AAHPM Fellow Status Application: June 3rd, 2019-September 16th, 2019

Eligibility Requirements to Apply

1. AAHPM physician members in good standing for at least five (5) consecutive years. Applicants who

have not completed 5 years of physician membership will NOT have their applications reviewed.

Fellow membership does not count toward this requirement.

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 the Hospice Medical Director Certification Board (HMDCB).

3. At least five (5) years of post-residency professional activity in the field of hospice and/or palliative

medicine. This requirement includes experience in clinical, educational, research, or administrative

roles, or combination of these activities as defined in the following pages.

4. Attendance at least one Annual Assembly in the past 5 years, or attendance at two in the course of

membership.

5. Significant expertise, commitment to scholarship and practice in the field of hospice and palliative

medicine, as provided on the following pages.

6. Two official forms of recommendation are required for consideration.

-One from a current Fellow of AAHPM; complete list of Fellows is available on the AAHPM web site

at: http://aahpm.org/membership/faahpm

-One from either a supervisor, colleague, or current member of AAHPM

Please share this link to the recommendation form. (Fellow of the AAHPM Recommendation Form

2019)

7. An attached Curriculum Vitae. (please limit to 8 pages)

8. Payment of the non-refundable $300 application processing fee. (Contact AAHPM Member

Services to pay at 847.375.4712)

9. If requested, complete a phone interview with a member(s) of the AAHPM Membership &

Communities Strategic Coordinating Committee.

Important Information:

-You must accrue a minimum of 120 points as defined by this application.

-Applications must be completed in a Word Document, hand written applications will not be

accepted

-Please note you do not need points in every section of this application to achieve the required 120

points.

-Enter each activity only once, do not duplicate entries, list each year separately where requested.

-If you need assistance, please contact AAHPM at 847.375.4712 or emuse@aahpm.org or

esmith@aahpm.org

Application Deadline: September 16th, 2019 at 12pm ET

AAHPM Application for Fellow Status 2019-2020

FAAHPM status will be awarded at convocation at Assembly 2020

Follow the instructions accompanying this form explicitly.

First Name: ___________________ Last Name: _________________________

Name as you wish it to appear on your FAAHPM Plaque:

__________________________________________________________________

Credentials: ___________________

Organization: ____________________________________________

Street Address: (Home preferred)__________________________________________

Apt/Suite/Office: ________________________________________

City: ___________________________________State: _______Postal Code: _________________

Email Address: ___________________________________________

Office Phone: ____________________________________________

Indicate current primary 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:____________________________________________

Indicate the year(s) you received re-certification.

____________________________________________

Section I: Academic Training and CME

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.) Please list the AAHPM Annual Assemblies you have attended.

(2 points per complete meeting attended, maximum 6 points)

Annual Assembly Month / Year

1

2

3

3.) List any AAHPM sponsored educational events (e.g., HMD Course, Intensive Board Review

Course, Fellowship Program Summit, LEAD, Leadership Forum Series; Ascend, Ignite or Clinical

Scholars Program) you have attended. (2 points per complete meeting, maximum 6 points)

Educational Event Month / Year

1

2

3

4) List any AAHPM sponsored CME activities (other than meetings) in which you have completed,

such as UNIPAC series, Essentials Series, HMD Prep, Webinars, HPM Fast or HPM PASS. (1 point

per activity, maximum 5 points)

AAHPM CME 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)

_______Attendance at AAHPM Annual Assemblies (max 6pts)

_______AAHPM Sponsored Educational Events (max 6 pts)

_______AAHPM Sponsored CME Activities (max 5 pts)

Section 1: Academic Training and CME Total: _______________________(max 25 pts)

Section II: Publishing and Research

1. List any Hospice and Palliative Medicine non-published research (Papers, Posters, or Case

Studies) presented at either an AAHPM Annual Assembly or National conference. (e.g. ASCO, AAP,

AGS, NHPCO, AMDA, etc.) (2 points per topic, maximum 10 points)

Title of Presentation Meeting Year

1

2

2.) List any research grants received relevant to Hospice and Palliative Medicine.

