A Fellowship Does Matter

I entered my Palliative Care and Hospice Fellowship in July of 2014, having previously weighed the benefits and burdens of grandfathering in vs. fellowship training. Encouraged by colleagues and my employer I hoped to pursue an experience that would be richer than on the job training and book learning. I did my research before applying to programs. I asked a lot of hard questions to my potential programs. My program director questioned me about what I would want to accomplish since I was already a Hospice Medical Director and had years of physician experience. I laid out my goals and eagerly anticipated the start of my year of learning. Now I am confident that the value of my experience needs to be shared so that other contemplating such a move can be reassured.

I knew it was not going to be easy to move my established life. I resigned from my clinical and administrative positions. I said goodbye to many wonderful coworkers, and patients. I packed my bags and returned to life as a student. My medical career has always been about caring for populations at risk. I embraced the growth that comes from ongoing transitions in my medical career.

I quickly was amazed by the talent of my co-fellows and attendings. As palliative care and hospice providers, we learn amazing skills and invaluable tools for patients in need of care and compassion. Now I realize that I am past the eleven months mark and the time has flown. The experience of my fellowship year has far exceeded my expectations.

I now know how to manage patients and families who appear at the doorsteps of a busy inpatient unit in the worst of situations. I understand the dynamics of highly trained interdisciplinary teams when providing for the physical and emotional needs of patients with advanced suffering. I have learned to palliate the terrible suffering in bodies that cease to sustain themselves. I can feel the deep gratitude as families leave us through the same entrance that greeted them only hours or days earlier.

I have worked in multiple palliative care settings, from solo physicians to full interdisciplinary teams. I have gathered the wisdom of the physicians and other team members to maximize communication across the many levels of human despair. I have gained wisdom from hearing and contrasting multiple attendings’ approaches on symptom management. I know about triaging scarce team resources, the dance of consultant etiquette, and the need to enhance the primary physician’s relationship with the patient.

We care for more than just the patients and their families. We serve and care for the entire range of hospital staff: from medical students to attendings, from CNAs to directors of nursing. We support and coach the new social workers trying to grasp the nuances of hospice placement. We continue to define our role and our skills within hospital systems that barely have time to breathe and reflect. We respect and serve our patients and their families. We advance the science of palliative medicine as we gather data that shows our value to administrators eager to improve quality, satisfaction, and cost savings. All in all, we do great work.

I have grown personally and professionally in ways I never imagined. The need to be in a fellowship is reinforced every day. The year of intense experience is balanced by the beautiful and unwavering support of the attending faculty. The confusion of new places and new rotations is organized and simplified by amazing support staff. When we feel lost, we are given a path and encouragement. When we stress, we are given support and relief. When we look to the future, we are prepared for change and reminded that our mentors are always there for us.

This experience has transformed my initial goals, allowing me to envision the future of palliative care. I see myself able to work in all of the settings of hospice and palliative care. In our developing specialty I see myself returning not only to clinical work but also to a position of leadership and advocacy. I see a great opportunity for supporting teams during the explosion of need for palliative care across the continuum of health care. I hear the warnings about burnout in hospice teams and palliative care teams that need to stay strong now more than ever. I see the need for networking and support among our professions at all levels.

My program is supporting me in my quest to learn about business strategies for hospice and palliative programs. I am actively connecting with our national and international organizations. This amazing fellowship has given me and my co-fellows an environment, a model, and a vision of how to care for patients, families, coworkers, healthcare teams, and ourselves. I am excited because I now see vast opportunities in my life. I look forward to working with hospital systems and healthcare systems as our profession carries forward the recommendations from the Institute of Medicine’s recent report on Dying in America. It is clear to me that this transformation and world of opportunities would have been missed if I simply grandfathered in to board certification. I will forever be thankful that I chose this fellowship experience.

