Mid-Career Training to Advance Palliative Care

DR. VON GUNTEN: This is the fourth in a series of round tables marking the 25th anniversary of Journal of Palliative Medicine. The purpose is to discuss topics that are important to the palliative care field right now. I'm hoping for a collegial discussion as if we were sitting around a table in the doctor's lounge or somewhere relatively informal. I expect we will both look back, and more importantly, look forward to your views on mid-career training in palliative care and where you think the field is going.

DR. BAILEY: I have broadened my mind to think about not just physicians but also advanced practice providers. Twenty-five years ago nurse practitioners (NPs) were a relatively new thing. Physician Assistants (PAs) were not that common. When you look at the work force need and the estimate that we need 16,000 to 20,000 additional specialist providers here in the United States, it can make you feel like it is a hopeless situation. It's not hopeless if you broaden your perspective to include providers in addition to physicians to include advanced practice providers and they, just like the physicians who we're working with in our programs here at Colorado, are often in mid-career.

Sometimes they've come to become an NP or a PA in mid-career. Training in palliative care is a further evolution. Mid-career people come with a lot of life experiences, a lot of practice experiences. I think that they are really going to be able to enrich the field and help us meet the need.

There are some barriers. Particularly for the physician group, the barrier is getting health care systems to recognize alternative credentials when requesting privileges to practice. Yet, I'm optimistic that mid-career providers are going to make a big difference for the field. And more importantly for the care of individual patients and families and communities.

DR. DINGFIELD: Increasing access to mid-career training for all of our providers is most on my mind. Advanced practice providers, like NPs and PAs, are definitely going to meet a need. There's also enormous demand for mid-career physicians who want to be retrained. There are a few ways for them to go about doing that. But not many ways if they really want to be board certified, at least in the United States.

Depending on the program that they're seeking, it requires significant sacrifice and investment. I think we have some really exciting innovative programs that are underway that have been incredibly successful so far. But, they really do need to grow and expand to meet the demand for mid-career physicians.

A significant question about the advanced practice providers and other members of the palliative care interprofessional team is what do those specialty training programs look like for nonphysicians? What are the accreditation pathways? What are the incentives for those providers to pursue specialty training beyond simply an onboarding process within their institution? How do we have some agreed upon standard? I think that everybody is served by that. We need to create common curricula, implement those curricula broadly to really train people who are well prepared. I think different disciplines are at different stages in the evolution of their mid-career training and specialty accreditation. The bottom line is that we need to increase access and increase the number of programs for all of them because this is how we are going to grow the workforce. For physicians, it won't be simply fellows training in our traditional one-year fellowship programs.

DR. MATHIAS SCHLÖGL: If we only think about mid-career training, we are already too late. We might need incentives because we cannot meet the projected workforce needs at the current pace. But I don't think that it will be enough, whatever the incentive might look like. I think we should start way earlier. We should start in medical school for the physicians, and the similar point in training of the other disciplines. The basic training will not just prepare them, but signal that this is a potential career path. All the cardiologists, all the oncologists, and all the geriatricians need basic palliative care training way more than before. The COVID-19 pandemic made it really clear that the need is definitely there.

DR. PERIYAKOIL: When I hear mid-career, I hear opportunity. We have this really wonderful opportunity for attracting people who are already deeply trained. It takes two decades to grow a physician. And then on top of that, you have residencies. You have fellowships. The example that comes to mind immediately is neuropalliative care, which is a robust and growing initiative. Neurologists have tremendous skills in caring for patients with various neurological disorders. They have neurohospitalists. They have people who specialize in memory disorders and movement disorders. More and more of them are applying to palliative care. Same is true for mid-career surgeons or psychiatrists or pediatricians; whoever it is, they see the big value of incorporating palliative care into their practice.

Exactly as Amos and Laura were saying, what are the rules and policies and procedures we need to put in place nationally to make this an attractive path? And this is a great way of reaching populations who are otherwise extremely difficult for us to reach. When you want to attract someone to your tribe and you want them to become integral members, you make it easier not harder. You make them feel wanted not unwanted. The question is, how can we make it easy for them?

DR. VON GUNTEN: When I look back, I think we trained our first fellow in 2000. We have trained >100 specialist physicians over the intervening years. As I look back, about half of them have been mid-career. Meaning they finished training. They were working. And then for some reason they decided to go back. Most of them came for traditional, full-time training. There's a self-selection to that group. Yet, the national discussions across the field at the time were “Oh those people that have already been in practice, it'll be faster.

