Career in palliative care (via FM, IM or Anesthesia)

[Dodo]

Med-3 student here thinking about upcoming CaRMS. I'm passionate about palliative care and I would love to make a career out of it. I'm considering an academic position and I'm absolutely determined to acquire extra training to make it happen (+1 yr CCFP(PC) certificate of added competency in family medicine or the new +2 yrs FRCPC palliative medicine subspecialty). However, I'm torn between the different options, any thoughts would be really appreciated!

1) Family medicine (2+1 years): Most palliative care docs are family medicine trained. I consider this option mainly because of the shorter training. However, the 2 yr core residency would be a grind, because I absolutely hate the bread and butter of family medicine clinic. I don't like obs/gyne/peds/derm/MSK/psych and I tend to enjoy a more acute setting. That being said, family medicine residency does include a fair bit of training in palliative care. The goal would be to work full-time in palliative care and avoid doing family medicine completely after residency.

2) Internal medicine (3+2 years): I've always gravitated more towards internal medicine, mostly because it's hospital-based, it involves older, sicker patients who are terminally ill or who benefit from palliative care for their severe chronic conditions. I enjoy studying internal medicine stuff (to a certain degree). I always thought I preferred IM, so I was thinking about doing 3 yrs IM + 2 yrs palliative medicine subspecialty. I then thought about ICU + palliative care (before realizing it would be a horrible lifestyle) or simply pursuing a subspecialty that allows me to do palliative care on a regular basis such as oncology, geri, etc. (before realizing there would probably not be enough palliative care). My biggest issue with this option is that I'm not convinced the extra 2 yrs of training translate into better palliative care. Although anecdotal, I was told by a program director that fam med trained docs tend to do just as good or better than IM in palliative. I'm probably wrong, but this option seems overkill to me.

3) Anesthesia (5+2 years): by far the longest option. 7 yrs sounds flat-out ridiculous. Paradoxically, the skill set is so unique and applicable to palliative care that I think it could still make sense if I'm willing to split my practice between palliative and anesthesia. To me, anesthesiologists are undisputed experts in pain and I feel like their pharmacological knowledge and procedural skills would be ideal for palliative care. However, it's borderline depressing to think about doing 7 yrs of residency if I can get to a similar point in 3 yrs. I did see the profile of a doctor in Yukon who mixed anesthesia with palliative care by doing 2yrs FM + 1yr FPA + 1yr palliative care. Another problem is I don’t like peds and obs. 

[1D7]

I am not a palliative care physician, but I'm wondering what's wrong with the tried and true 2+1 pathway?

1. Doing a full anesthesia residency doesn't make much sense to me if you're going to be doing mostly palliative care. I don't see the palliative care docs around the hospital doing regional blocks or neuraxial anesthesia. Doing years of extra training to be more comfortable with the pharmacologic nuances... you have to question if that is worth those extra years in training (considering you'll be doing CME and learning on the job to some extent).

2. Similar to the above, what specific skills are you looking to gain by doing IM or a IM subspecialty if you are going to be mainly doing palliative care? Sure you'd be more comfortable in the inpatient setting (especially whatever ward you specialize in), but it's not like you're going to be the "oncology-only palliative doctor".

Also going through about double the amount of training does not seem great to me.

[IMislove]

Agreed, 2+1 is the most common route iv seen at my centre and they’re damn well good and competent. Met a +2 IM fellow and they seemed to go that route just because they enjoyed some of the medicine aspects but didn’t want to do IM medicine in their career, but honestly you’re generally a consultant service not MRP. And the people you are MRP of are generally AND and not in an acute setting and not full code. But grain of salt this is just my limited experience of in and outpatient pall. 

[frenchpress]

On 5/22/2023 at 2:26 AM, Dodo said:

1) Family medicine (2+1 years): Most palliative care docs are family medicine trained. I consider this option mainly because of the shorter training. However, the 2 yr core residency would be a grind, because I absolutely hate the bread and butter of family medicine clinic. I don't like obs/gyne/peds/derm/MSK/psych and I tend to enjoy a more acute setting. That being said, family medicine residency does include a fair bit of training in palliative care. The goal would be to work full-time in palliative care and avoid doing family medicine completely after residency.

Do the FM+1. If you are sure you want to do palliative and nothing else in IM, then you will be happy to be done 2 years sooner and will probably have a much more enjoyable residency. There are lots of FM programs that allow you to tailor or don’t have too much of the things you said you don’t like - I spent less than 4 months doing obs/peds/derm/MSK/pysch, and some of that was electives I did by choice. In my program I focused more on hospitalist / critical care / EM, including during my rural rotations. 

There are also many opportunities in FM to do less clinic and more hospital medicine. Have you had any experience doing FM hospitalist? Many of my preceptors, particularly in more rural areas, deal with quite complex medical patients, and this may be an area of FM you actually enjoy.

[Dodo]

Thanks for the comment! The only IM subspecialty I need to rule out before I can confidently say I want palliative care and nothing else is Critical care.

From what I understand, it already involves a lot of palliative care and it’s not uncommon for staff to do both ICU and palliative. My fourth yr electives are 1 month anesthesia, 1 month palliative, 2 months ICU, 1 month Neuro-ICU so it should become very clear if I enjoy it or not.

For FM I did it all in a more rural setting: FM hospital was one of my best experiences, they docs here deal will really complex patients it’s amazing to see, but FM clinic was one of my worst experience. In Quebec, it’s now harder to do pure hospital practice and no clinic.

[hero147]

On 6/11/2023 at 12:44 AM, Dodo said:

Thanks for the comment! The only IM subspecialty I need to rule out before I can confidently say I want palliative care and nothing else is Critical care.

From what I understand, it already involves a lot of palliative care and it’s not uncommon for staff to do both ICU and palliative. My fourth yr electives are 1 month anesthesia, 1 month palliative, 2 months ICU, 1 month Neuro-ICU so it should become very clear if I enjoy it or not.

For FM I did it all in a more rural setting: FM hospital was one of my best experiences, they docs here deal will really complex patients it’s amazing to see, but FM clinic was one of my worst experience. In Quebec, it’s now harder to do pure hospital practice and no clinic.

Critical care isn't a good specialty for someone interested in palliative care but palliative care may be a good specialty for someone interested in critical care if that makes any sense. 

While there is a lot of death and dying in the ICU, there is also a lot of keeping patients alive for the sake of keeping patients alive. If you were originally interested in pallative care, ICU may make you want to throw up inside. 

[Asphalts]

I am not sure if this is something that you care about, but Canada is changing their billing codes for FM+1 vs IM palliative to promote more learners to go through the IM route (obviously with FM getting a decrease in their pay even though both do the same thing).

This is the last year before they implement this billing code change. Not all provinces are following this but I know that BC is definitely changing their billing codes. It seems like you appreciated aspects of IM so you might benefit more from the IM+2 route instead.

Might be something else to consider.