Archive for May, 2010
This post is reprinted from the Spring 2010 issue of AAHPM Bulletin.
by Larry Beresford
Some hospice and palliative care programs are helping physicians in their communities to qualify for board certification in hospice and palliative medicine (HPM), offering “practice pathway” opportunities to accumulate necessary hours of caring for patients while learning the medical subspecialty on the job.
When HPM was recognized by the American Board of Medical Specialties and ten of its constituent specialty boards, it was hailed as a great achievement for the field. However, it posed the challenge of how to qualify enough physicians to fill medical positions in hospice and palliative care organizations, especially after 2013, when completing a full-year fellowship becomes a prerequisite for HPM certification.
Although the practice pathway option is available until 2012 for mid-career physicians to sit for the HPM boards without first completing a full-year HPM fellowship, a more urgent deadline is looming for those who wish to pursue this direction. Because two years of experience with hospice and palliative care teams is required for this “grandfathering” option, physicians would need to start by the Spring 2010 in order to apply in Spring 2012 to sit for HPM boards in the Fall 2012.
“There is a shortage of HPM physicians for the number of programs we have today, and that need is going to grow rapidly,” says Loren Friedman, MD FAAHPM, Medical Director of the Palliative Care Service at Virginia Hospital Center in Arlington, VA, who chairs AAHPM’s Workforce Capacity Task Force. The task force projects a current need for 8,000 HPM physicians, double the number working in the field, with fewer than 200 new fellowship graduates each year.
“For our new field, there were limited opportunities for formal training in HPM in the early years. Initially, most of us switched to hospice and palliative care from some other medical specialty,” Dr. Friedman notes. “Things are different now. We have a large body of evidence-based medicine to define our field and we have fellowship-trained physicians. However, there are also mid-career physicians who have only recently developed an interest in hospice and palliative care. They have a level of life experience and professional expertise that is an asset to the field.”
For those physicians, the practice pathway option requires finding a hospice or palliative care program where they could accumulate HPM hours by working for the program and caring for its patients, either paid or unpaid, as part of a structured, part-time educational experience. The Palliative Care Service at University of Kansas Medical Center (KUMC), Kansas City, KS, includes two part-time faculty members who are not HPM board-certified but have shown an aptitude for the work, reports Karin Porter-Williamson, MD, section head for palliative medicine. KUMC also has two full-time HPM fellows and an extensive educational curriculum and Web-based learning portal already in place.
“What we’re doing here grew organically from the needs of my partners who do palliative medicine and from the fact that recruiting board-certified physicians has been very difficult for us. I wanted to take the people who were doing a good job and mentor them. It’s experiential cross training for people from other medical backgrounds,” in this case internal medicine, hospital medicine, and geriatrics, Dr. Porter-Williamson says. The two physicians are working toward qualifying for the boards in 2012 while attending palliative care interdisciplinary team meetings and serving as hospice physicians for appropriate patients discharged home.
“It’s been easier to operationalize the experience for internal people because they already have privileges at the medical center. A few doctors from outside the institution have come and shadowed us for a week, but haven’t gotten into our program. I actually tried to get privileges and a faculty appointment for one of them and couldn’t,” she says.
“Our goal is to help people work toward board certification, but how do you get your head around the experience that is required to become a good HPM physician—beyond just passing the test?” At KUMC, that experience includes both clinical and didactic components along with scholarship by attending a regional or national HPM conference, giving lectures to residents, and participating in a hospital quality improvement project. “The goal is to offer a well-rounded experience that creates practitioners who are good at the clinical and educational aspects of HPM.”
The fellowship program at KUMC collaborates with Kansas City Hospice & Palliative Care, which has found it easier to offer clinical opportunities to community physicians at its freestanding inpatient facility and in patients’ homes, along with didactic lectures and faculty supervision, without facing the academic barriers at KUMC, says medical director Ann Allegre, MD FACP FAAHPM. “But we have not found a good way to offer this experience on a hospital-based palliative care consult service, because of hospital privileging issues.” At least one community physician, an anesthesiologist, appears poised to complete the program at KCHPC and sit for the board exam within the window of opportunity.
Tina Smusz, MD MA MSPH, a palliative care physician at Carilion Clinic in rural Christiansburg, VA, has also received requests from local physicians wanting to get credit for hours. “I said join in and attend our weekly interdisciplinary team meeting. I didn’t get any takers.” For those physicians who don’t have first-hand experience with what a dedicated hospice or palliative care team does, it can be hard to understand the competence expected of a true HPM specialist,” Dr. Smusz says, and that is why an opportunity to work with an experienced team and mentor is such an important part of the practice pathway opportunity.
