The HPM Practitioner

Business/Practice News and Views for Physicians in
Hospice and Palliative Medicine
Issue No. 6                                                                                           June 2010
Greetings!

The academic medical center, with its research and training focus and emphasis on the latest high-tech therapies and experimental treatments, is sometimes viewed as a somewhat inhospitable landscape for the goals of hospice and palliative medicine: to help seriously ill patients find care that is consonant with their goals and values and maximize the quality of life that remains to them. Yet many of the pioneering physician leaders of HPM are based in large academic medical settings.

We tracked down a couple of younger HPM physicians in academic settings to talk about their jobs and how they built them, as well as their views on the opportunities for pursuing HPM as a viable career path within the academy. As always, let us know what you think.


Tim Cousounis

In This Issue
HPM Practitioner Profile - Dr. Karin Porter-Williamson
WilliamsonDr. Karin Porter-Williamson: Access to Learning in Academia
Interview with HPM Physician
Karin Porter-Williamson, MD   
by Larry Beresford

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Dr. Karin Porter-Williamson, director of the palliative care service and associate professor of medicine at the University of Kansas School of Medicine, Kansas City, KS, discovered as a second-year internal medicine resident at KU in 2000 that palliative medicine, with its focus on the whole person and the relief of patients' suffering, was the path to her future career. "I realized that my team, my attendings and I needed a different set of skills than we had been using to address the needs of some of our patients for whom there were no viable active treatment options. Still, we kept throwing chemotherapy at them without knowing how to discuss the reality of their situation."

 

She decided to explore what palliative medicine was all about. It helped to be in an academic environment where learning opportunities were plentiful. Viewing Bill Moyers' PBS television series on end-of-life care further solidified her resolve. "I saw Dr. Diane Meier on TV and said, 'That's it.' Once I recognized that palliative medicine could be a career option, I knew this was the way I needed to practice medicine. I couldn't go back and see internal medicine through any other eyes."

 

Dr. Porter-Williamson worked with a mentor, oncologist Dr. Sarah Taylor, to develop a one-month palliative medicine rotation for residents at KU and then did the first rotation. She spent time shadowing Dr. Ann Allegre, medical director of Kansas City Hospice and Palliative Care, and in 2002-03 completed a one-year fellowship in HPM at San Diego Hospice and the Institute for Palliative Medicine. She describes that as a profound experience for its high-powered physician leadership and opportunities to work with peers from a variety of professional backgrounds and with patients and families from all walks of life.

 

Then she returned to KU as the first full-time physician for a palliative care service and team that Dr. Taylor had established a few years earlier. "My interest from the beginning was to learn and then come back and try to change the culture where I was at," she relates. The new role involved a lot of "blood, sweat, and tears at first. I had no idea what I was getting into, taking the reins of a program that was primed to explode with demand. It took a few years to get my feet wet and to understand the KU system from the perspective of my new role as an attending."

 

The number of palliative care consultations doubled in her first year, to 300, and the program has since grown steadily by 15 to 18 percent per year --"no matter what we do." Now performing 750 to 800 consults per year in the 500-bed medical center, the palliative care service employs two full-time and five part-time physicians, along with two full- and two part-time nurses, two social workers, and the involvement of hospital chaplains. Dr. Porter-Williamson has been cross-training several KU physicians who have an interest in palliative care and in pursuing HPM board certification part-time via the practice pathway.

 

Later this year, the program plans to split into two attending-led teams in the medical center. Also on tap is an outpatient clinic service focused on providing supportive care further upstream in the disease trajectory. The clinic will start two half-days per week, in conjunction with cancer, internal medicine, and liver transplant extended care clinics on the KU campus.

 

Half of palliative care's referrals now come from its close partnership with the medical center's ICUs (medical, trauma, burn), Dr. Porter-Williamson says. "The growth of our relationship depended on our ability to spend time with patients and families in the ICUs, as the units and the hospital became busier. Initially, critical care doctors were a little wary. But once they realized we were there to partner with them, extending their work and helping them to be more efficient and their patients and families to be happier, that's where they found the value of our service, and where the growth occurred."

 

HPM's Contribution to the Hospital

           

The program at KU integrates palliative care into the fabric of the hospital's culture, which Dr. Porter-Williamson says came about through a lot of hard work. "One of my goals, and our mission as a team, is to try to spread the culture of palliative medicine such that everyone in the hospital is getting it on some level, with good pain and symptom management, team work, and communication, even when the patient is not labeled as being on palliative care." The demand for specialist-level palliative care isn't going away, "but we can't take care of all the patients by ourselves," she says.

