Development of Entrustable Professional Activities for...

Accepted Manuscript

Development of Entrustable Professional Activities for Hospice and PalliativeMedicine Fellowship Training in the United States

Lindy H. Landzaat, DO FAAHPM, Assistant Professor, Hospice and PalliativeMedicine Fellowship Program Director, Michael D. Barnett, MD MS FAAP FAAHPM,Palliative Medicine Fellowship Program Director, Assistant Professor of Medicine& Pediatrics, Gary T. Buckholz, MD FAAHPM, Associate Clinical Professor, Co-Program Director, Jillian L. Gustin, MD FAAHPM, Clinical Assistant Professor,Hospice and Palliative Medicine Fellowship Program Director, Jennifer M. Hwang,MD MHS, Director of Education, Pediatric Advanced Care Team and Hospice andPalliative Medicine Fellowship Director, Assistant Professor of Clinical Pediatrics,Stacie K. Levine, MD FAAHPM, Associate Professor, Hospice and Palliative MedicineFellowship Program Director, Director of Palliative Medicine Programs, Tomasz Okon,MD, Director, Marshfield Clinic Palliative Medicine Fellowship, Steven M. Radwany,MD FACP FAAHPM, Hospice and Palliative Medicine Fellowship Director, Holly B.Yang, MD MSHPEd HMDC FAAHPM FACP, Assistant Clinical Professor, Hospiceand Palliative Medicine Fellowship Program Co-Director, John Encandela, PhD,Associate Professor of Psychiatry, Associate Director for Curriculum and EducatorAssessment, Laura J. Morrison, MD FAAHPM, Hospice and Palliative MedicineFellowship Program Director, Associate Professor of Medicine

PII: S0885-3924(17)30266-X

DOI: 10.1016/j.jpainsymman.2017.07.003

Reference: JPS 9428

To appear in: Journal of Pain and Symptom Management

Received Date: 27 January 2017

Revised Date: 6 June 2017

Accepted Date: 6 July 2017

Please cite this article as: Landzaat LH, Barnett MD, Buckholz GT, Gustin JL, Hwang JM, Levine SK,Okon T, Radwany SM, Yang HB, Encandela J, Morrison LJ, Development of Entrustable ProfessionalActivities for Hospice and Palliative Medicine Fellowship Training in the United States, Journal of Painand Symptom Management (2017), doi: 10.1016/j.jpainsymman.2017.07.003.

http://dx.doi.org/10.1016/j.jpainsymman.2017.07.003

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service toour customers we are providing this early version of the manuscript. The manuscript will undergocopyediting, typesetting, and review of the resulting proof before it is published in its final form. Pleasenote that during the production process errors may be discovered which could affect the content, and alllegal disclaimers that apply to the journal pertain.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

1

Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States

Lindy H. Landzaat, DO FAAHPM, Assistant Professor, Hospice and Palliative Medicine Fellowship Program

Director, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA

Michael D. Barnett, MD MS FAAP FAAHPM, Palliative Medicine Fellowship Program Director, Assistant

Professor of Medicine & Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA

Gary T. Buckholz, MD FAAHPM, Associate Clinical Professor, Co-Program Director University of California San

Diego/Scripps Health Hospice and Palliative Medicine Fellowship, University of California San Diego, La

Jolla, CA, USA

Jillian L. Gustin, MD FAAHPM, Clinical Assistant Professor, Division of Palliative Medicine, Department of

Internal Medicine, Hospice and Palliative Medicine Fellowship Program Director, The Ohio State

University Wexner Medical Center, Columbus, OH, USA

Jennifer M. Hwang, MD MHS, Director of Education, Pediatric Advanced Care Team and Hospice and Palliative

Medicine Fellowship Director, The Children's Hospital of Philadelphia. Assistant Professor of Clinical

Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

Stacie K. Levine, MD FAAHPM, Associate Professor, Hospice and Palliative Medicine Fellowship Program

Director, Director of Palliative Medicine Programs, University of Chicago, Chicago, IL, USA.

Tomasz Okon, MD, Director, Marshfield Clinic Palliative Medicine Fellowship Marshfield Clinic, Marshfield, WI,

USA

Steven M. Radwany, MD FACP FAAHPM, Hospice and Palliative Medicine Fellowship Director, Ethics

Committee Chair, Summa Health / Northeast Ohio Medical University, Akron, OH, USA.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

2

Holly B. Yang, MD MSHPEd HMDC FAAHPM FACP, Assistant Clinical Professor, University of California San

Diego/Scripps Health Hospice and Palliative Medicine Fellowship Program Co-Director, Scripps Health

San Diego, CA, USA

John Encandela, PhD, Associate Professor of Psychiatry, Associate Director for Curriculum and Educator

Assessment, Teaching & Learning Center Yale School of Medicine, Yale School of Medicine, New

Haven, CT, USA

Laura J. Morrison, MD FAAHPM, Hospice and Palliative Medicine Fellowship Program Director, Yale Palliative

Care Program, Associate Professor of Medicine, Department of Medicine, Yale School of Medicine,

New Haven, CT, USA

Running Title: HPM Entrustable Professional Activities

Corresponding author contact information:

Lindy Landzaat DO FAAHPM,

3901 Rainbow Blvd, MS 1020, University of Kansas Medical Center, Kansas City, KS, 66160 USA

Phone: 913-588-3807 fax: 913-588-3877 email: [email protected]

Abbreviations used:

EPAs Entrustable Professional Activities

AAHPM American Academy of Hospice and Palliative Medicine

HPM Hospice and Palliative Medicine

ACGME Accreditation Council for Graduate Medical Education

NAS Next Accreditation System

CM Curricular Milestone

CMs Curricular Milestones

US United States

HMD Hospice Medical Director

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

3

FAQ Frequently Asked Question

ABMS American Board of Medical Specialties

IDT Interdisciplinary team

LST Life Sustaining Therapies

Figures in paper do not require color.

Keywords: Entrustable Professional Activities, Hospice, Palliative Care, Fellowship, Graduate Medical

Education

Author Contribution List

Lindy H. Landzaat: Lead manuscript author and primary EPA author; associate chair of workgroup with

significant input to overall project design and methods, primary data analysis and interpretation

Michael D. Barnett: Primary EPA author and critically revised manuscript for important intellectual content;

workgroup member; contributed to project design and methods, data analysis & interpretation

Gary T. Buckholz: Primary EPA author and critically revised manuscript for important intellectual content;


Jillian L. Gustin: Primary EPA author and critically revised manuscript for important intellectual content;


Jennifer M. Hwang: Primary EPA author and critically revised manuscript for important intellectual content;


Stacie K. Levine: Primary EPA author and critically revised manuscript for important intellectual content;


MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

4

Tomasz Okon: Primary EPA author and critically revised manuscript for important intellectual content;


Steven “Skip” Radwany: Primary EPA author and critically revised manuscript for important intellectual

content; workgroup member; contributed to project design and methods, data analysis & interpretation

Holly B. Yang: Primary EPA author and critically revised manuscript for important intellectual content;


John Encandela: Provided significant manuscript revisions; contributed to national survey design; performed

data analysis, statistical support and interpretation.

Laura J. Morrison: Senior author providing significant manuscript revisions and primary EPA author; chair of

workgroup and responsible for overall project design and methods, primary data analysis and interpretation.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

5

Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States

Landzaat LH, Barnett MD, Buckholz GT, Gustin JL, Hwang JM, Levine SK, Okon T, Radwany SM, Yang

HB, Encandela J, Morrison LJ

Context: Entrustable Professional Activities (EPAs) represent the key physician tasks of a specialty. Once a

trainee demonstrates competence in an activity, they can then be ‘entrusted’ to practice without supervision1.

A physician workgroup of the American Academy of Hospice and Palliative Medicine (AAHPM) sought to define

Hospice and Palliative Medicine (HPM) EPAs.

Objective: To describe the development of a set of consensus EPAs for HPM fellowship training in the United

States.

Methods: A set of HPM EPAs was developed through an iterative consensus process involving an expert

workgroup, vetting at a national meeting with HPM educators, and an electronic survey from a national

registry of 3,550 HPM physicians. Vetting feedback was reviewed and survey data were statistically analyzed.

Final EPA revisions followed from the multisource feedback.

Results: Through the iterative consensus process, a set of 17 HPM EPAs was created, detailed, and revised. In

the national survey, 362 HPM specialists responded (10%), including 58 of 126 fellowship program directors

(46%). Respondents indicated the set of 17 EPAs well-represented the core activities of HPM physician

practice (mean 4.72 on a 5-point Likert scale) and considered all EPAs to either be “essential” or “important”

with none of the EPAs ranking “neither essential, nor important.”

