- Email: [email protected]
Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States
Accepted Manuscript Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States Lindy H. Landzaat, DO FAAHPM, Assistant Professor, Hospice and Palliative Medicine Fellowship Program Director, Michael D. Barnett, MD MS FAAP FAAHPM, Palliative Medicine Fellowship Program Director, Assistant Professor of Medicine & Pediatrics, Gary T. Buckholz, MD FAAHPM, Associate Clinical Professor, CoProgram Director, Jillian L. Gustin, MD FAAHPM, Clinical Assistant Professor, Hospice and Palliative Medicine Fellowship Program Director, Jennifer M. Hwang, MD MHS, Director of Education, Pediatric Advanced Care Team and Hospice and Palliative Medicine Fellowship Director, Assistant Professor of Clinical Pediatrics, Stacie K. Levine, MD FAAHPM, Associate Professor, Hospice and Palliative Medicine Fellowship Program Director, Director of Palliative Medicine Programs, Tomasz Okon, MD, Director, Marshfield Clinic Palliative Medicine Fellowship, Steven M. Radwany, MD FACP FAAHPM, Hospice and Palliative Medicine Fellowship Director, Holly B. Yang, MD MSHPEd HMDC FAAHPM FACP, Assistant Clinical Professor, Hospice and Palliative Medicine Fellowship Program Co-Director, John Encandela, PhD, Associate Professor of Psychiatry, Associate Director for Curriculum and Educator Assessment, Laura J. Morrison, MD FAAHPM, Hospice and Palliative Medicine Fellowship Program Director, Associate Professor of Medicine PII:
S0885-3924(17)30266-X
DOI:
10.1016/j.jpainsymman.2017.07.003
Reference:
JPS 9428
To appear in:
Journal of Pain and Symptom Management
Received Date: 27 January 2017 Revised Date:
6 June 2017
Accepted Date: 6 July 2017
Please cite this article as: Landzaat LH, Barnett MD, Buckholz GT, Gustin JL, Hwang JM, Levine SK, Okon T, Radwany SM, Yang HB, Encandela J, Morrison LJ, Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States, Journal of Pain and Symptom Management (2017), doi: 10.1016/j.jpainsymman.2017.07.003.
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States Lindy H. Landzaat, DO FAAHPM, Assistant Professor, Hospice and Palliative Medicine Fellowship Program
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Director, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA Michael D. Barnett, MD MS FAAP FAAHPM, Palliative Medicine Fellowship Program Director, Assistant Professor of Medicine & Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
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Gary T. Buckholz, MD FAAHPM, Associate Clinical Professor, Co-Program Director University of California San Diego/Scripps Health Hospice and Palliative Medicine Fellowship, University of California San Diego, La
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Jolla, CA, USA
Jillian L. Gustin, MD FAAHPM, Clinical Assistant Professor, Division of Palliative Medicine, Department of Internal Medicine, Hospice and Palliative Medicine Fellowship Program Director, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Jennifer M. Hwang, MD MHS, Director of Education, Pediatric Advanced Care Team and Hospice and Palliative Medicine Fellowship Director, The Children's Hospital of Philadelphia. Assistant Professor of Clinical Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Stacie K. Levine, MD FAAHPM, Associate Professor, Hospice and Palliative Medicine Fellowship Program
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Director, Director of Palliative Medicine Programs, University of Chicago, Chicago, IL, USA. Tomasz Okon, MD, Director, Marshfield Clinic Palliative Medicine Fellowship Marshfield Clinic, Marshfield, WI, USA
Steven M. Radwany, MD FACP FAAHPM, Hospice and Palliative Medicine Fellowship Director, Ethics Committee Chair, Summa Health / Northeast Ohio Medical University, Akron, OH, USA.
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ACCEPTED MANUSCRIPT Holly B. Yang, MD MSHPEd HMDC FAAHPM FACP, Assistant Clinical Professor, University of California San Diego/Scripps Health Hospice and Palliative Medicine Fellowship Program Co-Director, Scripps Health San Diego, CA, USA
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John Encandela, PhD, Associate Professor of Psychiatry, Associate Director for Curriculum and Educator Assessment, Teaching & Learning Center Yale School of Medicine, Yale School of Medicine, New Haven, CT, USA
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Laura J. Morrison, MD FAAHPM, Hospice and Palliative Medicine Fellowship Program Director, Yale Palliative
New Haven, CT, USA
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Care Program, Associate Professor of Medicine, Department of Medicine, Yale School of Medicine,
Running Title: HPM Entrustable Professional Activities Corresponding author contact information:
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Lindy Landzaat DO FAAHPM,
Phone: 913-588-3807
fax: 913-588-3877
Abbreviations used:
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3901 Rainbow Blvd, MS 1020, University of Kansas Medical Center, Kansas City, KS, 66160 USA
AAHPM HPM ACGME NAS
Entrustable Professional Activities
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EPAs
email: [email protected]
American Academy of Hospice and Palliative Medicine
Hospice and Palliative Medicine
Accreditation Council for Graduate Medical Education Next Accreditation System
CM
Curricular Milestone
CMs
Curricular Milestones
US
United States
HMD
Hospice Medical Director 2
ACCEPTED MANUSCRIPT Frequently Asked Question
ABMS
American Board of Medical Specialties
IDT
Interdisciplinary team
LST
Life Sustaining Therapies
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FAQ
Figures in paper do not require color.
Keywords: Entrustable Professional Activities, Hospice, Palliative Care, Fellowship, Graduate Medical
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Education
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Author Contribution List
Lindy H. Landzaat: Lead manuscript author and primary EPA author; associate chair of workgroup with significant input to overall project design and methods, primary data analysis and interpretation Michael D. Barnett: Primary EPA author and critically revised manuscript for important intellectual content;
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workgroup member; contributed to project design and methods, data analysis & interpretation Gary T. Buckholz: Primary EPA author and critically revised manuscript for important intellectual content; workgroup member; contributed to project design and methods, data analysis & interpretation
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Jillian L. Gustin: Primary EPA author and critically revised manuscript for important intellectual content;
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workgroup member; contributed to project design and methods, data analysis & interpretation Jennifer M. Hwang: Primary EPA author and critically revised manuscript for important intellectual content; workgroup member; contributed to project design and methods, data analysis & interpretation
Stacie K. Levine: Primary EPA author and critically revised manuscript for important intellectual content; workgroup member; contributed to project design and methods, data analysis & interpretation
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ACCEPTED MANUSCRIPT Tomasz Okon: Primary EPA author and critically revised manuscript for important intellectual content; workgroup member; contributed to project design and methods, data analysis & interpretation
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Steven “Skip” Radwany: Primary EPA author and critically revised manuscript for important intellectual content; workgroup member; contributed to project design and methods, data analysis & interpretation
Holly B. Yang: Primary EPA author and critically revised manuscript for important intellectual content;
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workgroup member; contributed to project design and methods, data analysis & interpretation
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John Encandela: Provided significant manuscript revisions; contributed to national survey design; performed data analysis, statistical support and interpretation.
Laura J. Morrison: Senior author providing significant manuscript revisions and primary EPA author; chair of
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workgroup and responsible for overall project design and methods, primary data analysis and interpretation.
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Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States Landzaat LH, Barnett MD, Buckholz GT, Gustin JL, Hwang JM, Levine SK, Okon T, Radwany SM, Yang
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HB, Encandela J, Morrison LJ Context: Entrustable Professional Activities (EPAs) represent the key physician tasks of a specialty. Once a trainee demonstrates competence in an activity, they can then be ‘entrusted’ to practice without supervision1. A physician workgroup of the American Academy of Hospice and Palliative Medicine (AAHPM) sought to define
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Hospice and Palliative Medicine (HPM) EPAs.
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Objective: To describe the development of a set of consensus EPAs for HPM fellowship training in the United States.
Methods: A set of HPM EPAs was developed through an iterative consensus process involving an expert workgroup, vetting at a national meeting with HPM educators, and an electronic survey from a national registry of 3,550 HPM physicians. Vetting feedback was reviewed and survey data were statistically analyzed.
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Final EPA revisions followed from the multisource feedback.
Results: Through the iterative consensus process, a set of 17 HPM EPAs was created, detailed, and revised. In the national survey, 362 HPM specialists responded (10%), including 58 of 126 fellowship program directors
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(46%). Respondents indicated the set of 17 EPAs well-represented the core activities of HPM physician practice (mean 4.72 on a 5-point Likert scale) and considered all EPAs to either be “essential” or “important”
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with none of the EPAs ranking “neither essential, nor important.” Conclusions: A set of 17 EPAs was developed using national input of practicing physicians & program directors and an iterative expert workgroup consensus process. The workgroup anticipates EPAs can assist fellowship directors with strengthening competency-based training curricula.
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ACCEPTED MANUSCRIPT Introduction: The transition from the Accreditation Council for Graduate Medical Education’s (ACGME) 1999 Outcome Project to the 2013 Next Accreditation System (NAS) has evoked new challenges in graduate medical training as programs continue to adapt and evolve from process-related compliance to demonstration of meaningful
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competency-based outcomes in resident education.2,3 Entrustable Professional Activities (EPAs) emerged independent of, and complementary to, the new NAS framework. They define the “essential tasks of
professional practice.”4 EPAs are observable, meaningful, manageable points of assessment that characterize a
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physician’s key activities within a medical specialty5. These representative activities are “entrusted” to the trainee, to perform without supervision, once they gain and demonstrate competence.1,6 Each EPA requires a
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combination of knowledge, skills, and attitudes to execute, and draws on multiple ACGME core competencies for successful entrustment. Some medical disciplines in the US have defined specialty-specific EPAs.7,8,9,10 Additionally, the Canadian Society of Palliative Care Physicians released a set of Palliative Medicine EPAs in 2015.11
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HPM EPAs serve several valuable roles as they describe the essential work of the field for medical providers, educators, and the larger healthcare community6. First, by defining core HPM physician activities, EPAs aid in educating the wider community about the evolving role of HPM. This is particularly helpful since HPM fellows
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in the US may seek fellowship training after completing one of 11 different residency backgrounds. Additionally, as alternative mid-career training pathways develop to help address HPM workforce shortages12,
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EPAs can pave the way for innovative delivery of curricula with comparable core content. The hope is that EPAs will directly and positively influence fellowship training and ultimately improve patient and family care outcomes.
The American Academy of Hospice and Palliative Medicine (AAHPM) has a long history of sponsoring workgroups to promote development of Hospice and Palliative Medicine (HPM) medical education. Workgroups have created adult and pediatric focused HPM competencies, measurable outcomes, and a toolkit of assessment methods to support fellowship training. 13,14,15,16,17 In response to the NAS charge to better 6
ACCEPTED MANUSCRIPT define competency-based outcomes, AAHPM convened a 2014 workgroup of expert HPM educators charged with defining EPAs for HPM fellowship training, the EPA Workgroup (hereafter, “the workgroup”). This paper describes the workgroup’s process for developing the 17 HPM EPAs for US fellowship trainees.
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Methods: EPA Development:
To develop EPAs, a workgroup undertook a group vetting and consensus process that drew elements from modified Delphi and Nominal Group Processes18. The workgroup included ten physician members
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representing diversity in adult and pediatric care, geography, gender, years of practice, and hospice and
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academic practice settings. All members served as HPM fellowship directors and led multiple HPM educational initiatives at their institutions.
At an in-person inaugural meeting in May 2014, the workgroup benchmarked with other specialty and subspecialty EPAs and consulted with ACGME Milestone Development leadership to define the aims and processes for HPM EPA development. The workgroup defined HPM EPAs as the critical tasks expected of a
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fellow by the end of training. Throughout the EPA development path, the workgroup regularly referenced the EPA characteristics 6,9 originally defined by ten Cate. The workgroup recognized that while an HPM graduating fellow may not ultimately perform all the EPAs in future independent practice, the EPA set should include
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important activities that prepare graduating fellows for the diverse work of HPM. The workgroup favored a set of EPAs that was observable and limited in number, yet inclusive enough to meaningfully represent the
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essential work of an HPM physician.
After developing a common understanding of EPAs, the workgroup initially identified eighteen EPA topics. Working in 5 dyads that each drafted 3 or 4 EPAs, the workgroup created the first set of 18 EPAs. From May 2014 to October 2015, the workgroup conducted twenty 90-minute meetings: nineteen conference calls and another in-person session at the 2015 national AAHPM conference. Through an iterative process, (see Figure 1), each workgroup member fully reviewed each individual EPA for content as well as fit in the set at least twice. The set was reviewed multiple times as a whole to assess the need to combine, split, or add EPAs. In 7
ACCEPTED MANUSCRIPT addition to reviewing, workgroup members also revised assigned EPAs with group discussion for consensus. After two rounds of review and revision, 16 EPAs remained from the initial list of 18. EPA vetting process:
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The workgroup pursued a multiphase external vetting process to ensure the EPA set was comprehensive and to garner consensus within the HPM community. First, the workgroup invited a convenience sample of twenty recent fellowship graduates to review a preliminary set of EPAs for any omissions in light of the everyday tasks defining their current professional roles. Fifteen provided feedback that was examined by the
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workgroup and resulted in no EPA additions. Next, at the February 2015 AAHPM Annual Assembly, over 100
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HPM physician fellowship leaders (the majority being fellowship program directors) each participated in a twoand-a-half hours EPA vetting session, including a didactic presentation of background content and process information, a facilitated small group exercise to review and provide specific feedback on four assigned EPAs, and a large group debriefing to identify additional feedback. Additionally, a subsequent one-hour session at the same Assembly, open to all interprofessional conference attendees, garnered feedback from 74 registrants
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in a similar but abbreviated process. The workgroup performed a detailed review of the comments as part of the ongoing iterative process (Figure 2). Some feedback suggested changes for content felt to be more relevant at a learning objective or curricular milestone level, rather than an EPA level. Other times, the
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content was already included as part of the more detailed EPA set though that may not have been readily apparent to the participant. Three significant outcomes resulted: the creation of a new 17th EPA, targeted
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revisions to the EPA set, or the addition of text in the final document describing the workgroup’s rationale for content decisions.
National Survey Vetting:
The final vetting activity was an electronic survey distributed to the AAHPM physician membership (3,550 physician members listed in the national registry) with the goal of achieving a robust, broad measure of consensus across the field on how well the EPAs represented the essential activities of practicing HPM physicians. A 3-week time window for completion was provided. 8
ACCEPTED MANUSCRIPT After offering a brief context and description of Entrustable Professional Activities, participants were asked to reflect on the core tasks that define their role as an HPM physician and then, to rate, using a 5-point Likert Scale (“very poorly” to “very well”) how well the EPA-set represented core tasks of HPM practice. Participants
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were also asked to review each proposed EPA for “how essential or important is competence in each proposed EPA” for a graduating HPM fellow. Modeled off similar surveys,19,20 options included “Essential for all”, “Important for all but not essential”, or “Not important or essential.” The survey also solicited potential EPA omissions and collected demographic information on the participants (Table 1). This study received exempt
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status by both the Yale University Human Investigation Committee and the University of Kansas Human
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Subjects Committee. Statistical Analysis:
To analyze how well the EPAs represented the core tasks of HPM practice, means and frequencies for each of the EPAs were established. Percentages of respondents’ priority ratings (i.e., essential, important but not essential, and not important or essential) were also established for each EPA. Chi square tests were performed
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for each of 19 independent variables (e.g., respondent gender, age, role vis-à-vis HPM practice and teaching, years in practice, etc.) as these were associated with respondent perceptions of priority rating for each EPA. Only those associations found to be significant are reported below in the Results section, with explanations of
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how these findings informed our decisions about EPAs. Frequencies and percentages were also established to
Results:
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describe respondent demographics and characteristics of their work.
