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Opportunities and Challenges Facing the Integrated Physician Workforce of Emergency Medicine and Hospice and Palliative Medicine
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–10, 2016 Ó 2016 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2016.06.056
Clinical Review OPPORTUNITIES AND CHALLENGES FACING THE INTEGRATED PHYSICIAN WORKFORCE OF EMERGENCY MEDICINE AND HOSPICE AND PALLIATIVE MEDICINE Sangeeta Lamba, MD,* Paul L. DeSandre, DO,†‡ and Tammie E. Quest, MD†‡ *Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, †Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, and ‡Emory Palliative Care Center, Emory University School of Medicine, Atlanta, Georgia Reprint Address: Sangeeta Lamba, MD, Department of Emergency Medicine, Rutgers New Jersey Medical School, 185 South Orange Ave., Newark, NJ 07103
, Keywords—hospice and palliative medicine; integrated workforce; emergency medicine; career pathway; challenges
, Abstract—Background: The American Board of Emergency Medicine joined nine other American Board of Medical Specialties member boards to sponsor the subspecialty of Hospice and Palliative Medicine; the first subspecialty examination was administered in 2008. Since then an increasing number of emergency physicians has sought this certification and entered the workforce. There has been limited discussion regarding the experiences and challenges facing this new workforce. Discussion: We use excerpts from conversations with emergency physicians to highlight the challenges in hospice and palliative medicine training and practice that are commonly being identified by these physicians, at varying phases of their careers. The lessons learned from this initial dual-certified physician cohort in real practice fills a current literature gap. Practical guidance is offered for the increasing number of trainees and mid-career emergency physicians who may have an interest in the subspecialty pathway but are seeking answers to what a future integrated practice will look like in order to make informed career decisions. Conclusion: The Emergency and Hospice and Palliative Medicine integrated workforce is facing novel challenges, opportunities, and growth. The first few years have seen a growing interest in the field among emergency medicine resident trainees. As the dual certified workforce matures, it is expected to impact the clinical practice, research, and education related to emergency palliative care. Ó 2016 Elsevier Inc. All rights reserved.
INTRODUCTION Hospice and palliative medicine (HPM) is a subspecialty pathway for emergency physicians (EP) (1–3). Since the first HPM certification examination was held in 2008, an increasing number of EPs have achieved board certification in the subspecialty (1,4). Over the last decade, emergency medicine (EM) has also taken a prominent role in integrating HPM-related practice principles into routine care of patients eligible for such services in the emergency department (ED) (2,5–9). The ‘‘Choosing Wisely’’ campaign (American College of Emergency Physicians [ACEP]) has highlighted the integrated disciplines, stating, ‘‘Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit’’ (2,6,10). This is in the context of the national spotlight on palliative care by several reports/initiatives, such as the Integrating Palliative Medicine into Emergency Medicine (IPAL-EM) project (an initiative of the Center
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to Advance Palliative Care) and The Institute of Medicine (IOM) report, ‘‘Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.’’ This IOM report focuses on the current disconnect between how most Americans wish to be cared for at the end of their lives and what care is actually provided to them (11,12). The growing interest in EM for the subspecialty training pathway for HPM is evidenced by an engaged and active Palliative Medicine section in ACEP as well as the novel Special Interest Group/ Forum formed by emergency physicians within the American Academy of Hospice and Palliative Medicine (AAHPM) (9). Since the introduction of the pathway to HPM by the American Board of Emergency Medicine (ABEM), there has been no discussion in literature to explore the challenges and opportunities that are facing the now dual-certified EM-HPM physicians (5,6,13). This information is especially important to effectively mentor and guide the EM trainees with an interest in the subspecialty as a future career. In this article we use excerpts from conversations with EP’s; those interested in pursuing HPM certification/practice and those currently holding dual certifications in both disciplines. These excerpts illustrate the commonly voiced concerns of emergency physicians regarding training and practicing HPM and the unique challenges that EMHPM physicians are facing at varying phases of their careers. We discuss the current status of the integrated field of EM and HPM, provide guidance to the process of certification, and propose solutions to some of the identified challenges. DISCUSSION Emergency medicine and palliative care experts (authors SL, PLD, TEQ) are frequently approached by emergency physicians with multiple queries regarding the HPM subspecialty, and therefore we use four excerpts from these conversations to illustrate the common questions that are being voiced. Emergency Physician 1: Interest in Hospice and Palliative Medicine as a Subspecialty I am a third-year EM resident and have recently become quite interested in HPM as a career choice. How do I proceed to explore fellowship training? What does it involve? I do not have subspecialty faculty at my program to mentor me. I have recently heard that it may be difficult for me to get a position in a fellowship since most programs are based in internal medicine and they prefer candidates with an internal medicine background. I also have significant loan debt, so how will my decision to pursue a fellowship in HPM impact my financial status?
Emergency Physician 2: Dual Board-Certified in EM and Hospice and Palliative Medicine—Now What? I am an EM board certified physician finishing a fellowship in HPM. Soon I will be board certified in two disciplines; now what? I would like to practice in both settings of HPM and EM. How do I straddle these two disciplines successfully?
Emergency Physician 3: Seeking Leadership Roles in Hospice and Palliative Medicine I have been a dual board-certified physician in HPM and EM since ‘‘grandfathering’’ and successfully completing the requirements of the examination. I have a successful balanced practice in both disciplines and split my time equally between an EM and HPM practice. I would now like to advance my academic career in HPM at a national level. Whom can I contact for advice? How do I go about accomplishing this?
Emergency Physician 4: Practicing or Mid-Career Emergency Physician with an Interest in Exploring a Transition to Hospice and Palliative Medicine Practice I have been practicing EM for over 5 years and find myself increasingly interested in palliative and end-of-life care. I cannot afford to leave my EM practice due to do financial and family constraints. What are my options?
