Feature
Alternate Pathways to Education, Training, Credentialing, and Certification in Palliative Care
Larry Beresford
Board certification is the US medical system's recognized gold standard for medical specialty competency, including for the subspecialty of hospice and palliative medicine (HPM), which has been available in its current form since 2008. There are multiple paths to HPM certification, including five sponsoring and five qualifying boards for allopathic physicians and a conjoint committee of six boards for osteopathic physicians.
Starting in 2013, the pathway to board certification has been by completing a full-time, full-year fellowship in HPM. Many physicians who might otherwise be interested in the field are unable to interrupt their lives to pursue an HPM fellowship full time. It has been well documented that the supply and fellowship pipeline for HPM specialists is not sufficient to the need, with only about 360 fellowship slots per year,1,2 and that shortfall is expected to get worse.
What are some other sources of education, training, and credentialing that might help extend the field’s availability of clinical expertise? Other professional disciplines, including nurses, nurse practitioners, licensed vocational nurses, nurse aides, physician assistants, social workers, and chaplains, have their own hospice and palliative credentialing programs. The Hospice Medical Director Certification Board offers a special practice certification for hospice medical directors (which is different than and complementary to board certification). Palliative care certificates are offered for courses of study by a number of educational institutions.
Might an alternative to a full-year fellowship for midcareer physicians—who are not in a position to uproot their lives for a year to complete the fellowship but might still want to expand their clinical competency in this field—offer an opportunity for them to play greater roles in hospice and palliative care?
Fellowship Alternatives
With encouragement from the Accreditation Council for Graduate Medical Education (ACGME), the American Board of Internal Medicine, the American Board of Family Medicine, and other groups, a total of eight academic medical settings are currently piloting alternative pathways to HPM board certification. The fellows might take 2 or 3 years, part-time, to complete the alternative fellowship, either mostly via virtual study or largely through in-person rotations. But HPM educators emphasize that this alternative pathway to board certification is not the only way for adding to the field’s collective expertise—and its reach.
At the University of Colorado, three levels of palliative care training overlap to create varied opportunities for such professional enhancement. “The reason we started these programs is because of the predicted workforce shortage,” said Katherine Morrison, MD, associate professor of internal medicine at the University of Colorado. “By offering these opportunities, we hope to improve access to quality palliative care in the United States.”
First, a 9-month graduate certificate course in palliative care teaches professional students interdisciplinary coursework in palliative care concepts, communication, teamwork and leadership, assessment of pain and non-pain symptoms, and topics related to the psychosocial, cultural, spiritual, and ethical dimensions of patient and family care.
“It’s a very robust certificate,” added Melissa Palmer, JD LCSW, a clinical social worker, attorney, and director of the course. “It’s really about the collaboration. And we find opportunities for people to connect with others in the field, so they can build a network of support for when they are back to their communities.”
The certificate coursework also encompasses the first-year curriculum for a 2-year master’s of science in palliative care (MSPC), which started at Colorado in 2016. In the second year, students apply the palliative care principles learned in year one to various real-world settings and complete an integrative, systems-level capstone research project in their communities. The program includes two 3-day, virtual, real-time intensive experiences, as well as simulated communication practice and an intensive focus on personal well-being.
“Many of our learners could walk away from completing the master’s and get a job in palliative care in their profession,” Dr. Morrison said. The exception is for physicians, since many institutions insist on board certification as a prerequisite for a palliative medicine position. Physicians who complete Colorado’s master’s program can apply for its community-based HPM fellowship, with the second year of the MSPC overlapping the first of 3 years of the fellowship. Fellows present up to 100 cases from their current practice, some at a biweekly synchronous virtual seminar, and faculty assess all of these cases.
“We are confident that we are meeting the threshold for all of the entrustable professional activities (EPAs) and milestones required by ACGME for HPM. And while we’re doing it differently than a traditional fellowship, we’re showing proof of efficacy,” said Maurice Scott, MD, a palliative care physician at Colorado and teacher in the fellowship program.
