Wednesday, July 2, 2014

Deadline for Comments on HPM Fellowship Update July 2

Apologies for the late notice, but I only heard yesterday about the deadline today (July 2, 2014) to the ACGME update to the Hospice and Palliative Medicine Fellowship requirements.  These updates do not come around too often and this is the first significant chance for an update since the accreditation became official in the late 2000s.

Here are some of the key files for your reference:
Impact Statement (only 5 pages - summarized below)
Program Requirements (24 fun-filled pages)
Review and Comment Form (you need to complete this and send it to

Whether you agree or disagree it is important to offer feedback either through your official representation from your institution or even as a clinician or advocate for hospice and palliative medicine.  So here is a quick summary of some (not all) of the changes and why I think they may be critical to the future of our specialty.

1) Increasing the hospice experience from 8 weeks to 10 weeks

When I first heard the requirements for hospice experience were placed at only 8 weeks in the first edition of these guidelines I was quite surprised.  My fellowship experience was based out of a community hospice, and the one I helped found in Kansas City was also initially born out of a community hospice.  So a good balance in my eyes, was more around 50/50.  I think this is a step in the right direction.  I wish it was from 8 weeks to 12 weeks, but I'll take what I can get to advance the competencies of HPM clinicians in hospice. Of note a pediatric palliative home care experience can be an adequate substitute for a Medicare or a VA based hospice experience.  I do think all programs should have exposure to pediatric HPM, but not necessarily at the expense of a shortened hospice experience.

2) Changing the fellowship requirement to a total of 12 months instead of a duration of 12 months.
The duration of a fellowship program in hospice and palliative medicine is 12 months. A fellowship program in hospice and palliative medicine must consist of 12 months of education in the subspecialty. 
This change allows the flexibility to include mid-career learners who may not be able to devote an entire 12 months straight to a fellowship program.  And with the current growing HPM workforce shortage, we need flexibility to train HPM specialists.

3) Increasing the protected time for a program director to 20-50%

Original language was vague and left it up to the institution to set the time aside.  If we are to have strong programs across the nation, then we need PDs who are protected to develop great programs, and not just working into the wee hours

4) Faculty to match the program size
In addition to the program director, there must be at least one other hospice and palliative medicine physician faculty member who devotes at least 10 hours per week on average sufficient professional time to the program. For programs with more than two fellows, there must be additional at least three hospice and palliative medicine physician faculty members.
I came from a single faculty program way back in 2003-4.  The teaching was great, but I could see the concern about smaller programs not providing a broader knowledge and skill foundation when you are limited to one faculty member. It would be great to support some of the smaller programs with some of the support found in the PCHETA bill to establish more faculty in HPM.

5) Decrease longitudinal patients across settings from 25 to 10

This is a no-brainer.  This requirement is a good idea in theory, but in reality it is really hard to execute even with the best intentions and frequent reminders.  So 10 seems an achievable number that allows for exposure to the importance of continuity, but it is realistic when factoring in fractured health care delivery systems and a premium on the fellow's time.

If you like all those things then here is something basic you can add to the 'General Comments' section (feel free to personalize/edit:
As a hospice and palliative medicine/care clinician, I reviewed the impact statement to the hospice and palliative medicine fellowship program requirements.  I agree with the changes being proposed, especially the following:
Requirement Int.C. - Flexible scheduling of fellowships for a total of 12 months
Requirement II.A.1.b - Increased protected time for program directors
Requirement II.B.1.a)-b) - Adequate number and dedicated time for faculty
Requirement IV.A.3.e)e).(1) - Increasing the hospice experience from 8 weeks to 10 weeks
Requirement IV.A.3.k) - Decreasing the longitudinal requirement from 25 to 10 patients

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