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Board Certification in Palliative Care for U.S. Physicians
Vol. 17 No. 5 May 1999
Special Report
Board Certification in Palliative Care for U.S. Physicians Gerald H. Holman, MD and Dale C. Smith, MPA on behalf of the Officers and Trustees of the American Board of Hospice and Palliative Medicine
A recent report from the Institute of Medicine highlights the deficiencies in the health care system’s current approach to end-of-life care and calls for the development of a professional specialty devoted to the provision of palliative medicine.1 The concurring opinions from the U.S. Supreme Court that refused to recognize a constitutional right to assisted suicide also indicate Americans should expect adequate palliative care from their health care system.2 The American College of Physicians and the American Board of Internal Medicine have both called for physician competency in the care of persons with terminal illness3 and the Annals of Internal Medicine has been active in publishing timely articles in this area.4 Clearly, the time is propitious to support specialty status for physicians working in palliative medicine, as has been achieved in Great Britain, Ireland and Australia. We are writing to report on the efforts of the American Board of Hospice and Palliative Medicine in certifying physician competency in this area. The American Board of Hospice and Palliative Medicine was formed in 1996 to establish
Gerald H. Holman, MD is the former Chairman of the ABHPM, and is Chief of Staff at the VA Medical Center, Amarillo, Texas, USA. Dale C. Smith, MPA is President of the ABHPM, Gainesville, FL, USA. Address reprint requests to: American Board of Hospice and Palliative Medicine, 9200 Daleview Court, Silver Spring, MD 20901, USA.
Journal of Pain and Symptom Management
309
and measure the level of knowledge, attitudes and skills required for certification of physicians practicing hospice and palliative medicine. In so doing, the Board has hoped to set the minimum standard of specialty practice, thereby assisting the employer, public, and members of the health professions in the assessment of these physicians. To achieve certification, a physician must hold an active license to practice medicine and be certified by an American Board of Medical Specialties approved board, osteopathic medicine equivalent, or the equivalent in other countries. They must have been in the clinical practice of medicine for at least two years, have worked as a member of an interdisciplinary team for at least two years, and have directly participated in the active care of at least fifty terminally ill patients in the preceding three years. Finally, they must pass a 250-question examination weighted in the following manner: 25% pain management, 25% non-pain symptom management, 15% hospice and palliative approach to care, 15% ethical and legal decision making, 10% death and dying (psychological and spiritual pain), and 10% communication and team work. The Trustees of the American Board of Hospice and Palliative Medicine (administratively certified during their tenure as trustees) in consultation with the Professional Testing Corporation of New York City maintain the 250-question examination and prospectively set a passing score. This examination is administered at multiple centers nationally on a semi-annual basis. After five examinations, 522 physicians have achieved board certification in Hospice and Palliative Medicine. Those with ABMS primary board certifications report the following: Anesthesiology 20, Family Practice 119 (23%), Internal Medicine 293 (56%), Pediatrics 5, Radiation Oncology 9, and Surgery 7. They describe their practice location as follows: rural 16%, academic 30%, urban 53%. They report their percent of professional time practicing Hospice/ Palliative Medicine as ,25% 204, 25%-50% 160, 51%–75% 50 and more than 75% 106. Three hundred sixty-eight (70%) report more than 5 years of clinical experience in Hospice/Palliative Medicine. Applicants were drawn from 46 states, Canada, and two additional countries. The available data indicate that 20% were less than 40 years of age and that almost two-thirds were men.
310
Board Certification in Palliative Care
We conclude that there is a strong societal and professional need for standards of competence in end-of-life care, including the development of palliative medicine as a physician specialty. There is also significant physician interest in seeking professional recognition for their expertise in caring for terminally ill persons and their families. We are confident that this certification process recognizes a level of knowledge and the skills necessary for the comprehensive practice of hospice and palliative medicine in the United States. It is the goal of the American Board of Hospice and Palliative Medicine to certify fellowship programs in hospice and palliative medicine nationally. We look forward to watching the cadre of professionals in this field grow as we meet the chal-
Vol. 17 No. 5 May 1999
lenges of caring for patients with progressive disease for whom the prognosis is limited, and the focus of care is quality of life. PII S08855-3924(99)00016-0
References 1. Field MJ, Cassel CK. Approaching Death: Improving Care at the End of Life. Institute of Medicine. National Academy Press, Washington, DC 1997. 2. US Supreme Court. No 95-1858, 96-110. Justice O’Connor, Justice Stevens concurring opinions. 3. American Board of Internal Medicine. Caring for the Dying: Identification and promotion of physician competency. Philadelphia 1996. 4. Meier DE, Morrison S, Cassel CK. Improving Palliative Care. Annals of Internal Medicine 1997;127: 225–230.
