How a new fellowship requirement might affect hospitalists
Keywords: Hospital physicians debate whether they need palliative-care certification
by Paula S. Katz
Published in September 2012 issue of Today's Hospitalist
WHEN SATYA CHELAMKURI, MD, finished her residency two years ago, she knew the clock was ticking. If she could take the certification exam in palliative care by this October, she wouldn't need any additional training. If Dr. Chelamkuri misses next month's test, however, she'll have to complete a one-year fellowship in palliative care before she can sit for the exam in the future.
Dr. Chelamkuri, a hospitalist with the Cogent HMG program at Allegiance Hospital in Jackson, Mich., is studying hard and working more with patients who need palliative care, all of
"I don't feel the need to be certified, and it's unnecessary in this market."
–Mary Frances Barthel, MD Blessing Hospital
which is required to be eligible for next month's exam. Her goal is not only to be certified, but to be certified now.
What are her plans if she doesn't pass the test? Although it would be disruptive, Dr. Chelamkuri says she wants certification badly enough to consider leaving her job to do a fellowship. "If you want to take a year out of your life," she notes, "you must be passionate about it."
But leaving current careers or spending another year on training is not an option for many hospitalists. As a result, the new fellowship requirement is raising questions about how many palliative care physicians will actually become certified.
It's also raising concerns about what certification—or a lack of it—means for hospitals that are in desperate need of palliative care physicians.
Raising the bar
The decision to eventually make a one-year fellowship a requirement for certification in palliative care was born when the palliative care community pushed for recognition as a subspecialty.
The American Board of Medical Specialties requires all new subspecialties to eventually require a fellowship for certification. Palliative care was officially recognized as a subspecialty in 2006—so the clock runs out next month on the "grandfathering" period in which physicians who've completed hundreds of hours of palliative care practice can sit for the exam without doing a fellowship.
Those who support the idea of requiring fellowship for certification say it standardizes practice, gives cachet to the growing specialty, and opens doors for physicians who can fit a fellowship into their personal and professional lives.
But raising the bar comes at a particularly bad time for palliative care, given the nation's aging population and pressure from the Joint Commission to establish palliative care teams that include certified professionals. And health care reform has hospitals taking a second look at how palliative care can help them wring efficiencies out of the system.
In the last six years, the number of hospital-based palliative care services has doubled. More than 1,500 hospitals have a palliative care service, including 63% of all hospitals with more than 50 beds. And while experts estimate that up to 20,000 palliative care physicians are needed to meet the demands of older baby boomers, research in 2010 reported that only 4,400 physicians at that time worked in the specialty.
Next month, 3,900 physicians—the vast majority of which have taken a practice pathway, not a training one—are registered to take the exam being offered by nearly a dozen specialty boards, including the American Board of Internal Medicine (ABIM). Two years ago, 2012 sat for that exam; the pass rate in 2010 was 83%.
By contrast, palliative care fellowship programs in the U.S. can produce only 200 or fewer physicians each year. That means that the workforce of certified palliative physicians isn't expected to be anywhere close to what's needed.
Part of everyone's practice?
In pushing for specialty status, "We tried hard to follow in the footsteps of geriatrics, emergency medicine and sleep medicine in becoming recognized," says Porter Storey, MD, executive vice president of the American Academy of Hospital and Palliative Medicine (AAHPM). Dr. Storey, who has been a full-time hospice and palliative care physician for 30 years, is with Kaiser Permanente in Denver and Boulder. "That meant developing a fellowship training program, creating journals, doing more research and trying to get more people interested in the field."
Once palliative medicine was recognized as a subspecialty, physicians with experience or an interest in palliative care began accumulating the number of required patients served to be eligible to certify during the grandfathering period.
Janice M. Connolly, MD, who certified in 2010, spends 50% of her clinical time at Seattle's Swedish Medical Center on palliative care; two of her colleagues do it 25% of their time and one does it as a .125% FTE. She encouraged others to sit for the exam and hopes a total of eight of the medical center's 45 hospitalists will be certified after this fall's test.
Dr. Connolly acknowledges that even if that best-case scenario pans out, her hospital will still come up short. "There aren't enough palliative care-certified physicians to go around," she says. As a result, she expects to spend even more of her clinical time delivering palliative care.
