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Palliative Care Fellowship Training: Are We Training Fellows for Where the Field Is Going? (with Apologies to Wayne Gretzky)

2022; Mary Ann Liebert, Inc.; Volume: 25; Issue: 11 Linguagem: Inglês

10.1089/jpm.2022.0388

1096-6218

Meredith MacMartin, Amelia Cullinan, Maxwell T. Vergo, Ali John Zarrabi, Robert M. Arnold,

Patient Dignity and Privacy

Journal of Palliative MedicineVol. 25, No. 11 Guest EditorialFree AccessPalliative Care Fellowship Training: Are We Training Fellows for Where the Field Is Going? (with Apologies to Wayne Gretzky)Meredith A. MacMartin, Amelia Cullinan, Maxwell Vergo, Ali J. Zarrabi, and Robert M. ArnoldMeredith A. MacMartinAddress correspondence to: Meredith A. MacMartin, MD, MS, FAAHPM, Section of Palliative Care, Department of Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA E-mail Address: meredith.a.macmartin@hitchcock.orghttps://orcid.org/0000-0002-6614-6091Section of Palliative Care, Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA.Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.Search for more papers by this author, Amelia CullinanSection of Palliative Care, Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA.Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.Search for more papers by this author, Maxwell Vergohttps://orcid.org/0000-0002-7120-6482Section of Palliative Care, Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA.Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.Search for more papers by this author, Ali J. ZarrabiDivision of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.Search for more papers by this author, and Robert M. ArnoldSection of Palliative Care and Medical Ethics, Department of Medicine, Palliative Care Research Center, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Health System Palliative and Supportive Institute, Pittsburgh, Pennsylvania, USA.Search for more papers by this authorPublished Online:27 Oct 2022https://doi.org/10.1089/jpm.2022.0388AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail As medical practice and training have evolved over time, there have been periodic calls to assess how well residency training has prepared graduates for practice. In internal medicine, for example, some years ago critics pointed out that the heavy predominance of inpatient service experience left graduating residents uninterested and unprepared for outpatient practice. These critiques led to the growth of primary care internal medicine residencies and calls for changes in residency training to include more effectively integrated ambulatory practice into the training schedule.1 We wonder if similar critiques could be offered about hospice and palliative medicine fellowships. Is the training we are providing in our fellowship programs adequately preparing graduating fellows to practice in the outpatient setting? While similar questions might be asked about other training contexts, including community, home-based organizations, long-term care, or pediatric care, we are focusing our attention on ambulatory practices for multiple reasons.The most important reason to focus on ambulatory practice is that the data supporting the association between palliative care and improvements in patient quality of life are strongest in the outpatient setting. The ground-breaking 2010 Temel study, for example, consisted of monthly ambulatory palliative care visits.2 In 2014, Hui et al found that cancer patients who had outpatient referrals to palliative care had higher quality end-of-life care compared with those who were seen in the inpatient setting.3 In a recent study comparing outcomes for patients with cancer who received palliative care in different settings, Yeh et al found a differential effect for those seen outpatient versus inpatient.4 In their work, any exposure to palliative care was associated with improvements in end-of-life care, but outpatient palliative care specifically was associated with shorter length of stay in the hospital, and longer length of stay in hospice. In addition to the compelling evidence supporting the importance of outpatient palliative care, we know that most patients with serious illness want to avoid hospitalization. Referral to palliative care in the outpatient setting reflects both evidence-based practice and patient-centered care.Research on the specific domains and components of palliative care in each setting remains sparse; however, from our own clinical practices and from primary care data, there are compelling reasons to think that there are not only differences in outcomes, but also differences between how palliative care is delivered in the inpatient and outpatient settings. First, there are differences related to the environment of practice itself. In the hospital, patients are likely to have more acute problems, however, the structure of the day tends to be more flexible. Patients can be visited multiple times over a day to reassess symptoms or gather more information if needed, without delaying care for other patients. The hospital setting also benefits from relatively easier access to diagnostic testing and consultation with colleagues. On the other hand, in the ambulatory setting there is little to no flexibility in clinic schedules, and test results and consultation must often be obtained asynchronously and require increased coordination efforts.Differences in the patient population by setting also mean that the goals of inpatient and outpatient palliative care are different. In the outpatient setting, palliative care is focused on preparing for and preventing crises; in the hospital, palliative care is largely focused on responding to and mitigating crises that have occurred or are still occurring.Second, for the core domains of palliative care, there are differences in how each is addressed between settings and thus there are different competencies to manage them. Let us take the example of physical symptoms. In the hospital, diagnostic tests can be quickly obtained to investigate a new or changing symptom. Treatment is focused on acute, often intravenous management to get the patient well enough to be discharged. In the ambulatory setting, symptoms tend to be more diffuse, management may occur with less diagnostic testing, and knowledge of insurance coverage is required. Symptoms that are not classically associated with palliative care, such as chronic nonmalignant pain, may impede quality of life more than the acute pain seen in the hospital setting, and can require coordination with primary care or other specialists. Finally, symptoms for which