Whit Dunkle, MD, ABFP
Medstar Washington Hospital Center/Capital Caring Fellowship

Highlights of the August Issue of the Journal of Pain and Symptom Management

Listed below are a few articles from the most recent issue of the journal:

Original Articles

Cost Savings Associated with an Inpatient Palliative Care Unit: Results from the First Two Years
Jeremy D. Nathaniel, Melissa M. Garrido, Emily J. Chai, Gabrielle Goldberg, and Nathan E. Goldstein

Correlates and Predictors of Conflict at the End of Life Among Families Enrolled in Hospice
Betty J. Kramer and Amy Z. Boelk

Trajectories of Evening Fatigue in Oncology Outpatients Receiving Chemotherapy
Fay Wright, Gail D’Eramo Melkus, Marilyn Hammer, Brian L. Schmidt, M. Tish Knobf, Steven M. Paul, Frances Cartwright, Judy Mastick, Bruce A. Cooper, Lee-May Chen, Michelle Melisko, Jon D. Levine, Kord Kober, Bradley E. Aouizerat, and Christine Miaskowski

Predictors and Trajectories of Morning Fatigue Are Distinct from Evening Fatigue
Fay Wright, Gail D’Eramo Melkus, Marilyn Hammer, Brian L. Schmidt, M. Tish Knobf, Steven M. Paul, Frances Cartwright, Judy Mastick, Bruce A. Cooper, Lee-May Chen, Michelle Melisko, Jon D. Levine, Kord Kober, Bradley E. Aouizerat, and Christine Miaskowski

To access the articles, you must subscribe to JPSM or be a member of the American Academy of Hospice and Palliative Medicine (AAHPM). For further information on the Academy, call 847.375.4712 or visit aahpm.org.

Submitted by: David J. Casarett, MD, MA, Senior Associate Editor, JPSM

Sarah Elizabeth Harrington, MD FAAHPM – Inspiring Hospice and Palliative Medicine Leaders Under 40

This post is from one of the Inspiring Hospice and Palliative Medicine Leaders Under 40. Sarah Elizabeth Harrington, MD FAAHPM, was selected based on her involvement in AAHPM, educating others about hospice and palliative medicine, participation in charitable work, and mentoring of students or residents. The honoree was then asked who inspired her over the course of her career. We are sharing some of her answers in this post. Check back regularly for posts from other leaders.

Who has most influenced your work in hospice and palliative medicine and what impact has he or she had?
This is a hard question to answer, because I have been fortunate to learn from so many “trailblazers” in this field. Dr. Reed Thompson at UAMS first introduced me to hospice and end-of-life care when I was a medical student. He demonstrated how to infuse humanity and compassion into medical practice, and made a significant impression on me and my career path. I will be forever thankful for his mentorship and confidence in me. I can’t say enough about the Palliative Care Program at VCU Medical Center where I trained as a fellow. Dr. Tom Smith, Dr. Laurie Lyckholm, Pat Coyne APRN and all of the VCUHS Palliative Care staff shaped the practicing physician I am today. Not only did I learn the practice of palliative medicine, I was able to learn leadership, work-life balance, and program development from this amazing group of clinicians. I am also grateful for opportunities to have mentors like Drs. Susan Block, Diane Meier, and David Weissman through the Academy. Those of us who have found success in this field have many people to thank for their vision, perseverance, and willingness to teach along the way.

Where do you see yourself in 5 years?
I hope to see myself continuing to grow the palliative care program at UAMS and the VA. I enjoy practicing in an academic medical center, and find educating students and house staff the truly “fun” part of my job. It’s a challenging and exciting time in medicine, and I see so many opportunities to improve palliative care access and education. Areas like telemedicine are increasing in our predominantly rural state, and I think that is a place where palliative care can reach a number of patients and families.

What is the best advice you have ever received?
“Relationships first” and “it’s not about you” go hand-in-hand as the best advice I’ve received. The longer I’ve practiced in this field, the more I’ve come to appreciate these simple truths. There is value in being humble and coming to work with open hands. It is worth your time to build relationships with referring providers and to practice good consult etiquette. Thank the nursing staff on a regular basis, know the name of the housekeeper on the unit, bring breakfast to IDT meetings, and do something every day that demonstrates gratitude. Better relationships result in better communication and care for patients and families.

Keith Swetz, MD MA FACP FAAHPM – Inspiring Hospice and Palliative Medicine Leaders Under 40

This post is from one of the Inspiring Hospice and Palliative Medicine Leaders Under 40. Keith Swetz, MD MA FACP FAAHPM, was selected based on his involvement in AAHPM, educating others about hospice and palliative medicine, participation in charitable work, and mentoring of students or residents. The honoree was then asked who inspired him over the course of his career. We are sharing some of his answers in this post. Check back regularly for posts from other leaders.

