American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Surgical Palliative Care: Considerations for Career Development in Surgery and Hospice and Palliative Medicine

Halle B. Ellison, MD, FACSLee Ann Lau, MD, FACSAllyson C. Cook, MDRed Hoffman, MD, ND, FACSAna Berlin, MD, MPH, FACS

Palliative care is increasingly recognized as a necessary—yet underdeveloped—component of surgical education.1,2 Palliative care is a broad interdisciplinary field now represented by the specialty of hospice and palliative medicine (HPM). The American College of Surgeons (ACS) has supported integrating palliative care with surgery since the late 1990s. Surgeon interest in HPM certification has grown over the past few decades.3 Despite growing interest, few surgical residency programs offer dedicated palliative care experiences or have HPM-focused faculty to serve as mentors, leading to challenges supporting trainees with interest in pursuing HPM expertise or specialization. This practical guide reviews principles of surgical palliative care, provides resources for skill development, and addresses considerations for formal HPM training, certification, and practice models at the intersection of surgery and palliative care.

Principles of Surgical Palliative Care

Surgical palliative care is the treatment of suffering and promotion of quality of life for seriously ill patients undergoing surgical care.4 Core principles of the field are detailed in Box 1.

Box 1: Core Principles of Surgical Palliative Care5

  • Surgical palliative care focuses on relieving suffering and improving quality of life for patients under surgical care
  • Care to enhance quality of life is delivered with life prolonging therapies
  • The unit of care includes the patient and family
  • Surgery or other interventions are considered based on ability to meet the patient's goals, and are not limited by ability to change disease trajectory
  • Prognostication includes morbidity, mortality, and patient-centered outcomes, such as quality of life, function, and independence
  • Surgical palliative care at the end of life should relieve suffering physical, emotional, social, and spiritual domains, and may include surgery

Palliative care may be delivered by surgeons who are not palliative care specialists, termed "primary palliative care" (PPC). Experiences allowing surgeons in training to acquire PPC knowledge and skills are variable. A broad range of resources (Table 1) exist that provide trainees and educators with ideas for integrating PPC education into existing curricula and clinical experiences. Surgeons who desire specialty palliative care training may pursue HPM fellowship. Nonfellowship-based educational courses and advanced-degree programs in palliative care also offer pathways for skill development (Table 2). While completing a certificate or advanced-degree program does not necessarily confer board eligibility, innovative pathways are evolving.

Table 1: Palliative Care Resources for Surgeons

Resource

Key Features

Target Audience

Platform/Access Cost

Texts

Geoffrey P. Dunn, Robert Martensen, and David Weissman, Eds. Surgical Palliative Care: A Resident's Guide. American College of Surgeons and Cunniff-Dixon Foundation, 2009.

20 brief and accessible chapters include learning objectives and pre- and post-tests

Surgical residents and educators

PDF on ACS website(link)
Free

Anne C. Mosenthal and Geoff P. Dunn, Eds. Surgical Palliative Care: Integrating Palliative Care. Oxford University Press, 2019.

28 chapters including communication and care for various surgical patients across a range of surgical subspecialties including burn, emergency general surgery, head, and neck, thoracic, trauma and vascular

All surgeons at every level

Available for sale on Amazon, etc.
$75.11

Kate Aberger and David Wang, Eds. Palliative Care for Frontline Physicians: Case Vignettes in Everyday Hospital Medicine. Springer, 2020.

Includes 7 case-based chapters on surgical palliative care including code status limitations in the operating room, surgical decision-making for hospice patients, and geriatric trauma

All Physicians

Available for sale on Amazon, etc.
$109.14

Alberto R. Ferreres, Peter Angelos, and Eric A. Singer, Eds. Ethical Issues in Surgical Care. American College of Surgeons, 2019.

Excellent adjunct to the study of surgical palliative care, including a chapter on futility/end of life issues

All Surgeons

Available on American College of Surgeons Website (link)
$55 - $130

Recent Journals

Pringl Miller, ed. Surgical Clinics of North America: Practicing Primary Palliative Care. 2019.

17 articles on all aspects of surgical palliative care including wound care, ostomy management, image-guided palliative procedures, tracheostomy and gastrostomy, vascular access, and spirituality

All Surgeons

Free with most institutional memberships
$108.99

Pringl Miller, ed. The American Surgeon: Palliative Care Symposium. 2020

10 articles on various aspects of surgical palliative care including malignant bowel obstruction, portal hypertension, cholecystostomy tubes and DNR in the OR

All Surgeons

Free with most institutional memberships

Guidelines

ACS TQIP Palliative Care Best Practice Guidelines.
American College of Surgeons, 2017.