She also predicts that the specialty will have to continue to depend on not only hospitalists who aren't certified to do the majority of palliative care work, but on nonphysician providers. Her team, which includes a fulltime social worker and an almost full-time chaplain, will be involved with only the most complex patients.
"Palliative care is part of anyone's practice—pain and symptom management, supporting patients during their last days of life, and understanding resources," says Dr. Connolly.
The lack of training
While hospitalists should be trained to meet the core components of palliative care, that's often not the case, notes Diane Meier, MD, director of the New York-based Center to Advance Palliative Care. "We believe nobody should finish medical school or residency without being able to develop competency in treating pain and symptoms and managing serious illness across settings," Dr. Meier explains. "But right now, we're not teaching that in a reliable way in most U.S. medical schools and residency programs."
On-the-job training and experience may have to be enough in some cases, leading to what some call qualified but not certified. "It's a matter of degree," says Eric S. Holmboe, MD, ABIM's chief medical officer and senior vice president. "There's no question there are certain palliative care skills that all physicians should have, so that's the tension. We wouldn't want all physicians to default to a subspecialist, except for the most complex or difficult issues."
Dr. Chelamkuri agrees, saying that hospitalists shouldn't be asking for palliative consults to deliver bad news, for instance. Instead, primary attendings should be competent to do so.
However, the lack of certified physicians may prompt a closer look at hospitalists' training. "Because there's such an enormous deficit in board-certified physician specialists, many who aren't board certified will be delivering palliative care. There's no alternative," says Dr. Meier. As a result, she says, generalists need better training in core palliative medicine competencies.
Why certification matters
If so much palliative care will be delivered by noncertified physicians, why would young physicians in the future feel compelled to do a fellowship? Those physicians are often anxious to start earning a real paycheck, after all, and palliative care (like other cognitive specialties) isn't known for particularly stellar pay.
Despite the challenges surrounding fellowship, Dr. Meier says young doctors right out of residency are flocking to the fellowship programs. She also notes that certification sends a message to the public that a physician has been approved by a high-quality, accredited training program.
And being certified could make a difference in landing a job. Dr. Meier, who is professor of geriatrics and palliative medicine at New York's Mount Sinai Hospital, notes that while she took the boards during the grandfathering period, Mount Sinai now will hire a physician to do palliative medicine only if he or she has finished a fellowship.
Certification also can open doors. Hospitalist Avani Prabhakar, MD, MPH, hopes to add board certification to her CV after she takes the exam next month. Doing so, she says, will lead to more consults from other specialties at the 1,200-bed Beaumont Hospital in Royal Oak, Mich., where she works.
"Otherwise they might be hesitant to consult me," she says. Dr. Prabhakar also hopes it will put her in a position to expand palliative care at her hospital, have a louder voice there in terms of policies related to futile care, and give her career a boost if she decides to advance palliative care teaching to medical students and residents or develop a fellowship program at her institution.
For now, though, she appreciates the hospital-based team focus on palliative care. "I want palliative care as an important part of my practice, but I don't want to give up being a hospitalist," says Dr. Prabhakar. She plans to reevaluate her career goals at the new year, then talk to the hospital's palliative care team and her group partners to determine how to incorporate more palliative care into her practice.
More physician involvement
Murtaza Cassoobhoy, MD, has already been there. He was the co-medical director of the nurse-run palliative care program at the 353-bed Gwinnett Medical Center in Lawrenceville, Ga., before he became certified in 2010.
"I thought if I'm board certified, I'd have more credibility to expand palliative care in our hospital," he says. "I saw a need for physician involvement in the program and took the lead to make that happen."
When one nurse FTE left to staff a hospice program, Dr. Cassoobhoy persuaded the administration to replace her with a physician and to move the program from nursing administration to hospital medicine. Starting July 2012, he became the medical director of the physician-led palliative care program.
Among the 24 hospitalists in the practice, he picked five who have experience in palliative or hospice care. They each work one week of palliative care every six weeks.
Becoming certified during the grandfathering period worked for him because of his on-the-job training and timing. He says it would be impossible for him to do a fellowship now because of his family obligations and that it likewise may never work for the others rotating with him.
