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Fellowship Training in Hospice and Palliative Care: New Pathways for Surgeons


 

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Hospice and Palliative Medicine (HPM) has been a medical subspecialty recognized by the American Board of Medical Specialties since 2006. The American Board of Surgery (ABS) is one of 10 medical boards that offers board certification in HPM. Cosponsorship of HPM board certification by the ABS is significant because it signals an understanding and appreciation that patients in need of hospice and palliative care frequently require surgical services and also recognizes that many surgical patients benefit from palliative care.

Two specific domains of palliative care have been identified as core competencies for all surgeons: pain management and communication skills (Otolaryngology Clinics of North America 2009;42:1-13). Incorporation of these basic domains of care is considered primary palliative care for surgeons and inherent to good surgical care. For surgeons interested in obtaining subspecialty training in HPM, fellowship training is now required (the experiential pathway is no longer available).

Dr. Bridget Fahy

Dr. Bridget Fahy

Surgeons most likely to benefit from this additional training are those involved in the interdisciplinary care of chronically disease, critically ill, or terminally ill patients. Apparent in this description is the need for surgical palliative care providers across the full range of surgical subspecialties: pediatric to adult providers, trauma/critical care to oncology, cardiovascular surgery to transplant surgery. Currently, there are fewer than 100 surgeons with subspecialty board certification in HPM, constituting <1% of all physicians board certified in HPM.

The nascent field of HPM and needs surgeons as do the growing number of patients who require hospice and palliative medicine services. There currently exists a critical shortage of HPM physicians. A 2010 report by a task force appointed by the American Academy of Hospice and Palliative Medicine to study HPM physician workforce found that an estimated 6,000-18,000 additional physicians were needed to staff the then existing hospice and hospital-based palliative care programs (J. Pain Symptom Manage. 2010;40:899-91). The authors concluded that the capacity of fellowship programs at that time was insufficient to fill the shortage and changes in graduate medical education funding and structures were needed to increase the capacity to train sufficient numbers of HPM physicians. There are currently 108 Accreditation Council for Graduate Medical Education–accredited fellowships, up from 63 in 2009.

Surgeons interested in pursuing subspecialty training in HPM must complete a 1-year ACGME-accredited fellowship. Surgeons currently board-certified in surgery are eligible to apply. Many fellowship training programs have trained, or are willing to consider applications from, mid-career physicians, including surgeons (personal communication via HPM fellowship program directors listserv). Beginning July 1, 2015, an important change in eligibility for HPM fellowships goes into effect: Surgical residents with 3 years of training are now eligible to apply for ACGME-accredited HPM fellowships. This change in eligibility opens up an important pathway to HPM board certification, similar to that currently available for Surgical Critical Care. Trainees who complete HPM fellowship training through this pathway will not be eligible to obtain board certification in HPM until they have successfully achieved their primary board certification through the ABS.

Surgeons currently board certified in HPM incorporate their HPM training in a variety of ways: Some practice HPM full-time as members of a multidisciplinary in-patient palliative medicine consultation service while others integrate their training into their daily surgical practice, often serving as a resource on issues of surgical palliative care for their surgical colleagues. In my practice, I spend 1 day a week as a consultant on our in-patient palliative medicine consultation service in addition to providing faculty supervision to our palliative medicine fellows in our weekly outpatient clinic. For the remainder of the week, I am a practicing surgical oncologist and have found my training in palliative medicine invaluable in my daily care of patients with a variety of malignancies.

Like many of my surgical colleagues with HPM board certification, I am also actively engaged in teaching medical students, residents, and fellows about a variety of topics in palliative medicine, from evidence-based management of malignant bowel obstruction to communication skills for breaking bad news. Incorporating palliative medicine into my surgical practice has been incredibly rewarding, both personally and professionally.

In summary, HPM is in critical need of specialty trained physicians, including surgeons. Fellowship training is currently available to mid-career surgeons and, beginning July 1, 2015, surgical residents with 3 years of clinical training. Surgeons with subspecialty training in HPM are certain to find a wealth of clinical and academic opportunities as well as a path to a personally and professionally rewarding career.

For surgeons interested in obtaining more information about HPM fellowship training, go to the for a full list of programs and other training information.

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