Feature Larry Beresford When, in a moment of national racial reckoning, AAHPM was invited to join 30 other members of the Council of Medical Specialty Societies (CMSS) for ACGME Equity Matters, a learning collaborative hosted by the Accreditation Council for Graduate Medical Education (ACGME), it sent Kimberly Curseen, MD FAAHPM, as one of its representatives. ACGME Equity Matters was organized as a collective project of education, mutual learning, and process improvement in the areas of diversity, equity, inclusion (DEI) and anti-racism. Dr. Curseen, an AAHPM board member and the director of outpatient supportive care for Emory Healthcare and of the Winship Cancer Institute Palliative Care Program in Atlanta, GA, participated in its 18-month journey to create more diverse and inclusive environments for medical trainees. “Although the Academy wants to be inclusive for our patients, we also want to make sure the workforce, particularly physicians and advanced practice providers, can be as diverse as the patients we serve,” Dr. Curseen explained. Participating societies were encouraged to put their learning into a capstone project to advance these goals within their organizations. Dr. Curseen brought the Academy an idea for a “Next Gen” scholarship and sponsorship program aimed at encouraging interest in hospice and palliative medicine (HPM) as a career choice for minoritized medical residents. Its initial focus was on those from historically Black colleges and universities practicing in residency fields that could lead to an HPM fellowship. The Academy’s Next Gen Scholars for Equity in Hospice and Palliative Medicine program will pair eight chosen residents with palliative medicine thought leaders who will give them intensive mentorship and sponsorship over a 2-year period. Scholars and sponsors commit to monthly calls, quarterly group Zoom meetings, two in-person visits, and attendance at the 2024 Annual Assembly of Hospice and Palliative Care. Scholars will be encouraged to complete a personal research project, which they can share at the Assembly, as they learn how to advance professionally in this field. According to Dr. Curseen, the capstone project is the culmination of the Academy’s participation in a larger movement to address historic—and current—inequities in health care and medical education, reflecting its engagement with these issues. The aim for subsequent years is to build on first-year learnings and expand to other underrepresented communities and allied professions. “The Academy pulled together a diverse working group with influential people in the field who were all enthusiastic to participate. Our board supported funding travel expenses for the scholars and sponsors,” Dr. Curseen said. “Support from Academy leadership and membership has been tremendous.” The deadline for scholars and sponsors to apply is June 30. Interested candidates can apply on the AAHPM website's Next Gen Scholars for Equity in Hospice and Palliative Medicine page (link) or may contact AAHPM Workforce Initiatives Manager Laura Witt, MS-HSM, at
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. The Academy also wanted to hear from its members on how it is doing in terms of integrating a culture of DEI into its programming, so AAHPM fielded a survey and conducted focus groups. A final report was shared with all members in August 2022. In 2023, AAHPM is creating a DEI plan that will inform AAHPM's strategic plan. Going forward, AAHPM will be reaching out and building relationships with historically Black colleges and universities in support of the Next Gen Scholars program. With support from the board, AAHPM's commitment to DEI is a core organizational value. The Academy hired a DEI and membership engagement manager, Linda Sterling, who has been a strong advocate in moving this agenda forward. AAHPM also incorporated DEI themes into abstract submissions to the Annual Assembly, as it did for its State of the Science in Hospice and Palliative Care research meeting that was held for the first time in February 2022. That meeting sparked a meaningful discussion around anti- racist, antibias approaches to research,Dr. Curseen explained. AAHPM’s affiliated Journal of Pain and Symptom Management (see page 13) is engaging in similar efforts. A diversity committee of the AAHPM Board of Directors has been intimately involved in all these projects and in keeping an ear to the membership’s concerns. In other areas, such as public policy, the Academy strives to use its influence and positive reputation to advocate for advancing the field of hospice and palliative care and the ability of professionals to do a better job of providing that care. “I see that we’re having this important discussion with researchers, with Academy members, and with other organizations, and we’re putting the organization’s capital behind it,” Dr. Curseen said. But this effort starts with attracting more diverse professionals to the field. “The Gen Next Scholars is a great example,” she added. “But it only exists because people are dedicated to it. We’ve done the groundwork with our members, with the idea of growing it and moving beyond the pilot to make it more inclusive. We looked closely at ourselves and we’re doing the necessary work to act on this information.” Dr. Curseen said the importance of the pallative care community engaging with issues of inclusivity was borne out by her own experience. “The only reason I am part of this conversation now is because another Academy member working in academia took