Gary Winzelberg: Education Key to Hospice and Palliative Workforce Shortages

Gary Winzelberg, M.D., is director of the University of North Carolina (UNC) at Chapel Hill’s Hospice and Palliative Medicine Fellowship Program and associate professor in the Division of Geriatric Medicine of the UNC School of Medicine. Board certified in hospice and palliative, geriatric and internal medicine, his teaching focuses on improving providers’ serious illness communication skills, particularly with families of incapacitated patients.

The UNC Hospice and Palliative Medicine Fellowship Program is a career development initiative established in 2015 through a partnership with the hospice, palliative care and home health provider Transitions LifeCare to provide academic and community-based training with diverse patient populations. The Raleigh, N.C.-based hospice provider made moves last year to advance staff training with a symptom simulation program. The university and hospice collaboration fellowship training program seeks to develop future hospice and palliative medicine leaders in clinical care, education, quality improvement and research.

Winzelberg recently connected with Hospice News to talk about workforce shortages plaguing the hospice and palliative care industries. Expected to worsen in coming years, staffing concerns topped the list of 2020 challenges among 300 respondents of industry professionals, executive leaders and managers in a survey from Hospice News in collaboration with Dallas-based tech company Homecare Homebase.

A contributing factor to the staffing shortages is the limited availability of specialized training in these fields. Many providers have recognized the need to improve availability of hospice and palliative care training and plans for fellowship programs as avenues to redesign career paths and build up the workforce.

How did the UNC Hospice and Palliative Medicine Fellowship Program develop in partnership with Transitions Lifecare?

In the triangle of North Carolina the need was there before the fellowship program began, and it’s only increased in the last five years. From the start, we have partnered to train physicians in this specialty for the good of the hospice field. Truly also for the reality of the need to increase the workforce.

We slowly increased our program to train four fellows per year currently, both with the support of our health system and with what I think is a pretty distinctive partnership that we’ve had with Transitions LifeCare. It is a separate, nonprofit, community-based organization that’s been around in Raleigh in the triangle region of North Carolina for more than 40 years.

We’ve graduated 13 fellows, a small number in the last five years, but four have actually been taken on as physicians with Transitions LifeCare, who helped them grow.

How does the fellowship program work as a training and educational development advancement in the hospice and palliative care fields?

The fellows spend between about a quarter of their time with Transitions LifeCare, which provides hospice care training as well as some training related to palliative care, particularly in the long-term care setting. We do some hospice training through UNC, but most of it is Transitions. For our trainees, it’s a pretty distinctive combination of both academic and community-based training.

Our fellowship is a one-year training program, and there are certain requirements that each physician who goes through the program has to complete. They have to spend two and a half months of it doing hospice work, have experiences with inpatient hospice, and they have to complete at least 25 home hospice visits. Then there are also requirements related to hospital-based palliative care and long-term care, but hospice is a core component of their training.

What would you say are some of the issues that might be contributing to industry-wide shortages in hospice and palliative care fields?

There are lots of different sorts of workforce issues, but I think one is making sure that fellows have access to high-quality hospice care and dedicated interprofessional teams. Fortunately, that’s been the experience of the fellows in our program.

I’m part of some national discussions about training, and to me the more community-based hospices can link and serve as training sites for fellowship is sort of a win-win situation in terms of what I invariably hear from my fellows about how meaningful and impactful professionally the opportunity is to work in hospice. Essentially, no physician in their residency training receives any hospice experience or training. If they do, it may be very minimal. By working with hospice organizations, fellows learn a lot.

How does limited specialized training in the hospice and palliative care fields contribute to workforce shortages?

The number of physicians matched to our program is slowly increasing, but that is so much less than what the field needs in terms of hospice and palliative care.

Limited availability of specialized training in hospice and palliative care fields is a contributor to the workforce shortages. Another piece is that physicians in training are used to hospital-based care. There are other ways to get hospice training, but the main one is through a fellowship option.

What we’ve really tried to do is put hospice as much on an even playing field in terms of training as palliative care, and give sufficient time and attention into how the fellows are spending their time and the kind of education they’re getting because it’s such an important just plan on its own. Physicians who are providing palliative care need to know and have skills in what hospice actually provides, not just the regulations but the actual services.

What might be some of the reasons why these workforce shortages are expected to worsen in coming years?

In terms of physicians, I have a little bit of a sense from advanced practice providers like nurse practitioners or physician’s assistants that there’s a significant sort of gap between what the supply is and what the need is. I think that’s where we and other programs are seeking to be able to grow and to meet that need.

In general, medical training would benefit from increased attention to palliative care training because in terms of the population of individuals who receive hospice, there will never be a sufficient number of fellowship-trained physicians to provide the care and similarly with palliative care.

What can hospice and palliative care providers do to improve access to specialized training in end-of-life and seriously ill care?

In terms of trying to improve the skills of physicians in advance care planning and serious illness communication, all of us in hospice and palliative care are our own representatives of the field. Being able to work with our colleagues, support them and their skill development patient by patient, or offering talks with other kinds of professionals is something that we’re all committed to as well.

The more that we can do as physicians to receive training, be able to have a certain skill level, and then be able to turn colleagues with more expertise, that’s what we try to do in a fellowship. We educate our colleagues. It starts with those who are in residency training, but it includes our colleagues that are in practice to support them in their skill development.

In terms of the receptiveness to palliative care and moving things upstream, the culture of medicine towards serious illness catalyzed in part because attitudes are changing. That’s where these fellowships are sort of at the nexus of training the next generation of leaders. These programs train leaders that will provide care themselves, but hopefully in kind of a ripple effect also impact their colleagues.

How can hospice and palliative care providers break down any existing barriers to specialized training?

Some of the training issues are limited by the supply of our ability to teach. A dream is to have a training system where everyone — family physicians, pediatricians, internists — had required hospice training.

It is possible in physician training and internal medicine care of adults to not receive any direct training related to hospice care as part of their residency. Residents have required experiences in other disciplines of medicine, but not necessarily in hospice and palliative care.

There really are additional sorts of modifications to training that could be made that would enhance skill development for physicians and encourage that career path in hospice to develop.

What are some of the ways that hospice and palliative care fellowship programs are redesigning career paths in these fields?

It is a challenge to accomplish everything in a one-year training program, but it sets a foundation of skills. After completing the program, each fellow takes on helping to build on that foundation. The other piece that makes fellowship training so unique is that essentially any physician can pursue fellowship training in hospice and palliative medicine except for pathology. The individuals pursuing fellowship training are incredibly diverse.

A value of fellows training is that they have to see a number of patients across multiple care settings longitudinally. There’s a lot of fragmentation in medicine, or at least risk of fragmentation. Fellows are required to try to see as many patients as possible who are in different settings. That’s an important part of training in terms of trying to understand the health care system and potentially be able to advocate for changes based on trying to meet the needs of patients as well as possible.