EPA Development:
During the iterative process of review and revision, the initial draft of 18 EPA topics transitioned to 16 EPAs. Five EPA topics merged into one, 3 new topics emerged, and one was topic was eliminated. In direct response to vetting comments from the two national conference sessions, a new EPA, “Promote and teach hospice and palliative care,” was added, resulting in a final total of 17 EPAs (Appendix 1). In the end, each of the 17 EPAs included a title, an expanded description, and relevant, bulleted knowledge, skills, and attitudes. A summary 9
ACCEPTED MANUSCRIPT of feedback and resulting actions is included in Figure 2. The workgroup created a Frequently Asked Questions section of the EPA document to address some of the recurring feedback obtained during the vetting process. The final EPA list was released to the field on November 23, 2015 with an online document21.
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National Vetting Survey: A total of 362 physicians participated out of 3550 potential participants, yielding a 10% response rate. Participant demographics are listed in Table 1. Respondents generally dedicated over 75% of their time to practice of HPM, 41% served as hospice medical director or hospice team physician, and approximately 90%
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were involved in teaching medical trainees. Nearly three times as many respondents practiced primarily in
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palliative care settings as in hospice settings (58.9% vs. 20.4%). Fifty-eight respondents were HPM Fellowship Directors representing approximately 46% of the 126 HPM fellowship program directors. The mean rating of how well the set of 17 EPAs represent the core activities for HPM physicians using a 5-point Likert scale was 4.72 (SD=0.65). As noted in Table 2 and Figure 3, none of the 17 EPAs fell into the primary category of “not essential or important.” With EPAs being a new concept in HPM, there is no accepted level of
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consensus to guide inclusion or exclusion. The workgroup anticipated that any EPAs rating primarily as “not essential, nor important” would have been eliminated and those with a majority vote of “essential” would likely be retained.
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All but one of the EPAs fell primarily into the “essential” category. EPA 15, “Fulfill the role of a hospice medical director,” had a majority of responses in the “important but not essential for all” category. Chi square results
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showed, not surprisingly, that hospice medical directors, also referred to as hospice team physicians, (41% of respondents) were statistically more likely to rate this EPA higher than colleagues not working in hospice (p <0.01). The majority of respondents, however, (59%) practiced palliative care but not hospice. The workgroup reviewed all survey data in detail, including all comments, elected to retain all 17 EPAs, and made final revisions. Discussion
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ACCEPTED MANUSCRIPT This paper reports the development of 17 consensus HPM EPAs that expand the national education infrastructure for HPM fellowship training. This defined list of key physician activities is expected to serve as a guide to inform HPM Fellowship curricula and may serve as the basis for designing performance assessment
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tools to determine fellow physician entrustment. EPAs may prompt fellowship programs to examine their current curricula and highlight a need for focused attention on competence in key clinical tasks. Because they are not a current requirement, fellowship programs have flexibility in which EPAs to use and how to use them. The EPAs also provide fellows a more specific framing of the entrustment tasks expected of them by the end of
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fellowship, including detailing of the requisite knowledge, skills, and attitudes for each.
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Strengths of our process included an extensive iterative process by a workgroup of expert HPM educators, vetting at a national meeting with program directors and practicing providers, and vetting through a national survey of HPM physicians. Our survey participants were clinically active, represented both hospice and palliative care settings, and were routinely involved in HPM education.
The EPA development process and vetting included limitations. First, regarding the survey design, the
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measurement of reliability for survey takers is limited given the single administration design. The survey response rate was relatively low at 10%. The workgroup opted to err on the side of broader representation and ‘cast the net widely’ by sending the survey invitation to all AAHPM physician members. The 10% response
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rate is in line with the average for a convenience sample on AAHPM surveys22. Program directors were represented with 46% participating, a response rate in line with a similar national educational workgroup
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vetting process20. The threat of bias that exists with convenience sampling may be offset somewhat in our study by the fact that two important constituencies—hospice medical directors/team physicians and fellowship directors—were relatively well represented in the sample. Our process highlights a number of ongoing challenges for competency-based education and others pursuing EPA development. One challenge was how to effectively balance breadth and depth of EPAs in light of the need for practical application. The workgroup aimed to define EPAs that were discrete enough to be observable and potentially measurable while keeping the total number manageable for one-year HPM clinical 11
ACCEPTED MANUSCRIPT fellowships. Another challenge was finding the balance between “lumping and splitting” different EPAs. For instance, should the Psychosocial EPA #11, and Spiritual Care EPA #12 be merged into a broader Support EPA or remain distinct? Should EPA #6, ‘Participate as a member or leader of an interdisciplinary team,’ be its own
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EPA or simply be an element included within multiple EPAs? The workgroup chose to elevate particular constructs to individual EPAs in order to underscore the importance of certain sets of knowledge and skills necessary to perform the work as part of the field’s current growth and professional expectation. The workgroup chose to address some of the areas that generated a lot of discussion by offering rationales in a
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Frequently Asked Question (FAQ) section within the final EPA document21. EPAs are a new framework
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currently not required by the ACGME and may be unfamiliar to many educators. Therefore, how EPAs will be applied is unclear, complicating our goal of designing them to be useful and practical. Finally, as originally defined, EPAs are to be independently executable.6 This is important to successful evaluation of an individual’s performance, but for an inherently team-based specialty, “independently executable6” may prove a practical implementation challenge.
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Our vetting process also suggested that variability exists within the HPM field in the interpretation of “Hospice Medical Director” terminology (EPA #15). The title may broadly refer to any physician employed by a hospice (i.e. a hospice team physician). In some settings, however, this title is reserved for a single lead physician of a
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hospice organization. The workgroup intended the former definition for EPA #15. However, ambiguity around the term could have confounded and lowered the ratings for this EPA if respondents considered the narrower
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HMD definition. In addition, very few survey participants thought this EPA warranted the lowest category of 'not important or essential'. There was universal workgroup consensus that this EPA was in fact 'essential to all.' In considering the risk of burden to harm, since EPAs are not an ACGME requirement and program directors have discretion about which EPAs they use and how they use them, keeping a potentially less useful EPA in the set seemed to be a safer approach than discarding a potentially ‘essential-to-training’ EPA. Given that, the workgroup elected to retain EPA #15 as part of the final EPA set. Since field-specific terminology can
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ACCEPTED MANUSCRIPT be interpreted inconsistently and complicate the vetting process, the workgroup suggests that others proactively anticipate and address terminology dilemmas if vetting EPAs. Conclusion: The AAHPM EPA workgroup developed a consensus set of 17 EPAs that represent the essential
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activities of entrustment for US HPM fellowship graduates. The set of 17 EPAs rated highly as representing the core activities of HPM after a multi-phased vetting process. This final EPA list describes key HPM physician tasks and defines EPAs for the field of HPM. It offers fellowship programs a tool to assist with competency-
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based curricula and a launching point for developing entrustment assessments. The practical application and experience of applying the new EPA construct to HPM fellowship training, mid-career training pathways, and
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other settings will inform future research, revisions, and future iterations of HPM EPAs. Disclosures & Acknowledgments: This work received administrative support and travel-related funding for the workgroup’s initial in-person meeting from the Academy of Hospice and Palliative Medicine. There was no other additional funding for this work. The authors would like to thank the American Academy of Hospice and Palliative Medicine for supporting HPM EPA development, and specifically thanks Ms. Margaret Rudnik and
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Ms. Dawn Levreau for their administrative expertise and contributions to the project. In addition, the workgroup is appreciative of advising by Laura Edgar, EdD, CAE, ACGME Executive Director for Milestone
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Development. The authors declare no conflict of interest.
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ACCEPTED MANUSCRIPT References: 1.
Ten Cate O. Nuts and bolts of entrustable professional activities. J Grad Med Educ. 2013;5:157-158.
2.
Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system--rationale and benefits. N
3.
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Engl J Med. 2012;366:1051-1056. Nasca TJ, Weiss KB, Bagian JP, Brigham TP. The Accreditation System After the “Next Accreditation System.” Acad Med. 2014;89:27-29. 4.
Accreditation Council for Graduate Medical Education (ACGME). Frequently Asked Questions:
Accreditation Council for Graduate Medical Education (ACGME). Internal Medicine Subspecialty
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5.
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Milestones.
Reporting Milestones Frequently Asked Questions (FAQs). 6.
ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82:542-547.
7.
Leipzig RM, Sauvigné K, Granville LJ, et al. What is a geriatrician? American Geriatrics Society and
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Association of Directors of Geriatric Academic Programs end-of-training entrustable professional activities for geriatric medicine. J Am Geriatr Soc. 2014;62:924-929. 8.
Boyce P, Spratt C, Davies M, McEvoy P. Using entrustable professional activities to guide curriculum
9.
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development in psychiatry training. BMC Med Educ. 2011;11:96. Shaughnessy AF, Sparks J, Cohen-Osher M, et al. Entrustable professional activities in family medicine. J
10.
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Grad Med Educ. 2013;5:112-118.
Hauer KE, Kohlwes J, Cornett P, et al. Identifying entrustable professional activities in internal medicine training. J Grad Med Educ. 2013;5:54-59.
11.
Myers J, Krueger P, Webster F, et al. Development and Validation of a Set of Palliative Medicine Entrustable Professional Activities: Findings from a Mixed Methods Study. J Palliat Med. 2015;18:682690.
12.
Lupu D. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain 14
ACCEPTED MANUSCRIPT Symptom Manage. 2010;40:899-911. 13.
Morrison LJ, Arnold R, Billings JA, et al. Hospice and Palliative Medicine Competencies Project: Toolkit of Assessment Methods. 2010. Morrison LJ, Scott JO, Block SD. Developing Initial Competency-based Outcomes for the Hospice and
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14.
Palliative Medicine Subspecialist: phase I of the hospice and palliative medicine competencies project. J Palliat Med. 2007;10:313-330.
Arnold R, Billings J, Block S, et al. Hospice and Palliative Medicine Core Competencies. on-line.
16.
Klick J, Friebert S, Hutton N, et al. Pediatric-Hospice and Palliative Medicine Competencies, version 2.0.
SC
15.
17.
Klick JC, Friebert S, Hutton N, et al. Developing competencies for pediatric hospice and palliative medicine. Pediatrics. 2014;134:e1670-7.
18.
Fink A, Kosecoff J, Chassin M, Brook RH. Consensus methods: Characteristics and guidelines for use. Am J Public Health. 1984.
Schaefer KG, Chittenden EH, Sullivan AM, et al. Raising the bar for the care of seriously ill patients:
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19.
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on-line2.
results of a national survey to define essential palliative care competencies for medical students and residents. Acad Med. 2014;89:1024-1031.
Parks SM, Harper GM, Fernandez H, Sauvigne K, Leipzig RM. American Geriatrics Society/Association of
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20.
Directors of Geriatric Academic Programs curricular milestones for graduating geriatric fellows. J Am
21.
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Geriatr Soc. 2014;62:930-935.
Morrison LJ, Landzaat LH, Barnett MD, et al. Hospice and Palliative Medicine Entrustable Professional Activities. Online.
22.
Dawn Levreau. AAHPM Personal Correspondence. 2016.
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ACCEPTED MANUSCRIPT
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Age (355) 20-29 0.3% 1 30-39 18.0% 64 40-49 26.2% 93 50-59 29.0% 103 60-69 23.4% 83 70 and older 2.5% 9 Prefer not to answer 0.6% 2 Gender (352) Female 54.0% 190 Male 45.7% 161 Prefer not to answer 0.3% 1 Years in Practice (355) 0-5 25.6% 91 6-10 28.2% 100 11-15 19.4% 69 16-20 10.1% 36 More than 20 16.6% 59 ABMS certified in HPM (354) Yes 91.8% 325 No 8.2% 29 Hospice medical director/hospice team physician leader (355) Yes 41.1% 146 No 58.9% 209 Setting(s) where majority of professional time spent (358) Hospice 20.4% 68 Palliative Care 58.9% 196 Both Hospice and Palliative Care 20.7% 69 (close to evenly split) Other 7.0% 25 Practice setting (354) Academic medical center 42.9% 152 Community hospital 19.8% 70 Outpatient clinic 3.1% 11 Hospice 20.9% 74 Other 13.3% 47 Hours per week devoted to HPM (355) <25 % 10.4% 37 25-50% 13.5% 48 51-75% 9.6% 34 >75% 66.5% 236 Teaching Responsibilities (355) Involved in teaching medical trainees 89.6% 318 Not teaching medical trainees 10.4% 37
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Table 1 : National Survey Participant Demographics, n=362
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ACCEPTED MANUSCRIPT Table 2: Vetting Survey to AAHPM physician members with EPA rankings
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2
Provide comprehensive pain assessment and management for patients with serious illness. HPM physicians are able to use an interdisciplinary team approach to effectively manage complex pain in the context of serious illness using pharmacologic and non-pharmacologic approaches. Provide comprehensive non-pain symptom assessment and management for patients with serious illness. HPM physicians are able to lead and collaborate with an interdisciplinary team to effectively manage complex nonpain symptoms, including but not limited to anorexia, constipation and diarrhea, delirium, dyspnea, fatigue, nausea and vomiting, depression and anxiety, using pharmacologic and non-pharmacologic treatments. Manage palliative care emergencies. HPM physicians anticipate, prepare for, and respond to palliative emergencies to minimize distress in partnership with the patient, caregivers, and medical team, while taking into account the patient’s goals of care and prognosis. Estimate and communicate prognosis to aid medical decision-making. HPM physicians are able to estimate, communicate, and consider prognosis while acknowledging uncertainty as they facilitate shared decision-making and delineate goals of care based on patient/family values. Establish goals of care based on patient/family values and a specific medical circumstances . HPM physicians are able to elicit patient/family values, delineate goals of care based on patient/family values in the context of the patient’s medical condition, and make recommendations for an appropriate care plan. Participate as a member or leader of an interdisciplinary team. HPM physicians function effectively as a leader/member of an interdisciplinary team (IDT), manage patient and family care provided by an IDT, and facilitate IDT meetings, while sharing the leadership role with other IDT members as appropriate. Prevent and mediate conflict and distress over complex medical decisions. HPM physicians prevent and address clinical conflict and uncertainty as well as emotionally charged encounters and value laden suffering through advanced palliative communication techniques. Manage withdrawal of advanced life sustaining therapies. HPM physicians are skilled in the withdrawal of advanced life sustaining therapies including facilitation of goals of care discussions leading to the decision to withdraw advanced LST, management of symptoms pre- and postwithdrawal of advanced LST, orchestration of withdrawal of LST, and provision of family support for psychosocial and
EP
1
AC C
#
How essential or important is competence in each proposed EPA for a graduating HPM fellow? % % Important % Not EPA Description Essential but not important or N=362 to all essential essential
89.0
10.8
0.3
93.9
5.8
0.3
96.7
2.5
0.8
86.2
13.3
0.6
82.0
17.7
0.3
83.7
15.7
0.6
17
ACCEPTED MANUSCRIPT
13
14
15
16
17
5.2
0.3
74.0
22.9
3.0
31.5
1.1
SC
67.4
RI PT
94.5
M AN U
12
TE D
11
EP
10
AC C
9
spiritual distress including anticipatory grief and bereavement. Care for the imminently dying patient and their family. HPM physicians are able to identify signs of the dying process and tend to the needs of the multiple areas of suffering for an individual patient and their family during imminent dying and facilitate after death bereavement support for the family and health care providers. b Manage requests for hastened death . HPM physicians manage requests for hastened death in accordance with federal, state and local regulations as well as ethical and professional principles while remaining sensitive to patients’ individual values, preferences and sources of suffering. Support patient and family in the psychosocial domain. HPM physicians address patient and family suffering, coping, and healing in the emotional, psychological and social domains with focused and developmentally appropriate assessment followed by targeted communication, interventions and referrals. Support patient and family in the spiritual and existential domain. HPM physicians address patient and family suffering and identify strengths and needs within the spiritual and existential domain with basic assessment followed by identification of appropriate interventions and referrals. Promote self-care and resilience. HPM physicians value and promote resilience and personal well-being for themselves and others as a necessary element for professional success and sustainability. Facilitate transitions across the HPM continuum of care. HPM physicians are adept at caring for patients and families across the healthcare continuum (inpatient, long-term care, ambulatory, home) with an understanding of and appreciation for resource availability, care coordination, and transitions support required for effective, high-quality care. Fulfill the role of a hospice medical director. HPM physicians meet the clinical, regulatory, administrative and supportive responsibilities of a hospice medical director. Provide hospice and palliative medicine consultation and team support. HPM physicians render patient and family centered consultative care in a professional, timely, and effective manner which supports and educates the referring and invested team members. c Advocate for and teach palliative care . HPM physicians advocate for access to high quality palliative care services across the continuum of care and enhance other healthcare providers’ primary palliative care skills and knowledge.
