Welcome to the Hospice and Palliative Care Program Fellowship at the National Institutes of Health Clinical Center, America's research hospital.    

• Program Overview
• Rotations
• Sample Schedule (60 KB)
• Program Curriculum
  • Patient Care
  • Medical Knowledge
  • Practice-based Learning and Improvement
  • Interpersonal and Communication Skills
  • Professionalism
  • Systems-based Practice
• Research
• Career Paths
• Eligibility
• Ideal Candidate
• Application Process
• Faculty

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This fellowship program is designed for candidates who have clinical or academic career goals in hospice and palliative medicine. The fellowship program's home is in the National Institutes of Health (NIH) Clinical Center, a 240-bed research hospital dedicated to translational clinical research, and its core off-site rotations in home hospice, long-term care, and in-patient hospice are offered through the historic Washington Home and Community Hospices. This fellowship program has seven educational objectives:

• Develop and train experts in hospice and palliative medicine
• Teach and model communication and collaboration skills
• Develop and demonstrate clinical scholarship in hospice and palliative medicine
• Foster an understanding and expertise in pain and palliative care research
• Foster and exemplify professionalism
• Model advocacy for patients and families
• Model and teach systems-based palliative care practice

This one year fellowship program offers training that leads to board eligibility in Hospice and Palliative Medicine. In addition to didactic teaching, fellows receive broad, practical experience in palliative medicine and hospice care through inpatient and outpatient rotations at the NIH Clinical Center, and through clinical experiences in home hospice, inpatient hospice, and long-term-care hospice rotations at affiliate training sites. The fellowship includes a four-week elective clinical rotation. Fellows are expected to demonstrate academic proficiency either through literature review, a peer-review quality journal article, a book chapter, or other professional writing project, or a limited and closely-mentored research project. Fellows participate in ongoing quality improvement projects supported by the NIH Pain and Palliative Care service to learn the methodology of improving systems of care.

Fellows gain palliative medicine expertise as they provide consultations for medical, psychological, and spiritual problems and coordinate team-based, holistic integrative approaches in the NIH Pain and Palliative Care Service. Palliative care services are provided to adults and children through multiple settings, including inpatient wards, outpatient clinics, and day-hospital clinics. NIH patients are research participants, many with commonly encountered medical problems, including cancer of all types as well as heart, renal, genetic, infectious, and neurological diseases. Rare diseases are also encountered. This combination allows for a unique clinical experience for the fellow, rich in research opportunities in addition to “hands on” patient care.

Fellows work within an interdisciplinary team that includes members from spiritual ministry, social work, recreation and art therapy, massage therapy, acupuncture, bioethics, psychiatry, nutrition, and pharmacy. Fellows participate in consultative services that guide the direction of palliative care, and participate in the interdisciplinary care of patients and families. Weekly patient management conferences and seminars provide medical knowledge in patient management and pertinent research topics. Fellows learn to expertly explore and discuss psychosocial and spiritual issues through didactic and experiential learning exercises. Fellows are exposed to and learn about complementary healing methods such as movement therapy, relaxation therapy, hypnosis and biofeedback, guided imagery, spiritual therapy, healing touch and Reiki, and art and music therapy.

Community-based rotations occur in home hospice, long-term-care hospice, and inpatient hospice settings through participating sites at the Washington Home and Community Hospices of Washington. Community Hospices of Washington is a Medicare-certified health care organization that provides multidimensional supportive care for patients with end-stage conditions. This holistic care includes a full range of services to meet the medical, emotional, and spiritual needs of patients and their care-givers. Fellows receive a stipend based on the salary guidelines of the National Institutes of Health.

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Fellowship Rotations are structured in four-week blocks and include:

Palliative Medicine Consult Service
The National Institutes of Health: 8 blocks
During these four-week rotations at the NIH Clinical Center, fellows learn comprehensive and effective palliation of symptoms and treatment of physical, psychological, emotional and spiritual suffering for individuals and families with advanced conditions that limit or threaten life. This is achieved through well-rounded and thorough education in symptom-management techniques; effective team facilitation; knowledge and effective utilization of various components of the health-care system for patients facing life-threatening conditions and complex psychosocial and medical needs; and knowledge of and development of effective management strategies for suffering due to existential and spiritual suffering. Fellows participate daily in inpatient consultative palliative care on a very active consult service under close faculty supervision; twice-weekly outpatient clinics with an emphasis on continuity of care; interdisciplinary team meetings; and regularly scheduled didactic training.

