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Episode 12 - The Growing Trend in Hospice and Palliative Medicine Fellowship Training Among Emergency Physicians - Caroline Meehan, MD, and Alex Zirulnik, MD, MPH.
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In this episode we return for version 3.0 of the PalliEM Podcast. I am joined by Caroline Meehan, MD, and Alex Zirulnik, MD, MPH. They are the co-first authors and fellow collaborators in a recent study of the increasing numbers of emergency medicine physicians training in hospice and palliative medicine. We discuss the broader implications of this trend in both fields and reflect on our experiences in dual specialty practice.
Article: https://www.jpsmjournal.com/article/S0885-3924(25)00816-4/abstract
Outtro music: Synesthesia by Alaeus
Zirulnik A, Meehan C, Markwalter D, Gabbard J, Tilly A, Zimmerman P, Stafford J, Brooten J. Emergency Physicians and Hospice and Palliative Medicine: A Growing Trend in Fellowship Training. J Pain Symptom Manage. 2025 Dec;70(6):e498-e503. doi: 10.1016/j.jpainsymman.2025.08.036. Epub 2025 Sep 1. PMID: 40902736; PMCID: PMC12768106.
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Transcript
Introduction and New Beginnings
00:00:01
Speaker
Welcome to the Pallium Podcast. I'm your host, Justin Bruton. Today, we start off Pallium Podcast version 3.0. I took ah a bit of a hiatus after the the birth of our second child, um and I'm glad to ah get back to recording ah the the podcast and ah bring back some ah guests that I think we'll be excited to hear more from. um I'm joined today by my new co-host ah and Associate Program Director of our Fellowship Program,
00:00:27
Speaker
Alex Zorolnick. um I'm Justin Bruton. I'm the program director for the Hospice and Palliative Medicine Fellowship at Wake Forest University School of Medicine. And I'm also an emergency medicine physician, and I split my time between ah palliative care and between emergency medicine.
Journey from Emergency to Palliative Care
00:00:42
Speaker
um And Alex, tell us about yourself.
00:00:45
Speaker
My name is Alex Rolnick. As Justin mentioned, I'm the Associate Program Director for the Hospice and Palliative Medicine Fellowship here at Wake Forest University. um i actually have a primary background in emergency medicine. i did my training up at the Harvard-affiliated emergency medicine residency in Boston. spoke between MGH and Brigham.
00:01:02
Speaker
And then I came here to Wake Forest University for a fellowship in HBM. um And I was just really lucky and glad to stay on for faculty position here, where I split my time primarily in the ED, 70% of my time, but I do 30% of inpatient consults for the pilot care service here.
Trends and Research in EM to Palliative Care Transition
00:01:18
Speaker
And we're excited today to be joined by Caroline Meehan, who we ah worked on a a new paper that's come out looking at the emergency medicine workforce going to palliative care. There's been a big uptick in the number of people in emergency medicine who are doing palliative care training. um So we're excited to be able to share that with you and hear more from Caroline. Caroline, tell us more about yourself.
00:01:38
Speaker
Thanks, Justin. Happy to be here. So I'm Caroline. I'm originally from the Chicago area. um and I, like the the rest of y'all, did my my primary training in emergency medicine. um i did that at Brown in Providence, Rhode Island, and then ultimately became really interested in palliative medicine, stayed on at Brown and completed my hospice and palliative medicine fellowship there.
00:02:01
Speaker
um You know, I think EM embedded palliative care models have been a ah really rapidly growing model. And I was fortunate enough to learn of an opportunity up the road at MGH where they were expanding their ED embedded palliative care team.
00:02:14
Speaker
And so I've been working at MGH so the last year. This is the the start of my third year. and I and have the inverse of Alex. I do seventy thirty but the bulk of my time is palliative care with the the majority of that time being split between our our palliative OBS unit as well as our ED embedded model. um And then I do 30% just standard clinical emergency medicine. And it was my my first year as ah an attending at MGH where I got to meet Alex, um who was a Hammer resident at the time. And We've stayed in touch over the the past couple of years, and it's been really wonderful to be colleagues from afar and get to collaborate on some projects together, and including this, and and get to meet folks like Justin. So thank you for having me.
00:02:53
Speaker
Absolutely. And um you you played a big role along with Alex in getting this off the ground. It had been something that you envisioned for a while. I know when Alex ah was was starting off as a fellow, he started talking about this and saying, hey, I want to get some data on this.
00:03:05
Speaker
I want to take a look at all the people in emergency medicine going into palliative care. And um Alex, tell us a little bit ah more about what you discovered in this process and and kind of what the the um what kind of got you interested in in bringing this to bear so that that we could share that amongst our colleagues that are interested in this space.
00:03:22
Speaker
Sure. Yeah, no, I, um, ever since medical school, I kind of knew that I, I, um, had the spark for hospice and palliative medicine. And I knew that I was going to probably pursue a career in a split position. um I think what I was not expecting was when I was telling people over the years in my emergency training that I was going to do palliative care, they they kept saying, wait, what? You can do that? And um so I was really inspired. And I think my whole purpose and goal in life at this point in my career is I hope at one at one point people are going to hear folks coming from emergency medicine, going into hospice and palliative medicine and say, oh, that sounds great.
