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Training, Policy Changes Would End Clinician Shortages in Palliative Care, CAPC Leader Says

Analysis  |  By Christopher Cheney  
   July 16, 2019

A worsening shortage of palliative care physicians is predicted over the next 14 years. One healthcare leader suggests ways to address the crisis.

A research article recently published in Health Affairs warns of a looming "workforce valley" in the palliative care field. Unless new policies are adopted, a surge of retirements combined with early departures from the field linked to burnout will result in a steady decline of palliative care physicians over the next 14 years, the Health Affairs researchers found.

Diane Meier, MD, director of the Center to Advance Palliative Care (CAPC) at the Icahn School of Medicine at Mount Sinai in New York City, says, "We know palliative care works. We have a massive increase of Americans who are going to need palliative care. And we don't have a workforce pipeline that will make that care accessible to those who are in need."

She says there is a pressing need to bolster the ranks of palliative care professionals, and that innovative policy changes are needed to address the shortage in the palliative care workforce.

Following is a lightly edited transcript of HealthLeaders' conversation with Meier about what she thinks is needed to address the shortage.

HealthLeaders: Why is the predicted palliative care workforce shortage a concern for health systems, hospitals, and physician practices?

Meier: The first and most obvious reason is the rapid growth in the population living with serious and complex illness, particularly as 10,000 baby boomers are turning 65 every day. We are going to see a huge increase in the number of older adults living with not just one chronic illness but multiple chronic illnesses. Those illnesses are associated with substantial burdens—physical symptom burden, emotional burden, and financial burden on patients and their families. There's also social burden—patients might say, "If I can't afford food, I'm not going to be able to do what my doctor tells me to do to be healthy."

Multiple studies have shown palliative care markedly improves quality of life, increases quality of care, and reduces crises. Palliative care reduces patient need to call 911 or go to the ER.

HL: What are the most urgent issues raised in the recent Health Affairs article about the palliative care workforce shortage?

Meier: There are two pressing issues. The first is burnout

Just as with other specialties, the overwork, the overextension, and the typical 12-to-14-hour day that people work in palliative care is not sustainable. It's not just the physical labor of taking care of patients over many hours—it's the emotional labor of taking care of patients and their families who are going through the most difficult experiences of their lives.

There is failure to recognize that we need to give clinicians enough time to recover between days at work. Right now, they don't have that recovery time.

The level of need and suffering in the patient population could fairly be said to be infinite, but the workforce capacity is not infinite. We must be careful to protect this scarce and precious resource.

The second issue is that palliative care is a team sport—it's not just physicians. It's physicians with a team of nurses, nurse practitioners, physician assistants, social workers, chaplains, and, often, many others such as physical and occupational therapists. In every discipline, the same challenges exist. There is not an adequate workforce—there are jobs that go unfilled because we can't find people to recruit. Many palliative care professionals are working in programs that are understaffed and totally overextended. So, I'm worried about the sustainability and retention of the existing workforce.

HL: CAPC recently received a $2 million grant from the Hartford Foundation. How is that grant going to help address the palliative care workforce shortage?

Meier: Several years ago, we looked at what it would take to meet the palliative care needs of an enlarging population of older adults with serious and complex illness. It became clear very quickly that there would never be enough trained palliative care specialists—either doctors or nurses—to meet the need. Even if we multiplied by 10 the current training pipeline, we would still fall far short of an adequate workforce.

We decided the only rational solution was to do a better job of training the frontline clinicians already taking care of these patients. We built a comprehensive online training curriculum, which is not aimed at palliative care specialists. It is aimed at all clinicians—oncologists, nursing home nurses, social workers, doctors, and other professionals who take care of people with serious illness.

There are now about 46 separate courses. Each one is linked to continuing medical education credit for physicians and continuing education units for nurses, social workers, case managers, and licensed professional counselors. We have given out upward of 300,000 continuing education credits since 2015.

The Hartford Foundation grant is helping to fund course administration as well as marketing and communications. For example, the foundation is supporting the John A. Hartford Foundation Tipping Point Challenge. The challenge is an attempt to get palliative care training for at least 20% of the clinicians in every major health system. The research on reaching tipping points suggests that once 20% of a population has been influenced, their activities start to influence everybody else in their field.

HL: Beyond the online courses, what are the primary strategies to address the palliative care workforce shortage?

Meier: There are multiple levers that need to be pushed to solve this problem.

It starts with undergraduate and graduate medical and nursing education—changing the requirements that medical and nursing schools must meet to retain their accreditation. Right now, a newly minted physician or nurse can graduate from school without having any palliative care training.

A second approach would require policy change—increasing the funding for graduate medical education and specialty training in palliative care. Right now, many professionals pursuing advanced training in palliative care receive funding from either philanthropy, grants, or operational dollars from the health system in which they work. That is not a sustainable model for training the workforce of the future.

The third issue is changing how health insurance plans decide who is eligible to be in their network—hospitals as well as physicians and nurse practitioners. If health insurance plans required hospitals and clinicians in-network to demonstrate completion of palliative care training, our problem would be solved. If health insurance plans required hospitals to have specialty-level palliative care teams to remain in-network, then every hospital would have a palliative care team.

Lastly, hospitals can't get paid by Medicare unless they are accredited, either by The Joint Commission or other accrediting bodies. Right now, those accrediting bodies do not require the presence of a high-quality palliative care service as a condition of accreditation. We would like to see that changed.

Christopher Cheney is the CMO editor at HealthLeaders.


Workforce attrition linked to burnout and a wave of retirements are thinning the ranks of palliative care professionals.

The Center to Advance Palliative Care is offering online courses to all healthcare professionals working with older adults who have serious and complex illnesses.

Policy changes to address the palliative care workforce shortage include making palliative care services a requirement for hospital accreditation.

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