A Report on the Innovative University of Colorado Community Hospice and Palliative Medicine Fellowship

Introduction

Between 2008 and 2012 more than 5000 physicians passed the Hospice and Palliative Medicine (HPM) board exam. Since the end of that grandfathering period, board certification is now limited to those completing accredited HPM fellowships. Approximately 350–400 out of the 450 available fellowship positions are filled annually, ¹ and many pre-2012 physicians are expected to retire over the next 10–20 years. This will result in a projected shortage of HPM physicians. ² For physicians who develop an interest in HPM later in their careers, returning to a traditional HPM fellowship is often impractical due to professional, financial, and family responsibilities. Recognizing this, palliative care faculty at the University of Colorado have developed an HPM pathway to board certification tailored specifically for midcareer physicians.

In 2016, before the Community Hospice and Palliative Medicine (CHPM) fellowship was developed, faculty at the University of Colorado launched the Master of Science in Palliative Care (MSPC), an online clinical palliative care training program.^3,4 This curriculum emphasizes interprofessional training with the aim of producing “secondary palliative care providers.” ⁵ Nurse Practitioners and Physician Assistants who complete the program can receive HPM credentials from hospitals and clinics to deliver clinical palliative care services, even if their collaborating physician lacks HPM expertise or certification. ⁶ The MSPC alone does not allow physicians in the program a pathway toward board eligibility or certification, required by many health care systems for clinical practice. The CHPM fellowship was developed to address this issue of board certification and was approved by the Accreditation Council for Graduate Medical Education (ACGME) in 2019. This fellowship, an Advancing Innovation in Residency Education (AIRE) demonstration project, is an extension of the MSPC and offers a competency-based, online, distance learning approach over two years. ⁷ Together, the MSPC and CHPM fellowship enable mid-career physicians to develop expertise and board eligibility while not having to leave their local communities. The competencies are aligned with ACGME HPM Milestones and Entrustable Professional Activities.^8–10 Administratively, CHPM operates as a site within the University of Colorado HPM fellowship and its curricular development, assessment, and evaluation processes are documented in the ACGME Accreditation Data System for transparency and oversight. The fellowship can accommodate up to 24 fellows split between first- and second-year cohorts. In the future, we hope to matriculate 12 students in each class in 2024 and 2025 to reach maximum capacity. This program is supported by the tuition that the CHPM Fellows pay for the MSPC and CHPM courses. In this article, we present the theoretical constructs, practical concerns and issues, and future implications of the CHPM program in addressing the workforce shortage in HPM.

Methods

In the development of our demonstration project, we analyzed the ACGME competencies, subcompetencies, and clinical requirements for HPM fellowship training. We then audited the MSPC curriculum for these competencies and created a CHPM curriculum that reinforced or supplemented them.^8–11

Our curriculum is structured around three components, each playing a role in the development of the CHPM Fellow: 1.

MSPC: Eligibility for the CHPM program is limited to mid-career physicians, defined as those at least five years past their last training. Initially candidates enroll in the 33-credit, two-year MSPC program, confirm their interest in HPM and identify clinical sites in their community. Prospective fellows meeting requirements are interviewed during the second MSPC semester and may join the CHPM fellowship after the first MSPC year. While inpatient palliative consult services and home hospice are typically available in most communities, some fellows had to travel to have inpatient hospice and pediatric experiences. The faculty assists in finding suitable clinical sites and formalizes these arrangements through a Program Letter of Agreement (PLA). Driven by our mission to bring palliative care to underserved communities, most fellows work at community sites, although some have spent time in academic institutions. Admitted fellows complete the remaining MSPC courses, including a capstone project. All fellows are encouraged to complete both the MSPC and the fellowship in three to four years.

Unlike a traditional fellowship, CHPM Fellows do not have direct observation by fellowship faculty as part of their evaluation. Instead, as described previously, assessment modalities include MSPC and CHPM grades, clinical portfolios, patient/family and colleague evaluations, extensive video communication simulations, seminar performance, and written consults. There is no hourly requirement, but fellows must fulfill all clinical requirements, pass all assessments, achieve competency in HPM milestones, and show evidence of mastering the entrustable professional activities (EPAs). Some fellows do have further supervision by practicing as palliative care physicians at their clinical sites that are not CHPM faculty, and many do not. All data are reviewed by CHPM faculty, summarized by the fellow's mentor, and then presented to the Clinical Competency Committee (CCC) for the University of Colorado HPM fellowship at least twice each year over two years. The CCC recommends board eligibility when all requirements and competencies are fully met.

Results

Discussion

The CHPM fellowship AIRE demonstration project highlights the potential of an alternative pathway for mid-career physicians to complete their HPM fellowship training through part-time, online, distance learning. Early successes of the program are exemplified by the positions our fellows have been hired into, the leadership roles they have taken on, and the outcome of our first three physicians passing their boards.

The curriculum and requirements are continuously adjusted based on the feedback from both faculty and students but do not include direct observation. The challenge of assessing fellows effectively, particularly in the absence of direct observation, remains an ongoing endeavor. ¹⁷

We use Kirkpatrick levels to evaluate the CHPM fellowship. Up to this time, we have focused on levels 1 and 2, however with two classes having graduated from the program, plans for focused interviews to evaluate Levels 3 and 4 are in progress. As noted in Table 3, our graduated fellows send word of their success, and we hope to capture this data in our focus groups.

An unexpected and frustrating challenge has been the amount of time and effort needed for our program to negotiate PLAs with multiple, diverse programs and institutions. A traditional fellowship program might need to negotiate only 1–3 PLAs every 10 years, in contrast to our program which might negotiate more than 12 PLAs every year. Even when fellows have staunch support from institutional leadership, PLAs have delayed fellows' clinical work by as much as 18 months, as lawyers from our institution and the other sites negotiate changes. We have been unable to identify a more efficacious path forward on this issue.

Conclusion

The CHPM fellowship demonstrates initial success in facilitating HPM training for mid-career physicians, ultimately leading to board certification. This innovative model has the potential to serve as a template for other medical disciplines or be integrated into traditional training programs to address evolving health care needs.