Thursday, January 22, 2009
Palliative Medicine Board Certification Numbers
The American Academy of Hospice and Palliative Medicine and ABIM released the final test taking numbers for the first round of official accredited boards for HPM. Now we are all just waiting on them to release the actual board scores. Some interesting findings from the demographics of the 1,455 test takers.
Internal Medicine -892
Family Medicine - 400
Pediatrics 52
Psychiatry/Neurology -30
Anesthesiology -22
Radiology - 17
Emergency Medicine - 12
Surgery - 12
Obstetrics and Gynecology - 9
Physical Medicine and Rehabilitation - 9
So one big question I have about some of the less represented specialties is: are these mid career changes and these doctors are now doing strictly palliative medicine or are they still practicing radiologists, surgeons, etc and are adding palliative medicine to their repertoire? If you are from psych, neuro, anesthesiology, radiology, EM, surgery, OB/GYN, or PMR please comment and help the rest of palliative medicine understand what drew you to the field. I would like to see a much larger representation across the specialties, but with fellowship becoming the sole pathway to a HPM board certification in the future, the chance to establish foothold in the other fields is diminshing.
Looking at these numbers and comparing to rough estimates of work force can give us an idea of what the saturation of palliative medicine is within each specialty.
The Bureau of Labor and Statistics estimates about 633,000 physicians employed in 2006. Here are the following reordered breakdown of physicians by specialty (approx) with the number of HPM physicians in each. (1 HPM physician out of x specialists)
Internal Medicine (ABIM) - 177,000 - 1 out of 198
Family Medicine (AFP) - 100,000 - 1 out of 250
Physical Medicine and Rehabilitation (AAPMR) - 8,000 - 1 out of 888
Pediatrics (AAP) - 90,000 - 1 out of 1730
Radiology (ACR) 32,000 - 1 out of 1882
Psychiatry/Neurology (ABPN) - 46,000 & 13,000 - 1 out of 1966
Emergency Medicine (ABEM) - 34,000 - 1 out of 2833
Surgery (ABS) - 55,000 - 1 out of 4583
Obstetrics and Gynecology (ACOG) - 52,000 - 1 out of 5777
Anesthesiology (ABA) - unable to access ABA
(Here it is as a spreadsheet if you want to copy the numbers)
What are your thoughts on this distribution?
25 Responses to “Palliative Medicine Board Certification Numbers”
January 22, 2009
I wonder how many of those in internal medicine were once intensivists?
January 23, 2009
ABIM notes around 6800 valid certificates for critical care docs and 11,000 pulmonary docs certified.
I am guessing there are not a ton even though the fields of palliative medicine overlaps greatly with critical care medicine, mostly because of some of the certification requirements (fellowship or experiential).
January 23, 2009
Anonymous
I am gynecologic oncologist who sat for the boards to broaden my scope of care and to help heal my soul. I take care of a lot of young dying women and their families.
I would like to know that I passed the exam- but it doesn't even matter. This made me a better doctor and family member.
I will advocate that palliative care principles be integrated at all levels of patient care and medical training.
January 23, 2009
Anon Gyn/Onc,
Thank you so much for your comment. Do you have any insights into why palliative medicine certification is not pursued by more gynecologic oncologists? Is it about time commitment, goals, or something else?
Would you care to share how you 'found' palliative medicine so we might better understand how 'non-traditional' disciplines might get improved access to palliative care training?
Thanks so much,
Christian
January 23, 2009
It is a little frustrating the boards scores have not come out yet. But it is the first time around so maybe they are working out some kinks.
January 24, 2009
During my fellowship the care of pre-terminal patients fell to the fellow- the least qualified person- b/c the attendings could not handle their emotions. I learned fast- under fire. My previous background in psychology (BA) and work in HIV/AIDS (post BA)-helped. I landed a job caring for mostly advanced cancer cases (poor urban center). There I met some palliative care folks some years later and they helped me.
There are times that I do feel conflicted. When is enough, enough? I have been told that it's when the patient says it is. But
I am painfully aware of the coercive power of the white coat- and sometimes wonder.
Of note, one of the keynote speeches at our annual conferences this year is on palliative care.
This is a radical change from training, now almost 13 years ago, when I was told that we "failed" the patient at each death.