They have life experience. They'll learn all this much more quickly.” Yet, from the experience, I have come to the conclusion that the learning curve is precisely the same as for a brand-new fellow. The material is new. The skills, particularly the communication skills and the consultation skills are new. The learning curve is the same. What's different is the emotional stamina that the mid-career physicians have. When I say mid-career, I mean anywhere from 5 years out from training to a 20–25 year career. We've had surgeons, anesthesiologists, and Emergency Medicine folks who were drawn to this subspecialty because of their practice experiences.

Training in palliative care is full of emotional highs and lows. The physicians who are mid-career are better at it. Our best classes were those where they were mixed because the “old dogs” love the insouciance and the enthusiasm of the people who are straight out of their residency training. The mid-career folks are able to help the others moderate some of those highs and lows as they progress through training. We have experimented with some physicians training at distance who come for a time locally for the apprenticeship model training and then go back and practice and come back over a two-year period. We've used that innovation mostly with our international fellows.

DR. BAILEY: I agree with Mathias about this issue of palliative care early in training. There are people who are doing that. Yet, I think it's hard to say that primary palliative care training, alone, is working very well. We have had this conversation recently whether advance care planning is changing population health outcomes. There have been several articles in JAMA recently. That's an example of a primary palliative care intervention. Should we stop trying to get it to work? I am also concerned that what we teach medical students, interns, even some residents gets drowned out by all of the other things in the hidden curriculum. I'm not sure we get a great return on our efforts.

I do think we get a better return on our effort with the outcome of either integrating palliative care into their practice and/or potentially making a decision to pursue specialty palliative care training when they spend clinical time with our specialty services. I think its best when the physician is at least in the second or third year of their residency. Then, they are emotionally and experientially ready to take in the education. Some may come to the palliative medicine fellowship immediately after their residency is over. But there are a lot of people who need some life experiences to ground them and to discover themselves that this is what they really need to do.

That was true for me. I worked as a medical oncologist in West Virginia for five years. I was introduced to hospice. I then became an HIV primary care provider. I then moved to working in palliative medicine full time.

My work is very much influenced by what you wrote, Charles, in your article in JAMA about primary, secondary, and tertiary palliative care. I initially came to the University of Colorado to try to develop secondary palliative care training for mid-career physicians. Now, we have this demonstration project through the Accreditation Council for Graduate Medical Education (ACGME) to take secondary palliative care providers, what we call palliative care community specialists, to that tertiary level where they can become board certified.

It's a work in progress. It seems like it's going well with the first 10 people we've been working with. We haven't graduated anyone quite yet. So I think that the proof will ultimately be in the pudding. But I think that for some physicians and for many of our mid-career or advanced practice providers, getting them moved from being primary palliative care to secondary palliative care would be our very first step. They could become a real asset and a standard for hospital systems in our country. It would be interesting if we can demonstrate they are changing population health measures.

DR. PERIYAKOIL: Amos, can you describe a little bit more about the training and how you've structured it?

DR. BAILEY: I came from the University of Alabama-Birmingham to the University of Colorado because I had an idea to develop a Masters of Science in Palliative Care. The University of Colorado was interested in that idea. It's completely online. It does have intensives. Most of it is asynchronous, meaning people do it when they can during the week, because we have people on very different schedules and working full-time. We are also trying to emulate the in-person experience. So every week, we start with a patient provider family video, in which the student is asked to see themselves as going with a palliative care team to see this situation.

Then out of that situation, there always comes a biomedical topic, and a psycho, social, spiritual, and ethical topic. And then there are two learning module contents. One is focused on the biomedical, and the other on that psycho, social, spiritual, or ethical topic. All of that material is designed to be for adult learners, in that everything is chunked into 10 to 15 minute portions. Altogether, it gives the learner the content. The assignments require application of the content, often to the case that started it. We're influenced by McMaster University model of medical education, in that we start with a patient case and all the learning comes from that. We're trying to emulate that in-person training experience. The students are very engaged in this.

I have been asked about our attrition rate. We haven't had anyone who just said that this isn't working for me; I don't want to study this anymore. We've had people who had to take time off because there was illness or their family or their career was more demanding. But not because of the content. I think that's also because they're self-selected. They're mid-career people. They've come to a place where they're saying, “I want to do this but leaving my home, my family, my practice, disrupting myself, moving somewhere else is not practical for me.”