"I have five physicians not board certified in palliative care," he notes. "It would be great if in two years they could say, 'I've been part of this program. Can I take the test?' But it's impractical for most people to leave and go on a fellowship." At the same time, his five colleagues—like many hospitalists who provide some palliative care—do so only on a part-time basis, which Dr. Cassoobhoy finds understandable.
"It's emotionally draining work, so you're at much higher risk of burnout if you do it full time," he notes. Working palliative care one week out of six, on the other hand, "is doable."
No matter what advantages board certification offers, smaller hospitals may be shut out. They aren't as likely to attract physicians who are board certified in palliative care, pay them as much as larger hospitals or afford to lose an on-staff expert to a fellowship year.
Mary Frances Barthel, MD, is medical director with the Cogent HMG hospitalist program at the 330-bed Blessing Hospital in Quincy, Ill. She says that hospitals like Blessing would have a hard time recruiting someone board certified in palliative care.
Dr. Barthel also knows how the other half lives: Her previous job was as chief of medicine at Gundersen Lutheran Medical Center in La Crosse, Wis. The robust palliative care program there consisted of three full-time palliative medicine physicians, a full-time hospice director, three part-time physicians, three full-time nurse practitioners, additional nurses and other support staff. The team not only saw patients but admitted them to the service as the primary team.
Blessing, on the other hand, is starting slow, developing the palliative care program with one physician and one registered nurse, with Dr. Barthel in an advisory role.
Despite her interest and experience in palliative care, she is not pursuing certification. "I don't feel the need to be certified, and I wouldn't do a fellowship at this point in my life," says Dr. Barthel. "There's no time and it's unnecessary in this market. The need to provide service is there, but not exclusively as a board-certified physician."
And she doesn't believe that puts community hospitals at a disadvantage. "The care provided in a community hospital can be just as good, with or without certified physicians," she says. What limits programs in community hospitals isn't the lack of clinical knowledge among palliative care staff, she explains, but the lack of program infrastructure and the fact that some medical staff have not yet "embraced it as a valuable service."
Some smaller communities may get lucky. Kirstin LeSage, MD, a third-year internal medicine resident at Gundersen, is heading to Providence Alaska Medical Center Anchorage for a palliative care fellowship. When she's done, she hopes to return to a smaller community like the one where she grew up. She wants to make a small palliative care service successful by serving a larger region through telemedicine and by traveling regionally to care for patients who might not have access otherwise.
"The fellowship makes palliative care legitimate in the eyes of patients and other subspecialists," says Dr. LeSage. "Because the field is so new and many patients aren't familiar with it, being certified should help instill confidence in my skills." At the same time, she points out, she's going to learn "very valuable skills in program development, community integration and the business aspects of the field."
But experts say physicians, particularly those in the middle of their careers, need other options. Even Dr. Storey from AAHPM, which pushed for specialty recognition, knows that physicians won't opt to go through a fellowship that pays $60,000 a year to work 50 hours a week.
The AAHPM has responded to a similar challenge with hospice physicians by spinning off another credentialing organization for hospice medical directors, with the first exam slated for 2014.
It remains to be seen if a similar model might work for palliative care directors. In the meantime, organizations are exploring midcareer training pathways that could lead to both competencies and recognition, though not formal board certification.
Down the line, palliative care may be a candidate for part-time or "interrupted" training where physicians would complete three to six months of training, return to work, then go back to training. Such a model, Dr. Holmboe says, has been raised as a possibility for hospice, palliative care and geriatrics.
It's a challenging time for palliative care, Dr. Storey notes, but the rewards of doing the work will keep physicians looking for solutions. "The field is desperately needed," he says. "How we credential enough doctors is a big problem."
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.
For physicians interested in providing palliative who won't quit their day job to do a fellowship, experts say there may be other options, including:
Courses. There are a variety of courses, including three- or seven-day courses from The Harvard Medical School Center for Palliative Care.
Telemedicine. This may be a perfect fit for palliative care, in which small or rural hospitals tap into larger facilities’ expertise, says Eric S. Holmboe, MD, chief medical officer and senior vice president of the American Board of Internal Medicine.
Other staff. Nonphysician providers should also have core training and competencies in palliative care. “We recognize that much of the work is being done by other members of interdisciplinary teams, like nurse practitioners, nurses, social workers, chaplains and physician assistants,” says Diane Meier, MD, director of the Center to Advance Palliative Care.