Historical Perspective The term ‘‘hospice’’ or a place of shelter for weary travelers was applied to specialized care for the dying when Dr. Cicely Saunders first established modern hospice care in England in the late 1950s (14). The first hospice in the United States was established in Connecticut in 1974. The Institute of Medicine report in 1997, ‘‘Approaching Death: Improving Care At the End of Life’’ first highlighted major gaps and deficiencies in end-oflife care (15). This resulted in a major effort to bring palliative care into mainstream medicine with support from foundations such as the Robert Wood Johnson Foundation. The early 1990s saw the American Board of Hospice and Palliative Medicine (ABHPM) begin to offer their certifying examinations. Recognition for the subspecialty of HPM within the American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education (ACGME) followed in 2006 (1,4,16,17). ACGME Certification in Hospice and Palliative Medicine The ABMS organization formally recognizes specialties and subspecialties and confers specialty and subspecialty
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status (17–19). There are four steps to certification in HPM: 1) Complete the fellowship training that will meet the eligibility criteria (described below). 2) Apply for certification in HPM within the established application period through the home board – ABEM diplomates apply through ABEM. 3) Receive confirmation that the eligibility criteria have been met after ABEM review and independent verification of credentials. 4) Take and pass the certification examination in HPM. This examination is administered biennially, in even-numbered years, to candidates from multiple specialties at the same time in the same testing centers (1,4). Reflecting the roots of palliative medicine in many specialties, the certification examination for HPM is offered by 10 specialty boards, including Emergency Medicine (1,20). The certification examination is designed to evaluate the knowledge, diagnostic reasoning, and clinical judgment skills expected of the certified physician practicing in the broad domain of HPM (20). The broad content categories tested are shown in Table 1 (20). The overall pass rate is approximately 83% for this HPM examination. The first three examinations (2008, 2010, 2012) offered the option to applicants to list prior experience and thus qualify to ‘‘grandfather’’ for the certification (4). In 2006, the ACGME began the process of accreditation for HPM fellowship programs such that starting in 2013, only those applicants completing an ACGMEaccredited fellowship program are eligible to take the certification examination (4). Based on information obtained from ABEM, as of December 2015 there were 114 HPM diplomates certified by ABEM, of whom 36 are fellowship trained. The number of physicians dual-certified in both HPM and EM is likely higher because ABEM does not take into account those physicians who used a board other than ABEM for the pathway to certification. For example, a physician certified in both Internal Table 1. Hospice and Palliative Medicine Certification Examination Content (20) Medical Content Category Approach to Care Psychosocial and Spiritual Considerations Impending Death Grief and Bereavement Medical Management Communication and Team Work Ethical and Legal Decision Making Prognostication and Natural History of Serious Illness Total
% of Examination 9% 11% 9% 5% 45% 6% 7% 8% 100%
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Medicine and EM may have elected to certify in HPM via the American Board of Internal Medicine and not ABEM. ABEM currently ranks 6th out of 10 specialties in the numbers of HPM graduates. ACGME Hospice and Palliative Medicine Fellowship Training Successful completion of a 12-month accredited HPM fellowship program is now the only pathway to ABMS Certification. Fellowship training must occur over a 12month period with the elements outlined by the Core Curriculum in HPM (21). Fellowship training must occur in a minimum of three settings: inpatient hospital, long-term care, and ambulatory care. Fellows must complete the minimum following training sequence regardless of their primary specialty: a minimum of 4 months of inpatient palliative care consultation in addition to 2.5 months of hospice (both inpatient and home), 1 month of long-term care, and a minimum of 6 months of weekly ambulatory clinics. Fellows must complete a minimum of 25 home hospice visits and 100 new inpatient consultations, and a minimum of 10 patients must be followed longitudinally across settings (inpatient, home, and ambulatory clinics) (21). The Review Committee only accredits 12 months of training, and all requirements must be completed in these 12 months and must be completed consecutively (21). Fellowship is considered to be a full-time undertaking; splitting training over 2 years must be approved by the relevant board. Fellows must have training that exposes them to both adults and children, and they must be trained by an interdisciplinary team (e.g., nurse, chaplains, and social worker). The major competencies of subspecialist-level HPM are listed in Table 2 (22). Hospice Medical Director and the Hospice Medical Directors Certifying Board HPM training for emergency physicians that do not train directly after residency presents a significant challenge to increasing the number of emergency physicians. Barriers common to practicing emergency physicians returning to fellowship training mid-career include: 1) limited numbers of programs in the nation, which increases the likelihood that relocation will be necessary for 1 year. In addition, beginning in 2015, all but five of the accredited HPM training programs have elected to participate in the National Residency Match Program, contributing to further uncertainty; 2) Continued financial obligations during the training year (student loans, family and personal living costs); 3) limited ability to ‘‘moonlight,’’ as working in the ED must be included in the 80-h work week prescribed by the ACGME (21,22). Efforts are underway by the AAHPM that seek to
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Table 2. Major Competencies for Hospice and Palliative Medicine Fellowship Relieving suffering and improving the quality of life for patients and families with life-threatening illness Helping patient and family cope well with loss and engage in effective grieving Comprehensive interdisciplinary team management of the physical, psychosocial, social and spiritual needs of patients and their families Managing and coordination of the array of challenging problems associated with end-of-life care, including the management of the immediately dying patient Promoting closure and the possibility of growth at the end of life
explore mid-career pathways for board certification that would be compliant with requirements. The timetable, structure, and ultimate possibility of this remain unclear. Until new pathways become available, one option that remains for practice is that of a hospice medical director. Of the 2.4 million people that die each year, approximately 50% receive hospice care. There are over 4000 hospice agencies in America (14). All are required to have at least one physician medical director. It is not uncommon for community hospices to solicit the services of local physicians interested in serving in a part-time or full-time capacity in the role of hospice medical director. The hospice medical director is responsible for the quality oversight and clinical care of patients receiving hospice care. At the inception of the Medicare Hospice Benefit, the physician medical director was a volunteer role. However, Center for Medicare and Medicaid Services regulations have evolved. The hospice medical directors now play an essential role in the delivery of hospice services, including the certification of terminal illness, serving as the primary physician for patients when their own physician is unwilling or unable to serve in that role, and ensuring quality oversight for hospice care. The physician is a required and integral part of the interdisciplinary care team and provides direct patient care as well as oversight (14). Direct clinical care includes caring for patients in hospice inpatient units as well home visits. The role of hospice medical director is one that presents a unique opportunity for qualified emergency physicians. Because the work is often part time, some hospice medical directors are emergency physicians that serve full time as a hospice medical director with a part-time emergency medicine practice. Medical director services may be contracted with the hospice as an employee that works for the hospice agency or as a contractor where the emergency physician is paid hourly or on stipend for service. Typically, hospice medical directors take calls for the hospice nights, evenings, and weekends. Overall, for some emergency physicians, this may represent a gratifying clinical practice filled with new skills and opportunities for caring for patients and families at the end of life. The skills and training of hospice medical directors are varied. The large majority are not ABMS board certified in HPM. In 2014, the Hospice Medical Directors Certifying Board (HMDCB), a nonprofit organization, created
a certifying examination for hospice medical directors that focuses on the knowledge, skills, and regulatory/ compliance aspects of hospice practices (23). In 2014, over 368 physicians sat for this examination, with a 90% pass rate. In addition to a current, unrestricted license to practice medicine in the United States or Canada, the prerequisites for sitting for the HMDCB examination includes an ability to demonstrate a minimum of 400 h of broad hospicerelated activities during the previous 5 years (e.g., engagement in patient care, certification process, medication management, participating in performance improvement, and administrative activities in the hospice setting). In addition, candidates must meet at least one of the three following eligibility requirements: Practice Pathway: 2 years of work experience in a hospice setting in the previous 5 years Certification Pathway: Current, valid board certification in Hospice and Palliative medicine through ABHPM, ABMS, or the American Osteopathic Association (AOA), or Training Pathway: Successful completion of a 12month clinical HPM training program accredited by the ACGME or AOA (23). Status of the Field of Emergency Medicine – Hospice and Palliative Medicine The AAHPM appointed a Workforce Task Force in 2008 to assess the status of the palliative workforce, to determine whether a physician shortage existed in the field, and to develop an estimate of the optimal number of HPM-trained physicians needed (19,24,25). They describe an acute shortage of such physicians currently and for the foreseeable future. There is approximately one HPM physician for approximately every 1300 patients with serious advanced illness, in comparison to one cardiologist for about 71 patients with a myocardial infarction (25). Despite a modest recent increase in fellowship spots (see Table 3), there are many states with no training programs in HPM. This has spurred a call by AAHPM to explore solutions to the gaps in access to palliative care (19). Some of the proposals being considered include: 1) Promote generalist level competencies for non-HPM specialties such as EM, 2) Revise
Integrated Physician Workforce of Emergency Medicine and Hospice and Palliative Medicine Table 3. Hospice and Palliative Medicine Fellowship Training Programs
Core Program ACGME Internal Medicine Family Medicine Pediatrics Radiology/Oncology Anesthesia Psychiatry Total ACGME-approved fellowship slots ACGME-approved temporary fellowship slots Total slots Filled slots* AOA AOA Programs† AOA-approved slots† Funded slots† Filled slots†
New Programs for 2013-2014 2014–2015 2014–2015 65 22 4 2 2 1 96 285
3 1 1 0 0 0 5
68 23 5 2 2 1 101 296
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5
289 216
301
10 24 17 5
0
10
ACGME = Accreditation Council for Graduate Medical Education; AOA = American Osteopathic Association. * ACGME Web site notes that total filled will reflect the previous academic year. It does not note when annual update is completed. † Data obtained from the AOA Web site; core programs are not identified.