(5 points per grant, maximum 10 points)

Title Grant/Agency Month/Year Grant/Amount

1

2

3.) List authored research (systematic or narrative review) articles relevant to Hospice and

Palliative Medicine that you have published in a peer-reviewed journal. (5 five points per article,

maximum 20 points)

Article Title Name of Journal Month/Year

Published

1

2

3

4

5

4.) List other submissions (e.g. letter to editor, help desk answers, etc.) relevant to Hospice and Palliative

Medicine published in a peer reviewed journal. (2 points per published submission, maximum 10 points)

Article Title Name of Journal Month/Year

Published

1

2

3

4

5

5.) List any Hospice and Palliative Medicine articles you have published in a non-peer reviewed

clinical publication. (This may include Geri-Pall or PalliMed) (2 points per article, maximum 8

points)

Article/Title Name of Journal Month/Year

Published

1

2

3

4

6.) List any service on an editorial board for a medical publication or reviewer for any medical

journal related to Hospice and Palliative Medicine. (this may include service on the AAHPM

editorial board, PC-FACs editorial board or the AAHPM Quarterly editorial board) (1 point per

publication, maximum 4 points)

Publication Start/End Date

1

2

3

4

7.) List medical books, medical videos, medical web sites, medical recordings or CD-ROMS or

webinars you have authored or co-authored related to the field of Hospice and Palliative medicine.

(this may include AAHPM sponsored webinars, UNIPAC, Essentials, HMD Manual, HPM Primer,

HPM Pass or HPM Fast) (5 points per activity, maximum 20 points)

Title Month/Year

1

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 (20 pts max)

Other published submissions – Peer Reviewed (10 pts max)

_______Other Articles Published (8 pts max)

_______Editorial Board for Medical Publication(s) (4 pts max)

_______Authored or Co-Authored - Books, Videos, Webinars (20 pts max)

Section II: Publishing and Research Total: _______________________(max 82 pts)

Section III: Educational Activities and Teaching Awards

1.) List participation as a presenter at an AAHPM Annual Assembly. (pre-conference workshops,

concurrent sessions, and plenary sessions) (5 point per presentation, maximum 15 points)

Meeting Year Lecture Title

1

2

3

2) List participation as a presenter at an AAHPM educational course (this may include; HMD

Course, Current Concepts in Palliative Care, Intensive Board Review Course, LEAD, or Leadership

Forum Series) (3 point per presentation, maximum 9 points)

Meeting Lecture Title Month / Year

1

2

3

3.) List any service as a faculty member at a hospice and palliative medicine fellowship program.

(5 points per year, maximum 20 points)

Title Institution Location Year Served

1

2

3

4

4.) List any hospice and palliative medicine teaching activities where you have facilitated or

served as a preceptor for medical students, residents, nursing students or other clinical disciplines.

(4 points per student, max 40)

Name and

Professional Status

(Student, Resident,

Fellow, Med Student,

Other Health Care

Professional)

School / Institution Total Hours

1

2

3

4

5

6

7

8

9

10

5.) Describe mentoring of mid-career professionals, international clinicians, or team members.

Please indicate the length of time you worked with them. (4 points per individual mentored, 20

points max)

Description of Activity/ Time Dedicated Name and Professional

Discipline Year

1

2

3

4

5

6.) Provide information about occasions you have lectured about Hospice and Palliative Medicine,

to fellows, medical students and/or residents. (2 points per lecture hour, maximum 10 points)

Topic/Title of Lecture Organization Location Year Number of

hours

1

2

3

4

5

7.) Please list any teaching awards or honors you have received for your work in the educational

arena. (5 points per award, maximum 10 points)

Title of Award Organization Location Year

1

2

3

4

5

Please list your total point score below for Section III: Educational Activities and Teaching

Awards

_______Presenter at an AAHPM Annual Assembly (15 pts max)

_______Presenter at an AAHPM Course or Webinar (9 pts max)

_______Faculty Member at a Hospice and Palliative Medicine Fellowship Program (20 pts max)

_______Hospice and Palliative Medicine Educational Activities (40 pts max)

_______Mentoring Clinicians (20 pts max)

_______Lectured about HPM to clinical professionals (10 pts max)

_______Teaching awards and honors (10 pts max)

Section III: Educational Activities and Teaching Awards: _______________________(max 124 pts)

Section IV: Public Service

1.) List participation in charitable medical services or humanitarian medical missions outside your

regular practice or volunteer medical services you have performed (that relate to Hospice and

Palliative Medicine.) (i.e., humanitarian medical missions as a military physician, free clinic,

health care to homeless, etc.) (2 point per 8 hours, maximum 16 points)

Facility Activity Location Month /

Year

Number

of 8 - hrs

sessions

1

2

3

4

5

6

7

8

9

10

2.) 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. (2 point per activity, maximum 16 points)

Activity Group Location Month / Year

1

2

3

4

5

6

7

8

9

10

3.) List any hospice and palliative medicine education activities you performed outside of your

practice to educate the community. (this may include health fairs, writings for lay publications,

media activities, trainings for paramedics, EMTs, etc.)