55.0
43.1
1.9
78.2
20.7
1.1
75.1
24.3
0.6
30.1
63.0
6.9
83.4
15.5
1.1
55.5
43.4
1.1
a
Final Version included title change to “Establish goals of care based on patient and/or family values and specific medical circumstances” b Final Version included title change to “Address requests for hastened death” c Final Version included title change to “Promote and teach palliative care”
18
ACCEPTED MANUSCRIPT Figure 1: HPM EPA Step-Wise Development Process 1. Benchmark with other specialties' EPAs
RI PT
2. Compose initial list of 18 HPM EPAs
3. Author-dyads draft full EPAs including: title, description, required knowledge, skills, attitudes
SC
4. Workgroup members review each EPA individually; provide written feedback to authors
M AN U
5. Authors review written feedback, discuss revisions on conference calls, seek consensus
6. Repeat steps 4 & 5 for second round review of all EPAs
7. Input from 15 Recent Fellow Graduates
TE D
8. Vetting at AAHPM national meeting – approx. 174 fellowship leaders and HPM educators
9. Addition of EPA #17
EP
10. Vetting with national survey to field-362 respondents
AC C
11. Iterative review of national survey feedback, revisions
12. Final 17 HPM EPAs released
19
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
Figure 2 : Workgroup Review Process for Multisource Feedback by Comment Topic
20
ACCEPTED MANUSCRIPT
Figure 3 : Respondent Ratings of 17 Preliminary EPAs n=362 100% 90% 80%
RI PT
70% 60% 50% 40%
SC
30% 20% 10%
M AN U
0%
Important but not essential
Not important or essential
AC C
EP
TE D
Essential to all
21
ACCEPTED MANUSCRIPT Appendix 1 (option A)
RI PT
SC
M AN U
TE D EP
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Final List of HPM Entrustable Professional Activities Provide comprehensive pain assessment and management for patients with serious illness Provide comprehensive nonpain symptom assessment and management for patients with serious illness Manage palliative care emergencies Estimate and communicate prognosis to aid medical decision-making Establish goals of care based on patient and/or family values and specific medical circumstances Participate as a member or leader of an interdisciplinary team Prevent and mediate conflict and distress over complex medical decisions Manage withdrawal of advanced life-sustaining therapies Care for imminently dying patients and their families Address requests for hastened death Support patients and families in the psychosocial domain Support patients and families in the spiritual and existential domain Promote self-care and resilience Facilitate transitions across the HPM continuum of care Fulfill the role of a hospice medical director Provide HPM consultation and team support Promote and teach hospice and palliative care
AC C
1 2
22
ACCEPTED MANUSCRIPT Appendix 1 (option B)-[these are the full 17 EPAs if the journal chooses to include and pending discussions with AAHPM related to copyright]
Hospice & Palliative Medicine EPA EPA Title: EPA 1. Provide comprehensive pain assessment and management for patients with serious illness.
• Knowledge •
• • • • • • • • •
EP
Skills
SC
•
M AN U
•
Explain the pathophysiology of pain across the age spectrum, from pediatrics to geriatrics. List components of a detailed pain assessment, including developmentally appropriate screening and assessment tools. Explain the domains of whole-patient assessment and their potential impact on reported physical pain (total pain). Describe the pharmacokinetics, pharmacodynamics, and potential adverse effects of opioids and nonopioid pain medications to achieve proportionate symptom control. Describe safe opioid-prescribing practices such as use of the Opioid Risk Tool (ORT), pain contracts, appropriate storage and disposal, risk evaluation and mitigation strategies (REMS), state and local regulations, and aberrant behaviors associated with misuse. List nonpharmacologic approaches to manage pain. List procedural approaches (along with referral services) to manage pain. Describe relative costs of medications and other therapies to treat pain. Perform a comprehensive pain assessment, including all domains of suffering. Collaborate with the IDT and other providers to optimally manage pain. Utilize appropriate diagnostic workup and interpretation of diagnostic tests. Develop and implement plans to provide comprehensive pain management for the full spectrum of pain syndromes. Recognize and manage adverse effects of medications and other therapies. Communicate treatment plans clearly to individual patients, their families, and healthcare providers. Implement safe opioid-prescribing practices. Demonstrate cost-effective care. Appreciate the important, urgent nature of pain management. Recognize the necessity of managing physical suffering to allow patients to better address other domains of suffering and improve quality of life. Appreciate the complex interplay between physical and other domains of suffering and the role of the IDT
TE D
•
List specific
RI PT
Detailed Description: HPM physicians lead and collaborate with an interdisciplinary team (IDT) approach to effectively manage complex pain in the context of serious illness using pharmacologic and nonpharmacologic approaches.
AC C
• • • •
Attitudes
•
23
ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 2. Provide comprehensive comprehensive nonpain symptom assessment and management for patients with serious illness.
• • • Skills • • • • • Attitudes
•
AC C
EP
•
SC
•
M AN U
Knowledge
• • •
Describe the pathophysiology of common symptoms in serious illness across the age spectrum, from pediatrics to geriatrics. Describe diagnostic methods necessary for optimal symptom assessment. List developmentally appropriate nonpain symptom screening and assessment tools. Identify pharmacologic and nonpharmacologic treatments for nonpain symptoms using the current evidence base in palliative medicine. Recognize the expected benefits, burdens, and relative costs of various treatment modalities and medications. Perform a thoughtful, comprehensive, and systematic symptom assessment using validated scales or tools when appropriate. Demonstrate appropriate diagnostic workup and interpretation of test results. Use evidence-based nonpharmacologic and pharmacologic therapies and adjust treatment plan based on results and side effects. Make appropriate referrals to other specialists and members of the IDT to assist with symptom management. Communicate treatment plans clearly to patients, families, and healthcare providers. Demonstrate cost-effective care. Appreciate the important, urgent nature of nonpain symptom management. Recognize the value of input from multiple disciplines in addressing challenging nonpain symptoms. Appreciate the importance of symptom management in diminishing suffering and improving quality of life. Maintain a supportive presence for the suffering that comes with intractable symptoms
TE D
•
List specific
RI PT
Detailed Description: HPM physicians lead and collaborate with an interdisciplinary team (IDT) to effectively manage complex nonpain symptoms, including but not limited to anorexia, constipation and diarrhea, delirium, dyspnea, fatigue, nausea and vomiting, depression, and anxiety using pharmacologic and nonpharmacologic treatments.
24
ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 3. Manage palliative care emergencies. Detailed description: HPM physicians anticipate, prepare for, and respond to palliative care emergencies in partnership with the patient, caregivers, and medical team while taking into account the patient’s goals of care and prognosis.
• Skills
• • • •
Attitudes
•
AC C
EP
•
RI PT
•
SC
• •
M AN U
Knowledge
Define and list palliative care emergencies characterized by a high symptom burden and decreased quality of life. These may include medical, surgical, psychiatric, and iatrogenic emergencies as well as severe psychosocial crises for patients and/or families/caregivers. Describe the risk factors and pathophysiology of specific palliative care emergencies. Identify various modalities to decrease symptom burden and/or modify underlying pathology that can be implemented in each emergency. Anticipate, recognize, and proactively consider risk mitigation strategies for all categories of palliative care emergencies. Use an interdisciplinary approach to identify, prepare for, and provide comprehensive management of palliative care emergencies. Demonstrate judicious and rapid escalation of palliative therapies proportional to the degree of distress and suffering. Provide support to patients and/or families including prognostication and reassessment of goals of care before, during, and after a palliative care emergency. Demonstrate a supportive presence for patients, caregivers, and staff, especially when managing an “unfixable” emergency. Embrace the responsibility of identifying palliative care emergencies and expeditiously acting on them. Appreciate the emotional impact of preparing for, witnessing, and managing emergencies for patients, families, medical teams, and palliative care providers. Recognize that competent management of palliative care emergencies decreases suffering and may improve quality of life.
TE D
•
List specific
25
ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 4. Estimate and communicate prognosis to aid medical decisiondecision-making. Detailed Description: HPM physicians estimate, communicate, and consider prognosis while acknowledging uncertainty as they facilitate shared decision making and delineate goals of care based on patient and/or family values.
• •
Skills
• • • • • • • •
AC C
EP
Attitudes
RI PT
•
SC
•
M AN U
Knowledge
Describe prognostication in serious illness, identifying elements of history, physical exam, and diagnostic testing important to determining prognosis. List current prognostic methods and tools and the strengths and weaknesses of each approach. Describe techniques for communicating prognosis and medical uncertainty across the age spectrum, from pediatrics to geriatrics. Perform a thoughtful, comprehensive, and systematic palliative care assessment taking into account disease process, comorbidities, disease trajectory, psychosocial support, and available treatments. Use relevant evidence-based prognostic tools to help create a prognostic estimate when appropriate. Obtain and integrate prognostic estimates from other healthcare providers. Determine hospice eligibility based on a prognostic estimate. Assess patient and/or family interest in knowing prognostic information and explore the specific reasons for preferences, including cultural and/or spiritual influences. Assess and communicate disease trajectory, expected function, and prognosis to patients, families, and other healthcare providers. Acknowledge and express uncertainty. Direct a family meeting when necessary to help communicate prognosis and aid medical decision making. Appreciate the importance of prognosis in medical decision making and the weight of prognosis for all involved. Appreciate the challenge of uncertainty in prognostication across various patient populations.
TE D
•
List specific
26
ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 5. Establish goals of care based on patient and/or family values and specific medical circumstances.
• • • • • • •
Skills
• • •
EP
•
SC
Knowledge
M AN U
•
Describe prognostication in serious illness. Recognize techniques for communicating prognosis and medical uncertainty. Explain and differentiate essential elements of assessing decision-making capacity across the age spectrum. Identify techniques for engaging patients and family members in discussion and conflict resolution. Relate patient- and family-centered communication to delineation of goals of care, particularly in the determination of patient and/or family values. Describe the benefits and burdens of various medical therapies. Differentiate curative versus palliative intent of treatments. Define the concurrent care model which allows for coexisting curative and palliative goals of care in pediatric hospice and other similar settings. Perform a thoughtful, comprehensive, and systematic palliative assessment, taking into account disease process, comorbidities, characteristic symptom burden, and disease trajectory, together with input from other healthcare providers. Direct a family meeting to help set goals of care, communicate prognosis, reframe hope, and express uncertainty. Use a framework approach to give serious news or medical information, attending to emotion from the patient, family and other healthcare providers. Establish the patient’s definition and determinants of quality of life. Utilize the interdisciplinary team to explore and clarify patient and/or family values. Provide recommendations for medical care based on patient and/or family values and goals. Discuss withdrawal of medical therapies such as artificial hydration and nutrition, antibiotics, anticoagulation, or other medications based on goals of care. Work toward consensus among patients, families, and healthcare providers. Assist with conflict resolution between patients, families, and other healthcare providers. Guide patients, families, and healthcare providers through the shifting transitions between curative and palliative care. Introduce hospice care when appropriate based on overall prognosis. Appreciate the importance of determining and communicating prognosis to aid medical decision making. Respect individual patient and/or family differences in hopes and values related to serious illness. Anticipate the full spectrum of patient and family responses to goals of care discussions.
TE D
• • •
List specific
RI PT
Detailed Description: HPM physicians elicit patient/family values, delineate goals of care based on patient and/or family values in the context of the patient’s medical condition, and make recommendations for an appropriate care plan.
• •
AC C
• • •
Attitudes
• •
27
ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 6. Participate as a member or leader of an interdisciplinary team. Detailed Description: HPM physicians manage the medical care provided by interdisciplinary teams (IDTs) and facilitate IDT meetings while sharing the leadership role with other IDT members as appropriate.
• •
Skills
• • • • •
Attitudes
•
AC C
EP
TE D
•
RI PT
•
SC
Knowledge
Describe concepts of team processes and development and recognize elements that promote or hinder successful IDT function. Discuss the professional skill set, expertise, role, and potential contribution of each member of the interdisciplinary team. Lead and/or facilitate recurring IDT meetings. Evolve one’s own communication style with colleagues to optimize team function within and outside of IDT meetings. Accept and solicit insights from all IDT members in developing a patient care plan. Monitor and facilitate team function including managing distress and supporting resilience. Provide and accept feedback from IDT members. Help to develop the care plan and/or provide care to patients and families as a member of an IDT. Respect the unique contributions of each member of the IDT and the impact of each member on team function. Recognize the need to address all palliative care domains in the development of an effective care plan. Facilitate openness, receptivity, mutual respect, and trust among IDT members.
M AN U
•
List specific
28
ACCEPTED MANUSCRIPT Hospice & Palliative Medicine Medicine Title: EPA 7. Prevent and mediate conflict and distress over complex medical decisions. Detailed Description: HPM physicians prevent and address clinical conflict, uncertainty, emotionally charged encounters, and value-laden suffering through advanced palliative communication techniques.