pharmacological treatments are less effective, such as insomnia or fatigue, are more common in the ambulatory setting. Another example of key differences between the settings can be found when considering the work of exploring patient goals. In the outpatient setting, the focus is on building relationships, iterative exploration of goals and values, and planning as one acquires new clinical information. In the inpatient setting, the discussion of goals is typically in service of an acute choice, often with multiple clinical services and without a prior relationship. There are similar differences across multiple domains of palliative care (Table 1).Table 1. Key Differences between Palliative Care Delivered in the Inpatient and Outpatient SettingDomains of palliative care (adapted from Ferrell et al, 2018)Inpatient setting ACGME requirement: 120 daysOutpatient setting ACGME requirement: 13 daysPhysical aspect of careHigh availability of diagnostic testingCoordinating with other consultants to facilitate medical decision makingManaging acute pain and other symptom crisesManaging parenteral and interventional optionsBalancing work-up for new symptoms with increased logistical burden of coordinating work-up and multiple additional encountersLess immediate access to specialists for consultationIncreased risk of using controlled substances and other high-risk medications to manage symptoms outside of highly monitored settingPsychological and psychiatric aspects of careLack of longitudinal relationship to facilitate difficult discussionsOften a short time frame to adapt to changing medical courseIdentifying and managing deliriumDeveloping longitudinal relationshipsHigh burden of comorbid psychiatric illness with need to diagnose and treat or refer for appropriate mental health careLong-term assessment and management of demoralization associated with serious illnessFocus on adaptive coping and living well with serious illnessSocial aspects of careFocus on transitions of careDischarge planningIdentifying and supporting care partner needs: loneliness, financial toxicity, transportation needs, etc.Spiritual, religious, and existential aspects of careCoordinating with spiritual care providersCoordinating with community resourcesProviding primary spiritual careStructures and processes of carePhysical proximity facilitates team discussions and coordinationCoordinating care asynchronouslyOften fewer dedicated resources to help with social determinants of healthEthical and legal aspects of care"Real-time" decision making in compressed time frameExploring of goals and values over timeSerious illness conversations and scenario planningACGME, Accreditation Council for Graduate Medical Education.It is likely that many of the skills and experiences acquired during the inpatient experience can translate effectively to the outpatient setting; however, educational data suggest that translating knowledge and skills from one setting to another, takes time and training.5 So, what training do fellows currently get in ambulatory palliative care? Currently, fellows are only required to have ambulatory experience for at least six months. Assuming fellows spend a ½ day a week in an ambulatory clinic, their ambulatory clinic education would consist of 13 days of clinic. Compare this to the 80 days of inpatient hospital-based palliative care or 40 days of hospice care. One could argue that the training one receives in one setting is transferable to other locations. However, as we have described, the difference in care delivered in different settings means that there are some differences in competencies. We argue that developing the confidence to manage symptoms as independent clinicians, as opposed to functioning as a consultant, takes longer than 13 days.Finally, learning how to counsel and guide patients through adaptation to illness, which we believe is one of the most impactful skills in outpatient palliative care, requires far more intensive experience. Beyond the potential gap in competencies, we know that people like what they feel most comfortable doing. We worry that fellows' preference for inpatient palliative care (or hospice) is based on a lack of familiarity with ambulatory practice (much like current residents may prefer hospital medicine over ambulatory primary care).As Wayne Gretzky famously said about his success, "I skate to where the puck is going, not where it has been." In a field in which the evidence for improved patient outcomes is overwhelmingly from the outpatient setting, and with increasing guidance to improve access to, and integration of, early outpatient palliative care, we believe that fellowship training is lagging behind the needs of the field. It is time to reflect on where our field is going, and ensure that fellowship training is preparing new palliative care physicians to be part of that future.Funding InformationNo competing financial interests exist.Author Disclosure StatementM.A.M.: none. A.C.: none. M.V.: none. A.J.Z.: none. R.M.A.: VitalTalk Board of Directors, UptoDate Editor, AAHPM PC FACS Editor.References1. Meyers FJ, Weinberger SE, Fitzgibbons JP, et al. Redesigning residency training in internal medicine: The consensus report of the Alliance for Academic Internal Medicine Education Redesign Task Force. Acad Med 2007;82(12):1211–1219; doi: 10.1097/ACM.0b013e318159d010. Crossref, Medline, Google Scholar2. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363(8):733–742; doi: 10.1056/NEJMoa1000678. Crossref, Medline, Google Scholar3. Hui D, Kim SH, Roquemore J, et al. Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer 2014;120(11):1743–1749; doi: 10.1002/cncr.28628. Crossref, Medline, Google Scholar4. Yeh JC, Urman AR, Besaw RJ, et al. Different associations between inpatient or outpatient palliative care and end-of-life outcomes for hospitalized patients with cancer. JCO Oncol Pract 2022;18(4):e516–e524; doi: 10.1200/op.21.00546. Crossref, Medline, Google Scholar5. Ambrose SA, Bridges MW, Lovett MC, et al. How Learning Works: Seven Research-Based Principles for Smart Teaching. Wiley: Hoboken, NJ, USA; 2010. Google ScholarFiguresReferencesRelatedDetails Volume 25Issue 11Nov 2022 InformationCopyright 2022, Mary Ann Liebert, Inc., publishersTo cite this article:Meredith A. MacMartin, Amelia Cullinan, Maxwell Vergo, Ali J. Zarrabi, and Robert M. Arnold.Palliative Care Fellowship Training: Are We Training Fellows for Where the Field Is Going? (with Apologies to Wayne Gretzky).Journal of Palliative Medicine.Nov 2022.1619-1621.http://doi.org/10.1089/jpm.2022.0388Published in Volume: 25 Issue 11: October 27, 2022PDF download