Considering Fellowship

[MDMohawk]

Hi all!

I'm a 2nd year family medicine resident in the PNW still trying to find my way. Being that 3rd year is fast approaching, I'm trying to research possible plans for when I graduate. I've always had an interest in hospice and palliative care and did quite a lot of volunteering prior to and during medical school. Now that I'm a resident, I still feel the pull towards this specialty. Any information would be so helpful; specifically, information on the following questions:

1. How competitive is the specialty? Do many FM residents go without matching?
2. How can a resident be competitive? Extra rotations? Is research necessary?
3. What does the job market look like? What does a typical work schedule look like?
4. If I decided to work for a few years prior to applying for a fellowship position, would this be a negative to my application?

Very much appreciate your time!

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[Frazier]

Hi all!

I'm a 2nd year family medicine resident in the PNW still trying to find my way. Being that 3rd year is fast approaching, I'm trying to research possible plans for when I graduate. I've always had an interest in hospice and palliative care and did quite a lot of volunteering prior to and during medical school. Now that I'm a resident, I still feel the pull towards this specialty. Any information would be so helpful; specifically, information on the following questions:

1. How competitive is the specialty? Do many FM residents go without matching?
2. How can a resident be competitive? Extra rotations? Is research necessary?
3. What does the job market look like? What does a typical work schedule look like?
4. If I decided to work for a few years prior to applying for a fellowship position, would this be a negative to my application?

Very much appreciate your time!

Hello,

Thoughtful questions!

On the spectrum of fellowship competitiveness, I would say HPM falls on the low-moderate side of the curve.
Using 2018 data, US MD had about an 85% match rate, US DO about 80%, IMG closer to 70's. The data does not delineate between applicant specialty, so it is hard to say how many applicants which didn't match come from IM vs FM vs EM vs Radiology etc... There are 10 primary specialties eligible to apply to the fellowship.

IM and FM make up the great majority of applicants and currently practicing palliative docs. However, as noted above folks from other fields maintain a presence too. I am trained in EM for example.

One last comment on competitiveness, if your goal is to simply match anywhere, there I would say it is more on the low side; however if you are hellbent on matching in CA (insert specific geographic region) or at certain institutions (Harvard, Mayo, Stanford, Hopkins, etc) then it is obviously quite competitive since you are now shooting for a very limited number of spots.

Research is not necessary to match; however, it is a nice boost for your application -- bonus points if it is HPMcentric research. Many match without any significant research however. Likewise, you do not need to do away rotations or multiple HPM rotations. What you need to be competitive to just match somewhere is the following: graduate from an eligible primary specialty, have not failed Step 1/2/3, composed a strong personal statement which answers "why HPM", and have a good interview. The more picky you get with where you want to be, the more these facets need to ramp up.

Working a few years would not significantly hinder your application. At worst it will just be neutral, at best it will actually help out quite a lot. There are many mid-career applicants every year that apply and succeed.

In regard to schedule and jobs [borrowed from another one of my posts]:

As a fellow, my schedule depends on the service. I'm scheduled for clinic one day per week. We have a cap of 4 patients with the option to add-on 1 if we wish. I typically choose to have the add-on when someone needs close monitoring -- say H&N cancer doing a course of radiation. If the options are to 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 so be it.

I have 2 types of appointment windows -- 90 minute intakes and 45 minute follow-ups (so, yes, plenty of time for patients/families). Clinic goes from 8-5p. One hour lunch. If your schedule ends at 4 and you're done with your tasks at 4 -- go home at 4.

When I'm on the consult service, I typically carry about 6 patients per day. Days start at 8a and end at 4-5pm. One hour lunch. When I'm 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. One hour lunch.

GIP hospice typically 2-7 patients on census. One hour lunch.

Onward to the job market:
It is good... at baseline.

There is currently a bit of a shortage compared to regular years due to many large hospitals being on hiring freezes 2/2 COVID.

Often you can work in multiple settings pending your employer contract stipulations. Otherwise, many large robust practices actually have inpatient, hospice, and community presence -- so it is not rare to find positions that have split responsibilities across practice settings while still staying under the umbrella of the same institution.

There is a wide range in total comp between 160k-300k in being seen (to use MGMA's approach). Average is around 225k."

What about job satisfaction?

Longitudinal surveying show 98-99% satisfaction among grads in choosing the field and would recommend it to others.

Here is about 6 years worth of data on palliative fellowship graduate satisfaction. The percentages speak for themselves and to my knowledge unmatched in healthcare.

2014
View attachment 296618

2016
View attachment 296619

2018
View attachment 296620

 

[pccmaspirant2021]

I

Hello,

Thoughtful questions!

