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, kporter-williamson@kumc.edu; Ann Allegre, MD FACP FAAHPM, medical director of Kansas City Hospice and Palliative Care, aallegre@kchospice.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).

Training Pathway
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.