Special Report
Board Certification in Palliative Care for U.S. Physicians Gerald H. Holman, MD and Dale C. Smith, MPA on behalf of the Officers and Trustees of the American Board of Hospice and Palliative Medicine
A recent report from the Institute of Medicine highlights the deficiencies in the health care system’s current approach to end-of-life care and calls for the development of a professional specialty devoted to the provision of palliative medicine.1 The concurring opinions from the U.S. Supreme Court that refused to recognize a constitutional right to assisted suicide also indicate Americans should expect adequate palliative care from their health care system.2 The American College of Physicians and the American Board of Internal Medicine have both called for physician competency in the care of persons with terminal illness3 and the Annals of Internal Medicine has been active in publishing timely articles in this area.4 Clearly, the time is propitious to support specialty status for physicians working in palliative medicine, as has been achieved in Great Britain, Ireland and Australia. We are writing to report on the efforts of the American Board of Hospice and Palliative Medicine in certifying physician competency in this area. The American Board of Hospice and Palliative Medicine was formed in 1996 to establish
Gerald H. Holman, MD is the former Chairman of the ABHPM, and is Chief of Staff at the VA Medical Center, Amarillo, Texas, USA. Dale C. Smith, MPA is President of the ABHPM, Gainesville, FL, USA. Address reprint requests to: American Board of Hospice and Palliative Medicine, 9200 Daleview Court, Silver Spring, MD 20901, USA.
Journal of Pain and Symptom Management
309
and measure the level of knowledge, attitudes and skills required for certification of physicians practicing hospice and palliative medicine. In so doing, the Board has hoped to set the minimum standard of specialty practice, thereby assisting the employer, public, and members of the health professions in the assessment of these physicians. To achieve certification, a physician must hold an active license to practice medicine and be certified by an American Board of Medical Specialties approved board, osteopathic medicine equivalent, or the equivalent in other countries. They must have been in the clinical practice of medicine for at least two years, have worked as a member of an interdisciplinary team for at least two years, and have directly participated in the active care of at least fifty terminally ill patients in the preceding three years. Finally, they must pass a 250-question examination weighted in the following manner: 25% pain management, 25% non-pain symptom management, 15% hospice and palliative approach to care, 15% ethical and legal decision making, 10% death and dying (psychological and spiritual pain), and 10% communication and team work. The Trustees of the American Board of Hospice and Palliative Medicine (administratively certified during their tenure as trustees) in consultation with the Professional Testing Corporation of New York City maintain the 250-question examination and prospectively set a passing score. This examination is administered at multiple centers nationally on a semi-annual basis. After five examinations, 522 physicians have achieved board certification in Hospice and Palliative Medicine. Those with ABMS primary board certifications report the following: Anesthesiology 20, Family Practice 119 (23%), Internal Medicine 293 (56%), Pediatrics 5, Radiation Oncology 9, and Surgery 7. They describe their practice location as follows: rural 16%, academic 30%, urban 53%. They report their percent of professional time practicing Hospice/ Palliative Medicine as ,25% 204, 25%-50% 160, 51%–75% 50 and more than 75% 106. Three hundred sixty-eight (70%) report more than 5 years of clinical experience in Hospice/Palliative Medicine. Applicants were drawn from 46 states, Canada, and two additional countries. The available data indicate that 20% were less than 40 years of age and that almost two-thirds were men.
310
Board Certification in Palliative Care
We conclude that there is a strong societal and professional need for standards of competence in end-of-life care, including the development of palliative medicine as a physician specialty. There is also significant physician interest in seeking professional recognition for their expertise in caring for terminally ill persons and their families. We are confident that this certification process recognizes a level of knowledge and the skills necessary for the comprehensive practice of hospice and palliative medicine in the United States. It is the goal of the American Board of Hospice and Palliative Medicine to certify fellowship programs in hospice and palliative medicine nationally. We look forward to watching the cadre of professionals in this field grow as we meet the chal-
Vol. 17 No. 5 May 1999
lenges of caring for patients with progressive disease for whom the prognosis is limited, and the focus of care is quality of life. PII S08855-3924(99)00016-0
References 1. Field MJ, Cassel CK. Approaching Death: Improving Care at the End of Life. Institute of Medicine. National Academy Press, Washington, DC 1997. 2. US Supreme Court. No 95-1858, 96-110. Justice O’Connor, Justice Stevens concurring opinions. 3. American Board of Internal Medicine. Caring for the Dying: Identification and promotion of physician competency. Philadelphia 1996. 4. Meier DE, Morrison S, Cassel CK. Improving Palliative Care. Annals of Internal Medicine 1997;127: 225–230.