 

"It's about every attending physician, resident, and student understanding this at a basic level. I have done rounding on the hospitalist service as an attending, when scheduling blocks needed to be filled. It's a good experience for me, maintaining my skill set, and it's a very positive way to show residents how to do palliative care as a regular part of their jobs."

           

Dr. Porter-Williamson appreciates the opportunity to practice her specialty in an academic medical setting, but also emphasizes partnering with the community. "From the hospital's perspective, it's important that palliative care services for patients and families are solid across the continuum of their care needs. That requires the palliative care service in the hospital to work closely with community partners, because these patients' needs are complex," she explains. "We recognize that the continuum has to be strong at every level, with a solid hospice community fabric and infrastructure to handle our patients. If that doesn't exist, the bottom falls out and our patients return to the hospital."

           

An academic affiliation with Kansas City Hospice began in 2005 with joint planning for an HPM fellowship program. The fellowship's educational mission is divided equally between the two partners. "From there, our collaboration grew into the clinical realm." The fellowship includes a weekly core lecture series, which takes place at Kansas City Hospice House, the hospice agency's 32-bed freestanding inpatient unit, and is open to interdisciplinary teams from across the city.

 

"A lot of practitioners I see there are from the community. We partner with them on many levels. We spend time with them. We also host an evening palliative care grand rounds four times a year, with clinicians coming here from surrounding communities for didactic presentations and discussion, followed by dinner." An average of 20 clinicians show up for these events.

 

Dr. Porter-Williamson believes that the academic medical center can be a valuable resource to palliative care-oriented clinicians in the community, regardless of their career path or goals. "Whether they would ever want to go work full-time in an academic setting or not, there are likely to be opportunities for community physicians to partner with academic palliative care services in ways such as we have done here. It can be fulfilling for both the academic and the community partner."

 

Youngest Members of the Palliative Care Team

 

Dr. Porter-Williamson says her own job averages 50 to 60 hours per week, perhaps a little more than she would wish but in line with other full-time academic palliative care leadership positions around the country. About half of that time is clinical, including full-time coverage on the service in two-week increments. Two weeks is enough time to ensure continuity of care without causing burnout. Palliative care physicians take weekend call nine or ten times a year and that can be a busy weekend. Dr. Porter-Williamson also plans to spend eight weeks in the next year covering at Kansas City Hospice House.

 

A quarter of her time is dedicated to education and research, including directing the palliative care fellowship, working with rotating residents and other professional students, and participating in other educational activities. A quarter-time administrative commitment covers program development for palliative care; work on metrics for quality, safety, clinical outcomes, and costs; protocol and policy development; a variety of in-house educational presentations for nurses and other staff; and work with the medical center's administrators to help them understand the program's contributions to the institution and its growth curve.

           

"My job is pretty stressful but incredibly fulfilling and very meaningful," she says. "The stress comes in part from the volume of cases and their emotional intensity, but the bigger stress for me is trying to balance this career I love with two kids and a husband I love -- to be an effective leader as well as a wife and mother."

           

She wishes she could spend more time with her children, Katie, 6, and Sam, 4. "They are fairly advanced emotionally, and they ask about the work I do and about palliative care. I explain that I take care of people in the hospital who are really sick. If I'm late getting home, they'll say, 'Wow, there must have been a lot of sick people to help.' My husband, who is also a physician, and I have tried to instill in them that this is the work of our family, and that they're also a part of the team. They know the value of their contribution to it," she says. "They seem to be alright with this -- at least for now."

 

For more information, contact Dr. Porter-Williamson at: kporter-williamson@kumc.edu.

 

PracticeOpportunityFeatured Practice Opportunities


Showcase both your clinical expertise and business savvy as you implement clinical and service growth strategies for a hospital-based palliative consult service in Florida.  The service is well established (almost eight years old), and has helped redefine how late-life care is provided in the 458-bed flagship hospital of this regional health system.


While this service is well-established and some strategy is in place and activities have been underway for some time, you'll put your personal stamp on these programs as you expand development efforts and provide palliative services to patients in acute and long-term care settings throughout the health system.  The palliative care service has been instrumental in the hospital's citation by the DAI Hospital Palliative Performance Profiles as an Exemplar Hospital for its late-life care practices and outcomes. 

The opportunity is an employment-based position with the hospital-affiliated physician group, and will be viewed as the palliative medicine expert within the community.


