Has anyone here or someone you know of applied for a hospice + palliative medicine spot? I know some are FM or IM-centric, but any real world experiences out there? What would make it so hard for a psychiatry resident to transition to palli (other than maybe a fellowship director having some kind of bias against shrinks)? Sure we do less medicine, but we basically do palliative care for dementia and chronic SI, manage opiate detox, depression, anxiety, delirium, family meetings, capacity consults, I've seen my fair share of ethical dilemmas and we tend to know how to talk to patients...Is it the opiate management stuff that raises eyebrows in terms of our background? Palliative docs certainly don't manage vents...We can apply for pain fellowships, so remind me again why I once heard vague rumors that palli doesn't favors psychiatrists over FPs and internists even though their websites say we can apply?
Palli...
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yes I know of people doing palliative medicine after psychiatry. one of the attendings on the palliative medicine service is a psychiatrist at my program (and did not do a fellowship back then). I think the top programs like harvard, UCSF prefer people from IM because the fellowships are run by their IM departments and you do have to have a good working knowledge of medicine to be a good palliative physician. However, Harvard, which does not say anything about accepting applications from psychiatrists (mentions other specialties except for psych) actually accepted one into their palliative medicine fellowship for 2014, so there you go. apart from those snooty programs it's wide open for psychiatrists to apply for palliative medicine. it is NOT a competitive fellowship as its one of the fellowships you take a pay cut if you actually practice in that area. there used to be a specific palliative psychiatry fellowship at san diego hospice unfortunately the hospice recently closed because they were providing good care and it doesn't pay! Steve Irwin (a psychiatrist who used to do palliative psychiatry there) is now at one of the UCSD centers. MSKCC offers a psychosocial oncology fellowship for psychiatrists, and Dana Farber offers something similar - but you get certified in psychosomatic medicine rather than HPM. You could apply for the palliative medicine fellowship at MSKCC as a psychiatrist, but would have to have good reason, and with so many expert psychiatrists in end of life care who would train you in the fellowship for psychiatrists you would have to have a good reason. Certainly you ought to do more than 4 months of IM if you want to do HPM with medically ill patients, and preferably an ICU month during residency though not necessary.
It is MUCH easier for a psychiatry to apply to HPM than pain fellowship because they are just different magnitudes of competitiveness. One will cut your pay, the other could increase it significantly.
It is MUCH easier for a psychiatry to apply to HPM than pain fellowship because they are just different magnitudes of competitiveness. One will cut your pay, the other could increase it significantly.
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One of our local Palliative Medicine departments is actually headed by a Geriatric Psychiatrist.
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UCSF actually has a psychiatrist starting the hospice/palliative medicine next year.
Unless a program is looking to just fill slots with warm bodies (and there are hospice fellowships that likely meet that criteria), psychiatrists are going to have more of an uphill battle than their colleagues for these fellowships because of the dearth of general medicine knowledge. I was looking into this specialty for a while and the advice I got was that you need to demonstrate interest very early and take electives that get you with complex medical management.
Keep in mind that walking patients through end of life (the true psych-y stuff) is a small part of the gig. Comfort and dignity is a big part of it. And this is going to be done through quite a bit of patient care and pharmacology that your average psychiatrist has not touched since intern year, if at all. Even the part of the show that psychiatrists bring a big strength, the psychological part, is something we probably overassume. How many hospice rotations does a given psych program have? How much training did you receive in modalities like Dignity Therapy? There have been some interesting studies that show that psychiatrists receive much less training and experience surrounding end-of-life issues than your average internist.
Again, not to say hospice/palliative medicine is closed off to psychiatrists. Not even at the top programs. But you need to make yourself stand out and show that you will come in with the experience, otherwise there is a risk that you will be the "special case" requiring a bunch of training in how to manage complex medical cases. It would also help if you could tailor your psych residency to build up experience in end-of-life psychiatry, something most programs have minimal training in.
Hi and thanks for the great replies.
So this is where I'm trying to gather a little more info... What is the extent of complex medical issues that a palliative specialist is managing? If, as I assume, a lot of it is pain, anxiety, depression, delirum/psychosis, I don't see psychiatrists as coming in with a strong disadvantage and in fact maybe even have an advantage in some regards (i.e. I've had exposure to the use of methadone, suboxone, morphine and so on in my addictions rotations, and would argue that I may feel more comfortable than some IM residents).
