Hospice + Palliative Medicine Fellowship

The Tufts Medical Center palliative care service receives approximately 60 new consults monthly and carries a daily census of approximately 20 active patients. Consults come from various sources, including the advanced heart failure team, the medical, surgical, and subspecialty ICUs, oncology, infectious disease, renal, and general medical services. While in the inpatient service, the HPM fellow will join a team that includes physicians, a nurse practitioner, a nurse navigator, and a social worker. The fellow will meet with the supervising physician, nurse, and social worker each morning to assign new consults, review cases and plan family meetings. Fellows will see patients daily, communicate with the referring team, complete appropriate documentation, and precept each patient with a staff member. Fellows will join the team at weekly inter-disciplinary team meetings, attend clinical and educational conferences, participate in the education of rotating learners and alternate with other team members in leading weekly didactics.

At VA Hospital in West Roxbury, the palliative care service sees 40 new patients per month and is staffed by a physician, NP, SW, and RN team. Similar to the Tufts MC inpatient service, fellows will see patients daily, precept with their supervising physician, communicate with the referring team, and involve other members of the palliative care team (e.g., social worker) when needed and appropriate. Fellows will participate fully in clinical and educational conferences and interact with other learners rotating on the service.

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The strongest evidence for the impact of palliative care is for the integration of palliative care earlier in the disease course and in the outpatient setting. Thus, Tufts Medical Center is committed to providing fellows with a robust outpatient educational experience that prepares them to deliver palliative care in the ambulatory setting. The outpatient palliative care practice is growing, with over 1,000 encounters in 2022.  Palliative care providers see patients in clinics embedded in oncology, nephrology, and pulmonary. Patients are referred for pain, non-pain symptom management, psychosocial support and advance care planning.

Fellows will be assigned a half-day clinic session each week. The fellow is expected to prepare for these visits in advance. All patients will be precepted by an attending physician. The fellow is expected to communicate recommendations to the referring provider, prescribe medications, do phone call follow-up when necessary and complete documentation promptly. Patients will be booked with the fellow whenever possible to ensure longitudinal care. If patients from their clinic are hospitalized or referred to hospice, fellows will be encouraged to see them in these settings.

In addition to the longitudinal clinic, fellows will have multiple weeklong outpatient immersion experiences throughout the year. During these weeks, the fellow will see patients in the clinic for several half-day sessions. This will allow them to see patients outside their longitudinal clinic and ensure diversity of diagnoses and experience in the ambulatory setting. They can visit longitudinal clinic patients in another setting (home, long-term care, hospital). During these weeks, didactics will focus on ambulatory topics, such as opioid stewardship, practical aspects of prescribing (e.g., costs, prior authorization), prominent outpatient symptom management (e.g., fatigue, anorexia, sleep disorder), the assessment and facilitation of adaptive coping, and logistics of telemedicine. Fellows will be asked to present.

Tufts Medicine Care at Home serves as the site for the home hospice rotation. Deeply committed to providing emotional and physical support, the clinical team includes the Hospice Medical Director (HMD) and Associate Medical Directors, Nurse Practitioners, nurses, social workers, home health aides, bereavement counselors, a volunteer coordinator, spiritual care counselors, volunteers, and other therapists, including music therapy, as needed. The Hospice Medical Director and Associate Medical Directors have all served in academic appointments and worked for at least fifteen years in hospice and palliative care clinical practice. We are proud to participate as a level 3-member in the We Honor Veterans program, a National Hospice and Palliative Care Organization program, in collaboration with the Department of Veterans Affairs. During their rotation, fellows will make home visits primarily in conjunction with one of the hospice nurses and/or the Hospice Medical Director or Associate Medical Director and less frequently with another team member. Occasionally, fellows will visit patient homes independently toward the end of the rotation. Fellows will participate in weekly IDT meetings, presenting patients they have seen. The didactic curriculum will include lectures on the imminently dying syndrome and non-oral medication administration routes. The hospice medical director will meet with each fellow to review key components of hospice administration, including regulatory, administrative, legal, and ethical competencies, cost-effective policies and clinical skills appropriate for hospice patients.

High Pointe House has 21 private suites for patients and spacious common areas, including a kitchen, play area, library, and garden, to support the needs of families. High Pointe provides a general inpatient (GIP) level of care and routine hospice care for patients unable to receive such care at home. Patients on GIP have intense medical and/or nursing needs, such as the management of pain or other acute symptoms requiring IV medications. The site has 24/7 coverage to address these complex symptoms. Fellows will round on GIP patients with the supervising physician and spend time with various team members, including the on-site bereavement and spiritual counselors. The experience will educate them on addressing all aspects – physical, spiritual, psychological and existential – of suffering in patients at the end of life.