• Skills
• • • • • • • •
EP
Attitudes
RI PT
•
SC
• • •
M AN U
Knowledge
Describe treatment options and prognosis; indicators and impact of patient, family, provider, and team distress; and ethical and legal implications of decisions. Recall and understand the situations and decisions that lead to clinical conflict. Acknowledge and negotiate contentious clinical situations. Identify, recognize sources of, and formulate a differential diagnosis for the conflict, engaging the assistance of the interdisciplinary team as needed. Identify and attend to strongly expressed opinions and emotions; help to de-escalate situations in which conflict intensifies. Attend to the emotional and physical safety of providers, patients, and families in conflict situations. Compassionately and realistically mediate disagreements regarding care plans. Address current or anticipated grief among patients, families, providers, and teams, especially as it pertains to clinical decision making. Elucidate and address the ethical and legal implications of difficult decisions to be made when disagreement exists. Address conflict in a step-wise process (recognition, preparation, identification of involved/violated core concerns, exploration, reframing, alliance, support, and compromise) with the assistance of the team as needed. Direct a family meeting to help address conflict and distress when necessary. Demonstrate openness to patient and family preferences. Display commitment to meeting patient needs while preserving provider integrity. Exhibit self-awareness of personal values, how they might conflict with others’ values, and how they impact conflict mediation. • Demonstrate openness to identifying one’s own strong positive and/or negative feelings. • Reflect on negative emotions in oneself and one’s patients over time. Exhibit compassion for all disciplines and specialties involved in difficult patient-care situations. Display humility regarding one’s own clinical judgment and openness to other opinions in charged clinical situations.
TE D
•
List specific
•
AC C
•
29
ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 8. Manage withdrawal of advanced lifelife-sustaining therapies.
• • • • • • • •
Skills
• •
EP
•
SC
Knowledge
M AN U
• •
Describe the federal, state, and local laws that impact the withdrawal of advanced LST. Give examples of ethical principles relevant to the withdrawal of advanced LST. Discuss local institutional policies relevant to the process of withdrawal of advanced LST. Explain the process of withdrawal of various advanced LSTs. Describe symptom burden and appropriate interventions associated with withdrawal of common advanced LSTs. Recognize signs and symptoms of impending death after withdrawal of advanced LST. Recognize psychosocial and spiritual distress including anticipatory grief and bereavement responses from families. Facilitate discussions with patients and/or families regarding goals of care and preparation for withdrawal of advanced LST. Diagnose and manage symptom burdens associated with withdrawal of advanced LST. Orchestrate withdrawal of advanced LST. Attend to psychosocial and spiritual distress including anticipatory grief and bereavement responses from families. Utilize the interdisciplinary team (IDT) to support both the patient and family before, during, and after the withdrawal of LST. Demonstrate care that shows respectful attention to sociocultural characteristics of patients and their families. Demonstrate high standards of ethical behavior including utilizing the IDT, maintaining professional boundaries and scope of practice, and collaborating with other involved physicians and healthcare providers. Appreciate the need to attend to unique characteristics and needs of patients, their families, and healthcare providers. Value the key roles of IDT members, collaboration with colleagues, and maintenance of professional boundaries in withdrawal of LST. Appreciate the potential gravity of decisions to withdraw LST. Accept that personal experiences and the specific microculture of the care setting can contribute to bias, which can impact the recommendation to withdraw LST.
TE D
•
List specific
RI PT
Detailed Description: HPM physicians are skilled in the withdrawal of advanced life-sustaining therapies (LSTs), including facilitation of goals of care discussions leading to the decision to withdraw advanced LST, management of symptoms before and after withdrawal of advanced LST, orchestration of withdrawal of LST, and provision of family support for psychosocial and spiritual distress including anticipatory grief and bereavement.
AC C
• •
Attitudes
• •
30
ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 9. Care for imminently dying patients and their families.
• Knowledge • • • • • • • • • •
EP
Skills
SC
•
M AN U
•
Describe the physical signs and symptoms of the dying process and common challenges for symptom management. List medications used to treat symptoms of impending death and explain their mechanisms of action. Describe areas of whole-patient care as it relates to caring for the imminently dying patient. Recognize roles and skills of interdisciplinary team members needed to achieve whole-patient care. Describe communication techniques to provide psychosocial support. Recall and explain the range of potential indications for proportionate symptom control, which could include sedation. Describe ethical principles and how they do or do not apply to end-of-life care. Identify the characteristics of normal and complicated grief and bereavement. List medical conditions that require medical examiner involvement and requisite steps of sensitive death pronouncement and documentation. Recognize the imminently dying patient and associated signs and symptoms. Facilitate communication to prepare family and healthcare providers that death is imminent. Utilize an interdisciplinary team approach to provide whole-patient care for the imminently dying patient and their family. Provide psychosocial support to family and healthcare providers regarding common concerns, identify family members at risk for complex bereavement, and have patience and understanding for different coping and grieving styles. Recognize different perspectives of family and healthcare providers regarding the degree of symptom burden during the dying process. Manage physical symptoms of impending death. Inquire if spiritual or cultural rituals are important and provide assistance as appropriate. Make the death pronouncement in a sensitive, respectful way in the presence of family. Document the patient’s death and complete the death certificate appropriately. Appreciate the importance and time sensitivity in providing care for the imminently dying patient and their family. Acknowledge the uniqueness of the dying experience for each patient and family. Value the potential positive impact of effective interdisciplinary care on family bereavement. Recognize the importance of role modeling and teaching sensitive, skilled care of the dying patient to other care providers.
TE D
•
List specific
RI PT
Detailed Description: HPM physicians identify signs of the dying process, address multiple areas of suffering for the imminently dying patient and their family and facilitate after-death bereavement support for the family and healthcare providers.
• •
AC C
• • •
Attitudes
• • •
31
ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 10. Address requests for hastened death. Detailed Description: HPM physicians address requests for hastened death in accordance with federal, state, and local regulations as well as ethical and professional principles while remaining sensitive to a patient's individual values, preferences, and sources of suffering.
• • • Skills • • •
Attitudes
• •
AC C
EP
•
RI PT
•
SC
Knowledge
M AN U
•
Identify and summarize the federal and state laws, local regulations, and professional guidelines applicable to requests for hastened death. Demonstrate broad knowledge of epidemiology and etiologies of requests for hastened death. Elucidate a physician’s clinical, ethical, and professional responsibilities when faced with requests for hastened death. List and explain bioethical models relevant to requests for hastened death. Explore the full range of potential motivations in requests for hastened death using a routine and comprehensive approach. Communicate and counsel the patient about total pain, and provide state-of-the-art palliative therapies to manage total pain by addressing all aspects of suffering with time-limited trials. Explore the patient’s fears and expectations and facilitate establishing individual goals when hastened death is requested. Maintain meticulous, interdisciplinary records of requests for hastened death. Appreciate the importance of the federal and state laws, local regulations, and professional guidelines related to requests for hastened death. Remain mindful of the limits of medicine and a physician’s ability to relieve suffering. Seek awareness of and be willing to balance one’s own and others’ fundamental values regarding requests for hastened death. Be open to consideration of competing claims to safeguard human life and individual autonomy, and be prepared to reconsider previous opinions in light of new evidence or arguments.
TE D
•
List specific
32
ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 11. Support Support patients and families in the psychosocial domain.
• • • • • •
Skills • • • •
EP
Attitudes
SC
Knowledge
M AN U
• •
Describe approaches to developmentally appropriate assessment for coping, stressors, grief and bereavement, suffering, and behavioral health comorbidities. Identify techniques for expressing empathy. Describe how issues involving cultural sensitivity and diversity affect access to and utilization of hospice and palliative care. Discuss benefits, burdens, and risks for the caregiver role. Identify specific roles, expertise, and supportive interventions that individual team members, especially psychosocial clinicians, can provide in support of patients and families. List potential referrals and additional resources in various clinical settings. Elicit a focused, developmentally appropriate psychosocial history, tailored to each patient and family. Assess for coping, stressors, grief and bereavement, suffering, behavioral health comorbidities, and caregiver burden. Provide basic counseling, empathetic response, and cultural sensitivity in supporting expressions of distress. Develop appropriate patient- and family-centered assessments, communication, and care plans with the interdisciplinary team (IDT), especially psychosocial clinicians when available. Mobilize additional resources, make referrals, and navigate the healthcare system to meet patient and family needs. Appreciate the contribution of the psychosocial domain to patient and family coping, suffering, resilience, healing, well-being, and bereavement. Value the expertise of IDT members in formulating assessments and care plans for patient and family support. Prioritize developmentally appropriate and culturally sensitive patient and family care.
TE D
•
List specific
RI PT
Detailed Description: HPM physicians address patient and family suffering, coping, and healing within the emotional, psychological, and social domains with focused, developmentally appropriate assessment followed by targeted communication, interventions, and referrals.
AC C
•
33
ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 12. Support patients and families in the spiritual and existential domain. Detailed Description: HPM physicians address patient and family suffering and identify strengths and needs within the spiritual and existential domain with basic assessment followed by appropriate interventions and referrals.
• Skills
• • • •
Attitudes
EP
•
RI PT
• • • • •
SC
•
M AN U
Knowledge
• •
Describe approaches to screening and basic history taking of spirituality, religion, existential issues, and issues of meaning and purpose. Discuss types and causes of spiritual distress. Identify interventions the physician and/or interdisciplinary team (IDT) can provide depending on patient, family, and team composition and characteristics. Distinguish expertise that individual team members, especially chaplains, can provide in support of patients and families. List potential referrals and additional resources in various clinical settings. Provide compassionate presence and listening. Offer open, empathetic response to spiritual and existential suffering. Take a basic spiritual history tailored to each patient and family. Explore how patient and family spiritual, religious, and existential beliefs and values affect medical decision making and the provision of health care. Inquire about and support patients’ and families’ end-of-life spiritual and/or religious practices and rituals. Assist the IDT in identifying and promoting a sense of meaning and purpose and creation of legacy. Develop appropriate patient- and family-centered assessments and care plans with the IDT, especially the chaplain when available. Engage community clergy and, when appropriate, mobilize additional resources, make referrals, and navigate through the healthcare system to effectively meet patient and family needs. Appreciate the contribution of the spiritual and existential domain to patient and family coping, suffering, resilience, healing, well-being, and bereavement. Respect patients’ and families’ spiritual, religious, and existential beliefs even if these beliefs and values contradict one’s own beliefs and values. Value expertise of IDT members in formulating assessments and care plans for patient and family support. Be open to working with spiritual providers of diverse backgrounds and belief systems.
TE D
•
List specific
•
AC C
•
34
ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 13. Promote selfself-care and resilience. resilience. Detailed Description: HPM physicians value and promote resilience and personal well-being for themselves and others as a necessary element for professional success and sustainability.
• • Skills • •
Attitudes
• • •
AC C
EP
TE D
• •
RI PT
• •
SC
Knowledge
Understand the impact from personal and professional losses on oneself and others. Give examples and describe features of burnout, moral distress, compassion fatigue, depersonalization, inefficacy, and vicarious trauma. Recall factors that predispose individuals and teams to stress and burnout. Describe strategies to mitigate physical and emotional exhaustion, foster professional and personal growth and identity, promote compassion and equanimity, and strengthen resilience. Develop awareness of one’s own subjective experience and the work environment in order to achieve balance with the needs of patients and their families. Remain present to suffering of others and maintain resilience when experiencing one’s own distress and/or grief. Develop practices that promote regular reflections toward growth and self-care. Recognize risks for and features of excessive stress, impairment, and impending burnout in oneself and others. Appreciate the importance of and professional responsibility to attend to self-care. Value the need for balance around resilience and grief/bereavement. Utilize self-care tools and engage in strategies to mitigate physical and emotional exhaustion, cynicism, and inefficacy. Promote highly present, boundary-conscious, empathetic engagement. Role model and encourage effective self-care for other trainees.
M AN U
• •
List specific
35
ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 14. Facilitate transitions across the HPM continuum continuum of care.
• • • • Skills
• • •
•
AC C
Attitudes
EP
•
SC
•
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• Knowledge
Describe various settings in which patients and families may access palliative care. Discuss common characteristics of interdisciplinary team (IDT) resources and staffing available in different settings to meet patient and family needs around acuity and distress. Identify the range of diagnostic approaches and therapies that can be maintained in various care settings. Define systems-based reimbursement and payment structures, eligibility requirements, and key regulations in different care settings. Recognize potential gaps in care as patients transition between settings, including communication between providers, medication reconciliation, treatments, and emotional support for patients and families. Select and dose medications based on accessibility and availability of route of administration within and across care settings. Initiate and adjust medical interventions germane to specific care settings. Communicate with IDT, primary service, consultants, and other providers within and across care settings. Assess appropriateness of patients for specific care settings, clarifying necessary and available resources, and constructing transition plans that incorporate patient safety while aligning with patient and family goals. Provide guidance for smooth transitions across settings for patients, families, and providers that address medical, pharmaceutical, social, emotional, and spiritual concerns. Recognize challenges to patients, families, and providers in confronting differing formularies and costs of treatments across the continuum. Demonstrate appreciation for the culture and structure of each care setting and the need to work with their strengths and limitations to best meet patient and family goals. Recognize that care teams have their own values regarding care settings, which may influence their recommendations. Demonstrate appreciation for the roles of different healthcare team members in various care settings. Empathize with patient and family distress surrounding times of transition between care settings.
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• •
List specific
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Detailed Description: HPM physicians are adept at caring for patients and families across the healthcare continuum (eg, inpatient, long-term care, ambulatory, home) with an understanding of and appreciation for resource availability, care coordination, and transitions support required for effective and high-quality care.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 15. Fulfill the role of a hospice medical director. Detailed Description: HPM physicians meet the clinical, regulatory, administrative, and supportive responsibilities of a hospice medical director.
• • • • • • • • • • •
Attitudes
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Skills
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• • •
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Knowledge
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•
Describe hospice eligibility guidelines for common medical conditions, and pediatric patients, including concurrent care models. Identify specialty-level pain and symptom management expertise specific to the unique settings and requirements for hospice care. Discuss hospice regulatory requirements. Explain how hospice integrates into local, regional, and national health care. Monitor and identify financial issues affecting hospice programs, including public and private reimbursement and payment structures and philanthropy. Outline the appeals process for denied claims Provide hospice care to patients and families across diverse settings: home, longterm care, and inpatient hospice. Facilitate a hospice interdisciplinary team (IDT) meeting Comply with regulatory requirements and documentation including Certification of Terminal illness, Face to Face, etc. Provide leadership, education, and support to hospice IDT members. Manage medications with formulary restrictions. Work with hospice patients’ primary- and specialty-care providers. Engage pediatric palliative care resources to serve pediatric hospice patients. Work telephonically with hospice staff, patients, and families in critical situations. Ensure the safety of oneself and staff when working in challenging environments. Respect the skills and knowledge of diverse disciplines working to help patients and families. Appreciate the diverse cultural, socioeconomic, and ethnic backgrounds of patients. Display openness to collaboration and teamwork.
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•
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 16. Provide HPM consultation and team team support. Detailed Description: HPM physicians render patient- and family-centered consultative care in a professional, timely, and effective manner that supports and educates the referring and invested team members.