Who has most influenced your work in hospice and palliative medicine and what impact has he or she had?
Dr. Thomas J. Smith. Tom has been a tremendous mentor, life coach, and model of exceptional and compassionate clinical care. During my fellowship at Virginia Commonwealth University, I was fascinated by his vast wealth of knowledge (oncology, palliative care, and everything, in general). Moreover, Tom was approachable from my interview day to times he was on service with me, or even when not on service. This accessibility and transparency was not only evident to colleagues and house staff, but was evidenced by his patients who had complete confidence and faith in his care and recommendations. Tom’s empathy and genuineness is visible to all who work with him, and Tom continues to be a wonderful support to me from afar. Although Tom is prominent in our field, I feel it is important to mention others who may not have as visible in AAHPM or the field, but who have been exceptional role models and influences on my character development and passion for HPM—Bob Yanoshak (family med/HPM at Geisinger Wyoming Valley), Jarrett Richardson (psych/HPM/sleep/IntMed) at Mayo, and J.O. Ballard (humanities & hem/onc) at Penn State. Paul Mueller (Ethics/GenMed) has played an instrumental role in my academic development and I will be eternally grateful to him for his support of my career development during my first decade as a physician. Lastly, Arif Kamal continues to be an extraordinary peer mentor and friend who continues to challenge be to be the best scholar I can be in this field.

Where do you see yourself in 5 years?
I continue to strive to provide high-level, compassionate patient care, and that will remain important. As I approach 40, and as the field’s workforce size is limited, I see leadership as an important skill to cultivate for many of us in the field. I see these next 5 years as a time to work on developing leadership and team-building skills. I strongly desire to be a valued, reliable contributor to multiple teams (clinical, educational, research) that I am a part of. Increasingly, this will take shape as primary palliative care education to clinicians at all levels, but it will also take the shape of mentorship and promotion of academic and scholarly development of others in this field. I see myself as part of a team where I am valued for who I am and for the talents I possess, and where I can utilize my skills and gifts to their fullest potential. Lastly, I see my family as 5 years older as well—with my children then being 15, 13, 12, and 10. I want them to continue to develop confidence in who they are and be proud of what they represent and believe in. I want to be the best husband I can be and will be married then for 17 years. I want my wife to be proud to have me as her husband, as she is now and was the day we got married. This is critically important to prevent burnout and maintenance acceptable work-life balance.

What is the best advice you have ever received?
When I began on staff as an HPM physician after fellowship in 2008, Tom Smith told me, “You don’t do your patients, the field, or your family any good by staying past 6PM every night.” Although I know there are days when it is necessary, that perspective is helpful to me in determining what really needs to be done on a given day and helps me to prioritize my efforts appropriately.

Eric Roeland, MD FAAHPM – Inspiring Hospice and Palliative Medicine Leaders Under 40

This post is from one of the Inspiring Hospice and Palliative Medicine Leaders Under 40. Eric Roeland, MD FAAHPM, was selected based on his involvement in AAHPM, educating others about hospice and palliative medicine, participation in charitable work, and mentoring of students or residents. The honoree was then asked who inspired him over the course of his career. We are sharing some of his answers in this post. Check back regularly for posts from other leaders.

Who has most influenced your work in hospice and palliative medicine and what impact has he or she had?
My professional life changed after meeting Charles von Gunten, MD, PhD at the University of California, San Diego as an Internal Medicine resident. I knew that I wanted to practice oncology, but not in the same manner that I observed in so many oncologists. In observing Charles’ interactions with patients and loved ones, I realized that combining palliative care with oncology was my calling. After my palliative care fellowship, Charles continued to guide me through my training as an oncologist and encouraged me to seek out opportunities to pursue my clinical research interests. He continues to be a source of inspiration as he tackles new professional challenges and I am honored to call him both my friend and mentor.

Where do you see yourself in 5 years?
Fiji. No really…I hope that I continue to have the opportunity to pursue academic, clinical research across the entire spectrum of cancer care focusing on discovering and developing effective solutions for improving the quality of life. As palliative care continues to grow, I hope that I will be actively contributing to building palliative care evidence-based clinical practices and promoting rigorous scientific validation of novel approaches to treating symptoms.