ACGME program requirements to accommodate those needing a longer training period at less than full time to complete the fellowship, and 3) Develop a mid-career pathway for HPM as a way for established physicians to become board certified without having to do a full fellowship. These conversations not only highlight the need to expand the number of physicians, but also suggest that HPM may provide opportunities based on the predicted need in the coming decades. These recent years of subspecialty HPM certification have created new opportunities for practice and job growth for EPs (1,25). However, this has also presented new and unique challenges as the first dually trained EM-HPM physicians enter the integrated workforce and navigate uncharted territory. We discuss the challenges faced by the dual-certified physicians at varying phases of their career and also propose solutions to their commonly voiced questions and concerns. PHYSICIAN 1: EM RESIDENT INTEREST IN HOSPICE AND PALLIATIVE MEDICINE AS A SUBSPECIALTY There is an increasing level of interest in HPM among EM residents (26). However, multiple challenges exist for EM residents trying to decide whether to pursue this subspecialty, particularly a lack of mentors and a lack of
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guidance (9). There exists a lack of dual-certified EMHPM faculty in the majority of EM residency programs nationally. This presents significant challenges for program directors and faculty when mentoring and advising trainees interested in fellowship training in HPM (9,26). Because the field is new and evolving, the practice expectations and salaries are difficult to understand and vary by institutional and regional needs, making the decision process even more difficult for EM residents. EM residents may also find that they are challenged when they apply to fellowship programs because the vast majority of fellowships are offered by the primary care fields of internal medicine and family medicine, where a possible bias toward these primary disciplines may exist in the candidate-selection process. There is added concern about this primary care specialty bias related to the recent July 2015 ACGME decision to limit sponsorship of fellowships in HPM to six specialty ‘‘core’’ residency programs. This decision excludes EM as a ‘‘core’’ program and states that, ‘‘A Hospice and Palliative Medicine program must demonstrate that it exists in conjunction with, and is an integral part of, a core ACGME-accredited residency program in anesthesiology, family medicine, internal medicine, psychiatry, pediatrics, or radiation oncology. There are no exceptions to this requirement’’ (21). Suggested Solutions As with any career decision, an EM resident interested in HPM should undergo a process that involves thoughtful active career decision-making. Weighing the balances and risks before one starts is important. Advanced training in HPM may offer an added employment value, particularly for an academic position. Also, the personal value of participating in an alternate discipline for which one is passionate, work-life balance, and long-term career satisfaction all are important considerations. Early recognition of the need for mentors outside of the local EM residency program should allow for ample time to seek and connect with appropriate dual-certified EM-HPM faculty outside of the institution. There is an active conversation to develop a document from AAHPM outlining the process and providing a template for obtaining the sponsoring board and the ACGME’s permission for an exception to allow a single individual to complete a fellowship half time over 2 years. This would allow for EM trainees to use clinical practice to supplement income and may overcome some of the financial barriers to fellowship training. There is a valid concern that EM residents may often face a bias against them when applying for fellowships mainly offered by primary care disciplines. An increasing number of programs, however, now offer positions without consideration of primary specialty and are clearly
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open to EM-trained residents. EM residents applying to the field may therefore need to ask directed questions and pay close attention to a program’s selection patterns and identify some of the national programs with a prior history of acceptance of fellows from a variety of disciplines. Because HPM is focused on the care of serious advanced illness, management of chronic disease and primary care is likely to be a key component of the fellowship as well as life-long HPM practice. In addition to aggressive symptom management, HPM-certified physicians often must attend to the day-to-day chronic illness more typically managed in primary care, such as diabetes and blood pressure control or adjusting warfarin doses. Unlike HPM physicians from primary care pathways, EM-HPM dual-certified physicians may feel less prepared to manage such patients. An honest self-appraisal of interest in chronic disease management and the willingness to learn new knowledge and skills such as management and prevention of decubitus ulcers or care of chronic wounds may allow an EM resident to seek and fill knowledge gaps in primary and preventive care as they proceed through residency training and subsequently while in fellowship. Ultimately, this may help develop a level of confidence and comfort to join complex subspecialty HPM practice. PHYSICIAN 2: BOARD CERTIFIED IN EM AND IN HOSPICE AND PALLIATIVE MEDICINE; NOW WHAT? OPPORTUNITIES AND CHALLENGES FOR DUALLY CERTIFIED PHYSICIANS HPM practice varies with different settings and may include a community program, hospital-based programs, home-based palliative care (nonhospice), or an ED-based practice. Each setting and type of practice, in turn, has its own set of opportunities and challenges (Table 4). Most EM residency-trained physicians express a keen desire to give back to EM in a meaningful way, and thus want to practice both EM and HPM. This often creates timesharing and funding concerns when seeking jobs that include both EM and HPM roles and responsibilities. Negotiations for hiring will therefore involve two departments that may not necessarily understand each other’s mission, goals, and practice needs. Financial considerations may also play a big role in determining clinical practice ratios. The poor reimbursement rate for HPMrelated activities, particularly for the consultations with patients and their families, which HPM physicians regard as essential to patient-centered care, means that HPM is often reimbursed at a far lower rate than high-tech procedures/services. This pay differential between the two fields currently favors EM clinical practice over HPM, especially for young physicians just finishing training.
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Suggested Solutions As dual EM-HPM-certified physicians plan careers, there should be a personal appraisal of the desired EM-to-HPM balance; how much time to focus on HPM vs. EM. Also necessary is the understanding of how much of a financial impact is one willing to consider, and this may vary by personal responsibilities, stage of career, and financial pressures. Below we discuss three main phases of the EM-HPM physician academic careers, with specific concerns for each phase. 1. New EM graduate 0–10 years post residency Increased financial pressures may necessitate more EM practice initially; accept more limited HPM job and focus while building an HPM skillset and networking to create better defined roles for the future If leadership in HPM is desired, consider an early shift to a palliative care-based focus—this would be an early planned decision to work less EM similar to a research career (for example, a maximum of 25% for clinical EM practice) Choosing and working on better integration in education and research-focused areas of emergency palliative care 2. Mid-career 10–20 years post EM residency Transitioning down from EM with an increasing focus on HPM Solid joint EM-HPM skill set Expanded EM-HPM research and education focus Expanded HPM leadership opportunities at a regional and possibly national level 3. Late career > 20 years post EM residency Decision to transition fully to HPM practice that may be less physically hectic than an EM practice clinical schedule Staying active in the field of EM while practicing HPM. This may be accomplished by working actively to educate and implement HPM practice and protocols in generalist-level palliative care to EM providers Leadership in education, research, and practice of EM-HPM at a national level PHYSICIAN 3: SEEKING LEADERSHIP ROLES IN HOSPICE AND PALLIATIVE MEDICINE As the HPM subspecialty grows, there are ample opportunities for leadership available in both EM as an HPM expert and in HPM as an EM expert. It is important to become engaged at an institutional, regional, and national level. Beginning with leadership roles on institutional
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Table 4. Types of Practice in Hospice and Palliative Medicine: Related Challenges and Opportunities for Emergency Physicians with Dual Certification Type of Practice
Opportunity
Challenges
1. Hospital-based Palliative Care Inpatient Service/Palliative Care unit
High demand Good fit for EM – crisis-oriented care Ability to do dedicated weeks to share EM and palliative care schedule
2. Hospice (Home and Inpatient) Medical Director
Many hospices and positions Suited for emergency physicians where clinical judgment and rapid decisionmaking are key skills Core Interdisciplinary team concept that is compatible with the EM model of team Easy to job share and balance with EM schedules Increasing need Developing models of care Flexibility in schedules
3. Home-based palliative care
4. Outpatient palliative care clinics
Increasing need Developing models
5. EM-based palliative care services
Emerging Model Limited programs Meets hospital strategic planning for improved care, decreased readmission, and care that is goal aligned with patient
Lower EM salaries Difficulty getting ‘‘buy down time’’ from EM to work inpatient that balances the schedule Inpatient Credentialing Issues –Emergency physicians typically are not credentialed in hospital to admit or consult EM shift release does not balance palliative care time on service Limited leadership opportunities in palliative care if not wholly committed to palliative care Large salary differential – hourly and stipends are lower than EM salaries Home/On-call responsibilities can be heavy Often part-time positions make it difficult to have a significant practice or establish leadership with the hospice agency Skill set needed for longitudinal management of complex chronic conditions (diabetes, hypertension, wound care, and Coumadin dose adjustments) Hesitancy or an inability to be used in cross coverage situation with internal medicineor family medicine-trained clinicians Competencies in preventive medicine and chronic disease management needed Emergency clinicians have limited clinic/ outpatient training Possibly limited skill set for primary care issues that arise (example sugar and blood pressure control) Funding/reimbursement (between EM and PC); Needs to be cost shared Defining the role and efficiency Schedules, often a lone person for coverage Risk of a pigeonholed practice in palliative care
EM = emergency medicine; PC = palliative care.
