Hospice and palliative medicine:
filling its seats, and still short of doctors

At a glance

Every specialty on this site involves a trade, and hospice and palliative medicine (HPM) presents a distinctive one: you give up procedural income and steep earning growth, and you get one of medicine’s shortest fellowships, a largely controllable and non-procedural life, near-total job security, and work its practitioners describe as some of the most meaningful in medicine. Two facts sit side by side: HPM fills a solid majority of its training positions each year, and the field is nonetheless short of physicians by a wide, documented margin. It is not a wide-open door the way geriatrics or infectious diseases are — but it is an accessible, deeply needed field for the person drawn to the work itself.

What it involves

Hospice and palliative medicine is the care of people living with serious, life-limiting illness — advanced cancer, heart failure, COPD, end-stage kidney and liver disease, dementia, ALS, and frailty. The work centers on relieving suffering: expert management of pain, breathlessness, nausea, delirium, and psychological and existential distress; leading prognosis and goals-of-care conversations; aligning treatment with what matters most to the patient; and supporting families through serious illness and bereavement. HPM physicians lead interdisciplinary teams — nurses, social workers, chaplains, pharmacists, aides — rather than working solo.

One distinction the whole field rests on, because patients and trainees routinely conflate the two: palliative care is specialized care for serious illness, appropriate at any stage, with no prognosis requirement, deliverable alongside curative treatment, and billed like any consultation⁵. Hospice is the subset for patients with a terminal prognosis — under the Medicare Hospice Benefit it requires certification of a life expectancy of 6 months or less if the illness runs its normal course, the patient elects comfort-focused care over curative treatment of the terminal condition, and it is financed as an all-inclusive per-diem, most often where the patient lives⁶.

Three practice realities, side by side

The critique that the field “blends” palliative care and hospice is fair — at the career-design level they are quite different jobs. Compare them directly:

Most physicians assemble a career that blends two or three of these, and pediatric palliative care (entered chiefly from pediatrics) and dual certification with geriatrics or oncology are common further paths.

The pathway, at a glance

The entry structure is HPM’s defining organizational fact, and it is simpler as a diagram than as prose:

How your base training shapes the job: an internist typically works adult inpatient consults and hospice; an emergency physician or anesthesiologist brings a different base skill set and sometimes different niches; pediatric palliative care runs through pediatrics. The many-doorway structure is why the applicant pool is so wide — and, as the IMG section shows, why it skews toward US graduates.

Competitiveness

Read the numbers carefully, because HPM does not follow the pattern of the other lower-filling fellowships: it fills a solid majority of its seats. In the 2026 appointment-year Match, HPM filled 79.5% of its positions — 380 of 478 across 198 programs — with 62 programs finishing with at least one position unfilled. That is far higher than geriatrics (38.9%), infectious disease (60.9%), or addiction medicine (63.8%), and it means HPM is genuinely competitive in a way those fields are not, though it sits below sleep (93.7%) and the near-saturated procedural specialties. The process is still forgiving: of 406 applicants who preferred HPM, 372 (91.6%) matched². The five-year trend is a gentle downward drift in fill (85.3% in 2022 → 79.5% in 2026) against slowly growing capacity, and the independent peer-reviewed picture agrees: from 2016 to 2024 programs, positions, and applicants all grew by half or more while the filled-position rate stayed statistically flat around 81–83%⁹. The honest headline is neither “wide open” nor “hard to get”: a genuinely interested, well-rounded applicant can reasonably expect to enter, but the field still turns some away — the constraint is the size of the interested pool, not the number of seats.

Read it as a mentor would: the reasonable odds are an invitation, not a reason on their own. HPM asks for a specific temperament and a real tolerance for grief and ambiguity; a resident who enters for the short fellowship or the schedule alone tends to struggle. If a palliative rotation, a hard family meeting, or a patient you helped die well once moved you, this field will take you gladly.

Skills & personality

The single most important competency in HPM is communication — leading goals-of-care conversations, delivering serious news, eliciting a patient’s values, navigating prognostic uncertainty, and mediating conflict among patients, families, and clinicians. This is the field’s defining clinical act, its true “procedure,” learned with as much rigor as any technical skill. Alongside it, HPM rewards strong pharmacology — opioids and adjuvant analgesics, antiemetics, complex symptom regimens in fragile patients — and genuine comfort with prognostication across a huge range of diseases.

