Workforce and Education Issues in Palliative Medicine
in Palliative Medicine Susan Block, MD
Susan
Block MD
Dana‐Farber Cancer Institute and Brigham and Women’s Hospital Harvard Medical School d
di l S h l
Center for Palliative Care
HMS Center for Palliative Care
Expanding Access
p
g
• Palliative care one of 6 national priorities with potential to change health care (NPP)
potential to change health care (NPP)
• PC has potential to:
– control
control costs
costs
– improve quality – improve coordination of care for patients with chronic impro e coordination of care for patients ith chronic
illnesses
– enhance patient and family satisfaction
enhance patient and family satisfaction
• Adequately trained workforce is key to achieving these goals
these goals
HMS Center for Palliative Care
The Big Picture
g
• Demand>> supply anticipated until 2025
– Shortage of 169,000 MDs anticipated
Sh
f 169 000 MD
i i
d
• Many factors are likely to contribute: – Health care reform => more patients will enter the system, especially those with greater health care needs (4% increase expected)
– Aging of population (12%>65 now to 20% by 2030)
– 15% population growth
– More effective treatments for serious diseases
HMS Center for Palliative Care
The Big Picture
The Big Picture
• Patients requesting more treatments
• Specialties serving older patients likely to show greatest S i lti
i
ld
ti t lik l t h
t t
gap
• Younger physicians work fewer hours
Younger physicians work fewer hours
• Large number of boomer MDs retiring
• Even planned expansion in medical school and resident Even planned expansion in medical school and resident
slots will not meet needs
• Primary care gap means fewer primary care physicians to Primary care gap means fewer primary care physicians to
coordinate and manage care
Non‐physician
physician workforce issues impact need for workforce issues impact need for
• Non
physicians
HMS Center for Palliative Care
How general workforce issues impact Palliative Medicine
• Specialist (e.g., oncology) and nursing workforce gaps reduce access to needed care • Specialists are expecting PC clinicians to help fill their S i li t
ti PC li i i
t h l fill th i
workforce gaps
• Grandfathering option for PM to end after 2012, particularly Grandfathering option for PM to end after 2012 particularly
impacting mid‐career physicians
• Feminization of PM workforce
Feminization of PM workforce
• Representation of minority physicians in PM is half that of other fields (4.3% vs 8%) => contributes to gap in access for minority patients
i it
ti t
• Insufficient numbers of PM teachers and researchers
HMS Center for Palliative Care
Current PM Workforce
Current PM Workforce
Data Source
Number
AAHPM Physician Members
y
2750
AMA Masterfile self‐designated HPM
818
AAHPM Board Certified
2883
ABMS Board Certified
ABMS Board Certified
1226
Estimated overlap among categories
3700
Estimated total FTEs
1600‐2800 FTE
HMS Center for Palliative Care
Estimate of CURRENT PM need
(estimates not adjusted for pop growth, aging, etc.)
Hospice FTE
FTE'ss
Palliative Care
FTE'
FTE's
Total FTE’s:
FTE s:
Hospice &
Palliative Care
Low Estimate
Medium Estimate
High Estimate
1,713
1
713
2,700
2,265
2
265
3,780
4,516
4
516
6,098
4,413
6,045
10,814
HMS Center for Palliative Care
HPM Pipeline
HPM Pipeline
• 62 ACGME HPM training programs
• 160 fellows graduate annually
• Assuming 3% of physicians retire annually, Assuming 3% of physicians retire annually
new fellowship graduates don’t keep up with retirements
• NO GROWTH projected in number of HPM physicians
h i i
• And, no Medicare GME funding for additional PM fellowships available
HMS Center for Palliative Care
Current Palliative Medicine Training: Improving
• Medical School
Medical School
–
–
–
–
100% of schools offer something
Training improved but inadequate
Training improved but inadequate
Pervasive hidden/informal curricula Liaison Committee on Medical Education requirement; non‐
q
;
specific
• Residencyy
– Almost all IM, FM residencies have “structured EOL curriculum”
– ACGME requirements now exist for training in palliative medicine, but vague
HMS Center for Palliative Care
Opportunities during medical school and residency
• Students eager for in‐depth clinical experiences with d
f
d h l
l
h
patients during first two years • Medical students and residents have positive attitudes towards PM and want to learn d PM d
l
– Connects with idealism
– Distress about care can be a motivator for learningg
• Challenging cases represent teachable moments
• Teaching PM is an efficient way to teach other core competencies (e g professionalism communication
competencies (e.g., professionalism, communication, teamwork)
• Good teaching and enthusiastic teachers stimulate interest in the content
interest in the content
• How do we capitalize on these opportunities?