committees such as the Bioethics or Pain and Palliative Care committees, engaging in regional- or state-level issues such as creating and delivering continuing medical education sessions in HPM if required for state licensure and networking to lead such sessions in regional meetings can be a reasonable start. Active participation in national organizations such as the Palliative Medicine section of ACEP and the various AAHPM committees/Forums/Special Interest Groups are opportunities to grow in networking and leadership roles. In clinical practice, the role of the hospice medical director or the director of palliative care services and in academic medicine the opportunities for leadership in fellowship training programs are other areas of potential growth (7). Emergency
palliative care is also a niche area for research that has significant potential to build research leaders in the field (27). PHYSICIAN 4: PRACTICING OR MID-CAREER EMERGENCY PHYSICIAN Physicians in current EM practice must consider financial, geographical, and long-term goals because both fellowship training and HPM clinical practice create financial challenges to the EP in active clinical practice. Although not insurmountable, a decision to shift an established financial balance requires significant planning, patience, and flexibility, both personally and
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professionally. If, in the short-term, the practicing EP cannot feasibly accommodate the financial or geographical challenges of fellowship training in HPM, other opportunities remain to engage in HPM. These include becoming a Hospice Medical Director or developing sufficient knowledge and skills to become an EM-HPM physician leader. As described earlier in this article, even the full-time practicing EP may find it possible to develop the skills to integrate a Hospice Medical Director practice into their clinical work. Doing so can be used to establish qualification for HMDCB certification. These skills can easily translate into EM practice and create opportunities to improve the operational and clinical expertise of staff and colleagues as it relates to hospice concerns in the ED. EPs interested in developing HPM skills more broadly have many available resources. Nationally, the Education in Palliative and End-of-Life Care-Emergency Medicine program provides an intensive ‘‘train the trainer’’ approach to help foster improved understanding and practice of one’s clinical staff to better recognize and respond to patients with palliative care needs in the ED (28). The resources and structures to apply such improvements can also be obtained through the Improving IPAL-EM project of the Center to Advance Palliative Care. Developing skills and utilizing available resources to evolve one’s current clinical practice environment can significantly improve the care of ED patients with palliative needs. In addition, by promoting the palliative care concerns of ED patients within local, regional, and national organizations, one can collaborate in establishing best practices within EM as it relates to HPM, even in the absence of formal training. CONCLUSION The integrated workforce of EM and subspecialty Hospice and Palliative Medicine faces areas of new challenges, opportunities, and growth. The first few years of this subspecialty pathway have identified a growing interest in the field among EM resident trainees. As the dual certified integrated workforce matures, it is expected to impact the clinical practice, research, and education related to emergency palliative care.
REFERENCES 1. American Board of Emergency Medicine. Hospice and palliative medicine overview. Available at: https://www.abem.org/public/ subspecialty-certification/hospice-and-palliative-medicine/hospiceand-palliative-medicine-overview. Accessed August 1, 2015.
2. Quest TE, Marco CA, Derse AR. Hospice and palliative medicine: new subspecialty, new opportunities. Ann Emerg Med 2009;54: 94–102. 3. Lamba S, Mosenthal AC. Hospice and palliative medicine: a novel subspecialty of emergency medicine. J Emerg Med 2012;43:849–53. 4. American Board of Internal Medicine. Hospice and palliative medicine policies. Available at: http://www.abim.org/certification/ policies/imss/hospice.aspx. Accessed August 1, 2015. 5. Quest T, Herr S, Lamba S, Weissman D. IPAL-EM Advisory Board. Demonstrations of clinical initiatives to improve palliative care in the emergency department: a report from the IPAL-EM Initiative. Ann Emerg Med 2013;61:661–7. 6. Lamba S. Early goal-directed palliative therapy in the emergency department: a step to move palliative care upstream. J Palliat Med 2009;12:767. 7. Quest TE, Chan GK, Derse A, Stone S, Todd KH, Zalenski R. Palliative care in emergency medicine: past, present, and future. J Palliat Med 2012;15:1076–81. 8. Rosenberg M, Lamba S, Misra S. Palliative medicine and geriatric emergency care: challenges, opportunities, and basic principles. Clin Geriatr Med 2013;29:1–29. 9. Smith AK, Fisher J, Schonberg MA, et al. Am I doing the right thing? Provider perspectives on improving palliative care in the emergency department. Ann Emerg Med 2009;54:86– 93. 93.e1. 10. Choosing Wisely. American College of Emergency Physicians, 2013. Available at: http://www.choosingwisely.org/societies/ american-college-of-emergency-physicians/. Accessed August 1, 2015. 11. Institute of Medicine. Report Brief, September 2014: Dying in America: improving quality and honoring individual preferences near the end of life. Available at: http://iom.nationalacademies. org//media/Files/Report%20Files/2014/EOL/Report%20Brief.pdf. Accessed August 1, 2015. 12. Smith AK, Schonberg MA, Fisher J, et al. Emergency department experiences of acutely symptomatic patients with terminal illness and their family caregivers. J Pain Symptom Manage 2010;39: 972–81. 13. Lamba S, Quest TE, Weissman DE. Palliative care consultation in the emergency department #298. J Palliat Med 2016;19:108–9. 14. Lamba S, Quest TE. Hospice care and the emergency department: rules, regulations, and referrals. Ann Emerg Med 2011;57:282–90. 15. Approaching death: improving care at the end of life—a report of the Institute of Medicine. Health Serv Res 1998;33:1–3. 16. Portenoy RK, Lupu DE, Arnold RM, Cordes A, Storey P. Formal ABMS and ACGME recognition of hospice and palliative medicine expected in 2006. J Palliat Med 2006;9:21–3. 17. von Gunten CF, Lupu D. Development of a medical subspecialty in palliative medicine: progress report. J Palliat Med 2004;7:209–19. 18. American Board of Medical Specialties. Board certification and maintenance of certification. Available at: http://www.abms.org/ board-certification/. Accessed August 1, 2015. 19. American Academy of Hospice and Palliative Medicine. Expanding the hospice and palliative care workforce. Available at: http:// aahpm.org/issues/workforce. Accessed August 1, 2015. 20. American Board of Internal Medicine. Hospice and palliative medicine certification exam blueprint. Available at: https://www.abim. org/pdf/blueprint/HPM-CERT-Blueprint.pdf. Accessed August 1, 2015. 21. Accreditation Council for Graduate Medical Education (ACGME). Program requirements for graduate medical education in hospice and palliative medicine. Available at: http://www.acgme. org/acgmeweb/Portals/0/PDFs/FAQ/540_hospice_and_palliative_ medicine_FAQs_07012015.pdf. Accessed August 1, 2015. 22. The Hospice and Palliative Medicine Milestones Project. Available at: https://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/ HospiceandPalliativeMedicineMilestones.pdf. Accessed August 1, 2015.
Integrated Physician Workforce of Emergency Medicine and Hospice and Palliative Medicine 23. Hospice Medical Director Certification Board. Eligibility requirements. Available at: http://www.hmdcb.org/about-the-exam/default/ eligibility.html. Accessed August 1, 2015. 24. Maison D. Workforce shortage: a staggering need and a call to action. J Pain Symptom Manage 2010;40:912–3. 25. Lupu D, Force AA. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage 2010; 40:899–911.
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26. Lamba S, Pound A, Rella JG, Compton S. Emergency medicine resident education in palliative care: a needs assessment. J Palliat Med 2012;15:516–20. 27. Quest TE, Asplin BR, Cairns CB, Hwang U, Pines JM. Research priorities for palliative and end-of-life care in the emergency setting. Acad Emerg Med 2011;18:e70–6. 28. Emanuel LL, Ferris FD, Von Gunten CF. EPEC. Education for physicians on end-of-life care. Am J Hosp Palliat Care 2002;19:17.