Conclusions: A set of 17 EPAs was developed using national input of practicing physicians & program directors

and an iterative expert workgroup consensus process. The workgroup anticipates EPAs can assist fellowship

directors with strengthening competency-based training curricula.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

6

Introduction:

The transition from the Accreditation Council for Graduate Medical Education’s (ACGME) 1999 Outcome

Project to the 2013 Next Accreditation System (NAS) has evoked new challenges in graduate medical training

as programs continue to adapt and evolve from process-related compliance to demonstration of meaningful

competency-based outcomes in resident education.2,3

Entrustable Professional Activities (EPAs) emerged

independent of, and complementary to, the new NAS framework. They define the “essential tasks of

professional practice.”4 EPAs are observable, meaningful, manageable points of assessment that characterize a

physician’s key activities within a medical specialty5. These representative activities are “entrusted” to the

trainee, to perform without supervision, once they gain and demonstrate competence.1,6

Each EPA requires a

combination of knowledge, skills, and attitudes to execute, and draws on multiple ACGME core competencies

for successful entrustment. Some medical disciplines in the US have defined specialty-specific EPAs.7,8,9,10

Additionally, the Canadian Society of Palliative Care Physicians released a set of Palliative Medicine EPAs in

2015.11

HPM EPAs serve several valuable roles as they describe the essential work of the field for medical providers,

educators, and the larger healthcare community6. First, by defining core HPM physician activities, EPAs aid in

educating the wider community about the evolving role of HPM. This is particularly helpful since HPM fellows

in the US may seek fellowship training after completing one of 11 different residency backgrounds.

Additionally, as alternative mid-career training pathways develop to help address HPM workforce shortages12

,

EPAs can pave the way for innovative delivery of curricula with comparable core content. The hope is that

EPAs will directly and positively influence fellowship training and ultimately improve patient and family care

outcomes.

The American Academy of Hospice and Palliative Medicine (AAHPM) has a long history of sponsoring

workgroups to promote development of Hospice and Palliative Medicine (HPM) medical education.

Workgroups have created adult and pediatric focused HPM competencies, measurable outcomes, and a toolkit

of assessment methods to support fellowship training. 13,14,15,16,17

In response to the NAS charge to better

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

7

define competency-based outcomes, AAHPM convened a 2014 workgroup of expert HPM educators charged

with defining EPAs for HPM fellowship training, the EPA Workgroup (hereafter, “the workgroup”). This paper

describes the workgroup’s process for developing the 17 HPM EPAs for US fellowship trainees.

Methods:

EPA Development:

To develop EPAs, a workgroup undertook a group vetting and consensus process that drew elements from

modified Delphi and Nominal Group Processes18

. The workgroup included ten physician members

representing diversity in adult and pediatric care, geography, gender, years of practice, and hospice and

academic practice settings. All members served as HPM fellowship directors and led multiple HPM educational

initiatives at their institutions.

At an in-person inaugural meeting in May 2014, the workgroup benchmarked with other specialty and

subspecialty EPAs and consulted with ACGME Milestone Development leadership to define the aims and

processes for HPM EPA development. The workgroup defined HPM EPAs as the critical tasks expected of a

fellow by the end of training. Throughout the EPA development path, the workgroup regularly referenced the

EPA characteristics 6,9 originally defined by ten Cate. The workgroup recognized that while an HPM graduating

fellow may not ultimately perform all the EPAs in future independent practice, the EPA set should include

important activities that prepare graduating fellows for the diverse work of HPM. The workgroup favored a set

of EPAs that was observable and limited in number, yet inclusive enough to meaningfully represent the

essential work of an HPM physician.

After developing a common understanding of EPAs, the workgroup initially identified eighteen EPA topics.

Working in 5 dyads that each drafted 3 or 4 EPAs, the workgroup created the first set of 18 EPAs. From May

2014 to October 2015, the workgroup conducted twenty 90-minute meetings: nineteen conference calls and

another in-person session at the 2015 national AAHPM conference. Through an iterative process, (see Figure

1), each workgroup member fully reviewed each individual EPA for content as well as fit in the set at least

twice. The set was reviewed multiple times as a whole to assess the need to combine, split, or add EPAs. In

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

8

addition to reviewing, workgroup members also revised assigned EPAs with group discussion for consensus.

After two rounds of review and revision, 16 EPAs remained from the initial list of 18.

EPA vetting process:

The workgroup pursued a multiphase external vetting process to ensure the EPA set was comprehensive and

to garner consensus within the HPM community. First, the workgroup invited a convenience sample of

twenty recent fellowship graduates to review a preliminary set of EPAs for any omissions in light of the

everyday tasks defining their current professional roles. Fifteen provided feedback that was examined by the

workgroup and resulted in no EPA additions. Next, at the February 2015 AAHPM Annual Assembly, over 100

HPM physician fellowship leaders (the majority being fellowship program directors) each participated in a two-

and-a-half hours EPA vetting session, including a didactic presentation of background content and process

information, a facilitated small group exercise to review and provide specific feedback on four assigned EPAs,

and a large group debriefing to identify additional feedback. Additionally, a subsequent one-hour session at

the same Assembly, open to all interprofessional conference attendees, garnered feedback from 74 registrants

in a similar but abbreviated process. The workgroup performed a detailed review of the comments as part of

the ongoing iterative process (Figure 2). Some feedback suggested changes for content felt to be more

relevant at a learning objective or curricular milestone level, rather than an EPA level. Other times, the

content was already included as part of the more detailed EPA set though that may not have been readily

apparent to the participant. Three significant outcomes resulted: the creation of a new 17th EPA, targeted

revisions to the EPA set, or the addition of text in the final document describing the workgroup’s rationale for

content decisions.

National Survey Vetting:

The final vetting activity was an electronic survey distributed to the AAHPM physician membership (3,550

physician members listed in the national registry) with the goal of achieving a robust, broad measure of

consensus across the field on how well the EPAs represented the essential activities of practicing HPM

physicians. A 3-week time window for completion was provided.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

9

After offering a brief context and description of Entrustable Professional Activities, participants were asked to

reflect on the core tasks that define their role as an HPM physician and then, to rate, using a 5-point Likert

Scale (“very poorly” to “very well”) how well the EPA-set represented core tasks of HPM practice. Participants

were also asked to review each proposed EPA for “how essential or important is competence in each proposed

EPA” for a graduating HPM fellow. Modeled off similar surveys,19,20

options included “Essential for all”,

“Important for all but not essential”, or “Not important or essential.” The survey also solicited potential EPA

omissions and collected demographic information on the participants (Table 1). This study received exempt

status by both the Yale University Human Investigation Committee and the University of Kansas Human

Subjects Committee.

Statistical Analysis:

To analyze how well the EPAs represented the core tasks of HPM practice, means and frequencies for each of

the EPAs were established. Percentages of respondents’ priority ratings (i.e., essential, important but not

essential, and not important or essential) were also established for each EPA. Chi square tests were performed

for each of 19 independent variables (e.g., respondent gender, age, role vis-à-vis HPM practice and teaching,

years in practice, etc.) as these were associated with respondent perceptions of priority rating for each EPA.

Only those associations found to be significant are reported below in the Results section, with explanations of

how these findings informed our decisions about EPAs. Frequencies and percentages were also established to

describe respondent demographics and characteristics of their work.

Results:

EPA Development:

During the iterative process of review and revision, the initial draft of 18 EPA topics transitioned to 16 EPAs.

Five EPA topics merged into one, 3 new topics emerged, and one was topic was eliminated. In direct response

to vetting comments from the two national conference sessions, a new EPA, “Promote and teach hospice and

palliative care,” was added, resulting in a final total of 17 EPAs (Appendix 1). In the end, each of the 17 EPAs

included a title, an expanded description, and relevant, bulleted knowledge, skills, and attitudes. A summary

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

10

of feedback and resulting actions is included in Figure 2. The workgroup created a Frequently Asked

Questions section of the EPA document to address some of the recurring feedback obtained during the vetting

process. The final EPA list was released to the field on November 23, 2015 with an online document21

.

National Vetting Survey:

A total of 362 physicians participated out of 3550 potential participants, yielding a 10% response rate.

Participant demographics are listed in Table 1. Respondents generally dedicated over 75% of their time to

practice of HPM, 41% served as hospice medical director or hospice team physician, and approximately 90%

were involved in teaching medical trainees. Nearly three times as many respondents practiced primarily in

palliative care settings as in hospice settings (58.9% vs. 20.4%). Fifty-eight respondents were HPM Fellowship

Directors representing approximately 46% of the 126 HPM fellowship program directors.

The mean rating of how well the set of 17 EPAs represent the core activities for HPM physicians using a 5-point

Likert scale was 4.72 (SD=0.65). As noted in Table 2 and Figure 3, none of the 17 EPAs fell into the primary

category of “not essential or important.” With EPAs being a new concept in HPM, there is no accepted level of

consensus to guide inclusion or exclusion. The workgroup anticipated that any EPAs rating primarily as “not

essential, nor important” would have been eliminated and those with a majority vote of “essential” would

likely be retained.

