Novel Integration of a Health Equity Immersion Curriculum in Medical Training.

Health disparities education is an integral and required part of medical professional training, and yet existing curricula often fail to effectively denaturalize injustice or empower learners to advocate for change. We discuss a novel collaborative intervention that weds the health humanities to the field of health equity. We draw from the health humanities an intentional focus retraining provider imaginations by centering patient narratives; from the field of health equity, we draw the linkage between stigmatized social identities and health disparities. We describe a longitudinal health equity curriculum for the Hospice and Palliative Medicine fellowship in Memphis, Tennessee, to give trainees exposure to the concept of structural violence and how it affects clinical care. The curriculum was developed in partnership with humanities and social sciences faculty who staff a Health Equity academic program at a small liberal arts college in Memphis. This curriculum has been implemented for the past four years in support of 22 hospice and palliative medicine fellows. Group debriefs and a mixed methods survey have revealed widespread and lasting impact towards understanding health equity concepts, enhanced communication and treatment of patients, and empowerment to address the broader needs and policies affecting patients and the communities in which they live. Ultimately, we model an educational initiative that integrates equity across the full scope of healthcare practice and equips learners with skills for sustaining compassionate practices, focusing on equity-oriented, person-centered care across the full scope of healthcare practice.

Palliative Medicine Fellows' Discussions, Perceptions, and Training Regarding Medical Cannabis.

CONTEXT: Medical cannabis is increasingly considered for palliation of pain, nausea/vomiting, anorexia, and other symptoms. OBJECTIVES: We aimed to determine whether training in hospice and palliative medicine (HPM) adequately prepares fellows to counsel patients about medical cannabis. METHODS: A previously validated questionnaire was adapted for HPM fellows. Domains included fellows' practices recommending cannabis and their knowledge of its effectiveness and risks compared with standard treatments. U.S. HPM fellowships were sent surveys in 2022 and 2023. RESULTS: Forty six programs participated, 123 fellows responded (response rate of 42%) including 69% female; 55% White, and 28% Asian. Of respondents, 65% reported receiving formal training regarding medical cannabis; 57% reported discussing medical cannabis with over five patients; 23% recommended medical cannabis to more than five patients in the preceding year. Only 19%, however, felt sufficiently informed to issue cannabis-related recommendations. HPM fellows with prior training were not more likely to feel sufficiently informed to discuss cannabis (RR: 1.17; 95% CI: 0.82-1.66) or to recommend cannabis to patients (RR: 2.05, 95% CI: 0.89-4.71). Fellows rate cannabis as equally or more effective than conventional treatments for the following symptoms: anorexia/cachexia (63%), nausea/vomiting (43%), pain (25%), and neuropathic pain (21%). CONCLUSION: Most HPM fellows report formal training in the use of medical cannabis. Over half of trainees reported discussing medical cannabis with patients, but few considered themselves sufficiently informed to make cannabis-related clinical recommendations. These results suggest both a need for expanded high-quality evidence for medical cannabis in palliative care and for improved formal education for HPM fellows.

Hospice and Palliative Medicine Fellowship Training in Mental Health: A Survey of Program Directors.

CONTEXT: Psychological and psychiatric care is a core domain of palliative care. Despite a high burden of mental health comorbidity among individuals with serious illness, the Accreditation Council of Graduate Medical Education gives little guidance about training hospice and palliative medicine (HPM) fellows in this domain of care. Currently, there is a lack of empiric data on HPM physician fellowship training in mental health topics. OBJECTIVES: To characterize HPM physician fellowship training practices in the psychological and psychiatric aspects of palliative care. METHODS: A cross-sectional survey study querying HPM fellowship training directors nationally. RESULTS: A total of 95 programs participated (51% response rate). A total of 98% programs offered didactics on mental health topics. Topics universally deemed as important by program directors were commonly taught, but there was variability in both the perceived importance and the didactic coverage of several topics. Only 15% of programs offered core rotations in psychiatry. Most programs offered psychiatry electives, but such electives were only rarely utilized by fellows. Interdisciplinary team (IDT) rounds infrequently included doctoral mental health clinicians. CONCLUSIONS: Beyond a few commonly identified and taught key topics, there is variability in clinical and didactic exposure to mental health training among HPM fellowships. Standardizing key learning objectives and guiding educators in how to achieve these objectives could improve the preparedness of the physician workforce in HPM to meet the mental health needs of patients with serious illness.

