Palliative Care Externship Seeks to Advance Specialty Training

In the midst of ongoing staffing shortages that have been exacerbated by the pandemic, the hospice and palliative care communities have had to get creative in how they train incoming clinicians. The Medical University of South Carolina (MUSC) has designed an “externship” program to speed the professional development of advanced practice providers (APP).

The term “advanced practice provider” refers to advanced practice registered nurses (APRNs), as well as physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNS), and other non-physician licensed independent practitioners. These practitioners represent the fastest growing segment of the health care workforce. Palliative care specialty certifications currently only exist for NPs and CNS.

“We know we can’t put people through long-term [palliative care] training, because they can’t afford it, and it would take too long to meet the needs. So how do we get to primary palliative care? How do we get specialists everywhere that can handle probably about 80% of the palliative issues?” said Patrick Coyne, co-director of the Palliative APP Externship at MUSC, during a presentation at the Center to Transform Advanced Care National Summit on Advanced Illness Care. “We got to push things forward and to meet the needs. We know there’s an opportunity in rural areas, prison systems, nursing homes, where there just aren’t going to be enough physician specialists who are going to be available to do this. But there will probably be an APP that can do this, if they’ve been given the right kind of training and mentorship.”


More than 26% of hospice and palliative care providers in a Hospice News poll earlier this year indicated that staffing would be the greatest (pre-COVID-19) challenge they expected to face during 2020, compared to 18% who cited increased competition and another 18% who said new payment models were their biggest concern.

Currently the United States has 13.35 hospice and palliative care specialists for every 100,000 adults 65 and older. An April 2018 study estimated that by 2040 the patient population will need 10,640 to 24,000 specialists; supply is expected to range between 8,100 and 19,000.

Hospice and palliative care providers are already seeing shortages in other disciplines, including chaplains, nurses, and social workers. As far back as 2008, the U.S. Centers for Medicare & Medicaid Service (CMS) began allowing hospice providers to use contracted nursing staff because not enough nurses were available to fill permanent positions.


“This is when you have to think about getting really creative, given the constraints for APPs. They usually have less money for education and have less time off. There’s issues in terms of going across states to do any sort of clinical work because of scope of practice,” said Constance Dahlin, co-director of the Palliative APP Externship, during the presentation.  “We’ve been looking at the goal, when you think about immersion, and really try to promote advanced practice provider practice by looking at some basic primary palliative care skills. For each discipline, you need to have role models, and you need to have faculty who are within that discipline.” 

A number of barriers exist to expanding the palliative care workforce, including the limited number of graduate specialty programs for APRNs and PAs, the cost of those programs to the students, a general lack of funding for APP specialty education and testing concerns.

The externship program was implemented at a long-established palliative care program at an academic medical center. According to a study published by Dahlin, Coyne and co-authors in the Journal of Palliative Medicine, the program was an Institutional Review Board-approved, week-long intensive externship designed to provide education and training in primary palliative care for APRNs across disease populations.

The study indicated that the program increased participants’ knowledge, skills, and confidence in palliative care. The program trains cohorts of six APPs in pain and symptom management, communication skill building, quality, and program development, with clinical examples. The cost to participants is $2,500.

“In our externship, we have been focused on small cohorts with faculty intensive learning and group cohesion, so that small groups of people who are going through a learning experience also develop a network with each other,” Dahlin said.

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