• • • • Skills
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Attitudes
• • • • • • • •
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•
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Recognize the roles of different interdisciplinary team members. Educate others on appropriate indications for palliative care consultation. Describe consultation etiquette. Recognize that comprehensive care of a patient routinely involves attention to physical, emotional, psychosocial, and spiritual elements. Identify provider distress. Recognize the dual and sometimes conflicting roles of patient/family advocate and consultant. Gather and synthesize essential and accurate information relevant to the consult, including clarification of the consultation question when needed. Introduce and educate about the role of palliative care and hospice. Perform a palliative medicine–focused history and physical. Use available evidence to construct a palliative care assessment and management plan. Seek answers to outstanding patient, family, and clinical questions that arise in the course of consultation. Seek to understand, maintain rapport, and advocate for patient and family goals when healthcare providers have conflicting views. Respond to provider distress with empathy. Timely and effectively Communicate recommendations to patients, families, and referring providers and document these in the patient’s medical record in a timesensitive and effective manner. Engage the strengths and skills of IDT members. Support other teams in developing their palliative care skills. Exemplify professional and ethical behavior. Appreciate evidence-based medicine. Welcome and incorporate feedback from referring teams. Value patient advocacy. Show concern for provider and team well-being and needs. Appreciate the relationship between consultation etiquette and future referrals.
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Knowledge
• • • •
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List specific
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 17. Promote and teach hospice and palliative care. Detailed Description: HPM physicians promote access to high-quality palliative care services across the continuum of care through advocacy and health system improvement as well as by teaching hospice and palliative care to other healthcare providers.
• • • Skills
• • • • • • • •
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Attitudes
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• •
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• Knowledge
Describe the value and role of palliative and hospice care accounting for diversity of learning needs, backgrounds, learning styles, and education levels among patients, families, community members, and others. Identify educational needs of interprofessional colleagues, administrators, medical staff, and peers regarding the basics of hospice and palliative care for all healthcare providers. Describe the key roles of specialty HPM in the healthcare delivery system. Describe how to integrate quality improvement activities into the routine function of palliative and hospice programs. Demonstrate the ability to critically appraise, disseminate, and apply palliative care literature. Advocate for palliative care program development within systems. Promote hospice and palliative care education within healthcare systems/organizations. Identify key stakeholders in local and system-level healthcare improvement efforts. Deliver a succinct message to both community and professional audiences about the importance of hospice and palliative care for optimal patient care. Adapt different teaching formats based on the setting, content, and learners. Analyze clinical performance data and actively work to improve performance. Model lifelong learning in palliative care. Appreciate that basic palliative care skills are an essential competency for all health professionals. Recognize the responsibility to serve as a palliative care educator to patients, families, and the community. Appreciate the need to use meaningful metrics for hospice and palliative care program development. Value advocacy (local, regional, national) as a means to improve quality health care for patients and families. Remain open to feedback at the individual, programmatic, and system level. Value quality improvement as a tool to grow and improve palliative care programs.
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S0885-3924(17)30266-X
DOI:
10.1016/j.jpainsymman.2017.07.003
Reference:
JPS 9428
To appear in:
Journal of Pain and Symptom Management
Received Date: 27 January 2017 Revised Date:
6 June 2017
Accepted Date: 6 July 2017
Please cite this article as: Landzaat LH, Barnett MD, Buckholz GT, Gustin JL, Hwang JM, Levine SK, Okon T, Radwany SM, Yang HB, Encandela J, Morrison LJ, Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States, Journal of Pain and Symptom Management (2017), doi: 10.1016/j.jpainsymman.2017.07.003.
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States Lindy H. Landzaat, DO FAAHPM, Assistant Professor, Hospice and Palliative Medicine Fellowship Program
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Director, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA Michael D. Barnett, MD MS FAAP FAAHPM, Palliative Medicine Fellowship Program Director, Assistant Professor of Medicine & Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
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Gary T. Buckholz, MD FAAHPM, Associate Clinical Professor, Co-Program Director University of California San Diego/Scripps Health Hospice and Palliative Medicine Fellowship, University of California San Diego, La
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Jolla, CA, USA
Jillian L. Gustin, MD FAAHPM, Clinical Assistant Professor, Division of Palliative Medicine, Department of Internal Medicine, Hospice and Palliative Medicine Fellowship Program Director, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Jennifer M. Hwang, MD MHS, Director of Education, Pediatric Advanced Care Team and Hospice and Palliative Medicine Fellowship Director, The Children's Hospital of Philadelphia. Assistant Professor of Clinical Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Stacie K. Levine, MD FAAHPM, Associate Professor, Hospice and Palliative Medicine Fellowship Program
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Director, Director of Palliative Medicine Programs, University of Chicago, Chicago, IL, USA. Tomasz Okon, MD, Director, Marshfield Clinic Palliative Medicine Fellowship Marshfield Clinic, Marshfield, WI, USA
Steven M. Radwany, MD FACP FAAHPM, Hospice and Palliative Medicine Fellowship Director, Ethics Committee Chair, Summa Health / Northeast Ohio Medical University, Akron, OH, USA.
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ACCEPTED MANUSCRIPT Holly B. Yang, MD MSHPEd HMDC FAAHPM FACP, Assistant Clinical Professor, University of California San Diego/Scripps Health Hospice and Palliative Medicine Fellowship Program Co-Director, Scripps Health San Diego, CA, USA
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John Encandela, PhD, Associate Professor of Psychiatry, Associate Director for Curriculum and Educator Assessment, Teaching & Learning Center Yale School of Medicine, Yale School of Medicine, New Haven, CT, USA
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Laura J. Morrison, MD FAAHPM, Hospice and Palliative Medicine Fellowship Program Director, Yale Palliative
New Haven, CT, USA
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Care Program, Associate Professor of Medicine, Department of Medicine, Yale School of Medicine,
Running Title: HPM Entrustable Professional Activities Corresponding author contact information:
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Lindy Landzaat DO FAAHPM,
Phone: 913-588-3807
fax: 913-588-3877
Abbreviations used:
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3901 Rainbow Blvd, MS 1020, University of Kansas Medical Center, Kansas City, KS, 66160 USA
AAHPM HPM ACGME NAS
Entrustable Professional Activities
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EPAs
email: [email protected]
American Academy of Hospice and Palliative Medicine
Hospice and Palliative Medicine
Accreditation Council for Graduate Medical Education Next Accreditation System
CM
Curricular Milestone
CMs
Curricular Milestones
US
United States
HMD
Hospice Medical Director 2
ACCEPTED MANUSCRIPT Frequently Asked Question
ABMS
American Board of Medical Specialties
IDT
Interdisciplinary team
LST
Life Sustaining Therapies
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FAQ
Figures in paper do not require color.
Keywords: Entrustable Professional Activities, Hospice, Palliative Care, Fellowship, Graduate Medical
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Education
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Author Contribution List
Lindy H. Landzaat: Lead manuscript author and primary EPA author; associate chair of workgroup with significant input to overall project design and methods, primary data analysis and interpretation Michael D. Barnett: Primary EPA author and critically revised manuscript for important intellectual content;
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workgroup member; contributed to project design and methods, data analysis & interpretation Gary T. Buckholz: Primary EPA author and critically revised manuscript for important intellectual content; workgroup member; contributed to project design and methods, data analysis & interpretation
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Jillian L. Gustin: Primary EPA author and critically revised manuscript for important intellectual content;
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workgroup member; contributed to project design and methods, data analysis & interpretation Jennifer M. Hwang: Primary EPA author and critically revised manuscript for important intellectual content; workgroup member; contributed to project design and methods, data analysis & interpretation
Stacie K. Levine: Primary EPA author and critically revised manuscript for important intellectual content; workgroup member; contributed to project design and methods, data analysis & interpretation
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ACCEPTED MANUSCRIPT Tomasz Okon: Primary EPA author and critically revised manuscript for important intellectual content; workgroup member; contributed to project design and methods, data analysis & interpretation
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Steven “Skip” Radwany: Primary EPA author and critically revised manuscript for important intellectual content; workgroup member; contributed to project design and methods, data analysis & interpretation
Holly B. Yang: Primary EPA author and critically revised manuscript for important intellectual content;
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workgroup member; contributed to project design and methods, data analysis & interpretation
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John Encandela: Provided significant manuscript revisions; contributed to national survey design; performed data analysis, statistical support and interpretation.
Laura J. Morrison: Senior author providing significant manuscript revisions and primary EPA author; chair of
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workgroup and responsible for overall project design and methods, primary data analysis and interpretation.
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Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States Landzaat LH, Barnett MD, Buckholz GT, Gustin JL, Hwang JM, Levine SK, Okon T, Radwany SM, Yang
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HB, Encandela J, Morrison LJ Context: Entrustable Professional Activities (EPAs) represent the key physician tasks of a specialty. Once a trainee demonstrates competence in an activity, they can then be ‘entrusted’ to practice without supervision1. A physician workgroup of the American Academy of Hospice and Palliative Medicine (AAHPM) sought to define
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Hospice and Palliative Medicine (HPM) EPAs.
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Objective: To describe the development of a set of consensus EPAs for HPM fellowship training in the United States.
Methods: A set of HPM EPAs was developed through an iterative consensus process involving an expert workgroup, vetting at a national meeting with HPM educators, and an electronic survey from a national registry of 3,550 HPM physicians. Vetting feedback was reviewed and survey data were statistically analyzed.
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Final EPA revisions followed from the multisource feedback.
Results: Through the iterative consensus process, a set of 17 HPM EPAs was created, detailed, and revised. In the national survey, 362 HPM specialists responded (10%), including 58 of 126 fellowship program directors
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(46%). Respondents indicated the set of 17 EPAs well-represented the core activities of HPM physician practice (mean 4.72 on a 5-point Likert scale) and considered all EPAs to either be “essential” or “important”
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with none of the EPAs ranking “neither essential, nor important.” Conclusions: A set of 17 EPAs was developed using national input of practicing physicians & program directors and an iterative expert workgroup consensus process. The workgroup anticipates EPAs can assist fellowship directors with strengthening competency-based training curricula.
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ACCEPTED MANUSCRIPT Introduction: The transition from the Accreditation Council for Graduate Medical Education’s (ACGME) 1999 Outcome Project to the 2013 Next Accreditation System (NAS) has evoked new challenges in graduate medical training as programs continue to adapt and evolve from process-related compliance to demonstration of meaningful
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competency-based outcomes in resident education.2,3 Entrustable Professional Activities (EPAs) emerged independent of, and complementary to, the new NAS framework. They define the “essential tasks of
professional practice.”4 EPAs are observable, meaningful, manageable points of assessment that characterize a
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physician’s key activities within a medical specialty5. These representative activities are “entrusted” to the trainee, to perform without supervision, once they gain and demonstrate competence.1,6 Each EPA requires a
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combination of knowledge, skills, and attitudes to execute, and draws on multiple ACGME core competencies for successful entrustment. Some medical disciplines in the US have defined specialty-specific EPAs.7,8,9,10 Additionally, the Canadian Society of Palliative Care Physicians released a set of Palliative Medicine EPAs in 2015.11
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HPM EPAs serve several valuable roles as they describe the essential work of the field for medical providers, educators, and the larger healthcare community6. First, by defining core HPM physician activities, EPAs aid in educating the wider community about the evolving role of HPM. This is particularly helpful since HPM fellows
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in the US may seek fellowship training after completing one of 11 different residency backgrounds. Additionally, as alternative mid-career training pathways develop to help address HPM workforce shortages12,
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EPAs can pave the way for innovative delivery of curricula with comparable core content. The hope is that EPAs will directly and positively influence fellowship training and ultimately improve patient and family care outcomes.
The American Academy of Hospice and Palliative Medicine (AAHPM) has a long history of sponsoring workgroups to promote development of Hospice and Palliative Medicine (HPM) medical education. Workgroups have created adult and pediatric focused HPM competencies, measurable outcomes, and a toolkit of assessment methods to support fellowship training. 13,14,15,16,17 In response to the NAS charge to better 6
ACCEPTED MANUSCRIPT define competency-based outcomes, AAHPM convened a 2014 workgroup of expert HPM educators charged with defining EPAs for HPM fellowship training, the EPA Workgroup (hereafter, “the workgroup”). This paper describes the workgroup’s process for developing the 17 HPM EPAs for US fellowship trainees.
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Methods: EPA Development:
To develop EPAs, a workgroup undertook a group vetting and consensus process that drew elements from modified Delphi and Nominal Group Processes18. The workgroup included ten physician members
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representing diversity in adult and pediatric care, geography, gender, years of practice, and hospice and
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academic practice settings. All members served as HPM fellowship directors and led multiple HPM educational initiatives at their institutions.
At an in-person inaugural meeting in May 2014, the workgroup benchmarked with other specialty and subspecialty EPAs and consulted with ACGME Milestone Development leadership to define the aims and processes for HPM EPA development. The workgroup defined HPM EPAs as the critical tasks expected of a
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fellow by the end of training. Throughout the EPA development path, the workgroup regularly referenced the EPA characteristics 6,9 originally defined by ten Cate. The workgroup recognized that while an HPM graduating fellow may not ultimately perform all the EPAs in future independent practice, the EPA set should include
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important activities that prepare graduating fellows for the diverse work of HPM. The workgroup favored a set of EPAs that was observable and limited in number, yet inclusive enough to meaningfully represent the
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essential work of an HPM physician.
After developing a common understanding of EPAs, the workgroup initially identified eighteen EPA topics. Working in 5 dyads that each drafted 3 or 4 EPAs, the workgroup created the first set of 18 EPAs. From May 2014 to October 2015, the workgroup conducted twenty 90-minute meetings: nineteen conference calls and another in-person session at the 2015 national AAHPM conference. Through an iterative process, (see Figure 1), each workgroup member fully reviewed each individual EPA for content as well as fit in the set at least twice. The set was reviewed multiple times as a whole to assess the need to combine, split, or add EPAs. In 7
ACCEPTED MANUSCRIPT addition to reviewing, workgroup members also revised assigned EPAs with group discussion for consensus. After two rounds of review and revision, 16 EPAs remained from the initial list of 18. EPA vetting process:
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The workgroup pursued a multiphase external vetting process to ensure the EPA set was comprehensive and to garner consensus within the HPM community. First, the workgroup invited a convenience sample of twenty recent fellowship graduates to review a preliminary set of EPAs for any omissions in light of the everyday tasks defining their current professional roles. Fifteen provided feedback that was examined by the
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workgroup and resulted in no EPA additions. Next, at the February 2015 AAHPM Annual Assembly, over 100
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HPM physician fellowship leaders (the majority being fellowship program directors) each participated in a twoand-a-half hours EPA vetting session, including a didactic presentation of background content and process information, a facilitated small group exercise to review and provide specific feedback on four assigned EPAs, and a large group debriefing to identify additional feedback. Additionally, a subsequent one-hour session at the same Assembly, open to all interprofessional conference attendees, garnered feedback from 74 registrants
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in a similar but abbreviated process. The workgroup performed a detailed review of the comments as part of the ongoing iterative process (Figure 2). Some feedback suggested changes for content felt to be more relevant at a learning objective or curricular milestone level, rather than an EPA level. Other times, the
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content was already included as part of the more detailed EPA set though that may not have been readily apparent to the participant. Three significant outcomes resulted: the creation of a new 17th EPA, targeted
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revisions to the EPA set, or the addition of text in the final document describing the workgroup’s rationale for content decisions.