All but one of the EPAs fell primarily into the “essential” category. EPA 15, “Fulfill the role of a hospice medical

director,” had a majority of responses in the “important but not essential for all” category. Chi square results

showed, not surprisingly, that hospice medical directors, also referred to as hospice team physicians, (41% of

respondents) were statistically more likely to rate this EPA higher than colleagues not working in hospice (p

<0.01). The majority of respondents, however, (59%) practiced palliative care but not hospice. The workgroup

reviewed all survey data in detail, including all comments, elected to retain all 17 EPAs, and made final

revisions.

Discussion

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

11

This paper reports the development of 17 consensus HPM EPAs that expand the national education

infrastructure for HPM fellowship training. This defined list of key physician activities is expected to serve as a

guide to inform HPM Fellowship curricula and may serve as the basis for designing performance assessment

tools to determine fellow physician entrustment. EPAs may prompt fellowship programs to examine their

current curricula and highlight a need for focused attention on competence in key clinical tasks. Because they

are not a current requirement, fellowship programs have flexibility in which EPAs to use and how to use them.

The EPAs also provide fellows a more specific framing of the entrustment tasks expected of them by the end of

fellowship, including detailing of the requisite knowledge, skills, and attitudes for each.

Strengths of our process included an extensive iterative process by a workgroup of expert HPM educators,

vetting at a national meeting with program directors and practicing providers, and vetting through a national

survey of HPM physicians. Our survey participants were clinically active, represented both hospice and

palliative care settings, and were routinely involved in HPM education.

The EPA development process and vetting included limitations. First, regarding the survey design, the

measurement of reliability for survey takers is limited given the single administration design. The survey

response rate was relatively low at 10%. The workgroup opted to err on the side of broader representation

and ‘cast the net widely’ by sending the survey invitation to all AAHPM physician members. The 10% response

rate is in line with the average for a convenience sample on AAHPM surveys22. Program directors were

represented with 46% participating, a response rate in line with a similar national educational workgroup

vetting process20

. The threat of bias that exists with convenience sampling may be offset somewhat in our

study by the fact that two important constituencies—hospice medical directors/team physicians and

fellowship directors—were relatively well represented in the sample.

Our process highlights a number of ongoing challenges for competency-based education and others pursuing

EPA development. One challenge was how to effectively balance breadth and depth of EPAs in light of the

need for practical application. The workgroup aimed to define EPAs that were discrete enough to be

observable and potentially measurable while keeping the total number manageable for one-year HPM clinical

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

12

fellowships. Another challenge was finding the balance between “lumping and splitting” different EPAs. For

instance, should the Psychosocial EPA #11, and Spiritual Care EPA #12 be merged into a broader Support EPA

or remain distinct? Should EPA #6, ‘Participate as a member or leader of an interdisciplinary team,’ be its own

EPA or simply be an element included within multiple EPAs? The workgroup chose to elevate particular

constructs to individual EPAs in order to underscore the importance of certain sets of knowledge and skills

necessary to perform the work as part of the field’s current growth and professional expectation. The

workgroup chose to address some of the areas that generated a lot of discussion by offering rationales in a

Frequently Asked Question (FAQ) section within the final EPA document21

. EPAs are a new framework

currently not required by the ACGME and may be unfamiliar to many educators. Therefore, how EPAs will be

applied is unclear, complicating our goal of designing them to be useful and practical. Finally, as originally

defined, EPAs are to be independently executable.6 This is important to successful evaluation of an individual’s

performance, but for an inherently team-based specialty, “independently executable6” may prove a practical

implementation challenge.

Our vetting process also suggested that variability exists within the HPM field in the interpretation of “Hospice

Medical Director” terminology (EPA #15). The title may broadly refer to any physician employed by a hospice

(i.e. a hospice team physician). In some settings, however, this title is reserved for a single lead physician of a

hospice organization. The workgroup intended the former definition for EPA #15. However, ambiguity around

the term could have confounded and lowered the ratings for this EPA if respondents considered the narrower

HMD definition. In addition, very few survey participants thought this EPA warranted the lowest category of

'not important or essential'. There was universal workgroup consensus that this EPA was in fact 'essential to

all.' In considering the risk of burden to harm, since EPAs are not an ACGME requirement and program

directors have discretion about which EPAs they use and how they use them, keeping a potentially less useful

EPA in the set seemed to be a safer approach than discarding a potentially ‘essential-to-training’ EPA. Given

that, the workgroup elected to retain EPA #15 as part of the final EPA set. Since field-specific terminology can

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

13

be interpreted inconsistently and complicate the vetting process, the workgroup suggests that others

proactively anticipate and address terminology dilemmas if vetting EPAs.

Conclusion: The AAHPM EPA workgroup developed a consensus set of 17 EPAs that represent the essential

activities of entrustment for US HPM fellowship graduates. The set of 17 EPAs rated highly as representing the

core activities of HPM after a multi-phased vetting process. This final EPA list describes key HPM physician

tasks and defines EPAs for the field of HPM. It offers fellowship programs a tool to assist with competency-

based curricula and a launching point for developing entrustment assessments. The practical application and

experience of applying the new EPA construct to HPM fellowship training, mid-career training pathways, and

other settings will inform future research, revisions, and future iterations of HPM EPAs.

Disclosures & Acknowledgments: This work received administrative support and travel-related funding for

the workgroup’s initial in-person meeting from the Academy of Hospice and Palliative Medicine. There was no

other additional funding for this work. The authors would like to thank the American Academy of Hospice and

Palliative Medicine for supporting HPM EPA development, and specifically thanks Ms. Margaret Rudnik and

Ms. Dawn Levreau for their administrative expertise and contributions to the project. In addition, the

workgroup is appreciative of advising by Laura Edgar, EdD, CAE, ACGME Executive Director for Milestone

Development. The authors declare no conflict of interest.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

14

References:

1. Ten Cate O. Nuts and bolts of entrustable professional activities. J Grad Med Educ. 2013;5:157-158.

2. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system--rationale and benefits. N

Engl J Med. 2012;366:1051-1056.

3. Nasca TJ, Weiss KB, Bagian JP, Brigham TP. The Accreditation System After the “Next Accreditation

System.” Acad Med. 2014;89:27-29.

4. Accreditation Council for Graduate Medical Education (ACGME). Frequently Asked Questions:

Milestones.

5. Accreditation Council for Graduate Medical Education (ACGME). Internal Medicine Subspecialty

Reporting Milestones Frequently Asked Questions (FAQs).

6. ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory

and clinical practice? Acad Med. 2007;82:542-547.

7. Leipzig RM, Sauvigné K, Granville LJ, et al. What is a geriatrician? American Geriatrics Society and

Association of Directors of Geriatric Academic Programs end-of-training entrustable professional

activities for geriatric medicine. J Am Geriatr Soc. 2014;62:924-929.

8. Boyce P, Spratt C, Davies M, McEvoy P. Using entrustable professional activities to guide curriculum

development in psychiatry training. BMC Med Educ. 2011;11:96.

9. Shaughnessy AF, Sparks J, Cohen-Osher M, et al. Entrustable professional activities in family medicine. J

Grad Med Educ. 2013;5:112-118.

10. Hauer KE, Kohlwes J, Cornett P, et al. Identifying entrustable professional activities in internal medicine

training. J Grad Med Educ. 2013;5:54-59.

11. Myers J, Krueger P, Webster F, et al. Development and Validation of a Set of Palliative Medicine

Entrustable Professional Activities: Findings from a Mixed Methods Study. J Palliat Med. 2015;18:682-

690.

12. Lupu D. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

15

Symptom Manage. 2010;40:899-911.

13. Morrison LJ, Arnold R, Billings JA, et al. Hospice and Palliative Medicine Competencies Project: Toolkit of

Assessment Methods. 2010.

14. Morrison LJ, Scott JO, Block SD. Developing Initial Competency-based Outcomes for the Hospice and

Palliative Medicine Subspecialist: phase I of the hospice and palliative medicine competencies project. J

Palliat Med. 2007;10:313-330.

15. Arnold R, Billings J, Block S, et al. Hospice and Palliative Medicine Core Competencies. on-line.

16. Klick J, Friebert S, Hutton N, et al. Pediatric-Hospice and Palliative Medicine Competencies, version 2.0.

on-line2.

17. Klick JC, Friebert S, Hutton N, et al. Developing competencies for pediatric hospice and palliative

medicine. Pediatrics. 2014;134:e1670-7.

18. Fink A, Kosecoff J, Chassin M, Brook RH. Consensus methods: Characteristics and guidelines for use. Am

J Public Health. 1984.

