MEASURING THE INTANGIBLES IN HOSPICE AND PALLIATIVE MEDICINE

How satisfying, professionally and personally, is the work performed by hospice and palliative physicians? How stressful? Somewhere in the interface between hours worked, caseload, team functioning, bureaucratic demands, and intimate encounters with seriously ill patients and their families lies a job that can be satisfying, rewarding, and sustainable for the long haul. Hospice and palliative medicine physicians who do experience significant stress often say it’s less from their work with patients who may be dying than from caseload pressures, administrative issues, programmatic growing pains, and the need to fight for recognition and support within their institutions.

Little research exists to quantify how stressful or satisfying hospice and palliative medicine are as careers. AAHPM’s Physician Compensation and Benefits Survey: 2010 Report (see p. 15) was one of the first publications to capture such data. In the survey, respondents were asked to rate how satisfied they were as a physician in the field of hospice and palliative medicine (Figure 1) and whether they would be likely to recommend a career in the field to other medical professionals (Figure 2). The numbers reflect an extraordinarily high level of satisfaction; 96% reported feeling satisfied or very satisfied with their career in the field, and, likewise, 93% indicated that they would recommend the field to another professional. Open-ended comments offered by participants emphasized the personal and professional rewards and satisfaction associated with working with patients with life-threatening illness and their families.

In addition, a 2011 study by David Casarett, MD MA, and colleagues in the Journal of Palliative Medicine (JPM)1 compared job satisfaction among hospice team members and found significant variation between hospices and between disciplines. In general, physicians had higher Survey of Team Attitudes and Relationships (STAR) scores than nurses, chaplains, social workers, or nurses’ aides, reflecting higher job satisfaction.

“When people respond to surveys like these, they look around at their own jobs, at the people around them, and at jobs they’ve held in the past,” Dr. Casarett explains. Physicians in general often report burnout, he says, but hospice care, despite increased documentation demands, additional documentation requests (ADRs) from government claims reviewers, and mandated face-to-face recertification visits, is still a favorable place to work. According to his article in JPM, burnout and job satisfaction are often closely linked; physicians who feel satisfied with their careers are less likely to experience burnout.

Dr. Casarett recently accepted a job as chief medical officer (CMO) for the University of Pennsylvania’s hospice and palliative care program. “It’s a blast. I love it. There’s a huge amount of variety, not a lot of drudge work, and a great mix of opportunities.” The position is half CMO, including time on the hospice unit as well as hospice medical director administrative responsibilities, and half research. “On a personal note, being CMO for a hospice in an academic medical center is the best of the best for me.”

Dr. Casarett does not have data to compare palliative care to hospice as a setting for job satisfaction, but he wonders if physicians doing hospital-based palliative care full time may face more pressures for demonstrating cost avoidance, generating return on investment, and justifying the institution’s support for their work. If palliative care physicians have protected time for teaching, research, and program development, that may provide needed balance, he says. “If they only do consults all day, it can be physically and emotionally draining.”

A growing number of hospice and palliative medicine physicians have both hospice and palliative care responsibilities or may divide their time between multiple agencies or multiple settings such as hospital service, hospice unit, outpatient clinic, skilled nursing facility, or patients’ homes. This could offer the variety cited by Dr. Casarett, but it may also impose schedule-balancing demands. It is widely reported that new palliative care services quickly achieve a level of referrals beyond what was expected, and the shortage of fellowship-trained or board-certified physicians has also been well documented.

“I would not say that caring for dying patients is not stressful. But it’s the work I want to do,” says Sarah Friebert, MD FAAP FAAHPM, who directs the Haslinger Family Pediatric Palliative Care Division of Akron Children’s Hospital in Akron, OH. Dr. Friebert, who advises other palliative care programs through the CAPC Palliative Care Leadership Center at Akron Children’s, says, “Palliative care can be sustainable and rejuvenating, but if you’re constantly fighting for full-time equivalents and no one is listening, no amount of journaling will help with that.”

She finds tremendous personal and professional satisfaction in her work with young patients and their families and says her hospital is supportive of the work she does. But as any program grows, it becomes harder to manage competing demands and to achieve a satisfying work-life balance. Hours are long for many palliative care program directors, but for her, it’s not as bad as when she first started. “It was just me, 24/7/365.”

Dr. Friebert also worries about a new generation of palliative care physicians, who come straight from residency and 1-year fellowships, rather than via mid-life career change. “They are being asked to come in and build programs and be administrative leaders, but with no management or leadership experience. That’s a recipe for burnout.”

Charles Wellman, MD FAAHPM, CMO at Hospice of the Western Reserve in Cleveland, OH, says that although long hours and occasionally unrealistic expectations from patients and families can be stressful, the rewarding nature of the work helps relieve burnout. “There’s immediate gratification because most patients come to you with symptoms that are not fully relieved. If you can take away the patient’s pain, stop vomiting, and relieve dyspnea right away, you’ll earn immediate gratitude from the patient and family.”