January 24, 2009
above posted by anon gyne/onc-duh
January 27, 2009
Looking at these numbers I wonder what the future of HPM as a physician profession will be in the US, after the non-fellowship trained generations go on. Essentially up until now HPM boarding has been more of a certification that anyone can get. Well not anyone, and this is not meant to imply there weren't rigorous standards, but that a doc (e.g. gyn-oncologist, anesthesiologist pain doc, etc.) who mostly practice their primary specialty but who have a special interest in HPM could get board certified). Now that fellowship training will be mandatory (in a few years) how many people will go through an extra year of low-pay training for HPM boarding if they aren't particularly planning on practicing in HPM-specific settings (again this is not to imply that HPM-competencies aren't critical to a variety of care settings but to do an extra year of training for it when there aren't easy-to-integrate practice models out there which make sense from a payment standpoint etc.). Mostly what I'm saying I guess is I'm curious as to what practice models will evolve for these 'non-core' specialtists who aren't doing HPM practice full time or even part time but who seek HPM training and board certification. From a career and reimbursement standpoint HPM is a relatively competitive/attractive field for internists, family docs, pediatricians - it seems less so for anesthesiologists, EM docs, etc. I'm sure many people will make it work, I'm just curious as to how, and if there will be sufficient numbers for it to continue to be a viable career path....
January 27, 2009
Drew's point/query about the attractiveness of palliative medicine as a practice track for future docs is indeed THE QUESTION those of us working to advance the field must give serious consideration. As I see it right now, there does NOT exist a practice model (one that can be replicated anywhere)that enables a physician to sustain a free-standing, autonomous, full-time practice in palliative medicine.
I don't expect $150,000 salaries to serve as a hospice medical director will be enticing to future medical school graduates, especially when a fellowship is required.
January 27, 2009
Hi Tim good to hear from you. Well while we're on the topic do you have any reliable sources for what HPM docs are actually making out there. Like it or not, it is a consideration for people entering the field, and while I know what I earn and what some of my former fellows were offered, I get questions from residents/potential fellows about what people actually earn and I have no clue what to say. These are internists usually and I usually say, based on impressions I have, 'somewhat comparable to general medicine, can be somewhat more at times, but depends of course on region, academic vs. private, size of organization, etc.' Clearly though I don't know. Tim, given what you do, I'm sure you have a lot of insider info but I'm wondering if you know of any public reporting of salaries. In the interests of enticing future generations of HPM docs, I'd like to know.
W/r/t the problems with docs establishing autonomous practice (by which I assume you mean sustainable by billings as opposed to underwritten by a hospital/health care organization or salaried by a hospice) - it worries me a little too. If the floor falls out from the cost-savings model which most hospital based palliative care services are based on (falls out due to budget cuts and short-sightedness or whatever) we are royally screwed. There seems to be so much momentum for us right now that this won't be an issue for a long time I think but what about 20 or 30 years from now when we're a mature profession? I'd like to think we'll have a 'rational' health care system then in the US by then and this won't be a problem but, you know, who the hell knows. Maybe I'll go begging Canada way where the pay will be more modest but the work will be valued by stake-holders.
January 27, 2009
First off - Thanks Anon Gyn/Onc for your insights. it is good to hear palliative care being a keynote level talk at your annual conference.
Drew & Tim,
I agree that the salary/reimbursement issue is a difficult one to sort out for our field. I know of two surveys about HPM salaries. One by MGMA which is utterly complex and somewhat confusing and did not seem really applicable to HPM practices. I have not heard of anyone speaking of the results of this survey launched with the support of the AAHPM last year.
And the second one was by Bob Arnold out of Pittsburgh about three years ago, but I did not hear if that got published or passed around. One of the issues in completing that survey was the lack of clarity if as a reward for giving your information you would actually be given the results of the entire survey.
Maybe we need to do another one here at Pallimed? Informal yes, but it might get us all an idea.
Since no one is willing to say numbers I will go out on a limb and say I have heard from low 100k's to above 200k's With most of the higher end salaries being people who had transferred from another high paying speciality and 'kept' their rank so to speak. Most recent offers I have heard have been in the 130-180 range again depending on the location of care with community based hospices being on the lower end and thriving palliative care hospital based practices being on the higher end.
So this jibes with Drew's statement about it being attractive to IM, FP, Peds, but maybe not traditionally higher paying specialties.
i too worry about the future of palliative care solely based on the cost savings model since an efficient and well integrated palliative care team is eventually not saving any money anymore once it becomes the norm. And the interdisciplinary nature naturally leads to a higher human capital outlay which could be exposed in times of less economic certainty.
something I plan to post on in my top 5 series of issues in HPM!
January 28, 2009
We should all be concerned about the future of palliative care solely based on the cost savings model since an efficient and well integrated palliative care team is eventually not saving any money anymore ONCE IT BECOMES THE NORM.
Indeed, that's the key issue. If such a team is expected by the hospital to save money, then could the team members reasonably expect to receive a portion of the cost savings for doing their job? I wouldn't think so.