Home Hospice Care & Administrative Hospice
Community Hospices of Washington: 1 block
The fellow participates in hospice medical visits in patients' homes with supervising faculty, nursing, social work, and chaplains, to foster an understanding of the unique roles of each of these team members in patient- and family-centered plans of care. Emphasis is placed on attaining skills for assessment and management of end-of-life symptoms addressed in the home setting, where advanced medical technology is commonly absent or limited. Fellows also learn to assess hospice appropriateness and learn the hospice medical director's role in leadership, education, administration, and collaboration within the interdisciplinary hospice team. Fellows also learn to facilitate hospice interdisciplinary team meetings and participate in all clinical educational activities.

Long-Term Care
Community Hospices of Washington: 1 block
Fellows primarily conduct medical consultations for patients in long-term care facilities under faculty supervision to gain skills in assessing and managing symptoms associated with advanced illness and multiple comorbidities for patients in long-term care facilities. This rotation teaches fellows how to work within and coordinate with health care teams at long-term care facilities and to evaluate needs for health care services in these settings. Fellows participate in interdisciplinary team meetings where they learn to facilitate medical care across settings of care and throughout trajectories of illness.

Inpatient & Administrative Hospice Care
Washington Home: 2 blocks
Fellows participate in the inpatient hospice management of patients during this rotation to provide aggressive symptom management for uncontrolled symptoms at the end-of-life such as pain crisis, malignant bowel obstruction, refractory nausea, delirium, and non-pain symptoms that cannot be managed in an outpatient hospice setting. Fellows also participate in the end-of-life care of actively dying patients in this inpatient hospice unit. Care is supervised by mentoring faculty at an inpatient hospice hospital which has 24-hour nursing, nursing assistants, patient care volunteers, social workers, chaplains, dietitians, and physical therapy. Fellows learn to deal effectively with the ethical and practical issues around palliative sedation for refractory symptoms, rapid opioid titration, and care coordination across settings. Fellows participate in and facilitate interdisciplinary team meetings on all patients. Fellows learn to expertly facilitate goals of care discussions and family meetings in end-of-life situations. Fellows also learn the administrative responsibilities of the hospice medical director and are mentored in regulatory and administrative tasks commonly encountered in hospice medicine.

Elective Rotation
Consult Liaison Psychiatry, Physiatry, or Research: 1 block
This elective rotation is designed to enhance didactic and experiential learning objectives unique to the individual fellow. A broad range of settings and experiences facilitate individualized learning goals.

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Our program is designed to develop the following competencies at or above the level expected of a new Palliative Care practitioner.

Patient Care
Fellows learn to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows are expected to develop a strong knowledge base of hospice and palliative medicine, including:

• A comprehensive understanding of the clinical problems and symptoms of advanced disease and effective strategies for their management.
• The ability to systematically gather comprehensive clinical information and manage complex symptomatology, including physical, psychosocial, and spiritual domains of suffering in patients with palliative care needs.
• Patient care skills that demonstrate respectful attention to age, developmental stage, gender, sexual orientation, culture, belief system, and physical disability.
• Appropriate methods for assessing prognoses and disease trajectories and strategies and communicating these to patients and caregivers.
  

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Medical Knowledge
Fellows learn to demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Fellows are expected to:

• Identify the roles and boundaries of palliative care and hospice interdisciplinary teams and members.
• Understand the psychological stressors and disorders experienced by patients and families facing advanced or life-threatening conditions.
• Demonstrate expertise in the mechanisms and best management strategies for common symptoms encountered in advanced life-threatening illnesses.

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Practice-based Learning and Improvement
Fellows learn to evaluate their own patient-care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Fellows are expected to:

• Maintain safe and competent hospice medical practice, including self-evaluation and continuous learning.
• Access, analyze, and apply the evidence base to the clinical practice of palliative and hospice medicine.
• Demonstrate competencies as an educator of palliative medicine and hospice principles.
• Participate effectively in quality improvement and safety assurance activities in palliative medicine and hospice settings.

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Interpersonal and Communication Skills
Fellows learn to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates.

Fellows learn to:

• Demonstrate excellent communication skills with referring clinicians.
• Demonstrate empathy in relationships with patients, caregivers, and staff.
• Demonstrate awareness of one's own reactions to grief and stress and discuss ways to deal with them.
• Demonstrate ability to engage and educate families and caregivers about the various domains associated with advanced, life-limiting, or life-threatening illness.
• Coordinate, direct, and facilitate key events in patient care such as family meetings, goals of care consultations, advance directive completion, conflict resolution, and withdrawal of aggressive medical interventions utilizing an interdisciplinary approach.