National Survey Vetting:
The final vetting activity was an electronic survey distributed to the AAHPM physician membership (3,550 physician members listed in the national registry) with the goal of achieving a robust, broad measure of consensus across the field on how well the EPAs represented the essential activities of practicing HPM physicians. A 3-week time window for completion was provided. 8
ACCEPTED MANUSCRIPT After offering a brief context and description of Entrustable Professional Activities, participants were asked to reflect on the core tasks that define their role as an HPM physician and then, to rate, using a 5-point Likert Scale (“very poorly” to “very well”) how well the EPA-set represented core tasks of HPM practice. Participants
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were also asked to review each proposed EPA for “how essential or important is competence in each proposed EPA” for a graduating HPM fellow. Modeled off similar surveys,19,20 options included “Essential for all”, “Important for all but not essential”, or “Not important or essential.” The survey also solicited potential EPA omissions and collected demographic information on the participants (Table 1). This study received exempt
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status by both the Yale University Human Investigation Committee and the University of Kansas Human
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Subjects Committee. Statistical Analysis:
To analyze how well the EPAs represented the core tasks of HPM practice, means and frequencies for each of the EPAs were established. Percentages of respondents’ priority ratings (i.e., essential, important but not essential, and not important or essential) were also established for each EPA. Chi square tests were performed
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for each of 19 independent variables (e.g., respondent gender, age, role vis-à-vis HPM practice and teaching, years in practice, etc.) as these were associated with respondent perceptions of priority rating for each EPA. Only those associations found to be significant are reported below in the Results section, with explanations of
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how these findings informed our decisions about EPAs. Frequencies and percentages were also established to
Results:
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describe respondent demographics and characteristics of their work.
EPA Development:
During the iterative process of review and revision, the initial draft of 18 EPA topics transitioned to 16 EPAs. Five EPA topics merged into one, 3 new topics emerged, and one was topic was eliminated. In direct response to vetting comments from the two national conference sessions, a new EPA, “Promote and teach hospice and palliative care,” was added, resulting in a final total of 17 EPAs (Appendix 1). In the end, each of the 17 EPAs included a title, an expanded description, and relevant, bulleted knowledge, skills, and attitudes. A summary 9
ACCEPTED MANUSCRIPT of feedback and resulting actions is included in Figure 2. The workgroup created a Frequently Asked Questions section of the EPA document to address some of the recurring feedback obtained during the vetting process. The final EPA list was released to the field on November 23, 2015 with an online document21.
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National Vetting Survey: A total of 362 physicians participated out of 3550 potential participants, yielding a 10% response rate. Participant demographics are listed in Table 1. Respondents generally dedicated over 75% of their time to practice of HPM, 41% served as hospice medical director or hospice team physician, and approximately 90%
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were involved in teaching medical trainees. Nearly three times as many respondents practiced primarily in
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palliative care settings as in hospice settings (58.9% vs. 20.4%). Fifty-eight respondents were HPM Fellowship Directors representing approximately 46% of the 126 HPM fellowship program directors. The mean rating of how well the set of 17 EPAs represent the core activities for HPM physicians using a 5-point Likert scale was 4.72 (SD=0.65). As noted in Table 2 and Figure 3, none of the 17 EPAs fell into the primary category of “not essential or important.” With EPAs being a new concept in HPM, there is no accepted level of
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consensus to guide inclusion or exclusion. The workgroup anticipated that any EPAs rating primarily as “not essential, nor important” would have been eliminated and those with a majority vote of “essential” would likely be retained.
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All but one of the EPAs fell primarily into the “essential” category. EPA 15, “Fulfill the role of a hospice medical director,” had a majority of responses in the “important but not essential for all” category. Chi square results
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showed, not surprisingly, that hospice medical directors, also referred to as hospice team physicians, (41% of respondents) were statistically more likely to rate this EPA higher than colleagues not working in hospice (p <0.01). The majority of respondents, however, (59%) practiced palliative care but not hospice. The workgroup reviewed all survey data in detail, including all comments, elected to retain all 17 EPAs, and made final revisions. Discussion
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ACCEPTED MANUSCRIPT This paper reports the development of 17 consensus HPM EPAs that expand the national education infrastructure for HPM fellowship training. This defined list of key physician activities is expected to serve as a guide to inform HPM Fellowship curricula and may serve as the basis for designing performance assessment
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tools to determine fellow physician entrustment. EPAs may prompt fellowship programs to examine their current curricula and highlight a need for focused attention on competence in key clinical tasks. Because they are not a current requirement, fellowship programs have flexibility in which EPAs to use and how to use them. The EPAs also provide fellows a more specific framing of the entrustment tasks expected of them by the end of
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fellowship, including detailing of the requisite knowledge, skills, and attitudes for each.
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Strengths of our process included an extensive iterative process by a workgroup of expert HPM educators, vetting at a national meeting with program directors and practicing providers, and vetting through a national survey of HPM physicians. Our survey participants were clinically active, represented both hospice and palliative care settings, and were routinely involved in HPM education.
The EPA development process and vetting included limitations. First, regarding the survey design, the
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measurement of reliability for survey takers is limited given the single administration design. The survey response rate was relatively low at 10%. The workgroup opted to err on the side of broader representation and ‘cast the net widely’ by sending the survey invitation to all AAHPM physician members. The 10% response
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rate is in line with the average for a convenience sample on AAHPM surveys22. Program directors were represented with 46% participating, a response rate in line with a similar national educational workgroup
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vetting process20. The threat of bias that exists with convenience sampling may be offset somewhat in our study by the fact that two important constituencies—hospice medical directors/team physicians and fellowship directors—were relatively well represented in the sample. Our process highlights a number of ongoing challenges for competency-based education and others pursuing EPA development. One challenge was how to effectively balance breadth and depth of EPAs in light of the need for practical application. The workgroup aimed to define EPAs that were discrete enough to be observable and potentially measurable while keeping the total number manageable for one-year HPM clinical 11
ACCEPTED MANUSCRIPT fellowships. Another challenge was finding the balance between “lumping and splitting” different EPAs. For instance, should the Psychosocial EPA #11, and Spiritual Care EPA #12 be merged into a broader Support EPA or remain distinct? Should EPA #6, ‘Participate as a member or leader of an interdisciplinary team,’ be its own
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EPA or simply be an element included within multiple EPAs? The workgroup chose to elevate particular constructs to individual EPAs in order to underscore the importance of certain sets of knowledge and skills necessary to perform the work as part of the field’s current growth and professional expectation. The workgroup chose to address some of the areas that generated a lot of discussion by offering rationales in a
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Frequently Asked Question (FAQ) section within the final EPA document21. EPAs are a new framework
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currently not required by the ACGME and may be unfamiliar to many educators. Therefore, how EPAs will be applied is unclear, complicating our goal of designing them to be useful and practical. Finally, as originally defined, EPAs are to be independently executable.6 This is important to successful evaluation of an individual’s performance, but for an inherently team-based specialty, “independently executable6” may prove a practical implementation challenge.
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Our vetting process also suggested that variability exists within the HPM field in the interpretation of “Hospice Medical Director” terminology (EPA #15). The title may broadly refer to any physician employed by a hospice (i.e. a hospice team physician). In some settings, however, this title is reserved for a single lead physician of a
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hospice organization. The workgroup intended the former definition for EPA #15. However, ambiguity around the term could have confounded and lowered the ratings for this EPA if respondents considered the narrower
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HMD definition. In addition, very few survey participants thought this EPA warranted the lowest category of 'not important or essential'. There was universal workgroup consensus that this EPA was in fact 'essential to all.' In considering the risk of burden to harm, since EPAs are not an ACGME requirement and program directors have discretion about which EPAs they use and how they use them, keeping a potentially less useful EPA in the set seemed to be a safer approach than discarding a potentially ‘essential-to-training’ EPA. Given that, the workgroup elected to retain EPA #15 as part of the final EPA set. Since field-specific terminology can
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ACCEPTED MANUSCRIPT be interpreted inconsistently and complicate the vetting process, the workgroup suggests that others proactively anticipate and address terminology dilemmas if vetting EPAs. Conclusion: The AAHPM EPA workgroup developed a consensus set of 17 EPAs that represent the essential
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activities of entrustment for US HPM fellowship graduates. The set of 17 EPAs rated highly as representing the core activities of HPM after a multi-phased vetting process. This final EPA list describes key HPM physician tasks and defines EPAs for the field of HPM. It offers fellowship programs a tool to assist with competency-
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based curricula and a launching point for developing entrustment assessments. The practical application and experience of applying the new EPA construct to HPM fellowship training, mid-career training pathways, and
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other settings will inform future research, revisions, and future iterations of HPM EPAs. Disclosures & Acknowledgments: This work received administrative support and travel-related funding for the workgroup’s initial in-person meeting from the Academy of Hospice and Palliative Medicine. There was no other additional funding for this work. The authors would like to thank the American Academy of Hospice and Palliative Medicine for supporting HPM EPA development, and specifically thanks Ms. Margaret Rudnik and
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Ms. Dawn Levreau for their administrative expertise and contributions to the project. In addition, the workgroup is appreciative of advising by Laura Edgar, EdD, CAE, ACGME Executive Director for Milestone
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Development. The authors declare no conflict of interest.
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ACCEPTED MANUSCRIPT References: 1.
Ten Cate O. Nuts and bolts of entrustable professional activities. J Grad Med Educ. 2013;5:157-158.
2.
Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system--rationale and benefits. N
3.
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Engl J Med. 2012;366:1051-1056. Nasca TJ, Weiss KB, Bagian JP, Brigham TP. The Accreditation System After the “Next Accreditation System.” Acad Med. 2014;89:27-29. 4.
Accreditation Council for Graduate Medical Education (ACGME). Frequently Asked Questions:
Accreditation Council for Graduate Medical Education (ACGME). Internal Medicine Subspecialty
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5.
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Milestones.
Reporting Milestones Frequently Asked Questions (FAQs). 6.
ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82:542-547.
7.
Leipzig RM, Sauvigné K, Granville LJ, et al. What is a geriatrician? American Geriatrics Society and
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Association of Directors of Geriatric Academic Programs end-of-training entrustable professional activities for geriatric medicine. J Am Geriatr Soc. 2014;62:924-929. 8.
Boyce P, Spratt C, Davies M, McEvoy P. Using entrustable professional activities to guide curriculum
9.
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development in psychiatry training. BMC Med Educ. 2011;11:96. Shaughnessy AF, Sparks J, Cohen-Osher M, et al. Entrustable professional activities in family medicine. J
10.
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Hauer KE, Kohlwes J, Cornett P, et al. Identifying entrustable professional activities in internal medicine training. J Grad Med Educ. 2013;5:54-59.
11.
Myers J, Krueger P, Webster F, et al. Development and Validation of a Set of Palliative Medicine Entrustable Professional Activities: Findings from a Mixed Methods Study. J Palliat Med. 2015;18:682690.
12.
Lupu D. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain 14
ACCEPTED MANUSCRIPT Symptom Manage. 2010;40:899-911. 13.
Morrison LJ, Arnold R, Billings JA, et al. Hospice and Palliative Medicine Competencies Project: Toolkit of Assessment Methods. 2010. Morrison LJ, Scott JO, Block SD. Developing Initial Competency-based Outcomes for the Hospice and
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Palliative Medicine Subspecialist: phase I of the hospice and palliative medicine competencies project. J Palliat Med. 2007;10:313-330.
Arnold R, Billings J, Block S, et al. Hospice and Palliative Medicine Core Competencies. on-line.
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Klick J, Friebert S, Hutton N, et al. Pediatric-Hospice and Palliative Medicine Competencies, version 2.0.
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Klick JC, Friebert S, Hutton N, et al. Developing competencies for pediatric hospice and palliative medicine. Pediatrics. 2014;134:e1670-7.
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Fink A, Kosecoff J, Chassin M, Brook RH. Consensus methods: Characteristics and guidelines for use. Am J Public Health. 1984.
Schaefer KG, Chittenden EH, Sullivan AM, et al. Raising the bar for the care of seriously ill patients:
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results of a national survey to define essential palliative care competencies for medical students and residents. Acad Med. 2014;89:1024-1031.
Parks SM, Harper GM, Fernandez H, Sauvigne K, Leipzig RM. American Geriatrics Society/Association of
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Directors of Geriatric Academic Programs curricular milestones for graduating geriatric fellows. J Am
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Geriatr Soc. 2014;62:930-935.
Morrison LJ, Landzaat LH, Barnett MD, et al. Hospice and Palliative Medicine Entrustable Professional Activities. Online.
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Dawn Levreau. AAHPM Personal Correspondence. 2016.