At an affiliate—Carilion Roanoke Medical Center—Dr. Smusz’s colleague, Dr. Christopher Piles, did get takers—physicians who now attend team meetings, see palliative care patients, and provide backup coverage for him. “That works well for hospitalists,” Smusz notes. “It’s certification that motivates physicians to approach us. But once they see the real requirements, you can see if they are serious.”
At the University of Massachusetts (UMASS) Medical School in Worcester, MA, an embryonic palliative care program has been growing through a learning community comprised of physicians, nurses, social workers, and other professionals within the healthcare system, according to Suzana Makowski, MD MMM FACP, the only full-time palliative medicine specialist on staff. “It’s not yet a formal interdisciplinary team, but this is a way for us to start building that culture.”
This group has monthly face-to-face meetings, complemented by online discussions, social networking tools, and interdisciplinary discussions of real cases. The program incorporates mindfulness practice and aims to attract a broad range of physician specialties to this learning community. A team retreat and online curriculum are planned for January 2010. UMass physicians interested in preparing for HPM boards can set aside time to make rounds with Dr. Makowski or use the work they are already doing in the medical center, supplemented with intensive study weeks at a palliative care training site, such as Harvard Medical School, Cambridge, MA, or San Diego Hospice and the Institute for Palliative Medicine, San Diego, CA.
Stephen Leedy, MD FAAHPM, chief medical officer of Tidewell Hospice in Sarasota, FL, says his agency was approached by several physicians in the community seeking HPM hours, and is now investigating the costs and benefits of offering a mini-fellowship program. “Our starting point was getting online and reviewing the board certification requirements. You need 800 hours of clinical involvement in the subspecialty-level practice of HPM, 100 hours of participation on a hospice interdisciplinary team, and caring for 50 terminally ill patients over two years,” he explains.
If physicians consistently attend an hourly interdisciplinary meeting every week and complete 8 hours of clinical involvement, they could meet the standard in one full day a week, 50 weeks a year, for two years. But it isn’t just a matter of hours, Dr. Leedy says. “We want people to actually succeed and pass the exam.” Tidewell would also want to give these physicians a real hospice experience, immersing them in the culture by working alongside experienced hospice nurses and other members of the interdisciplinary team, supplemented by a didactic curriculum via conference call or online. “We realized that time alone doesn’t get them to where they need to be.”
The Academy offers a number of resources to help physicians advance their skills in conjunction with a practice pathway experience, including the Clinical Scholars Program and the new Job Mart found on the AAHPM website. Dr. Leedy recommends to community physicians, “If you want to do something like this, make some noise with your local hospice or palliative care program. But be prepared to spend some time on it.”
For more information on how some programs are trying to offer practice pathway opportunities to help physicians in their communities to prepare for the HPM boards, contact Karin Porter-Williamson, MD, medical director for palliative care, Kansas University Medical Center, email@example.com; Ann Allegre, MD FACP FAAHPM, medical director of Kansas City Hospice and Palliative Care, firstname.lastname@example.org; Tina Smusz, MD MA MSPH, palliative care physician with the Carilion Health System; Suzana Makowski, MD MMM FACP, palliative care physician at the University of Massachusetts Medical Center; and Stephen A. Leedy, MD FAAHPM, chief medical officer of Tidewell Hospice.
Pathway Certification Requirements
All physicians seeking eligibility will need to fulfill the following:
(*) at the time of application, hold a current certificate from one of the ten cosponsoring American Board of Medical Specialties or four American Osteopathic Association Boards
(*) demonstrate clinical competence in the care of patients
(*) hold a valid, unrestricted license to practice medicine in the United States or Canada
(*) pass the certification exam in hospice and palliative medicine.
Practice Pathway for Mid-Career Physicians
In addition to the general requirements mentioned above, physicians seeking certification through the practice pathway will need to complete either:
(*) Pathway A, which requires prior certification by the American Board of Hospice and Palliative Medicine with an expiration date of December 31, 2008, or later
(*) Pathway B, which requires at least two years and 800 hours of clinical involvement in subspecialty-level practice of hospice and palliative medicine during the five years prior to application including.
(*) At least 100 hours of participation with a hospice or palliative care team
(*) Active care of at least 50 terminally ill patients (25 for pediatrics).
Physicians seeking certification through the training pathway will need to complete a 12-month hospice and palliative medicine fellowship training experience. The program must be consistent with guidelines established by the Accreditation Council for Graduate Medical Education.