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Professionalism
Fellows learn to demonstrate their commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

Fellows are expected to:

• Understand and gain competence in the roles and responsibilities of a hospice medical director.
• Ethically and consistently fulfill professional commitments.
• Demonstrate knowledge of ethics and law in the provision of care to patients and caregivers in situations common to palliative medicine and hospice practice.
• Demonstrate respect and compassion towards all patients, caregivers, and other healthcare providers.
• Demonstrate the capacity to reflect on personal attitudes, values, strengths, vulnerabilities, and experiences to optimize personal wellness and capacity to meet the needs of patients and caregivers.

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System-based Practice
Fellows develop an awareness of and a responsiveness to the larger context and system of healthcare, and the ability to effectively call on system resources to provide care that is of optimal value.

Fellows are expected to:

• Demonstrate palliative medicine and hospice care that is cost-effective and represents evidence-based practice.
• Integrate knowledge of the healthcare system in developing plan of care.
• Demonstrate knowledge of the various settings and related structures for organizing, regulating, and financing end-of-life medical care.
• Partner with healthcare managers and healthcare providers to assess, coordinate, and improve patient safety and healthcare while understanding how these activities can affect system performance.

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The NIH Pain and Palliative Care Service actively participates in research projects including Phase 0, I, II, III, and IV clinical studies. Studies are being or have been conducted in pain and symptom management, translational (bench to bedside) pain management, quality of life, complementary therapies, education, and palliative medicine outcome studies. Fellows have opportunities to participate in and observe an Institutional Review Board (IRB) for the National Institutes of Health, which is dedicated to ensuring the protection of all study participants. The program's research activities, as reflected by the number of protocols initiated by Pain and Palliative Care Service investigators, continues to expand. Fellows are routinely involved in many aspects of clinical research in their daily activities on the NIH rotations. NIH fellows have abundant opportunities to interact clinically with investigators at all Institutes within the National Institutes of Health and at affiliated institutions. Under the supervision of clinical faculty, fellows are encouraged to participate in or conduct clinical trials. Fellows are encouraged to complete a certificate post-graduate course in the Principles and Practice of Clinical Research during the fellowship year.

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This fellowship prepares graduates for career paths as:

• academic palliative medicine consultant
• community palliative medicine consultant
• academic palliative medicine educator and/or researcher
• community hospice physician
• potential combination of any of the above clinical components

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Candidates must have a MD or DO degree from an accredited medical school and have satisfactorily completed three postgraduate years of training at the time of appointment as a fellow in this training program. Eligible candidates must also have board eligibility or certification in one of the following specialties: internal medicine, family practice, pediatrics, psychiatry, neurology, oncology, anesthesiology, surgery, or radiation oncology. Applicants in other specialties are considered on a case by case basis.

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The ideal candidate has:

• successfully completed training in an ACGME-accredited residency program
• become ABMS board eligible or certified in a primary specialty
• demonstrated abilities and interest in working with clinical care teams
• demonstrated commitment to life-long learning
• clear and balanced personal and emotional strength, and the ability for self-reflection and personal growth in challenging situations
• a strong passion to serve and lead in hospice or palliative medicine as clinician, researcher, or educator as demonstrated by:
  • attendance or presentations at regional or national HPM conferences
  • elective time spent with HPM service or faculty,
  • research or other educational endeavor, or
  • other personal or professional activities related to hospice and palliative medicine.

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Fellows will usually be selected six to eighteen months before the training period that begins on July 1st of each academic year the program participates in the ERAS system and all applications to this fellowship should be completed through ERAS. The completed application must include three letters of recommendation. Candidates are evaluated based on the strength of prior training, demonstrated clinical competence, and potential for excellence in a career in hospice and palliative medicine. Faculty members interview selected candidates before final offers are made. Successful candidates must have unrestricted state medical licenses and the ability to be licensed in Washington DC by the beginning of training.

It is the policy of the National Institutes of Health and its Pain and Palliative Care Service not to discriminate against any individuals on the basis of race, color, religion, national origin, sex, sexual orientation, marital status, age, handicap or veteran status in matters of admissions, employment, or services in the educational programs or activities that it operates, in accordance with civil rights legislation and agency commitment.

