Professional Certification of Professional Certification of Palliative MedicinePalliative Medicine

Charles F. von Gunten, MD, PhDCharles F. von Gunten, MD, PhDPast ChairmanPast Chairman

Setting the Standard of Setting the Standard of Excellence in Hospice and Excellence in Hospice and

Palliative MedicinePalliative Medicine

Professional Professional certification is certification is

important for the fieldimportant for the field

Palliative Care Palliative Care Interdisciplinary care focused Interdisciplinary care focused

on relieving suffering and on relieving suffering and improving quality of life.improving quality of life.

May be May be combinedcombined with with therapies aimed at reducing therapies aimed at reducing or curing the illness, or it may or curing the illness, or it may be the total focus of care.be the total focus of care.

Standard Model of CareStandard Model of Care

PresentationPresentation DeathDeath

Therapy with Curative IntentTherapy with Curative IntentBereavementBereavement

CareCare

6m6m

Medicare Medicare Hospice Hospice BenefitBenefit

Field & Cassel (eds) IOM Report, 1997

Palliative Care ModelPalliative Care Model

PresentationPresentation DeathDeath

Therapy with Curative IntentTherapy with Curative IntentBereavementBereavement

CareCare

Symptom Rx Symptom Rx Relieve Relieve

SufferingSuffering

Palliative Care

6m6m

Medicare Medicare Hospice Hospice BenefitBenefit

Who does palliative care?Who does palliative care?

PrimaryPrimarySecondarySecondaryTertiaryTertiary

JAMA 2002;287:875-881

Example: Interface of Palliative Example: Interface of Palliative Care and NephrologyCare and Nephrology

Primary Primary Palliative CarePalliative Care

Secondary Secondary Palliative CarePalliative Care

Tertiary Tertiary Palliative CarePalliative Care

Pt with Pt with ESRD, ESRD, nausea & nausea & abdominal abdominal painpain

Nephrologist Nephrologist successfully successfully uses uses antiemetics, antiemetics, analgesics & analgesics & coanalgesicscoanalgesics

Asks for Asks for consult for consult for refractory sx refractory sx and for time-and for time-consuming consuming family family dynamicsdynamics

Admitted to Admitted to pc unit for pc unit for refractory refractory Sx. Rx. PM Sx. Rx. PM fellowfellow

Palliative MedicinePalliative Medicine

The term palliative medicine The term palliative medicine refers to the physician refers to the physician discipline as part of discipline as part of interdisciplinary palliative interdisciplinary palliative care at secondary and care at secondary and tertiary levelstertiary levels

Why a Palliative Medicine Why a Palliative Medicine Subspecialty?Subspecialty?

Improve patient careImprove patient careCreate and disseminate new Create and disseminate new

knowledge knowledge Credibility and recognitionCredibility and recognitionRecognized in UK, Ireland, Recognized in UK, Ireland,

Canada, Australia, New Canada, Australia, New ZealandZealand

Field & Cassel (eds) IOM Report, 1997

The case for palliative The case for palliative medicine subspecialtymedicine subspecialty

Board certificationBoard certificationScholarly researchScholarly researchFellowship trainingFellowship trainingProfessional AssociationProfessional AssociationProfessional RoleProfessional Role

Board CertificationBoard Certification Founded 1995Founded 1995 First examination 1996First examination 1996 1800 diplomates1800 diplomates Exam by NBMEExam by NBME

– 230 items in 4 hour exam230 items in 4 hour exam– 688 items in bank688 items in bank

> 500 applicants for 2005> 500 applicants for 2005 20% growth per year20% growth per year MOC initiated in 2004MOC initiated in 2004

J Palliat Med 2000; 3:441-447

New ABHPM DiplomatesNew ABHPM Diplomates

0

50

100

150

200

250

300

350

400

1996 1998 2000 2002 2004

0 10 20 30 40 50 60

Anesthesia

Family Practice

Internal Medicine

Pediatrics

Radiation Oncology

Surgery

Other

No Response

percent

ABMS BoardsABMS Boards

J Palliat Med 2000; 3:441-447

n = 1535

Scholarly ResearchScholarly Research > 7 Medline-listed peer-> 7 Medline-listed peer-

reviewed specialty journalsreviewed specialty journals– Listed on Fact SheetListed on Fact Sheet

Also published in major Also published in major journals (NEJM, JAMA)journals (NEJM, JAMA)

Many TextbooksMany Textbooks

Fellowship TrainingFellowship Training

47 programs in 200447 programs in 2004– 3 NCI-funded3 NCI-funded

– 6 VA programs6 VA programs

– 97 slots total annually97 slots total annually

www.aahpm.org Accessed May 4, 2004

Fellowship TrainingFellowship Training

1.9 slots per program 1.9 slots per program (median 2, range 1 – 8)(median 2, range 1 – 8)

8.5 applicants per program 8.5 applicants per program (median 6, range 0 – 40)(median 6, range 0 – 40)

4.5 applicants per slot4.5 applicants per slot

February 2004 E-mail surveyFebruary 2004 E-mail survey 86% response rate86% response rate

Fellowship TrainingFellowship Training Voluntary Guidelines Voluntary Guidelines

modeled after ACGME modeled after ACGME modelmodel

Palliative Medicine Review Palliative Medicine Review Committee accredits after Committee accredits after ACGME RRC modelACGME RRC model

ACGME application initiatedACGME application initiated

J Palliat Med 2002; 5:23-33

Professional AssociationProfessional Association

American Academy of American Academy of Hospice and Palliative Hospice and Palliative MedicineMedicine

1900 members1900 members

Professional RoleProfessional Role

Hospital-based consultantsHospital-based consultants– Ambulatory outpatient Ambulatory outpatient

componentcomponent

Hospice medical directorsHospice medical directors

Cohen B, Salsberg, E. SUNY Albany, 2002. http://chws.albany.edu

Professional RoleProfessional Role

30% US hospitals (26% of 30% US hospitals (26% of teaching hospitals) have teaching hospitals) have palliative care consult palliative care consult teamsteams

20% increase annually20% increase annually 6,021 hospitals listed by 6,021 hospitals listed by

AHAAHA

J Palliat Med 2001;4:315-24 J Palliat Med 2001;4:309-14

Professional RoleProfessional Role

3,200 hospice programs3,200 hospice programs care for 25% of US deathscare for 25% of US deaths Each must have at least Each must have at least

one physician medical one physician medical directordirector

Volume of NeedVolume of Need Rapid growth in serious, Rapid growth in serious,

chronic illnesschronic illness Consequence of effective Consequence of effective

technologiestechnologies 2.3 million deaths2.3 million deaths

– 10% sudden10% sudden– Of remaining 90%Of remaining 90%

• 40-60% with unrelieved suffering40-60% with unrelieved suffering

The case for palliative The case for palliative medicine subspecialtymedicine subspecialty

Board certificationBoard certificationScholarly researchScholarly researchFellowship trainingFellowship trainingProfessional AssociationProfessional AssociationProfessional RoleProfessional Role

Setting the Standard of Setting the Standard of Excellence in Hospice and Excellence in Hospice and

Palliative MedicinePalliative Medicine

Professional Professional certification is certification is

important for the fieldimportant for the field