Defining Key Elements of a Clinical Experience in Hospice and Palliative Medicine for Medical Residents in the United States

Abstract

Training in hospice and palliative medicine (HPM) is essential for practicing internists, who routinely care for patients and families facing serious illness. Program directors and medical residents acknowledge the importance of palliative medicine skills, and trainees themselves desire more such training. The ACGME has also recognized the importance of HPM training for medical residents, establishing in its 2022 Common Program Requirements for Internal Medicine a new expectation that all residents have a clinical experience in HPM. However, internal medicine residencies vary significantly in their approach to teaching HPM skills, and what constitutes a useful clinical experience in HPM has not been well-described. In this perspective, we draw from the available literature and our experience as educators to propose 5 core elements for creating an optimal HPM experience for medical residents. These include practice with symptom management and communication in serious illness, exposure to interdisciplinary care, appreciation of the continuum of care settings for HPM delivery, and an understanding of the key principles of hospice care. We then describe the relevance of each element and offer educational strategies regarding how each can be achieved.

Introduction

Generalist skills in hospice and palliative medicine (HPM) are essential for practicing internists, who routinely care for patients and families facing serious illness. ¹ The growing demand for palliative medicine services and limited supply of trained specialists only heightens the importance of developing these skills among internists.^2,3 The ACGME has also recognized the importance of HPM training for medical residents, establishing in its 2022 Common Program Requirements for Internal Medicine a new expectation that all residents have a clinical experience in HPM. ⁴ This expectation represents an important step toward embedding HPM training within all US medicine residencies, yet what comprises an optimal “clinical experience” in HPM has not been well-described.

Internal medicine residencies vary significantly in their approach to teaching HPM skills, ⁵ and while program directors agree on the importance of palliative care training, ⁶ most US medical residencies allocate limited hours to palliative and end-of-life care skills. ⁷ Concurrently, medical residents themselves report suboptimal preparedness to navigate serious illness communication^8,9 and desire more training in HPM skills.^10,11 In this perspective, we draw from the available literature and our experience as internists and palliative medicine educators to propose 5 core elements for creating an optimal clinical experience in HPM for medical residents. Additionally, we describe educational strategies regarding how each element can be achieved.

Core elements of a clinical experience in HPM

Table 1 lists 5 proposed elements of an optimal clinical experience in HPM, as well as preferred and alternative methods for teaching. These elements are derived from expert guidance on essential palliative care competencies for medical residents ¹² and the descriptions of palliative care practice offered by the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, and the World Health Organization. These sources highlight palliative medicine's emphasis on symptom management, skilled communication, an interdisciplinary care team, the continuum of care settings, and the role of hospice care. The teaching methods listed in Table 1 are drawn from our clinical experience and from the available HPM education literature regarding each core element below.

Table 1.

Core elements of a clinical experience in hospice and palliative medicine for internal medicine residents.

Core Element	Proposed Ideal Teaching Method	Alternative Teaching Methods
Practice with symptom management in serious illness	Clinical rotation in inpatient or outpatient palliative care	Clinical rotation with a local hospice agency
		Web-based education modules
		Clinical decision support tools
Practice with serious illness communication	Interactive workshop involving skills practice, followed by direct observation and feedback during a clinical rotation in palliative care	HPM clinical rotation without prior skills practice workshop
		Just-in-time coaching by HPM specialists during clinical rotations
		Dedicated ambulatory clinic sessions focused on advance care planning
Exposure to interdisciplinary care	Clinical rotation in inpatient or outpatient palliative care, with dedicated time to observe and collaborate with nonphysician interdisciplinary team members	Clinical rotation with a local hospice agency
		Attendance at an interdisciplinary team meeting of a local hospice agency
Appreciation of the continuum of care settings for HPM delivery	One or more days spent with nonhospital based palliative care clinicians during a clinical rotation; including HPM clinicians practicing in outpatient, home, or facility settings	Attendance at an interdisciplinary team meeting of a local palliative care practice or hospice agency
Appreciation of the key elements of hospice care	One or more days spent conducting home visits with a hospice nurse or rounding at an inpatient hospice facility	Attendance at an interdisciplinary team meeting of a local hospice agency
		Web-based education modules

Abbreviation: HPM, hospice and palliative medicine.

Practice with symptom management in serious illness

Grounded in enhancing quality of life the seriously ill, HPM practice prioritizes skilled symptom management. This encompasses effective management of pain and non-pain symptoms, including nausea, dyspnea, anxiety, and delirium. Pain management is a core HPM proficiency, including pharmacologic and nonpharmacologic strategies to treat cancer pain and other complex pain needs. Trainees should appreciate how HPM clinicians titrate opioids, monitor for adverse effects, rotate opioids when necessary, and combine them with nonopioid medications and nonmedication modalities (eg, nerve blocks and radiation therapy).