Facilitators and Barriers to Recruiting Surgeons into Hospice and Palliative Medicine Training.

CONTEXT: Few individuals have fellowship training in both hospice and palliative medicine (HPM) and a surgical specialty including general surgery, general obstetrics and gynecology, or affiliated subspecialties. There is a paucity of data to explain why some surgeons choose to pursue HPM fellowship training. OBJECTIVE: Identify facilitators and barriers to palliative medicine fellowship training among physicians from a surgical specialty. METHODS: We conducted individual semistructured interviews with 17 surgeons who were also fellowship-trained in HPM. Interviews were recorded, transcribed, and thematic analysis was conducted to identify themes. RESULTS: Participants reported pivotal experiences-either positive exposure to palliative care or suboptimal surgical care experiences-as a key motivator for pursuing specialty palliative care training. Additionally, participants chose HPM training because they felt that practicing from a HPM perspective aligned with their personal care philosophy, and in some cases, offered professional opportunities to help achieve career goals. Participants reported encountering bias from both HPM and surgical faculty, and also found that some HPM fellowship programs did not accept surgical trainees. Surgeons also reported logistical concerns related to coordinating a one-year fellowship as a barrier to formal HPM training. CONCLUSIONS: Understanding the motivations of surgeons who pursue HPM training and identifying challenges to completing fellowship may inform solutions to expand surgeon representation in palliative care. Both HPM and surgical faculty should be educated on the benefits of specialty HPM training for surgical trainees and practicing surgeons. Further research should explore HPM fellowship best practices for welcoming and training surgeons and other underrepresented specialties.

A Call for the Creation of LGBTQ+ Competencies for Hospice and Palliative Medicine (HPM) Fellowship Programs.

CONTEXT: LGBTQ+ people and their families have unique needs, concerns, and issues when navigating serious illness. OBJECTIVES: To develop curricular milestones and an educational framework for hospice and palliative medicine (HPM) fellowship programs to meet the needs of this community. METHODS: A working group has developed a plan for the inclusion of LGBTQ+ competencies in HPM fellowship programs, utilizing input from an AAHPM Special Interest Group (SIG) at a national meeting. DISCUSSION: Learning to provide culturally competent care is essential for all HPM providers. Our group recommends specific clinical training competencies with plans to pilot them in upcoming academic years. Creating curricular recommendations will help guide fellowship programs education in the care of LGBTQ+ patients with serious illness.

An Educational Needs Assessment for Outpatient Palliative Care Clinicians.

Introduction: As the field of palliative medicine continues to grow in community-based settings, outpatient palliative care clinics have become an important site for providing upstream palliative care to patients and families. It is unclear whether current training models, focused predominantly on the inpatient setting, adequately prepare clinicians for outpatient palliative care practice. Methods: We performed an online educational needs assessment survey of physicians and advanced practice providers working in outpatient palliative care clinics. Survey questions focused on the importance of specific palliative care knowledge, skills, and attitudes in outpatient practice using the Accreditation Council of Graduate Medical Education Hospice and Palliative Medicine (HPM) curricular milestones to guide survey development. We also explored clinician perception of training adequacy and current educational needs relevant to outpatient practice. Results: One hundred sixty-four clinicians, including 122 (74.4%) physicians, 32 (19.5%) nurse practitioners, and 8 (4.9%) physician assistants, completed our survey. Clinicians had a median of 10 years of HPM experience and 6 years of outpatient experience. We identified two main areas of perceived knowledge or skill deficit: navigating insurance and prior authorizations and co-management of pain and opioid use disorder. Conclusion: Addressing gaps in education and preparedness for outpatient practice is essential to improve clinician competence and efficiency as well as patient care, safety, and care coordination. This study identifies practice management and opioid stewardship as potential targets for educational interventions. The development of curricula related to these outpatient skills may improve clinicians' ability to provide safe, patient-centered care with confidence.