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ARTICLE SUMMARY 1. Why is this topic important? Many emergency physicians have sought dual certification since Hospice and Palliative Medicine became a subspecialty training pathway for emergency medicine. Multiple challenges and opportunities now face these physicians as they enter the workforce. 2. What does this review attempt to show? This review highlights the challenges facing the dually trained physicians in emergency palliative care and proposes solutions to the issues related to varying phases of their careers. It also provides career guidance to residents interested in this subspecialty. 3. What are the key findings? The practice of Hospice and Palliative Medicine offers a unique set of skills and opportunities for early, mid-, and late-career emergency physicians. These integrated workforce physicians may face challenges when balancing their roles in both fields. 4. How is patient care impacted? Palliative and end-of-life care improves quality of life and patient/family satisfaction. There is an acute and growing shortage of palliative care physicians. Increasingly, patients with palliative care needs are seeking care in our emergency departments. The skill set of currently practicing emergency physicians may not be sufficient to meet these needs. Emergency physicians certified in Hospice and Palliative Medicine are an evolving resource that will impact standards of care for the future practice of emergency palliative care.
http://dx.doi.org/10.1016/j.jemermed.2016.06.056
Clinical Review OPPORTUNITIES AND CHALLENGES FACING THE INTEGRATED PHYSICIAN WORKFORCE OF EMERGENCY MEDICINE AND HOSPICE AND PALLIATIVE MEDICINE Sangeeta Lamba, MD,* Paul L. DeSandre, DO,†‡ and Tammie E. Quest, MD†‡ *Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, †Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, and ‡Emory Palliative Care Center, Emory University School of Medicine, Atlanta, Georgia Reprint Address: Sangeeta Lamba, MD, Department of Emergency Medicine, Rutgers New Jersey Medical School, 185 South Orange Ave., Newark, NJ 07103
, Keywords—hospice and palliative medicine; integrated workforce; emergency medicine; career pathway; challenges
, Abstract—Background: The American Board of Emergency Medicine joined nine other American Board of Medical Specialties member boards to sponsor the subspecialty of Hospice and Palliative Medicine; the first subspecialty examination was administered in 2008. Since then an increasing number of emergency physicians has sought this certification and entered the workforce. There has been limited discussion regarding the experiences and challenges facing this new workforce. Discussion: We use excerpts from conversations with emergency physicians to highlight the challenges in hospice and palliative medicine training and practice that are commonly being identified by these physicians, at varying phases of their careers. The lessons learned from this initial dual-certified physician cohort in real practice fills a current literature gap. Practical guidance is offered for the increasing number of trainees and mid-career emergency physicians who may have an interest in the subspecialty pathway but are seeking answers to what a future integrated practice will look like in order to make informed career decisions. Conclusion: The Emergency and Hospice and Palliative Medicine integrated workforce is facing novel challenges, opportunities, and growth. The first few years have seen a growing interest in the field among emergency medicine resident trainees. As the dual certified workforce matures, it is expected to impact the clinical practice, research, and education related to emergency palliative care. Ó 2016 Elsevier Inc. All rights reserved.
INTRODUCTION Hospice and palliative medicine (HPM) is a subspecialty pathway for emergency physicians (EP) (1–3). Since the first HPM certification examination was held in 2008, an increasing number of EPs have achieved board certification in the subspecialty (1,4). Over the last decade, emergency medicine (EM) has also taken a prominent role in integrating HPM-related practice principles into routine care of patients eligible for such services in the emergency department (ED) (2,5–9). The ‘‘Choosing Wisely’’ campaign (American College of Emergency Physicians [ACEP]) has highlighted the integrated disciplines, stating, ‘‘Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit’’ (2,6,10). This is in the context of the national spotlight on palliative care by several reports/initiatives, such as the Integrating Palliative Medicine into Emergency Medicine (IPAL-EM) project (an initiative of the Center
RECEIVED: 30 January 2016; FINAL SUBMISSION RECEIVED: 28 May 2016; ACCEPTED: 29 June 2016 1
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to Advance Palliative Care) and The Institute of Medicine (IOM) report, ‘‘Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.’’ This IOM report focuses on the current disconnect between how most Americans wish to be cared for at the end of their lives and what care is actually provided to them (11,12). The growing interest in EM for the subspecialty training pathway for HPM is evidenced by an engaged and active Palliative Medicine section in ACEP as well as the novel Special Interest Group/ Forum formed by emergency physicians within the American Academy of Hospice and Palliative Medicine (AAHPM) (9). Since the introduction of the pathway to HPM by the American Board of Emergency Medicine (ABEM), there has been no discussion in literature to explore the challenges and opportunities that are facing the now dual-certified EM-HPM physicians (5,6,13). This information is especially important to effectively mentor and guide the EM trainees with an interest in the subspecialty as a future career. In this article we use excerpts from conversations with EP’s; those interested in pursuing HPM certification/practice and those currently holding dual certifications in both disciplines. These excerpts illustrate the commonly voiced concerns of emergency physicians regarding training and practicing HPM and the unique challenges that EMHPM physicians are facing at varying phases of their careers. We discuss the current status of the integrated field of EM and HPM, provide guidance to the process of certification, and propose solutions to some of the identified challenges. DISCUSSION Emergency medicine and palliative care experts (authors SL, PLD, TEQ) are frequently approached by emergency physicians with multiple queries regarding the HPM subspecialty, and therefore we use four excerpts from these conversations to illustrate the common questions that are being voiced. Emergency Physician 1: Interest in Hospice and Palliative Medicine as a Subspecialty I am a third-year EM resident and have recently become quite interested in HPM as a career choice. How do I proceed to explore fellowship training? What does it involve? I do not have subspecialty faculty at my program to mentor me. I have recently heard that it may be difficult for me to get a position in a fellowship since most programs are based in internal medicine and they prefer candidates with an internal medicine background. I also have significant loan debt, so how will my decision to pursue a fellowship in HPM impact my financial status?
Emergency Physician 2: Dual Board-Certified in EM and Hospice and Palliative Medicine—Now What? I am an EM board certified physician finishing a fellowship in HPM. Soon I will be board certified in two disciplines; now what? I would like to practice in both settings of HPM and EM. How do I straddle these two disciplines successfully?
Emergency Physician 3: Seeking Leadership Roles in Hospice and Palliative Medicine I have been a dual board-certified physician in HPM and EM since ‘‘grandfathering’’ and successfully completing the requirements of the examination. I have a successful balanced practice in both disciplines and split my time equally between an EM and HPM practice. I would now like to advance my academic career in HPM at a national level. Whom can I contact for advice? How do I go about accomplishing this?
Emergency Physician 4: Practicing or Mid-Career Emergency Physician with an Interest in Exploring a Transition to Hospice and Palliative Medicine Practice I have been practicing EM for over 5 years and find myself increasingly interested in palliative and end-of-life care. I cannot afford to leave my EM practice due to do financial and family constraints. What are my options?