time to befriend me. Instead of just telling me, ‘This is what you need to do to get involved in this field,’ she took an interest in actually sponsoring me, supporting me in tangible ways that introduced me to the field and opened doors that otherwise would not have been available to me,” she explained. That is an experience many doctors have enjoyed through the support of sponsors. “Somebody has to show you how it’s done.” Her mentor, Shaida Talebreza Brandon, MD AGSF FAAHPM, is professor of geriatric medicine at The University of Utah and a member of AAHPM’s Board of Directors. “I had wandered into a geriatrics special interest group meeting at an Annual Assembly all those years ago, not knowing anyone and feeling very much like an imposter,” Dr. Curseen recalled. “She just grabbed me, introduced herself, and said, ‘Kim, you should get involved in the Academy.’ The next thing I knew, I was involved.” “Within the broad field of healthcare associations, what differentiates us from other hospice and palliative care organizations at the national level is that we are the only one that functions as a medical specialty society,” said Joe Rotella, MD, AAHPM’s chief medical officer and another participant in ACGME Equity Matters. “We have close working relationships with ACGME, the American Medical Association (AMA), and the cosponsoring and qualifying boards for certification in our specialty. We belong to CMSS and collaborate with other important medical organizations,” he said. “We learn so much from each other, and we’ve formed long-term relationships with our partners,” Dr. Rotella explained. “We will follow up on our commitments to advance health equity together.” Members may not be aware of how much the Academy does to advance the cause of high- quality hospice and palliative care, or its unique role as the only medical society that speaks exclusively for physicians and allied professionals specializing in hospice and palliative care and in engagement with the larger medical community. Chad Kollas, MD, medical director of supportive and palliative care at Orlando Health Cancer Institute in Orlando, FL, represents the Academy at the AMA’s House of Delegates, sometimes speaking in an official capacity for the Academy and other times expressing his personal opinions while sharing Academy guidelines and policy statements. “When it comes to pain care and palliative care, we take more of a leadership role,” Dr. Kollas said. “I testified at the September meeting of the Federation of State Medical Boards and presented Academy policies with regard to pain care and access for patients who are underserved. The Academy has a been a leader in trying to make sure patients continue to have access to needed pain medications, and to influence federal policy in this area,” he said. “Because we’re a recognized stakeholder, we get to lead with the positions we take. We’re often the ones they ask regarding pain care. Within the AMA, we’re the go-to group on palliative care,” Dr. Kollas further explained. “The Academy is known as a voice for access to pain medications and the need for balance as a guiding principle. We’re looking for balanced opioid policy.” When the Centers for Disease Control and Prevention issued its 2022 updated guidelines on managing pain, it included new qualifying language aimed at helping prescribers to understand that pain care needs to be individualized to each patient, with no hard dosing limits. “This was viewed as a softening of previously hard language in the new guidelines, and we believe what we said was impactful in encouraging that approach,” Dr. Kollas said. The Academy is known for its diligent advocacy for the Palliative Care and Hospice Education and Training Act (PCHETA), a bill repeatedly introduced in Congress to enhance the hospice and palliative care workforce. It also is involved in a number of discussions about updating the Medicare hospice benefit, both to better serve a serious illness population that has changed dramatically over the four decades since its inception and to eliminate fraud, waste, and abuse, such as the practices highlighted in an article copublished by the The New Yorker and ProPublica in November 2022: “How Hospice Became a For- Profit Hustle.” In response to the article, Tara Friedman, MD FAAHPM, president of AAHPM at the time, submitted a letter to the editor of The New Yorker on behalf of AAHPM, condemning the fraud presented in the article and acknowledging the need for change. AAHPM has participated in listening sessions convened by the US Department of Health and Human Services Office of the Inspector General, a roundtable discussion in Congress hosted by Rep. Earl Blumenauer (D-OR), and a technical expert panel of the Quality, Safety, and Oversight Group at the Centers for Medicare & Medicaid Services. “People in the late stages of serious illness and their families need and deserve the services a good hospice provides,” Dr. Rotella said. “The diversion of these scarce resources through waste, fraud, and abuse is totally unacceptable. We can and must do better, and that starts with a renewed commitment to our mission, values, and guiding principles. We must improve the integrity, safety, and quality of hospice care while taking care neither to limit access for those who need it nor to overburden good programs with ineffective audits and more.” According to Dr. Rotella, the government instead should focus its scrutiny on bad performers to make sure patients aren’t being exploited. “But an effective solution