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Age (355) 20-29 0.3% 1 30-39 18.0% 64 40-49 26.2% 93 50-59 29.0% 103 60-69 23.4% 83 70 and older 2.5% 9 Prefer not to answer 0.6% 2 Gender (352) Female 54.0% 190 Male 45.7% 161 Prefer not to answer 0.3% 1 Years in Practice (355) 0-5 25.6% 91 6-10 28.2% 100 11-15 19.4% 69 16-20 10.1% 36 More than 20 16.6% 59 ABMS certified in HPM (354) Yes 91.8% 325 No 8.2% 29 Hospice medical director/hospice team physician leader (355) Yes 41.1% 146 No 58.9% 209 Setting(s) where majority of professional time spent (358) Hospice 20.4% 68 Palliative Care 58.9% 196 Both Hospice and Palliative Care 20.7% 69 (close to evenly split) Other 7.0% 25 Practice setting (354) Academic medical center 42.9% 152 Community hospital 19.8% 70 Outpatient clinic 3.1% 11 Hospice 20.9% 74 Other 13.3% 47 Hours per week devoted to HPM (355) <25 % 10.4% 37 25-50% 13.5% 48 51-75% 9.6% 34 >75% 66.5% 236 Teaching Responsibilities (355) Involved in teaching medical trainees 89.6% 318 Not teaching medical trainees 10.4% 37
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Provide comprehensive pain assessment and management for patients with serious illness. HPM physicians are able to use an interdisciplinary team approach to effectively manage complex pain in the context of serious illness using pharmacologic and non-pharmacologic approaches. Provide comprehensive non-pain symptom assessment and management for patients with serious illness. HPM physicians are able to lead and collaborate with an interdisciplinary team to effectively manage complex nonpain symptoms, including but not limited to anorexia, constipation and diarrhea, delirium, dyspnea, fatigue, nausea and vomiting, depression and anxiety, using pharmacologic and non-pharmacologic treatments. Manage palliative care emergencies. HPM physicians anticipate, prepare for, and respond to palliative emergencies to minimize distress in partnership with the patient, caregivers, and medical team, while taking into account the patient’s goals of care and prognosis. Estimate and communicate prognosis to aid medical decision-making. HPM physicians are able to estimate, communicate, and consider prognosis while acknowledging uncertainty as they facilitate shared decision-making and delineate goals of care based on patient/family values. Establish goals of care based on patient/family values and a specific medical circumstances . HPM physicians are able to elicit patient/family values, delineate goals of care based on patient/family values in the context of the patient’s medical condition, and make recommendations for an appropriate care plan. Participate as a member or leader of an interdisciplinary team. HPM physicians function effectively as a leader/member of an interdisciplinary team (IDT), manage patient and family care provided by an IDT, and facilitate IDT meetings, while sharing the leadership role with other IDT members as appropriate. Prevent and mediate conflict and distress over complex medical decisions. HPM physicians prevent and address clinical conflict and uncertainty as well as emotionally charged encounters and value laden suffering through advanced palliative communication techniques. Manage withdrawal of advanced life sustaining therapies. HPM physicians are skilled in the withdrawal of advanced life sustaining therapies including facilitation of goals of care discussions leading to the decision to withdraw advanced LST, management of symptoms pre- and postwithdrawal of advanced LST, orchestration of withdrawal of LST, and provision of family support for psychosocial and
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10.8
0.3
93.9
5.8
0.3
96.7
2.5
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13.3
0.6
82.0
17.7
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spiritual distress including anticipatory grief and bereavement. Care for the imminently dying patient and their family. HPM physicians are able to identify signs of the dying process and tend to the needs of the multiple areas of suffering for an individual patient and their family during imminent dying and facilitate after death bereavement support for the family and health care providers. b Manage requests for hastened death . HPM physicians manage requests for hastened death in accordance with federal, state and local regulations as well as ethical and professional principles while remaining sensitive to patients’ individual values, preferences and sources of suffering. Support patient and family in the psychosocial domain. HPM physicians address patient and family suffering, coping, and healing in the emotional, psychological and social domains with focused and developmentally appropriate assessment followed by targeted communication, interventions and referrals. Support patient and family in the spiritual and existential domain. HPM physicians address patient and family suffering and identify strengths and needs within the spiritual and existential domain with basic assessment followed by identification of appropriate interventions and referrals. Promote self-care and resilience. HPM physicians value and promote resilience and personal well-being for themselves and others as a necessary element for professional success and sustainability. Facilitate transitions across the HPM continuum of care. HPM physicians are adept at caring for patients and families across the healthcare continuum (inpatient, long-term care, ambulatory, home) with an understanding of and appreciation for resource availability, care coordination, and transitions support required for effective, high-quality care. Fulfill the role of a hospice medical director. HPM physicians meet the clinical, regulatory, administrative and supportive responsibilities of a hospice medical director. Provide hospice and palliative medicine consultation and team support. HPM physicians render patient and family centered consultative care in a professional, timely, and effective manner which supports and educates the referring and invested team members. c Advocate for and teach palliative care . HPM physicians advocate for access to high quality palliative care services across the continuum of care and enhance other healthcare providers’ primary palliative care skills and knowledge.
55.0
43.1
1.9
78.2
20.7
1.1
75.1
24.3
0.6
30.1
63.0
6.9
83.4
15.5
1.1
55.5
43.4
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a
Final Version included title change to “Establish goals of care based on patient and/or family values and specific medical circumstances” b Final Version included title change to “Address requests for hastened death” c Final Version included title change to “Promote and teach palliative care”
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ACCEPTED MANUSCRIPT Figure 1: HPM EPA Step-Wise Development Process 1. Benchmark with other specialties' EPAs
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Figure 3 : Respondent Ratings of 17 Preliminary EPAs n=362 100% 90% 80%
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ACCEPTED MANUSCRIPT Appendix 1 (option A)
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Final List of HPM Entrustable Professional Activities Provide comprehensive pain assessment and management for patients with serious illness Provide comprehensive nonpain symptom assessment and management for patients with serious illness Manage palliative care emergencies Estimate and communicate prognosis to aid medical decision-making Establish goals of care based on patient and/or family values and specific medical circumstances Participate as a member or leader of an interdisciplinary team Prevent and mediate conflict and distress over complex medical decisions Manage withdrawal of advanced life-sustaining therapies Care for imminently dying patients and their families Address requests for hastened death Support patients and families in the psychosocial domain Support patients and families in the spiritual and existential domain Promote self-care and resilience Facilitate transitions across the HPM continuum of care Fulfill the role of a hospice medical director Provide HPM consultation and team support Promote and teach hospice and palliative care
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ACCEPTED MANUSCRIPT Appendix 1 (option B)-[these are the full 17 EPAs if the journal chooses to include and pending discussions with AAHPM related to copyright]
Hospice & Palliative Medicine EPA EPA Title: EPA 1. Provide comprehensive pain assessment and management for patients with serious illness.
• Knowledge •
• • • • • • • • •
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Explain the pathophysiology of pain across the age spectrum, from pediatrics to geriatrics. List components of a detailed pain assessment, including developmentally appropriate screening and assessment tools. Explain the domains of whole-patient assessment and their potential impact on reported physical pain (total pain). Describe the pharmacokinetics, pharmacodynamics, and potential adverse effects of opioids and nonopioid pain medications to achieve proportionate symptom control. Describe safe opioid-prescribing practices such as use of the Opioid Risk Tool (ORT), pain contracts, appropriate storage and disposal, risk evaluation and mitigation strategies (REMS), state and local regulations, and aberrant behaviors associated with misuse. List nonpharmacologic approaches to manage pain. List procedural approaches (along with referral services) to manage pain. Describe relative costs of medications and other therapies to treat pain. Perform a comprehensive pain assessment, including all domains of suffering. Collaborate with the IDT and other providers to optimally manage pain. Utilize appropriate diagnostic workup and interpretation of diagnostic tests. Develop and implement plans to provide comprehensive pain management for the full spectrum of pain syndromes. Recognize and manage adverse effects of medications and other therapies. Communicate treatment plans clearly to individual patients, their families, and healthcare providers. Implement safe opioid-prescribing practices. Demonstrate cost-effective care. Appreciate the important, urgent nature of pain management. Recognize the necessity of managing physical suffering to allow patients to better address other domains of suffering and improve quality of life. Appreciate the complex interplay between physical and other domains of suffering and the role of the IDT
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Detailed Description: HPM physicians lead and collaborate with an interdisciplinary team (IDT) approach to effectively manage complex pain in the context of serious illness using pharmacologic and nonpharmacologic approaches.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 2. Provide comprehensive comprehensive nonpain symptom assessment and management for patients with serious illness.
• • • Skills • • • • • Attitudes
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Describe the pathophysiology of common symptoms in serious illness across the age spectrum, from pediatrics to geriatrics. Describe diagnostic methods necessary for optimal symptom assessment. List developmentally appropriate nonpain symptom screening and assessment tools. Identify pharmacologic and nonpharmacologic treatments for nonpain symptoms using the current evidence base in palliative medicine. Recognize the expected benefits, burdens, and relative costs of various treatment modalities and medications. Perform a thoughtful, comprehensive, and systematic symptom assessment using validated scales or tools when appropriate. Demonstrate appropriate diagnostic workup and interpretation of test results. Use evidence-based nonpharmacologic and pharmacologic therapies and adjust treatment plan based on results and side effects. Make appropriate referrals to other specialists and members of the IDT to assist with symptom management. Communicate treatment plans clearly to patients, families, and healthcare providers. Demonstrate cost-effective care. Appreciate the important, urgent nature of nonpain symptom management. Recognize the value of input from multiple disciplines in addressing challenging nonpain symptoms. Appreciate the importance of symptom management in diminishing suffering and improving quality of life. Maintain a supportive presence for the suffering that comes with intractable symptoms
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Detailed Description: HPM physicians lead and collaborate with an interdisciplinary team (IDT) to effectively manage complex nonpain symptoms, including but not limited to anorexia, constipation and diarrhea, delirium, dyspnea, fatigue, nausea and vomiting, depression, and anxiety using pharmacologic and nonpharmacologic treatments.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 3. Manage palliative care emergencies. Detailed description: HPM physicians anticipate, prepare for, and respond to palliative care emergencies in partnership with the patient, caregivers, and medical team while taking into account the patient’s goals of care and prognosis.
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Define and list palliative care emergencies characterized by a high symptom burden and decreased quality of life. These may include medical, surgical, psychiatric, and iatrogenic emergencies as well as severe psychosocial crises for patients and/or families/caregivers. Describe the risk factors and pathophysiology of specific palliative care emergencies. Identify various modalities to decrease symptom burden and/or modify underlying pathology that can be implemented in each emergency. Anticipate, recognize, and proactively consider risk mitigation strategies for all categories of palliative care emergencies. Use an interdisciplinary approach to identify, prepare for, and provide comprehensive management of palliative care emergencies. Demonstrate judicious and rapid escalation of palliative therapies proportional to the degree of distress and suffering. Provide support to patients and/or families including prognostication and reassessment of goals of care before, during, and after a palliative care emergency. Demonstrate a supportive presence for patients, caregivers, and staff, especially when managing an “unfixable” emergency. Embrace the responsibility of identifying palliative care emergencies and expeditiously acting on them. Appreciate the emotional impact of preparing for, witnessing, and managing emergencies for patients, families, medical teams, and palliative care providers. Recognize that competent management of palliative care emergencies decreases suffering and may improve quality of life.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 4. Estimate and communicate prognosis to aid medical decisiondecision-making. Detailed Description: HPM physicians estimate, communicate, and consider prognosis while acknowledging uncertainty as they facilitate shared decision making and delineate goals of care based on patient and/or family values.
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Describe prognostication in serious illness, identifying elements of history, physical exam, and diagnostic testing important to determining prognosis. List current prognostic methods and tools and the strengths and weaknesses of each approach. Describe techniques for communicating prognosis and medical uncertainty across the age spectrum, from pediatrics to geriatrics. Perform a thoughtful, comprehensive, and systematic palliative care assessment taking into account disease process, comorbidities, disease trajectory, psychosocial support, and available treatments. Use relevant evidence-based prognostic tools to help create a prognostic estimate when appropriate. Obtain and integrate prognostic estimates from other healthcare providers. Determine hospice eligibility based on a prognostic estimate. Assess patient and/or family interest in knowing prognostic information and explore the specific reasons for preferences, including cultural and/or spiritual influences. Assess and communicate disease trajectory, expected function, and prognosis to patients, families, and other healthcare providers. Acknowledge and express uncertainty. Direct a family meeting when necessary to help communicate prognosis and aid medical decision making. Appreciate the importance of prognosis in medical decision making and the weight of prognosis for all involved. Appreciate the challenge of uncertainty in prognostication across various patient populations.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 5. Establish goals of care based on patient and/or family values and specific medical circumstances.
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Describe prognostication in serious illness. Recognize techniques for communicating prognosis and medical uncertainty. Explain and differentiate essential elements of assessing decision-making capacity across the age spectrum. Identify techniques for engaging patients and family members in discussion and conflict resolution. Relate patient- and family-centered communication to delineation of goals of care, particularly in the determination of patient and/or family values. Describe the benefits and burdens of various medical therapies. Differentiate curative versus palliative intent of treatments. Define the concurrent care model which allows for coexisting curative and palliative goals of care in pediatric hospice and other similar settings. Perform a thoughtful, comprehensive, and systematic palliative assessment, taking into account disease process, comorbidities, characteristic symptom burden, and disease trajectory, together with input from other healthcare providers. Direct a family meeting to help set goals of care, communicate prognosis, reframe hope, and express uncertainty. Use a framework approach to give serious news or medical information, attending to emotion from the patient, family and other healthcare providers. Establish the patient’s definition and determinants of quality of life. Utilize the interdisciplinary team to explore and clarify patient and/or family values. Provide recommendations for medical care based on patient and/or family values and goals. Discuss withdrawal of medical therapies such as artificial hydration and nutrition, antibiotics, anticoagulation, or other medications based on goals of care. Work toward consensus among patients, families, and healthcare providers. Assist with conflict resolution between patients, families, and other healthcare providers. Guide patients, families, and healthcare providers through the shifting transitions between curative and palliative care. Introduce hospice care when appropriate based on overall prognosis. Appreciate the importance of determining and communicating prognosis to aid medical decision making. Respect individual patient and/or family differences in hopes and values related to serious illness. Anticipate the full spectrum of patient and family responses to goals of care discussions.
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Detailed Description: HPM physicians elicit patient/family values, delineate goals of care based on patient and/or family values in the context of the patient’s medical condition, and make recommendations for an appropriate care plan.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 6. Participate as a member or leader of an interdisciplinary team. Detailed Description: HPM physicians manage the medical care provided by interdisciplinary teams (IDTs) and facilitate IDT meetings while sharing the leadership role with other IDT members as appropriate.
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Describe concepts of team processes and development and recognize elements that promote or hinder successful IDT function. Discuss the professional skill set, expertise, role, and potential contribution of each member of the interdisciplinary team. Lead and/or facilitate recurring IDT meetings. Evolve one’s own communication style with colleagues to optimize team function within and outside of IDT meetings. Accept and solicit insights from all IDT members in developing a patient care plan. Monitor and facilitate team function including managing distress and supporting resilience. Provide and accept feedback from IDT members. Help to develop the care plan and/or provide care to patients and families as a member of an IDT. Respect the unique contributions of each member of the IDT and the impact of each member on team function. Recognize the need to address all palliative care domains in the development of an effective care plan. Facilitate openness, receptivity, mutual respect, and trust among IDT members.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine Medicine Title: EPA 7. Prevent and mediate conflict and distress over complex medical decisions. Detailed Description: HPM physicians prevent and address clinical conflict, uncertainty, emotionally charged encounters, and value-laden suffering through advanced palliative communication techniques.
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Describe treatment options and prognosis; indicators and impact of patient, family, provider, and team distress; and ethical and legal implications of decisions. Recall and understand the situations and decisions that lead to clinical conflict. Acknowledge and negotiate contentious clinical situations. Identify, recognize sources of, and formulate a differential diagnosis for the conflict, engaging the assistance of the interdisciplinary team as needed. Identify and attend to strongly expressed opinions and emotions; help to de-escalate situations in which conflict intensifies. Attend to the emotional and physical safety of providers, patients, and families in conflict situations. Compassionately and realistically mediate disagreements regarding care plans. Address current or anticipated grief among patients, families, providers, and teams, especially as it pertains to clinical decision making. Elucidate and address the ethical and legal implications of difficult decisions to be made when disagreement exists. Address conflict in a step-wise process (recognition, preparation, identification of involved/violated core concerns, exploration, reframing, alliance, support, and compromise) with the assistance of the team as needed. Direct a family meeting to help address conflict and distress when necessary. Demonstrate openness to patient and family preferences. Display commitment to meeting patient needs while preserving provider integrity. Exhibit self-awareness of personal values, how they might conflict with others’ values, and how they impact conflict mediation. • Demonstrate openness to identifying one’s own strong positive and/or negative feelings. • Reflect on negative emotions in oneself and one’s patients over time. Exhibit compassion for all disciplines and specialties involved in difficult patient-care situations. Display humility regarding one’s own clinical judgment and openness to other opinions in charged clinical situations.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 8. Manage withdrawal of advanced lifelife-sustaining therapies.