00:03:55
Speaker
And that's totally normal. um So I wanted to normalize that and I wanted to um make it make it known to all the people who are inspired to go into hospice palliative medicine for emergency medicine that um this
Awareness and Inspiration for Palliative Path
00:04:06
Speaker
trend is growing. There's a lot of us out here who are interested in both.
00:04:09
Speaker
um And, you know, the the field is kind of unlimited in terms of all the opportunities that are out there for us. um So, you know, I, It came into fellowship and ah i think we had kind of heard, I had heard through a lot of interviews through fellowship that, um you know, there's a lot lot more EM folks kind of on the trail going into pal palliative care. and But I don't think that we've actually kind of put a numerator on that yet.
00:04:34
Speaker
um And we were not sure how many people were actually doing it. So that was one of the big drivers for us.
00:04:41
Speaker
and And Caroline, kind of ah with your experience, what was some of the other things that led to the impetus of this paper? Similar experience to Alex or what would you add? Yeah, I think a lot of what Alex said resonated with me as well. i I didn't even know hospice and palliative medicine was a fellowship you could pursue from emergency medicine until I was about to start my fourth year. And then I had to scramble to get all my application materials ready.
00:05:05
Speaker
um So I think, and and yet, like, I do think awareness is really growing. And even in the last, I think about the past four years of attending AHPM, and our little EM significant and interest group within that subset of people, just the amount of energy in that room, and that the numbers growing year to year, and we all talk anecdotally about how this is a growing field, there's so much opportunity and overlap. And yet, like, And there's really very, that the previous to the study, there really very little information available publicly online about how many people are dual trained in EM and palliative care.
00:05:38
Speaker
And I think as I was sort of scrambling in this really new combined field to to think about career opportunities for myself, so much of this is is really through grassroots, just talking to the handful of folks who I knew were in this field, and they connected to me with others. And then you realize there is an enormous web. It's just, I think it's still in its infancy enough that the numbers are small and and just wanted to bring awareness to the the growing group of us and and some of the factors that could be contributing to that.
Impact of COVID-19 on Career Shifts
00:06:06
Speaker
for For either of you, what do you think is the most maybe surprising finding that we have ah in this study? What what what surprised you as we dug into the data and and got the actual facts on where we stand?
00:06:19
Speaker
um i think I think for me, i think it was kind of the explosion, especially after COVID. um You know, we we started, when we were looking at our data, we looked from 2016 to 2023. And in 2016, there were a mere 11 people who were going into hospice and palliative medicine for emergency medicine. um And that number has just exploded. And 2023, it was 55 So,
00:06:42
Speaker
Really, every every few years, um we we looked at the number of people going into HPM from EM, and it's increasing by about 25 to 27% every year. um So i think that was kind of the one of the surprises to me was, and maybe it's not surprising, that after COVID-19 pandemic in 2020, we saw a huge increase number of folks going into HPM.
00:07:03
Speaker
um And we can speculate for all sorts of reasons why that's going on. I'm sure we all have our own personal experiences and thoughts around it, but I think that was a big takeaway for me. Yeah, I think for me, actually, I was really struck by the the match success rates of EM applicants, I think, especially because it is still a somewhat unknown. a lot There are programs that have never had an EM provider in their fellowship. And and I certainly found as an applicant that there were there were programs that were a lot more friendly to someone with an EM background and I think could see the the overlap there and potential um hybrid for these two things. But I think there were there are plenty of programs like EM, why here? Why now? um But I think it speaks to because and this is something I do think is changing, especially as it's becoming it sort of a core tenant of emergency medicine training, having some of these primary palliative care skills.
00:07:55
Speaker
um But I i i think It speaks to the fact that a lot of programs don't already have palliative as part of their EM education. And so I think there's a self-selecting group of people that are are interested in palliative medicine that are seeking out opportunities and and potentially are are are pretty strong applicants that are pursuing this with those backgrounds because it's not something that's standardly part of a lot of EM residency curriculums presently.
00:08:20
Speaker
Yeah, and I do think it's improving. One of the things I've been really super excited that that Alex has been able to stay on faculty with us is just the amount of education we actually need to do that can still be integrated into the framework of emergency medicine, right? When we talk about when we talk about pain management, we can incorporate what cancer patients, ah what their pain management challenges are like, or what you do when you have someone come in that has acute pain that's already on a really, really significant opiate regimen, because that's stuff that they need to be comfortable with. yeah So I think that there's... i bleed having a component of that vehicles of care discussion it's really
00:08:55
Speaker
integrated in all of the care we're doing on a day-to-day basis already correct. and um And I just think about the topics. I've been fortunate to have his help because there's so many topics we need to cover. The other thing too is you definitely need to have a residency programs buy-in because they need to be able to see that that investment in time um that they're giving up for conference, especially in three-year programs, which eventually it sounds like we're move to four-year programs across the board. Just the amount of time that that has to be given to each topic to be able to cover an EM curriculum, you can only spend so much time on each thing. So they have to see that it's high yield. And I feel like So Alex and I both, I feel like the the lectures we've been able to give that fall into this space, I feel like they've been well received both by the residents and and the other faculty. So that's encouraging. Yeah, that's wonderful.