                  --------------------


In one of America's most livable cities, enjoy a blended position with direct patient care (inpatient hospice unit oversight, home and outpatient visits), management and educational (HPM fellowship program and trainee rotations) responsibilities that will enrich your palliative medicine portfolio of competencies. This practice opportunity offers stability with a financially strong and highly-regarded hospice, an exceptional work environment in an organization selected "Best Place to Work" in its region, and where senior management has made a concerted effort to design practice opportunities with reasonable, well-articulated workloads which strive for a sought-after work-life balance. Compensation will be in the top quartile, and relocation assistance will be provided.


To learn more about these opportunities (confidentially, of course), send an email to Tim Cousounis at tcousounis@digital-action.com

For more opportunities, click here.

PracticeSubsidyThe Role of the Chief Palliative Care Officer

There are communities across the nation whose end-of-life care practices produce outcomes superior to those in other communities: fewer people dying in hospitals, fewer hospitalizations and less days in an ICU during the final six months of life, to cite a few. Study of these exemplar communities by the DAI Palliative Care Group reveals several common attributes.  One is the presence of a physician who essentially serves in the role of the chief palliative care officer (CPCO). Looking more closely at the CPCO role, one finds the following:

These CPCOs are particularly skilled at envisioning, energizing, and stimulating a change process that coalesces communities, patients, and professionals around new models of late-life care. These leaders have an uncanny ability to align their own priorities with those of the organization and the needs and values of the community. Call this a transformation competency.

These CPCOs display the ability to use metrics and evidence-based techniques to hold stakeholders to high standards of performance, using force of personality rather than the power of one's position. These leaders also understand the formal and informal decision-making structures around late-life care. In other words, they are adept at execution, translating vision and strategy into optimal organizational AND community performance.

And, these leaders are competent at building and sustaining relationships that evolve into networks, and take a personal interest in coaching and mentoring others. Put another way, these leaders possess exceptional people skills.

Of course, these CPCOs have deep knowledge of palliative medicine, and expertly apply this knowledge in clinical settings. But it is these leadership competencies that stand them, and the communities in which they practice, apart.

Contact Us

Tim Cousounis
Managing Director,
DAI Palliative Care Group
Phone: (610) 941-9419

tcousounis@digital-action.com


Larry Beresford
Editor
Phone: (510) 536-3048
larryberesford@hotmail.com
www.larryberesford.com
Larry's Blog

The DAI Palliative Care Group is a national consultancy partnering with hospices and palliative care practices to build their medical staffs. Recruiting, medical staff development planning, physician performance management and opportunity assessments for palliative medicine practices are our competencies. We invite a discussion of how a partnership would benefit you.

What do you think of our publication? How can we best serve the needs of the HPM community? What would you like to know about the business and practice issues facing HPM doctors today? What do you know that your HPM colleagues need to learn?

Click here to send us your comments.

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StratonDr. Joseph Straton: Finding the 'Sweet Spot'
Interview with HPM Physician
Joseph Straton, MD                       
by Larry Beresford
Dr. Ed Martin

Hospices and hospital-based palliative care consulting services share an underlying philosophy of care and many of the same processes and techniques for relieving suffering and enhancing the quality of life of patients with advanced illnesses and their families. The two approaches also share a medical subspecialty certification process and, at least in theory, belong to a continuum of response to such patients' needs -- even though that continuum is not always seamless, especially in the academic medical setting.

 

However, Dr. Joseph Straton, chief medical officer at Penn Wissahickon Hospice, a program serving the University of Pennsylvania's health system and hospitals in Philadelphia, believes that opportunities for synergy are numerous. "They have different, complementary roles to play," he says, adding that in many ways such synergy is being realized at Penn. "The health system's leadership is highly supportive of both hospice and palliative care, and sees both playing major roles."

 

Dr. Straton's own career suggests the overlaps, starting in his family medicine residency and through a two-year research fellowship at Penn focused on palliative medicine and end-of-life decision making. He co-founded and co-directed the palliative care consultation service at Penn starting in 2003 and in 2006 was asked to become the system's hospice medical director, starting half-time but soon full-time.

 

He taught high school English and chemistry after college but eventually followed his life's dream into medical school. An experience with his older brother's brain tumor and death in the hospital gave him a personal perspective on the importance of end-of-life care and the role of the interdisciplinary team.

