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Geriatric Emergency Medicine
Palliative Care Fellowship: An Option for EPs Passionate About End of Life Issues
By Ashley Shreves on behalf of the SAEM Academy of Geriatric Emergency Medicine
My emergency medicine (EM) residency director told me he was “surprised” (read “disappointed”) that I was not pursuing “There has been an explosion of fellowship a fellowship. It was my third and final year of residency and I was going to stay programs over the past decade and essentially on as an attending where I had trained, but with no clear niche. I wanted to be all are available to emergency physicians.”passionate about something in EM but none of the available fellowships were a good fit. The hospital where I worked my first couple of years out of residency was surrounded by long-term care facilities and it seemed like a large part of the job would involve “doing everything,” no matter how uncomfortable or lacking in dignity, to prolong the lives of frail, older patients with advanced dementia. I suspected that many of these patients would be horrified if their cognitivelyintact former selves could see the “care” they were receiving in their later years. The POLST (Physician Orders for Life-Sustaining Treatment) program was in its infancy in New York City so advance directives rarely accompanied patients to the emergency department (ED). Unfortunately, when I tried to talk to family members about goals of care, I lacked any appreciable skills to navigate these discussions. In fact, I don’t think I was even familiar with the concept of a “goals of care conversation” and had only a rudimentary understanding of palliative care. In 2009, I had a particularly challenging end of life case and my failure to advocate for the patient gutted me. I started to question everything. Fortunately, that same year, a series of articles were published in the July 2009 Annals of Emergency Medicine about a new subspecialty available to emergency physicians: hospice and palliative medicine. As I read these articles, the proverbial lightbulb went on, and soon after I started to research palliative medicine fellowships. Then in 2010 I read Atul Gawande’s “Letting Go” (the best piece of medical journalism ever written, in my opinion) and any lingering doubts were put to rest. In 2011, four years after completing residency, I started my palliative medicine fellowship at Mt. Sinai. It was a huge leap of faith
for their program, as they had never before accepted an emergency physician, but I am eternally grateful they did. The year was supposed to be educational — instead, it was transformative.
Fellowship training in hospice and palliative medicine is 12 months long and officially recognized by the American Board of Medical Specialties and American Osteopathic Association; 2012 was the last year one could sit for these boards without completing a fellowship. There has been an explosion of fellowship programs over the past decade and essentially all are available to emergency physicians. I used to know a few dual-boarded EM-palliative medicine physicians; now there are too many to count. The application process has been streamlined as these programs now participate in the National Residency Match Program, with applicants using the Electronic Residency Application Service (ERAS). While I completed my fellowship over a one-year period, many programs offer more flexible training programs for the mid-career physician, allowing fellows to complete their requirements over a two-year period so that they can simultaneously work as emergency physicians. When choosing a program, this is not the year to prioritize time off. Since there are only 12 months of training, selecting a program with an intense clinical load and educational experience is critical.
Career opportunities abound for those who complete fellowship training. Some bring their unique skill set and knowledge base back to the academic EM setting to improve residency education and/or pursue research. Others split their clinical time between the ED and palliative care departments. Full and part-time hospice work is also an option, particularly for those who want to continue their work in the ED. Some EM physicians complete their fellowship training in palliative medicine and never look back, making the transition to full-time palliative care. For emergency physicians interested in quality improvement and administrative work, there are endless opportunities to integrate palliative care principles into the ED and hospital workflow. I have personally split my clinical time between both specialties, working in the ED and inpatient palliative care service at my hospital. Both jobs are challenging and complex, but in completely different ways. Working in the ED is exciting and intellectually stimulating, but it can be a grind. Working on the palliative care service is deeply meaningful and rewarding but emotionally overwhelming at times. Each offers respite from the other.
There are endless opportunities in the form of online and in-person courses for those who want to improve their endof-life (EOL) skill set. But for emergency physicians deeply passionate about EOL issues, for those who want to devote their careers to the care of patients at or near the EOL, hospice and palliative medicine fellowship is a terrific option to consider.
ABOUT THE AUTHOR Dr. Shreves is an assistant professor of emergency medicine specializing in geriatrics and palliative medicine at Mount Sinai’s Icahn School of Medicine. She is a member of SAEM’s Academy of Geriatric Emergency Medicine.
About AGEM
The Academy of Geriatric Emergency Medicine (AGEM) works to improve the clinical care of older patients, prepare trainees to care for older patients, and advance the geriatric EM research agenda. Joining AGEM is free! Just log into your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”