00:09:38
Speaker
What um the other thing, too, I think that makes such a difference, and you alluded to this, is having, you know, the the residents come in and some residents come in and they've been at a medical school where they got almost no exposure to palliative care. They didn't know it was something you could go to from EM. And if they're at a residency program where this is at least like brought up as a topic, they can start to unpack that and go, oh, wow, this is pretty interesting. It actually overlaps with a lot of what I do.
00:10:01
Speaker
Both of you happen to be at a place where you got a lot of exposure to to all of this. So it was it was ripe to be an opportunity after completing residency. What do you think is the challenge still in in getting education moved forward or getting awareness for this for people that are training now or moving into EM training?
00:10:22
Speaker
go ahead,
Care Models and Challenges in Palliative Care
00:10:23
Speaker
Caroline. No, I think... one of the So i i was late to to be aware of it of palliative as an option for an EM applicant. And I think in part part of my awareness was that we had someone who had trained at Brown who had an EM background who was coming back as faculty. So I started some conversations with her. Right.
00:10:41
Speaker
But I think that was such a huge piece of it was just awareness of this as an opportunity and seeing role models in the field who are who are working in careers. I think so much of, of at least for me, when i when I think about what I want to pursue next is seeing an example of someone who's who's already doing it and imagining like a similar lifestyle for myself. And so I think with this rapid expansion of EM folks going into hospice and palliative medicine, I think we're going to see more and more focusing potential role models or examples of careers that they would want to model their own after. And so I think exposure is is is the biggest barrier, or just people being, because I think so much of, it's it's striking to me just how many residents are interested in hospice and palliative medicine,
00:11:26
Speaker
I feel like so so much of the sort of stereotype of emergency medicine as being these sort of cowboys who want just purely procedural lives. But but we're we're doing this work every single day, just given the nature of what emergency medicine is. So I think people recognize that it's an important skill and there are folks who want to go into it. And I think seeing an example of someone who's doing it is is the first step.
00:11:48
Speaker
Yeah, absolutely. And I think to echo that sentiment too, I mean, there's like 66,000 emergency medicine physicians in the country and there's only, i think, dual board and around 315 EM HPM folks out there. So we're like less than half a percent right now of the EM workforce. But um as as we continue to grow, and I think this was a big inspiration for our paper, as we're seeing this explosion emergency medicine folks going into HPM, I hope that that continues to be a big,
00:12:19
Speaker
a big role model. um I don't know how to say that. A good ah good way to ah emphasize all the different role models that are going to be out there for folks who are interested in this field.
00:12:30
Speaker
and And one of the things that I feel like we come back to a lot is you're going to see a patient that falls into our realm almost every shift, depending on where you are. You might, you think about, you know, as many head bleeds as we treat or as many other things that we treat that are pretty serious. Like how many, how many patients a shift are you going to have, you know, flash pulmonary edema? You know, how many patients a shift you going to have, you know, a bleed with shift, right? But you're going to have somebody with a palliative care need almost every shift, depending on where you are. yeah um I can certainly say that. So um the other thing that's interesting to me, I was pretty surprised by just the, now granted, it's a big increase in part because 2016, you started with what, 11 people that were that were getting trained in palliative medicine, but an increase of 400%
00:13:16
Speaker
over that time period, 2016 to 2023. I think some of the things we've mentioned all contribute to that increase, but what are some other things that you both think have led to that huge increase in the number of people in EM that are interested in palliative care and seeking training?
Lifestyle and Emotional Dynamics in Dual Practices
00:13:33
Speaker
I think I do, I do think I'm i'm going to speculate here, but I do think that the pandemic kind of taught us a lot in terms of um providing value congruent care to folks. um weve I think the the pandemic played a large role in, um you know, i want i don't want to you know i don't want to use the word burnout for emergency positions, but um I'll scroll around it and say a lot of emotional fatigue that people face in the ED.
00:13:59
Speaker
And I think when we had a lot of folks like we, I was really fortunate when I was at MGH that we had embedded palliative medicine in my training. And it was just so inspirational to see people who were very, very sick during the pandemic.
00:14:13
Speaker
and We were all very worried that they were not going to do very well. And then you had this this, I want to say, team of heroes um from from palliative medicine that was able to swoop in and have these really difficult conversations under duress while um the EM team is is doing other things to try and stabilize and seeing other patients. um And it was just inspirational to see, you know,
00:14:34
Speaker
how you were having these conversations with folks, oftentimes alone, oftentimes using video recording devices to like get other family members involved. um And for me, that that was a huge inspiration. And I think a lot of folks and that I was working around and were also inspired and kind of introduced to the the field of palliative medicine at the time.