Historical Perspective The term ‘‘hospice’’ or a place of shelter for weary travelers was applied to specialized care for the dying when Dr. Cicely Saunders first established modern hospice care in England in the late 1950s (14). The first hospice in the United States was established in Connecticut in 1974. The Institute of Medicine report in 1997, ‘‘Approaching Death: Improving Care At the End of Life’’ first highlighted major gaps and deficiencies in end-oflife care (15). This resulted in a major effort to bring palliative care into mainstream medicine with support from foundations such as the Robert Wood Johnson Foundation. The early 1990s saw the American Board of Hospice and Palliative Medicine (ABHPM) begin to offer their certifying examinations. Recognition for the subspecialty of HPM within the American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education (ACGME) followed in 2006 (1,4,16,17). ACGME Certification in Hospice and Palliative Medicine The ABMS organization formally recognizes specialties and subspecialties and confers specialty and subspecialty
Integrated Physician Workforce of Emergency Medicine and Hospice and Palliative Medicine
status (17–19). There are four steps to certification in HPM: 1) Complete the fellowship training that will meet the eligibility criteria (described below). 2) Apply for certification in HPM within the established application period through the home board – ABEM diplomates apply through ABEM. 3) Receive confirmation that the eligibility criteria have been met after ABEM review and independent verification of credentials. 4) Take and pass the certification examination in HPM. This examination is administered biennially, in even-numbered years, to candidates from multiple specialties at the same time in the same testing centers (1,4). Reflecting the roots of palliative medicine in many specialties, the certification examination for HPM is offered by 10 specialty boards, including Emergency Medicine (1,20). The certification examination is designed to evaluate the knowledge, diagnostic reasoning, and clinical judgment skills expected of the certified physician practicing in the broad domain of HPM (20). The broad content categories tested are shown in Table 1 (20). The overall pass rate is approximately 83% for this HPM examination. The first three examinations (2008, 2010, 2012) offered the option to applicants to list prior experience and thus qualify to ‘‘grandfather’’ for the certification (4). In 2006, the ACGME began the process of accreditation for HPM fellowship programs such that starting in 2013, only those applicants completing an ACGMEaccredited fellowship program are eligible to take the certification examination (4). Based on information obtained from ABEM, as of December 2015 there were 114 HPM diplomates certified by ABEM, of whom 36 are fellowship trained. The number of physicians dual-certified in both HPM and EM is likely higher because ABEM does not take into account those physicians who used a board other than ABEM for the pathway to certification. For example, a physician certified in both Internal Table 1. Hospice and Palliative Medicine Certification Examination Content (20) Medical Content Category Approach to Care Psychosocial and Spiritual Considerations Impending Death Grief and Bereavement Medical Management Communication and Team Work Ethical and Legal Decision Making Prognostication and Natural History of Serious Illness Total
% of Examination 9% 11% 9% 5% 45% 6% 7% 8% 100%
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Medicine and EM may have elected to certify in HPM via the American Board of Internal Medicine and not ABEM. ABEM currently ranks 6th out of 10 specialties in the numbers of HPM graduates. ACGME Hospice and Palliative Medicine Fellowship Training Successful completion of a 12-month accredited HPM fellowship program is now the only pathway to ABMS Certification. Fellowship training must occur over a 12month period with the elements outlined by the Core Curriculum in HPM (21). Fellowship training must occur in a minimum of three settings: inpatient hospital, long-term care, and ambulatory care. Fellows must complete the minimum following training sequence regardless of their primary specialty: a minimum of 4 months of inpatient palliative care consultation in addition to 2.5 months of hospice (both inpatient and home), 1 month of long-term care, and a minimum of 6 months of weekly ambulatory clinics. Fellows must complete a minimum of 25 home hospice visits and 100 new inpatient consultations, and a minimum of 10 patients must be followed longitudinally across settings (inpatient, home, and ambulatory clinics) (21). The Review Committee only accredits 12 months of training, and all requirements must be completed in these 12 months and must be completed consecutively (21). Fellowship is considered to be a full-time undertaking; splitting training over 2 years must be approved by the relevant board. Fellows must have training that exposes them to both adults and children, and they must be trained by an interdisciplinary team (e.g., nurse, chaplains, and social worker). The major competencies of subspecialist-level HPM are listed in Table 2 (22). Hospice Medical Director and the Hospice Medical Directors Certifying Board HPM training for emergency physicians that do not train directly after residency presents a significant challenge to increasing the number of emergency physicians. Barriers common to practicing emergency physicians returning to fellowship training mid-career include: 1) limited numbers of programs in the nation, which increases the likelihood that relocation will be necessary for 1 year. In addition, beginning in 2015, all but five of the accredited HPM training programs have elected to participate in the National Residency Match Program, contributing to further uncertainty; 2) Continued financial obligations during the training year (student loans, family and personal living costs); 3) limited ability to ‘‘moonlight,’’ as working in the ED must be included in the 80-h work week prescribed by the ACGME (21,22). Efforts are underway by the AAHPM that seek to
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Table 2. Major Competencies for Hospice and Palliative Medicine Fellowship Relieving suffering and improving the quality of life for patients and families with life-threatening illness Helping patient and family cope well with loss and engage in effective grieving Comprehensive interdisciplinary team management of the physical, psychosocial, social and spiritual needs of patients and their families Managing and coordination of the array of challenging problems associated with end-of-life care, including the management of the immediately dying patient Promoting closure and the possibility of growth at the end of life
explore mid-career pathways for board certification that would be compliant with requirements. The timetable, structure, and ultimate possibility of this remain unclear. Until new pathways become available, one option that remains for practice is that of a hospice medical director. Of the 2.4 million people that die each year, approximately 50% receive hospice care. There are over 4000 hospice agencies in America (14). All are required to have at least one physician medical director. It is not uncommon for community hospices to solicit the services of local physicians interested in serving in a part-time or full-time capacity in the role of hospice medical director. The hospice medical director is responsible for the quality oversight and clinical care of patients receiving hospice care. At the inception of the Medicare Hospice Benefit, the physician medical director was a volunteer role. However, Center for Medicare and Medicaid Services regulations have evolved. The hospice medical directors now play an essential role in the delivery of hospice services, including the certification of terminal illness, serving as the primary physician for patients when their own physician is unwilling or unable to serve in that role, and ensuring quality oversight for hospice care. The physician is a required and integral part of the interdisciplinary care team and provides direct patient care as well as oversight (14). Direct clinical care includes caring for patients in hospice inpatient units as well home visits. The role of hospice medical director is one that presents a unique opportunity for qualified emergency physicians. Because the work is often part time, some hospice medical directors are emergency physicians that serve full time as a hospice medical director with a part-time emergency medicine practice. Medical director services may be contracted with the hospice as an employee that works for the hospice agency or as a contractor where the emergency physician is paid hourly or on stipend for service. Typically, hospice medical directors take calls for the hospice nights, evenings, and weekends. Overall, for some emergency physicians, this may represent a gratifying clinical practice filled with new skills and opportunities for caring for patients and families at the end of life. The skills and training of hospice medical directors are varied. The large majority are not ABMS board certified in HPM. In 2014, the Hospice Medical Directors Certifying Board (HMDCB), a nonprofit organization, created
a certifying examination for hospice medical directors that focuses on the knowledge, skills, and regulatory/ compliance aspects of hospice practices (23). In 2014, over 368 physicians sat for this examination, with a 90% pass rate. In addition to a current, unrestricted license to practice medicine in the United States or Canada, the prerequisites for sitting for the HMDCB examination includes an ability to demonstrate a minimum of 400 h of broad hospicerelated activities during the previous 5 years (e.g., engagement in patient care, certification process, medication management, participating in performance improvement, and administrative activities in the hospice setting). In addition, candidates must meet at least one of the three following eligibility requirements: Practice Pathway: 2 years of work experience in a hospice setting in the previous 5 years Certification Pathway: Current, valid board certification in Hospice and Palliative medicine through ABHPM, ABMS, or the American Osteopathic Association (AOA), or Training Pathway: Successful completion of a 12month clinical HPM training program accredited by the ACGME or AOA (23). Status of the Field of Emergency Medicine – Hospice and Palliative Medicine The AAHPM appointed a Workforce Task Force in 2008 to assess the status of the palliative workforce, to determine whether a physician shortage existed in the field, and to develop an estimate of the optimal number of HPM-trained physicians needed (19,24,25). They describe an acute shortage of such physicians currently and for the foreseeable future. There is approximately one HPM physician for approximately every 1300 patients with serious advanced illness, in comparison to one cardiologist for about 71 patients with a myocardial infarction (25). Despite a modest recent increase in fellowship spots (see Table 3), there are many states with no training programs in HPM. This has spurred a call by AAHPM to explore solutions to the gaps in access to palliative care (19). Some of the proposals being considered include: 1) Promote generalist level competencies for non-HPM specialties such as EM, 2) Revise
Integrated Physician Workforce of Emergency Medicine and Hospice and Palliative Medicine Table 3. Hospice and Palliative Medicine Fellowship Training Programs
Core Program ACGME Internal Medicine Family Medicine Pediatrics Radiology/Oncology Anesthesia Psychiatry Total ACGME-approved fellowship slots ACGME-approved temporary fellowship slots Total slots Filled slots* AOA AOA Programs† AOA-approved slots† Funded slots† Filled slots†
New Programs for 2013-2014 2014–2015 2014–2015 65 22 4 2 2 1 96 285
3 1 1 0 0 0 5
68 23 5 2 2 1 101 296
4
5
289 216
301
10 24 17 5
0
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ACGME = Accreditation Council for Graduate Medical Education; AOA = American Osteopathic Association. * ACGME Web site notes that total filled will reflect the previous academic year. It does not note when annual update is completed. † Data obtained from the AOA Web site; core programs are not identified.