Those who thrive share comfort with emotionally intense, ambiguous situations and with death and dying; a real team orientation, because HPM physicians lead interdisciplinary teams rather than direct care alone; patience and humility; and a tolerance for outcomes measured in quality and dignity rather than cure. Much of the inpatient work is consultative, so cross-specialty diplomacy — influencing rather than commanding — matters.

Who tends to be unhappy? Physicians who draw their primary satisfaction from procedures, from “fixing” and curing, or from fast-paced acute intervention; those for whom income is the dominant motivator; those who find repeated grief exposure corrosive rather than meaningful; and those who dislike advising within a team. The meaning has to carry you here, because the paycheck and the pace will not.

Lifestyle & the emotional labor

HPM generally offers a more controllable lifestyle than most IM subspecialties: minimal procedural load, no procedure-related emergencies, and after-hours work that is triage and phone advice rather than physical rescue. But it varies by setting (the three-practice table above): an outpatient clinic is the most predictable; an inpatient consult service is weekday-heavy with some weekend coverage and a census that can run busy; hospice practice is scheduled and community-based but adds home visits, driving, and after-hours certification and symptom calls. The low procedural load and the feasibility of part-time and telehealth work make HPM unusually flexible over a career.

Now the part no candid profile can skip: this is emotionally demanding work, and the “meaning–burnout paradox” is real — a strong, durable sense of purpose coexisting with genuine grief exposure. Burnout in the field is about 38.7% overall (41.9% among physicians) by the best corrected data — real and worth respecting, and notably, that figure supersedes a widely circulated 62% that was retracted in 2020 for a scoring error, so treat older crisis-framing citations with caution¹⁰. The emotional labor is genuine; the crisis framing was overstated.

Compensation

Be candid up front: HPM is one of the more modestly compensated physician fields, structured very differently from the procedural specialties. Every major survey places it among the lower-paid fields, roughly at general internal medicine levels — Doximity put general internal medicine near $326,116 in 2024 data, and HPM tracks there rather than to the high-RVU specialties³¹¹. There is no clean standalone HPM figure because pay is blended and salaried, but the direction is unambiguous: below cardiology, GI, and the procedural fields, with a lower and flatter ceiling.

Why pay is structured this way. HPM income comes almost entirely from cognitive work — E/M billing for inpatient and outpatient consults, and advance-care-planning billing — and the field performs virtually no high-RVU procedures; the long family meeting and interdisciplinary coordination are time-intensive and under-rewarded by fee-for-service. On the hospice side the economics run through the Medicare per-diem, not fee-for-service, and most hospice physicians are salaried or hold medical-director roles rather than billing per encounter. The common income supplement is a hospice or inpatient-unit medical directorship, and compensation rises modestly with experience and, more so, with administrative and leadership roles. The economics may improve structurally as value-based and serious-illness payment models increasingly pay for exactly the coordination HPM produces.

Intellectual scope

The intellectual life of HPM is cognitive, integrative, and communication-heavy rather than procedural, and it is a real draw for generalists. A typical day mixes complex symptom management (pharmacologic reasoning across opioids, neuropathic agents, antiemetics, and palliative sedation), goals-of-care and family meetings (often the most demanding part of the day), interdisciplinary team rounds, and prognostication across an enormous range of diseases — oncologic, cardiac, pulmonary, renal, neurologic, and geriatric. That diagnostic and pharmacologic breadth appeals to physicians who do not want to narrow to a single organ.

The field rests on a real and growing evidence base. Its foundational result is Temel and colleagues’ 2010 NEJM trial: patients with metastatic lung cancer randomized to early palliative care alongside oncology had better quality of life and mood, less aggressive end-of-life care, and — strikingly — longer median survival (11.6 vs 8.9 months) despite less aggressive treatment¹². It captures the field’s central, counterintuitive claim: attending to suffering and goals is not giving up on a patient, and can go hand in hand with living longer and better. Beyond the bedside, HPM supports active work in research, medical education (teaching “primary palliative care” skills to all clinicians), quality and health-services work, and telehealth and community-based care-model design.

Pathways & career arc

The job market is one of HPM’s strongest practical selling points: demand consistently outstrips supply. Employment spans hospital and health-system roles (the most common, bundling inpatient consults and often an outpatient clinic), academic practice, hospice employment (clinical care plus medical directorship), and hybrid and non-clinical roles. Palliative care is now standard in most large hospitals — 83.6% of hospitals with 50+ beds, 96.2% with 300+ — but access is deeply uneven, reaching only 49.0% of for-profit and 34.5% of rural hospitals, and the specialist base is thin: about 19,920 certified clinicians nationwide (2.86 per 100,000)⁴. The peer-reviewed workforce literature points the same way — the field would need to grow from ~325 to 500–600 fellowship graduates a year by 2030 to keep pace, a pipeline that has not grown nearly that fast¹³¹⁴.

