There are many paths to a career in pediatric hospice and palliative medicine, and one physician’s day may look very different from another’s day. To answer this question, we reached out to the group of our colleagues to comment and share their “typical” day.
Dr. David Korones, MD, University of Rochester Medical Center, Rochester, NY, 2017
I am a pediatric hematologist/oncologist and also practice pediatric and adult palliative care. I guess I would be considered senior in my career, although that is hard to believe because I feel like I just started and I continue to be humbled by things on a daily basis. My time is approximately 50% pediatric heme/onc and 50% palliative care. One of the things I like about my typical “day in the life” is that there is no such thing as a typical day, and no matter what hat I’m wearing, the other hat comes into play. So as I see my pediatric oncology patients, I try to integrate palliative care, and plenty of my palliative care patients are struggling with cancer – it all speaks to how tightly integrated and intertwining it all is.
It is easier to describe a typical week than a typical day: Mondays – Fridays I spend a few hours with our inpatient pediatric palliative care consultations, Mondays I have an adult palliative care clinic, Tuesdays and Wednesdays I work with a community-based pediatric palliative care group and make lots of house calls, which is lots of fun (more overlap and integration, as many are my oncology patients), Thursdays is my pediatric hematology/oncology clinic (more overlap because many have palliative care needs), and Fridays are my day of rest (sort of). This all changes when I attend on the pediatric heme/onc inpatient or adult palliative care inpatient rotation (about 12 weeks a year). It’s all fun and I wouldn’t have it any other way!
Dr. Sirisha Perugu, MD, Children’s Hospital of Orange County, Orange, CA ,2017
I completed my Neonatology fellowship 4 years ago and work with a group that covers a busy academic children's hospital and other peripheral NICUs. I obtained palliative care certification and training just last year and currently limit myself to only the children's hospital and another hospital with busy perinatology service. My day at work is rounding with pediatric residents and fellows on complex NICU patients. I initially started a palliative care program and Q/I development in my personal time but am now clarifying administrative or research time definitions.
I still believe that there is now more recognition for the value that a neonatologist/critical care doctor with advanced training in palliative care. I do round on medically and ethically complex patients and teach skills like family conferences and processing of care integration on the job. I did spend a lot of time and effort in team building and education so there is always someone in addition to my nurse practitioner to bridge my absence. Day-day patient and family care, team leadership and my own job/personal satisfaction seems so much more enriching with the enhanced knowledge and skill sets from PC education and training. I think I am still "midlevel"/"young" on a career time span trajectory but believe that there will be more exciting and academically solid years ahead for future trainees also.
Dr. Kris Catrine, MD, Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN, 2017
I'm on a combined pain/palliative care service. We come in around 7, divide up the inpatient service between the available providers (MD and APRN) and pre-round by computer until 8. We meet as a team at 8 and review the patients on the list, then see our patients for the rest of the day. We see anywhere between 5 and 8 patients on a typical day inpatient including consults, more on weekends.
I have a clinic day once per week, slots are also used for home visits (telemedicine starting shortly) and I may see 1-3 inpatients if the clinic isn't full. I am on call one night per week and 1 in 5 weekends. Weekends are busy as most patients are rounded on and the others managed by phone if needed, average Saturday is usually 6-15 patients seen.
For palliative care we see anything from symptom management to medical decision making conversations to running compassionate extubation or compassionate removal from ECMO. I work on a multidisciplinary team inpatient, outpatient and in our home palliative and hospice programs. We meet weekly to review management of the patients in the home programs. I'm on service daily, with a half day off per week.
Dr. Elaine Morgan, MD, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, 2017
I attend on Hem/Onc and Palliative Care. I do not do simultaneous inpatient service on the two services and so spend close to 40% of the year on an inpatient service somewhere. Our Palliative Care inpatient is currently a consult service, so when we are on, we are coordinating with residents and staff on multiple services. We are hospital based and provide oversight/consultation for two outpatient palliative care/hospice organizations who care for the majority of our patients.
