The HPM Practitioner

Business/Practice News and Views for Physicians in
Hospice and Palliative Medicine
Issue No. 10                                                                                                  October 2011
Greetings!

 

What draws physicians to hospice and palliative medicine (HPM)? For some, it's a mission or calling; for others, a single personal encounter with mortality or with a charismatic mentor can draw them irrevocably into the field.

 

For Dr. Suzana Makowski, her whole life seemed to point in this direction, while for Dr. Daniel Maison, it was a suggestion by his supervisor 13 years ago to apply for an open position in a local hospice program. But both physicians are now working full-time leading palliative care services----and loving it. They say they can't imagine doing anything else for a living.

 

Tim Cousounis 

In This Issue
HPM Practitioner Profile - Dr. Suzana Makowski
MakowskiDr. Suzana Makowski: 'The kind of care I wanted to do all along' 
Interview with HPM Physician
Suzana Makowski, MD
by Larry Beresford

Dr. Susan Makowski 

Why do some physicians choose to specialize in hospice and palliative medicine, which was until recently----and still is in some quarters----considered a rather eccentric career path? Some may have a personal experience with a dying patient, which awakens their interest in end-of-life care. Others may find the challenges of relieving suffering and helping patients clarify their deepest hopes and aspirations at a difficult time of life intellectually satisfying. But for Suzana Makowski, MD, MMM, FACP, associate director of palliative medicine in the Cancer Center of Excellence at the University of Massachusetts in Worcester, her life has prepared her for this work.

 

Dr. Makowski was born in Brazil and raised in England, the Philippines and Peru. "Growing up I was a foreigner in many different cultures. I became intrigued with different ways of seeing the world and the different stories people told. I learned from my father, an international commercial banker, the value of hard work in a profession that sought to improve the lives of others. His field and approach to banking helped build infrastructure in the developing world," she says.

 

"I remember making a commitment as a child to helping people who didn't have the advantages I did." She recalls children her own age who would beg for coins for wiping the windows of the car that drove her home from school. "What drew me into medicine were the stories----and the resilience people have when ill. I had seen people respond to adversity and I wanted to lend support to that resilience when I went into medicine. I realized that the patient's story ultimately was more important than any kind of medical treatment I could provide."

 

She chose the University of Rochester, N.Y., School of Medicine, with its emphasis on whole-person care and bio-psycho-social-spiritual approach to medical education. Timothy Quill, MD, a national leader in HPM, was a mentor and a major influence. "One of our other teachers, a diabetologist, would get angry with us if we referred to a patient by diagnosis"----as in "the diabetic in 703," rather than the grandmother of 13 who was trying to cope with the effects of diabetes. After completing residency she pursued a two-year fellowship in integrative medicine at the University of Michigan, and ended up working in primary care, directing an integrative wellness center at Deaconess Billings Clinic in Montana from 2003 to 2005.

 

"During my residency in internal medicine, I was very good at family meetings and at communicating with patients. It was a skill I had developed in medical school. They started inviting me to come and talk to various groups about palliative care. I didn't understand; wasn't this just what every physician did?" Then, at the clinic in Billings, she found herself practicing integrative medicine with the whole-person care she had learned in Rochester. She discovered that she was using a palliative approach, integrating the patient's story, family and sense of meaning and hope. "Patients started finding their way to me from the cancer clinic, and other doctors started sending me their complicated patients to figure out where we should go next with their treatment."

 

Then a colleague, Dr. Derek Weiss, asked Dr. Makowski to join the palliative care consultation service in Billings. "I didn't know much about symptom management at that time. The residents I teach now know more about symptom management than I did when starting out as a palliative care consultant. But I realized during my time in Billings that this was the kind of care I had wanted to do all along," she relates.

 

"What was intriguing to me was this ability to help people live at the end of their lives with the same consistency and values as in the rest of their lives. I knew I needed to get subspecialist-level training because, while I was pretty good at staying with patients' suffering when others shied away, I needed more knowledge in the management of complex symptoms. The nurse practitioner I worked with was teaching me something new every day," she says. "So I called Tim Quill again and asked him whether I should pursue a fellowship or try to grandfather into hospice and palliative medicine. With his encouragement, I ended up going to San Diego Hospice and Palliative Care for a one-year, full-time HPM fellowship, because that was the medicine I needed to learn."

