Programs aim to address ‘pending and widening gap’ in palliative care workforce
The field of palliative care appears to be moving in two opposite directions.
Demand for services continues to increase as more people with chronic and serious conditions gain access to therapies that prolong their lives. At the same time, researchers project the number of trained palliative care professionals could shrink dramatically, resulting in a “workforce valley” that could have considerable implications for patients.
“The integration of specialty palliative care services into routine care is increasing. Previously viewed as synonymous only with end-of-life care, palliative care has moved upstream and is increasingly integrated from time of diagnosis throughout the course of serious illness,” Arif H. Kamal, MD, associate professor of medicine at Duke Cancer Institute, and colleagues wrote in a study published in June in Health Affairs.
Their analysis showed half of palliative care physicians are aged 56 years or older, with a high burnout rate among the workforce.
The researchers predicted that the overall number of palliative care physicians will decline gradually over the next 14 years and — absent significant policy and structural changes — will not return to the current level until 2045.
HemOnc T oday spoke with palliative care professionals about the obstacles the workforce faces and the measures that should be taken to address the looming shortage of providers.
Delivering on promises
Palliative care specialists traditionally acted as an extra layer of support for patients facing life-limiting illnesses. As treatments have advanced, the role of these specialists has evolved to include those with chronic illness, Kamal said.
For a disease such as melanoma, the conversation has shifted from end-of-life planning to planning for an uncertain future, along with other issues — financial, emotional and physical — that come with new treatment options.
“We operate a lot in areas of uncertainty — particularly in advanced cancers, where there are no clear answers, yet patients still have lots of worries,” Kamal told HemOnc Today. “With increasing calls for the integration of specialty palliative care and usual oncology care, there is a need to understand whether the specialty palliative care workforce will be in place, so as to not overpromise and underdeliver.”
Studies have suggested palliative care remains underutilized in cancer care. A study by Osagiede and colleagues, published last year in Journal of Palliative Care, showed less than 10% of patients with solid tumors received palliative care.
“There has to be a balance between calls for more palliative care and recognizing whether those resources will be available,” Kamal said.
Kamal explained that his group’s model showed the number of clinicians in palliative care will decrease over the next 25 years before returning to an upward trajectory. The initial decline is largely due to 40% of the current palliative care workforce being within 10 years of standard retirement age.
“We worry that the loss in clinicians might actually be steeper due to burnout,” he added.
Approximately one-third of the clinicians who participated in the study by Kamal and colleagues reported burnout, including 33.6% of physicians, 31.9% of nurses and 29.7% of social workers.
Among this group, nurses (OR = 1.61; 95% CI, 1.26-2.05) and social workers (OR = 1.92; 95% CI, 1.41-2.61) had higher odds of leaving their jobs than physicians.
“As palliative care specialists become more accepted in clinical practice, with the addition of more responsibilities and demands, there is a concern that the burnout rate may go up over time,” Kamal said.
“The age of the workforce is more of an issue when it comes to the pending and widening gap in the palliative care workforce, but at this moment burnout is not as big a problem as many had feared,” he added. “Now is the time to take advantage of the opportunity to not let that rate go higher.”
Bridging the gap
Kamal and colleagues identified several strategies to help address the imminent shortage of providers in the specialty.
The first is to ensure an adequate and efficient training pipeline. This means identifying the gaps, as well as creative ways to fill them.
“We need to think of alternative training pathways,” Kamal said. “It’s untenable to ask many physicians to stop their usual practice, leave for a 1-year fellowship to learn specialty palliative care skills, then reinsert themselves.”
The Center to Advance Palliative Care (CAPC) — part of Icahn School of Medicine at Mount Sinai — provides health care professionals and organizations with training, tools and technical assistance to deliver specialized care to those with serious or life-limiting illnesses.
CAPC also offers a variety of online clinical training resources, with course topics ranging from pain management and dementia care best practices to advance care planning. Clinicians can earn CME Maintenance of Certification points from the American Board of Internal Medicine and a CAPC Designation Certificate that reflects having received comprehensive training in a particular core competency.
More than 40,000 clinicians have completed over 320,000 courses using CAPC’s online training, which includes interactive, case-based courses, according to center director Diane E. Meier, MD, FACP, FAAHPM.
“You don’t have to leave your practice for weeks or longer or immerse yourself in a fellowship to learn palliative care techniques,” Meier, also a professor in the department of geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai and a HemOnc Today Editorial Board Member, told HemOnc Today. “You can gain quite a bit of the knowledge and skills that you need with this series of courses.”