For palliative care I have morning meetings with the peds residents (not pall care related) and clinic two days a week. On those two days, rounds and consults happen later in the day. On non-clinic days I try to round in the mornings. Our inpatient census can vary from minimal to up to 10-12 in general. Likewise inpatient consults are not predictable and we have as few as none to as many as 4-5 on a given day. We try to see those patients same day or within 24 hours if there are no pressing needs.
We confer with our outpatient colleagues about patients every two weeks. We also have palliative care educational and program meetings twice weekly and attempt to provide resident teaching several times a year. We are on call when we are on service plus one weekend every three to 3.5 weekends. We may have no night calls or on bad nights multiple calls and occasionally have to return to the hospital at night. We generally round once daily on the weekends.
Outpatient consults are not predictable as well and tend to happen in coordination with other general and specialty appointments, sometimes are scheduled in advance but in general timing is not within our control.
Dr. Norbert Weidner, MD, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, 2017
Arrive at work 6:30ish and finish any remaining notes from the prior day, and work through email. Morning rounds 7 to 8 am. Hospice interdisciplinary team rounds on Monday mornings every week til 9:30am. Round on assigned patients through the morning to early afternoon. Spend time speaking with patients and their families and connecting with collaborating MD during joint rounds or following their rounds. Afternoon may involve formal appointed meetings with collaborating MD or jointly with primary MD and patient/family in conferences to sort through goals for care, ethical issues, conflict, etc. Pending the situation, I will see outpatients in subspecialty or palliative clinic scattered in morning and afternoon. Depending on the day there may be scheduled home visit either in afternoon or early evening. Teaching of med students, residents rotating on service, and fellows is at point of care.
The variety in these responses illustrates the breadth and depth of possibility in the field of palliative medicine. Many PHPM physicians divide their time between palliative care and other specialties: general pediatrics, hospital medicine, complex care, hematology-oncology, intensive care, neonatology, anesthesia, and so on. Some physicians divide time based on weeks of one service line versus another, while others integrate palliative care consults into their days serving in other areas.
Many patients cared for in pediatric hospitals are eligible for palliative care, but not all programs care for the same populations of patients. Some teams focus a great deal on pain and symptom management, in addition to other responsibilities, while other teams are not invited to consult for this purpose. Some teams are consulted to assist in evaluating patients for solid organ transplant, others are consulted in all patients receiving bone marrow transplants, and yet others are not involved in caring for children in either population. Many of these differences are reflective of institution-specific practices and structures. Many PHPM teams work with institution leadership to develop department-specific diagnoses and conditions for consults. Most palliative care teams have close relationships with hospice organizations nearby. Some PHPM physicians serve as the medical director of the pediatric arm of a hospice; some pediatric hospitals directly provide pediatric home-based hospice and palliative care through their affiliated homecare organizations. Palliative care teams in those institutions are typically intimately involved in caring for patients who are receiving home-based hospice and palliative care through the institutional program.
There are commonalities to differing palliative care programs; here is a list of general activities a given team may encounter in a day:
- Complicated pain and/or symptom management
- Evaluating goals of care with a family
- Assisting families as they define quality of life
- Evaluating and recognizing the importance of spirituality
- Coordinating care between multiple hospital-based teams, primary care doctors and home health care
- Improving communication between teams and families
- Leading or participating in care conferences
- End of life care, advance directives, DNR orders
- Hospice care
- Bereavement support and follow up
There is some truth to the aphorism, “If you have seen one pediatric palliative care team, you have seen one pediatric palliative care team.” But spending time with any PHPM team in an elective rotation can offer you critical insight into how all teams care for a variety of patients! For this reason, we recommend that any resident considering a career in PHPM seek to spend time with a palliative care team, either in their institution or on an away rotation. If your institution does not offer a palliative care rotation, consider reaching out to adult palliative care teams in your area or to programs with palliative care fellowships. Most programs that offer fellowships also offer elective rotations for residents.
Academy of Pediatrics