I have significant confidence that we can get those people to that secondary palliative care level. And I say that because we do standardized patients and case simulations and things like that. They do really well on that. It's not direct observation of them seeing patients themselves.

The next step was developing a community hospice and palliative medicine fellowship. This is for those students who have mostly completed the Masters. So, they've had two years of virtual training. Then they start seeing patients in their own community as palliative care patients. They often join a nascent palliative care team. Or, they work with a hospice team. These physicians are often working with advanced practice providers who have been hired because that system hasn't been able to hire a physician. Then they start seeing those patients and they develop a portfolio. And that portfolio has all of the requirements that are in the traditional fellowship requirement. That's a two-year process.

So over a course of three to four years, they complete first the masters work, then the community palliative medicine specialist training part-time. We're seeing a lot of them make career transitions, during this time. For example, they were working in an emergency room. Then they work part-time in the emergency room and part-time in palliative care. Then at the end, they're working in palliative care full time because their system or their community needs that. As they develop their skill and credentials and their reputation locally, those opportunities open for them.

The challenge is that we don't have direct observation. Assessment is where we're really trying to be innovative. We get more patient, family, and provider feedback. And 360-degree feedback. We're looking at, for instance, doing some videotaping of real live patient situations in addition to the simulations that we're doing.

In a nutshell, those are the two big programs we have which are the Masters, which is for all providers of any sort. And then that the community hospice and palliative medicine fellowship is something that the physicians in the Masters could potentially do to become board certified.

DR. VON GUNTEN: Mathias, I think of seeking a Masters degree after qualifying as a physician as much more common in the United Kingdom. And from what I can tell, across Europe as well. I'm curious if you have opinions about how that mechanism works for people wanting to skill-up or change or adapt across a career?

DR. SCHLÖGL: I am a German living and working in Switzerland. I'm a part-time, dual-career clinician and academician. From the academic side, I agree that a Masters degree is helpful. This advances your career. But, I do not see a single colleague of mine who works only as a clinician in the last 12 years who acquired an additional Masters degree. I don't see the reason why a clinician who works 60–80 hours per week would say “I need a piece of paper.” Rather, they would say, “Why do I need to do a Masters degree right now?” So that's the clinician side. I mean they are happy when they are off at 8:00 at night and they can go home to family and just lay on the couch, right?

But for me working in academia, the Masters degree is helpful. I obtained my Masters in Public Health with Harvard. I'm doing an executive Masters in Business Administration right now. It's not just nice for the career; I encourage everybody to pursue a Masters even outside the field because it enriches you personally. I have met different people outside my field. It's just lovely to get outside views.

DR. DINGFIELD: I do think for the nonphysician group, the Masters degree is a concrete credential that they can receive in the discipline and so that may be useful for them. Especially because there are a real paucity of clinical training programs. Clinical fellowship programs for advanced practice providers, social workers, and others are few and far between.

For physicians, I don't know that it's necessary. They are really looking for board certification. As Innovative programs that lead to board certification without a Masters become more accessible, that may be of greater interest. Amos' pilot is tied to the Masters and that's another way for them to access board certification. They have to do the Masters to eventually achieve that goal. So I think that that can be attractive to them.

We have a mid-career pilot project with the ACGME. While the University of Pennsylvania is the sponsoring institution, it is multisite program at seven institutions nationally. We have a hub and spoke model. It's not attached to a Masters program, but it's attached to existing fellowship programs. So those trainees tap into the didactics, the nonclinical educational elements that are existing in those sites.

Those individuals who don't have an existing fellowship program that they can tap into where they can receive that nonclinical education, the didactics, and the simulation, they're in a tough spot. And so I would imagine that that's where a Masters becomes more attractive to those people who just don't have access to other innovations that are attached to specialty training programs.

So, I think there's need for both and they do serve slightly different groups. Our mid-career fellowship is very much located within large academic centers. Serving the faculty of those institutions for now. I think that there is a possibility that individuals from outside will become fellows in those programs. Two of our sites have fellows that are participating that are not faculty members at those institutions. But for the most part, they are large academic centers training mid-career faculty within their own institution who will then reach specialty areas as VJ mentioned that need additional specialty palliative care integration into those fields.