ACGME program requirements to accommodate those needing a longer training period at less than full time to complete the fellowship, and 3) Develop a mid-career pathway for HPM as a way for established physicians to become board certified without having to do a full fellowship. These conversations not only highlight the need to expand the number of physicians, but also suggest that HPM may provide opportunities based on the predicted need in the coming decades. These recent years of subspecialty HPM certification have created new opportunities for practice and job growth for EPs (1,25). However, this has also presented new and unique challenges as the first dually trained EM-HPM physicians enter the integrated workforce and navigate uncharted territory. We discuss the challenges faced by the dual-certified physicians at varying phases of their career and also propose solutions to their commonly voiced questions and concerns. PHYSICIAN 1: EM RESIDENT INTEREST IN HOSPICE AND PALLIATIVE MEDICINE AS A SUBSPECIALTY There is an increasing level of interest in HPM among EM residents (26). However, multiple challenges exist for EM residents trying to decide whether to pursue this subspecialty, particularly a lack of mentors and a lack of
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guidance (9). There exists a lack of dual-certified EMHPM faculty in the majority of EM residency programs nationally. This presents significant challenges for program directors and faculty when mentoring and advising trainees interested in fellowship training in HPM (9,26). Because the field is new and evolving, the practice expectations and salaries are difficult to understand and vary by institutional and regional needs, making the decision process even more difficult for EM residents. EM residents may also find that they are challenged when they apply to fellowship programs because the vast majority of fellowships are offered by the primary care fields of internal medicine and family medicine, where a possible bias toward these primary disciplines may exist in the candidate-selection process. There is added concern about this primary care specialty bias related to the recent July 2015 ACGME decision to limit sponsorship of fellowships in HPM to six specialty ‘‘core’’ residency programs. This decision excludes EM as a ‘‘core’’ program and states that, ‘‘A Hospice and Palliative Medicine program must demonstrate that it exists in conjunction with, and is an integral part of, a core ACGME-accredited residency program in anesthesiology, family medicine, internal medicine, psychiatry, pediatrics, or radiation oncology. There are no exceptions to this requirement’’ (21). Suggested Solutions As with any career decision, an EM resident interested in HPM should undergo a process that involves thoughtful active career decision-making. Weighing the balances and risks before one starts is important. Advanced training in HPM may offer an added employment value, particularly for an academic position. Also, the personal value of participating in an alternate discipline for which one is passionate, work-life balance, and long-term career satisfaction all are important considerations. Early recognition of the need for mentors outside of the local EM residency program should allow for ample time to seek and connect with appropriate dual-certified EM-HPM faculty outside of the institution. There is an active conversation to develop a document from AAHPM outlining the process and providing a template for obtaining the sponsoring board and the ACGME’s permission for an exception to allow a single individual to complete a fellowship half time over 2 years. This would allow for EM trainees to use clinical practice to supplement income and may overcome some of the financial barriers to fellowship training. There is a valid concern that EM residents may often face a bias against them when applying for fellowships mainly offered by primary care disciplines. An increasing number of programs, however, now offer positions without consideration of primary specialty and are clearly
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open to EM-trained residents. EM residents applying to the field may therefore need to ask directed questions and pay close attention to a program’s selection patterns and identify some of the national programs with a prior history of acceptance of fellows from a variety of disciplines. Because HPM is focused on the care of serious advanced illness, management of chronic disease and primary care is likely to be a key component of the fellowship as well as life-long HPM practice. In addition to aggressive symptom management, HPM-certified physicians often must attend to the day-to-day chronic illness more typically managed in primary care, such as diabetes and blood pressure control or adjusting warfarin doses. Unlike HPM physicians from primary care pathways, EM-HPM dual-certified physicians may feel less prepared to manage such patients. An honest self-appraisal of interest in chronic disease management and the willingness to learn new knowledge and skills such as management and prevention of decubitus ulcers or care of chronic wounds may allow an EM resident to seek and fill knowledge gaps in primary and preventive care as they proceed through residency training and subsequently while in fellowship. Ultimately, this may help develop a level of confidence and comfort to join complex subspecialty HPM practice. PHYSICIAN 2: BOARD CERTIFIED IN EM AND IN HOSPICE AND PALLIATIVE MEDICINE; NOW WHAT? OPPORTUNITIES AND CHALLENGES FOR DUALLY CERTIFIED PHYSICIANS HPM practice varies with different settings and may include a community program, hospital-based programs, home-based palliative care (nonhospice), or an ED-based practice. Each setting and type of practice, in turn, has its own set of opportunities and challenges (Table 4). Most EM residency-trained physicians express a keen desire to give back to EM in a meaningful way, and thus want to practice both EM and HPM. This often creates timesharing and funding concerns when seeking jobs that include both EM and HPM roles and responsibilities. Negotiations for hiring will therefore involve two departments that may not necessarily understand each other’s mission, goals, and practice needs. Financial considerations may also play a big role in determining clinical practice ratios. The poor reimbursement rate for HPMrelated activities, particularly for the consultations with patients and their families, which HPM physicians regard as essential to patient-centered care, means that HPM is often reimbursed at a far lower rate than high-tech procedures/services. This pay differential between the two fields currently favors EM clinical practice over HPM, especially for young physicians just finishing training.
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Suggested Solutions As dual EM-HPM-certified physicians plan careers, there should be a personal appraisal of the desired EM-to-HPM balance; how much time to focus on HPM vs. EM. Also necessary is the understanding of how much of a financial impact is one willing to consider, and this may vary by personal responsibilities, stage of career, and financial pressures. Below we discuss three main phases of the EM-HPM physician academic careers, with specific concerns for each phase. 1. New EM graduate 0–10 years post residency Increased financial pressures may necessitate more EM practice initially; accept more limited HPM job and focus while building an HPM skillset and networking to create better defined roles for the future If leadership in HPM is desired, consider an early shift to a palliative care-based focus—this would be an early planned decision to work less EM similar to a research career (for example, a maximum of 25% for clinical EM practice) Choosing and working on better integration in education and research-focused areas of emergency palliative care 2. Mid-career 10–20 years post EM residency Transitioning down from EM with an increasing focus on HPM Solid joint EM-HPM skill set Expanded EM-HPM research and education focus Expanded HPM leadership opportunities at a regional and possibly national level 3. Late career > 20 years post EM residency Decision to transition fully to HPM practice that may be less physically hectic than an EM practice clinical schedule Staying active in the field of EM while practicing HPM. This may be accomplished by working actively to educate and implement HPM practice and protocols in generalist-level palliative care to EM providers Leadership in education, research, and practice of EM-HPM at a national level PHYSICIAN 3: SEEKING LEADERSHIP ROLES IN HOSPICE AND PALLIATIVE MEDICINE As the HPM subspecialty grows, there are ample opportunities for leadership available in both EM as an HPM expert and in HPM as an EM expert. It is important to become engaged at an institutional, regional, and national level. Beginning with leadership roles on institutional
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Table 4. Types of Practice in Hospice and Palliative Medicine: Related Challenges and Opportunities for Emergency Physicians with Dual Certification Type of Practice
Opportunity
Challenges
1. Hospital-based Palliative Care Inpatient Service/Palliative Care unit
High demand Good fit for EM – crisis-oriented care Ability to do dedicated weeks to share EM and palliative care schedule
2. Hospice (Home and Inpatient) Medical Director
Many hospices and positions Suited for emergency physicians where clinical judgment and rapid decisionmaking are key skills Core Interdisciplinary team concept that is compatible with the EM model of team Easy to job share and balance with EM schedules Increasing need Developing models of care Flexibility in schedules
3. Home-based palliative care
4. Outpatient palliative care clinics
Increasing need Developing models
5. EM-based palliative care services
Emerging Model Limited programs Meets hospital strategic planning for improved care, decreased readmission, and care that is goal aligned with patient
Lower EM salaries Difficulty getting ‘‘buy down time’’ from EM to work inpatient that balances the schedule Inpatient Credentialing Issues –Emergency physicians typically are not credentialed in hospital to admit or consult EM shift release does not balance palliative care time on service Limited leadership opportunities in palliative care if not wholly committed to palliative care Large salary differential – hourly and stipends are lower than EM salaries Home/On-call responsibilities can be heavy Often part-time positions make it difficult to have a significant practice or establish leadership with the hospice agency Skill set needed for longitudinal management of complex chronic conditions (diabetes, hypertension, wound care, and Coumadin dose adjustments) Hesitancy or an inability to be used in cross coverage situation with internal medicineor family medicine-trained clinicians Competencies in preventive medicine and chronic disease management needed Emergency clinicians have limited clinic/ outpatient training Possibly limited skill set for primary care issues that arise (example sugar and blood pressure control) Funding/reimbursement (between EM and PC); Needs to be cost shared Defining the role and efficiency Schedules, often a lone person for coverage Risk of a pigeonholed practice in palliative care
EM = emergency medicine; PC = palliative care.