 

"I didn't go into medical school to become a palliative care physician," Dr. Straton says. "But throughout my residency, when we were following patients in the hospital for days or even weeks, after they ended up in hospice, we stopped rounding on them. That felt conflicted to me -- it was like our input was no longer needed because they were in hospice now. But I felt we could still have a lot of input in assisting the patient and family," he relates.

 

"I pursued the fellowship because I wanted to have an impact on the way care is provided at the end of life. I got excellent research training in clinical epidemiology, but learned that while research is important to me, what I find most enjoyable is building new programs to fill identified needs." Dr. Straton continues to participate in published research studies (see http://www.ncbi.nlm.nih.gov/sites/pubmed, search Straton JB).

 

His hospice opportunity followed a visit to Penn by J. Donald Schumacher, president of the National Hospice and Palliative Care Organization, to keynote a conference on hospice and palliative care organized by Dr. David Casarett, an influential researcher and author on end-of-life care. "A number of us went out to dinner, including Joan Doyle, director of Penn's home care and hospice programs. Don Schumacher asked her about the hospice's medical direction, which at the time was just two physicians putting in two hours per week each to attend team meetings and sign papers. He said, 'You've got to get a full-time medical director.' As we went around the table, I introduced myself and Don said: 'Hire Joe.' A month later they offered me the job."

 

Aligning Incentives

 

Penn Wissahickon Hospice carries a current home hospice census of about 175 patients and operates a 20-bed inpatient unit, Penn Hospice at Rittenhouse, in one of the system's affiliated hospitals. It also offers a palliative home care service staffed by nurses, with a current census of about 50. The hospice team includes 2.5 FTEs of physician coverage, expanding to 3.5 in September, covering the IPU, home visits, terminal certifications and other hospice administrative roles, and program building. "To make physician FTE growth work, you have to keep a careful eye on the finances, working closely with the hospital director and finance officer, maximizing billing revenues, and incenting the physicians appropriately," he explains.

 

Dr. Straton estimates that he works about 60 hours per week, a little more than he would prefer. Most of his work day is spent in the hospital, including rounding on the IPU six hours a day. His other responsibilities include fielding clinical calls from nurses in the field, educating medical students and residents, attending health system leadership meetings, and participating in continuous quality improvement and other essential functions of an academic medical center.

 

"One of the things I've learned, and the basis for success in my career, is that for any program in an academic medical center there are really three customers: the patient and family, the referral source, and the health system itself. To build a successful program, it is necessary to identify the needs of all three -- even though those needs may not exactly align. Where is the sweet spot in the middle of the Venn diagram of their respective needs? Find the area where those three meet and direct your services at that sweet spot."

 

In 2003 Dr. Straton and his palliative care colleagues named their new program the Symptom Management and Palliative Care Service or SYMPAC. "By allowing clinicians to order symptom management consults, it helped people to get around any queasiness they may have felt about a palliative care consultation." But it was a difficult birth.

 

"The barriers included misunderstandings about what palliative care is, the help it can provide, and does it even belong in the setting of an academic medical setting." The service started on the hospital oncology units, with the aim of fanning out from there, he says. "We grew much faster than we planned. As residents from oncology rotated out after a month, they started calling us from their new services."

 

After Dr. Straton moved over to hospice, he helped to set up a hospital-based hospice team comprised of nurse practitioners, social workers, and him. "We worked in the hospitals, taking care of hospitalized patients referred for hospice care and educating clinicians about hospice and palliative care. We set it up on a scatter-bed model for inpatient hospice care, so that the same attending, house staff, and nurses would be primarily in charge of their referred patients' care and the hospice team would be an add-on. That way everybody could learn and all clinicians could see the value-added of hospice -- how it makes care more satisfying for patients and clinicians. So referrals in the hospital to hospice skyrocketed."

 

Dr. Straton helped to increase the visibility of hospice care just by his presence in the hospital. "I was also able to help the hospice team gain a better understanding of the needs of patients and clinicians in the hospital and how we could meet those needs." He helped administrators understand how hospice could help decrease the system's reported mortality rates, "which really got the attention of the leadership. With that high level of support, we were able to interface with clinicians and find out how we could better meet their needs -- and their patients'." The growth of the hospital-based program led to the hospice unit, opened with 12 beds in November, 2008, and expanded to 20 beds in May of this year.

 

Division of Labor, Mentoring, and Downtime

 

An interesting wrinkle on HPM at Penn is the division of labor between the palliative care service and the hospice inpatient team. Primary services consult with palliative care for symptom management issues related to life-limiting illnesses, whereas hospice might be called in to help families clarify their goals of care, well in advance of when a formal referral to hospice care might be appropriate, as well as to expedite direct admits to hospice care and the hospice unit.