00:14:53
Speaker
um That's one, i think that's one reason. um I don't know. I don't know if what your thoughts are, Caroline. Yeah, Alex, I think everything you said really resonates with me. And and so much of this is conjecture. But I i've personally, I think ah the pandemic hit about halfway through my residency. and And we were a busy critical care center. And so it wasn't it wasn't as though it was the first time I was seeing patients who were actively dying at end of life. That was a big part of sort of day-to-day emergency medicine. But I think being involved in in more of the conversational piece and decisional piece was was a first for for me, at least during the pandemic. And I think a first for a lot of emergency departments, depending on how they structured resource utilization. So when there simply aren't enough ventilators to go around, there aren't enough ICU beds, suddenly you're thrust into having some of these conversations about,
00:15:41
Speaker
who's going to get care, who wants to get critical care, who do we think it will make a meaningful difference in. And was really the first time that in that the context of the ER, i was I was having a lot of those decisions beyond the sort of nuts and bolts we we're all doing of DNR, DNI, basic code status conversations. i was really thinking about care utilization and and what makes sense and and goal aligned care for the first time.
00:16:02
Speaker
um and i I think, you know, one thing I... i my personal hypothesis is that I think a lot of, a lot of folks who were trainees at that time were inspired by that. But one thing we don't know about from, from this work is where and in training and in careers were people when they ultimately decided to transition. And I think that's, that's one thing I'm really curious to find out is that, was it a lot of folks who were mid-career who were potentially working in the community, seeing the same things in the pandemic or was it more affecting trainees? And so I think that's ah a question we have we have yet to answer and are are hopeful to explore going forward. But I think the pandemic was was a huge, huge driver. and And even after the pandemic, I think one of the the big things that impacted so many of emergency departments was boarding. And so even just your run-of-the-mill patient coming in with a UTI, some delirium, Some of these conversations that were happening on day two when the delirium's not clearing, they're not making improvements, there was a consideration of pressors, were happening in the ED, and the ED team is is now integrally i part um a part of some of these conversations in a way they they they weren't necessarily before pre-pandemic when EDs were getting patients directly up to the floors to have some of these inpatient conversations.
00:17:16
Speaker
So i think it's it's really put itself at the the forefront, I think, um Alliative medicine and and goals of care are really at the forefront of the the the thought process for a lot of emergency docs in a way they may not have been previously. Yeah, I i agree. And I think i think boarding does play ah does have a big impact. for one One thing, even working both at ah at a tertiary center and in the community, when I think about transfers, when you started having more boarding, you also had bigger delays in patient transfers. And it used to be that the path of least resistance was just get them upstairs or just get them to the other hospital. But when they're waiting, you know, 20, 24, 30 hours to go upstairs or they're waiting, you know, 12, 18, 24 hours to leave your emergency room, ah the invested time in actually maybe changing the, the you know, transitioning their care, or changing the goal for the patient. If it's clear that they they might want to change their goals, that they might not want to just go the path of least resistance. um
00:18:14
Speaker
that time invested actually has a payoff. you know Before, they were going to go upstairs in three hours, and I remember when I was a resident, and I mean, it just admissions were quick. you know um If they were going to go upstairs in three or four hours, you were just dragging your feet if you did some more stuff downstairs. But now, It's a different landscape. And even getting people to hospice, same thing, right? if you're if you're If you can get them to a hospice bed in you know three or four hours, you know in pre-pandemic times, it's like, why are you slowing things down, right? Let them deal with that later. But now, wow, you got a bed. You got a bed in three or four hours and it's not one of our beds in the hospital that we're taking up now. I think we all have skin in the game now, right? Like if we can do something that will impact a disposition, then we're we're feeling that in a way we didn't previously feel it.
00:18:57
Speaker
That's a great point. um I was going to say, do what do you guys think about, you in terms of like lifestyle too? So there's like a lifestyle difference between working in emergency medicine and working in and palliative medicine. And it's so funny. My my wife was just asking me, she's like, do you feel more tired when you're on your three weeks of eating or palliative? And actually, I think it's my palliative week. I'm more tired. It's like the early morning, you know, eight to five. And it's so emotionally difficult to go through the day.
00:19:23
Speaker
um you know, I just kind of i want to hear your thoughts on what you think about like lifestyle choices to you, because I do think that probably plays a factor in some people's decisions to pursue HBM2.
00:19:36
Speaker
Yeah, Alex, that is such a good point. And I think about that on a day-to-day basis. I feel really spoiled to be able to split my time between palliative and emergency medicine. And I think if I was doing either one exclusively, i would have a very short-lived career.
00:19:51
Speaker
um and I think... Which one I find to be more emotionally trying and more rewarding, really, it swaps around on a day-to-day basis. So um I feel really lucky to be able to swap around. one of the things I always tell um residents I'm working with is that I do feel like, you know, there's a high amount of burnout in both fields and for for good reason. and And I feel like some of the the things we do in palliative medicine are antidotes to the burnout in emergency medicine and and vice versa. So i i just finished a long stretch actually now of of palliative medicine and I feel emotionally fried. i like i don't have an empathetic bone left in my body. I don't want to talk to a friend about some some issue they're dealing with in this horrific and selfish way. And so I'm looking forward to going back to the ED and having this like really rapid fire and just transient sort of interaction that's more procedural and interventionally based. And then after a few days of that, I'm sure i'll be I'll be feeling like I need a longer connection and want to have more in-depth conversations with my patients. And so I i i love being able to swap
Integrating EM Skills into Palliative Care
00:20:52
Speaker
between the two. But i i do think that the palliative care piece initially, I was like, these are such like, when I started my fellowship, I remember I had like three hospice patients. was like, I could be done with this day in 20 Yeah, yeah.