On the compensation issue,the reason that you haven't heard anything about the MGMA study on salaries for HPM is that there were literally only a handful of responses. Not surprising for a number of reasons, which we could discuss at a later time. Over the past five years I've been compiling and updating compensation data for full-time palliative medicine physicians, and making the info available to our clients as part of our consulting engagements. I have not made it available as a standalone product, but I'm in conversations presently with AAHPM to make it available to the membership at a heavily discounted rate.It is compiled by our research group largely from documents filed in the public domain and from self-reported information by our clients. My foremost objective is to do my small part to help the field of palliative medicine advance, so I'm not looking to make money on this, simply to recoup our time in compilation and preparation. I'm curious what the readers of this blog would be willing to pay for a compensation report. $100, $500, $1000. Not a cent?
January 28, 2009
"There seems to be so much momentum for us right now that this won't be an issue for a long time I think but what about 20 or 30 years from now when we're a mature profession?" Drew, there are some who say that the profession reached maurity when it was recognized as a subspecialty. Let's not forget that physicians have practicing HPM for more than 15 years (albeit not as a recognized subspecialty, but ceertifed and practicing nonetheless), and there have been a few full-time devotees going back to the origins of the hospice benefit nearly 30 years ago. And surely there is momentum, but is that momentum propelling the field in the right direction? Other than geriatrics, I can't think of another field (OK, maybe occupational medicine)in which the practitioners must "petition" executives to support a practice and attendant program/service. I content that we need to be more creative in the practice models we establish, until primary care regains its rightful place in the reimbursement scheme of American medicine. But I digress here. We can discuss why primary care is in shambles at another time, if there's interest.
Tim Cousounis
DAI Palliative Care Group
January 28, 2009
TC to answer your question I guess I was hoping for a freebie. Zing!
Anyway I can't say I argue with your point that maybe 20 years is too long. I'm worried that what is happening with geriatrics in many places will eventually happen to us, too, and certainly lack of reimbursement for the time-intensive nature of what we do is the big issue. I know smarter and savvier people in the academy and elsewhere are working on this....
January 28, 2009
Regarding those in Radiology. I doubt if any are diagnostic radiologists. They are probably all like me, a radiation oncologist. You may not be aware but radiation oncology still alligns itself with the American Board of Radiology for clout. Radiation Oncologists who practice quite a bit of palliative medicine everyday were given the opportunity this year to sit for the board exam in palliative medicine without going through a fellowship...
January 28, 2009
Anon that's interesting. I had always assumed there were different boards and that those radiologists taking the exam were part of the new breed of interventional oncologists (interventional radiologists who do mostly cancer related procedures - chemoembolization, palliative/analgesic procedures, etc.)....
January 30, 2009
As an anesthesiologist I felt stuck in a rut in the OR. My favorite workdays were those where I was out and about a bit, doing procedures in the pain clinic, placing labor epidurals, basically days where I saw some daylight instead of being in those 4 OR walls from sun up til sundown.
An opportunity to become medical director of a home hospice fell into my lap about 5 years ago and I ran with it never looking back after I resigned from my private practice group. I was able to use skills I hadn't used in years, and thrived on the deep conversations I was able to have with patients and their families. My experience in pain management that I brought from the OR and pain clinic was invaluable. I now am also the medical director of a freestanding hospice house, and love blending my experiences from various settings into delivering care in the inpatient hospice setting.
It is a big paycut to leave the field of anesthesiology entirely and pursue hospice and palliative care. Few are likely willing to do it. Fortunately, I am not the only breadwinner in my family, and was able to pursue my goals despite less pay. It would be great to have more of a representation from the field of anesthesiology. I am one of the 22 anesthesiologists who took the board exam last October and am anxiously awaiting results!
January 30, 2009
I am one of the OB-Gyns who took the board exam (and where are those results?) My story's a bit different--I have MS and left my ob-Gyn practice after 18 yrs. I have lost most of the feeling in my hands and that's not good for an obstetrician or a gynecologist.
The death of a friend in the hospital coincided with Bill Moyer's “On Our Own Terms” and I realized there was another way. I set about getting educated (including a stint at Harvard's wonderful PCEP program) and then did “stealth palliative care” at my hospital as I spent the next four years trying to convince the powers that be to start a palliative care program. Along the way, I continue to grapple with the loss of my beloved profession, and I think this helps me in my work.
We started in August 2006 with a full time PA/MSW and me at half time. We survived an attempt to cut us when we finally got them to do the proper financials and were able to show we saved the hospital $500,000 in 2007.
Of course we remain anxious in these “uncertain economic times.”
