EM Resident : Palliative Medicine and You (Emergency Medicine)

[DetroitERDO]

I literally feel like I’m in med school again! If I apply to 7 programs should hopefully be enough to match? Hahah

I'm right there with you. Only, I'm limited to applying to only about 4 places due to family ties to area. I would love to hear more from those
that went EM--> HPM.

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[Frazier]

I just had a fellow that went from EM to HPM... she landed a job in southern california at a large center and will be practicing HPM full-time. Very exciting for her and their family.

Also there is an EM resident from my alma mater that is starting HPM fellowship. He will be heading to a great academic institution... the possibilities are out there!

Enjoy the ride.

 

[workethic712]

I'm right there with you. Only, I'm limited to applying to only about 4 places due to family ties to area. I would love to hear more from those
that went EM--> HPM.

I was limited to geographic area, applied to a handful of places and got my top choice.

About to finish HPM fellowship straight from EM residency. An incoming fellow is also EM to HPM.

 

[Frazier]

Sorry to bump an old post. Can you expand on why concierge or cash-based palliative care would not be a good idea?

As a disclaimer, the following is an amalgamation of previous responses to similar questions over the years, so if something looks familiar -- you're not crazy.

You can start your own practice where you are the boss. This has a notable amount of risks to it. Specifically given our patient population and their needs. Unlike the cosmetic practice or concierge PCP practice where you will have the same patients returning for years (decades?) for their botox, coolsculpting, laser XYZ, or general medical care... our palliative patients typically have a short relationship with us by dying from whatever brought them to us to begin with... So with a cash-based practice, there will likely not be a sense of stability to your revenue in the same sense that those other specialties get to enjoy (the cash-based psych patient that has followed with the same psychiatrist for 20+ years).

In palliative, we are essentially a consultant's consultant... you will need Heme/Onc, Nephro, Cards, Neuro, Pulm to be making referrals to you. These fields crave for you to be accessible for their patient's acute needs (not just with open slots for acute needs, but insurance coverage/in-network, etc.) They need to readily ensure you have access to their notes and plans -- and that they have access to your's.

Onc patient in need of palliation for their mucositis? Only a small subset of patients who are using their insurance for cancer-directed therapy is going to be happy about then having to pay cash for palliative services. Why not just use the in-network palliative doc, or better yet the one integrated into the cancer center? Once the Onc gets burned once or twice ("Yeah I tried to go see that Palli-whatever doc you sent me too, but they don't accept insurance!"), those referrals will be dried up.

Direct marketing to patients for palliative services runs risk of attracting patients with questionable motives (i.e. drug issues). You see posts on social media or advertisements in local papers for cash-based cosmetics or family practice -- and the general public knows and understands what they are looking at when seeing those ads. Great majority of general population have no idea what palliative medicine is or means. Many of the patients that are meeting me for the first time, even after being referred by their doc, still don't know what our specialty is walking into the initial appt. They would not be signing up for a subscription-based concierge practice or cash-pay without knowing what their agenda is walking in...

Which brings me to: What is their agenda?

For the patient that loves the concierge model of practice and has already purchased into a PCP/IM doc being their full-time concierge service, those docs are likely not going to want to give up patients... so they will try to appease and prescribe whatever the patient thinks they need.

So as you know, oncologists, surgeons, cardiologists, hematologists, etc make the referrals and are gatekeepers for our patients -- which makes perfect sense. These physicians tend to be protective of their folks and refer to palliative services they know and trust to help in either ongoing concurrent care or taking over care of these patients. I guess there could be a cancer center somewhere out there where they send all their referrals to a cash-pay palliative doc. I haven't seen it. But that doesn't mean it isn't out there somewhere.

Depending on your neck of the woods, there will be different availability of palliative services already in place for hospitals/specialists. On the one hand, if you are in a location with a lot of robust health systems or one main health system (but all the docs in the community are owned by the health system), it will be pretty damn hard. And on the other hand, if you are in an underserved area and the hospital has no formal palliative program (or maybe just a doc/np that does inpatient goals of care discussions), it is wide open for driving your stake in the ground with a private practice. But if you are in an underserved area, how many of those patients are A) going to be appropriate for palliative medicine, B) have the resources/urge to seek those services at a cash-based model?

