Outpatient Training During Hospice and Palliative Medicine Fellowship: A National Survey

Abstract

Context: Outpatient palliative care (PC) has strong evidence demonstrating impact across serious illnesses, resulting in growing demand for skilled outpatient PC clinicians. However, there is limited literature examining the existing state and quality of outpatient PC education during postgraduate training.

Objectives: Characterize the current state of outpatient training in United States (US) Hospice and Palliative Medicine (HPM) physician fellowships and elicit perceptions regarding quality of outpatient PC education.

Methods: A cross-sectional survey of US adult HPM fellowship program directors (PDs) or their designee conducted between March and July, 2023.

Results: Of 161 programs, 85 participated (53% response rate) with representation across all US regions. HPM fellows spend a median of 4.8 weeks in outpatient PC compared to 24 weeks inpatient PC and 10.5 weeks in hospice settings. Over half (51%) of fellows saw outpatients from primarily one disease type with limited exposure to patients with other serious illnesses. Across programs, fellows' clinic structure, interdisciplinary team composition, and didactic experiences varied. On a 5-point rating scale, PDs reported significantly lower quality outpatient versus inpatient training (mean rating: 3.58 vs. 4.62, P<0.001) and perceived fellows as less prepared for independent outpatient practice upon graduation (mean: 4.06 vs. 4.73, P<0.001).

Conclusion: Our survey of US HPM fellowships identified multiple gaps between outpatient and inpatient PC education and training during fellowship and raises concern about the adequacy of outpatient PC training. To prepare the HPM workforce to meet the diverse needs of seriously ill populations and ensure adequate access, outpatient PC training requires reform.

Keywords: Graduate medical education; Hospice and palliative medicine fellowship; Outpatient palliative care; Workforce development.

Figure 1:. HPM Fellows’ Exposure to Different Serious Illnesses.

Program directors rated on a 5-point scale how frequent their fellows see patients with each serious illness type in their longitudinal outpatient clinic experience.

Figure 2:. Perceived Quality of Outpatient PC Training during HPM Fellowship.

Program directors rated their perceptions regarding (a) the quality of their fellowship program’s clinical training and didactic experience across care settings, (b) fellows’ preparedness for independent practice upon graduation across care settings, and (c) confidence in fellows’ ability to independently perform core PC clinical skills in inpatient (IP) or outpatient (OP) settings. Graphs depict mean rating scores with error bars showing standard error of the mean. Reported significance values calculated using the Wilcoxon Sign Rank test between specified pairwise comparisons. ***p<0.0001, **p=0.006.

Figure 3:. Perceived Confidence in HPM Fellows Performing Outpatient-Focused Skills.

Program directors rated how confident they perceive their fellows independently perform the listed outpatient-focused skill upon fellowship graduation. Clinical skills related to opioid use and misuse are labeled with asterisks. Graphs depict mean rating scores and error bars show standard error of the mean. OUD: Opioid Use Disorder; Mgmt: management.