19. Schaefer KG, Chittenden EH, Sullivan AM, et al. Raising the bar for the care of seriously ill patients:

results of a national survey to define essential palliative care competencies for medical students and

residents. Acad Med. 2014;89:1024-1031.

20. Parks SM, Harper GM, Fernandez H, Sauvigne K, Leipzig RM. American Geriatrics Society/Association of

Directors of Geriatric Academic Programs curricular milestones for graduating geriatric fellows. J Am

Geriatr Soc. 2014;62:930-935.

21. Morrison LJ, Landzaat LH, Barnett MD, et al. Hospice and Palliative Medicine Entrustable Professional

Activities. Online.

22. Dawn Levreau. AAHPM Personal Correspondence. 2016.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

16

Table 1 : National Survey Participant Demographics, n=362

Age (355)

20-29 0.3% 1

30-39 18.0% 64

40-49 26.2% 93

50-59 29.0% 103

60-69 23.4% 83

70 and older 2.5% 9

Prefer not to answer 0.6% 2

Gender (352)

Female 54.0% 190

Male 45.7% 161

Prefer not to answer 0.3% 1

Years in Practice (355)

0-5 25.6% 91

6-10 28.2% 100

11-15 19.4% 69

16-20 10.1% 36

More than 20 16.6% 59

ABMS certified in HPM (354)

Yes 91.8% 325

No 8.2% 29

Hospice medical director/hospice team physician leader (355)

Yes 41.1% 146

No 58.9% 209

Setting(s) where majority of professional time spent (358)

Hospice 20.4% 68

Palliative Care 58.9% 196

Both Hospice and Palliative Care

(close to evenly split) 20.7% 69

Other 7.0% 25

Practice setting (354)

Academic medical center 42.9% 152

Community hospital 19.8% 70

Outpatient clinic 3.1% 11

Hospice 20.9% 74

Other 13.3% 47

Hours per week devoted to HPM (355)

<25 % 10.4% 37

25-50% 13.5% 48

51-75% 9.6% 34

>75% 66.5% 236

Teaching Responsibilities (355)

Involved in teaching medical trainees 89.6% 318

Not teaching medical trainees 10.4% 37

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

17

Table 2: Vetting Survey to AAHPM physician members with EPA rankings

How essential or important is competence in each proposed EPA for a graduating HPM fellow?

# EPA Description

N=362

%

Essential

to all

% Important

but not

essential

% Not

important or

essential

1 Provide comprehensive pain assessment and management

for patients with serious illness. HPM physicians are able

to use an interdisciplinary team approach to effectively

manage complex pain in the context of serious illness using

pharmacologic and non-pharmacologic approaches.

99.2 0.8 0

2 Provide comprehensive non-pain symptom assessment

and management for patients with serious illness. HPM

physicians are able to lead and collaborate with an

interdisciplinary team to effectively manage complex non-

pain symptoms, including but not limited to anorexia,

constipation and diarrhea, delirium, dyspnea, fatigue,

nausea and vomiting, depression and anxiety, using

pharmacologic and non-pharmacologic treatments.

98.1 1.9 0

3 Manage palliative care emergencies. HPM physicians

anticipate, prepare for, and respond to palliative

emergencies to minimize distress in partnership with the

patient, caregivers, and medical team, while taking into

account the patient’s goals of care and prognosis.

89.0 10.8 0.3

4 Estimate and communicate prognosis to aid medical

decision-making. HPM physicians are able to estimate,

communicate, and consider prognosis while acknowledging

uncertainty as they facilitate shared decision-making and

delineate goals of care based on patient/family values.

93.9 5.8 0.3

5 Establish goals of care based on patient/family values and

specific medical circumstancesa. HPM physicians are able

to elicit patient/family values, delineate goals of care based

on patient/family values in the context of the patient’s

medical condition, and make recommendations for an

appropriate care plan.

96.7 2.5 0.8

6 Participate as a member or leader of an interdisciplinary

team. HPM physicians function effectively as a

leader/member of an interdisciplinary team (IDT), manage

patient and family care provided by an IDT, and facilitate

IDT meetings, while sharing the leadership role with other

IDT members as appropriate.

86.2 13.3 0.6

7 Prevent and mediate conflict and distress over complex

medical decisions. HPM physicians prevent and address

clinical conflict and uncertainty as well as emotionally

charged encounters and value laden suffering through

advanced palliative communication techniques.

82.0 17.7 0.3

8 Manage withdrawal of advanced life sustaining therapies.

HPM physicians are skilled in the withdrawal of advanced

life sustaining therapies including facilitation of goals of

care discussions leading to the decision to withdraw

advanced LST, management of symptoms pre- and post-

withdrawal of advanced LST, orchestration of withdrawal of

LST, and provision of family support for psychosocial and

83.7 15.7 0.6

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

18

spiritual distress including anticipatory grief and

bereavement.

9 Care for the imminently dying patient and their family.

HPM physicians are able to identify signs of the dying

process and tend to the needs of the multiple areas of

suffering for an individual patient and their family during

imminent dying and facilitate after death bereavement

support for the family and health care providers.

94.5 5.2 0.3

10 Manage requests for hastened deathb. HPM physicians

manage requests for hastened death in accordance with

federal, state and local regulations as well as ethical and

professional principles while remaining sensitive to

patients’ individual values, preferences and sources of

suffering.

74.0 22.9 3.0

11 Support patient and family in the psychosocial domain.

HPM physicians address patient and family suffering,

coping, and healing in the emotional, psychological and

social domains with focused and developmentally

appropriate assessment followed by targeted

communication, interventions and referrals.

67.4 31.5 1.1

12 Support patient and family in the spiritual and existential

domain. HPM physicians address patient and family

suffering and identify strengths and needs within the

spiritual and existential domain with basic assessment

followed by identification of appropriate interventions and

referrals.

55.0 43.1 1.9

13 Promote self-care and resilience. HPM physicians value

and promote resilience and personal well-being for

themselves and others as a necessary element for

professional success and sustainability.

78.2 20.7 1.1

14 Facilitate transitions across the HPM continuum of care.

HPM physicians are adept at caring for patients and families

across the healthcare continuum (inpatient, long-term care,

ambulatory, home) with an understanding of and

appreciation for resource availability, care coordination,

and transitions support required for effective, high-quality

care.

75.1 24.3 0.6

15 Fulfill the role of a hospice medical director. HPM

physicians meet the clinical, regulatory, administrative and

supportive responsibilities of a hospice medical director.

30.1 63.0 6.9

16 Provide hospice and palliative medicine consultation and

team support. HPM physicians render patient and family

centered consultative care in a professional, timely, and

effective manner which supports and educates the

referring and invested team members.

83.4 15.5 1.1

17 Advocate for and teach palliative carec. HPM physicians

advocate for access to high quality palliative care services

across the continuum of care and enhance other healthcare

providers’ primary palliative care skills and knowledge.

55.5 43.4 1.1

a

Final Version included title change to “Establish goals of care based on patient and/or family values and specific medical

circumstances” b Final Version included title change to “Address requests for hastened death”

c Final Version included title change to “Promote and teach palliative care”

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

19

Figure 1: HPM EPA Step-Wise Development Process

1. Benchmark with other specialties' EPAs

2. Compose initial list of 18 HPM EPAs

3. Author-dyads draft full EPAs including: title, description, required knowledge, skills, attitudes

4. Workgroup members review each EPA individually; provide written feedback to authors

5. Authors review written feedback, discuss revisions on conference calls, seek consensus

6. Repeat steps 4 & 5 for second round review of all EPAs

7. Input from 15 Recent Fellow Graduates

8. Vetting at AAHPM national meeting – approx. 174 fellowship leaders and HPM educators

9. Addition of EPA #17

10. Vetting with national survey to field-362 respondents

11. Iterative review of national survey feedback, revisions

12. Final 17 HPM EPAs released

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

20

Figure 2 : Workgroup Review Process for Multisource Feedback by Comment Topic

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

21

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Figure 3 : Respondent Ratings of 17 Preliminary EPAs

n=362

Essential to all Important but not essential Not important or essential

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

22

Appendix 1 (option A)

Final List of HPM Entrustable Professional Activities

1 Provide comprehensive pain assessment and management for patients with serious illness

2 Provide comprehensive nonpain symptom assessment and management for patients with serious

illness

3 Manage palliative care emergencies

4 Estimate and communicate prognosis to aid medical decision-making

5 Establish goals of care based on patient and/or family values and specific medical circumstances

6 Participate as a member or leader of an interdisciplinary team

7 Prevent and mediate conflict and distress over complex medical decisions

8 Manage withdrawal of advanced life-sustaining therapies

9 Care for imminently dying patients and their families

10 Address requests for hastened death

11 Support patients and families in the psychosocial domain

12 Support patients and families in the spiritual and existential domain

13 Promote self-care and resilience

14 Facilitate transitions across the HPM continuum of care

15 Fulfill the role of a hospice medical director

16 Provide HPM consultation and team support

17 Promote and teach hospice and palliative care

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

23

Appendix 1 (option B)-[these are the full 17 EPAs if the journal chooses to include and pending discussions

with AAHPM related to copyright]

Hospice & Palliative Medicine EHospice & Palliative Medicine EHospice & Palliative Medicine EHospice & Palliative Medicine EPA Title: EPA 1. Provide comprehensive pain assessment and PA Title: EPA 1. Provide comprehensive pain assessment and PA Title: EPA 1. Provide comprehensive pain assessment and PA Title: EPA 1. Provide comprehensive pain assessment and

management for patients with serious illness.management for patients with serious illness.management for patients with serious illness.management for patients with serious illness.