committees such as the Bioethics or Pain and Palliative Care committees, engaging in regional- or state-level issues such as creating and delivering continuing medical education sessions in HPM if required for state licensure and networking to lead such sessions in regional meetings can be a reasonable start. Active participation in national organizations such as the Palliative Medicine section of ACEP and the various AAHPM committees/Forums/Special Interest Groups are opportunities to grow in networking and leadership roles. In clinical practice, the role of the hospice medical director or the director of palliative care services and in academic medicine the opportunities for leadership in fellowship training programs are other areas of potential growth (7). Emergency
palliative care is also a niche area for research that has significant potential to build research leaders in the field (27). PHYSICIAN 4: PRACTICING OR MID-CAREER EMERGENCY PHYSICIAN Physicians in current EM practice must consider financial, geographical, and long-term goals because both fellowship training and HPM clinical practice create financial challenges to the EP in active clinical practice. Although not insurmountable, a decision to shift an established financial balance requires significant planning, patience, and flexibility, both personally and
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professionally. If, in the short-term, the practicing EP cannot feasibly accommodate the financial or geographical challenges of fellowship training in HPM, other opportunities remain to engage in HPM. These include becoming a Hospice Medical Director or developing sufficient knowledge and skills to become an EM-HPM physician leader. As described earlier in this article, even the full-time practicing EP may find it possible to develop the skills to integrate a Hospice Medical Director practice into their clinical work. Doing so can be used to establish qualification for HMDCB certification. These skills can easily translate into EM practice and create opportunities to improve the operational and clinical expertise of staff and colleagues as it relates to hospice concerns in the ED. EPs interested in developing HPM skills more broadly have many available resources. Nationally, the Education in Palliative and End-of-Life Care-Emergency Medicine program provides an intensive ‘‘train the trainer’’ approach to help foster improved understanding and practice of one’s clinical staff to better recognize and respond to patients with palliative care needs in the ED (28). The resources and structures to apply such improvements can also be obtained through the Improving IPAL-EM project of the Center to Advance Palliative Care. Developing skills and utilizing available resources to evolve one’s current clinical practice environment can significantly improve the care of ED patients with palliative needs. In addition, by promoting the palliative care concerns of ED patients within local, regional, and national organizations, one can collaborate in establishing best practices within EM as it relates to HPM, even in the absence of formal training. CONCLUSION The integrated workforce of EM and subspecialty Hospice and Palliative Medicine faces areas of new challenges, opportunities, and growth. The first few years of this subspecialty pathway have identified a growing interest in the field among EM resident trainees. As the dual certified integrated workforce matures, it is expected to impact the clinical practice, research, and education related to emergency palliative care.
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2. Quest TE, Marco CA, Derse AR. Hospice and palliative medicine: new subspecialty, new opportunities. Ann Emerg Med 2009;54: 94–102. 3. Lamba S, Mosenthal AC. Hospice and palliative medicine: a novel subspecialty of emergency medicine. J Emerg Med 2012;43:849–53. 4. American Board of Internal Medicine. Hospice and palliative medicine policies. Available at: http://www.abim.org/certification/ policies/imss/hospice.aspx. Accessed August 1, 2015. 5. Quest T, Herr S, Lamba S, Weissman D. IPAL-EM Advisory Board. Demonstrations of clinical initiatives to improve palliative care in the emergency department: a report from the IPAL-EM Initiative. Ann Emerg Med 2013;61:661–7. 6. Lamba S. Early goal-directed palliative therapy in the emergency department: a step to move palliative care upstream. J Palliat Med 2009;12:767. 7. Quest TE, Chan GK, Derse A, Stone S, Todd KH, Zalenski R. Palliative care in emergency medicine: past, present, and future. J Palliat Med 2012;15:1076–81. 8. Rosenberg M, Lamba S, Misra S. Palliative medicine and geriatric emergency care: challenges, opportunities, and basic principles. Clin Geriatr Med 2013;29:1–29. 9. Smith AK, Fisher J, Schonberg MA, et al. Am I doing the right thing? Provider perspectives on improving palliative care in the emergency department. Ann Emerg Med 2009;54:86– 93. 93.e1. 10. Choosing Wisely. American College of Emergency Physicians, 2013. Available at: http://www.choosingwisely.org/societies/ american-college-of-emergency-physicians/. Accessed August 1, 2015. 11. Institute of Medicine. Report Brief, September 2014: Dying in America: improving quality and honoring individual preferences near the end of life. Available at: http://iom.nationalacademies. org//media/Files/Report%20Files/2014/EOL/Report%20Brief.pdf. Accessed August 1, 2015. 12. Smith AK, Schonberg MA, Fisher J, et al. Emergency department experiences of acutely symptomatic patients with terminal illness and their family caregivers. J Pain Symptom Manage 2010;39: 972–81. 13. Lamba S, Quest TE, Weissman DE. Palliative care consultation in the emergency department #298. J Palliat Med 2016;19:108–9. 14. Lamba S, Quest TE. Hospice care and the emergency department: rules, regulations, and referrals. Ann Emerg Med 2011;57:282–90. 15. Approaching death: improving care at the end of life—a report of the Institute of Medicine. Health Serv Res 1998;33:1–3. 16. Portenoy RK, Lupu DE, Arnold RM, Cordes A, Storey P. Formal ABMS and ACGME recognition of hospice and palliative medicine expected in 2006. J Palliat Med 2006;9:21–3. 17. von Gunten CF, Lupu D. Development of a medical subspecialty in palliative medicine: progress report. J Palliat Med 2004;7:209–19. 18. American Board of Medical Specialties. Board certification and maintenance of certification. Available at: http://www.abms.org/ board-certification/. Accessed August 1, 2015. 19. American Academy of Hospice and Palliative Medicine. Expanding the hospice and palliative care workforce. Available at: http:// aahpm.org/issues/workforce. Accessed August 1, 2015. 20. American Board of Internal Medicine. Hospice and palliative medicine certification exam blueprint. Available at: https://www.abim. org/pdf/blueprint/HPM-CERT-Blueprint.pdf. Accessed August 1, 2015. 21. Accreditation Council for Graduate Medical Education (ACGME). Program requirements for graduate medical education in hospice and palliative medicine. Available at: http://www.acgme. org/acgmeweb/Portals/0/PDFs/FAQ/540_hospice_and_palliative_ medicine_FAQs_07012015.pdf. Accessed August 1, 2015. 22. The Hospice and Palliative Medicine Milestones Project. Available at: https://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/ HospiceandPalliativeMedicineMilestones.pdf. Accessed August 1, 2015.
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ARTICLE SUMMARY 1. Why is this topic important? Many emergency physicians have sought dual certification since Hospice and Palliative Medicine became a subspecialty training pathway for emergency medicine. Multiple challenges and opportunities now face these physicians as they enter the workforce. 2. What does this review attempt to show? This review highlights the challenges facing the dually trained physicians in emergency palliative care and proposes solutions to the issues related to varying phases of their careers. It also provides career guidance to residents interested in this subspecialty. 3. What are the key findings? The practice of Hospice and Palliative Medicine offers a unique set of skills and opportunities for early, mid-, and late-career emergency physicians. These integrated workforce physicians may face challenges when balancing their roles in both fields. 4. How is patient care impacted? Palliative and end-of-life care improves quality of life and patient/family satisfaction. There is an acute and growing shortage of palliative care physicians. Increasingly, patients with palliative care needs are seeking care in our emergency departments. The skill set of currently practicing emergency physicians may not be sufficient to meet these needs. Emergency physicians certified in Hospice and Palliative Medicine are an evolving resource that will impact standards of care for the future practice of emergency palliative care.