When there is a lot of competition, many of the patients who will benefit from your expertise are going to be funneled to the palliative teams that already have done good work for that Oncologist (or XYZ specialist). If the docs are all owned by the health system, they will likely not refer to an outsider (per se) easily or ever, for big brother admin is always watching.

This doesn't even bring up the point of having an IDT to deliver comprehensive palliative care to your patients (social worker, psych, chaplain, etc).

The well-meaning business-minded palliative doc might say: "Well, I am going to be different. I want to cater to my patient's needs with a cash-based model, so we won't need insurance dictating care or needing prior auths for my medications. I do not have an IDT, so will just be focusing on physical symptoms in my palliative cash-based practice. Pain is our most frequent complaint... so I will frame my advertisements as specializing in managing pain in my cash-based practice. All the other docs are comfortable prescribing APAP and NSAIDS all day... so I will need to be managing the meds that most other docs aren't prescribing patients already and find those patients willing to pay cash to get these medications, in a way that their insurance wouldn't approve payment of." ..............It just tends to meander into being a pill mill.

If you are thinking concierge or cash-based practice, I would heavily lean toward "no" -- it likely will not go well. But there is no law against it, so while my money is on that "most will fail", there will be some that succeed.

 

[crop]

I know it has been mentioned earlier but what are good textbooks to buy for fellowship? I couldn’t be more excited

In addition are UNIPAC books worth the purchase from AAHPM website?

 

[Frazier]

I know it has been mentioned earlier but what are good textbooks to buy for fellowship? I couldn’t be more excited

In addition are UNIPAC books worth the purchase from AAHPM website?

You might be given some books or have a book list rendered (+/- funds) when you start.

That said, Evidence-Based Practice of Palliative Medicine
Textbook of Palliative Medicine and Supportive Care is heavy but good
Hospice and Palliative Medicine Handbook: A Clinical Guide is a nice reference of facts
Fast facts is a high yield, easily digestable free online resource
The AAHPM Primer is also easy reading for ground-level knowledge walking into fellowship

You will get the unipac books somewhere along the way to prep for boards.

Don't buy them all -- it will be informational overload/paralysis. And likely your programs might already have some of the above in stock or will pay for them with CME money.

Congrats!

 

[crop]

Any issues/difficulties from the em folks being able to manage patients in palliative care clinic in terms of medication management etc… As ed docs obviously do not have much “outpatient medicine” exposure

 

[throway134]

Any issues/difficulties from the em folks being able to manage patients in palliative care clinic in terms of medication management etc… As ed docs obviously do not have much “outpatient medicine” exposure

Short answer no

Longer answer noooooooo

No one is consulting/referring to you to mess with their inhalers or antihypeetensives and that shouldn’t be you. You’re managing symptoms, if there is an obvious low hanging fruit you might send the referring doc a message but 95% of them have a specialist (e.g. pulm) that sent them to you and also…a pcp. Any of them should be concentrating on that. Stay in your lane. Adjuvants, opioids, and other stuff that you specialize in.

Admittedly I hated outpt, so I am perhaps not the best source as I have no intent of ever doing it again outside fellowship

 

[Frazier]

Yes, I agree with the above sentiment. When I started fellowship, one of my co-fellows was IM and the other one was FM. On the first day, they were more comfortable with the IDEA of clinic and walked in with a better understanding of the cadence inherent to working in an outpatient clinic... and good news is that after your first week, you will be on equal footing regarding the "logistics" of the clinic as your non-EM co-fellows.

I have no doubt they would be able to manage chronic conditions much more efficiently than I could have hoped -- but that never came up because we are talking about a specialty clinic, not primary care. You will be managing what the patient was referred to you for. They were not any more comfortable with complex symptom management or complicated goals of care discussions than I was coming out of EM.

New fellows are mostly on equal footing starting fellowship. What you get out will depend largely on what you put in.