 

Dr. Makowski remembers hearing an early lecture at San Diego Hospice on nausea and vomiting. "I was sitting there thinking I didn't learn anything like this in residency and yet I called myself an internist. I was humbled, early on, at how much this field entails." Another surprise: the pathophysiology of disease, which she had learned in medical school, came alive for her. "I began to integrate those lessons in order to better anticipate what might happen next and how to plan for it. Palliative care required me to think----and to use the knowledge I had learned to make judgments and decisions in a way that medicine had not previously given me the opportunity to do. It was an intellectual awakening that palliative care offered to me----and then to integrate that aspect with spiritual and interpersonal care."

 

After the fellowship in San Diego, Dr. Makowski took a job as a palliative care consultant and then medical director for Hospice and Palliative Care of Cape Cod, Hyannis, Mass., in part to be closer to her parents, who had retired and moved back to the United States. The hospice was transitioning to a new CEO, opening a new inpatient center, developing a palliative care service and experiencing significant census growth, all of which posed interesting new challenges. "But I also realized I wanted to teach medical students and work with medical colleagues. I missed having an active inpatient setting and the complex symptom management of the hospital. Basically, I missed academia." She started at UMass in October 2007.

 

Four Years Later, Still Going Strong

 

Currently Dr. Makowski's primary responsibility is palliative care consultations in UMass hospitals, along with a half-day-per-week palliative care clinic in its Cancer Center. She teaches medical students, residents and fellows, both on the wards and in the lecture hall. She runs a lecture series and clinical rotation for Hem/Onc fellows and lectures to first-year medical students in the Cancer Concepts course and third-year students during their medical rotations. She mentors UMass physician and nurse practitioner faculty pursuing their certifications in palliative medicine. As a visiting professor, Dr. Makowski has also taught communication skills and palliative care principles at Tongji University in Shanghai, China.

 

Other roles also include running a course on spirituality and surgery for medical students, co-chairing the medical center's Pain Quality Steering Committee and sitting on the Cancer Center's executive leadership team, representing palliative care. "The Cancer Center is growing rapidly----with a strong commitment to comprehensive and compassionate care, and my role is developing a business and strategic plan for building palliative care in the center." She also sits on the hospital's ethics committee and medical humanities committee and is medical director for the Center for Mindfulness, which was founded by Jon Kabot-Zinn.

 

She says the job is definitely full-time, ranging from 50 to 70 hours per week, as well as taking call from home Monday through Thursday evenings and every third weekend. Is that sustainable? "It's growing. I've been here four years, and I'm still going strong and loving it. I'm definitely hoping to get more people to help. But the nice thing about this setting is the ability to balance clinical work with teaching and working on culture change within the medical center. There's a lot of flexibility, and I find that refreshing."

 

A Learning Community

 

Dr. Makowski's interest in teaching led her to set up the Lois Green Learning Community, an interdisciplinary, social media-based network for professional development in palliative care. (For information, see: http://www.loisgreenlearningcommunity.org/.) It started in January 2010 as a platform to help physicians, nurse practitioners, nurses, pharmacists and chaplains at UMass who wanted to learn more about palliative care or even pursue HPM board certification under its grandfathering clause. "Not everyone wants or has flexibility to do a year-long fellowship like I had done," she explains. While the grandfathering opportunity for HPM board certification ends after next year, Dr. Makowski is committed to keeping the site alive and growing.

 

The learning community has now grown to 200 members across the country. Dr. Makowski worked with UMass information technologist Carrie Saarinen to create the self-directed, online learning platform, which features monthly topics, case discussions, journal clubs, recommended readings and reflective personal writing. "It helps people learn the content that they might get in a setting where palliative care was being taught with regular lectures," she says.

 

Dr. Makowski, who finds release in back-country downhill skiing, hiking with her Labrador retrievers, sailing, poetry, wine and good food, expressed one other career wish. That is to combine her international upbringing with her interest in palliative care. One of her electives at San Diego Hospice was to spend two weeks at the Institut Catala de Oncologia in Barcelona, Spain. Utilizing her facility in Spanish, she was able to observe palliative care practice at that World Health Organization palliative care demonstration site.