What is the best advice you have ever received?
My wife Kim once told me that the true meaning of life is “to love and be loved.” I try to remember that each and every day. In this way, I am a very blessed man.

Rupali Rajpathak, MD – Inspiring Hospice and Palliative Medicine Leaders Under 40

This post is from one of the Inspiring Hospice and Palliative Medicine Leaders Under 40. Rupali Rajpathak, MD, was selected based on her involvement in AAHPM, educating others about hospice and palliative medicine, participation in charitable work, and mentoring of students or residents. The honoree was then asked who inspired her over the course of her career. We are sharing some of her answers in this post. Check back regularly for posts from other leaders.

Who has most influenced your work in hospice and palliative medicine and what impact has he or she had?
I don’t think I can name one particular person. There are several individuals who deserve a mention-
Dr. Roma Tiku- my mentor during fellowship. Her command over effective communication, patience and attention to minute details regarding patient history was commendable. I have learned a great deal by observing her ease in conversations with patients and families.
Dr. Nessa Coyle: fellowship mentor. She has the art of simplifying a complicated social, medical issue and explaining it with ease.
Dr. Tara Friedman: She has a great deal of practical experience with clinical and nonclinical issues related to everyday Palliative care conundrums. She is my go to person!

And lastly Id like to say that all my colleagues, patients and their families influence my work on a daily basis. I learn a tremendous amount from every family meeting.

Where do you see yourself in 5 years?
I hope to see our palliative care program grow further and gain recognition in the local community in North East Philadelphia. I would like to be able to contribute to our field of HP through my clinical experience and work. I hope to be an inspiration to the new and upcoming hospice and palliative care professionals and be a source of information/guidance to them.

What is the best advice you have ever received?
Many a times I would get very emotionally involved, stressed and feel disappointed after an unexpected decision made after a family meeting; sometimes I’d almost feel like a failure and feel that there must have been something else I could have explained or said. At such times I always remember an advise by a nurse practitioner from my fellowship training-” You can only do what you can do at this time. Decision making is a journey/process and families at times need to travel a longer distance prior to the destination. Your input is always valuable.”

Highlights of the July Issue of the Journal of Pain and Symptom Management

Listed below are a few articles from the most recent issue of the journal:

Original Articles

Physical and Psychological Distress Are Related to Dying Peacefully in Residents with Dementia in Long-Term Care Facilities
Maaike L. De Roo, Gwenda Albers, Luc Deliens, Henrica C. W. de Vet, Anneke L. Francke, Nele Van Den Noortgate, and Lieve Van den Block, on behalf of EURO IMPACT

Timing of Survey Administration After Hospice Patient Death: Stability of Bereaved Respondents
Eleanor L. DiBiasio, Melissa A. Clark, Pedro Gozalo, Carol Spence, David J. Casarett, and Joan M. Teno

The Association Between Home Palliative Care Services and Quality of End-of-Life Care Indicators in the Province of Québec
Bruno Gagnon, Serge Dumont, Lyne Nadeau, Susan Scott, Neil MacDonald, Michèle Aubin, and Nancy Mayo

A Cross-Sectional Relationship Between Social Capital, Self-Compassion and Perceived HIV Symptoms
Allison Webel, Dean Wantland, Carol Dawson Rose, Jeanne Kemppainen, William L. Holzemer, Wei-Ti Chen, Mallory O. Johnson, Patrice Nicholas, Lucille Sanzero Eller, Puangtip Chaiphibalsarisdi, Elizabeth Sefcik, Kathleen Nokes, Inge B. Corless, Lynda Tyer-Viola, Kenn Kirksey, Joachim Voss, Kathy Sullivan, Marta Rivero-Méndez, John Brion, Scholastika Iipinge, J. Craig Phillips, and Carmen Portillo

To access the articles, you must subscribe to JPSM or be a member of the American Academy of Hospice and Palliative Medicine (AAHPM). For further information on the Academy, call 847.375.4712 or visit aahpm.org.

