AAHPM Fellow Status Application: June 2015
Eligibility Requirements to Apply
1. AAHPM physician members in good standing for at least five (5) consecutive years. (If you
have not been a member for 5 consecutive years, please provide an explanation). Applicants
who have not completed 5 years of physician membership will NOT have their applications
reviewed.
2. Current Hospice and Palliative Medicine board certification by one of the 10 cosponsoring
members of the American Board of Medical Specialties (ABMS) sub-specialty, the American
Osteopathic Association Bureau of Osteopathic Specialists, the American Board of Hospice
and Palliative Medicine (ABHPM) or ) or the Hospice Medical Director Certification Board
(HMDCB).
3. At least five (5) years of post-residency professional activity predominantly in the field of
hospice and palliative medicine. This requirement can be met bytime spent in a palliative
medicine fellowship or
• evidence of experience in clinical, educational, research, or administrative roles in this
area, or
• combination of these activities as defined in the following pages.
4. Attendance at two out of the past five Annual Assemblies, or attendance at least three total
Assemblies.
5. Significant expertise, commitment to scholarship and practice in the field of hospice and
palliative medicine, as provided on the following pages.
6. Two letters of recommendation are required for consideration. One from a current Fellow
of AAHPM. Another from either a supervisor, colleague, or fellow member of AAHPM.
These letters MUST accompany the application and should address dedication and
contribution to the field of Hospice and Palliative Medicine. Applications without support letters
will not be reviewed. A complete list of Fellows is available on the AAHPM web site
at: http://www.aahpm.org/membership/fellows.html
7. An attached Curriculum Vitae.
8. If requested, complete a phone interview with a member(s) of the AAHPM Membership &
Communities Strategic Coordinating Committee.
9. You must accrue a minimum of 120 points as defined by this application.
• Please note you do not need to complete every section to obtain your points.
• Complete all items that apply.
• List each year separately where requested.
• If you need assistance, please contact AAHPM at 847.375.4712 or resources@aahpm.org
• Please contact AAHPM Member Services to pay the $275 processing fee at 847.375.4712.
Deadline: September 1, 2015 @ Noon ET.
AAHPM Application for Fellow Status
Follow the instructions accompanying this form explicitly.
First Name: ___________________ Middle Name: ________________ Last Name:
_________________________
Credentials: ___________________
Organization: ____________________________________________
Street Address: __________________________________________
Apt/Suite/Office: ________________________________________
City: ___________________________________State: _______Postal Code: _________________
Email Address: ___________________________________________
Office Phone: ____________________________________________
Section I: Academic Training and CME
Indicate current primary board certification and date:
ABMS: ________________________
AOA: _________________________
Indicate any non Hospice and Palliative Medicine sub-specialty board certification and date:
ABMS: ________________________
AOA: _________________________
Indicate the year(s) you received Hospice and Palliative Medicine Certification for the following:
ABHPM: ______________________
ABMS: ________________________
AOA: _________________________
Indicate the year(s) you received Hospice Medical Director Certification.
HMDC:____________________________________________
1) List all additional degrees or Fellowships that have enhanced your work in the field or contributed to
the development of your expertise in Hospice and Palliative Medicine. (e.g. MBA, MPH, PhD).
Please explain how these additional degrees developed your expertise.
(2 points per additional degree, maximum 8 points)
Degree/Contribution:
_________________________________________________________________________
Degree/Contribution:
_________________________________________________________________________
Degree/Contribution:
_________________________________________________________________________
Degree/Contribution:
_________________________________________________________________________
2) List any AAHPM sponsored educational events (e.g., Medical Director Course, Intensive Board
Review Course, Fellowship Program Summit, LEAD, Leadership Forum Series or Clinical Scholars
Program) you have attended.
(2 points per complete meeting, maximum 6 points)
Meeting
1
2
3
Month / Year
3) List any AAHPM sponsored CME activities (other than meetings) in which you have participated,
such as Hospice Medical Director Course/ or recordings, UNIPAC series, Webinar, AAHPM Editorial
Board, or PC-FACS Editorial Board.
(1 point per activity, maximum 5 points)
Activity
Date Completed
1
2
3
4
5
Please list your total point score for Section 1: Academic Training and CME
_______Additional Degrees/Fellowships (max 8 pts)
_______AAHPM Sponsored Educational Events (max 6 pts)
_______AAHPM Sponsored CME Activities (max 5 pts)
Section II: Publishing and Research
4) List non-published research presented at an AAHPM Annual Assembly. (case studies, posters, or
papers)
(5 points per topic, maximum 10 points)
Topic
Meeting Year
1
2
5) List research grants received, that are relevant to Hospice and Palliative Medicine.