00:21:07
Speaker
That's so true. And you know, it's so weird too. you i I just worked at shift in kind of our, our fast track area last night too. And it's like, I just saw like 20 people without life limiting illness, you know, with like very minor complaints. And it's, it it is just kind of a reset, I think going back and forth between the two and it's, um but I think it marries well together. and I think, you know, a lot of people don't think about it like this, especially if they're not emergency folks, but like we, we are trained from day one to know nothing about a person, build immediate rapport, um you know, in a way, figure out their goals in terms of like workups and admission, things like that, um and meet people in crisis. And i think that's exactly what we do in palliative care consults too, is like, we know nothing about these people. We're being asked to enter their care at the most, you know, critical times often.
00:21:52
Speaker
And, um you know, I think, I think I personally think ER folks are very good at building rapport very quickly. And so I think that, um that again, the the two fields marry so well together. That's such a good point, Alex. And sorry, I didn't i don't mean to interrupt you, Justin.
00:22:08
Speaker
and Yeah, I think one of the other things, too, that people don't always necessarily associate with the ED is that like we're really no strangers to death and the end of life. And I think it's something that... you're you're really inundated with that in emergency medicine. And so being able to be in that space and be able to honor people's wishes as a sort of transition of care feels really nice as opposed to being the person at the head of the bed running a code. um And that that I found to be a really healing experience to be quite honest, I think coming from emergency medicine.
00:22:40
Speaker
the ah i like I really like ah one of the things you said there, Caroline, about it being the antidote. for some of the things we encounter in emergency medicine. And I find like, I still get excited after a reduction when I get to see an x-ray and I'm like, yeah, you know, like I nailed it, you know? And, and I feel really good after a really, you know, if I feel like i I steered a family that was like, you know, on the ledge or like angry or, you know, stuck and mired and I was able to help unglue them out of that space and get them to a decision that, that wasn't easy, but it was the right decision. Like,
00:23:11
Speaker
like that feels really good. So it's nice how they compliment each other. And I bet the two of you probably experienced this, but one of the things when I was in residency, it was evident that this was kind of the space I liked working in. So I kind of developed that reputation. And to this day, like my colleagues will come up to me and they'll go like, yeah, yeah, I had a hospice patient last shift. I got, i got a person to hospice and they'll be like, you'd be really proud of me. And they'll they'll tell me about it, but their, their, their faces light up. Like they get excited And the irony is as much as, and I do, I still, I, I like intubating people. I like putting lines in, I have fun with it. I love, I love defibrillating people, but cardioversion. I really love cardioversion. Um, but like I, it's funny, we don't get a lot of thank yous for that stuff. Right. And, and you think about the sickest people we take care of, they just are whisked off and they, we're a phantom. They never knew who we were. And and I don't mind being anonymous because they don't have to remember who I was when they when they make that decision to you know further for their mom to go to hospice.
00:24:09
Speaker
But that's where I get most of my thank yous. And I think our colleagues see that too. they They take these families through that difficult journey. They give them the tough information. They help them process that decision and make a conclusion about it that that makes the most sense for the patient. And afterwards, they're like, wow, wow. That felt really good. You know, just a good point. I remember being like a week into my fellowship and and turning to my my program director. and it's like, I don't think someone said thank you to me in the last three years. And like here it's every encounter. And I don't like ah gratitude is not why I went into emergency medicine. And it's not something I need at all to to find this work fulfilling.
00:24:46
Speaker
That is nice. it is And it's nice. And I think it just speaks to the the types of interactions we're having are are so fundamentally different. and I think a thank you is not necessarily appropriate and in the context of an emergency room visit. Yeah. Yeah. I wonder, I wonder what you guys do. I think about this too. Um,
00:25:06
Speaker
especially when I'm when i'm transitioning out of the ED onto my week of palliative consults, is like it's kind of fun to be able to leave the ED and like be in the hospital. And I do feel like it's kind of nice to have a presence. And like you you put names to faces when you go upstairs and you're seeing consults like, oh, you had met my patient two weeks ago, um but now I can actually have a conversation with you in a different sphere um and kind of get that relationship, especially like with our ICU teams and ICU docs. i think it's... i just think it's um Another, you wouldn't think of it as a reward going in this field, but I do love that aspect of me splitting my role between the two. Because I kind get to call them. Instead of the consultor, you get to, I think, the interactions tend to a little more positive when you're wearing your consultant hat and interacting with the primary team. You're not making more work for everybody. being a leader.
00:25:52
Speaker
Well, and you know, the thing that's interesting is in the emergency room, while we are experts in what we do, all the people we talk to are more expert in their thing that we're asking them about. So they kind of, there's a different power dynamic. And I think about like when you're the Swiss, army I think of an ER doc's a Swiss army knife, right? When we're downstairs, we're a Swiss army knife. We have a tool for everything, but we're still reaching out to somebody who's a specialist in that piece of whatever it is that they're admitting that patient for.