The population of Americans living with serious illnesses is growing, Meier said. This puts pressure on palliative care programs, which are threatened by an inadequate workforce pipeline, she told HemOnc Today.
“Hematologists/oncologists need to recognize that, if they are in a system where they have come to rely on partnership with palliative care teams, then those teams’ ability to absorb a substantially higher volume of referrals is going to be limited and other methods of addressing the needs of their patients will be required,” Meier said.
The CAPC clinical training curriculum is not equivalent to a fellowship, but it’s one way to help bridge the rift and train what both Meier and Kamal call “palliative care champions.”
These “champions” have a bit more skill and familiarity with palliative care issues than the average clinician, but not to the level of a specially trained fellowship clinician.
“But they serve an important role, bridging the gap between patients who have a little more need than the average patient but who don’t need such high-level support from a specialist,” Kamal said. “We think there is a lot of benefit to creating a network of champions who work with primary palliative care clinicians — those who deliver foundational services — to create a palliative care ecosystem across the health care system.”
Training these champions is one alternative method to expand the palliative care team, Meier said. The other is mid-career training of frontline clinicians who routinely care for patients with serious illnesses.
A different type of fellowship
University of Pennsylvania’s Perelman School of Medicine offers a new type of fellowship intended for mid-career physicians. It is based on demonstrating proficiency rather than time served.
“In the clinical setting, we are seeing that the volume of patients who need specialty palliative care services exceeds capacity even in a well-resourced institution, and providing those services is taxing for the members of the palliative care team,” Laura Dingfield, MD, MSEd, director of the hospice and palliative medicine fellowship program at Perelman School of Medicine, told HemOnc Today. “That, coupled with the growth in the number of Medicare beneficiaries, will result in a worsening workforce shortage if nothing changes.
“One of the big barriers to increasing the workforce is the inflexibility and lack of resources for traditional fellowship training programs,” Dingfield added. “It would be wonderful if we could expand those, but there are a number of barriers to easily doing that.”
Penn is attempting to change the status quo and overcome the barriers with its new pilot program: a first-in the-nation, part-time, competency-based, mid-career fellowship in palliative care.
“It is intended to be part time and interrupted so that the fellow who is participating will engage in palliative care fellowship clinical experiences during the time when they're not scheduled for other clinical work,” Dingfield said. “They will continue their ‘day job,’ so to speak, continuing their main practice while maintaining their faculty positions, salary and benefits during this training period.”
The program, which received approvals last year from Accreditation Council for Graduate Medical Education and American Board of Internal Medicine, enrolled its first mid-career fellow in July. A second faculty member at Penn will begin in January.
Participants in the program balance palliative care training with their clinical duties.
The fellowship’s philosophy is that of a competency-based program rather than the traditional 12-month, time-based fellowship, Dingfield said. Some fellows may finish in less than a year, and some may take 16 or 24 months to complete the program.
“We assess the fellow’s competence in key palliative care skills when they enter the program and, based on that assessment, we define an individualized education curriculum for the fellow to close their specific competency gaps,” she said.
The individualized curriculum places the fellow at the center of the process.
“There’s a dialogue with the mid-career fellow about the design of their educational program and then, as they go through the program, they are assessed in a kind of programmatic and standardized way so that we can monitor their progression on key competency areas,” Dingfield said.
The mid-career fellowship is just one of many programs that will be required to address the palliative care workforce deficit that is expected to grow over the next decade.
Another important challenge will be attracting the interest of early-career physicians.
“We need to make sure that students and residents are aware of palliative care as a specialty and an option for training and encourage them to pursue additional expertise,” she said. “We need to make sure that we're focusing on continuing to recruit people to pursue specialty care and that they have exposure to the field. Otherwise we could expand the number of slots and still not fill them.” – by Drew Amorosi
Laura Dingfield, MD, MSEd , can be reached at Hospital of University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104; email: firstname.lastname@example.org.
Arif H. Kamal, MD , can be reached at Duke University, Box 2715, Durham, NC 27710; email: email@example.com.
Diane E. Meier, MD, FACP, FAAHPM , can be reached at Icahn School of Medicine at Mount Sinai, 55 W. 125th St., Suite 1302, New York, NY 10027; email: firstname.lastname@example.org.
Kamal AH, et al. Health Aff (Millwood). 2019;doi:10.1377/hlthaff.2019.00018.
Osagiede O, et al. J Palliat Care. 2018;doi:10.1177/0825859718777320.
Disclosures: Dingfield, Kamal and Meier report no relevant financial disclosures.