Staffing shortages have been weighing heavily on the minds of hospice and palliative care organization leaders in recent years. The hospice and palliative care workforce has been shrinking due to staff retirement, burnout and limited opportunities for specialty training.
The United States has 13.35 hospice and palliative care specialists for every 100,000 adults 65 and older, according to an April 2018 study. The research 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. Research published in 2019 found that the hospice and palliative care workforce will likely deplete even further during the next two decades due to retirement and burnout.
Greg Phelps, M.D., chief medical officer of Alleo Health System, indicated that widespread burnout among hospice and palliative care clinicians is an issue that will rise as medical education programs nationwide fall short in terms of fellowship opportunities, training and experience in end-of-life and serious illness care.
Chattanooga, Tenn.-based provider Alleo Health System offers education and training focused on hospice and palliative care, including social work, nursing, physician, chaplain and seminary educational outreach programs. They have trained more than 200 students from nine schools in 2019, according to the company.
Alleo is the parent company of Hospice of Chattanooga, Palliative Care Services, Good Shepherd Hospice, Comprehensive Care, and KangarooKidz, the Chattanooga region’s only pediatric specialty hospice and palliative care provider. The company grew last year with the acquisition of Upper Cumberland Hospice and Palliative Care Services in Cookeville, Tenn., and purchase of ABC Hospice in Alabama and Angel Heart Hospice in Georgia.
Phelps recently authored “Education of a Hospice Doctor,” a book detailing the education, training and patient care that hospice clinicians experience. Inspiration for the book came after the loss of Phelps’ mother, when he returned to medical school to complete a fellowship in hospice and palliative care after experiencing burnout in his administrative position.
He recently sat down with Hospice News to discuss the changes needed to expand the hospice and palliative care workforce, including the need to grow fellowship programs in these specialties for clinicians and nurses.
How has your experience in health care led you to the hospice and palliative care fields? What are some of the struggles you experienced?
I often joked with the other residents in the program to think of me as an intern with 30 years of experience. I learned some amazing things from patients and families. I’ve always been intrigued by people on the margins. I’ve practiced medicine in a very poor community for eight years and I’ve treated addicts for a number of years as well.
Having wandered through a variety of different medical experiences in my career, hospice is very rewarding work, but the burnout rate is unbelievably high. With concern to these staffing shortages in hospice and palliative care, if we don’t figure out how to do health care better and address the fact that our patients and staff are getting older, then our whole system is going to break.
Do you see staffing shortages in the hospice industry having a ripple effect? What is the overall health care systems’ perspective on end-of-life care?
The dying are kind of on the periphery of the health care system, and part of what’s needed is changing culture in the hospitals, care teams and health care systems, because I still come across doctors who think that hospice just gives people morphine and kills them. Changing that mindset early on in training and education is so crucial to being able to deliver better care.
I see a tremendous need as a hospice medical director to improve communication. Communication is one of the six core competencies for physicians, and we’re terrible at it. We need to reorient education, starting at the medical school level, about how to talk to people to deliver good news, bad news, goals of care and talk about death and dying. The system right now does not reward that kind of learning. The problem is, nobody’s really training doctors how to do conversations about goals of care and advanced care planning in a streamlined and universal way. Medicare only started paying for doctors to have these conversations a few years ago, but the education is really a crucial missing part.
What inspired you to write a book about education and training in hospice and palliative care?
This book was about going back to medical school and confronting the educational health care system at an advanced age. The number of board-certified doctors in hospice and palliative has gone down and is expected to see another drop in the next 20 years. These fields are usually a mid-career choice that doctors make, with many of them already are burned out by this point.
We need a lot more of these doctors. We have a shortage by the thousands of providers and specialists for older patients with chronic, severe and terminal diseases.
What are some of the book’s key takeaways for providers looking to develop career paths and recruit and retain staff?
A big part of the book is how I, as a physician, learned about end-of-life care and death, going from before medical school until the current day. I think we don’t teach enough about end-of-life care, with medical students having limited experience related to hospice and palliative care. You may never deliver a baby when you get out of medical school, but you are going to have patients die. We need to reorient the medical school curriculum towards what is actually going on out in the world, and people getting old and dying is a big part of that.
Another part of it was intended for a general public and medical audience to help them learn about hospice, palliative and end-of-life care, and how a physician would learn about it, because most physicians and people don’t know much about it. That was one educational aspect: for any health professional that picked up the book to learn something new. I spent a long time explaining how goals-of-care discussions go with a family and what the dynamics of that are, how you can deal with that, and how you can deflect some of the issues that come up at that stage of life.
Are there sufficient resources for hospice and palliative care training in the United States, given the industry’s workforce needs?
I think we can pretty much say “no,” there are not enough resources from a workforce standpoint. The question is, how do we get doctors into this field when there’s only so many fellowship spots in these specialty programs, and to get board-certified, you have to do the fellowship. We need to try to increase the number of people with some training or certification, and try to increase the profession of hospice, because the vast majority of staff such as hospice medical directors don’t have any specialized training.
What are some significant changes that have occurred in hospice and palliative care education and are needed?
The short answer is: not much, but we’re working on it.
So much of what we hear is that hospice means giving up. Instead, we’ve said no to this idea and we’re changing the focus in medicine that we can’t always cure what you have and that life is limited. We need to be working on what we can do to make the time we’ve got as good as we can, when it’s so precious. Our jobs as hospice doctors are to get the patient and their family ready to have those conversations about what the end of life can mean, what you are there for, and what comes next for them and afterwards for their loved ones.