Some of them do intend to go out into the community and make a career pivot and change course. Others are leaders within subspecialty areas. For example, one of our graduates is the director of our cystic fibrosis program at Penn. The physcian is helping establish the outpatient palliative care practice with other colleagues with patients with advanced lung disease and is speaking nationally about this in cystic fibrosis and transplant forums.

I did want to come back to the learning curve for the mid-career individuals. In our experience, that has really depended on the individual. In my experience, the learning curve hasn't been the same. I do think part of that is emotional maturity. There's a lot of discussion in our mid-career program up front about having a growth mindset. About the amount of direct observation. You are returning to the learner role. We do a lot of preparation around that. The mid-career physicians come in really expecting and wanting constructive feedback and seeking that out in a different way.

Those people do progress more quickly than our traditional fellows. I haven't mapped it out, but it is different in how they approach this idea of deliberate practice and master adaptive learning where they're really trying to get mastery and they're less focused on performance with the, “I have to do this perfectly because you're my preceptor and I'm trying to impress you” mindset. They're very invested in, “how can I grow, how can I become a specialist.” “I only have a short amount of time on this rotation because I'm going to go back and be a hospitalist for the next three weeks. So I need to make the most of what I'm doing now.” By design of the program, by the fact that they are mid-career, that is really different from traditional fellows.

DR. SCHLÖGL: What I really love about Amos' program is that it gives the participants the opportunity to join in whenever they have the opportunity or the time based on their busy clinical schedule. As I compare with Europe or Germany or Switzerland, there are more MD, PhD programs, at least at the university hospitals, which are in high favor and which are supported by research or other funding grants. We don't have such opportunities as Amos describes that gives the participants the possibility to work at the home base and to participate part-time on their own schedule. We will not have an increase of whatever work force we are looking for.

The Masters at Harvard that I did was the first part-time online Masters offered from Harvard ever. So I was able to remain 100% of the time here in Switzerland and participate over two years in Boston. Without this, I could never have done it. The executive MBA is the same. Whether or not it's a MPH or it's whatever Masters or PhD. We need to make it accessible like the program as Amos has done.

DR. PERIYAKOIL: Listening to everyone makes me think about how we finance these mid-career plans. Traditionally, after medical school is a period of apprenticeship. You work while you learn. You are in the student mode and you earn much less money, but you do get full health and other benefits. In contrast, the mid-career approach seems to shift the entire financial burden, the financial responsibility, back to the learner. Is this approach feasible?

DR. BAILEY: Yes, the fellows and the students are paying us; they actually pay tuition. We're not paying them. We have a waiver for the fellowship that we don't provide a stipend. Our program was influenced by those online Masters of Business Administration programs targeted to people who were working in business. I tell all of my students that they should ask the hospital or the health care system they're working for to pay their tuition. That doesn't happen all the time, but I have often said, until people are saying no, you have not asked for enough things. You'll know when you've asked for enough things when people start saying no. I offer to get on a call with their leadership and advocate for them to pay for at least part of the tuition. I do that both for the advanced practice providers as well as for the physicians.

We talked to some health economists about this. If you leave your practice and move to do traditional training, your costs are $300,000–$400,000 dollars to wind down a practice, be out of practice for at least a year, then come back into practice potentially at a lower income level. So you're talking about an enormous cost of hundreds of thousands of dollars in the United States for physicians to do traditional fellowship training. In contrast, our program's tuition is right now somewhere between $75,000 and $90,000 dollars over a three-year to four-year period depending on if the student is in-state or out-of-state. The community fellowship's the same price regardless of where you are.

So, it's a cost effective way to do fellowship training compared with the traditional pathway. The other thing is that if somebody leaves a little town, like Glenwood Springs, Colorado, and they come down to the big city of Denver for training, you might never get them back up into Glenwood Springs. So having people stay where they are is, I think, helpful to try to keep the work force ability dispersed.

I want to respond to what Laura mentioned about the Masters that could be very helpful for nonphysicians. I think it is helpful for physicians. I'm discouraged by health care systems and hospitals who have open positions for palliative medicine specialists for years because they can't find a person to take that job. Does it really matter in Casper, Wyoming if the person has a Masters in Palliative Care or if they're board certified? They're definitely going to be a big step up from people who are just learning on their own.