On the spectrum of fellowship competitiveness, I would say HPM falls on the low-moderate side of the curve.
Using 2018 data, US MD had about an 85% match rate, US DO about 80%, IMG closer to 70's. The data does not delineate between applicant specialty, so it is hard to say how many applicants which didn't match come from IM vs FM vs EM vs Radiology etc... There are 10 primary specialties eligible to apply to the fellowship.

IM and FM make up the great majority of applicants and currently practicing palliative docs. However, as noted above folks from other fields maintain a presence too. I am trained in EM for example.

One last comment on competitiveness, if your goal is to simply match anywhere, there I would say it is more on the low side; however if you are hellbent on matching in CA (insert specific geographic region) or at certain institutions (Harvard, Mayo, Stanford, Hopkins, etc) then it is obviously quite competitive since you are now shooting for a very limited number of spots.

Research is not necessary to match; however, it is a nice boost for your application -- bonus points if it is HPMcentric research. Many match without any significant research however. Likewise, you do not need to do away rotations or multiple HPM rotations. What you need to be competitive to just match somewhere is the following: graduate from an eligible primary specialty, have not failed Step 1/2/3, composed a strong personal statement which answers "why HPM", and have a good interview. The more picky you get with where you want to be, the more these facets need to ramp up.

Working a few years would not significantly hinder your application. At worst it will just be neutral, at best it will actually help out quite a lot. There are many mid-career applicants every year that apply and succeed.

In regard to schedule and jobs [borrowed from another one of my posts]:

As a fellow, my schedule depends on the service. I'm scheduled for clinic one day per week. We have a cap of 4 patients with the option to add-on 1 if we wish. I typically choose to have the add-on when someone needs close monitoring -- say H&N cancer doing a course of radiation. If the options are to 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 so be it.

I have 2 types of appointment windows -- 90 minute intakes and 45 minute follow-ups (so, yes, plenty of time for patients/families). Clinic goes from 8-5p. One hour lunch. If your schedule ends at 4 and you're done with your tasks at 4 -- go home at 4.

When I'm on the consult service, I typically carry about 6 patients per day. Days start at 8a and end at 4-5pm. One hour lunch. When I'm 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. One hour lunch.

GIP hospice typically 2-7 patients on census. One hour lunch.

Onward to the job market:
It is good... at baseline.

There is currently a bit of a shortage compared to regular years due to many large hospitals being on hiring freezes 2/2 COVID.

Often you can work in multiple settings pending your employer contract stipulations. Otherwise, many large robust practices actually have inpatient, hospice, and community presence -- so it is not rare to find positions that have split responsibilities across practice settings while still staying under the umbrella of the same institution.

There is a wide range in total comp between 160k-300k in being seen (to use MGMA's approach). Average is around 225k."

What about job satisfaction?

Longitudinal surveying show 98-99% satisfaction among grads in choosing the field and would recommend it to others.

Here is about 6 years worth of data on palliative fellowship graduate satisfaction. The percentages speak for themselves and to my knowledge unmatched in healthcare.

2014
View attachment 296618

2016
View attachment 296619

2018
View attachment 296620

Excellent insight. Infact your post is helping me make my decision to choose HPM, one last question. What about the mid level encroachment that everyone keeps talking about? How do we maintain our exclusivity as a HPM physician When NP/PA are primarily employed by most mid sized hospitals.

 

[Frazier]

Excellent insight. Infact your post is helping me make my decision to choose HPM, one last question. What about the mid level encroachment that everyone keeps talking about? How do we maintain our exclusivity as a HPM physician When NP/PA are primarily employed by most mid sized hospitals.

That is a very reasonable concern across all of medicine, as you know! I have been asked on here in the past about my thoughts on if NP/PA's would be taking over HPM in the future? My take...

"Taken over? No. NP's and PA's are very much part of the team however in HPM -- especially so -- the same as are palliative social workers, chaplains, RN's, pharmacists, music therapists, fellows, residents, and med students.

As you can imagine, within the realm of HPM typically the more robust the team (with unique individuals and training backgrounds), the better care provided overall. This is in opposition to many other fields in medicine -- say neurosurgery or radonc -- where a solo doc at a busy medium-sized hospital can effectively serve all the needs a patient might have on their service in concordance with their specialty.

In contrast, a solo palliative doc at a busy hospital isn't going to be able to provide the same level of palliative care consistently over time without an IDT to facilitate the variety of unique needs across the multiple domains of our patients' -- specifically our patients' -- needs.

