Hospice and Palliative Medicine Fellowship Training for the 21st Century

Dear Editor:

Are we providing palliative medicine fellows with the skills they will require in the 21st century? As the number of fellowship programs for hospice and palliative medicine (HPM) increases in the United States, this question grows in urgency.

Today, fellowship programs emphasize excellent clinical care for the individual, focusing on effective symptom management and compassionate communication. The consensus statement by Landzaat et al. ¹ on entrustable professional activities for HPM fellowship programs reflects this focus. Such an emphasis on direct patient care alone will not provide fellows with all of the critical skills they will require to improve the care of the dying.

As of January 2016, there were nearly 6400 active HPM physicians reported by the American Medical Association with a projected net gain of 120 providers per year. ² Recent statistics reveal that more than 2.5 million people die each year in the United States. Those with chronic, ultimately fatal diseases far exceed that number. As the “baby-boom” generation ages, this discrepancy will dramatically increase.

Further exacerbating the mismatch of supply and demand is the significant attrition the field will suffer due to its inherent design. Studies of burnout among HPM physicians show rates as high as 60%. ³ Dangers arise from a multitude of sources: constant exposure to death, growing workload, lack of institutional support, and inadequate coping skills and resources. ⁴ Regardless of the self-care principles espoused, caring exclusively for the dying is profoundly difficult. Physicians will inevitably diversify their activities to attain emotional balance.

Based on these factors, it is clear that HPM physicians will never be able to provide care for all who are dying. Therefore, I propose that if the goal of palliative medicine is to improve the care of all patients near the end of life, fellows must be trained in the skills necessary to achieve that goal. In addition to providing excellent direct patient care, they must be trained to change systems of care. What are those skills?

An understanding of population health is critical to success. How can resources be organized in the health system to meet the needs of patients suffering from cancer, organ failure, frailty, and dementia? Understanding information technology is another essential skill. How can individuals near the end of life be accurately identified? Without a fundamental grasp of healthcare finance, the HPM physician will not be able to leverage system-level resources to provide effective service. Finally, HPM physicians must have effective management and leadership skills. Without the ability to create a vision of excellence and mobilize other providers to achieve that vision, success will be limited.

Palliative medicine physicians in the 21st century must be more than excellent clinicians. They must be agents of change, with insight into how to change systems of care to improve the care of those with serious illness. The training of our fellows must reflect that need.