Continuity of Care from EM to Palliative
00:26:17
Speaker
and when you go upstairs, you get to be an expert, you know, we're already an expert at something,
00:26:21
Speaker
But I think upstairs when we're consulting, we kind of get recognized for the expertise we have in that space, you know, and and even our really good critical care colleagues or whatever. They're like, man, they're really good at talking about this stuff. Are they? Wow. You really helped that family. You know, thanks for helping with that family. I think that's also nice because it's a different kind of interaction. Kind of like you said, you do it's a different hat we're wearing, but I think it's very affirming, which I'm with you. I get a lot of, I get a lot of, um,
00:26:46
Speaker
gra I get my cup filled just knowing that I did something that I felt was meaningful in the day, but it's nice to get acknowledged. You know, I think none none of us, none of us, you know, mind that we don't necessarily have to live on it. But the, I think that's a good, a good point.
00:27:00
Speaker
And I think we also, so you know, Justin, I think we've talked about this a little bit. Like we also speak the language of every other specialist in the hospital, right? Like we are so used to calling um folks and and giving a story to, you know, it's gonna very different probably talking to like an internal medicine hospitalist than it would be like a neurosurgeon who has maybe more limited time. So I think that's another great skill set that we bring to HPM is when the teams consult us, like, you know, we we know how to speak their language. um And we've been kind of taught that since day one of emergency. So I think that's also really cool.
00:27:29
Speaker
I think it's helpful just thinking about the downstairs interactions. Like I think about our surgical colleagues, you know, like when I go to the surgical ICU or I go to the trauma ICU, it's like I was elbow to elbow with these people a few days ago in the trauma bay. Right. So I think that's also something that's nice is there' we're We have, because of our because of our niche kind of between the procedural and the medical, they kind of, I don't know, I think they they tend to relate. I feel like I relate with the the surgeons pretty well um because they because we share some of that space together. um and And I feel like they appreciate that.
00:28:02
Speaker
um And it it seems to work it seems to work well, um especially with diverse patients. I wanted to ask, have you guys ever taken care of a patient in the ED and then seen them as a consult? Has that ever come up for you? I have.
00:28:14
Speaker
yep present mya yeah how how What was that experience like for you, Caroline? It was wonderful, to to be totally honest. And I think ah it was actually someone I i anticipated. I was working an ED shift. It was actually just last, about a week and a half ago. and and it was a patient who came in ah who was end-stage malignancy, uncontrolled pain,
00:28:37
Speaker
And I knew I was going to be the doc on for the week, the the next day wearing my palliative care hat. And so I i put the consult in knowing that it it would be me. And so it' was really, it was really wonderful to to be able to sort of frame shift and start, I mean, such that was like a micro dose of what I was able to do um in terms of palliative care and the ED, but it was, it was a really cool opportunity to be both the person who initially saw someone from square one and then to continue their care and evolve some of those conversations and, It also is so I mean, I think, I guess that's like what it is to be a primary team in so many ways, but to to be able to understand some of those influences of what did this person look like in distress in their worst moment and have that as context for some of the later later days of their admission, I think was really helpful.
00:29:25
Speaker
Um, I, I had the reverse direction experience, um, and it was pretty memorable. So I had somebody where I saw them, no, not reverse in a bad way, like reverse, like I saw them as a consultant and then I saw them as an yeah ER doc. Um, and it was somebody that, no one wants to return to the ED. It was, they had, um, they had come in and, um,
00:29:45
Speaker
I actually saw him and I did kind of advanced care planning. It was somebody was of advanced pulmonary disease. And I got to talk with him and his wife. And I think we, I think we made it a plan for like no intubation kind of based on whatever it else had happened or or a series of things. And I think a couple weeks later I ended up, um I ended up, I was getting sign out and I was like, wait a second, I've seen them before. And like, he was not doing good respiratory wise. I can't remember the whole scenario.
00:30:11
Speaker
But I remember i was able, it was so unique because I was able to say to his wife, I said, you remember the stuff we were talking about? I'm like, this is the stuff we were talking about. And it was just, it honestly, it felt very humbling to be able to be, to kind of book in that, that process.
00:30:27
Speaker
um Because I'm like, what are the odds? You know, they're not, I mean, it's, it's, it's kind of like divine intervention. Like the fact that I was in both of those places. The other thing I've had happen that was similar was people I've seen serial times in the ED, and I've had a chance to see them on more than one visit, and and things have progressed or things have happened. and you just Because you've got a rapport with them, um it it does facilitate a little more in-depth conversation and and
Advocacy and Holistic Patient Care
00:30:51
Speaker
transitions. but those are i mean Those aren't frequent, but when they happen, they're like, whoa, that was...