Value of Hospice and Palliative Medicine Fellowship After Surgical Training: Bridging the Gap for Improved Patient Care.

Objective: Surgeons comprise 2% of HPM-trained physicians. Little is known about the perceived value of HPM training to the surgeon or medical community. We aim to demonstrate the value of HPM fellowship training to surgeons and surgical practice from the point of view of HPM fellowship trained surgeons. Design: A qualitative analysis was performed using semi-structured zoom interviews that elicited the lived experiences of HPM trained surgeons. Data was analyzed using descriptive statistics and thematic analysis. Setting: Researchers were from the University of Kansas School of Medicine and the University of Alabama at Birmingham. Participants were trained and worked across the United States in a variety of settings. Participants: Eligibility included training in general surgery, obstetrics and gynecology, or affiliated subspecialties and completion of a 1-year HPM fellowship. Results: 17 interviews were performed. Several themes emerged regarding the transformative value of HPM training to their medical and surgical practice: (1) Learning to apply shared decision making and goal-concordant care to surgical decision making, and (2) Decreasing personal bias in medical decision making, and (3) Enabling wellness in surgeons. Two themes emerged regarding the perceived value to both the surgical community and the HPM community: (1) Value of the HPM Fellowship Trained Surgeon to the Surgical Community, and (2) Value of the HPM Fellowship Trained Surgeon to the HPM Community. All study participants valued their HPM training and felt highly valued by the healthcare team. Conclusion: HPM trained surgeons are highly valued on the healthcare team and improve patient-centered surgical care.

Hospice and Palliative Medicine Fellowship after Surgical Training: A Roadmap to the Future of Surgical Palliative Care.

OBJECTIVE: Surgeons comprise only 2% of Hospice and Palliative Medicine (HPM) board-certified physicians. Little is known about the motivations of individuals who pursue this combined training or the perceived benefits of this pathway. This study aimed to capture the pathways and experiences of HPM fellowship trained surgeons and to establish recommendations for surgical trainees who may benefit from HPM fellowship training. DESIGN: A qualitative study was designed using semi-structured zoom interviews that elicited experiences of HPM trained surgeons. Data was analyzed using descriptive statistics and thematic analysis. SETTING: Researchers were from the University of Kansas School of Medicine and the University of Alabama at Birmingham. Participants were trained and worked across the United States in a variety of settings. PARTICIPANTS: Eligibility included completion of a 1-year HPM fellowship and training in general surgery, general obstetrics and gynecology, or affiliated subspecialties. RESULTS: Seventeen interviews were conducted. All participants expressed satisfaction with their HPM fellowship training. Four themes emerged as recommendations for surgeons to pursue HPM fellowship training: 1) a commitment to joining the HPM workforce, 2) becoming ambassadors for HPM and surgical culture change, 3) desire for advanced communication and symptom management skills at the specialist level, and 4) specialist level HPM skills may enhance surgical career. CONCLUSIONS: HPM fellowship training is achievable through multiple pathways for surgeons from a variety of training backgrounds.

Geriatrics and palliative medicine leadership is needed now more than ever: What are the training gaps?

BACKGROUND: Geriatrics and palliative medicine specialists are uniquely trained to provide expert coordinated care for older adults and seriously ill and complex patients. Health system leadership geared towards this patient population is critically important as society ages. Currently, there is no standardized approach to teaching core leadership skills. To assess the leadership training needs of geriatrics and palliative medicine fellowship graduates, we conducted a needs assessment to identify (1) early career leadership trajectories and challenges and (2) knowledge and skills deemed essential for effective leadership. METHODS: Individuals identified as leaders in geriatrics and/or palliative medicine completed an electronic survey and a semi-structured qualitative interview. These leaders were divided into two categories: Icahn School of Medicine at Mount Sinai (ISMMS) trained leaders or non-ISMMS trained leaders. The semi-structured interviews were recorded, transcribed, and reviewed using thematic analysis. RESULTS: Within 1 year of fellowship graduation, 50% of ISMMS trained leaders had leadership positions; within 6 years, 100% had a leadership role. Based on qualitative interviews, both ISMMS trained leaders and non-ISMMS trained leaders perceived leadership training gaps in two domains: (1) knowledge and (2) skills. Knowledge and skill gap themes included communication and management, mentorship and negotiation, program development, knowledge, and apprenticeship. CONCLUSION: Geriatrics and palliative medicine physicians obtained leadership roles quickly after fellowship. Both ISMMS trained leaders and non-ISMMS trained leaders often felt unprepared, learned "on the job," and sought out additional leadership training. Early leadership training is needed to prepare fellowship graduates for the pressing demands of accelerated leadership.

