PROGRAMS and SERVICES
J. Hunter Groninger, MD; Program Director
Suzanne B. Richardson, Fellowship Coordinator
- Program Overview
- Sample Schedule (60 KB)
- Program Curriculum
- Patient Care
- Medical Knowledge
- Practice-based Learning and Improvement
- Interpersonal and Communication Skills
- Systems-based Practice
- Career Paths
- Ideal Candidate
- Application Process
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, inpatient rotations at Suburban Hospital, 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. 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.
Fellowship Rotations are structured in four-week blocks and include:
Palliative Medicine Consult Service: NIH Clinical Center (6 blocks)
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 interdisciplinary education in symptom-management techniques; effective team facilitation; effective utilization of various components of the health-care system for patients facing life-threatening conditions and complex psychosocial and medical needs; and development of effective management strategies for suffering due to existential and spiritual distress. Fellows participate daily in inpatient consultative palliative care,- twice-weekly in outpatient clinics with an emphasis on continuity of care, and weekly in interdisciplinary team meetings.
Palliative Medicine Consult Service: Suburban Hospital (2 blocks)
Fellows participate in inpatient palliative care consultation in this community-based setting. Here, skills in symptom assessment and management are further honed. Particular attention may be paid to development of communication skills important to successful transitions of goals of care and coordination of hospice services. Suburban Hospital’s patient population facilitates care experience with common diagnoses requiring a palliative approach and an emphasis on a geriatric care.
Home Hospice Care: Community Hospices of Washington (1 block)
Fellows participate in hospice medical visits in patients' homes with supervising medical 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.
Inpatient Hospice Care: Community Hospice of Washington (2 blocks)
Fellows develop experience providing 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.
Elective Rotation (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. Fellows work with the program director and mentors to optimize this opportunity. Examples of electives include, but are not limited to, Consult Liaison Psychiatry, Physiatry, Bioethics, Hospice Administration, Pediatric Palliative Care, and Public Policy. Fellows may also choose to devote this elective block to a research project.
Our program is designed to develop the following competencies at or above the level expected of a new Palliative Care practitioner.
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.
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.
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.
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.
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.
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.
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. Fellows are encouraged to complete a certificate post-graduate course in the Principles and Practice of Clinical Research during the fellowship year.
This fellowship prepares graduates for career paths as:
- academic palliative medicine consultant educator and/or researcher
- community palliative medicine consultant
- community hospice medical director
- potential combination of any of the above clinical components
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.
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.
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:
Hunter Groninger, M.D., Program Director
NIH Clinical Center
10 Center Drive, Room 2-1733
Bethesda, MD 20892
Ann Berger, MSN, MD; Chief of Pain and Palliative Care Service, NIH Clinical Center
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.
J. Hunter Groninger, MD; Program Director
M. Jennifer Cheng, MD; Medical Faculty
Steven Wilks, MD; Medical Faculty
Karen Baker, RN, MSN, CRNP; Faculty
Jayne Phillips, RN, MS, CRNP, OCN; Faculty
Deborah Snyder, MSW, LCSW-C; Adjunct Faculty
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