Job availability is not the same as a good job. The shortage means you can find work almost anywhere, but the roles differ enormously in quality: a solo palliative consultant with no social worker or chaplain and an uncapped census is a fundamentally different (and less sustainable) job than a fully staffed interdisciplinary team. “Geographic freedom” is real, but assess team staffing, inpatient coverage, and a sustainable census — not merely whether a job exists — before you take it.

The career arc, honestly. HPM is one of the more durable and sustainable careers in medicine — cognitive, non-procedural, part-time- and telehealth-friendly — and its distinctive arc is toward leadership and program-building: medical direction, palliative-program development, education, quality and serious-illness-payment work. The emotional load, not a physical clock, is the real sustainability variable, which is why the team-and-supports questions above matter as much for a thirty-year career as the starting salary. A second, non-clinical domain (program leadership, health-services research, education) is unusually accessible.

Choosing a fellowship & first job

Because a seat is usually available and the roles vary so much, the applicant’s real job is to choose a good program and a sustainable job — and, for hospice work, to understand the compliance duties before you sign.

On the fellowship itself: because programs vary in setting breadth and team resources, weigh mentorship, the mix of inpatient/outpatient/hospice exposure, and whether the program actually teaches the communication and leadership skills the field runs on — not merely that a seat is open.

IMG considerations

Here the honest picture is more nuanced than the enthusiasm you may have read elsewhere. HPM is accessible — it fills only 79.5% of its seats and 91.6% of preferring applicants match — but, unlike geriatrics, nephrology, or infectious diseases, it is not an IMG-dependent field. In the 2026 Match, of 380 filled positions, US MD graduates took 59.2% and DO graduates 20.5%, while US-citizen IMGs took 12.6% and non-US-citizen IMGs 7.6% — IMGs 20.3% of the matched class, below the 29.5% SMS average². And the peer-reviewed analysis shows US MD graduates matched at a higher rate than non-US MD graduates (86.1% vs 79.8%) over 2016–2024, with the US-citizen-IMG share of fellows declining from 15.9% to 10.7%⁹. So this is a field an IMG can absolutely enter — IMGs are one in five fellows, a meaningful and valued presence — but it is a more competitive door than the wide-open IM fellowships, and the trend has been gently downward. Frame it as attainable with genuine, demonstrated commitment, not a soft landing. (Two companion analyses take up the wider questions: whether international graduates take US graduates' spots, and the H-1B for physicians in training; practical planning lives on the IMG guide.)

On the practical hurdles: visa sponsorship and the compensation trade are the hard parts, not the Match. J-1 sponsorship through ECFMG is the standard training route; H-1B is program-specific and less widespread, so confirm each program’s policy early¹⁵. HPM’s need sits partly in the rural, community-based, and underserved settings that open J-1 waiver routes such as Conrad 30 — so an IMG willing to serve where the need is greatest can align job availability with a waiver placement, though because palliative demand is spread across hospitals nationally, this coherence is real but looser than in infectious diseases, and each waiver job must be verified¹⁶.

Eligibility follows the usual package: completion of an ACGME-accredited residency in a qualifying specialty, a valid ECFMG certificate, USMLE and licensure requirements met, and — most persuasively — evidence of sustained, genuine interest in the care of seriously ill patients.

Bottom line

Consider hospice and palliative medicine if you find deep meaning in caring for seriously ill and dying patients and their families; you want to master the goals-of-care conversation rather than avoid it; you value broad diagnostic and pharmacologic reasoning without a procedural focus; you want a controllable, largely non-procedural life with lighter call and flexible, part-time-feasible options; and you want excellent job security and geographic choice, and are content to trade top-tier income for mission and balance. One of medicine’s shortest fellowships opens all of it.

It may not fit if income or procedures are primary motivators; if repeated grief exposure and sustained empathy under distress wear on you rather than sustain you; if you would rather direct care unilaterally than work consultatively within a team; or if you want a steep, volume-driven income trajectory. And for IMGs specifically: it is attainable but more competitive and more US-graduate-heavy than the wide-open IM fellowships, so enter it for the work.