As a medical director for VITAS in the greater Philadelphia region, Joseph Straton, MD MSCE, is tasked with growing the program to ensure greater access to hospice services for patients with complex medical conditions. “The main reason my job is so extremely satisfying is that I leave feeling that I have improved our specialty’s ability to address the critically important needs of patients and families that are often left unmet by other areas of the US healthcare system,” he says.

Michelle Weckmann, MD, physician and assistant professor at the University of Iowa Hospitals and Clinics (UIHC), has an unusual background, with board certifications in family medicine and psychiatry as well as hospice and palliative medicine. She dedicates 70% of her working hours to research, with a particular focus on delirium in cancer patients. The rest of her time is divided between hospice associate medical director duties at Iowa City Hospice and staffing the UIHC inpatient palliative care service 4 days a month.

“I’ve always been interested in hospice and palliative medicine,” she says. “I struggled to figure out my identity, but now I’m a hospice and palliative physician who just happens to do research. I wanted to be able to impact more people,” she explains. Research offers more flexible scheduling than her days on service, which can be difficult with two young children at home.

“I’m not sure I could do palliative care in this setting full time. It’s incredibly rewarding—but also exhausting.” It should be possible to work compassionately, without taking on patients’ suffering, Dr. Weckmann says. “But you are exposed to so many raw emotions. Plus, as a consultant, I’m not always able to advocate for what I believe is best for the patient, because that’s not what the referring physician wants, and that doctor, ultimately, is my client,” she points out.

“I have the privilege of working with patients at very intimate times in their lives and asking them very intimate questions. It’s a source of awe and wonder that people let me in. It’s a huge responsibility, but the fact that I can come in at these times and potentially make things better for them is incredible,” Dr. Weckmann says. “Having that attitude can make this work incredibly rewarding, not stressful. Yes, some patients really touch me, but it makes me cherish the things I have in my life.”

AAHPM’s Compensation Survey Offers Career Exploration Tool

Certainly, one component of job satisfaction in any field is compensation. For physicians who are actively exploring career options, AAHPM’s recent Physician Compensation and Benefits Survey2 provides the most comprehensive data on salary and benefits, time commitments, and other facets of hospice and palliative medicine work, including regional variations. It compiles data from nearly 800 physicians who responded to the November 2010 survey.

These data are extremely helpful when making an argument for matching market salary data in the field, says Greg Sachs, MD, professor of medicine and geriatrics and chief of the division of general internal medicine at Indiana University School of Medicine in Indianapolis, IN. “The compensation survey provided data we were desperately seeking, as both the school of medicine and our physician groups are using external benchmarks quite explicitly in determining physician compensation. Other surveys to which our administration routinely turns simply do not have adequate numbers of respondents in palliative care to give one any confidence about their figures. Having the AAHPM ‘stamp of approval’ provides additional credibility.”

Likewise, the data can help program directors determine appropriate title and salary information based on averages in the field, says Tim Cousounis, a consultant with the DAI Palliative Care Group in greater Philadelphia, PA. “The survey can be helpful for users considering professional changes, because it gives some idea of job titles— the sorts of positions that are out there.”

Cousounis, who has helped place physicians in hospice and palliative medicine positions and consulted with agencies on strategic planning for physician staffing needs, finds a high sense of professional satisfaction among this group of doctors. “What keeps it from being an enormously desirable job are factors such as workload and schedule, sometimes ill-conceived positions, and a lag between the need for additional positions based on program growth and bringing new physicians on board. On the hospice side, there can be some role drift, since agencies aren’t always adept at utilizing physician resources or even understanding what the role entails,” he says.

“This field is still young and still attracting the best and brightest because of its extraordinary professional rewards. But for the field to continue to grow, these issues need to be addressed,” Cousounis says. The degree of control or autonomy over a position often is a key factor in job satisfaction, while on-call responsibilities, which can be a heavy burden, are a major dissatisfier. “I also wonder if the fact that compensation is generally lower than for other medical specialties outside of geriatrics may be a dissatisfier. But physicians who go into this specialty are drawn by other factors. They know full well what the compensation is like, and they aren’t driven professionally by compensation.”

Stephen Bekanich, MD, medical director of palliative care services at the University of Miami Miller School of Medicine, offers himself as a real-life example of using AAHPM’s compensation survey data to help plan his next career step. He loves his job, but moving from Utah to Florida 2 years ago was quite a culture shock. “Things have gone remarkably well for me here. If anything, I feel overly appreciated at work.”

Dr. Bekanich believes HPM physicians’ compensation, generally, is at a reasonable level, “especially given that the bean counters don’t always see our value proposition the same way we do.” He finds it in the ballpark relative to sources like the Medical Group Management Association’s Physician Compensation Survey.3 “I’ve had a tremendous opportunity here in Miami to build palliative care from the ground up, with protected time for research, teaching, and program building. That, to me, is more important than a salary dollar amount,” he says.

“I think a lot of people who go into palliative care have a personality type where they want to be innovators. It’s still a fledgling specialty, not firmly established in the way, for example, cardiology is. But to see the changes we achieve as time goes on—it’s incredibly exhilarating.”