships do not fill every year? A qualified psych applicant may be better than an empty spot.

 

[clement]

Also, consider looking into openings after the programs have not filled. I am envisioning that these fellowships do not fill every year? A qualified psych applicant may be better than an empty spot.

hmm but that shouldn't be the culture...either we're qualified or not. now i wonder, job-wise does anyone care if your residency was psych or fm? don't most pall patients have an oncologist or "medically-trained" person taking care of them anyways?

anyway, let's see, why the "psych-specific" fellowships? i.e. sloane kettering.
i don't know, are there addictions fellowships for psych and addiction fellowships for fm/im that are vastly different?

guess it would be great to hear from anyone who has done a "regular" pall fellowship out of psych.

 

[splik]

to my knowledge mskcc doesnt have a psych specific palliative fellowship - they have psycho-oncology fellowship in addition to palliative care but these are different fields. psycho-oncology fellowship is basically for the psychosomatic medicine boards, not HPM. they also have an HPM fellowship which is open to various specialties. There are to my knowledge NO psych-specific palliative medicine fellowships and why would there be?

 

[clement]

to my knowledge mskcc doesnt have a psych specific palliative fellowship - they have psycho-oncology fellowship in addition to palliative care but these are different fields. psycho-oncology fellowship is basically for the psychosomatic medicine boards, not HPM. they also have an HPM fellowship which is open to various specialties. There are to my knowledge NO psych-specific palliative medicine fellowships and why would there be?

that's a good question. if you look at the mskcc site under the regular pall care fellowship, it is encouraging applicants from psych residencies to apply to the psycho-onc fellowship INSTEAD...implying that there is some parallelism btwn the two fellowships.

 

[notdeadyet]

hmm but that shouldn't be the culture...either we're qualified or not. now i wonder, job-wise does anyone care if your residency was psych or fm? don't most pall patients have an oncologist or "medically-trained" person taking care of them anyways?

I would hope there would be a preference. If my wife were to be deathly ill and suffering from multiple comorbidities and various types of side effects and pain, I think I'd want someone with more experience and training in handling complex physical medical concerns than a psychiatrist.

Just my opinion. If I wanted someone to help us deal with end-of-life psych issues, I'd love to consult a psychiatrist, but for overall management of my wife's pain and medical condition? I'll take the FM/IM-trained PCM doc.

 

[DebDynamite]

hmm but that shouldn't be the culture...either we're qualified or not. now i wonder, job-wise does anyone care if your residency was psych or fm? don't most pall patients have an oncologist or "medically-trained" person taking care of them anyways?

anyway, let's see, why the "psych-specific" fellowships? i.e. sloane kettering.
i don't know, are there addictions fellowships for psych and addiction fellowships for fm/im that are vastly different?

guess it would be great to hear from anyone who has done a "regular" pall fellowship out of psych.

Agreed. Which is why I stated, "qualified psych applicant". But also suggesting that PD's fill from their own specialty first, then others. Which would be a phenomenon to consider.

Does palli have a match, or an open application season?

 

[sunlioness]

They don't have a match. From the blogs I read, it seems they are hopeful of having one at some point, but they don't yet.

 

[MDchouette]

At my program, we've had people go into pain fellowship afterwards. They did other rotations (not sure which ones) to make them qualified for and attractive applicants to the pain match. I imagine that if a psychiatry resident knew he/she wanted to do palliative care earlier on, something like that could be arranged.

 

[clement]

I would hope there would be a preference. If my wife were to be deathly ill and suffering from multiple comorbidities and various types of side effects and pain, I think I'd want someone with more experience and training in handling complex physical medical concerns than a psychiatrist.

Just my opinion. If I wanted someone to help us deal with end-of-life psych issues, I'd love to consult a psychiatrist, but for overall management of my wife's pain and medical condition? I'll take the FM/IM-trained PCM doc.

I would hope the palliative care physician would not be the only physician taking care of a terminally ill individual with multiple comorbidities + complex physical medical concerns. I imagine this person would have more than one type of physician involved in his or her care. An oncologist? A general internist? A geriatric specialist? An infectious disease specialist? I respect your opinion and I don't believe it's without plausible basis but if in your opinion the psych trained individual is mostly only qualified to "deal with end-of-life psych issues," then why are such individuals even allowed to partake in the palliative care boards? Seems to me like it would be violating the premise of do no harm and therefore a huge liability for those who got together and decided psych could train in such a fellowship.

 

[vistaril]

I really don't see how us maybe needing some extra training in certain medical stuff is all that different that what someone from another specialty might need in terms of managing depression, anxiety and delirium or determining capacity. *shrug*. There's a lot of overlap and it seems silly to prioritize some skill sets over others. Which doesn't mean that it doesn't happen, of course.

I may yet do palliative/hospice someday. Maybe.

"certain medical stuff"?......like pulmonology, infectious disease, etc perhaps?

Don't get me wrong I think mental health care providers do and can play some role in palliative units, but we aren't meant to be primary palliative care providers......

 

[vistaril]

I would hope there would be a preference. If my wife were to be deathly ill and suffering from multiple comorbidities and various types of side effects and pain, I think I'd want someone with more experience and training in handling complex physical medical concerns than a psychiatrist.

Just my opinion. If I wanted someone to help us deal with end-of-life psych issues, I'd love to consult a psychiatrist, but for overall management of my wife's pain and medical condition? I'll take the FM/IM-trained PCM doc.

exactly.....before this thread I never had even considered the possibility as it would make zero sense.

 

[splik]

I would hope the palliative care physician would not be the only physician taking care of a terminally ill individual with multiple comorbidities + complex physical medical concerns. I imagine this person would have more than one type of physician involved in his or her care. An oncologist? A general internist? A geriatric specialist? An infectious disease specialist? I respect your opinion and I don't believe it's without plausible basis but if in your opinion the psych trained individual is mostly only qualified to "deal with end-of-life psych issues," then why are such individuals even allowed to partake in the palliative care boards? Seems to me like it would be violating the premise of do no harm and therefore a huge liability for those who got together and decided psych could train in such a fellowship.

palliative care is multidisciplinary by its nature, it is also not a very renumerative, and thus not very competitive a specialty. For these reasons, there are many routes into palliative care, but ultimately you will be expected to work within the boundaries of your own professional competence. I am keen on doing a HPM fellowship, but I do not think it will leave me as proficient as someone from an internal medicine background - for one thing the training is too short. The HPM boards cover a core body of knowledge - symptom control, ethics, end of life issues, pharmacology, and so on, but don't kid yourself that will mean you are better at providing palliative care to a cancer patient than an oncologist who is also trained in HPM. Yes you will both be able to manage pain, delirium, fatigue, vomiting and so on but when it comes to selling yourself in the jobs market you are likely to draw upon your psych training as your strength whilst the oncologist, neurologist or anesthesiologist will likely be bringing theirs. I would also add if you are in a specialty like anesthesiology, oncology, general surgery, you are going to have more experience dealing with patients at the end of life before you come to do your HPM fellowship than a psychiatrist.