I was really hopeful that I could convince hospital systems and health care to think about alternative credentials. I mean after all, we let nurse midwives, family practitioners, and obstetricians deliver babies. Three very, very different credentials and training paths, yet, they can each deliver a baby. But only one kind of physician credential can be a palliative medicine provider? I'm a little frustrated by that. I've decided not to tilt at that windmill right now though.

DR. VON GUNTEN: VJ, you've had a lot of experience training disciplines together. You've led the Veterans Administration (VA) training program there at Stanford for years. Do you have insights into training the various disciplines along with physicians and how it affects the mix?

DR. PERIYAKOIL: In many ways, the VA has led the way in interprofessional training programs. Different allied health experts have different domain expertise. As health care teams, we learn how to work with each other; for example, we know when to consult our social worker or when to call the nurse or when to call the chaplain. We learn that by doing. But it's a different thing to actually learn to learn together. It sounds a little bit meta, but working with a colleague from a very different discipline and learning together with them without succumbing to the least common denominator syndrome is a whole other skill.

When we first started the program, we thought, “we know how to work as teams. It should immediately translate into how to educate other allied health professionals.” That was not the case. There is a steep learning curve even if you have the basics of being respectful, being collegial, learning to listen. There is a challenge of how can I, for example, as a physician, say anything or teach anything meaningful to a chaplain? And how does one do that?. We learned to work together because we learned how to manage conflict. Invariably, when you work with people over a period of time, there's going to be differences in opinion and how those differences bubble up.

The issue is not just managing conflict, the issue is how does one use the growth mindset that Laura was talking about to use conflict for the betterment of all and improvement of patient quality of care. It's wonderful to hear Amos talk about how you're educating multiple professions. But, don't we as a nation have some kind of obligation to provide financing for this kind of endeavor because it's solving a very mission critical health problem for the entire nation?

DR. DINGFIELD: The funding of graduate medical education, at least, for physicians, contributes to how we are in this work force crisis. We've been successful in growing traditional physicians fellowships to a degree. But even if we had the applicants, it is very difficult to establish another slot in a traditional fellowship program. Because most systems are capped. The health system would have to put up additional funds to establish another physician training slot for a specialty palliative care program. There is a separate issue around whether we have enough people to fill those slots. The answer is probably no.

For the mid-career financing though, the cost is put more on the individual in our innovative program. Or on the system or the individual's department. We have mid-career fellows who come and train part-time. They take a week or two a month over a few years to train and do palliative care clinical rotations with us. They're not doing their day job during those weeks. For some of our trainees, and this is true across all of our sites, if they're a hospitalist, they may have nonclinical weeks. So they have, I wouldn't say anyone has a lot of free time, nonclinical time that they essentially are donating to their training.

They continue to get paid their faculty salary. They receive their faculty benefits. They don't get paid extra for completing the fellowship. But they are working more because that would be an administrative week. So they're doing more clinical work. It's emotionally heavy clinical work. So it may not be a financial cost, but it is a cost of time that these folks are shouldering and just increased emotional costs.

Some individuals who are in the mid-career fellowship have decreased their clinical effort in their primary jobs. We have primary care physicians. We have emergency medicine physicians who are doing mid-career fellowship at some of our sites. They are decreasing their clinical effort by 20%. So their salary is decreased by 20% for that time, but it frees up nonclinical weeks, the nonclinical time that they can then devote to the fellowship and to their training.

In some cases, clinical departments or health systems have kicked in and paid for that clinical effort to make the person whole and to fill their full time equivalent (FTE) so that they can decrease their clinical effort without decreasing their salary. But that's not universally true. There is a cost. It's either from the trainee or in the best case scenarios from divisions, departments, and health systems that are contributing 10%, 20% of a person's salary so that they can decrease their clinical effort to pursue training.

DR. VON GUNTEN: I'm struck by these two work force needs that are being met by the term “mid-career training.” First, we need to train enough palliative medicine physicians and other disciplines to meet the needs of patients and families. Second, we're trying to facilitate a synthesis across tribal boundaries. It looks like that the ACGME will approve a joint training program for palliative medicine and medical oncology together. So there doesn't have to be the either/or, before and after. It's going to be together because that's one of the areas where the data are the best. If you have a synthesis between the two specialties, the two tribes, everybody benefits.

I see that need in geriatrics. I see it in pulmonary. I see it in cardiology. It's clear in the neurosciences. The best way to help the tribes work together is to have somebody who's a member of both tribes and that is the way I see it.

