Abstract
Dear Editor:
Since its inception, palliative care (PC) has enjoyed increasing acceptance and successful integration into the U.S. health care system. According to a 2020 report by the center to advance palliative care (CAPC), 83% of U.S. hospitals with 50 or more beds report having a PC team. This is increased from 75% in 2016 and 60% in 2008. 1 The number of hospice and palliative medicine (HPM) physicians has also grown, with approximately 4000 board certified physicians practicing today. Moreover, in 2024, there were 185 fellowship programs, which accepted 385 trainees. 2
Should we be satisfied with this success? Projected changes in both the U.S. population and HPM physician manpower would suggest otherwise. The United States is facing explosive growth in the number of elderly. By 2030, more than 20% of U.S. residents are projected to be aged 65 and over, compared with 13% in 2010 and 9.8% in 19703,4 Many of these individuals will have serious complex medical needs. Indeed, it is estimated that 12% of Medicare enrollees will be appropriate for PC services, a dramatic increase over the number served today. 5 Moreover, advances in all areas of medical care have resulted in a growing number of younger individuals living longer with serious illness.
A growing demand for PC services is not our only challenge. Given an expected wave of retirements over the next decade, the projected number of HPM physician providers is also a pressing issue. Multiple models have concluded that there is a marked gap between the available supply of subspecialty trained PC specialist and the projected need.6,7
Due to a cap on the number of Medicare-funded graduate medical education positions, programs must rely on philanthropy and development to fund fellows, thereby limiting training opportunities. Creating more fellowship positions, however, may not result in more trainees. According to the 2024 National Residency Match Program data, 76 of 451 HPM fellowship positions did not fill. 2
So how should we respond? One solution is to reimagine the role of the HPM physician—one focused less on direct patient care and more on teaching those skills necessary to become effective change agents at the system level. The HPM fellowship curriculum milestones currently focus on “hands-on” clinical care. Given limited manpower, such an emphasis will do little to impact the current system of care or the population as a whole. By adding the training necessary to become effective change agents (health care finance, leadership, quality improvement, education), HPM graduates will be equipped to facilitate transformational change in institutional, state, and national policies, thereby having a far greater impact on improving care. Such training will also give our graduates the fundamental skills necessary to train and equip the large numbers of providers in every discipline who can offer primary PC.
Such a change to the curriculum of HPM fellows will not require additional training time. The fundamentals of symptom management and communication can be taught in less than the 12 months currently required. Indeed, honing these skills is then a lifelong task. Freeing up time to focus on areas critical to affecting system change should not pose significant educational challenges.
By making these changes in the HPM fellowship curriculum, future HPM physicians will affect the care of a far greater number of patients and make meaningful change in serious illness care—the original intent of our profession.