A Complex Landscape of Certification and Credentialing Defines the HPM Workforce
By Larry Beresford
Shortfalls in the subspecialty-trained and -credentialed workforce in hospice and palliative medicine (HPM) in the United States have been well documented1 and have been a major focus for the American Academy of Hospice and Palliative Medicine (AAHPM) for nearly a decade. Progress is being made on a number of fronts, but need continues to outstrip supply. Although the Academy is not responsible for board certification of physicians in HPM, it is actively engaged in providing education and resources, as well as advocating on behalf of its members.
“We just don’t have enough people trained in the subspecialty of HPM or in generalist palliative care skills like pain management or communication with patients and families about treatment decisions,” said Holly Yang, MD MSHPEd HMDC FACP FAAHPM, a palliative care physician in San Diego, CA, and immediate past-chair of AAHPM’s Workforce Advisory Group.
“It’s a critical issue of access for patients and families who have serious illnesses. At the same time, we are gaining ground and have more highly trained people than we’ve ever had,” Yang said. “But state and national advocacy will be critical for us to continue to work on improving access to care from appropriately credentialed professionals for our patients and families who need palliative care and hospice.”
With demand continuing to increase for both hospice and palliative care, the good news is that HPM has become well established as a medical subspecialty and as an essential part of the healthcare continuum. In a sense, the workforce pressures and dilemmas reflect the field’s successes over the past decade in achieving recognition as a legitimate medical subspecialty with a particular body of knowledge. But with that recognition comes limitations imposed by the medical establishment.
The push to achieve recognition as a subspecialty led to a decision in 2006 by the American Board of Medical Specialties (ABMS) and 10 of its constituent specialty boards to offer HPM subspecialty board certification starting in 2008. The American Osteopathic Association (AOA) and four of its constituent boards instituted similar recognition.
Previously, approximately 5,000 practicing HPM physicians were allowed to sit for the ABMS and AOA board certification exams based on their work experience and prior certification from the former American Board of Hospice and Palliative Medicine without having to complete a fellowship, a process known as “grandfathering.” But starting in 2012, board certification has required completion of a full-time, full-year fellowship in an accredited HPM fellowship program, just as with other recognized medical specialties. Current cumulative totals are 7,618 HPM board certifications from ABMS and AOA—and 7,469 active certifications.
What Are the Workforce ‘Inputs’?
Workforce inputs—the various factors that shape the complex landscape of the HPM workforce—include the number of annual HPM fellowship slots, currently 344 based at 143 accredited programs (including about 25 pediatric HPM slots). Even though the number of fellowship slots has grown year over year, with projected physician shortfalls in the thousands, the field likely could use 500–600 slots per year. But such rapid growth would require greatly expanded funding for training sites. It also is unclear whether there are enough residents interested in filling that many slots given the current “fill rate” for fellowship programs of 88%.
Board certification is the gold standard for physician credentialing, driving the search for alternatives to a full- time, year-long fellowship to qualify. “I think for a long time, people thought that maybe once we got in the door, we could convince the medical establishment that hospice and palliative medicine is unique and might be treated differently,” said Steve Smith, AAHPM executive director and CEO. “But we’ve been told multiple times by ABMS that granting board certification without a traditional fellowship is not going to happen—even though there are creative alternatives that have been proposed and explored.” However, as graduate medical education moves toward competency-based training, there will be new opportunities to propose innovative fellowship models in the future.
Some board-certified physicians in HPM eventually will leave the workforce as the result of retirement or prematurely in response to stress, burnout, lack of job satisfaction, and other factors. Others may be dissuaded from keeping up their board certification status because of the requirements for maintaining their certification in their primary field—particularly if they feel these requirements are not relevant to their current medical practice in HPM.
Mid-career physicians who feel an affinity for this work may find it difficult to take time off for a year-long, full-time fellowship in HPM in order to qualify for subspecialty board certification—even though they may bring experience and personal qualities that the field needs. “Being drawn to this work doesn’t necessarily happen at the beginning of a medical career. Many physicians only develop an interest in palliative or end-of-life care after considerable professional and life experience,” said Dale Lupu, MPH PhD, associate research professor in the Center for Aging, Health, and Humanities at George Washington University. “We need innovative options for physicians who want to enter the subspecialty mid-career.”
Other new models are emerging for those who seek additional expertise in hospice and palliative care but don’t plan to become HPM subspecialists. Two interdisciplinary Master of Science degree programs in palliative care at the University of Colorado and University of Maryland offer online access and flexible schedules for most or all of their curriculum. The Hospice Medical Director Certification Board (HMDCB) is another avenue for recognizing and credentialing a relevant skill set, having credentialed nearly a thousand physicians for demonstrating the skills needed to serve as a medical director in hospice care.