Study of Shadowing Experiences among Chaplains in the Coleman Palliative Medicine Fellowship.

While shadowing is a relatively common practice in the education of many health professionals, it is not widely used in chaplaincy education. Findings from our qualitative study of 12 chaplains who participated in the Coleman Palliative Medicine Training Program suggest it may offer benefits for practicing chaplains. In interviews with seven fellows who shadowed more experienced palliative care (PC) chaplains and the five mentors who were shadowed at their work settings, participants reported opportunities for mutual learning, self-reflection, and collegiality. Fellows observed how members of a PC team collaborate and contribute equally to the care of patients. Mentors found shadowing was a rare opportunity to share their chaplaincy practice with colleagues. It helped them to appreciate different aspects of their work settings and to distinguish between PC and generalist chaplaincy. We discuss the challenges participants experienced while shadowing and offer recommendations for incorporating the practice more widely into chaplaincy education.

Launching the Next Steps to Improve Hospice and Palliative Medicine Fellow Performance Assessment: A Look Back to the Initial Toolkit of Assessment Methods.

Education leaders in hospice and palliative medicine (HPM) have long acknowledged the challenge of fellow performance assessment and the need for HPM-specific fellow assessment tools. In 2010, and in alignment with the Accreditation Council for Graduate Medical Education's (ACGME's) directive toward competency-based medical education, the national HPM Competencies Workgroup curated a set of assessment tools, the HPM Toolkit of Assessment Methods. The Toolkit has been a resource for HPM fellowship directors in evolving practical, multifaceted fellow assessment strategies. Now, as American Academy of Hospice and Palliative Medicine plans for a national workgroup in 2020 to define current HPM fellow assessment methods and to propose strategies to strengthen and standardize future assessment, the Toolkit provides a strong base from which to launch. However, the field learned important lessons from the 2010 Workgroup about the consensus process, gaps in areas of assessment, opportunities to address gaps with new or adapted tools, and limitations in implementing the Toolkit over time in terms of tracking, accessibility, and dissemination. This article describes the development of the Toolkit, including recommended tools and methods for assessment within each ACGME competency domain, and links the lessons learned to recommendations for the 2020 workgroup to consider in creating the next HPM assessment strategy and toolkit. Effective implementation will be crucial in supporting fellows to reach independent practice, which will further strengthen the field and workforce to provide the highest quality patient and family-centered care in serious illness. This will require an inspired, committed effort from the HPM community, which we enthusiastically anticipate.

Lack of Exposure to Palliative Care Training for Black Residents: A Study of Schools With Highest and Lowest Percentages of Black Enrollment.

CONTEXT: The palliative medicine workforce lacks racial diversity with <5% of specialty Hospice and Palliative Medicine (HPM) fellows identifying as black. Little is known about black trainees' exposure to palliative care during their medical education. OBJECTIVES: To describe palliative care training for black students during medical school, residency, and fellowship training. METHODS: We conducted a cross-sectional descriptive study using Internet searches and phone communication in September 2019. We evaluated 24 medical schools in three predetermined categories: historically black colleges and universities (HBCUs; N = 4) and non-under-represented minority-serving institutions with the highest (N = 10) and lowest (N = 10) percentages of black medical students. Training opportunities were determined based on the presence of a course, clerkship, or rotation in the medical school and residency curricula, a specialty HPM fellowship program, and specialty palliative care consult service at affiliated teaching hospitals. RESULTS: None of the four HBCUs with a medical school offered a palliative care course or clerkship, rotation during residency, or specialty HPM fellowship program. Three of four HBCUs were affiliated with a hospital that had a palliative care consult service. Institutions with the highest black enrollment were less likely to offer palliative care rotations during internal medicine (P = 0.046) or family medicine (P = 0.019) residency training than those with the lowest black enrollment. CONCLUSION: Residents at schools with the highest black medical student enrollment lack access to palliative care training opportunities. Efforts to reduce health disparities and underrepresentation in palliative care must begin with providing palliative-focused training to physicians from under-represented minority backgrounds.