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Describe the federal, state, and local laws that impact the withdrawal of advanced LST. Give examples of ethical principles relevant to the withdrawal of advanced LST. Discuss local institutional policies relevant to the process of withdrawal of advanced LST. Explain the process of withdrawal of various advanced LSTs. Describe symptom burden and appropriate interventions associated with withdrawal of common advanced LSTs. Recognize signs and symptoms of impending death after withdrawal of advanced LST. Recognize psychosocial and spiritual distress including anticipatory grief and bereavement responses from families. Facilitate discussions with patients and/or families regarding goals of care and preparation for withdrawal of advanced LST. Diagnose and manage symptom burdens associated with withdrawal of advanced LST. Orchestrate withdrawal of advanced LST. Attend to psychosocial and spiritual distress including anticipatory grief and bereavement responses from families. Utilize the interdisciplinary team (IDT) to support both the patient and family before, during, and after the withdrawal of LST. Demonstrate care that shows respectful attention to sociocultural characteristics of patients and their families. Demonstrate high standards of ethical behavior including utilizing the IDT, maintaining professional boundaries and scope of practice, and collaborating with other involved physicians and healthcare providers. Appreciate the need to attend to unique characteristics and needs of patients, their families, and healthcare providers. Value the key roles of IDT members, collaboration with colleagues, and maintenance of professional boundaries in withdrawal of LST. Appreciate the potential gravity of decisions to withdraw LST. Accept that personal experiences and the specific microculture of the care setting can contribute to bias, which can impact the recommendation to withdraw LST.
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Detailed Description: HPM physicians are skilled in the withdrawal of advanced life-sustaining therapies (LSTs), including facilitation of goals of care discussions leading to the decision to withdraw advanced LST, management of symptoms before and after withdrawal of advanced LST, orchestration of withdrawal of LST, and provision of family support for psychosocial and spiritual distress including anticipatory grief and bereavement.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 9. Care for imminently dying patients and their families.
• Knowledge • • • • • • • • • •
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Describe the physical signs and symptoms of the dying process and common challenges for symptom management. List medications used to treat symptoms of impending death and explain their mechanisms of action. Describe areas of whole-patient care as it relates to caring for the imminently dying patient. Recognize roles and skills of interdisciplinary team members needed to achieve whole-patient care. Describe communication techniques to provide psychosocial support. Recall and explain the range of potential indications for proportionate symptom control, which could include sedation. Describe ethical principles and how they do or do not apply to end-of-life care. Identify the characteristics of normal and complicated grief and bereavement. List medical conditions that require medical examiner involvement and requisite steps of sensitive death pronouncement and documentation. Recognize the imminently dying patient and associated signs and symptoms. Facilitate communication to prepare family and healthcare providers that death is imminent. Utilize an interdisciplinary team approach to provide whole-patient care for the imminently dying patient and their family. Provide psychosocial support to family and healthcare providers regarding common concerns, identify family members at risk for complex bereavement, and have patience and understanding for different coping and grieving styles. Recognize different perspectives of family and healthcare providers regarding the degree of symptom burden during the dying process. Manage physical symptoms of impending death. Inquire if spiritual or cultural rituals are important and provide assistance as appropriate. Make the death pronouncement in a sensitive, respectful way in the presence of family. Document the patient’s death and complete the death certificate appropriately. Appreciate the importance and time sensitivity in providing care for the imminently dying patient and their family. Acknowledge the uniqueness of the dying experience for each patient and family. Value the potential positive impact of effective interdisciplinary care on family bereavement. Recognize the importance of role modeling and teaching sensitive, skilled care of the dying patient to other care providers.
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Detailed Description: HPM physicians identify signs of the dying process, address multiple areas of suffering for the imminently dying patient and their family and facilitate after-death bereavement support for the family and healthcare providers.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 10. Address requests for hastened death. Detailed Description: HPM physicians address requests for hastened death in accordance with federal, state, and local regulations as well as ethical and professional principles while remaining sensitive to a patient's individual values, preferences, and sources of suffering.
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Identify and summarize the federal and state laws, local regulations, and professional guidelines applicable to requests for hastened death. Demonstrate broad knowledge of epidemiology and etiologies of requests for hastened death. Elucidate a physician’s clinical, ethical, and professional responsibilities when faced with requests for hastened death. List and explain bioethical models relevant to requests for hastened death. Explore the full range of potential motivations in requests for hastened death using a routine and comprehensive approach. Communicate and counsel the patient about total pain, and provide state-of-the-art palliative therapies to manage total pain by addressing all aspects of suffering with time-limited trials. Explore the patient’s fears and expectations and facilitate establishing individual goals when hastened death is requested. Maintain meticulous, interdisciplinary records of requests for hastened death. Appreciate the importance of the federal and state laws, local regulations, and professional guidelines related to requests for hastened death. Remain mindful of the limits of medicine and a physician’s ability to relieve suffering. Seek awareness of and be willing to balance one’s own and others’ fundamental values regarding requests for hastened death. Be open to consideration of competing claims to safeguard human life and individual autonomy, and be prepared to reconsider previous opinions in light of new evidence or arguments.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 11. Support Support patients and families in the psychosocial domain.
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Describe approaches to developmentally appropriate assessment for coping, stressors, grief and bereavement, suffering, and behavioral health comorbidities. Identify techniques for expressing empathy. Describe how issues involving cultural sensitivity and diversity affect access to and utilization of hospice and palliative care. Discuss benefits, burdens, and risks for the caregiver role. Identify specific roles, expertise, and supportive interventions that individual team members, especially psychosocial clinicians, can provide in support of patients and families. List potential referrals and additional resources in various clinical settings. Elicit a focused, developmentally appropriate psychosocial history, tailored to each patient and family. Assess for coping, stressors, grief and bereavement, suffering, behavioral health comorbidities, and caregiver burden. Provide basic counseling, empathetic response, and cultural sensitivity in supporting expressions of distress. Develop appropriate patient- and family-centered assessments, communication, and care plans with the interdisciplinary team (IDT), especially psychosocial clinicians when available. Mobilize additional resources, make referrals, and navigate the healthcare system to meet patient and family needs. Appreciate the contribution of the psychosocial domain to patient and family coping, suffering, resilience, healing, well-being, and bereavement. Value the expertise of IDT members in formulating assessments and care plans for patient and family support. Prioritize developmentally appropriate and culturally sensitive patient and family care.
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Detailed Description: HPM physicians address patient and family suffering, coping, and healing within the emotional, psychological, and social domains with focused, developmentally appropriate assessment followed by targeted communication, interventions, and referrals.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 12. Support patients and families in the spiritual and existential domain. Detailed Description: HPM physicians address patient and family suffering and identify strengths and needs within the spiritual and existential domain with basic assessment followed by appropriate interventions and referrals.
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Describe approaches to screening and basic history taking of spirituality, religion, existential issues, and issues of meaning and purpose. Discuss types and causes of spiritual distress. Identify interventions the physician and/or interdisciplinary team (IDT) can provide depending on patient, family, and team composition and characteristics. Distinguish expertise that individual team members, especially chaplains, can provide in support of patients and families. List potential referrals and additional resources in various clinical settings. Provide compassionate presence and listening. Offer open, empathetic response to spiritual and existential suffering. Take a basic spiritual history tailored to each patient and family. Explore how patient and family spiritual, religious, and existential beliefs and values affect medical decision making and the provision of health care. Inquire about and support patients’ and families’ end-of-life spiritual and/or religious practices and rituals. Assist the IDT in identifying and promoting a sense of meaning and purpose and creation of legacy. Develop appropriate patient- and family-centered assessments and care plans with the IDT, especially the chaplain when available. Engage community clergy and, when appropriate, mobilize additional resources, make referrals, and navigate through the healthcare system to effectively meet patient and family needs. Appreciate the contribution of the spiritual and existential domain to patient and family coping, suffering, resilience, healing, well-being, and bereavement. Respect patients’ and families’ spiritual, religious, and existential beliefs even if these beliefs and values contradict one’s own beliefs and values. Value expertise of IDT members in formulating assessments and care plans for patient and family support. Be open to working with spiritual providers of diverse backgrounds and belief systems.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 13. Promote selfself-care and resilience. resilience. Detailed Description: HPM physicians value and promote resilience and personal well-being for themselves and others as a necessary element for professional success and sustainability.
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Understand the impact from personal and professional losses on oneself and others. Give examples and describe features of burnout, moral distress, compassion fatigue, depersonalization, inefficacy, and vicarious trauma. Recall factors that predispose individuals and teams to stress and burnout. Describe strategies to mitigate physical and emotional exhaustion, foster professional and personal growth and identity, promote compassion and equanimity, and strengthen resilience. Develop awareness of one’s own subjective experience and the work environment in order to achieve balance with the needs of patients and their families. Remain present to suffering of others and maintain resilience when experiencing one’s own distress and/or grief. Develop practices that promote regular reflections toward growth and self-care. Recognize risks for and features of excessive stress, impairment, and impending burnout in oneself and others. Appreciate the importance of and professional responsibility to attend to self-care. Value the need for balance around resilience and grief/bereavement. Utilize self-care tools and engage in strategies to mitigate physical and emotional exhaustion, cynicism, and inefficacy. Promote highly present, boundary-conscious, empathetic engagement. Role model and encourage effective self-care for other trainees.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 14. Facilitate transitions across the HPM continuum continuum of care.
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Describe various settings in which patients and families may access palliative care. Discuss common characteristics of interdisciplinary team (IDT) resources and staffing available in different settings to meet patient and family needs around acuity and distress. Identify the range of diagnostic approaches and therapies that can be maintained in various care settings. Define systems-based reimbursement and payment structures, eligibility requirements, and key regulations in different care settings. Recognize potential gaps in care as patients transition between settings, including communication between providers, medication reconciliation, treatments, and emotional support for patients and families. Select and dose medications based on accessibility and availability of route of administration within and across care settings. Initiate and adjust medical interventions germane to specific care settings. Communicate with IDT, primary service, consultants, and other providers within and across care settings. Assess appropriateness of patients for specific care settings, clarifying necessary and available resources, and constructing transition plans that incorporate patient safety while aligning with patient and family goals. Provide guidance for smooth transitions across settings for patients, families, and providers that address medical, pharmaceutical, social, emotional, and spiritual concerns. Recognize challenges to patients, families, and providers in confronting differing formularies and costs of treatments across the continuum. Demonstrate appreciation for the culture and structure of each care setting and the need to work with their strengths and limitations to best meet patient and family goals. Recognize that care teams have their own values regarding care settings, which may influence their recommendations. Demonstrate appreciation for the roles of different healthcare team members in various care settings. Empathize with patient and family distress surrounding times of transition between care settings.
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Detailed Description: HPM physicians are adept at caring for patients and families across the healthcare continuum (eg, inpatient, long-term care, ambulatory, home) with an understanding of and appreciation for resource availability, care coordination, and transitions support required for effective and high-quality care.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 15. Fulfill the role of a hospice medical director. Detailed Description: HPM physicians meet the clinical, regulatory, administrative, and supportive responsibilities of a hospice medical director.
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Describe hospice eligibility guidelines for common medical conditions, and pediatric patients, including concurrent care models. Identify specialty-level pain and symptom management expertise specific to the unique settings and requirements for hospice care. Discuss hospice regulatory requirements. Explain how hospice integrates into local, regional, and national health care. Monitor and identify financial issues affecting hospice programs, including public and private reimbursement and payment structures and philanthropy. Outline the appeals process for denied claims Provide hospice care to patients and families across diverse settings: home, longterm care, and inpatient hospice. Facilitate a hospice interdisciplinary team (IDT) meeting Comply with regulatory requirements and documentation including Certification of Terminal illness, Face to Face, etc. Provide leadership, education, and support to hospice IDT members. Manage medications with formulary restrictions. Work with hospice patients’ primary- and specialty-care providers. Engage pediatric palliative care resources to serve pediatric hospice patients. Work telephonically with hospice staff, patients, and families in critical situations. Ensure the safety of oneself and staff when working in challenging environments. Respect the skills and knowledge of diverse disciplines working to help patients and families. Appreciate the diverse cultural, socioeconomic, and ethnic backgrounds of patients. Display openness to collaboration and teamwork.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 16. Provide HPM consultation and team team support. Detailed Description: HPM physicians render patient- and family-centered consultative care in a professional, timely, and effective manner that supports and educates the referring and invested team members.
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Recognize the roles of different interdisciplinary team members. Educate others on appropriate indications for palliative care consultation. Describe consultation etiquette. Recognize that comprehensive care of a patient routinely involves attention to physical, emotional, psychosocial, and spiritual elements. Identify provider distress. Recognize the dual and sometimes conflicting roles of patient/family advocate and consultant. Gather and synthesize essential and accurate information relevant to the consult, including clarification of the consultation question when needed. Introduce and educate about the role of palliative care and hospice. Perform a palliative medicine–focused history and physical. Use available evidence to construct a palliative care assessment and management plan. Seek answers to outstanding patient, family, and clinical questions that arise in the course of consultation. Seek to understand, maintain rapport, and advocate for patient and family goals when healthcare providers have conflicting views. Respond to provider distress with empathy. Timely and effectively Communicate recommendations to patients, families, and referring providers and document these in the patient’s medical record in a timesensitive and effective manner. Engage the strengths and skills of IDT members. Support other teams in developing their palliative care skills. Exemplify professional and ethical behavior. Appreciate evidence-based medicine. Welcome and incorporate feedback from referring teams. Value patient advocacy. Show concern for provider and team well-being and needs. Appreciate the relationship between consultation etiquette and future referrals.
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ACCEPTED MANUSCRIPT Hospice & Palliative Medicine EPA Title: EPA 17. Promote and teach hospice and palliative care. Detailed Description: HPM physicians promote access to high-quality palliative care services across the continuum of care through advocacy and health system improvement as well as by teaching hospice and palliative care to other healthcare providers.
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Describe the value and role of palliative and hospice care accounting for diversity of learning needs, backgrounds, learning styles, and education levels among patients, families, community members, and others. Identify educational needs of interprofessional colleagues, administrators, medical staff, and peers regarding the basics of hospice and palliative care for all healthcare providers. Describe the key roles of specialty HPM in the healthcare delivery system. Describe how to integrate quality improvement activities into the routine function of palliative and hospice programs. Demonstrate the ability to critically appraise, disseminate, and apply palliative care literature. Advocate for palliative care program development within systems. Promote hospice and palliative care education within healthcare systems/organizations. Identify key stakeholders in local and system-level healthcare improvement efforts. Deliver a succinct message to both community and professional audiences about the importance of hospice and palliative care for optimal patient care. Adapt different teaching formats based on the setting, content, and learners. Analyze clinical performance data and actively work to improve performance. Model lifelong learning in palliative care. Appreciate that basic palliative care skills are an essential competency for all health professionals. Recognize the responsibility to serve as a palliative care educator to patients, families, and the community. Appreciate the need to use meaningful metrics for hospice and palliative care program development. Value advocacy (local, regional, national) as a means to improve quality health care for patients and families. Remain open to feedback at the individual, programmatic, and system level. Value quality improvement as a tool to grow and improve palliative care programs.
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