(5 points per grant, maximum 10 points)
Title
1
2
Grant/Agency
Month/Year
Grant/Amount
6) List authored research or clinical review articles relevant to Hospice and Palliative Medicine that you
have published in a peer-reviewed journal.
(5 five points per article, maximum 25 points)
Article Title
Name of Journal
Month/Year
Published
1
2
3
4
5
7) List any Hospice and Palliative Medicine articles you have published (clinical or socio-economic) in
non-peer reviewed medical publications.
(2 points per article, maximum 6 points)
Article/Title
Name of Journal
Month/Year
Published
1
2
3
8) List if you served as an editor or on the editorial board for a medical publication or reviewer for any
journal related to Hospice and Palliative Medicine.
(1 point per publication, maximum 4 points)
Publication
Start/End Date
1
2
3
4
9) List medical books, medical videos, medical web sites, medical recordings or CD-ROMS or
monographs you have authored or co-authored related to the field of Hospice and Palliative medicine.
(5 points per activity, maximum 20 points)
Title
1
Month/Year
2
3
4
Please list your total point score below for Section II: Publishing and Research
_______Non-Published Research (10 pts max)
_______Research Grants Received (10 pts max)
_______Research or Clinical Review Articles Published -Peer Reviewed (25 pts max)
_______Other Articles Published (6 pts max)
_______Editor or Editor Board for Medical Publication(s) (4 pts max)
_______Authored or Co-Authored - Books, Videos, Websites.. (20 pts max)
________________________________________________________________________________
Section III: Teaching Activities
10) List participation as a presenter at an AAHPM Annual Assembly. (this includes pre-conference
workshops, concurrent sessions, papers, posters and plenary sessions)
(5 point per presentation, maximum 10 points)
Meeting Year
Lecture Title
1
2
11) List participation as a presenter at an AAHPM Medical Director Course, Current Concepts in
Palliative Care Update and Review Course, Intensive Board Review Course, LEAD, Leadership Forum
Series or Webinar.
(3 point per presentation, maximum 6 points)
Meeting
Lecture Title
Month / Year
1
2
12) List any service as a faculty member at a palliative medicine fellowship program.
(5 points per year, maximum 20 points)
Title
Institution
Location
Year Served
1
2
3
4
13) List any Palliative Medicine teaching activities you have facilitated or time served as a preceptor with
medical students, residents, etc. in your practice and the length of time you spent with them.
(12 hours = 1 point, maximum 40 points)
Professional Status
(Student,
Resident,Fellow,
PreMed Student, Other
Health Care
Professional)
School / Institution
Total Hours
1
2
3
14) Describe mentoring of mid-career professionals, or international clinicians, and the length of time you
spent with them.
(12 hours = 1 point, maximum 20 points)
Description of Activity
Year
1
2
3
4
5
6
15) Detail occasions you have lectured about Hospice and Palliative Medicine, to students and/or
residents.
(1 point per lecture hour, maximum 10 points)
Topic
1
2
3
4
Organization
Location
Month /
Year
Number of
hours
5
6
7
8
9
10
Please list your total point score below for Section III: Teaching Activities
_______Presenter at an AAHPM Annual Assembly (10 pts max)
_______Presenter at an AAHPM Course or Webinar (6 pts max)
_______Faculty Member at Palliative Medicine Fellowship Program (20 pts max)
_______Palliative Medicine Teaching Activities (40 pts max)
_______Mentoring Clinicians (20 pts max)
_______Lectured about HPM to Students or Residents (10 pts max)
Section IV: Public Service
16) List participation in charitable medical services or humanitarian medical missions outside your
regular practice (i.e., humanitarian medical missions as a military physician, free clinic, health care to
homeless, etc.)
or volunteer medical services you have performed (that relate to Hospice and Palliative Medicine.
(1 point per 8 hours, maximum 10 points)
Facility
1
2
3
4
5
6
7
8
9
Activity
Location
Month /
Year
Number
of 8 - hrs
sessions
10
17) Describe if you have performed public relations activities that explain the specialty of hospice and
palliative medicine to the public, such as lectures to civic groups or public service announcements, radio
or TV appearances, etc.
(1 point per activity per year, maximum 10 points)
Activity
Group
Location
Month / Year
1
2
3
4
5
6
7
8
9
10
18) List any patient education activities you performed outside of your practice to educate the
community about hospice and palliative medicine (such as health fairs, writings for lay publications,
media activities, etc.)