Submitted by: David J. Casarett, MD, MA, Senior Associate Editor, JPSM

Joseph Milano, MD – Inspiring Hospice and Palliative Medicine Leaders Under 40

This post is from one of the Inspiring Hospice and Palliative Medicine Leaders Under 40. Joseph Milano, MD, was selected based on his involvement in AAHPM, educating others about hospice and palliative medicine, participation in charitable work, and mentoring of students or residents. The honoree was then asked who inspired him over the course of his career. We are sharing some of his answers in this post. Check back regularly for posts from other leaders.

Who has most influenced your work in hospice and palliative medicine and what impact has he or she had?
During my short career as physician, and an advocate of the fragile population, there is one person who has overwhelmingly pushed me to new heights of positive impact. This individual has not only influenced the direction of my career but has shaped my perception of how we treat patient and families during times of crisis. Her name is Susan Degnan. Susan was an employee at Huntington hospital for nearly a half of a century. The role of a social worker fit her best, and fortunately for me that role was the greatest impression on my career.

Susan was not only my team-mate, but also was a mentor. She released her knowledge and wisdom very easily. She never held back to offer a compassionate answer or solution but actually leaned forward by offering more of herself. It was an absolute honor and privilege to work alongside an individual that appreciated the very granular pieces of human interaction. It is with great honor that I am able to recognize Susan Degnan as the individual that has impacted me the most.

Where do you see yourself in 5 years?
Recently, the honor and privilege came to me by being given the opportunity to medically direct the house call program for the North Shore-LIJ health system. Currently I am very excited about developing and spreading the program beyond its current capacity. This journey for our team will be very exciting and full of new experiences.

The journey will likely take me years to feel that the groundwork which is being laid, and the efforts which will be accomplished, will set a foundation for a community and for the health system.

Therefore, within the next few years, I see myself with in this role developing, learning, and achieving a better understanding of what our community needs when dealing with our fragile population.

What is the best advice you have ever received?

Advice comes from many directions and normally advice that does come pertains to only what you’re going through at the time. Keeping this in mind, if the information given to you makes sense, reasonable, and realistic I accept the advice and use it accordingly.

The one specific example of a life lesson was from the same person that influenced my career the most my former social worker Susan Degnan. Susan, always reflected, never presumed, and never judged quickly. It was because of the way that she approached every difficult situation; she was able to leave with me an impression that was life lasting.

The best advice that she ever came to me with was not a secret, it was not even her own words. The advice was from a well- known prayer. That prayer was called the Serenity prayer. The words within that prayer gave me comfort and a deeper understanding of why things do not always work out the way you would wish. As a young physician that was difficult to infuse with in my practice. The more I remembered the words the easier it was to practice the understanding.

So again, I owe the best advice given to me within my career to Mrs. Susan Degnan.

Lori Earnshaw, MD – Inspiring Hospice and Palliative Medicine Leaders Under 40

This post is from one of the Inspiring Hospice and Palliative Medicine Leaders Under 40. Lori Earnshaw, MD, was selected based on her involvement in AAHPM, educating others about hospice and palliative medicine, participation in charitable work, and mentoring of students or residents. The honoree was then asked who inspired her over the course of her career. We are sharing some of her answers in this post. Check back regularly for posts from other leaders.

Who has most influenced your work in hospice and palliative medicine and what impact has he or she had?
Dr. Joe Rotella introduced me to the field and has been a constant source of support and wisdom. He brings a humanistic approach to all of his relationships, and his message of compassion keeps me connected with my original motivation for becoming a physician.

I must also include my first boss, Dr. Ann Shaw, who has always nurtured me toward realizing my full potential. As a woman in academic medicine, I try to model myself after her example.

Where do you see yourself in 5 years?
I envision myself continuing to improve patient care through education of practicing health care professionals, inter-professional students, and the broader community. I hope to lead the integration of palliative care throughout the statewide health care system in order to bring best palliative care practices to patients and families throughout the state of Kentucky.

What is the best advice you have ever received?
My mother introduced me to the writings of Joseph Campbell while I was in high school, and I try to “follow my bliss” as I make important decisions. When I align myself with people and projects that highlight my values, my happiness and fulfillment make a positive impact on those around me.