Detailed Description: HPM physicians lead and collaborate with an interdisciplinary team (IDT) approach to effectively

manage complex pain in the context of serious illness using pharmacologic and nonpharmacologic approaches.

List specific

Knowledge

• Explain the pathophysiology of pain across the age spectrum, from pediatrics to

geriatrics.

• List components of a detailed pain assessment, including developmentally

appropriate screening and assessment tools.

• Explain the domains of whole-patient assessment and their potential impact on

reported physical pain (total pain).

• Describe the pharmacokinetics, pharmacodynamics, and potential adverse effects of

opioids and nonopioid pain medications to achieve proportionate symptom control.

• Describe safe opioid-prescribing practices such as use of the Opioid Risk Tool (ORT),

pain contracts, appropriate storage and disposal, risk evaluation and mitigation

strategies (REMS), state and local regulations, and aberrant behaviors associated with

misuse.

• List nonpharmacologic approaches to manage pain.

• List procedural approaches (along with referral services) to manage pain.

• Describe relative costs of medications and other therapies to treat pain.

Skills

• Perform a comprehensive pain assessment, including all domains of suffering.

• Collaborate with the IDT and other providers to optimally manage pain.

• Utilize appropriate diagnostic workup and interpretation of diagnostic tests.

• Develop and implement plans to provide comprehensive pain management for the

full spectrum of pain syndromes.

• Recognize and manage adverse effects of medications and other therapies.

• Communicate treatment plans clearly to individual patients, their families, and

healthcare providers.

• Implement safe opioid-prescribing practices.

• Demonstrate cost-effective care.

Attitudes

• Appreciate the important, urgent nature of pain management.

• Recognize the necessity of managing physical suffering to allow patients to better

address other domains of suffering and improve quality of life.

• Appreciate the complex interplay between physical and other domains of suffering

and the role of the IDT

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

24

Hospice & Palliative Medicine EPA Title: EPA 2. Provide comprehHospice & Palliative Medicine EPA Title: EPA 2. Provide comprehHospice & Palliative Medicine EPA Title: EPA 2. Provide comprehHospice & Palliative Medicine EPA Title: EPA 2. Provide comprehensive nonpain symptom ensive nonpain symptom ensive nonpain symptom ensive nonpain symptom

assessment and management for patients with serious illness.assessment and management for patients with serious illness.assessment and management for patients with serious illness.assessment and management for patients with serious illness.

Detailed Description: HPM physicians lead and collaborate with an interdisciplinary team (IDT) to effectively manage

complex nonpain symptoms, including but not limited to anorexia, constipation and diarrhea, delirium, dyspnea,

fatigue, nausea and vomiting, depression, and anxiety using pharmacologic and nonpharmacologic treatments.

List specific

Knowledge

• Describe the pathophysiology of common symptoms in serious illness across the age

spectrum, from pediatrics to geriatrics.

• Describe diagnostic methods necessary for optimal symptom assessment.

• List developmentally appropriate nonpain symptom screening and assessment tools.

• Identify pharmacologic and nonpharmacologic treatments for nonpain symptoms

using the current evidence base in palliative medicine.

• Recognize the expected benefits, burdens, and relative costs of various treatment

modalities and medications.

Skills

• Perform a thoughtful, comprehensive, and systematic symptom assessment using

validated scales or tools when appropriate.

• Demonstrate appropriate diagnostic workup and interpretation of test results.

• Use evidence-based nonpharmacologic and pharmacologic therapies and adjust

treatment plan based on results and side effects.

• Make appropriate referrals to other specialists and members of the IDT to assist with

symptom management.

• Communicate treatment plans clearly to patients, families, and healthcare providers.

• Demonstrate cost-effective care.

Attitudes

• Appreciate the important, urgent nature of nonpain symptom management.

• Recognize the value of input from multiple disciplines in addressing challenging

nonpain symptoms.

• Appreciate the importance of symptom management in diminishing suffering and

improving quality of life.

• Maintain a supportive presence for the suffering that comes with intractable

symptoms

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

25

Hospice & Palliative Medicine EPA Title: EPA 3. Manage palliative care emergencies.Hospice & Palliative Medicine EPA Title: EPA 3. Manage palliative care emergencies.Hospice & Palliative Medicine EPA Title: EPA 3. Manage palliative care emergencies.Hospice & Palliative Medicine EPA Title: EPA 3. Manage palliative care emergencies.

Detailed description: HPM physicians anticipate, prepare for, and respond to palliative care emergencies in partnership

with the patient, caregivers, and medical team while taking into account the patient’s goals of care and prognosis.

List specific

Knowledge

• Define and list palliative care emergencies characterized by a high symptom burden

and decreased quality of life. These may include medical, surgical, psychiatric, and

iatrogenic emergencies as well as severe psychosocial crises for patients and/or

families/caregivers.

• Describe the risk factors and pathophysiology of specific palliative care emergencies.

• Identify various modalities to decrease symptom burden and/or modify underlying

pathology that can be implemented in each emergency.

Skills

• Anticipate, recognize, and proactively consider risk mitigation strategies for all

categories of palliative care emergencies.

• Use an interdisciplinary approach to identify, prepare for, and provide

comprehensive management of palliative care emergencies.

• Demonstrate judicious and rapid escalation of palliative therapies proportional to the

degree of distress and suffering.

• Provide support to patients and/or families including prognostication and

reassessment of goals of care before, during, and after a palliative care emergency.

• Demonstrate a supportive presence for patients, caregivers, and staff, especially

when managing an “unfixable” emergency.

Attitudes

• Embrace the responsibility of identifying palliative care emergencies and

expeditiously acting on them.

• Appreciate the emotional impact of preparing for, witnessing, and managing

emergencies for patients, families, medical teams, and palliative care providers.

• Recognize that competent management of palliative care emergencies decreases

suffering and may improve quality of life.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

26

Hospice & PalliativeHospice & PalliativeHospice & PalliativeHospice & Palliative Medicine EPA Title: EPA 4. Estimate and communicate prognosis to aid Medicine EPA Title: EPA 4. Estimate and communicate prognosis to aid Medicine EPA Title: EPA 4. Estimate and communicate prognosis to aid Medicine EPA Title: EPA 4. Estimate and communicate prognosis to aid

medical decisionmedical decisionmedical decisionmedical decision----making.making.making.making.

Detailed Description: HPM physicians estimate, communicate, and consider prognosis while acknowledging

uncertainty as they facilitate shared decision making and delineate goals of care based on patient and/or family values.

List specific

Knowledge

• Describe prognostication in serious illness, identifying elements of history, physical

exam, and diagnostic testing important to determining prognosis.

• List current prognostic methods and tools and the strengths and weaknesses of each

approach.

• Describe techniques for communicating prognosis and medical uncertainty across the

age spectrum, from pediatrics to geriatrics.

Skills

• Perform a thoughtful, comprehensive, and systematic palliative care assessment

taking into account disease process, comorbidities, disease trajectory, psychosocial

support, and available treatments.

• Use relevant evidence-based prognostic tools to help create a prognostic estimate

when appropriate.

• Obtain and integrate prognostic estimates from other healthcare providers.

• Determine hospice eligibility based on a prognostic estimate.

• Assess patient and/or family interest in knowing prognostic information and explore

the specific reasons for preferences, including cultural and/or spiritual influences.

• Assess and communicate disease trajectory, expected function, and prognosis to

patients, families, and other healthcare providers.

• Acknowledge and express uncertainty.

• Direct a family meeting when necessary to help communicate prognosis and aid

medical decision making.

Attitudes

• Appreciate the importance of prognosis in medical decision making and the weight of

prognosis for all involved.

• Appreciate the challenge of uncertainty in prognostication across various patient

populations.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

27

Hospice & Palliative Medicine EPA Title: EPA 5. Establish goals of care based on patient and/or Hospice & Palliative Medicine EPA Title: EPA 5. Establish goals of care based on patient and/or Hospice & Palliative Medicine EPA Title: EPA 5. Establish goals of care based on patient and/or Hospice & Palliative Medicine EPA Title: EPA 5. Establish goals of care based on patient and/or

family values and specific medical circumstances.family values and specific medical circumstances.family values and specific medical circumstances.family values and specific medical circumstances.

