Will HPM go the way of EM?

[hihimedmed]

Per this article: Celebrating Hospice and Palliative Medicine as the Fifth Largest Medical Subspecialty,

HPM is now the 5th largest subspeciality, and it has not been a true "specialty" for very long with room to grow. Per NMRP data, about 10-20 new HPM fellowship programs have opened up per year (aside from last year, which saw only about 6 new programs open up). Obviously, more HPM physicians, the better! In most cases, at least. As an EM resident, I am of course worried about job markets in any specialty I decide to invest time into (see the recent "EM Workforce Study" where there will be a surplus of EM docs by 2030).

What I have seen is that a popular website called DocCafe that posts physician job offers by specialty, also lists how many job openings there are per specialty. This is of course not the entire job market, but could be a potential representation of the job market (when COVID hit, EM jobs went to less than 500 postings; now it is over 4000 and has bounced back, for now). There are not many job openings on other websites for HPM, either.

My point is, the job market for EM is projected to get tight despite there being more jobs available at the moment per grads (about 2000-3000 EM grads per year, 4000+ jobs available on DocCafe). What I am seeing is that there are bout 400-500 HPM grads per year now, but only 200 job postings on DocCafe, and HPM fellowships are still proliferating, and is now the "5th largest subspeciality".

Will HPM go the way of EM?

Thoughts?

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[pageantry]

I’m just applying for fellowship now (from EM), and what I personally think is that HPM is not a field to go into for money or career stability. In many places it was and still is the realm of NPs, RNs, and social workers. “Midlevel creep” isn’t a problem; it’s the structure of the field. So I think many fellows are looking for an expansion of skills without necessarily planning to practice full time. And a lot of people seem to practice their original career path at least part time.

That said, I do think the field still has an amazing career outlook if you want to start your OWN palliative programs, hospices, integrative centers, or if you want to be part of developing the future of the field. That’s what attracts me.

Again, this is just from my side of the fence. I’d love to be corrected or otherwise hear from more established voices.

 

[Entadus]

I graduated fellowship this year, and out of 4 fellows we secured a total of 2.5 palliative jobs. So keep in mind that not every graduate wants to or will practice palliative full time at the exclusion of their primary specialty.

Another thing to consider is that the field of HPM is growing. Who is to say how the rate of growth in departments/jobs will compare to the rate of growth of fellowship positions and job applicants? I agree it is troublesome that we have no guarantees the balance will remain in the favor of recent graduates.

For now, the number of palliative jobs available is relatively small (for example compared to hospitalist or primary care). The number of applicants also remains relatively small, so it's still manageable to find a job, especially if one is not geographically bound. As someone who has my foot in the door for my first palliative job already, I'm grateful. Having said that, I keep my eyes wide open and spend a decent amount of time reading the woes of our colleagues in the rad-onc and nephrology forums, and am aware that danger could lie ahead. If I'm flexible and vigilant, I should be okay.

 

[DocHoliday84]

I’m just applying for fellowship now (from EM), and what I personally think is that HPM is not a field to go into for money or career stability. In many places it was and still is the realm of NPs, RNs, and social workers. “Midlevel creep” isn’t a problem; it’s the structure of the field. So I think many fellows are looking for an expansion of skills without necessarily planning to practice full time. And a lot of people seem to practice their original career path at least part time.

That said, I do think the field still has an amazing career outlook if you want to start your OWN palliative programs, hospices, integrative centers, or if you want to be part of developing the future of the field. That’s what attracts me.

Again, this is just from my side of the fence. I’d love to be corrected or otherwise hear from more established voices.

Im applying this year from EM too. Alot of this stuff I still have no clue about to be honest. Would love to know what goes into starting a new palliative program/how hard is it to convince a hospital to hire you to be involved in this. Definitely seems like a lot of hospitals need it.Ho

Hoping to have career stability doing 100% HPM after fellowship. I guess if I had to do EM to bring home the bacon I would, but man, I would really be a lot happier if I never had to do a night shift in the ED again. That would be so priceless.

 

[Frazier]

Graduates this year, and likely for the next couple years, will have minimal problems finding a full-time HPM job, if they so choose. This is anticipating that the ebb and flow of the workforce remains consistent. However they might not land full-time employment with a job description they want in their goal geographic location. This requires ongoing monitoring of the market as an attending.

There is a significant portion of the fellows every year that do HPM as a stepping stone to another fellowship, VISA extension, or plan to just use the training in their primary specialty. Many HPM fellows, unlike cards and GI, do not intend to actually practice as full-time HPM docs. I imagine if it was a 3 year fellowship like Cards/GI then some of that would change. But it doesn't need to be a 3 year fellowship.

What needs to be stressed is: yes, the volume of HPM graduates will eventually tip the scale from demand to over-supply. This is going to exacerbate with continued proliferation of NP/PA usage (i.e. $$$).

There are ways to protect yourself.

1) Be flexible with willingness to use all the skills you learned in fellowship. Some people might be gung-ho "I want to do 100% outpatient hospice" or "I want to do 100% inpatient palliative". If they can be flexible to point of "I'm okay doing some XYZ as long as I get plenty of 123", then they are better off from standpoint of getting hired and staying happy.

2) Consider academic centers (whether university, community, or VA). Fellowships need physicians to function as faculty for their program. Less likely that you are going to be replaced by a NP/PA.

...WAIT! What??? Replaced by NP/PA? Yes. This isn't to say that HPM isn't complex or shouldn't be a medical subspecialty... this is due to money. If you have a small department of 4 docs and 2 midlevels, but volume is growing fast --the current state of medicine pushes to hire 2 additional midlevels for the price of 1 additional physician. (In reality, it would more likely be allocation of funds for just 1 new midlevel and the health system pocketing the rest.)

So, reframed another way, I dont think that current physicians are going to be fired and replaced with midlevels... but I think positions that will be created in the future are more likely to be targeting midlevels unless there is good reason for a physician to be hired (i.e. director position, academics, current physician leaving and they will need a new doc to supervise midlevels, etc.)

3) Start your own practice where you are the boss. This has a notable amount of risks to it given our patient population and their needs, plus we are essentially a consultant's consultant... you will need Heme/Onc, Nephro, Cards, Neuro, Pulm to be making referrals to you. Direct marketing to patients for palliative services runs risk of attracting patients with questionable motives (i.e. opioid issues).

Regardless of specialty, most physicians change jobs within a couple years of finishing their training. While it is reasonable to take solace in that fact ("Ah, I will take this decent job in region I hate because I'd prob end up leaving any job within a couple years anyway...") I would strongly suggest given the trajectory of medicine and HPM to try to locate and lock-in on positions that you feel could potentially be your "forever job" as soon as possible. If you want to move to Florida as your top priority longterm, then make it happen for your first job. If practicing 100% inpatient palliative is your top priority and you dont forsee ever caring about geography, then find that gig and land it ASAP.

Overall HPM is a great field and I enjoy going to work every day. I am compensated for my time and take pride in what I offer patients/families. That said, jobs for physicians are going to become fewer (IMO) and jobs for midlevels are going to continue to increase to meet the growing demand for the field.

Don't stay for long in a job that ends up not being a great fit for you as the water level in the pool is decreasing and you want your spot in the pool.

 

[baileyfal]

OP, I think your concerns are valid and should be considered by anyone planning to enter the field or is currently an attending early in their career. I agree with what’s been mentioned in this thread so far; there are several mitigating factors that hopefully will prevent significant oversupply of physicians. I’ll add that not all of the HPM fellowship positions historically or currently fill and if the job market tightens, I would expect these new programs would have trouble filling.