Additional information may be obtained from:

Daniel L. Handel, M.D., Fellowship Director
dhandel@cc.nih.gov
National Institutes of Health Hospice and Palliative Medicine Fellowship Director
10 Center Drive, MSC 1517
Bethesda, MD 20892
Phone: 301.594.9767
Fax: 301.594.9807

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Physician Faculty:

	Ann Berger, MSN, MD; Chief of Pain and Palliative Care Service, NIH Clinical Center, Medical Faculty Dr. Ann Berger has served as the founding chief of the Pain and Palliative Care Service at the NIH Clinical Center since 2000, where she has clinical, teaching, research and administrative responsibilities. Dr. Berger has chaired of the NIH Clinical Center Pain and Palliative Care Collaborative Working Group and member of the steering committee for the National Palliative Care Consensus Project, and has participated and chaired national professional palliative medicine meetings, participated in professional editorial boards, and has authored and edited more than twenty books, chapters, and professional journal articles. Prior to her work at NIH, Dr. Ann Berger earned her undergraduate degree from New York University, an M.S.N. in oncology nursing from University of Pennsylvania, medical training at Medical College of Ohio in Toledo, and a fellowship in medical oncology and pain/palliative care at Yale University in Connecticut. She then served as assistant professor at Yale University. Dr. Berger founded palliative care services at Yale University and at Cooper Hospital/University Medicine and Dentistry in New Jersey, and served as medical director of Lighthouse Hospice. Dr. Berger was awarded grants as project director of a pain and palliative care scholars program and as project director for a project designed to develop pain/palliative care teams in New Jersey long-term care facilities. For this work Dr. Berger has received multiple awards, including the Circle of Excellence Award-Samaritan Hospice,2002; NJ State Senate & Legislative Proclamation, 2002; Clinical Center Director's Award, National Institutes of Health, 2001; outstanding leadership in palliative care in long-term care - New Jersey Seed, NJ Dept. of Health and Senior Services, Office of the Ombudsman for the Institutionalized Elderly, Cooper Health System, 1998-2000; Spirit of Hospice Award - NJ Hospice & Palliative Care Organization, 1999; Hospice Medical Director Award - NJ Hospice & Palliative Care Organization, 1998.
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	Dan Handel, MD; Fellowship Director, NIH Hospice and Palliative Medicine Dr. Handel has served as Program Director for the Hospice and Palliative Medicine Fellowship since its inception in 2004 and its ACGME-accreditation in 2009. He is a clinical staff member of the National Institutes of Health Pain and Palliative Care Service. Prior to his appointment at NIH, Dr. Handel held faculty positions at medical colleges in Texas and Minnesota. Dr. Handel received his medical degree from Case Western Reserve University in Cleveland and completed a Family Practice residency at the University of Minnesota. He holds board certification in Family Practice and Hospice and Palliative Medicine, is a Fellow of the American Academy of Family Practice and the American Society of Clinical Hypnosis, and a member of the American Academy of Hospice and Palliative Medicine. Dr. Handel has prior experience as a hospice medical director for a nonprofit hospice, as President and Medical Director of a multidisciplinary, nonprofit medical institute devoted to pain management and pain research, as founding medical director of an inpatient pain and palliative care service in a large Texas hospital, and as the founding medical director of a free-standing inpatient hospice hospital. Dr. Handel has participated in the development of national guidelines for opioid management and, has authored more than twenty articles and book chapters, and serves on three editorial boards of professional journal. Dr. Handel's interests include the integration of mind-body approaches in the management of advanced illness, and he participates in research and training in medical hypnosis.
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	J. Hunter Groninger, MD; Medical Faculty Hunter Groninger, M.D. currently serves as a staff clinician in the NIH Pain and Palliative Care Service since 2011 where he conducts patient care, actively teaches students, residents, and fellows as faculty in the fellowship program, and participates in research activities. Prior to this, he served as a Site Director for the NIH Physician Fellowship Program and as Senior Medical Director of Capital Caring. Dr. Groninger also served as the founding Medical Director for Palliative Care at the Washington Hospital Center. After completing his medical degree and training in internal medicine at the University of Virginia, Dr. Groninger successfully completed a fellowship in hospice and palliative medicine at Capital Caring. He joined its faculty in 2006 and served as Medical Director for home and long term hospice care in Washington, D.C. for three years. As a clinician-educator, Dr. Groninger is a Master Facilitator with the Education for Palliative and End-of-Life Care (EPEC) Program at Northwestern University and Assistant Professor of Medical Education at the University of Virginia. His professional interests include communication skills, medical humanities, and mindfulness training.
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Off-site Physician Faculty