Detailed Description: HPM physicians elicit patient/family values, delineate goals of care based on patient and/or

family values in the context of the patient’s medical condition, and make recommendations for an appropriate care

plan.

List specific

Knowledge

• Describe prognostication in serious illness.

• Recognize techniques for communicating prognosis and medical uncertainty.

• Explain and differentiate essential elements of assessing decision-making capacity

across the age spectrum.

• Identify techniques for engaging patients and family members in discussion and

conflict resolution.

• Relate patient- and family-centered communication to delineation of goals of care,

particularly in the determination of patient and/or family values.

• Describe the benefits and burdens of various medical therapies.

• Differentiate curative versus palliative intent of treatments.

• Define the concurrent care model which allows for coexisting curative and palliative

goals of care in pediatric hospice and other similar settings.

Skills

• Perform a thoughtful, comprehensive, and systematic palliative assessment, taking

into account disease process, comorbidities, characteristic symptom burden, and

disease trajectory, together with input from other healthcare providers.

• Direct a family meeting to help set goals of care, communicate prognosis, reframe

hope, and express uncertainty.

• Use a framework approach to give serious news or medical information, attending to

emotion from the patient, family and other healthcare providers.

• Establish the patient’s definition and determinants of quality of life.

• Utilize the interdisciplinary team to explore and clarify patient and/or family values.

• Provide recommendations for medical care based on patient and/or family values

and goals.

• Discuss withdrawal of medical therapies such as artificial hydration and nutrition,

antibiotics, anticoagulation, or other medications based on goals of care.

• Work toward consensus among patients, families, and healthcare providers.

• Assist with conflict resolution between patients, families, and other healthcare

providers.

• Guide patients, families, and healthcare providers through the shifting transitions

between curative and palliative care.

• Introduce hospice care when appropriate based on overall prognosis.

Attitudes

• Appreciate the importance of determining and communicating prognosis to aid

medical decision making.

• Respect individual patient and/or family differences in hopes and values related to

serious illness.

• Anticipate the full spectrum of patient and family responses to goals of care

discussions.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

28

Hospice & Palliative Medicine EPA Title: EPA 6. Participate as a member or leader of an Hospice & Palliative Medicine EPA Title: EPA 6. Participate as a member or leader of an Hospice & Palliative Medicine EPA Title: EPA 6. Participate as a member or leader of an Hospice & Palliative Medicine EPA Title: EPA 6. Participate as a member or leader of an

interdisciplinary team.interdisciplinary team.interdisciplinary team.interdisciplinary team.

Detailed Description: HPM physicians manage the medical care provided by interdisciplinary teams (IDTs) and facilitate

IDT meetings while sharing the leadership role with other IDT members as appropriate.

List specific

Knowledge

• Describe concepts of team processes and development and recognize elements that

promote or hinder successful IDT function.

• Discuss the professional skill set, expertise, role, and potential contribution of each

member of the interdisciplinary team.

Skills

• Lead and/or facilitate recurring IDT meetings.

• Evolve one’s own communication style with colleagues to optimize team function

within and outside of IDT meetings.

• Accept and solicit insights from all IDT members in developing a patient care plan.

• Monitor and facilitate team function including managing distress and supporting

resilience.

• Provide and accept feedback from IDT members.

• Help to develop the care plan and/or provide care to patients and families as a

member of an IDT.

Attitudes

• Respect the unique contributions of each member of the IDT and the impact of each

member on team function.

• Recognize the need to address all palliative care domains in the development of an

effective care plan.

• Facilitate openness, receptivity, mutual respect, and trust among IDT members.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

29

Hospice & Palliative MediHospice & Palliative MediHospice & Palliative MediHospice & Palliative Medicine Title: EPA 7. Prevent and mediate conflict and distress over cine Title: EPA 7. Prevent and mediate conflict and distress over cine Title: EPA 7. Prevent and mediate conflict and distress over cine Title: EPA 7. Prevent and mediate conflict and distress over

complex medical decisions.complex medical decisions.complex medical decisions.complex medical decisions.

Detailed Description: HPM physicians prevent and address clinical conflict, uncertainty, emotionally charged

encounters, and value-laden suffering through advanced palliative communication techniques.

List specific

Knowledge

• Describe treatment options and prognosis; indicators and impact of patient, family,

provider, and team distress; and ethical and legal implications of decisions.

• Recall and understand the situations and decisions that lead to clinical conflict.

Skills

• Acknowledge and negotiate contentious clinical situations.

• Identify, recognize sources of, and formulate a differential diagnosis for the conflict,

engaging the assistance of the interdisciplinary team as needed.

• Identify and attend to strongly expressed opinions and emotions; help to de-escalate

situations in which conflict intensifies.

• Attend to the emotional and physical safety of providers, patients, and families in

conflict situations.

• Compassionately and realistically mediate disagreements regarding care plans.

• Address current or anticipated grief among patients, families, providers, and teams,

especially as it pertains to clinical decision making.

• Elucidate and address the ethical and legal implications of difficult decisions to be

made when disagreement exists.

• Address conflict in a step-wise process (recognition, preparation, identification of

involved/violated core concerns, exploration, reframing, alliance, support, and

compromise) with the assistance of the team as needed.

• Direct a family meeting to help address conflict and distress when necessary.

Attitudes

• Demonstrate openness to patient and family preferences.

• Display commitment to meeting patient needs while preserving provider integrity.

• Exhibit self-awareness of personal values, how they might conflict with others’

values, and how they impact conflict mediation.

• Demonstrate openness to identifying one’s own strong positive and/or negative

feelings.

• Reflect on negative emotions in oneself and one’s patients over time.

• Exhibit compassion for all disciplines and specialties involved in difficult patient-care

situations.

• Display humility regarding one’s own clinical judgment and openness to other

opinions in charged clinical situations.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

30

Hospice & Palliative Medicine EPA Title: EPA 8. Manage withdrawal of advanced lifeHospice & Palliative Medicine EPA Title: EPA 8. Manage withdrawal of advanced lifeHospice & Palliative Medicine EPA Title: EPA 8. Manage withdrawal of advanced lifeHospice & Palliative Medicine EPA Title: EPA 8. Manage withdrawal of advanced life----sustaining sustaining sustaining sustaining

therapies.therapies.therapies.therapies.

Detailed Description: HPM physicians are skilled in the withdrawal of advanced life-sustaining therapies (LSTs),

including facilitation of goals of care discussions leading to the decision to withdraw advanced LST, management of

symptoms before and after withdrawal of advanced LST, orchestration of withdrawal of LST, and provision of family

support for psychosocial and spiritual distress including anticipatory grief and bereavement.

List specific

Knowledge

• Describe the federal, state, and local laws that impact the withdrawal of advanced

LST.

• Give examples of ethical principles relevant to the withdrawal of advanced LST.

• Discuss local institutional policies relevant to the process of withdrawal of advanced

LST.

• Explain the process of withdrawal of various advanced LSTs.

• Describe symptom burden and appropriate interventions associated with withdrawal

of common advanced LSTs.

• Recognize signs and symptoms of impending death after withdrawal of advanced

LST.

• Recognize psychosocial and spiritual distress including anticipatory grief and

bereavement responses from families.

Skills

• Facilitate discussions with patients and/or families regarding goals of care and

preparation for withdrawal of advanced LST.

• Diagnose and manage symptom burdens associated with withdrawal of advanced

LST.

• Orchestrate withdrawal of advanced LST.

• Attend to psychosocial and spiritual distress including anticipatory grief and

bereavement responses from families.

• Utilize the interdisciplinary team (IDT) to support both the patient and family before,

during, and after the withdrawal of LST.

• Demonstrate care that shows respectful attention to sociocultural characteristics of

patients and their families.

• Demonstrate high standards of ethical behavior including utilizing the IDT,

maintaining professional boundaries and scope of practice, and collaborating with

other involved physicians and healthcare providers.

Attitudes

• Appreciate the need to attend to unique characteristics and needs of patients, their

families, and healthcare providers.

• Value the key roles of IDT members, collaboration with colleagues, and maintenance

of professional boundaries in withdrawal of LST.

• Appreciate the potential gravity of decisions to withdraw LST.

• Accept that personal experiences and the specific microculture of the care setting

can contribute to bias, which can impact the recommendation to withdraw LST.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

31

Hospice & Palliative Medicine EPA Title: EPA 9. Care for imminently dying patients and their Hospice & Palliative Medicine EPA Title: EPA 9. Care for imminently dying patients and their Hospice & Palliative Medicine EPA Title: EPA 9. Care for imminently dying patients and their Hospice & Palliative Medicine EPA Title: EPA 9. Care for imminently dying patients and their

families.families.families.families.

