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Design and Participants: This study conducted a cross-sectional survey of program directors (PDs) from US ACGME-accredited adult hospice and palliative medicine (HPM) fellowship programs to characterize the current state of outpatient training and perceptions regarding outpatient PC education quality. A 27-item instrument, including multiple-choice, Likert rating, and free-text questions, was developed, covering program demographics (location, setting, size); fellows’ exposure to care settings; fellows’ outpatient clinic structure, processes, and didactics; and perceptions of educational experience across settings. A 5-point scale assessed perceptions about the importance of outpatient PC education during fellowship, quality of programs’ clinical and didactic experiences, and fellows’ preparedness for independent practice across settings. Wilcoxon rank-sum and Fisher’s tests were used.
Results: Of 161 programs, 85 participated. Fellows spent a median of 4.8 weeks in outpatient PC vs 24 weeks inpatient and 11 weeks in hospice settings. Fifty-one percent of fellows saw outpatients from primarily one disease type with limited exposure to other illnesses. Across programs, fellows’ clinic structure, interdisciplinary team composition, and didactic experiences varied. Respondents rated the outpatient clinical training and didactic experience as lower quality vs inpatient (clinical: mean=3.6 vs 4.6; didactics: 3.4 vs 4.5), and rated fellows as less prepared for independent practice upon graduation for outpatient PC and hospice vs inpatient (outpatient vs inpatient: 4.1 vs 4.7; hospice vs inpatient: 4.2 vs 4.7) (all P<.001).
Commentary: This nationally representative survey with a high response rate provides important information on the state of outpatient training among HPM fellowships. The numerous gaps identified highlight the need to improve training, and the data provide both a needed baseline to compare changes over time and a benchmark for programs to assess their current models of training. The findings that most fellows are limited to primarily seeing outpatients with cancer and that over a quarter of programs lack outpatient-targeted didactics suggest national standards could be updated to address specific gaps. However, the limitations of variable fellowship settings and 1-year training length necessitate nuanced approaches. The authors did not identify any associations between perceptions of fellows’ preparedness and training structure; more study is needed in how to efficiently prepare fellows for outpatient care.
Bottom Line: HPM fellowship programs throughout the country provide significantly less and perceived lower-quality outpatient training compared to inpatient.
Reviewer: Jared Lowe, MD HMDC, University of North Carolina School of Medicine, Chapel Hill, NC
References:
1. Haun MW, Estel S, Rucker G, et al. Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev. 2017;6(6):CD011129.
2. Bakitas MA, Dionne-Odom JN, Ejem DB, et al. Effect of an early palliative care telehealth intervention vs usual care on patients with heart failure: the ENABLE CHF-PC randomized clinical trial. JAMA Intern Med. 2020;180:1203-1213.
3. Rogers JG, Patel CB, Mentz RJ, et al. Palliative care in heart failure: the PAL-HF randomized, controlled clinical trial. JAMA Coll Cardiol. 2017;70:331-341.
Source: Han HJ, Ouellette MC, Yeh JC, et al. Outpatient training during hospice and palliative medicine fellowship: a national survey. J Pain Symptom Manage. 2024;68(4):340-351. doi:10.1016/j.jpainsymman.2024.06.017.
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