The palliative care team for the hospice and palliative care unit consists of a physician, nurse practitioner, social worker, nurse manager, chaplain, speech pathologist, pharmacist, nutritionist, recreational therapist, and kinesiotherapist. The hospice and palliative care unit cares for 15 veterans and accepts patients for both end-of-life care and ongoing symptom management and support during palliative chemotherapy or other supportive care.

During this rotation, the fellow will round daily with the care team, including the physician, nurse practitioner, and charge nurse. The fellow will initially manage patients, accept admissions with close supervision from the attending physician, and move to a more independent model as the year progresses. The fellow will learn how to triage admission requests, coordinate family meetings, run an IDT meeting, develop a care plan, and discharge patients from hospice. The team meets for IDT and care plans weekly, and the fellows will have the opportunity to run this meeting toward the end of the rotation.  The fellow will be expected to complete admission notes and daily progress notes.

The fellow will have the opportunity to work with other learners, including psychiatry interns, physician assistant interns, psychology interns, and pharmacy interns. The fellow will also have the opportunity to educate the team and will be expected to educate on one topic of interest during the rotation.

More details

HPM fellows will gain exposure and expertise with pediatric patients from a variety of sources. They will see inpatient consults from the neonatal intensive care unit (NICU), precepted by Dr. Tamara Vesel a pediatric palliative care physician and the Division Chief. They will also rotate at the New England Pediatric Care nursing home, an 80-bed facility designed for children who are medically complex and have severe cognitive and neurological impairments. During this experience, they will be supervised by Dr. Harry Webster, a pediatric physiatrist and Medical Director of New England Pediatric Care. They will see patients with Dr. Webster in the clinic and round with other interdisciplinary team members (e.g., physical therapists, occupational therapists, social workers, speech-language pathologists, and nurses) to learn their role in caring for their seriously ill children. Finally, fellows will see children and young adults when referred for hospice care with Tufts Medicine Care at Home or High Pointe House inpatient hospice. Patients from NEPC referred to hospice are commonly seen by Tufts Medicine Care at Home, which would allow fellows to see patients at two different locations and stages in their illness trajectory.

More details

Each fellow has the opportunity to spend at least four weeks in a focused experience. For fellows interested in an academic career, this is a chance to advance a scholarly project, which can be an educational endeavor, a quality improvement project, a clinical innovation, or other scholarly work. The fellowship will provide guidance and mentoring and help craft time to maximize productivity.

Fellows can also use this time to gain additional clinical exposure. The program director can help arrange rotations with allied fields, such as interventional pain, radiation oncology, physical medicine and rehabilitation, spiritual care or social work. 

• Symptom management series
• Communication skills
• Integration of palliative care series
• General topics

For their elective, the palliative care fellow can choose to function as a teaching assistant for the 4th year medical student elective in end-of-life care. In this role, the students will read literature relevant to end of life from a variety of fields, including ethics, sociology, as well as medicine. The HPM fellow helps facilitate the class with Dr. Tamara Vesel and Dr. Klemens Meyer.

Interested fellows are encouraged to engage in a variety of projects with an eye toward scholarly output. Recent examples of work carried about by residents, medical students and other learners, mentored by faculty in the division include: pilot of integrating palliative care into nephrology clinic; examining life-sustaining treatment and advance care directives among Chinese American decedents in the ICU; communication preferences among Chinese Americans with cancer; impact of cancer on commensality among Chinese Americans; integration of palliative care into TAVR clinic; impact of COVID on palliative care perceptions among hospital leadership. Results of such work has been presented at the American Academy of Hospice and Palliative Medicine (AAHPM), the McGill International Palliative Care Congress. Some mentees have co-authored book chapters and peer-reviewed journal articles on their projects.

For qualified fellows interested in obtaining additional experience and expertise in education or clinical research there are opportunities to apply, through a competitive process, for an additional 1-2 years of funding.
The Clinical and Translational Science program at Tufts MC provides 1-2 year fellowship slots. The application opens mid-September for admission the following July. Applicants must complete an online application.

The Boston VA also accepts applicants from physicians interested in becoming educational leaders for a 2-year advanced fellowship program. Additional info available at the VA website.
 