00:30:56
Speaker
That was a lot. That was a lot to take in, you know. um some okdo no no no i I had some similar experiences. i do We do the ED-embedded palliative care consult model. And so it's not uncommon that we get a lot of repeat consultations on the same patients. And there's nothing more powerful, I think, than than seeing the the physical decline in someone. It's like, remember what we talked we talked about being worried about happening? I think we're there um like today in comparison to before. It's just a really wonderful, and I guess that's what most outpatient providers get to experience on a a regular basis is is seeing people at various cross points in time. But we we don't often get to see that even as consultants. You're seeing people for like a snapshot of a few days or this discrete ED visit. And so getting to see that progression and those changes is really, really a unique lens and I think can can really impact the the care decisions they make and and how the conversation goes.
00:31:47
Speaker
And i I think it's really cool too that, you know, all three of us work in academic centers. And so we work with trainees every day and I've started to do this thing. I'm a new attending, but I've started to to come on shift and, you know, I introduced myself and everyone knows I do palliative medicine too. And I'll say to them, I was like, Hey, let's try to find like somebody who might benefit from palliative care today on shift.
00:32:06
Speaker
um Especially in our higher acuity pods. And they're always like, maybe, maybe we'll find somebody you want to know. And the end of the shift, they're like, I think we need to put in like five consults. There's like all these people that probably need palliative care, um whether it's uncontrolled symptoms or the family's like in distress and, you know, goals aren't clear. Like it's it's just amazing. I do think it's it's so cool to um to be this presence in ED. And I think it kind of, as you were kind of alluded to earlier, Justin, like people come up to you excited. Like, I think we're kind of like ah a lighthouse in a way that that shines a light on people who really need us when we're down there.
00:32:40
Speaker
And we kind of like, remind everyone, oh, wait a minute, like we probably should involve these special services. And I think it also speaks to, like, that I have had similar experiences with my colleagues, which is just like the best feeling in the world that someone's excited about having done palliative care in the ed But i I do think we, as a specialty and just as healthcare care in America, we do really horrific things to people at the end of their lives. And and getting the moment to sort of take a step back and a beat and say, like, hey, does this make sense? this Is this what you want? Is this really the right path forward? Just, I think, can be a really powerful moment in the ED. Yeah.
00:33:15
Speaker
Right. and And the activation energy to to perform very good palliative like medicine in the ED is is hard for folks who don't do this every day. Like, how much easier is it? i was just talking to Reza about this on shift.
00:33:26
Speaker
Like, You have a patient who unfortunately has a pain crisis overnight from hospice. Well, the easiest thing in the world is just like the easy button, to admit, get labs, get imaging if you're worried about their abdominal pain and you're done.
00:33:38
Speaker
um But, you know, to take a step back and like ah maybe we need to talk to the family overnight and we need to call the hospice agency. We need do all those things. I mean, it's a lot more work, but so much more rewarding when you realize that you're providing, again, goal concordant care for a patient who who, you know, probably does not want to spend what limited time they have left lingering in a hallway or being boarded in the ED waiting to be admitted.
00:34:00
Speaker
So, um, yeah, that, I think that's, I think that's another really cool aspect of our job is that we can, we can be there to, uh, to shield people from that if we, if it comes up. Um, I like what you said, activation energy, cause it is, there's almost like this little threshold that has to be crossed. And I think one of the things that's fun, is when people learn just a little bit of language that basically like pivot makes that pivot happen a lot easier than they realize.
00:34:26
Speaker
Um, so it's kind of, it's kind of fun. I, I, I joke that they're like Jedi mind tricks. They're really not, but, but there's just a few things you just ask it a little differently. And it's like, oh my gosh, you got like such a different answer than I was expecting from that family. And it's not manipulating them. It's just, it's asking a question in a way that they actually are understanding what you're, what you're getting at.
00:34:45
Speaker
Um, One thing i'm I'm curious about as we look at, as we see this, you alluded to it earlier, Caroline, there's still some digging that we've got to do. There's still some unanswered questions about what this group looks like. Like you mentioned, we know that a lot more people from emergency medicine are are going into palliative care.
00:35:01
Speaker
um I'm happy to say, I can say from our, like our our applicant pool, when we have emergency medicine people, most of them are pretty new in training. And I haven't seen a lot of people that are like coming like late career and they're just like, I've had it. I just need to do something different, which unfortunately sometimes People can see palliative care as an off ramp for that. But most of the people I've seen, it's been very intentional. It's been very much like a like ah a guided decision or or kind of an epiphany that they had during residency.
00:35:26
Speaker
um What are some of the next steps that you think we have in this space to kind of get a better idea for what the workforce looks like and where are they at their careers? And and what what is that next step that that needs to be explored?