But, while it may overcome barriers between medical tribes, to your point, Amos, that doesn't solve rural access. It doesn't solve access problems in places where there are no specialists at all.

One potential driver that I have seen, at least in the community where I've been working, is the competition for palliative medicine specialists is driving up the salaries. They have tripled. That is a powerful message to those who could potentially chose the training path. The potential mid-career recruit could say, “if I made a switch here, I could still have the future that I and my family want.” For those high-income specialties, the message is, “I'm not going to be giving up that much because the law of supply and demand has driven up the value of palliative medicine training.” I've seen the same pressures among advanced practice nurses and certainly in the pharmacists who are specializing in palliative care.

Market forces do create animosity. For example, the rift with geriatrics where palliative medicine is seen as stealing potential geriatricians.

DR. SCHLÖGL: I'm a geriatrician by training with special interest in palliative care. I'm not board certified in palliative care. In Switzerland, you need three years of specialist palliative medicine training. I only have one. I always said that training in palliative care made me a better geriatrician. I always see a patient like a picture. As more puzzle pieces we see of a patient, the better we understand our patient. As a human being, I see more now after working in palliative care. I'm not the same Matthias as I used to be before I did my palliative care training. So this brings me to this joint training of oncologists and geriatricians or oncologists and palliative care physicians.

It's not only palliative care. A geriatrician who has special knowledge in cardiology is a better geriatrician. A geriatrician who has a special interest in neurology will be a better geriatrician. I think we should stop thinking in boxes that we are only in one field. I think we need to grasp all the ideas from different colleagues to progress in our field, whatever this field is.

DR. VON GUNTEN: One of the things that I've seen in the training of mid-career physicians is the grief which sometimes reaches a catastrophic level early in the course of training. “Oh my God, if I had only known! Oh my God, I think of all the patients I would have treated differently. Why didn't somebody teach me this earlier?!.” Physicians who are coming straight through generally don't grieve in the same way. Has anybody else seen this?

DR. BAILEY: Absolutely. I was just talking to someone who's just finished the first semester. He said, “I had no idea what I did not know.” It's like that for every person that we've had come through our program. I think that's part of the reason why we've had good retention is that we help them discover that there are many things that they don't know and that they can apply in real time. We often hear participants talking about how they're applying what they learned last week or even this week in their clinical care.

I think that people do sometimes have real grief about this. You remember particular patients and families. I mean I still remember a patient of mine where we got an experimental medicine and the patient died while we were infusing it. I felt really weird about it. Many years later, it was something that I processed with my colleagues in palliative medicine.

ACGME is interested in the model that Laura and others have created for mid-career changes. It has utility not just for palliative care, but for those areas where we have shortages such as geriatrics, occupational health, or addiction medicine. These areas are sometimes attractive to people who have gained more life experience and have grown emotionally or, for example, have dealt with addiction issues themselves. I feel a great sense of responsibility as a demonstration project because the impact is likely to reach far beyond palliative care. It's implementation science. It's not a foregone conclusion that our model will work. But I need to do everything I can to try to learn as much as I can about how to do it.

I've been very excited to work with ACGME because, if I need to change something, I want to talk about it so that others will benefit. The ACGME has been respectful and flexible about those situations which I thought might work and might need adjustments as we go along. Laura, have you had that experience too?

DR. DINGFIELD: Yes, I completely agree. The ACGME have described graduate medical education as a Quality Improvement process. They're constantly trying to improve. They take our data and reevaluate. The ACGME and the specialty boards are interested in innovative pathways for other specialties within medicine in particular.

For better or worse, the COVID-19 pandemic has had some silver linings. It has accelerated interest in these innovations. In thinking outside the box about competency-based education programs, we set aside the focus on dwell time and how long somebody is in training. Instead, we look at output and competency. How do we measure that? We think differently about how people are educated beyond the existing program requirements.

The pandemic has forced all of graduate medical education to adapt as people were pulled from their primary specialty areas. Trainees missed big chunks of time. Program directors really did have to answer the question, are these trainees competent even though they missed perhaps a quarter of a year? In a family medicine residency program or an internal medicine residency program, that's not insignificant time and training. I think that will benefit our specialty training programs; our traditional programs or our mid-career programs. With luck, this will lead to innovations in other specialty areas where there also is a work force need.