Detailed Description: HPM physicians identify signs of the dying process, address multiple areas of suffering for the

imminently dying patient and their family and facilitate after-death bereavement support for the family and healthcare

providers.

List specific

Knowledge

• Describe the physical signs and symptoms of the dying process and common

challenges for symptom management.

• List medications used to treat symptoms of impending death and explain their

mechanisms of action.

• Describe areas of whole-patient care as it relates to caring for the imminently dying

patient.

• Recognize roles and skills of interdisciplinary team members needed to achieve

whole-patient care.

• Describe communication techniques to provide psychosocial support.

• Recall and explain the range of potential indications for proportionate symptom

control, which could include sedation.

• Describe ethical principles and how they do or do not apply to end-of-life care.

• Identify the characteristics of normal and complicated grief and bereavement.

• List medical conditions that require medical examiner involvement and requisite

steps of sensitive death pronouncement and documentation.

Skills

• Recognize the imminently dying patient and associated signs and symptoms.

• Facilitate communication to prepare family and healthcare providers that death is

imminent.

• Utilize an interdisciplinary team approach to provide whole-patient care for the

imminently dying patient and their family.

• Provide psychosocial support to family and healthcare providers regarding common

concerns, identify family members at risk for complex bereavement, and have

patience and understanding for different coping and grieving styles.

• Recognize different perspectives of family and healthcare providers regarding the

degree of symptom burden during the dying process.

• Manage physical symptoms of impending death.

• Inquire if spiritual or cultural rituals are important and provide assistance as

appropriate.

• Make the death pronouncement in a sensitive, respectful way in the presence of

family.

• Document the patient’s death and complete the death certificate appropriately.

Attitudes

• Appreciate the importance and time sensitivity in providing care for the imminently

dying patient and their family.

• Acknowledge the uniqueness of the dying experience for each patient and family.

• Value the potential positive impact of effective interdisciplinary care on family

bereavement.

• Recognize the importance of role modeling and teaching sensitive, skilled care of the

dying patient to other care providers.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

32

Hospice & Palliative Medicine EPA Title: EPA 10. Address requests for hastened death.Hospice & Palliative Medicine EPA Title: EPA 10. Address requests for hastened death.Hospice & Palliative Medicine EPA Title: EPA 10. Address requests for hastened death.Hospice & Palliative Medicine EPA Title: EPA 10. Address requests for hastened death.

Detailed Description: HPM physicians address requests for hastened death in accordance with federal, state, and

local regulations as well as ethical and professional principles while remaining sensitive to a patient's individual values,

preferences, and sources of suffering.

List specific

Knowledge

• Identify and summarize the federal and state laws, local regulations, and professional

guidelines applicable to requests for hastened death.

• Demonstrate broad knowledge of epidemiology and etiologies of requests for

hastened death.

• Elucidate a physician’s clinical, ethical, and professional responsibilities when faced

with requests for hastened death.

• List and explain bioethical models relevant to requests for hastened death.

Skills

• Explore the full range of potential motivations in requests for hastened death using a

routine and comprehensive approach.

• Communicate and counsel the patient about total pain, and provide state-of-the-art

palliative therapies to manage total pain by addressing all aspects of suffering with

time-limited trials.

• Explore the patient’s fears and expectations and facilitate establishing individual

goals when hastened death is requested.

• Maintain meticulous, interdisciplinary records of requests for hastened death.

Attitudes

• Appreciate the importance of the federal and state laws, local regulations, and

professional guidelines related to requests for hastened death.

• Remain mindful of the limits of medicine and a physician’s ability to relieve suffering.

• Seek awareness of and be willing to balance one’s own and others’ fundamental

values regarding requests for hastened death.

• Be open to consideration of competing claims to safeguard human life and individual

autonomy, and be prepared to reconsider previous opinions in light of new evidence

or arguments.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

33

Hospice & Palliative Hospice & Palliative Hospice & Palliative Hospice & Palliative Medicine EPA Title: EPA 11. SMedicine EPA Title: EPA 11. SMedicine EPA Title: EPA 11. SMedicine EPA Title: EPA 11. Support patients and families in the upport patients and families in the upport patients and families in the upport patients and families in the

psychosocial domain.psychosocial domain.psychosocial domain.psychosocial domain.

Detailed Description: HPM physicians address patient and family suffering, coping, and healing within the emotional,

psychological, and social domains with focused, developmentally appropriate assessment followed by targeted

communication, interventions, and referrals.

List specific

Knowledge

• Describe approaches to developmentally appropriate assessment for coping,

stressors, grief and bereavement, suffering, and behavioral health comorbidities.

• Identify techniques for expressing empathy.

• Describe how issues involving cultural sensitivity and diversity affect access to and

utilization of hospice and palliative care.

• Discuss benefits, burdens, and risks for the caregiver role.

• Identify specific roles, expertise, and supportive interventions that individual team

members, especially psychosocial clinicians, can provide in support of patients and

families.

• List potential referrals and additional resources in various clinical settings.

Skills

• Elicit a focused, developmentally appropriate psychosocial history, tailored to each

patient and family.

• Assess for coping, stressors, grief and bereavement, suffering, behavioral health

comorbidities, and caregiver burden.

• Provide basic counseling, empathetic response, and cultural sensitivity in supporting

expressions of distress.

• Develop appropriate patient- and family-centered assessments, communication, and

care plans with the interdisciplinary team (IDT), especially psychosocial clinicians

when available.

• Mobilize additional resources, make referrals, and navigate the healthcare system to

meet patient and family needs.

Attitudes

• Appreciate the contribution of the psychosocial domain to patient and family coping,

suffering, resilience, healing, well-being, and bereavement.

• Value the expertise of IDT members in formulating assessments and care plans for

patient and family support.

• Prioritize developmentally appropriate and culturally sensitive patient and family

care.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

34

Hospice & Palliative Medicine EPA Title: EPA 12. Support patients and families in the spiritual and Hospice & Palliative Medicine EPA Title: EPA 12. Support patients and families in the spiritual and Hospice & Palliative Medicine EPA Title: EPA 12. Support patients and families in the spiritual and Hospice & Palliative Medicine EPA Title: EPA 12. Support patients and families in the spiritual and

existential domain.existential domain.existential domain.existential domain.

Detailed Description: HPM physicians address patient and family suffering and identify strengths and needs within the

spiritual and existential domain with basic assessment followed by appropriate interventions and referrals.

List specific

Knowledge

• Describe approaches to screening and basic history taking of spirituality, religion,

existential issues, and issues of meaning and purpose.

• Discuss types and causes of spiritual distress.

• Identify interventions the physician and/or interdisciplinary team (IDT) can provide

depending on patient, family, and team composition and characteristics.

• Distinguish expertise that individual team members, especially chaplains, can provide

in support of patients and families.

• List potential referrals and additional resources in various clinical settings.

Skills

• Provide compassionate presence and listening.

• Offer open, empathetic response to spiritual and existential suffering.

• Take a basic spiritual history tailored to each patient and family.

• Explore how patient and family spiritual, religious, and existential beliefs and values

affect medical decision making and the provision of health care.

• Inquire about and support patients’ and families’ end-of-life spiritual and/or religious

practices and rituals.

• Assist the IDT in identifying and promoting a sense of meaning and purpose and

creation of legacy.

• Develop appropriate patient- and family-centered assessments and care plans with

the IDT, especially the chaplain when available.

• Engage community clergy and, when appropriate, mobilize additional resources,

make referrals, and navigate through the healthcare system to effectively meet

patient and family needs.

Attitudes

• Appreciate the contribution of the spiritual and existential domain to patient and

family coping, suffering, resilience, healing, well-being, and bereavement.

• Respect patients’ and families’ spiritual, religious, and existential beliefs even if these

beliefs and values contradict one’s own beliefs and values.

• Value expertise of IDT members in formulating assessments and care plans for

patient and family support.

• Be open to working with spiritual providers of diverse backgrounds and belief

systems.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

35

Hospice & Palliative Medicine EPA Title: EPA 13. Promote selfHospice & Palliative Medicine EPA Title: EPA 13. Promote selfHospice & Palliative Medicine EPA Title: EPA 13. Promote selfHospice & Palliative Medicine EPA Title: EPA 13. Promote self----care and resiliencecare and resiliencecare and resiliencecare and resilience....

Detailed Description: HPM physicians value and promote resilience and personal well-being for themselves and others

as a necessary element for professional success and sustainability.

List specific

Knowledge

• Understand the impact from personal and professional losses on oneself and others.

• Give examples and describe features of burnout, moral distress, compassion fatigue,

depersonalization, inefficacy, and vicarious trauma.

• Recall factors that predispose individuals and teams to stress and burnout.

• Describe strategies to mitigate physical and emotional exhaustion, foster professional

and personal growth and identity, promote compassion and equanimity, and

strengthen resilience.