(1 point per activity, maximum 10 points)
Description of Activity
1
2
3
4
5
6
7
8
9
10
Group / Publication
Year
Please list your total point score below for Section IV: Public Service
_______Participation in charitable medical services (10 pts max)
_______Public Relations activities (10 pts max)
_______Patient Education activities (10 pts max)
Section V: Organizational Leadership
19) List information pertaining to administrative positions held in organizations and provide information
on how this position has advanced the field of Hospice and Palliative Medicine:
(2 points per year of service, maximum 10 points)
Position
Hospital
Year
Rationale
1
2
3
4
5
20) List where and when you served as a Hospice Medical Director.
(2 points per year of service, maximum 10 points)
Hospice
1
2
3
4
5
Please list your total point score below for Section V: Organizational Leadership
_______Positions in Hospital Services (10 pts max)
_______Hospice Medical Director (10 pts max)
Year
Section VI: Service to the Subspecialty / AAHPM
21) List legislative services you have performed in or been involved in pertaining to the sub specialty.
(1 point per year, maximum 3 points)
Activity
Date
1
2
3
22) List if you have served as a committee chair, officer, or delegate/alternate in another medical
organization such as AMA or AOA, state or county medical society, etc. that have served to advance the
field of hospice and palliative medicine.
(1 point per year of service, maximum 4 points)
Position
Organization
Year
1
2
3
4
23) List any of the following offices held in AAHPM (service as President-Elect, Treasurer, Secretary or
member at large of the Board of Directors)
(3 points per year in office, maximum 6 points)
Position / Office Held
1
2
Year
24) List any of the AAHPM committees/tasks forces/SIG's you have chaired
(2 points per year in office, maximum 10 points)
Committee Chaired
Year
1
2
3
4
5
25) List any of the AAHPM committees/tasks forces/SIG's you have been a member of
(1 points per year in office, maximum 4 points)
Committee
Year
1
2
3
4
26) List any services for AAHPM publications, i.e. PC-FACS, AAHPM Quarterly, etc.
Editor in Chief: 4 points per year, maximum 8 points
Associate Editor in Chief: 4 points per year, maximum 8 points
Senior Section Editor: 3 points per year, maximum 6 points
Associate Editor: 2 points per year, maximum 4 points
Ad Hoc Reviewer: 1 point per year, maximum 4 points
Contributor: 1 point per year, maximum 4 points
Publication
1
2
3
4
Year Served
Position Held
27) List if you were a recipient of a hospice or palliative medicine award given by an organization within
hospice or palliative medicine.
(3 points per award, maximum 6 points)
Name of Award
Year
Received
Organization Presenting Award
1
2
Please list your total point score below for Section VI: Service to the Subspecialty / AAHPM
_______Legislative Services (3 pts max)
_______Positions Held as a Member in Another Medical Organization (4 pts max)
_______Committee Chair, Officer in Another Medical Organization (4 pts max)
_______Offices Held in AAHPM (6 pts max)
_______AAHPM Committees/Task Forces/SIGs Chaired (10 pts max)
_______AAHPM Committees/Task Forces/SIGs Membership (4 pts max)
_______Service to AAHPM Publications (8 pts max)
_______Recipient of a Hospice or Palliative Medicine Award (6 pts max)
Total Point Count:
Total Point Count AAHPM Fellow Status (maximum – 295 points, minimum of 120 points needed to be
considered as a fellow, in addition to the requirements listed on page 1)
_______Section I: Academic Training and CME (maximum allowed points 19)
_______Section II: Publishing and Research (maximum allowed points 75)
_______Section III: Teaching Activities (maximum allowed points 106)
_______Section IV: Public Service (maximum allowed points 30)
_______Section V: Organizational Leadership (maximum allowed points 20)
_______Section VI: Service to the Subspecialty/ AAHPM (maximum allowed points 45)
Additional Requirements
Fellow Status Processing Fees
Fellow Status Processing Fee
The non-refundable fee for processing the fellow status application is $275, please pay by check, or
contact AAHPM Member Services at 847-375-4712 if you wish to pay by credit card.
Please make check payable to AAHPM and mail to:
AAHPM - Fellow Status Application
P.O. Box 3781
Oakbrook, IL 60522
All applications will be reviewed upon reciept of payment.
If you have any questions, please contact Emily Muse at emuse@aahpm.org or 847-375-6309.
30) Certification
I certify that the information I gave in this application accurately represents my professional status and
experience. If granted Fellow status, I understand that I must continue my membership in the
American Academy of Hospice and Palliative Medicine to maintain my FAAHPM. Further, I recognize
that any information on this application that is falsified may lead to the revocation of my Fellow status.
Name (Please Print): ___________________________________
Date: ____________________