 

"I have dreamed about practicing outside of the United States, and I realized then that I can go and do this work in any part of the globe. I hope to keep the commitment I made living in Peru and Brazil: to alleviate suffering, both in the developing world and closer to home." (Contact Dr. Makowski at: suzana.makowski@umassmemorial.org.)

PracticeOpportunityFeatured Practice Opportunity

 

Community Palliative Care Officer/Hospice Medical Director

 

As hospices transform themselves into community-based palliative care enterprises, new practice opportunities are emerging for Hospice and Palliative Medicine (HPM) physicians. While incorporating some traditional aspects of the hospice medical director, these positions are distinguished by a focus on caring for persons with advanced or complex illnesses in late-life (in contrast to end-of-life) in a multitude of settings throughout the community. 

 

One such opportunity is currently available with a fast-growing, not-for-profit hospice serving a highly desirable suburban community of Chicago. This full-time position is part of a growing medical staff collaborating with the executive team to carry out (clinically and administratively) a highly ambitious plan to reposition the hospice as the community's leading network of palliative services to the chronically and seriously ill.

 

Expectations of this position are high, of course, yet will be compensated accordingly.

 

This role provides an exceptional opportunity for a HPM physician to showcase one's clinical skills and knowledge of HPM best practices, as well as developing strategies to build sustaining relationships with community organizations to establish palliative care as a recognized and sought after service within the community

 

If you're considering advancement along your career path and would like to learn more about this opportunity, and you plan to attend the November CAPC conference in San Diego, contact Tim Cousounis at tcousounis@digital-action.com or (610) 733-7201. He'll coordinate for you a meeting with the hospice chief executive officer during the CAPC conference.

 

For more opportunities, click here.

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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.

StratonDr. Daniel Maison: 'You'd be good at it, and you'd like it' 
Interview with HPM Physician
Daniel Maison, MD
 
by Larry Beresford

 Dr. Daniel Maison

In 1998, Daniel Maison, MD, FAAHPM, today the medical director of palliative care for Spectrum Health, a non-profit health system based in Grand Rapids, Mich., was finishing up his residency in internal medicine in San Francisco, when hospice work "kind of found me. My boss at the time approached me and said, 'There's a job opening with a nearby hospice. A friend of mine is leaving the job.' I asked him, why would I want to do that? 'Because I think you'd be good at it, and you'd like it. So you should apply for it.' I went for the interview," Dr. Maison says. "To make a long story short, we clicked."

On July 1 of that year, literally the first day after residency, he became hospice medical director for Visiting Nurses and Hospice of San Francisco, an agency that today is part of the regional Sutter health system's Sutter Care at Home. It was a part-time job, while he also worked as a hospitalist, and he occasionally made home visits as well as attending hospice interdisciplinary team meetings and similar administrative duties.

"I spent much of my first six months at the hospice learning and keeping my mouth shut. A lot of people there were really committed to what they were doing and willing to teach me," he recalls. But he caught the bug and within a couple of years was telling friends that his dream job would be to do hospice and palliative medicine full-time. Soon thereafter he was approached by Hospice of Martin and St. Lucie (today Treasure Coast Hospice) in Stuart, Fla., with an offer to do just that.

 

As the Florida hospice's first full-time physician, and eventually a key player in developing its palliative care service, he experienced another steep learning curve. "Any time you come in as the first full-time physician, you have to figure out where you fit on the team. We underwent tremendous growth while I was there. It was not so much stressful as just lots to process through. It was a challenge----but a good one."

 

A year ago Dr. Maison was recruited away from Florida to take a new challenge. He leads the palliative care team (now growing to include two physician FTEs and 2.5 nurse practitioner FTEs) for three hospitals in the Spectrum system, helping to guide its expansion into other arenas, starting with a half-day outpatient clinic. The program, by and large, follows the CAPC model and answers physician requests for consultations, he says.

 

"We haven't done heavy marketing but we've focused on relationship-building, one patient and one physician at a time. There's tremendous need and demand everywhere in the hospitals. It's incredible to see how much we've been embraced by the system in the short time I've been here. There's also tremendous potential for future collaboration, beyond the hospitals into out-patient and long-term care settings."

 

Dr. Maison estimates that he puts in a 50-60 hour week on average, with fluctuation based on caseload demands. His job is mostly doing inpatient consults, with 20 to 30 percent devoted to administration, including program development, teaching students from Michigan State University, and participating in a collaborative HPM fellowship program with other local hospitals and hospices.