DR. PERIYAKOIL: In the field of palliative care, we talk a lot about goal-concordant care, right? I'm reflecting that our discussion today seems to be more about goal concordant careers. If we attract people who are mid-career to come into our field and if they feel fulfilled by pivoting their career and refocusing on palliative care careers, I would guess that that's going to mitigate their burn out, increase their job satisfaction, and thereby lead to longevity in their medical careers, rather than leave medicine entirely. Amos, Laura, and Matthias, are you measuring this or hearing anything in that direction?

DR. DINGFIELD: I think that is true. For our mid-career fellows at our multiple sites, we are doing a longitudinal qualitative study where we are following them both during training and for several years after their training to interview them both about their professional identity and then we've added a question about well being; how they make meaning of their careers. It will be interesting to see what our results are. I do sometimes although worry about this; mid-career providers coming to palliative care because they're seeking something. They're not happy in their current position or their current specialty. Do they really know what they're getting into? They are surprised by the emotional toll that the work takes. They're surprised by some aspects of the work.

This is something that I keep in mind when I'm talking to people about mid-career training. What do they know about what they're getting into? Are they running toward this or are they running away from something else? I think that that's a really important distinction.

DR. VON GUNTEN: As a way of wrapping up, particularly as you look into the future, if you were directing funding, if you were directing research dollars, what would you direct it to so that we're further along when Journal of Palliative Medicine is another 25 years older?

DR. SCHLÖGL: I think this issue of how we get people into our programs is important. I think following people after they complete the programs is important. When you look at all those executive MBA schools, they are running a business with their alumni programs. It gives them insight into how to make it better. That's where I would invest money.

DR. DINGFIELD: More funding for these education innovation projects. We really do need to know if they work or not; it is not a foregone conclusion that Amos or my projects are going to produce effective graduates. There may be better alternatives as well as ways to study the outcomes. What is most important?

DR. BAILEY: I think about rural access and access in areas that are underserved. I wonder about things like debt forgiveness for people who have debt from medical school or from even their undergraduate before they went to medical school. Could they get some forms of debt forgiveness by going into and training as a mid-career person in a high-need area? It doesn't have to be palliative medicine. It could be geriatrics. It could be addiction medicine. Also, funding to distribute the access to the high-quality palliative care more equitably across our country. Right now, it's a happy accident if you get good palliative care for yourself or your family member if you have a serious illness. There's nothing guaranteed about it. So I would be interested in ways to use economics, particularly since we do have a lot of people who have debt, if debt forgiveness could be helpful.

I'm also thinking that there are ways that the Center for Medicare and Medicaid Services (CMS) could work with health care systems that are billing CMS to encourage them to invest money into training advanced practice providers, other interdisciplinary team members and physicians as a way of improving the care of Medicaid and Medicare patients where CMS has the portfolio for the quality of their care. I'm interested in the potential of using economic levers to try to do that. In general, I feel that the neoliberal experiment is not going very well. So I'm a little reluctant to suggest that. But that seems to be one of the few levers that we have the potential to pull on.

DR. SCHLÖGL: How wonderful would it be if one of the big folks with all the money, like Elon Musk, or the Gates Foundation, spends just one percent for the cause of palliative care. Maybe this alumni association networking idea of the executive MBA. If someone gets me access, I will ask.

DR. PERIYAKOIL: Our education system has not fundamentally changed in the last 50 years. It is not fully serving the needs of our aging population. We need more experiments like what we've been talking about. Social experiments. We need disruptive innovation if we want to change the course of the future. Right now, we keep doing the same thing and expecting different results and that's not going to work. I hope that it'll all come together so that we can pick up best practices from all these projects and implement them. The education system really needs an overhaul and you're already doing it. And so many of us are behind you and willing to help to the extent that we can. I'm excited for the future.

DR. SCHLÖGL: VJ, I participated in your on-line Stanford Aging and Ethnogeriatrics mini-fellowship training program (geriatrics.stanford.edu) about six or seven years ago. Charles, there was this communication video in a ballroom of a hotel where you interviewed this patient with advanced lung cancer who had a prognosis of days, and you had never met him before. Within 10 minutes, you were able to get the overall picture and to get to his emotions. This was a huge influence on me and my career. Participating, today, is a way to thank you for this, Charles. Although this call is late at night in Switzerland, I would have been up at 3 AM because I want to give back to you, so thank you very much.

DR. VON GUNTEN: That means a lot. And you're paying it forward in what you're doing. So that is thanks enough.