Physicians practicing in hospice aren’t always fellowship trained, so offering this additional HMDC credential has been a very good thing, Yang said. “It’s a certification that recognizes physicians for expertise in hospice care based on their time spent providing hospice care and a knowledge exam. It’s a mark that you have the know-how to care for people who need hospice care, with a specialized body of knowledge. Some of us are certified both ways: HPM and HMDC.”
Efforts to engage, motivate, and train all physicians in primary palliative care also are important to help extend capacity and complement the credentialed subspecialists. “But training in this area is very ad hoc and we don’t have a way currently to give a stamp of approval for skills in primary palliative care or to quantify the extent to which practitioners possess primary palliative care skills,” Lupu said.
The Supply and Demand Model
Yang compared workforce issues in HPM to any economic model of supply and demand. “What is the job market for new fellows? Where are the gaps in supply and demand? And looking at the other side, what do these new people think about their career opportunities? We can say there is not enough workforce—but we’ve never had enough doctors in this field,” she said. “That doesn’t mean we should stop trying to advocate for increasing the workforce, but I’m from the glass-is-filling school. I think our field has become more recognized by mainstream medicine as we’ve expanded our role and moved into newer areas such as community-based palliative care.”
Every year the fellowship numbers go up, Yang said. “But the issue remains: how do we draw more people into the field and enable them to practice to the maximum of their training? We need a workforce of people who truly care about and are committed to this work. How can we be more creative in growing the field?” she asked. Burnout is another huge topic in medicine, Yang said. “How can the Academy help promote resiliency for its members, which could help them stay in their careers longer?” (See AAHPM’s spring 2018 Quarterly newsletter for an exploration of this subject.)
F. Amos Bailey, MD FACP FAAHPM, professor of palliative medicine and founding director of the Master of Science in Palliative Care/Interprofessional Palliative Care Certification at the University of Colorado, was involved in the push to make HPM a subspecialty. “I’ve always been supportive, and I thought becoming a board subspecialty was the right thing to do in order for us to have credibility as a field. It certainly has lent credibility to the university work I do as a tenured full professor. So from an academic standpoint, it was the right thing to do,” he said.
But despite opening some doors, the recognition may have closed others. “When we look at the landscape of our field, I see a lot of people who were grandfathered in that are now at an advancing age. I’m 61, and it’s hard for me to think that the board-certified doctors who are now approaching retirement age will be easily replaced. It’s also clear that we’re never going to make up the gap by fellowships alone,” he said.
“I also see a number of mid-career physicians who work in family practice, internal medicine, or other specialties but have found a vocation for palliative care. I use that word intentionally—it really is a calling and a practice they feel they are supposed to be doing with their lives. Some of them might feel this calling so greatly that they’d quit their jobs to do a full-year, full-time fellowship. Others can’t do a fellowship, and for many doctors there are limits to how much they can achieve with self-education,” he said. “ABMS and ACGME are careful about the quality of training a person needs to complete in order to be eligible for board certification. They don’t want it to be devalued. And that’s our dilemma.”
Online Education Innovations
For Dr. Bailey, the Master in Palliative Care at the University of Colorado offers a partial answer. The interprofessional coursework prepares professionals to work as a palliative care providers in the community. Physicians, nurses, pharmacists, and physician assistants can earn a master’s degree after completing the full program of 12 classes and 36 credit hours over 2 years of training, along with a capstone scholarly project.
“We’ll graduate our first 13 master participants in July, and we have potential to scale up from there. We use the best online pedagogy and offer it asynchronously, but also with three 4-day, long-weekend, on-campus intensives,” Bailey said. The program is set up to mirror the HPM fellowship curriculum as much as possible. “We’re case based and narrative driven. Every week’s coursework starts with a video of a simulated patient/family encounter, with problems to solve that lend themselves to bio-medical, psychosocial, spiritual, and ethical approaches,” he said.
A similar master’s program, offered entirely online at the University of Maryland, started in the spring of 2017 with 130 participants. Courses are team-taught by experts in the field. “I’m a big fan of self-determined learning,” said the program’s director, Mary Lynn McPherson, PharmD. It includes 10 courses and 30 academic credits. Initial sessions present principles and practices of hospice and palliative medicine, and then students can specialize and earn two or more of five specialized graduate certificates. Final courses for the master’s degree highlight research and clinical outcomes and other courses explore advanced illness in special settings and communication skills refinement.
“One thing I hear from our participating physicians is they want to sit for board exams after completing our master’s program,” Bailey said. “I have to tell them that is not feasible. Physicians who complete our program will have the skills to start hospice and palliative programs and to perform palliative consultations. But it will be up to their institutions whether or not to accept this credential for those roles.”
Maintenance of Certification Generates Controversy
One of the biggest flashpoints in physician credentialing today is maintenance of certification (MOC), which is defined by ABMS as “a system of ongoing professional development and practice assessment and improvement” for the continuous development of board-certified physicians’ skill sets. MOC is complicated, Lupu said, and that’s part of what people don’t like about it. Since 2015, ABMS has been working on addressing physicians’ dissatisfaction with MOC, trying to place greater emphasis on practical applications such as patient safety and working on teams.