A last mentor’s note, and it is the honest thesis of this page: HPM is unusual in filling most of its seats while remaining badly short of physicians — because demand for serious-illness care is growing far faster than a small, one-year pipeline can. It offers one of medicine’s shortest fellowship paths, one of its most reliable job markets, and one of its highest senses of purpose, at the cost of modest, largely flat pay and genuine emotional demands. For the right physician, that trade is not a compromise; it is the whole point. Find a palliative physician at your program, spend a day on the consult service or in a hospice, ask why they do this work — and, when the offers come, weigh the team and the supports as carefully as the salary. If their reasons resonate, you have likely found your calling.

References

1. American Academy of Hospice and Palliative Medicine. (n.d.). Subspecialty certification. https://aahpm.org/career-resources/subspecialty-certification/ One subspecialty shared across ten ABMS member boards (anesthesiology, emergency medicine, family medicine, internal medicine, ob-gyn, pediatrics, PM&R, psychiatry and neurology, radiology, surgery); ABIM administers a single exam on behalf of all ten. The 12-month fellowship has been the only route since 2014. ↩
2. National Resident Matching Program. (2026). Results and data: Specialties Matching Service, 2026 appointment year. https://www.nrmp.org/match-data/ Hospice and palliative medicine: 478 positions across 198 programs, 380 filled (79.5%); 62 programs finished with ≥1 unfilled position. Of 406 applicants preferring it, 372 (91.6%) matched; of 451 ranking it, 233 (51.7%) matched their first-ranked program, 34 (7.5%) unmatched. Five-year fill trend: 85.3% (2022) → 79.5% (2026). Matched class: 225 US MD (59.2%), 78 DO (20.5%), 48 US-citizen IMG (12.6%), 29 non-US-citizen IMG (7.6%) — IMGs 20.3%, below the 29.5% SMS average. ↩₁ ↩₂ ↩₃
3. Doximity. (2025). Physician compensation report 2025 (2024 data). https://www.doximity.com/reports/physician-compensation-report/2025 Self-reported/modeled survey. HPM has no clean standalone figure, but its pay sits roughly at general internal medicine, which Doximity placed near $326,116. Well below the procedural specialties. ↩₁ ↩₂
4. Center to Advance Palliative Care. (2024). Serious illness scorecard. https://scorecard.capc.org/ 83.6% of US hospitals with 50+ beds and 96.2% with 300+ beds report specialty palliative care, but only 49.0% of for-profit and 34.5% of rural hospitals; 19,920 clinicians hold HPM specialty certification nationwide (about 2.86 certified prescribers per 100,000 population). ↩₁ ↩₂
5. Center to Advance Palliative Care. (n.d.). What is palliative care? https://www.capc.org/about/palliative-care/ Specialized care for people living with a serious illness, appropriate at any age and stage, deliverable alongside curative treatment; no prognosis requirement, billed like any specialist consultation. ↩
6. Certification of terminal illness, 42 C.F.R. § 418.22. https://www.law.cornell.edu/cfr/text/42/418.22 The Medicare Hospice Benefit requires certification of a life expectancy of 6 months or less if the terminal illness runs its normal course, made for the initial period by the hospice medical director (or designee) and, if the patient has one, the attending physician (§418.22(c)(1) conditions the second certifier on the patient having an attending). ↩
7. Accreditation Council for Graduate Medical Education. (2025). Program requirements for graduate medical education in hospice and palliative medicine (reformatted). https://www.acgme.org/globalassets/pfassets/programrequirements/2025-reformatted-requirements/540_hospicepalliativemedicine_2025_reformatted.pdf The fellowship "must consist of 12 months" of training. ↩
8. American Board of Internal Medicine. (n.d.). Hospice and palliative medicine certification policies. https://www.abim.org/certification/policies/internal-medicine-subspecialty-policies/hospice-and-palliative-medicine/ 12-month fellowship, no required procedures; ABIM administers the exam; the earlier practice pathway was discontinued after the 2012 administration. ↩
9. Goyal, A., et al. (2025). Demographic variations and temporal trends in hospice and palliative care fellowship matches in the United States. Scientific Reports. https://pmc.ncbi.nlm.nih.gov/articles/PMC12334630/ 2016–2024: programs grew 122→185 (+51.6%), positions 280→451 (+61.1%), applicants 259→454 (+75.2%); filled-position rate moved only 80.7%→83.1% (flat). US MD graduates matched at 86.1% vs 79.8% for non-US MD graduates (P<0.001); the US-citizen-IMG share of fellows declined from 15.9% to 10.7%. ↩₁ ↩₂