April 22, 2021: "Pathways to Wellness: Exploring the Interrelationships between Obesity, Pain Management, and Psychological Factors"
Olutosin “Tosin” Ojugbele, MD

June 17, 2021: "Advance Care Planning in the Chinese Diaspora”
Zhimeng Jia, MD, CCFP, PC

October 21, 2021: “The unique privilege of caring for young adults who are survivors of childhood cancer and hopes for the future”
Lisa Mueller, MD

October 17, 2019: "Conflict Engagement: Strategies for Connecting with Patients, Families, Colleagues and Yourself"
Debra Gerardi, RN, MPH, JD

September 19, 2019: “Opioid-Related Challenges in Palliative Care Patients”
Dustin Patil, MD, Director, Addiction Psychiatry, Tufts Medical Center
Tamara Vesel, MD, Chief, Division of Palliative Care, Tufts Medical Center

June 20, 2019: “A Year in Palliative Care: Education and research at Tufts Medical Center and Tufts Medicine”
Katherine Hicks-Courant, MD, Department of Obstetrics and Gynecology at Tufts Medical Center
Emma Ernst, 3rd Year Medical Student at Tufts University 
Bernice Burkarth, MD HMDC FAAHPM, CMO of Home Health Foundation
Benjamin Wessler, MD, Cardiologist at Tufts Medical Center
Tamara Vesel, MD, Chief of the Division of Palliative Care at Tufts Medical Center

May 16, 2019: “Can We Generate a More Sustaining and Inclusive Power of Compassion for our Lives and Work?”
John Makransky, PhD

February 21, 2019: “Dialysis: High Tech Palliative Care" 
Klemens B. Meyer, MD

December 13, 2018: “Courageous Parents Network: Using Patient and Family Voices in Pediatric Palliative Care”
Patricia O’Malley, MD

September 20, 2018: “Spirituality and Palliative Care: From Asclepius to P-Values”
Tracy Balboni, MD, MPH, FAAHPM

July 19, 2018: Team and Systems-Based Approaches to Quality and Safety in Pain Management
Daniel B. Carr, MD, DABPM, FFPMANZCA (Hon)

June 14, 2018: “Palliative Care Discussion: Needs Assessment for Bereavement Services at Tufts Medical Center”.
Panel Discussion: Kathy Hershfield, SW; Linda Russo, RN (spouse); Megan DeLisi (parent); Chris Roehr (parent and spouse)

April 19, 2018: “Home Hospice: Debunking the Myths, Understanding the Realities.”  
Diana Taylor, SW

February 15, 2018: “Grief and Bereavement: Best Practices for Supporting Bereaved Families” 
Sue Morris, PsyD.

January 18, 2018: “Emerging Role of Palliative Care for Patients with Advance Heart Failure” 
Jatin Dave, MD

October 19, 2017: “Shifting from Rescue to Right: Palliative Care and Healthcare Reform”
Jennifer Clark, MD

September 21, 2017: “Humanism, Burnout, and Patient Care: Excerpts from a Work in Progress”
Julius Yang, MD, PhD

August 17, 2017: “Difficult encounters in clinical care”
Guy Maytal, MD

Marc-David Munk, MD, MPH, MHCM

Dr. Munk is the 2024-2025 HPM fellow in the Division of Palliative Care.  Prior to joining the department, he held a variety of roles in academic and non-academic medicine.

Dr. Munk received his medical education at Jefferson Medical College in Philadelphia, and completed residency/chief residency in emergency medicine and a fellowship in international health at the University of Pittsburgh. He earned a Master of Public Health degree in epidemiology and global health from Boston University and a Master of Healthcare Management degree from Harvard University.

His academic interests include policy, alternative payment models at end of life, and value-based systems of care. 
 

Tamara Vesel, MD

Role: Hospice and Palliative Medicine Fellowship Program Director; Chief of Division of Palliative Care; Clinical Associate Professor of Medicine and Pediatrics, Tufts University School of Medicine

Biography: Tamara Vesel, MD is the Chief of the Division of Palliative Care in the Department of Medicine at Tufts Medical Center. Most recently, she has been working as the medical director of Pediatric Services as well as a senior Palliative Care physician at the Hospice of the North Shore and Greater Boston/Care Dimensions. In addition to establishing a premier pediatric hospice service for the organization, Dr. Vesel provided care for children and adults of all ages in the North Shore and Greater Boston area. She returned to Tufts Medical Center, where she completed a pediatric residency in 1993 and was an attending physician from 1996 to 2003.

Dr. Vesel has been on staff at Boston Children's Hospital and the Dana Farber Cancer Institute, where she was the director of the interdisciplinary pediatric palliative care fellowship program. She has extensive work experience in teaching: she was the course director at Harvard Medical School for "Living with Life-Threatening Illness," which taught medical students the fundamental knowledge, attitudes, and skills for working with a dying patient and their families. She also cofounded a curriculum and was the pediatric co-director for PCEP and Harvard Center for Palliative Care, an interdisciplinary, international palliative care course, until 2012.