(2 point per activity, maximum 10 points)

Description of Activity Group / Publication Year

1

2

3

4

5

6

7

8

9

10

Please list your total point score below for Section IV: Public Service

_______Participation in charitable medical services (16 pts max)

_______Public Relations activities (16 pts max)

_______Public Education activities (10 pts max)

Section IV: Public Service Total Points_____________________________ (42 pts max)

Section V: Organizational Leadership

1.) List where and when you served in an administrative position. (this may include, Hospice

Medical Director, IDG/IDT lead physician, CMO, Chief, etc) (4 points per year of service,

maximum 20 points)

Institution/ Facility/ Organization Year

1

2

3

4

5

2.) List information pertaining to positions held in external organizations and provide information

on how this position has advanced the field of Hospice and Palliative Medicine. (An example is

serving as a board member or chair of a committee for a professional society other than AAHPM. This may also

include leadership positions within your organization, Ethics Committee Chair, Hospital department chair,

Cancer Committee Chair or Representative) (2 points per year of service, maximum 10 points)

Position Hospital Year Rationale

1

2

3

4

5

Please list your total point score below for Section V: Organizational Leadership

_______Positions in Leadership within Institution (20 pts max)

_______ Positions in Leadership in External Organizations (10 pts max)

Section V: Organizational Leadership Total Points__________________________ (30 pts max)

Section VI: Service to the Subspecialty / AAHPM

1.) List any advocacy services you have performed in or been involved in pertaining to the sub

specialty. (1 point per activity, maximum 10 points)

Activity Date

1

2

3

2.) List if you have served as a delegate/alternate in the AMA or AOA, or state or county medical

society. (1 point per year of service, maximum 4 points)

Position Organization Year

1

2

3

4

3.) List any offices held in AAHPM (service as President, President-Elect, Treasurer, Secretary or

member at large of the Board of Directors, Strategic Coordinating Committee Chair) (3 points per

year in office, maximum 6 points)

Position / Office Held Year

1

2

4.) List the AAHPM committees/tasks forces/work groups/communities (SIGs, Forums,

Councils) where you have served as Chair, Chair Elect or Past Chair. (2 points per year in office,

maximum 10 points)

AAHPM Group Year

1

2

3

4

5

5.) List the AAHPM committees/tasks forces/work groups/communities (SIGs, Forums,

Councils) you have been a member of. (1 points per year, maximum 4 points)

AAHPM Group Year

1

2

3

4

6.) List any service 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 Year Served Position Held

1

2

3

4

7.) 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

_______Advocacy Services (10 pts max)

_______Positions Held as a Member of AMA, AOA (4 pts max)

_______ Offices Held in AAHPM (6 pts max)

_______ AAHPM Committees/Task Forces/Communities (Chaired) (10 pts max)

_______ AAHPM Committees/Task Forces/Communities (Membership) (4 pts max)

_______Service to AAHPM Publications (8 pts max)

_______Recipient of a Hospice or Palliative Medicine Award (6 pts max)

Section VI: Service to the Subspecialty / AAHPM Total Points _______________________ (48 pts

max)

FAAHPM Application Total Point Count:

Total Point Count AAHPM Fellow Status (maximum 357 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 25)

_______Section II: Publishing and Research (maximum allowed points 82)

_______Section III: Educational Activities and Awards (maximum allowed points 124)

_______Section IV: Public Service (maximum allowed points 42)

_______Section V: Organizational Leadership (maximum allowed points 30)

_______Section VI: Service to the Subspecialty/ AAHPM (maximum allowed points 48)

_______ Total Points

Fellow Status Processing Fee;

The non-refundable fee for processing the fellow status application is $300, 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

c/o Elizabeth Smith

P.O. Box 3781

Oakbrook, IL 60522

All applications will be reviewed upon receipt of payment.

If you have any questions, please contact Elizabeth Smith, esmith@aahpm.org.

Certification

I certify that the information I provided in this application accurately represents my professional

status and experience. If granted Fellow status, I understand that I must maintain 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: ____________________