This midcareer fellowship began in the summer of 2020. At least three graduates have sat for—and passed—their board exams, while 14 others will be taking the test when it is next offered in November of 2024. The HPM fellowship is approved to enroll 12 new part-time fellows next year. Participants’ medical specialties have ranged from hospital medicine, family medicine, and emergency medicine to pediatrics, oncology, and anesthesiology; even two trauma surgeons, an ENT surgeon, and a psycho-oncologist participated in the program.
“I think the graduates would tell you that they now have a different framework with which to approach every single patient. That is a palliative care framework that they can take back to their primary specialty, even if they are not practicing palliative care,” Dr. Scott said. “They would tell you that they have advanced communication skills that are quite patient centered in a way that they were not trained during their own medical education or residency programs. And I think they would say that they’re a lot more comfortable with IV opioids and other physical symptom management skills and with how to manage pain aggressively.”
Innovative Training Modules
Colorado’s part-time, nonresidential pathway to HPM board certification for physicians is not the only pilot under ACGME’s supervision. A second pilot for alternative fellowship training, which began in 2019, is being spearheaded by the University of Pennsylvania, joining six other fellowship programs backed by academic medical settings: Icahn School of Medicine at Mount Sinai in New York City; Harvard Medical School (in collaboration with Massachusetts General Hospital, Dana-Farber Cancer Institute, and Brigham and Women's Hospital) in Boston; George Washington University in Washington, DC; the University of Minnesota in Minneapolis; Kaiser Permanente Southern California; and Washington University School of Medicine (in collaboration with Barnes-Jewish Hospital and St. Louis Children’s Hospital) in St. Louis, MO.
This fellowship can take 15 to 30 months to complete and involves some mix of in-person clinical rotations, participation in educational conferences, and self-directed learning and scholarship, depending on the program. Most participating fellows are employed by the participating site where they are completing their training, said Laura Dingfield, MD MSEd, program director of the Hospice and Palliative Medicine Fellowship at the Hospital of the University of Pennsylvania and leader of this pilot.
“Our program at Penn came about because we had a midcareer physician, actually the division chief of our hematology and oncology division, who was doing a part-time HPM fellowship with us,” Dr. Dingfield said. That led to explorations of turning this approach into a pilot. After starting with two pilot fellows at Penn, and “once we had the pilot approved by ACGME and by a number of the cosponsoring boards, other fellowship programs wanted to join our pilot.” It’s been helpful to have people come in under the same pilot, leading to a larger sample size of fellows to test it, she added. The current target is for the pilots to be completed by 2026 to evaluate whether they are a model for replication and broader dissemination.
“What is critical is that ACGME has been incredibly supportive of innovative training programs like this,” considering flexibility in program requirements, Dr. Dingfield said. “They’re really encouraging a movement through the milestones and EPAs towards a competency-based education approach. The emphasis in this kind of competency-based education is on individualized education and curriculum for the individual. I think that flexibility is probably something that would benefit our traditional fellows, too.”
One big question, she said, is whether the part-time, nonresidential fellowships should only be at institutions that also offer the traditional full-year, full-time option, allowing the part-time fellows to work alongside traditional HPM fellows for the best learning opportunity.
Creating New Champions
Another graduate certificate course in hospice and palliative care is offered at the University of Washington (UW). “The first thing to know about our graduate certificate in palliative care is that it’s not a fellowship—and was never designed to replace fellowship,” said Helene Starks, PhD MPH, associate professor in the department of bioethics and humanities and codirector and core faculty for UW’s certificate course.
“In our minds, fellowships are really important for physicians who will become specialty palliative care practitioners. Our goal is to train clinicians of all professions, including physicians, nurses, social workers, and spiritual care providers, to become proficient in person-centered communication skills and interprofessional team practice and then be clinical system change agents for improving the environment for palliative care. We’re providing advanced training to improve the skill level of clinicians from all the palliative care professions, who are already practicing across settings from primary care to hospital medicine to outpatient specialty care
to emergency departments—you name it,” Dr. Starks said.
“I would say that the physicians who have come through our course are people for whom a fellowship is not really an option—although we’ve had two people go through our program first and get their appetites whetted such that they did go on and do a traditional fellowship in HPM,” Dr. Starks explained. Another is pursuing the remote fellowship option through the University of Colorado.