Dr. Vesel is a pediatric and adult palliative care physician passionate about clinical patient care and teaching interdisciplinary learners in various care settings. She enjoys traveling, learning about new cultures, hiking and meditating in nature. Dr. Vesel loves music and other arts, in particular playing the harp. Her favorite time spent is with friends and family.

Rachel Bernstein, MD

Role: Attending Physician, Inpatient Palliative Care Consult Service; Clinical Assistant Professor of Medicine, Tufts University School of Medicine

Biography: Dr. Bernstein joined Tufts Medical Center and the Division of Palliative care in 2018 after completing her Hospice and Palliative Medicine fellowship with a focus on inpatient care and clinical work. Currently, Dr. Bernstein attends part-time on the inpatient palliative care consult service. In addition to inpatient care, her clinical interests include physician wellness and the medical humanities, including reflective writing and narrative medicine.

After completing medical school at SUNY Buffalo (her hometown - Go Bills!), she completed an Emergency Medicine residency at Case Western Reserve University/University Hospitals Case Medical Center in Cleveland, OH.

She started her attending career as an Emergency Medicine physician at Columbia University Irving Medical Center in Manhattan but soon gravitated towards Palliative Care. She completed her fellowship in Hospice and Palliative Medicine at Columbia University Irving Medical Center in 2018 before coming to Tufts to focus exclusively on Palliative Medicine.

She lives with her husband and young son and enjoys her bike commute to work, rain, snow or shine!

Elizabeth Figuracion, DO

Role: Attending Physician, Inpatient Palliative Care Consult Service; Clinical Assistant Professor of Medicine, Tufts University School of Medicine

Biography: Dr. Figuracion is an active clinician on both the inpatient palliative care consult service and in the palliative care clinic. She loves teaching and oversees the weekly palliative care didactics for the team and residents rotating with the palliative care service.

After graduating from Binghamton University of the State University of New York, she earned her medical degree from the New York Institute of Technology, College of Osteopathic Medicine. Dr. Figuracion completed her residency in Family Medicine and her Hospice and Palliative Medicine fellowship at Jamaica Hospital Medical Center in Queens New York. She is a board-certified physician in family medicine, hospice and palliative medicine.

Dr. Figuracion is passionate about providing empathetic and equitable care for vulnerable populations, especially through difficult times. Outside the hospital, some of her favorite things include being a food enthusiast (sushi!), traveling, shopping, and streaming her favorite shows.

Jatin K. Dave, MD, MPH

Role: part-time attending physician on the inpatient palliative care consultation service; Assistant Professor, Tufts University School of Medicine

Biography: Besides attending part-time on the Tufts Inpatient Palliative Care, Dr. Dave is a member of the Medical-Scientific Committee of the New England Alzheimer's Association.  He is board-certified in Internal Medicine, Hospice and Palliative Care, Geriatric Medicine and Clinical Informatics. A few of the topics of special interest include the Management of Cardiac Devices in Hospice and Palliative Care, Payer-Provider Partnerships, and Care During the Last Hours.

Previously, at Brigham and Women's Hospital, Dr. Dave served as a primary care physician, consultant geriatrician, and director of education. While there, he received the Geriatric Academic Career Award and the Clinical Innovation Award. After training in internal medicine at the University of Illinois College of Medicine, Dr. Dave completed a general internal medicine fellowship at New York University. Dr. Dave then completed a fellowship in geriatric medicine at Harvard University. He also received a master's degree in public health from the Harvard School of Public Health and earned a bachelor's degree in medicine and in surgery at Gujarat University in Gujarat, India.

Jatin enjoys traveling, spending time with his family and collecting stamps!

Carol R. Pilgrim, MS, AOCN, FNP-BC

Role: Nurse practitioner on the inpatient palliative care consult service.

Biography: Carol has a bachelor's degree in political science from Grinnell College.  After working in a homeless shelter, she went back to school to become a nurse. She received a Bachelor of Science in Nursing from Grand View College and later a Master of Science from the school of Public Health Nursing at the University of Illinois at Chicago.

After years of working various roles in oncology, including outpatient breast cancer, gastrointestinal cancers, and inpatient bone marrow transplant, she transitioned to working in palliative care. She joined Tufts Medical Center in June of 2022 with the goal of building a practice providing palliative care to patients with long hospital stays who would benefit from continuity of care.

Outside of work she is a proud mother and loves to hike, cross country ski and travel.

Barbara Ratto, RN BSN

Nurse Navigator, Palliative Care Division