I think, perhaps part of what you're saying is that applying is about how one markets oneself, because let's face it, there will be some degree of bias from a specialty like IM running a fellowship, i.e.,
"A psychiatrist won't know enough medicine" regardless of the extent of medicine actually involved, even for something like palliative (albeit SOME of this bias has truth to it but I doubt it's a deal-breaker). I think this bias actually supports "special palliative fellowships for psychiatrist" perhaps. For example, the MSK HPM fellowship website does strongly seem to encourage psychiatry applicants to apply to the psychosocial palliative fellowship they have. What I'm saying is, it feels like there's less actual vent managment involved than knowing the culture of the ICU and interpreting the status of a vent-dependent patient when discussing decision-making...Which isn't too horrible of a learning curve to climb?
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I think this highlights why they scrutinize psychiatry folks. The short list you're giving here (with the exception of pain) is the psych component, which makes up a small portion. You will need to handle the refractory diarrhea caused by antibiotics, or the constipation caused by other medications. Nausea. Insomnia. Cognitive decline. Etc. In some environments, you are potentially taking on the bulk of a patient's medical care at end of life, you're just not searching to cure. Psychiatrists are entirely capable of this, but it will require a lot of boning up on general medical stuff that will have lapsed.
Addiction medicine handling of opiates is a different animal than what folks who have done rotations in pain management will have learned. Few if any psychiatry residents will have been primary manager of as many pain complaints as your average internist.
Nope. I think psychiatrists have an uphill learning curve to catch up to their fellow fellows for 85% of what they'll be doing. And you'll be lightyears ahead of your fellow fellows on the other 15%. But I'd be very cautious about minimizing the 85% as it might give the indication that you don't appreciate what you'll be doing, which could be a deal killer.
Psychiatrists can make awesome Palliative care docs, but there's further learning they need to do to get there.
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Would a combined IM/Psych residency be good?
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That would be awesome for palliative care, but certainly not necessary. A smart psychiatrist who bones up on their medicine will do fine at programs that allow psychiatrists and an internist who is open-minded to therapy and psychosocial issues will do great as well.
I'm under the impression at least at most academic centers (and even many community) that palliative specialists are often consultants that wouldn't necessarily be managing chronic diarrhea from antibiotics, but certainly nausea and constipation from opiates . Insomnia and cognitive decline are not new to us as psychiatrists, especially in comparison to IM residents. I suppose all of this is to say, the spectrum of medical issues to be managed will depend upon the environment. I respectfully disagree that my list highlights why psychiatrists are more scrutinized (simply because the curriculum of these programs emphasizes things noted in my list). I believe the bias is really a general bias against psychiatrists, from internist to shrink (and from psychiatrists toward themselves). Let's not forget the psychiatry folks that have grandfathered into palliative without additional formal fellowship training...Another thing to note in the culture of palliative fellowships is that some are on the internal med cycle of fellowship application (applying 1.5 years in advance) because HPM was once (still is?) viewed an "easy touchy feely back-up" type of fellowship...So they have that bias against themselves and potentially becoming a feeding ground for psychiatrists doesn't help that issue.
Couldn't agree with you more on this one, but it is also environment and residency culture dependent. At my program, we get referrals when others from internal medicine, neurology, pmr, etc., have given up for chronic pain (often with suicidality and/or addiction). These are people we then admit and manage as inpatients on suboxone, methadone, etc (esp at the VA). I've interfaced with IM residents who balked at the idea of starting anyone on methadone even when they were on it as an outpatient (some hospitals have rules against this as well). To ferret out the root of the pain is certainly not our strong-hold, but believe me when I say I've seen more medically-oriented folks way less comfortortable with the above than some psychatry residents. So coming from IM can be a "false advantage."
I still don't have a full sense of what the 85% is, but appreciate all the input 🙂 I imagine it to be end-stage COPD, CHF, etc etc. There, I really do appreciate the medical knowledge that has rusted up...
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That makes sense, but I think this is exactly the kind of thing good HPM folks do take on. HPM may be consulted for pain, but the discomforts and indignities patients tend to go through are often overlooked by the ward teams and HPM does pick up these pieces. You will learn a lot about treating diarrhea, which isn't so hard, unless the patient is fighting multiple bugs, is on multiple antibiotics, and a cancer and/or ARV cocktail that make it much more difficult to treat effectively and safely. Internists have more experience dealing with this than psychiatrists, so we have to play catch up, then HPM training will take it up a notch..