“Most of the physicians that go through our program become very active and strong champions of palliative care embedded within other fields of medicine,” added Amy Trowbridge, MD, assistant professor of pediatrics at the University of Washington and codirector of its palliative care training center. “One of the things that really makes our program unique is that we train a wide variety of professions all together. That’s unheard of in a lot of medical training programs,” she said.
The course became all virtual during the COVID-19 pandemic and stayed that way. Its foundations include advance care planning, goals-of-care conversations, care plan assessment and management, and interdisciplinary team practice. A key element is a partnership with VitalTalk, an organization specializing in advanced communication training for clinicians. Each quarter combines webinars, web-based modules, recorded lectures, and reflection assignments, along with a 3-day intensive workshop on skills practice in communication, interprofessional team practice, and program development and sustainability.
One of the graduates of the UW certificate course, Mike Ross, MD, an emergency physician with 20-plus years of experience at St. Luke’s Hospital in Boise, ID, had found himself increasingly dissatisfied with what he was able to offer to his patients through the ED’s usual triage process. “What I kept seeing were these crisis situations where patients and families confronted with serious illnesses were having to make big decisions. I was thirsty for more knowledge—and to learn palliative communication skills. That’s how I came across the UW program in 2018.”
His expectation for the certificate program was that it would allow him to learn more about palliative care. “I feel like all my expectations were blown away—far surpassed. The experience gave me tools I use every single day at work to make a more profound connection with patients and families. It really helped with my job satisfaction and feelings of burnout,” he explained.
Today Dr. Ross considers himself a leader in palliative care within his health system. He presented a brown-bag class on palliative care concepts and a more intensive four-session workshop on communication for clinicians in the emergency department. He has gone on to teach with the UW graduate certificate program. The local Veterans Affairs medical center hired him as part of its palliative care team. Some of his colleagues at St. Luke’s and other Boise institutions have followed his lead and signed up for the UW certificate course.
“That nugget of having this beautiful connection with patients and families happened because of the skills I learned. You can’t put a price tag on that,” Dr. Ross said. “The health care system is better for it, as are the patients. Everybody wins.”
An Amazing Jolt
Rebecca Martin, MD, now a full-time palliative care consultant at Westchester Medical Center, a 415-bed academic medical center in Valhalla, NY, always knew she wanted to be involved in palliative care, based in part on observing her mother’s dying experience without palliative care support when Dr. Martin was a first-year medical student. But she wanted to first prove herself as a “full-spectrum” doctor without prematurely closing in on palliative care only.
She was working as a hospitalist and in multiple roles in a busy family residency training program at Phelps Hospital in Sleepy Hollow, NY, when she heard that an alternative HPM fellowship was being launched at Mount Sinai Medical Center in New York City—as part of the University of Pennsylvania–based pilot—“basically right in my backyard.” She was quick to apply.
For 15 months, starting August 1, 2021, she spent 1 week per month in an immersive palliative medicine experience at Mount Sinai while making up her preceptorship responsibilities at Phelps with extra effort during the rest of the month. Dr. Martin found the fellowship “an amazing kind of jolt to help me learn to be more empathetic to our learners,” with techniques taught by the seasoned clinicians at Mount Sinai.
“I also think it was a good fit for where I was at in life and in my professional skills. It certainly was innovative. I came into it as a trainee, being on the receiving end of feedback, but also with an eye toward administration: how would I replicate this model as a program director myself?”
Dr. Martin’s work is now 80% clinical on the inpatient palliative care consult service at Westchester and 20% educational, including mentoring medical students, residents, and fellows who rotate through the palliative care program and revising its curriculum. “We hope at some point to create our own palliative care fellowship,” she said.
“I loved it, although it certainly required a lot of diligence in scheduling and very careful attention to detail, with a lot of self-directed learning. But it worked well for me. I felt like I was growing in many different ways. I also felt that being part of something that was helping to advance the palliative medicine workforce, with all of these other kinds of benefits, was a real gift.”
References
- 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;55(4):1216-1223. doi:10.1016/j.jpainsymman.2018.01.011.
- Beresford L. A complex landscape of certification and credentialing defines the HPM workforce. AAHPM Quarterly. Fall 2018;19(3):12-16.
Larry Beresford is a medical journalist in Oakland, CA, with a strong interest in hospice and palliative care.
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