Different specialty boards have taken different approaches to MOC for HPM. Half require continuing the doctor’s primary board certification, with additional fees and testing, and half do not. The boards also are exploring annual or biannual check-ins or longitudinal assessments (for example, a question of the week sent to diplomats, who need to answer a certain percentage of the questions over a year). These more frequent assessments could better reflect the latest research in the field and rapid changes in medical practice.
AAHPM’s Chief Learning Officer Julie Bruno, MSW LCSW, works closely with leaders at the 10 specialty certifying boards and often relays the concerns of HPM practitioners. “We want to maintain the value of certification, but if you have people doing activities that aren’t relevant to their careers, it will turn them off and they may stop participating,” she said. “And we need to have as many actively certified HPM physicians recertified as possible—that is the key to retaining the workforce.”
“These are complex issues requiring a kind of balancing act,” said Joseph Rotella, MD MBA HMDC FAAHPM, the Academy’s chief medical officer. “On the one hand, it is important that we are recognized as a medical subspecialty in our own right. That will be even more important to retain a seat at the table where organized medicine defines healthcare reform. To be recognized as a subspecialty, we must have standards and competencies and all that these entail, including accredited fellowship programs. But if that makes it too hard to obtain or to retain certification, what does that mean to our workforce?”
Academy Leads Workforce Initiatives
“AAHPM defines workforce broadly,” Smith said. The Academy sees its role as helping qualified people find their way into the workforce and then keeping them engaged throughout their career. It also has undertaken research to better understand workforce needs and trends. “Attracting physicians to the field is only part of the challenge. We also need to retain as many practicing physicians as possible by supporting their learning, certification preparations, and professional resilience,” he said.
“We also are interested in alternative pathways and building bridges to primary care practitioners, who are—or should be—interested in developing primary/generalist palliative care skills. For example, we now have a Primary Care Special Interest Group within the Academy. This group and other committees are considering ways AAHPM can support this emerging and expanding group.”
Reflecting on the complexity of the issues and the varied inputs that contribute to the workforce and its adequacy, AAHPM has pursued workforce development and credentialing on a variety of fronts. For example, AAHPM has
- collaborated with the George Washington University Health Workforce Institute to study the supply, distribution, need, and demand for HPM physicians.2 This includes surveys of new graduates of HPM fellowship programs about their experiences and attitudes, with plans to hold focus groups of physicians.
- gathered case stories from members who contact the Academy seeking guidance on certification and wrote letters on their behalf to the various certification boards. The AAHPM Connect member online community also offers additional opportunities to discuss MOC issues.
- sought and obtained grants to establish and support additional fellowships in HPM and published a fellowship funding guide.
- recommended a team of AAHPM leaders to work with the National Board of Medical Examiners in reviewing palliative care content in the U.S. Medical Licensure Exam—and the need to better reflect in the exam basic palliative care concepts that should be part of the skill set of all licensed physicians.
- advocated with the Accreditation Council for Graduate Medical Education (ACGME) regarding the possibility of granting waivers from time-based fellowship requirements to foster innovation in graduate medical education.
- participated for the past 5 years in the American Board of Internal Medicine (ABIM) Liaison Committee on Certification and Recertification.
- testified at the ABMS Visioning Commission, which is charged with helping enable the current MOC process to better demonstrate the profession’s commitment to professional self-regulation.
- organized an MOC/Osteopathic Continuous Certification Advisory Group that has met with representatives from diverse certifying boards to monitor updates in MOC process and presented a half-day preconference workshop at the last Annual Assembly.
- offered training opportunities, learning modules, and other resources for medical education and MOC-approved lifelong learning points for required educational activities by certified physicians.
- empaneled a working group to develop Curricular Milestones and Entrustable Professional Activities for HPM fellowship training and assessment under ACGME’s Milestones system.
- recommended a team of leaders to ACGME to update the reporting milestones for fellowship training to be HPM subspecialty specific.
- advised ACGME, AOA, and the American Association of Colleges of Osteopathic Medicine on their pursuit of a single graduate medical education system in the United States with common milestones and competencies.
- continued to lead and advocate for passage of the Palliative Care and Hospice Education and Training Act, HR 1676, which was introduced into the 115th Congress by Rep. Eliot Engel (D-NY) as a step toward bringing more training opportunities to physicians in the field.
- Lupu D, Quigley L, Mehfoud N, Salsberg ES. The growing demand for hospice and palliative medicine physicians: will the supply keep up? J Pain Symptom Manage. 2018 April;55(4):1216–1223.
- Salsberg E, Mehfoud N, Quigley L, Lupu D; George Washington University Health Workforce Institute. A profile of active hospice and palliative medicine physicians, 2016. Retrieved from http://aahpm.org/uploads/AAHPM17_WorkforceStudy_July_2017_Profile_Final.pdf.
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