Dr. Karin Porter-Williamson: Access to Learning in Academia
Interview with HPM Physician
Karin Porter-Williamson, MD
by Larry Beresford
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."
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."
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.
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
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.
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
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.
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."
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."
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
"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.
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
Youngest Members of
the Palliative Care Team
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 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."
information, contact Dr. Porter-Williamson at: firstname.lastname@example.org.
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The Role of the Chief Palliative Care Officer
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:
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.
DAI Palliative Care Group
Phone: (610) 941-9419
Phone: (510) 536-3048
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.
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Dr. Joseph Straton: Finding the 'Sweet Spot'
Interview with HPM Physician
Joseph Straton, MD
by Larry Beresford
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.
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."
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
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.
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.
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).
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."
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.
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.
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.
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."
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
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
Division of Labor, Mentoring,
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.
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."
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?"
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.
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 firstname.lastname@example.org.
|Securing the Right Practice Opportunity for You
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.
consider the following in your career planning
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
your "ideal" practice opportunity in the context of four career "satisfiers".
Ask yourself what are your expectations
Rewards:monetary (compensation) and
non-monetary (title) for a job well
Workload and Sustainable Schedule: your need for quality of life
for autonomy and/or control to impact the key factors that will affect job
role of the HPM physician is viewed by the professional and lay communities
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).
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
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.
information on HPM career planning and development, contact Tim Cousounis.
He'll connect with you with tools, resources, and experts at DAI Palliative