I got my board certification from ABHPM but decided to take the ABIM exam because I still have to prove that I'm not just an OB-Gyn playing at palliative care.
From beginning of life to end of life--all part of the cycle. As I often tell the families of my dying patients--waiting for a death is a lot like waiting for a birth. You know it's going to happen, you just don't know exactly when.
January 31, 2009
I would second the comment made by the previous radiation oncologist - the majority of physicians who stated they were radiologists who sat for the palliative boards are in fact radiation oncologists. I chair the multidisciplinary tumor board at my primary institution, and sit in on many of the palliative medicine teams consult discussions.
As a radiation oncologist, I was contacted by the chair of hospice and palliative medicine and informed that I may qualify to sit for the exam. upon researching the exam, I ran across an article in the red journal (International Journal of Radiation Oncology * Biology * Physics) by Stephen T. Lutz M.D. This article urged radiation oncologists to become more involved with palliative medicine and to sit for the boards.
I do not plan on directly changing my job description to become a categorical palliative medicine physician, rather I think that by putting the effort in to study for this exam it has made me a better radiation oncologist.
As the days pass I find myself anxious to learn the results, but I am of the opinion of the first gyn oncologist to post in this thread - just to study and to take the the test has helped me become more involved with palliative medicine and hopefully a better physician.
January 31, 2009
To the radiation anons - thanks for piping up and correcting my misconception that rad oncs weren't taking the hpm exam. And to the last one I think the needs go two ways - rad onc docs need HPM skills, and it is as good of a mix of skills as anything in medicine - but HPM clinicians need radiation oncology knowledge and there's been a trickle of research over the last few years (both in US and Canada) about the knowledge gap in, for instance, hospice medical directors about indications for palliative (analgesic) radiation, etc. Not to speak of the barriers to access as well.
Anyway...I'm excited by the number of (if you'll excuse the phrase) non-core specialists commenting on this post (and it's nice to know you're reading the blog!), and perhaps my worries about the sustainability of other specialities in HPM are premature....
February 01, 2009
I thought the Palliative Board results were due within 3 months of the Oct 29th test date. Anyone have any info?
Hospice Medical Director
February 01, 2009
In response to questions about the non-core specialists who sat for the boards. Cancer rehabiliation is a growing subspecialty within PM&R as well as a main topic on the written and oral boards for PM&R. Cancer rehabilitation is loosely divided into "sports medicine" for people who have been treated for cancer but are largely free of active disease although they may have impairments such as lymphedema, cancer related fatigue, amputations, pain, etc. The other area involves maintaining functional independence for people with progessive disease including end of life. Success in this area requires deft integration of physiatric interventions and knowledge with the princeples and practice of palliative medicine. The purest example of this probably occurs when we admit patients with advanced disease to our inpatient rehabilitation unit for family training prior to discharge home on hospice. Standards of PM&R such as transfer training, bowel and bladder programs and pain management have to be adjusted for the specific disease process and the psychosocial needs of the family which are different from say, the family with the teenage quadripalegic SCI patient.
February 03, 2009
My colleague took the exam along with me, and called the ABIM about why the delay in results. She was told that it might be another 2 weeks they want to ensure the results are "fair." I thought the test was challenging. I also re-certified for internal medicine in May and that test was a breeze in comparison. I suspect people did not do as well as they expected and they are trying to decide where to put the cutoff.
March 27, 2011
My colleague took the exam along with me, and called the ABIM about why the delay in results. She was told that it might be another 2 weeks they want to ensure the results are "fair." I thought the test was challenging. I also re-certified for internal medicine in May and that test was a breeze in comparison. I suspect people did not do as well as they expected and they are trying to decide where to put the cutoff.
March 27, 2011
I would second the comment made by the previous radiation oncologist - the majority of physicians who stated they were radiologists who sat for the palliative boards are in fact radiation oncologists. I chair the multidisciplinary tumor board at my primary institution, and sit in on many of the palliative medicine teams consult discussions.
As a radiation oncologist, I was contacted by the chair of hospice and palliative medicine and informed that I may qualify to sit for the exam. upon researching the exam, I ran across an article in the red journal (International Journal of Radiation Oncology * Biology * Physics) by Stephen T. Lutz M.D. This article urged radiation oncologists to become more involved with palliative medicine and to sit for the boards.
I do not plan on directly changing my job description to become a categorical palliative medicine physician, rather I think that by putting the effort in to study for this exam it has made me a better radiation oncologist.
As the days pass I find myself anxious to learn the results, but I am of the opinion of the first gyn oncologist to post in this thread - just to study and to take the the test has helped me become more involved with palliative medicine and hopefully a better physician.
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