	Cynthia Williams, DO; Site Director, The Washington Home and Community Hospices of Washington Dr. Williams received her medical degree from the Philadelphia College of Osteopathic Medicine and completed the Naval Hospital at Camp Pendleton Residency Program in California. After serving a twenty-seven year career in military academic family practice medicine, Dr. Williams returned to training and completed the NIH Hospice and Palliative Medicine Fellowship in 2006. Dr. Williams currently serves as the Medical Director of the Washington Home, and serving as Site Director for all rotations at The Washington Home and Community Hospice. To promote awareness of hospice, Dr. Williams is a frequent lecturer at local medical institutions.
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	Katie Roth, MD; site faculty at The Washington Home and Community Hospices of Washington Dr. Roth graduated from the George Washington University Hospice and Palliative Medicine fellowship program following an internal medicine residency, and has been a valued member of the medical staff of the Washington Home and Community Hospices since graduation. Dr. Roth provides medical care and supervision within the home hospice rotations and provides part time medical support to the inpatient and long-term care facilities. Dr. Roth is board certified in internal medicine and in hospice and palliative medicine. Dr. Roth enjoys educating professionals and the community about the benefits of hospice care and in working within the interdisciplinary team to provide holistic care for her patients.
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Interdisciplinary Faculty:
	Karen Baker, RN, MSN, CRNP; Faculty As a founding member of the NIH Pain and Palliative Care Service, Karen Baker has been intimately involved in the inception and development of the fellowship training program. In addition to providing clinical palliative care to patients enrolled in research studies, Karen participates in the clinical teaching of the fellows. She also serves as Associate Investigator in pain & palliative care research, and participates in the NIDCR Institute Review Board. Karen received her BSN degree from George Mason University, an MSN in Gerontology from George Mason University, and a post Masters Certificate as an Adult Nurse Practitioner from the University of Maryland. She has additional expertise in complimentary therapies such as a Reiki (Master III) and IGM acupressure. Ms. Baker has lectured nationally on palliative care topics and has contributed journal articles and posters in national professional publications and chapters devoted to pain and palliative care.
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	Jayne Phillips, RN, CRNP; Faculty Jayne Phillips, R.N., M.S., CRNP-A, is a Certified Registered Nurse Practitioner and an Oncology Certified Nurse (O.C.N.). She received a B.A. degree in Social Work from Michigan State University and a Diploma in Nursing from Sentara Norfolk General Hospital. She is a graduate of the Primary Care Adult Nurse Practitioner/Oncology Clinical Nurse Specialist Program at the University of Maryland and is a summa cum laude graduate of the University's R.N. to M.S. program. Her post graduate studies include a certificate in Teaching in Nursing and Health Care Professions from University of Maryland. Her social work experience includes VISTA volunteer service at a poverty law center, director of a rural senior citizens outreach program, director of a Retired Senior Citizens Volunteer Program and director of group activities at a senior citizens center. Her 24-year nursing career has included inpatient oncology, home health, infectious disease, internal medicine and both inpatient and outpatient hospice. She is a member of the Oncology Nursing Society, the American Academy of Nurse Practitioners and the Nurse Practitioner Association of Maryland. She is an End of Life Nursing Education Consortium (ELNEC) trainer and has held certifications in hospice and palliative and infusion nursing, and prepared childbirth education for the American Red Cross.
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	Deborah Snyder, MSW, LCSW-C; Adjunct Faculty As adjunct faculty for our fellowship, Debbie Snyder provides didactic and experiential training on mental health issues, counseling issues, and interviewing skills. Deborah received her Master's Degree in Social Work, Phi Kappa Phi, from the University of Maryland and additional post-graduate training under the tutelage of Marianne Walters.  Since 1992, Ms. Snyder  , has worked within the NIH in several capacities, including the Social Work Department where she provided counseling, social work services, and taught graduate students; and the National Institute of Mental Health's Psychiatry Consult Team where she evaluates and treats patients with co-morbid medical and psychiatric diagnoses; assists the Psychiatry Clinical Fellowship Training Program; facilitates and conducts house-wide educational activities; engages in research initiatives in suicidality and the medically ill; and presents both locally and nationally on a variety of topics. She has several publications including Solicitation of Deceased and Living Organ Donor (Letter to the Editor, NEJM, 2007) and Patients' Opinions about Suicide Screening in a Pediatric Emergency Department (Pediatric Emergency Care, 2012). Deborah has received awards including the NIMH Directors Merit Award and the NIMH Director's Award for Significant Achievement.
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