 

The distinction may be hard for other clinicians to understand, although the two services are comfortable with their respective roles and continue to zero in on who does what best, he explains. "Many patients never enroll in hospice care. They may be in the ICU, with their family struggling over decisions about terminal extubation. The hospice team can help clarify those issues. I may go in without a hospice badge, explaining that I'm one of the experts within the health system who can help families think through these decisions."

 

When is the right time for hospice? "I say it's when the benefits of hospice care outweigh whatever you might be giving up in exchange. For some dying patients, the benefits never outweigh the things they think they'd be giving up. I find that a limitation of the insurance benefit that is hospice. But is any insurance benefit perfect?"

 

Dr. Straton meets regularly with Dr. Casarett, "who has been a mentor to me since my first day at Penn. He and I constantly bat around ideas, and he asks provocative questions: What are patients' real needs? What kind of model would fill those needs? Can we build that?" A larger group of about eight clinical leaders representing all of the adult and pediatric palliative care programs at Penn and its affiliated VA medical center also meet regularly to discuss shared interests.

 

He belongs to HPM-LEAD (Leadership, Education and Academic Development), established by the American Academy of Hospice and Palliative Medicine to bring together senior and junior clinical leaders twice a year for mentoring and information exchange. "A lot of time is spent on the issues we are all bumping up against and how to bridge them, where the movement has been, and where it is going."

 

Dr. Straton and his wife have two children, aged 12 and 10. Off duty he spends a lot of time at his children's sporting events, swimming, sailing the family's catamaran, "and going to Phillies games." Except for the long hours, he says, "I'm incredibly happy to have a wonderfully fulfilling career." For more information, contact him at joseph.straton@uphs.upenn.edu.

CompensationSecuring the Right Practice Opportunity for You

Effectively implementing a career plan to secure your desired practice in Hospice and Palliative Medicine (HPM) doesn't happen by serendipity. Rather, it involves self-analysis, planning, preparation, and methodical execution. Marketers refer to the process as branding, so that a product or service stands apart. And while you may think that compiling a five-page CV is your brand and will be sufficient to win you an offer, it likely won't be the "right" practice opportunity for you. Because the HPM field is in its nascency, there isn't a clearly defined career path, nor is there uniformity in HPM practices. When you've seen one HPM practice, you've seen one HPM practice.


So, consider the following in your career planning


1. Decide what you like to do.For direct patient care, have you a preference for inpatient hospital consults, home visits, inpatient hospice units, or long-term care facilities? Or perhaps an opportunity that entails clinical responsibilities in all of those settings? How about administrative responsibilities? Overseeing an interdisciplinary team, developing new programs, or leading quality improvement initiatives are each important activities yet require different competencies. Andhow do you feel about teaching or research responsibilities? 


2. Create your "ideal" practice opportunity in the context of four career "satisfiers". Ask yourself what are your expectations  regarding:

  • Practice Rewards:monetary (compensation) and non-monetary (title) for a job well done

  • Manageable Workload and Sustainable Schedule: your need for quality of life

  • Your need for autonomy and/or control to impact the key factors that will affect job performance

  • How the role of the HPM physician is viewed by the professional and lay communities

3. Develop a CV that is at once concise (no more than three pages, two is best), and differentiating (be sure to spend time developing a list of accomplishments, and makethem specific and quantified).


4. Prepare for job interviews, or How to Sell Yourself...Subtly. Don't simply plan to recite your CV; instead share information about your successes. Physician Candidates often spend too much time detailing their job duties and responsibilities and often skip the accomplishments: the specific clinical improvements, the growth of a program or service, patient/family satisfaction, expenses reduced, or revenue generated.


5. The Art of the Deal.You've been through all the interviews, and you like the organization and the practice opportunity -- you think it's a good fit. The organization likes you, too, and offers you the position. How can you make sure you get the best possible package--one that satisfies you and your new employer? Remember that you are about to enter a partnership with a new organization, and a "me-versus-them" attitude will be a barrier to forming a strong alliance. Trust, communication, and candor are the most important elements in compensation negotiations. And, of course, realism. Beware of setting your expectations too high. Remember that parity is important in an organization. Be aware that some of your requests may be denied because they would shake up the organization's existing compensation ranges and structures.


For more information on HPM career planning and development, contact Tim Cousounis. He'll connect with you with tools, resources, and experts at DAI Palliative Care Group.

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