Going one step further, there are also too many millions of patients needing care for palliative physicians to do everything from the standpoint of both time and money. Many current well-developed teams around the country would crash without the manpower -- others wouldn't get off the ground in the future. For example with my team this week, there was an attending, fellow, resident, nurse navigator, and two NP's. On any given day we had 6 new consults 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 and grind through more patients? Because that isn't good palliative care. Back in my EM days, I would 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 medicine services. 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 and the goals of care-focused consults (with maybe some straightforward symptom overlap) go to our NP/PA colleagues. The attending oversees the team and is essentially the boss. If there were no NP/PA on the team, who would do the heavy lifting each day regarding those ~10 patients? The fellow and resident can't -- they are learning the subspecialty, taking time with their patients, savoring the medicine. The attending can't as it would take away from the oversight and in-depth teaching of the team and particularly physician trainees. 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? Who is paying for that? Read on...

Financially, palliative isn't a big revenue-generator. In fact, historically its value is framed as "cost-saving". So depending on the number of consults per year you can typically justify a physician salary and PA/NPs salaries, and still remain well within net "cost-saving" -- however, if you make an army of only physicians all demanding to be full-time and expecting physician level reimbursement, well, the teams are going to end up as a skeleton crew of burnt out folks providing patients with less than ideal palliative services because they are simply 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 much revenue and only so much "costs" can be "saved".

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 a great service to patients and their families -- as well as to the physicians on the team.

From everything I've seen the PA/NP folks who choose to go into HPM are NOT militant or trying to take over/hang a shingle, or striving to practice outside their scope. They 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 for anyone involved.

One important take away is that, at least in this subspecialty of medicine -- they 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 for all the reasons I mentioned above.

Let me know what I can clarify upon further!

 

[pccmaspirant2021]

That is a very reasonable concern across all of medicine, as you know! I have been asked on here in the past about my thoughts on if NP/PA's would be taking over HPM in the future? My take...

"Taken over? No. NP's and PA's are very much part of the team however in HPM -- especially so -- the same as are palliative social workers, chaplains, RN's, pharmacists, music therapists, fellows, residents, and med students.

As you can imagine, within the realm of HPM typically the more robust the team (with unique individuals and training backgrounds), the better care provided overall. This is in opposition to many other fields in medicine -- say neurosurgery or radonc -- where a solo doc at a busy medium-sized hospital can effectively serve all the needs a patient might have on their service in concordance with their specialty.

In contrast, a solo palliative doc at a busy hospital isn't going to be able to provide the same level of palliative care consistently over time without an IDT to facilitate the variety of unique needs across the multiple domains of our patients' -- specifically our patients' -- needs.

Going one step further, there are also too many millions of patients needing care for palliative physicians to do everything from the standpoint of both time and money. Many current well-developed teams around the country would crash without the manpower -- others wouldn't get off the ground in the future. For example with my team this week, there was an attending, fellow, resident, nurse navigator, and two NP's. On any given day we had 6 new consults 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 and grind through more patients? Because that isn't good palliative care. Back in my EM days, I would 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 medicine services. 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 and the goals of care-focused consults (with maybe some straightforward symptom overlap) go to our NP/PA colleagues. The attending oversees the team and is essentially the boss. If there were no NP/PA on the team, who would do the heavy lifting each day regarding those ~10 patients? The fellow and resident can't -- they are learning the subspecialty, taking time with their patients, savoring the medicine. The attending can't as it would take away from the oversight and in-depth teaching of the team and particularly physician trainees. 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? Who is paying for that? Read on...

Financially, palliative isn't a big revenue-generator. In fact, historically its value is framed as "cost-saving". So depending on the number of consults per year you can typically justify a physician salary and PA/NPs salaries, and still remain well within net "cost-saving" -- however, if you make an army of only physicians all demanding to be full-time and expecting physician level reimbursement, well, the teams are going to end up as a skeleton crew of burnt out folks providing patients with less than ideal palliative services because they are simply 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 much revenue and only so much "costs" can be "saved".

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 a great service to patients and their families -- as well as to the physicians on the team.

From everything I've seen the PA/NP folks who choose to go into HPM are NOT militant or trying to take over/hang a shingle, or striving to practice outside their scope. They 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 for anyone involved.

One important take away is that, at least in this subspecialty of medicine -- they 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 for all the reasons I mentioned above.

Let me know what I can clarify upon further!

Honestly, I absolutely love your perspective Of midlevel roles and it probably stands true in palliative Medicine on the contrary To all other specialties(burnt before!!).
I am applying for HPM this week, wish me good luck. You should try being motivational writer.. I am truly influenced.. thanks

 

[Frazier]

Honestly, I absolutely love your perspective Of midlevel roles and it probably stands true in palliative Medicine on the contrary To all other specialties(burnt before!!).
I am applying for HPM this week, wish me good luck. You should try being motivational writer.. I am truly influenced.. thanks

You are too kind. I'm glad you found some useful information in there!

Congratulations on your decision and good luck -- the field will be delighted to have you join!