Future Opportunities and Closing Remarks
00:35:42
Speaker
funny you should ask that, Justin. It's almost like that was planted. So I think the next step really is exploring what what does this group look like? Who are they? Where are they coming from? Where in their careers are they? And and what is driving the factors for one, exploring ah a fellowship in hospice and palliative medicine, but then The other thing we don't understand presently about this this workforce is how many folks are splitting time between EM and palliative care. I would imagine my my hypothesis is that we're we're probably a minority of of of people who are are still doing both clinically. i think the majority wind up in one camp or the other. And
00:36:23
Speaker
As I experienced, and I'd be curious to hear your guys' experiences as well, it was hard to find. I wanted to do both. I i was in the camp of people. i I didn't go into hospice and palliative medicine because I was running away from emergency medicine. really It was a genuine passion and ah a desire to combine the two. But it was it was tough to find institutions that could buy in. And I feel really fortunate to to have found one that ah allows me to do both. And there are very real drivers that are are kind of continuing to to play and in making that that balance somewhat difficult to manage as opposed to just having a a single house to to be within. and But those are some of the questions we were really curious about. And so Alex and I are are are hoping to to launch and in accordance with the rest of this group. And I think Justin, you're involved as well and surveying some people, um people who have
00:37:11
Speaker
primary education in emergency medicine who have gone on to pursue careers in hospice and palliative medicine and some of the driving factors that went into those decisions and then what their practice model is and other factors that contributed to that. um But because we could we can hypothesize until the cows come home about why people went into hospice and palliative medicine, but we really want to hear from the horse's mouth what what those factors were. Yeah. And I mean, all three of us were sitting in Denver last year at HPM and and you know I think it just started like like popcorn in this room of like 100 people of like, wait, what do you do? And how do you split your time? And like we all wanna know what we're all doing, but no one's ever like looked at this before. So I think i think having that data out there um almost as like a reference for folks who like, let's say you know you are a mid-career or you are an intern,
00:38:01
Speaker
and you're interested in HPM from from EM, like i you know I hope through our work um together as a group that you know they'll have a ah ah a reference to go by and say, okay, well, there's a lot of folks going into fellowship. That's totally normal now.
00:38:15
Speaker
And then what do I do after I've done fellowship? like What are the options? And um what are some of the driving factors that I should think about when I'm thinking about this career? So So, you know, I'm really excited about it. i think I think most of us who do work in this field from emergency medicine are excited to tell our story because our stories are pretty unique.
00:38:32
Speaker
um Again, we're less than 1% of the EM workforce. And so um i think I think it'll be pretty great to to get that info out there. and Alex, I think to to that point, even though this is such a rapidly growing subset of people pursuing HPM fellowship, it's still, we're often, I think, sometimes the first EM candidate a program has had or one of the first few. And so I think you know a lot of programs aren't as familiar with advising career paths for for folks coming from EM. And so i I hope that this information will be helpful to people.
00:39:07
Speaker
And actually to piggyback on what you said, I think one of the most useful things to help with that, because this does, I think, require some mentorship. um So we've got different national organizations that each have like subsections of ah palliative care interest groups where we're a fairly small group of people. So so that can be a good ah source of information and guidance. Having worked with several fellows that have ah have needed to have looked for jobs, like combined jobs, I think it's it's helpful. to be able to to advise other people. um I will make a quick plug just because, and I'll be universal on it to include the other groups, but i ah both Alex and I co-lead the ASAP palliative medicine section. So we're happy to provide some guidance and mentorship to sort for those members that want to that want to join us on that. There's also some excellent groups at SAEM, AAEM, and AAHPM, as Alex mentioned, that that you have a nucleus of people who have worked in both spaces, have explored different opportunities and jobs in both spaces and can help be a source of guidance for the people who are looking at, you know, do I want to take a plunge and do this? If I do, what is my job opportunity landscape going to look like? um How do I navigate, a you know, dual position? I think there's there's people out there who've done it that can be ah a source of guidance.
00:40:24
Speaker
Well, I think um I really appreciate the discussion and thank you both for being on today. And I'm really excited about what um what can come of this next stage of this exploration. And I think it was extremely enlightening to to be able to see a little bit of the landscape of who's out there going into palliative care from EM, um how much it's increased. And I think it's going to continue to increase ah because, as you both mentioned, we we have kind of an innate skillset and EM to build rapport, to jump in on an emergency, to be able to help people in crisis. And I think that that translates really well. Um, and it's continuing to be recognized and, and even for those residents who aren't necessarily interested in the fellowship, they see the value in that, that primary palliative education that they can still use in practice, regardless of where they're going to be. Um, so thank you both for being on. And I look forward to the next time we can meet where we can talk about the next stage of the study.
00:41:13
Speaker
And, uh, and ah and And thanks, ah Alex, for ah for joining me now as my ah my now co-host on the podcast. And thank you, Caroline, for joining us. I've i've enjoyed you for having me. You guys are such a dynamic duo. I love this.
00:41:27
Speaker
No, I love this group. I love it. So it was really good to see you, Caroline. Thank you so much for for being here. and um You know, again, i have to thank you for being a mentor for me back at MGH and ah helping me helping my find my way here at HPM as well, too. Thank you for being a continued mentor to me, Alex, and for the enthusiasm behind this work. This has been just such a fun project to work on together, and I'm i'm really excited to to see what happens next.
00:41:51
Speaker
Awesome. Thank you for joining us on the Pallion Podcast. Our outro music today is brought to you by my DJ alter ego, Elias, A-L-A-E-U-S. You can find my content on Spotify and iTunes and other streaming services.
00:42:05
Speaker
This is a snippet from the track, Thinesthesia.
00:42:36
Speaker
Thank you for joining us for the Pallium Podcast, a production of pallium.org.