10. Retraction: Prevalence and predictors of burnout among hospice and palliative care professionals. (2020). Journal of Pain and Symptom Management, 59(5), 965. https://pubmed.ncbi.nlm.nih.gov/32334776/ The widely cited 62% burnout figure was retracted in 2020 for a Maslach Burnout Inventory scoring error; the corrected prevalence is 38.7% overall (41.9% physicians, 37.1% other clinicians). The original 2016 paper should not be cited for a burnout figure. Burnout numbers in this field vary by instrument and era. ↩
11. MGMA / Medscape. (2024–2026). Provider compensation data. Subscription-gated, not reproduced here. Every major survey places HPM among the lower-paid fields, roughly at general internal medicine levels and well below cardiology, GI, and other high-RVU specialties; the federal wage tables do not break the field out. ↩
12. Temel, J. S., et al. (2010). Early palliative care for patients with metastatic non–small-cell lung cancer. New England Journal of Medicine. https://pubmed.ncbi.nlm.nih.gov/20818875/ 151 patients randomized to early integrated palliative care vs standard oncology care: better quality of life and mood, less aggressive end-of-life care, and longer median survival (11.6 vs 8.9 months, P=0.02) despite less aggressive treatment. ↩
13. Lupu, D., et al. (2018). The growing demand for hospice and palliative medicine physicians: Will the supply keep up? Journal of Pain and Symptom Management. https://pubmed.ncbi.nlm.nih.gov/29410071/ Projected a need to grow from roughly 325 to 500–600 fellowship graduates per year by 2030 — a pipeline the Match numbers show has not grown nearly that fast. A model with explicit assumptions. ↩
14. Kamal, A. H., et al. (2019). Policy changes key to promoting sustainability and growth of the specialty palliative care workforce. Health Affairs. https://pubmed.ncbi.nlm.nih.gov/31158018/ Modeled clinician attrition and concluded that sustained growth in fellowship positions over a decade could reverse the worsening shortage — a solvable pipeline question rather than an inevitability. ↩
15. Educational Commission for Foreign Medical Graduates. (n.d.). Exchange Visitor Sponsorship Program (J-1): General information. https://www.ecfmg.org/evsp/applying-general.html ↩
16. U.S. Citizenship and Immigration Services. (n.d.). Conrad 30 Waiver Program. https://www.uscis.gov/working-in-the-united-states/students-and-exchange-visitors/conrad-30-waiver-program J-1 waiver requires placement in a designated shortage area and employer sponsorship; the eligible job location must be verified. ↩
17. Restriction on Entry of Certain Nonimmigrant Workers, Proclamation No. 10973. (2025, September 24). Federal Register. https://www.federalregister.gov/documents/2025/09/24/2025-18601/restriction-on-entry-of-certain-nonimmigrant-workers Signed September 19, 2025; effective September 21, 2025. Imposes a $100,000 payment requirement on certain new H-1B petitions for beneficiaries outside the United States, with national-interest exemptions and a twelve-month sunset absent extension. ↩
18. U.S. Citizenship and Immigration Services. (2025). H-1B: Frequently asked questions on the September 2025 proclamation. https://www.uscis.gov/newsroom/alerts/h-1b-faq USCIS guidance that the payment requirement applies to new petitions for beneficiaries outside the United States without a valid H-1B visa, and does not reach previously issued visas, earlier-filed petitions, renewals, or change-of-status, amendment, and extension petitions for people already in the country. ↩
19. State of California v. Mullin, No. 1:25-cv-13829-LTS (D. Mass. June 8, 2026) (Sorokin, J.), appeal docketed, No. 26-01699 (1st Cir. 2026). https://www.fragomen.com/insights/united-states-district-court-temporarily-stays-order-vacating-dollar100000-h-1b-fee.html The district court vacated the payment requirement on June 8, 2026 as an unlawful tax and Administrative Procedure Act violation, then temporarily stayed its own order on June 12, 2026 pending appeal; the government appealed to the First Circuit. The requirement therefore remains operational for affected petitions at this writing. A fast-moving matter — verify current status before relying. ↩

Figures here are survey-, model-, and Match-based and shift year to year; there is no clean standalone HPM compensation figure, so pay is anchored to general internal medicine and read directionally; workforce figures are model-based; and the visa landscape is in active flux and litigation. Verify against the primary source before relying on any single figure for a career, contract, or immigration decision. This page is educational and is not career, financial, immigration, or legal advice.