A Typical "Day in the Life" of a PHPM Physician

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 Renee Boss, MD, MHS, FAAP
John Hopkins School of Medicine, Baltimore, MD, 2022

"As new faculty in Neonatology and Palliative Care, I spent 4 very busy years doing a Masters in Clinical Research and a Faculty Fellowship in Bioethics. I squeezed my clinical time everywhere in between. Those were challenging years (I also had a newborn) but I saw them as a time-limited investment in my research career.

Since then, I’ve maintained a balance of clinical work/ research/ education and home life. I like to work intensely and efficiently during business hours M-F, then turn it all off. No emails, meetings, or work on nights/ weekends unless I have clinical duties. I stick to this ~95% of time-- I get plenty done and (mostly) avoid burnout.

My clinical work is in 2-week service blocks. Just before a block, I take notes about my projects and to-do’s for when I finish service. I tell everyone—myself included— to expect I will do no scholarly work for 2 weeks. I schedule no meetings my first 1-2 days after service, to regroup and recenter.

My scholarly days are largely a combo of meetings and nudging along 5-10 active projects. I eventually became skilled at mentoring (that took several years) and most of my projects involve both helping mentees do things and doing some myself. The parts of research I don’t love (chasing potential study participants, keeping databases) I enlist mentees/ research assistants to shoulder. I love analyzing qualitative data and writing, so I like to lead those parts of projects. I have a lot of control over my scholarly schedule, and this really improves my quality of life at work."

Dr Jared Rubenstein, MD, FAAP
Texas Children’s Hospital, Houston, TX, 2022

"I’m a pediatric palliative care doctor and fellowship program director at a large quaternary care children’s hospital. Our interdisciplinary palliative care team is a consult service that sees inpatients and outpatients and includes doctors, nurses, nurse practitioners, social workers, a chaplain, research coordinators, and grief/bereavement support. In my roles, I have both clinical and academic responsibilities.

I spend my clinical time on the inpatient consult service. We see patients throughout the hospital and from all different subspecialties. My typical day starts around 8am where I review charts from the patients on our census. Then at 8:30 the rounding team members (attending, social worker and/or chaplain, trainees) huddle and make our plan for the day. We spend the morning seeing patients to assist with pain/symptom management, eliciting goals of care, shared decision making, and quality of life support. I aim to always break for lunch around noon. I strive to normalize that me and my colleagues take a break to eat together, have some camaraderie, and debrief/process the events of the morning. I find it really hard to be a good doctor without food and a bit of time for socializing and processing our challenging work. After lunch is more patient care, often with new consults and family meetings until around 4 where we stop to write notes and sign out. Our team often spends time at the end of each day debriefing/processing some more. This helps us leave some of the emotional weight of our work at work so we can be present at home. When trainees are present, these debriefings also include time reviewing treatment plans and communication procedures from the day for learning points.

On weeks I’m not on clinical service, I have education and administrative time. I use that time for the administrative work of our fellowship program as well as our elective rotations for residents, medical student, and nursing students. This is also time I can use to read, work on research or publication writing, and to give lectures.

I truly feel like we have the best job in healthcare. We get to help care for amazing people and support them through the most challenging times in life. We get to work with amazing colleagues who make doing this challenging work a joy. And we get to train others to learn more about this amazing field."

Dr Melanie Brown, MD, MSE, FAAP
Johns Hopkins School of Medicine, Baltimore, MD, 2022

"I am a Palliative and Integrative Medicine physician. I have a number of different roles and love that each day is different from the next. I am fortunate to be able to combine my passions into a career where I feel that I am truly able to make a difference in the lives of children through both direct patient care and medical education.

My various roles include Medical Director for the Palliative Medicine service at Johns Hopkins Children’s Center where I lead the outpatient palliative medicine clinic and collaborate in the Integrative GI Clinic for chronic abdominal pain. When on the inpatient service, my day starts at around 7am with chart review and covering any urgent inpatient needs. We then start rounds at around 9 and discuss both the inpatients and outpatients. The rest of the day is busy seeing new consults, following up on the patients on our services and meetings with the team and the families. In addition to assisting with symptom management, we also help with family decision making, goals of care and staff support. During the inpatient service week, I also cover call on nights and weekends and lead the inpatient team interdisciplinary meetings which consists of psychosocial support staff, providers, and trainees. I also hold a palliative medicine clinic one day a week and an integrative pain clinic with the GI team one half day a week.

As Medical Director for Gilchrist Kids, a community hospice organization, I cover night and weekend call 1 full week a month and work closely with the nurse manager of the program. My roles in medical education include Assistant Program Director for the Palliative Medicine Fellowship and Course Director for the Medical Student Integrative Medicine Course. I also have the opportunity to participate in collaborations outside of the institution including research projects and advocacy with the American Academy of Pediatrics."

Dr Kara Huncik, MD, FAAP
Hand of Hope, Agape Care, SC, 2022

"My path to Pediatric Palliative and Hospice care was not linear, but definitely fruitful. After residency, I began my career in Pediatrics as Medical Director for a start-up, hospital-based, Medicaid funded program for children with special needs and chronic medical conditions. Within this role, I learned a tremendous amount about patient care within an interdisciplinary team, patient and family-centered care, legislation/politics, leadership, and advocacy. When we lost the funding for that program, I turned my sights to private practice in pediatrics, where I eventually became a partner in a large pediatric group. I spent the next 12 years honing my skills in patient care, leadership, practice management and business, all while continuing to care for a sizeable population of children with chronic medical conditions and special needs. Then in 2021, I took on the position that I currently hold, as Medical Director for a private company offering home-based palliative and hospice care to children and families. In taking this position, I believe I have found my calling! It’s as if all my passions, interests, values, experiences, and training have converged together, and I have a profound gratitude for my role, my colleagues, the patients, and their families. On any given day, I have the great honor of direct patient care, mentorship to many different professional disciplines, leadership for my team, coordination of care with my medical colleagues, advocacy for patient rights and access to services, and education through outreach and speaking engagements. Make no mistake, though, I still take call nearly every night, and I have a lot of paperwork! Honestly, though, there is some truth to the adage, 'when you find a job you love, you never work a day in your life.' It’s work, but it doesn’t feel like a burden."

Differences and Similarities in PHPM Care Programs

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; the following are activities a given team may encounter in a day:

• Complicated pain and/or symptom management
• Assisting families as they define quality of life
• Evaluating and recognizing the importance of spirituality
• Coordinating care among 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, Do-not-resuscitate (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."