Early Career Physician Award

1/9 Nominator's Information

Please fill out this form as the nominator suggesting a nominee for the Early Physician Career Award.
As nominator, please tell us about yourself.
Name*
First Last
Title
Organization
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Email Address*

2/9 Nominee's Information

Please fill out this form with your nominee's contact information.
Name*
First Last
Title*
Organization
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Email Address*

3/9 Nominee's CV
Please provide a current CV for the nominee at the PDF, JPG, DOC or TXT format
Drop files here or

Accepted file types: pdf, jpg, doc, txt, Max. file size: 300 MB.

4/9 TECHNICAL COMPETENCE
Please provide a description of the nominee's excellence in TECHNICAL COMPETENCE*
Competence is a baseline requirement. It encompasses both technical knowledge of the best means of care as well as skill in determining how best to deploy care with individual patients. The ‘art’ and science of medicine and nursing comes into play. Please consider specific examples of board certifications, advance trainings/certificates received and/or new or novel curriculum developed, etc (500 words or less)

5/9 PERSONAL INTEGRITY
Please provide a description of the nominee's excellence in PERSONAL INTEGRITY*
Personal integrity means that combination of personality traits and virtues most conducive to good end-of-life care. Humility is a key virtue.That means knowing what one does not know, a willingness to shift modes of treatment when an earlier course proves inefficacious, and a sharing of uncertainty with colleagues. Friendship with patients, though not always possible, is an advantage. Dying can be lonely, and often only the clinician is in a position to be a steadfast companion. Availability is hardly less important, but it requires openness to inconvenience and schedule disruption. A willingness to make house calls to avoid unnecessary visits to hospitals or physician offices is an important mark of availability. Most fundamentally, patients need to know they will not be abandoned. Come what may, the clinician must be there until the very end. Notes for items to consider in this section can include but not limited to: specific examples of other awards or recognitions from other organizations received by nominee, quotes from patients or care givers of loved one, examples of an “extra layer of care” provided, etc. (500 words or less)

6/9 FAMILY AND FRIENDS
Please provide a description of the nominee's excellence in ACTIVE ENGAGEMENT OF FAMILY AND FRIENDS*
Most patients have family and friends, and how a patient fares will be affected by their relationship with them. The family needs its own assessment and dialogue initiated. While a clinician may not be well placed to help resolve all problems or tensions between patients and families, it is useful to be aware of them. (500 words or less)

7/9 DOCTOR/PATIENT DIALOGUE
Please provide a description of the nominee's excellence in CLINICIAN/PATIENT DIALOGUE*
As far as possible, a dying person should be actively engaged in his or her care. Minimally, this means understanding the likely nature, course, and trajectory of treatment. The clinician should let the patient know what to expect and what is being done to help. The physician should also seek the patient’s informed involvement in decision-making. A clinician’s first task should be to assess the patient to gain a sense of what to say and not say – that is, what kind of a dialogue it is likely to be, and how to change it if it is initially not promising. Dialogue involves more than just communicating information; it is as much about listening. Notes for items to consider in this section can include but not limited to: specific examples of trainings that the nominee has completed, titles of any publications or articles authored by applicant in this arena, awards for communication or empathy, specific patient or caregiver quotes, etc. (500 words or less)

8/9 TEAM WORK
Please provide a description of the nominee's excellence in TEAM WORK*
Few clinicians work alone and, especially with end-of-life care, cooperation among caregivers is crucial. There will be different people providing different kinds of care, so coordination and full engagement among them is important. This is particularly so with regard to nurses and nursing assistants. Often, nurses have the greatest knowledge of the patient’s day to day experience and family concerns. This is true in all settings, and especially in home care. Continuity of care is especially important, and the principal clinician caring for the patient has a special responsibility to make certain the patient knows who is in charge and that his or her personal physician will be there when needed. For all these reasons, the ability to work well with a team is an important ingredient of good care. Notes for items to consider in this section can include but not limited to: specific examples of team trainings that applicant developed or participated in, quotes from colleagues, awards for team work, titles of any publications or articles authored by the applicant in this arena, examples of other committees or initiatives led by nominee, etc. (500 words or less)

9/9 SUMMARY
SUMMARY*
Provide a brief (250 words or less) summary of the leadership and impact the nominee has as a role model for other physicians and nurses and for those in the community they serve. Nominating individuals are encouraged to provide as many specific examples of how this particular nominee exhibits exemplary characteristics in each category appropriate for their stage of career and experience. General statements about the importance of each of these arenas are commonly assumed by the selection committee for all nominees.