to complex issues is never as simple as it seems,” he explained. “Some solutions will take years to implement before they can bear fruit. We want what’s best for people living with serious illness and to elevate and support the professionals committed to helping them. Let them continue to do their good work while we address these concerns. The Academy is engaging with these issues at every level.” Academy member Edward Martin, MD, section chief of palliative medicine at Brown University in Providence, RI, and a long-time hospice medical director, has represented the Academy and its Hospice Medical Council at some of these meetings. “The New Yorker article went off like a bomb—these storefront hospices with no legitimate business interest looking to get a hospice license and sell it. There has been tremendous growth in the numbers of hospices in certain parts of the country,” he said. “I’m glad we were asked to be at the table. Hopefully, we will have a large voice in these conversations, including for the new special focus program for low-performing hospices,” Dr. Martin said. “I’m glad the Academy’s leadership has stepped forward on these important issues.” For Rep. Blumenauer, a long-time supporter of hospice, the New Yorker article was cause for concern, Dr. Martin reported. “When we sat with him at the roundtable, he asked for recommendations to improve quality and program integrity and for possible changes in the hospice benefit—proposals which we finalized for him in January.” The Academy’s Journal of Pain and Symptom Management (JPSM) also has been trying to enhance diversity and call out implicit bias, explained editor in chief David J. Casarett, MD MA, professor of medicine at the Duke University School of Medicine in Durham, NC. In June 2021, JPSM began requesting that authors report their basic demographic data, such as gender, ethnicity, geographic location, and race. “We issued a request for applications for an academic partner to help analyze these results and selected the University of Colorado to look at our self-reported data and to publishing decisions we made for evidence of implicit bias. We committed in advance to publishing their report with an accompanying editorial,” Dr. Casarett said. “From my perspective, it’s a combination of things we are doing. Next step is to try to understand the differences. We need to do more than just say our acceptance rate is different based on demographic differences. If we find discrepancies, that’s an invitation to dig deeper.” The journal also issued a call for stories on population-based approaches to palliative care, asking researchers to look at the field in new and different ways. “How do you provide core elements of palliative care to everyone in the community?” Controversies in Palliative Care is a new series in the journal that began in January 2023 to enlist authors on both sides of clinical issues about which there is legitimate disagreement on what is the best approach. The journal also appointed an associate editor for diversity and inclusion, Vyjeyanthi Periyakoil, MD, professor of medicine at Stanford University in California. Tammie Quest, MD, of Emory University has started a series of race roundtables to air aspects of diversity and inclusion, with the discussion transcribed and edited for publication in the journal. “I just think highlighting the Academy’s self- examination on these issues is important,” Dr. Curseen said. “We’re not as big as some medical societies. But to take a part of our budget and dedicate it to diversity, to hire a consultant who spent time with our members, and then to release their results to members—that shows real commitment. It’s something for us to be proud of.” The Academy is the dedicated home for physicians in hospice and palliative medicine and for the field of hospice and palliative care, said Holly Yang, MD, AAHPM board president and a hospice and palliative medicine physician at Scripps Health in San Diego, CA. “We’re working hard to move hospice and palliative care forward—[by] training and growing “I’m incredibly proud of our focus and intentionality, how we listen to our diverse membership and gain from their wisdom,” she said. “It’s important that there is a specialist level of hospice and palliative medicine and that we’re teaching palliative care skills to other physicians and clinicians at the same time.” Dr. Yang also hopes to see the Academy continue to exercise its leadership on hospice quality, including supporting clinicians in getting patients the care they need. “I think solutions will take time and real thoughtfulness, and it won’t be our organization alone. There’s not one fix to the issues that are impacting hospice care, but we have a passion for making things better.” Larry Beresford is a medical journalist in Oakland, CA, with a strong interest in hospice and palliative care. Read the next article or go to the table of contents.
Academy Leads on Issues of Accessible, Equitable, High-Quality Care for Patients with Serious Illness
Analyzing How We're Doing
An Important Conversation
What the Academy Does to Advance the Field
Other Public Policy Initiatives
Inclusiveness at the Journal
A Passion for Quality Care
our workforce, mentoring incoming leaders, expanding our evidence base, and advocating for policies that matter—so that seriously ill patients and families can get appropriate palliative care and hospice services. Our North Star is ensuring access to high-quality hospice and palliative care for those who need it,” Dr. Yang said.