Residents can gain exposure and practice with symptom management in serious illness through palliative care clinical rotations, web-based education, clinical decision support tools, and programs involving mixed educational methods. ¹³ In our experience, clinical rotations with inpatient or outpatient palliative care teams, as well as home-based or inpatient hospice teams, can offer practice with these important skills. Additionally, web-based content, such as the interactive modules offered by the Center to Advance Palliative Care, ¹⁴ may introduce key symptom management principles before a clinical rotation or boost skills after. Direct patient care also allows trainees to engage with nuances of opioid therapy and other symptom management strategies, as well as individualize treatment principles to meet specific patients’ needs.

Practice with serious illness communication

Effective communication skills for navigating serious illness conversations are a core element of HPM practice and an established component of high-quality care. ¹⁵ These skills include assessing patients’ illness understanding, delivering serious news, responding to emotion, exploring goals and values, and recommending goal-concordant plans of care. ¹⁶ Increasingly, effective communication is being framed as a medical procedure which requires preparation, component steps, and practice by trainees, akin to other learnable clinical skills. ¹⁷

Several education strategies have been shown to enhance residents’ communication skills. A structured clinical rotation with HPM specialists, including an inpatient consult service rotation, has been associated with increased trainee use of key communication skills. ¹⁸ Other effective training models include just-in-time coaching of residents by faculty during inpatient rotations, ¹⁹ dedicated ambulatory sessions focused on advanced care planning and supervised by palliative care faculty, ²⁰ and workshops involving simulation ²¹ or interactive skills practice ⁸ to supplement real-time clinical care. In our experience, workshops involving interactive skills practice followed by supervised opportunities to apply skills in clinical settings can be a highly effective strategy for providing serious illness communication training.

Exposure to interdisciplinary care

Interdisciplinary team-based care is foundational to HPM practice. The field draws on the perspectives of clinicians from various disciplines, who collaborate in assessment and management of the patient's physical, psychological, and spiritual sources of distress. Core members of the interdisciplinary team typically include physicians, advanced practice providers, nurses, social workers, chaplains, pharmacists, and others. Interdisciplinary teams often meet regularly to discuss key concerns identified through multiple specialty perspectives in order to develop comprehensive and multidimensional care plans for a panel of patients. Given their role as patients’ primary clinicians in the inpatient and outpatient settings, medical residents may often communicate with various members of the palliative care team, especially around patients’ goals and transitions in care; thus residents’ awareness of the interdisciplinary nature of HPM feels particularly important. Residents may gain exposure to interdisciplinary care through a clinical rotation with palliative care or hospice clinicians in the inpatient, ambulatory, or home-based settings. Such experiences may deepen trainees’ appreciation of the team's communication, their unique professional roles, and the importance of all members in the assessment and care planning process. ²²

In our experience, it is beneficial for residents to spend clinical time with nonphysician team members to build core HPM clinical skills, in addition to gaining a deeper sense of that discipline's perspective and scope of practice. If a more traditional clinical rotation is not possible, residents may also attend a weekly interdisciplinary meeting for a local hospice team, to gain basic exposure to their collaborative practice.

Appreciation of the continuum of care settings for HPM delivery

HPM clinicians care for patients across the continuum of care settings and often provide continuity through transitions in care. These include inpatient, outpatient, home-based care, nursing and long-term care facilities, and home or facility-based hospice settings. While hospital-based palliative care may be most familiar to graduate medical trainees, educators have recognized a need to shift greater emphasis to ambulatory and other nonhospital settings where a majority of patients receive care and the benefits of palliative care are well-described. ²³ Even a single day spent with a home-based palliative care nurse practitioner, a home hospice nurse, or an HPM physician in clinic, can allow residents to experience HPM delivery beyond the hospital. If such experiences are not possible, resident attendance at an interdisciplinary team meeting can also foster learning about how HPM clinicians support patients as care needs change and they transition between care settings.

Appreciation of the key components of hospice care

Medical residents may struggle to distinguish palliative from hospice care, ²⁴ and we believe that a meaningful HPM clinical experience should highlight the key components of hospice. The term “hospice care” both refers to a philosophical approach to care and often carries connotations regarding where care will be delivered. Hospice care focuses on maximizing quality of life for patients with terminal illness during the final months of life, who are typically not pursuing further disease-modifying treatments. Most patients in the United States receive routine level hospice care, delivered by an interprofessional team in a private home or skilled nursing facility, while a smaller portion of patients have more complex symptom management needs necessitating general inpatient level hospice care, delivered in a hospital or inpatient hospice facility. ²⁵

Effective exposure to hospice care should emphasize which patients may qualify, how patients’ symptom and psychosocial needs are matched to the care setting, and how clinicians approach the care of the dying patient. Residents should appreciate that most hospice care in the United States is funded and regulated based on the Medicare hospice benefit (or analogous hospice benefit via commercial insurance), which typically covers costs related to the terminal illness for patients with an estimated prognosis of 6 months or less. ²⁶ A clinical rotation with a hospice program can enhance trainees’ confidence with HPM skills ²⁷ and may be an effective strategy for training residents in the other core elements discussed above, including complex symptom management and interdisciplinary team collaboration.

Conclusion

We have organized the broad scope of HPM into 5 core elements, which program leaders may employ in creating an effective clinical experience. We believe these elements have relevance for both internal medicine and other graduate medical education programs aiming to increase trainee exposure to HPM practice.