 

Does he miss the hospice piece in his new job? Dr. Maison responds that hospice and palliative care are part of the same continuum, and he finds satisfaction at both ends of the spectrum. "I had a wonderful career in hospice----very fulfilling. When I was in Florida, we were just trying to expand to take total care of the community's end-of-life care needs. Now I'm getting to work on further program development----bringing that experience of working in hospice into palliative care and making sure both programs grow. Having been immersed in understanding and celebrating the value hospice brings to patient care, and now transitioning to palliative care and the larger context of care in an integrated health system, I feel like I'm having my cake and eating it, too."

 

Palliative care takes the best part of hospice and tries to make it happen upstream, Dr. Maison says. The two programs can learn from each other and help make the best care happen for each patient. "We've only scratched the surface here in the potential we could have in patient care. In this system, people are starting to recognize and use palliative care much earlier than the end of life. I feel our community is well ahead of the curve."

 

Where it goes from here is yet be determined, he says. "Financial models are still being worked out. We don't know how health care reform will play out with accountable care organizations and rules for 30-day readmissions. The take-home message I hear is that there's not one model. It requires understanding your local community's needs and coming up with a plan that meets those needs. For those in palliative care who are trying to go beyond the four walls of the hospital, the message seems to be: keep your eyes and ears open and stay flexible."

 

Spectrum, like many health care systems, is talking about care transitions and how to reduce preventable readmissions. "I'm sure it's on everybody's mind, and I'm sure we'll have a seat at that table in one form or another. I believe we clearly have a role to play within this integrated system. How that plays out, what the job entails, and the concrete ways we could start to extend and knit together these various pieces----those are great questions. I've been here less than a year," he says. "Ask me again in another year."

 

Growing Up With Hospice

 

Although his entrance into the HPM field was rather fortuitous, Dr. Maison was acquainted with the hospice concept growing up. His mother was a volunteer nurse at one of the country's earliest hospices in Monterey, Calif., in the late 1970s. "She never pushed me to be a hospice doctor----or even a doctor at all. But the experience must have been formative for me." Now retired, she volunteers with Red Cross. "She thinks it's wonderful that I'm working in this field. We talk about it all the time, how it's changed, the kinds of patients she saw back then. The experience she had was very different than hospice care today."

 

Today at Spectrum, his biggest challenge is to grow in smart ways. "We're finding that the need----which is everywhere----is outstripping our ability to staff it well. As we grow, we want to be able to provide excellent, state-of-the art care wherever we are. So our growth is not limited by demand as much as by staffing. But the goal is to make it a sustainable model," he explains.

 

"One thing I learned from my experience in Florida is not to try to do everything yourself. Have a realistic understanding of what you are able to do and do it well. That lesson has served me well here as we've continued to grow. It's not a matter of saying no to things, but we want to be sure what we're saying yes to. We haven't ever said no. We say yes, but.... We want to work toward those, making sure that people understand what they are asking for, and then working with them to understand what it will take to get there," he explains.

 

"There can be tremendous opportunities, all confronting you at the same time, which is wonderful. But you need to find a balance so you don't burn out, or get so over-extended that you're not able to do what you are supposed to be doing. We don't want to lose this enthusiasm and sense of people wanting us everywhere. But at the same time, as we commit to doing more, we want to be sure we do it in a thoughtful, deliberate way. That's something I remind myself of every day."

 

Another key to growth, he says, is effective communication. In his current setting that means working closely with the hospice medical director and team, whenever appropriate. "There's such a rich amount of experience here between what we offer and what they offer. It's how can we put that together and collaborate as things come up, where they see where we might contribute, such as for patients not ready for hospice----either prognostically or philosophically----and as we work collaboratively to make sure those transitions happen as smoothly as possible."

 

Dr. Maison says that the palliative care program at Spectrum ultimately "is only limited by our imagination, as we grow and continue to integrate and get a better sense of the opportunities. If we keep our eyes on the prize and what we want to accomplish, we'll have a tremendous role in shaping health care and providing care to lots and lots of people. I can't imagine doing anything else for a living, which is curious considering how I kind of stumbled into this job 13 years ago, with no idea of how fulfilling it could be."