For more information on specific requirements for certification, visit the website of the primary board by which you are certified.
Lifelong learning is imperative in the medical profession- especially for physicians. Then, every 10 years this knowledge is tested by the American Board of Medical Specialty to assess one’s foundation of knowledge. I understand tests are important, yet rarely have I found them fun and exciting. For me, every board exam causes stress and high anxiety
- Do I have the right board prep books?
- Does my study schedule cover everything I need?
- Will I actually follow the schedule this time?
- Do I need to take a prep course? If so, did I sign up for the right one?
So, I purchased the 3rd edition of UNIPAC. Seems a bit thin… Does this really have everything I need to know? The 2nd edition was a great supplement when I took the ABHPM Exam. Just in case, I signed up for the review course in Chicago. I love courses!! Brings me back to the simple days of medical school… and forces me to focus exhausting hours with my brain on overload days on end. Yet, I am certain, this too will not be enough. So, I plan on buying the HPM Pass, just to get a few more test questions in. Oh and of course, I have my Oxford Text book of HPM, files of PC-FACs and nauseating long list of web resources http://www.aahpm.org/certification/resources.html ready at the helm to fill in all the gaps.
Tanya Stewart MD FAAHPM
What, if anything, is the relationship between geriatrics and palliative medicine? They are clearly separate fields, each with their own distinct areas of competence and interests. There is though an area of overlap that holds the power to transform the way we care for patients with advanced illness. We saw a preview of this at the American Geriatrics Society annual meeting at Walt Disney World. Here are some highlights:
• Christine Ritchie gave a powerful talk at the fellowship director’s forum on bridging the divide between geriatrics and palliative care. She notes that collaboration makes sense in 2010 as unprecedented gains in life expectancy are leading to an exponential rise in the number of old frail patients with multiple chronic complex diseases. There is high symptom burden and care needs of these patents and their caregivers, and yet they are pitted against a fragmented health care system that is facing enormous financial pressures. Each field has areas of strength that the other can learn from, however this will require mutual respect and, per Dr. Ritchie, a clear recognition of the areas of non-overlap and distinctiveness.
• VJ Periyakoil’s pre-conference workshop on “Updates in Hospice and Palliative Medicine, was not only co-sponsored by AAHPM and AGS, but also used the GeriPal, a geriatrics and palliative care community [http://www.geripal.org/2010/05/need-your-expertise.html], to solicit input prior to her workshop. Are you sad that you missed it? Don’t worry – VJ will also be leading a similar collaborative pre-conference session at the upcoming AAHPM/HPNA meeting in Vancouver.
• Sandra Sanchez-Reilly and Jennifer Kappo led the palliative care SIG. Attendees received an overview of the where the two fields are collaborating from Greg Sachs. We also discussed new possible avenues for collaboration (combined fellowship anyone???)
• Jane Givens won the award for best scientific abstract in the ethics and health disparities section. Look for interesting new findings about the impact of antimicrobial treatment of pneumonia in nursing home patients with advanced dementia – is it associated with longer life? Are there tradeoffs in terms of quality of life? We’ll await the final paper
• Interesting findings from an MSTAR student at Mt. Sinai Tony Vullo suggesting two previously underappreciated barriers to hospice: (1) patients don’t want to give up their current home-care providers, with whom they have established relationships; and (2) patients would receive fewer hours of in-home support than they currently receive if they switch to hospice.
What were your highlights? Leave them as comments below.
by Alex Smith, MD and Eric Widera, MD
The first piece of education reviews the basic Center for Medicare & Medicaid Services (CMS) requirements for authentication of services provided or ordered. When CMS reviewed numerous examples of CERT signature denials, they found in almost every instance that the documentation was acceptable. Services were denied because of one of four “not acceptable” signature reasons, including
1. Illegible, unrecognizable handwritten signature or initials
2. Unsigned “typewritten” progress notes with a typed name only
3. Unverified or unauthorized electronic signatures
4. No indication of the rendering physician/practitioner
The Palmetto GBA Medical Directors strongly encourage the following improvements
1. Be sure a handwritten signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance or obligation
2. Records should clearly indicate they have been “electronically signed by” and include a date/time, including verbiage that makes this clear
3. Establish a protocol to ensure valid signatures are affixed to every order, record, or report within a reasonable time frame (i.e., customarily 48-72 hour after the encounter – but certainly before the claim is submitted to CMS for payment)
Additional information about the CERT program is available on the Palmetto GBA website under the CERT link. This focus is likely to apply to other intermediaries soon, so watch for additional educational updates and start looking into your current processes.