HMS Center for Palliative Care
Faculty Development
• Dramatic growth in need for palliative medicine educators for students residents fellows etc
for students, residents, fellows, etc.
– 18,000 medical students/year
– 24,000 residency positions/year
24,000 residency positions/year
– Assuming 8 hours of education TOTAL for each student in medical school and residency => 200 FTE PM educators
• General faculty report inadequate preparation to teach about EOL care
• Specialist PM educators are needed to teach other faculty these core competencies
• Only two national HPM faculty development programs, training <100 faculty per year
HMS Center for Palliative Care
How to grow the field
g
• Expand medical school and residency training nationally
– Expanded medical school classes and residency positions
E
d d
di l h l l
d id
iti
• Better and more HPM training of medical students, residents, fellows to stimulate interest
fellows to stimulate interest
– Meaningful clinical experiences in hospice and palliative medicine
– Exposure to role models
• Medicare GME funding for HPM fellowship programs
– HPM should be considered a workforce shortage field
– Support growth of strong HPM fellowships
Support growth of strong HPM fellowships
• Career development opportunities for junior faculty
– Leadership gap identified
– HPM LEAD, PACA, etc. HMS Center for Palliative Care
Mid‐career
Mid
career Training Urgently Training Urgently
Needed
• Develop mid‐career HPM educational program
– Strong interest from mid‐career physicians
– Provide mechanism for mid‐career physicians to transition into HPM – Requires flexible training program to address feasibility R
i fl ibl t i i
t dd
f ibilit
issues
– Funding needed
Funding needed
– Specialized sites
– Route to ABMS certification needed
– Will require a collaborative national effort
HMS Center for Palliative Care
Basic PM competencies for all physicians h
To meet current and future need, all To
meet current and future need all
physicians should have basic PM competencies according to clinical population served: – By level of exposure to death (oncology, critical care versus rheumatology, general medicine)
– By complexity (community‐based versus tertiary)
– By population (pediatricians for kids, hospitalists for hospitalized patients, geriatricians for older patients)
HMS Center for Palliative Care
Interdisciplinary Care
p
y
• A core element of hospice and palliative care
• Associated with improved outcomes in multiple settings
• Workforce needs across disciplines are interwoven
W kf
d
di i li
i t
• Can improve access, compensate for physician shortage
• Requires MD training in teamwork
• Need for new PM training programs for NPs, PAs, Need for new PM training programs for NPs PAs
mental health clinicians, pharmacists, chaplains, etc. to suppo t t s ode
to support this model
HMS Center for Palliative Care
Summaryy
•
•
•
•
•
•
•
•
•
PM a key element in addressing health care quality and costs
Competent well‐trained
Competent, well
trained workforce essential
workforce essential
Many general and PM‐specific workforce challenges
Demand for PM likely to increase dramatically without capacity
Demand for PM likely to increase dramatically without capacity to increase supply of PM physicians
PM pipeline inadequate
PM pipeline inadequate
Need to integrate PM training throughout medical education p
process and to train faculty
y
More focus on training of non‐PM physicians to spread basic competencies
Need for a mid‐career PM training program
Collaboration with other disciplines key
HMS Center for Palliative Care