 

Dr. Maison's family includes his wife Andrea and five-year-old son, Jacob, who is growing up hearing about hospice and palliative care, just like his father did. Dr Maison is actively involved in committee work for the National Hospice and Palliative Care Organization and the American Academy of Hospice and Palliative Medicine, and is enjoying the opportunity to discover and explore the state of Michigan, treating his new home "as the adventure that it is."

 

For Dr. John Mulder (see HPM Practitioner, Issue 1, August 2009), an HPM physician in Grand Rapids who helped recruit Dr. Maison to Michigan and now collaborates with him on the local HPM fellowship program, "Daniel really embraces life. He's very positive, he's outgoing, never without a smile."

 

Like many people who work in the emotionally demanding field of HPM, Dr. Maison is also a serious foodie, Dr. Mulder relates. "You'll never have a bad meal or glass of wine if Dan is by your side. He's on my speed dial to call regarding wine pairings. It's so clear that he knows a lot about wine: the grapes, the soil, the vintages. And now that he's in Michigan, he also brews his own beer." (Contact Dr. Maison at: daniel.maison@spectrum-health.org.)

CareerAdvancementToolCareer Advancement Tools

 

The Resume: An HPM Physician's Essential Career Development Tool 

 

Our role as partner in your career development is to help you make the best presentation possible on paper and in your interviews. To do that, we need to submit career documents to our client organizations that are written in a professional manner and show the value that you will bring to that organization.

 

Developing a resume that effectively presents your qualifications is the critical first step in the career development process for a Hospice and Palliative Medicine (HPM) physician. That's correct; a resume, not a traditional CV, is the career document you need.

 

A CV, which, as a physician, you probably have, is a chronological listing of your professional history. Other than portraying your educational and experience history accurately, it has no particular goal and makes no particular point. Readers make of it what they can.

 

A resume, on the other hand, is a business document with specific purposes and markets you to prospective employers. In this situation, you are the product, and this tool represents you and your competencies to employers. It's accomplishment based. It answers the employer's pointed questions, "What have you done before that's relevant to our organization, how can you help me and why should I hire you over other candidates?"

 

"A traditional CV is typically a listing of information of where you were and when, beginning with your education first and emphasizing your academic credentials, publications, and positions held", says Louise Garver, Physician Resume Specialist, Career Directions LLC (a partner with the DAI Palliative Care Group). "It's just a list of lists. It doesn't help you to distinguish yourself from other candidates who have similar education and experience. Also, CVs are too long (well over 3 pages), poorly written and formatted. Therefore, they are difficult to follow and make employers spend too much time trying to find what they need."

 

Other recommendations from Louise Garver:

  • Resumes are accomplishment-oriented, and each position presents those contributions.

"It's the critical component that will help you to differentiate yourself from other candidates because no one else will have your accomplishments," says Garver. "Everything on the page is built around your achievements. They are your success stories: the results of your efforts and the quantifiables associated with those efforts."

  • An effective, employer-friendly resume is well organized with clearly visible headings.

Headings usually include: Professional Profile, Clinical and Management Experience & Achievements, Education and Certifications, and Professional Memberships.

 

Essentially a well-written resume looks like an inverted pyramid. Your most recent experience receives the most real estate on the document, and earlier employment gets less attention (space) as you go backwards in time.

  • Paragraphs and bulleted accomplishments are short so that your resume will flow and be readable. There are no laundry list of unrelated bullets that are difficult to follow.

It's concise, not wordy. It's written in crisp phrases beginning with action verbs-not complete sentences (I or My statements). Therefore, omit words like "a, an, and the" and "I, me, and my."

  • It's interesting to read, enthusiastic and weighted to emphasize recent experience.

As a general rule, employers care most about what you've done within the last five to ten years.

 

Prepared properly, your resume will position you as the candidate of choice even before you shake hands. That's the goal.

 

Additional Career Advancement Tools 

 

Emerging Leaders Program - a program offering insights into securing and then succceding in the right HPM leadership position. Contact Tim Cousounis at tcousounis@digital-action.com to learn more.

 

Palliative Care Network - a membership group on LinkedIn providing a forum for timely exchange of issues influencing HPM practices. Join LinkedIn if you're not a member, and then search under Groups for Palliative Care Network.

 

Palliative Care Success - a subscriber blog posting commentaries on trends shaping the future of HPM practices www.palliativemedicine.blogspot.com

 

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?

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