Development of Subspecialty-Specific Reporting Milestones for Hospice and Palliative Medicine Fellowship Training in the U.S.

Continuing the transition to competency-based education, Hospice and Palliative Medicine (HPM) fellowship programs began using context-free reporting milestones (RMs) for internal medicine subspecialties in 2014 but quickly recognized that they did not reflect the nuanced practice of the field. This article describes the development of 20 subspecialty-specific RMs through consensus group process and vetting by HPM educators. A workgroup of content experts used an iterative consensus building process between December 2017 and February 2019 to draft new RMs and create a supplemental guide that outlines the intent of each RM, examples of each developmental trajectory, assessment methods, and resources to guide educators. Program directors, program coordinators, and designated institutional officers were contacted directly to solicit feedback. Most respondents agreed or strongly agreed that each RM represented a realistic progression of knowledge, skills, and behaviors, and that the set of milestones adequately discriminated between meaningful levels of competency. Similarly, respondents felt that the supplemental guide was a useful resource. The result is a set of carefully developed and broadly vetted RMs that represent a progression of development for HPM physicians during one year of clinical fellowship training.

Palliative Radiotherapy Education for Hospice and Palliative Medicine Fellows: A National Needs Assessment.

Background: Insufficient knowledge of palliative radiotherapy (PRT) among hospice and palliative medicine (HPM) physicians is thought to be a barrier to the provision of high-quality palliative care. Objective: To assess the need for PRT education in HPM fellowship. Design: A cross-sectional survey of HPM fellows was conducted in June 2018. Setting/Subjects: The survey was distributed to accredited HPM fellowship programs in the United States for distribution to enrolled fellows; 114 fellows responded to the survey. Results: Nearly all respondents agreed that the principles of PRT should be taught in HPM fellowship, yet 51% had received no PRT education and 35% had received only one or two hours. Only 25% of respondents rated their working knowledge of PRT as sufficient, 40% felt confident in identifying radiation oncology emergencies or managing radiotherapy side effects, and 52% felt confident in assessing which patients to refer for radiotherapy. More than 75% agreed that were they more knowledgeable about PRT, they would be more likely to consider referral to radiation oncology, to collaborate with radiation oncologists, and to advocate for a short course of treatment based on a patient's prognosis or goals or care. Fellows who received PRT education in fellowship had significantly greater knowledge of and more favorable attitudes toward the use of radiotherapy. This difference was the greatest among fellows who had received at least five hours of PRT education. Conclusion: There is a need for PRT education in HPM fellowship. Efforts to address this need may lead to more appropriate utilization of PRT for patients with advanced cancer.

Characterizing Palliative Radiotherapy Education in Hospice and Palliative Medicine Fellowship: A Survey of Fellowship Program Directors.

Background: Educational deficiencies among hospice and palliative medicine (HPM) physicians contribute to suboptimal utilization of palliative radiotherapy (PRT) for patients with advanced cancer. Objective: To survey HPM fellowship program directors regarding the need for PRT education in HPM fellowship. Design: We conducted a cross-sectional survey of HPM fellowship program directors in June 2018. We used a 5-point Likert-type scale to assess agreement with statements related to PRT education. Setting/Subjects: Program directors for all United States Accreditation Council for Graduate Medical Education-accredited HPM fellowship programs with at least one enrolled fellow at the time of survey distribution were included. Results: Eighty-one of 120 eligible program directors completed the survey (68% response rate). Nearly all of the respondents agreed that HPM physicians should possess a working knowledge of PRT and that the principles of PRT should be formally taught in HPM fellowship. Thirty percent of HPM fellowship programs, however, lacked a PRT curriculum and only 14% of programs provided more than two hours of PRT education. Limited didactic time, lack of interest among fellows, and lack of collaboration with radiation oncologists were not perceived to be significant barriers to incorporating PRT education into HPM fellowship. More than 75% of program directors indicated that they would consider implementing a PRT curriculum designed specifically for HPM physicians if one were available. Conclusion: There is a need for PRT education in HPM fellowship. This need may be best addressed by developing a widely accessible PRT curriculum designed to meet the needs of HPM physicians.