Skills

• Develop awareness of one’s own subjective experience and the work environment in

order to achieve balance with the needs of patients and their families.

• Remain present to suffering of others and maintain resilience when experiencing

one’s own distress and/or grief.

• Develop practices that promote regular reflections toward growth and self-care.

• Recognize risks for and features of excessive stress, impairment, and impending

burnout in oneself and others.

Attitudes

• Appreciate the importance of and professional responsibility to attend to self-care.

• Value the need for balance around resilience and grief/bereavement.

• Utilize self-care tools and engage in strategies to mitigate physical and emotional

exhaustion, cynicism, and inefficacy.

• Promote highly present, boundary-conscious, empathetic engagement.

• Role model and encourage effective self-care for other trainees.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

36

Hospice & Palliative Medicine EPA Title: EPA 14. Facilitate transitions across the HPM contHospice & Palliative Medicine EPA Title: EPA 14. Facilitate transitions across the HPM contHospice & Palliative Medicine EPA Title: EPA 14. Facilitate transitions across the HPM contHospice & Palliative Medicine EPA Title: EPA 14. Facilitate transitions across the HPM continuum inuum inuum inuum

of care.of care.of care.of care.

Detailed Description: HPM physicians are adept at caring for patients and families across the healthcare continuum

(eg, inpatient, long-term care, ambulatory, home) with an understanding of and appreciation for resource availability,

care coordination, and transitions support required for effective and high-quality care.

List specific

Knowledge

• Describe various settings in which patients and families may access palliative care.

• Discuss common characteristics of interdisciplinary team (IDT) resources and staffing

available in different settings to meet patient and family needs around acuity and

distress.

• Identify the range of diagnostic approaches and therapies that can be maintained in

various care settings.

• Define systems-based reimbursement and payment structures, eligibility

requirements, and key regulations in different care settings.

• Recognize potential gaps in care as patients transition between settings, including

communication between providers, medication reconciliation, treatments, and

emotional support for patients and families.

Skills

• Select and dose medications based on accessibility and availability of route of

administration within and across care settings.

• Initiate and adjust medical interventions germane to specific care settings.

• Communicate with IDT, primary service, consultants, and other providers within and

across care settings.

• Assess appropriateness of patients for specific care settings, clarifying necessary and

available resources, and constructing transition plans that incorporate patient safety

while aligning with patient and family goals.

• Provide guidance for smooth transitions across settings for patients, families, and

providers that address medical, pharmaceutical, social, emotional, and spiritual

concerns.

Attitudes

• Recognize challenges to patients, families, and providers in confronting differing

formularies and costs of treatments across the continuum.

• Demonstrate appreciation for the culture and structure of each care setting and the

need to work with their strengths and limitations to best meet patient and family

goals.

• Recognize that care teams have their own values regarding care settings, which may

influence their recommendations.

• Demonstrate appreciation for the roles of different healthcare team members in

various care settings.

• Empathize with patient and family distress surrounding times of transition between

care settings.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

37

Hospice & Palliative Medicine EPA Title: EPA 15. Fulfill the role of a hospice medical director.Hospice & Palliative Medicine EPA Title: EPA 15. Fulfill the role of a hospice medical director.Hospice & Palliative Medicine EPA Title: EPA 15. Fulfill the role of a hospice medical director.Hospice & Palliative Medicine EPA Title: EPA 15. Fulfill the role of a hospice medical director.

Detailed Description: HPM physicians meet the clinical, regulatory, administrative, and supportive responsibilities of a

hospice medical director.

List specific

Knowledge

• Describe hospice eligibility guidelines for common medical conditions, and pediatric

patients, including concurrent care models.

• Identify specialty-level pain and symptom management expertise specific to the

unique settings and requirements for hospice care.

• Discuss hospice regulatory requirements.

• Explain how hospice integrates into local, regional, and national health care.

• Monitor and identify financial issues affecting hospice programs, including public and

private reimbursement and payment structures and philanthropy.

• Outline the appeals process for denied claims

Skills

• Provide hospice care to patients and families across diverse settings: home, long-

term care, and inpatient hospice.

• Facilitate a hospice interdisciplinary team (IDT) meeting

• Comply with regulatory requirements and documentation including Certification of

Terminal illness, Face to Face, etc.

• Provide leadership, education, and support to hospice IDT members.

• Manage medications with formulary restrictions.

• Work with hospice patients’ primary- and specialty-care providers.

• Engage pediatric palliative care resources to serve pediatric hospice patients.

• Work telephonically with hospice staff, patients, and families in critical situations.

• Ensure the safety of oneself and staff when working in challenging environments.

Attitudes

• Respect the skills and knowledge of diverse disciplines working to help patients and

families.

• Appreciate the diverse cultural, socioeconomic, and ethnic backgrounds of patients.

• Display openness to collaboration and teamwork.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

38

Hospice & Palliative Medicine EPA Title: EPA 16. Provide HPM consultation and teaHospice & Palliative Medicine EPA Title: EPA 16. Provide HPM consultation and teaHospice & Palliative Medicine EPA Title: EPA 16. Provide HPM consultation and teaHospice & Palliative Medicine EPA Title: EPA 16. Provide HPM consultation and team support.m support.m support.m support.

Detailed Description: HPM physicians render patient- and family-centered consultative care in a professional, timely,

and effective manner that supports and educates the referring and invested team members.

List specific

Knowledge

• Recognize the roles of different interdisciplinary team members.

• Educate others on appropriate indications for palliative care consultation.

• Describe consultation etiquette.

• Recognize that comprehensive care of a patient routinely involves attention to

physical, emotional, psychosocial, and spiritual elements.

• Identify provider distress.

• Recognize the dual and sometimes conflicting roles of patient/family advocate and

consultant.

Skills

• Gather and synthesize essential and accurate information relevant to the consult,

including clarification of the consultation question when needed.

• Introduce and educate about the role of palliative care and hospice.

• Perform a palliative medicine–focused history and physical.

• Use available evidence to construct a palliative care assessment and management

plan.

• Seek answers to outstanding patient, family, and clinical questions that arise in the

course of consultation.

• Seek to understand, maintain rapport, and advocate for patient and family goals

when healthcare providers have conflicting views.

• Respond to provider distress with empathy.

• Timely and effectively Communicate recommendations to patients, families, and

referring providers and document these in the patient’s medical record in a time-

sensitive and effective manner.

• Engage the strengths and skills of IDT members.

• Support other teams in developing their palliative care skills.

Attitudes

• Exemplify professional and ethical behavior.

• Appreciate evidence-based medicine.

• Welcome and incorporate feedback from referring teams.

• Value patient advocacy.

• Show concern for provider and team well-being and needs.

• Appreciate the relationship between consultation etiquette and future referrals.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

39

Hospice & Palliative Medicine EPA Title: EPA 17. Hospice & Palliative Medicine EPA Title: EPA 17. Hospice & Palliative Medicine EPA Title: EPA 17. Hospice & Palliative Medicine EPA Title: EPA 17. Promote and teach hospice and palliative Promote and teach hospice and palliative Promote and teach hospice and palliative Promote and teach hospice and palliative care.care.care.care.

Detailed Description: HPM physicians promote access to high-quality palliative care services across the continuum of

care through advocacy and health system improvement as well as by teaching hospice and palliative care to other

healthcare providers.

List specific

Knowledge

• Describe the value and role of palliative and hospice care accounting for diversity of

learning needs, backgrounds, learning styles, and education levels among patients,

families, community members, and others.

• Identify educational needs of interprofessional colleagues, administrators, medical

staff, and peers regarding the basics of hospice and palliative care for all healthcare

providers.

• Describe the key roles of specialty HPM in the healthcare delivery system.

• Describe how to integrate quality improvement activities into the routine function of

palliative and hospice programs.

Skills

• Demonstrate the ability to critically appraise, disseminate, and apply palliative care

literature.

• Advocate for palliative care program development within systems.

• Promote hospice and palliative care education within healthcare

systems/organizations.

• Identify key stakeholders in local and system-level healthcare improvement efforts.

• Deliver a succinct message to both community and professional audiences about the

importance of hospice and palliative care for optimal patient care.

• Adapt different teaching formats based on the setting, content, and learners.

• Analyze clinical performance data and actively work to improve performance.

• Model lifelong learning in palliative care.

Attitudes

• Appreciate that basic palliative care skills are an essential competency for all health

professionals.

• Recognize the responsibility to serve as a palliative care educator to patients,

families, and the community.

• Appreciate the need to use meaningful metrics for hospice and palliative care

program development.

• Value advocacy (local, regional, national) as a means to improve quality health care

for patients and families.

• Remain open to feedback at the individual, programmatic, and system level.

• Value quality improvement as a tool to grow and improve palliative care programs.

Development of Entrustable Professional Activities for...

Documents

Transcript of Development of Entrustable Professional Activities for...