Even with the surge in palliative care training, workforce studies suggest the U.S. is woefully short of credentialed palliative care physicians. And many think hospitalists can help fill that void.
The Center to Advance Palliative Care (CAPC, www.capc.org) counts 1,400 hospital-based palliative care programs in the U.S., while the Centers for Medicare & Medicaid Services (CMS) recognizes about 3,500 Medicare-certified hospice programs. A 2010 estimate by Dale Lupu and the American Academy of Hospice and Palliative Medicine (AAHPM), however, suggested a need for between 4,487 and 10,810 palliative care physician FTEs just to staff existing programs at appropriate levels—without considering growth for the field or its spread into outpatient settings.1
In the past, mid-career physicians had an experiential pathway to the HPM board exam, based on hours worked with a hospice or palliative care team, but physicians now must complete an HPM fellowship of at least one year in order to sit for the boards. And, according to AAHPM, only 234 HPM fellowship positions are offered nationwide by 85 approved fellowship programs.
A one-year fellowship is a big commitment for an established hospitalist, according to Stephen Bekanich, MD, co-director of Seton Palliative Care at Seton Healthcare, an 11-hospital system in Austin, Texas. A former hospitalist, Dr. Bekanich says that in his region a fellow stipend is about $70,000, whereas typical hospitalist compensation is in the mid- to upper-$200,000s.
AAHPM is exploring other approaches to expanding the workforce with mid-career physicians. One approach, authored by Timothy Quill, MD, and Amy Abernethy, MD, the past and current AAHPM board presidents, is to develop a two-tiered system in which palliative medicine specialists teach basic palliative care techniques and approaches to primary care physicians, hospitalists, and such specialists as oncologists.2 The article also suggested equipping clinicians with the tools to recognize when more specialized help is needed.
“As in any medical discipline, some core elements of palliative care, such as aligning treatment with a patient’s goals and basic symptom management, should be routine aspects of care delivered by any practitioner,” Drs. Quill and Abernethy wrote. “Other skills are more complex and take years of training to learn and apply, such as negotiating a difficult family meeting, addressing veiled existential distress, and managing refractory symptoms.”
Dr. Bekanich is trying the two-tiered approach at Seton Healthcare. At facilities with no palliative care service, he is transplanting palliative-trained nurse practitioners in hospital medicine groups.
“This model is locked into our budget for fiscal year 2014,” Dr. Bekanich says. “We’ll train folks, starting with hospitalists and primary care physicians.”
The training will start with a pair of three-hour sessions on palliative care techniques for hospitalists and PCPs, followed by homework assignments. “Then we’ll meet again in three months to do some role plays,” he says.
Two final rounds of training will focus on skills, philosophy, values, and practice.
Palliative care is incredibly intense but richly rewarding work. The patients you see are never simple. It allows us to practice the type of medicine we originally set out to do, with people at the most vulnerable times in their lives.
—Marianne Novelli, MD, FHM, FACP, former chief of the division of hospital medicine, Kaiser Permanente, Denver, Colo.
David Weissman, MD, FACP, a palliative care specialist in Milwaukee, Wis., and consultant to the CAPC, recommends hospitalists do what they can to improve their knowledge and skills. “There are a lot of opportunities for palliative care training out there,” he says.
HM conferences often include palliative care content. AAHPM and CAPC offer annual conferences that immerse participants in content, with opportunities to mingle with palliative care colleagues. AAHPM also offers specific content through its “Unipac” series of nine self-study training modules (www.aahpm.org/resources/default/unipac-4th-edition.html.)