Yeah, me too. It's a natural part of the process. IM folks deal with the physical complaints of dying patients all the time whereas we don't. But with some time and energy, you can make up for that, and once you do, many great HPM programs would love to take on a psychiatrist. And that will especially be true if they have done some end-of-life work themselves (e.g.: dignity therapy and other specific modalities like that). I think it's a very cool career path. Not for me, but definitely very cool. Good luck with it...
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while I think there can certainly be a role for psychiatrists to aid in the mgt of some palliative care patients and units, the laundry list of things you mention does not constitute a very large percentage of palliative care issues. Most of the relevant issues are issues related to........medicine. So it makes sense that internal medicine and family medicine grads(you know....people who spend their training doing medicine and not psychiatry) are going to be favored for such things.
I also think there is more to palli than just the work that goes on in the palli unit itself. Consults in the hospital are much more than ust supportive care for example. There is non-trivial medicine involved in those discussions with the primary team that most psychiatrists aren't in any position to handle.
If you want to do palliative care, just do internal medicine. You certainly don't need to do a combined IM/psych program anymore than you need to do a combined medicine/neuro program.
Palliative care is not exclusively a fellowship of medicine, but many people probably guess that it is. You certainly don't need to do a psychiatry residency to understand(or even better prepare for possibly) issues of ethics, capacity, and other end of life issues found in palliative. In fact short of things like radiology, pathology and maybe pediatrics, psychiatry would probably be about the least useful specialty to transfer into a palliative generalist position. As I said before, I do think psychiatrists can play a role in some palliative care cases however.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3762465/
Notably,
..."When asked about specific areas of palliative care, the psychiatry residents in the Tait and Hodges17 study felt prepared in areas of managing pain and recognizing opioid tolerance, as well as in certain areas of communication (e.g., addressing patients’ fears, discussing end-of-life issues, and delivering bad news). The residents noted a significant lack of preparedness in cultural or spiritual aspects of care, assisting in patients’ efforts to say goodbye, or handling requests for physician-assisted suicide. These findings led the researchers to note that “education is not currently preparing psychiatrists to feel competent in many of the aspects that both trainees and patients agree are important” (p. 456).17"
and
"Compared with family and internal medicine residents, the psychiatry residents demonstrated less competence initially, but exhibited an equal competence level to family medicine residents at the end of the clinical rotation. Notably, the psychiatry, family, and internal medicine residents were not significantly different with regard to their concerns or knowledge before the clinical rotation, and all three groups exhibited similarly decreased concern and increased knowledge after the rotation.
In sum, this study demonstrates that (1) US psychiatry residents are not commonly receiving training in hospice and palliative care within their educational settings, (2) US psychiatry residents are in fact interested in learning more about this area, and (3) when given the opportunity to complete a formalized hospice and palliative care rotation, US psychiatry residents gain the competence necessary, at a level equal to peers in other specialties"
Notably,
..."When asked about specific areas of palliative care, the psychiatry residents in the Tait and Hodges17 study felt prepared in areas of managing pain and recognizing opioid tolerance, as well as in certain areas of communication (e.g., addressing patients’ fears, discussing end-of-life issues, and delivering bad news). The residents noted a significant lack of preparedness in cultural or spiritual aspects of care, assisting in patients’ efforts to say goodbye, or handling requests for physician-assisted suicide. These findings led the researchers to note that “education is not currently preparing psychiatrists to feel competent in many of the aspects that both trainees and patients agree are important” (p. 456).17"
and
"Compared with family and internal medicine residents, the psychiatry residents demonstrated less competence initially, but exhibited an equal competence level to family medicine residents at the end of the clinical rotation. Notably, the psychiatry, family, and internal medicine residents were not significantly different with regard to their concerns or knowledge before the clinical rotation, and all three groups exhibited similarly decreased concern and increased knowledge after the rotation.
In sum, this study demonstrates that (1) US psychiatry residents are not commonly receiving training in hospice and palliative care within their educational settings, (2) US psychiatry residents are in fact interested in learning more about this area, and (3) when given the opportunity to complete a formalized hospice and palliative care rotation, US psychiatry residents gain the competence necessary, at a level equal to peers in other specialties"