Shared leadership in interprofessional teams: beyond team characteristics to team conditions.

Shared leadership has been shown to enhance processes, effectiveness, and performances in interprofessional teams. While earlier studies suggest the association of internal team environment (ITE) and transactive memory system (TMS) with shared leadership, the relative influence of these team conditions vis-a-vis team characteristics (such as team size, stability, and interprofessional roles) on shared leadership is not well understood. This study aims to examine the comparative influence of team characteristics versus team conditions of ITE and TMS on shared leadership during interprofessional team meetings (IPTMs). We compared interprofessional teams from two departments, namely larger and more diverse teams of Geriatric Medicine versus the smaller and more homogeneous Palliative Medicine. We administered a questionnaire survey to healthcare professionals who attended IPTMs in both departments (N = 133). Our results revealed significantly higher scores in shared leadership, ITE and TMS in Palliative Medicine (p < .05). Using hierarchical regression analysis adjusting for team conditions, department and number of IPTMs attended were not significant in the final model (both p > .05). Instead, TMS (ß= 0.250, p < .01) and ITE (ß= 0.584, p < .01) outperformed team characteristics as conditions that are highly associated with shared leadership, explaining an additional 29.8% and 19.0%, respectively, of model variance. Further analysis revealed a stronger correlation between shared leadership subdomains with TMS in Geriatric Medicine and with ITE in Palliative Medicine. Our results demonstrate how a positive working environment with a high level of shared memory engendered a perception of shared leadership, and how these team conditions can be tapped upon to circumvent differences in team characteristics to facilitate shared leadership. Identifying key conditions that are highly associated with shared leadership is critical for the teaching of dynamic leadership roles to junior clinicians which in turn, can enhance patient care.

Integrating Ethics Education and Training Into Palliative Medicine Fellowships: A Response to Vig and Merel.

In a recent American Journal of Hospice and Palliative Medicine article entitled "Ethics Education During Palliative Medicine Fellowship," Dr Elizabeth Vig and Dr Susan Merel detail the ethics curriculum of the University of Washington School of Medicine's Palliative Medicine Fellowship, including their efforts in the past several years to increase and bolster the fellowship's ethics curriculum. This letter builds upon this topic and discusses some other strategies and methods for ethics education and training that fellowship programs may consider adopting to bolster their ethics curriculum.

Incorporating palliative radiotherapy education into hospice and palliative medicine fellowship training: a feasibility study.

BACKGROUND: Insufficient knowledge of radiotherapy among hospice and palliative medicine (HPM) physicians is a barrier to providing optimal palliative care. We sought to assess the impact of a palliative radiotherapy curriculum on the knowledge, attitudes, and practice behaviors of HPM fellows at a single institution. METHODS: We implemented a palliative radiotherapy didactic course for HPM fellows. The course consisted of three one-hour lectures and a guided tour of the radiation oncology suite. Anonymous pre-post was performed using descriptive statistics with P values calculated using the Wilcoxon rank-sum test with continuity correction. RESULTS: All eligible fellows completed the questionnaires. Prior to the course, all fellows agreed that possessing a working knowledge of palliative radiotherapy was important yet lacked confidence in this domain. Fellow-reported confidence increased significantly on post-course assessment, as did the mean score on objective knowledge assessment. This increased knowledge was retained on longitudinal evaluation at three months. The curricular intervention also impacted fellow-reported practice behaviors and attitudes. In the three months following the intervention, fellows were more likely to refer patients for palliative radiotherapy, more likely to collaborate with radiation oncologists, and more likely to view radiation oncologists as members of a comprehensive palliative care team. CONCLUSIONS: This feasibility study suggests that a brief curricular intervention can impact HPM fellows' knowledge about, attitudes towards, and practice behaviors associated with the use of radiotherapy in the palliative management of advanced cancer patients.