Jeff Klick, MD – Inspiring Hospice and Palliative Medicine Leaders Under 40

This post is from one of the Inspiring Hospice and Palliative Medicine Leaders Under 40. Jeff Klick, MD, was selected based on his involvement in AAHPM, educating others about hospice and palliative medicine, participation in charitable work, and mentoring of students or residents. The honoree was then asked who inspired him over the course of his career. We are sharing some of his answers in this post. Check back regularly for posts from other leaders.

Who has most influenced your work in hospice and palliative medicine and what impact has he or she had?
I have always been drawn to helping children and families in distress. Early in my career, I formed relationships with amazing Pediatric Hospice and Palliative Care (P-HPC) clinicians Dr. Chris Feudtner, Dr. Tammy Kang, and Gina Santucci, PNP at Children’s Hospital of Philadelphia (CHOP). At that time, P-HPC was an emerging field and I found myself drawn to every aspect of it. Managing suffering in all of its forms was the core of why I became a doctor. Tammy, Chris, and Gina taught me how to do this as a professional within a team.

I found myself with tremendous mentorship from leaders in Pediatrics such as Drs. Lou Bell and Steven Ludwig at CHOP. They showed me how to patient in following my passion and how to be a leader without taking myself too seriously.

My first major contribution came a year into my career when my team started the third Pediatric-HPM fellowship in the country at CHOP. During this process I formed relationships with Drs. JoAnne Wolfe (P-HPC at Boston Children’s and Dana-Farber Cancer Institute) and Sarah Friebert (P-HPC at Akron Children’s). JoAnne and Sarah have provided mentorship, encouragement, and collaboration in many projects. They also provided a vision for career paths in academic pediatric hospice and palliative medicine.

I then attended the AAHPM Fellowship Summit where I formed relationships with Dr. Rodney Tucker (HPM at University of Alabama at Birmingham) and Sally Weir (at the time with AAHPM). They encouraged me to get engaged in AAHPM where I found my passion for developing communities and energy around specific ideas. AAHPM has provided a tremendous community for me, to which I am indebted.

I have been blessed to work with many leaders and wonderful people in HPM. From leaders in adult-focused HPM, such as Susan Block (Chair, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute) and Tammie Quest (Director, Palliative Care Center, Emory University); to my many friends and collaborators who make up the tremendous community of pediatric palliative care; to the leaders within the academy who create such a great collaborative environment to foster our field; to my team at CHOA which makes the real work of caring for kids possible and rewarding every day; to my former fellows who continue to teach me so much.

Each of these leaders proved instrumental in engaging me in leadership roles throughout my career. I have found myself with opportunity after opportunity to lead in a field that I am passionate about. Along the way, I have been influenced by many incredible people. I truly wish I had space to name them all.

In my mind, though, the greatest influence has always been the children and their families. It is their experiences, courage, and raw life stories which drive the passion in all of us. If you let them, they will all have a tremendous impact on your life.
They all taught me that leadership is about collaborative practice. If managing suffering is why I became a doctor, the joy of collaborative practice is why I became a leader. HPM offers me a place to practice both of these passions.

Where do you see yourself in 5 years?
Four years ago, I took on the task of creating a center of excellence in Pediatric Palliative Care at Children’s Healthcare of Atlanta and Emory University School of Medicine. I have been joined in that task by many tremendous clinicians—Nicolas Krawiecki, Khaliah Johnson, Erin Mullaney, Meghan Tracewski, and Maura Savage—each giving up a lot of themselves to join this vision of creating a center that can serve the state of Georgia and the Southeast region in improving the care for kids with serious illnesses. We have come a long way, affected countless lives, and developed a tremendous program, but we have big goals and a long way to go to meet them.

The next five years will be focused and dedicated to that vision (and being a good husband and dad). We will have to see where we go…

What is the best advice you have ever received?
This probably came early in life following a season of pee-wee football. After spending the whole year lobbying the coach to “just throw me the ball,” I got a special award…it was a bumper sticker that simply said “lighten up.”

In our clinical and programmatic work, we find ourselves in intense situations. In this field, we are very lucky to have many strong leaders who are excellent at solving problems and moving solutions forward. This fact, however, can significantly add to the intensity, as we are always focused on fixing things and not just being still. Being able to manage and cope with that intensity and to be calm in the craziness—to lighten up when it matters most—has proven to be an essential skill. I just wish it was always easy to do.