Guidelines focused on the integration of palliative medicine into the care of all trauma patients; includes chapters on pediatrics, SCI and TBI

Trauma Surgeons

PDF on ACS website (link)
Free

ACS TQIP Geriatric Best Practice Guidelines.
American College of Surgeons, 2013.

Guidelines intended for the care of geriatric trauma patients; includes chapters on decision-making capacity, care preferences and frailty

Trauma Surgeons

PDF on ACS website (link)
Free

Optimal Resources for Geriatric Surgical Care. American College of Surgeons, 2019.

Program standards for the ACS Geriatric Surgery Verification Program, multiple chapters on Goals of Care, Decision Making and Communication

All Surgeons

PDF on ACS website (link)
Free

Webinars and Podcasts

RAS-ACS Surgical Palliative Care Webinar. Presented by Dr. Geoff Dunn, 2019.

Introduction to surgical palliative care, including its history and how to incorporate it into surgical practice

All surgeons, particularly surgical residents

Video on ACS website (link)
Free for members

The Surgical Palliative Care Podcast. Created and hosted by Dr. Red Hoffman.

Interviews with the founders and leaders of the field of palliative care and surgical palliative care

All healthcare professionals

Available on Apple Podcasts (link)
Free

Behind the Knife: The Surgery Podcast

1. A Discussion on Palliative Care (4/5/16)
2. Palliative Care & Surgery (9/31/20)

All Surgeons, particularly surgical residents

Available on Apple Podcasts (link)
Free

EAST Traumacast.

1. Palliative Care in Your ACS Practice (10/21/19)

Trauma Surgeons

Available on Apple Podcasts (link)
Free

Geripal Podcast. Created and hosted by Drs. Alex Smith and Eric Widera.

1. Trauma Surgery (9/1/17)
2. Managing Uncertainty (10/10/17)
3. Advance Care Planning Before Major Surgery (6/21/19)
4. Surgical Palliative Care (5/8/20)

All Surgeons

Available on Apple Podcasts (link)
Free

Online Forums

ACS Communities: Surgical Palliative Care

https://acscommunities.facs.org/home

All Surgeons

Free for members

AAHPM Connect: Perioperative SIG

https://connect.aahpm.org/home

Surgeons, Anesthesiologists, Interventionalists

Free for members

Social Media

Twitter @surgpallcare

Highlights the latest surgical palliative care research and home of Surgical Palliative Care Podcast

Anyone providing care to surgical patients

@surgpallcare
Free

Society

Surgical Palliative Care Society (SPCS)

First interdisciplinary professional society dedicated to the integration of palliative medicine into the care of all surgical patients through mentorship, education, research, quality improvement and advocacy

Membership open to all physicians, allied healthcare professionals, healthcare students and trainees, patients, and caregivers

Website (link)
@spcsociety
Annual conference and
webinars

Membership fees: Free - $250

Abbreviations: AAHPM, American Academy of Hospice and Palliative Medicine; ACS, American College of Surgeons; DNR, do not resuscitate; EGS, emergency general surgery; OR, operating room; RAS, resident and associate society; SCI, spinal cord injury; TBI, traumatic brain injury; SIG, Special Interest Group; TQIP, Trauma Quality Improvement Project

Table 2: Palliative Care Educational Courses and Programs

Resource

Key Features

Target Audience

Platform/Access Cost

Courses (all offer Continuing Medical Education)

Master of Science and Graduate Certificate in Palliative Care

36-credit interprofessional online Master of Science degree in Palliative Care (with three 3-day on campus sessions).
12-credit online graduate certificate in Palliative Care (with one 3-day on campus session).
For physicians interested in board certification there is an ACGME-approved mechanism through the Advancing Innovation in Residency Education (AIRE) program, involving additional coursework and clinical practicum training.

Wide range of healthcare professionals
Biomedical track is geared towards physicians

Online and in-person through University of Colorado Anschutz Medical Campus (link)
No fees listed

Master of Science and Graduate Certificates in Palliative Care

30-credit, 5 semester online interprofessional Master of Science degree in Palliative Care
5 individual 12-credit graduate certificates, focused on various aspects of palliative care
Led by PharmD Mary Lynn McPherson (opioid conversion guru)

Wide range of healthcare professionals

Completely online through University of Maryland Graduate School (link)
No fees listed

Center to Advance Palliative Care (CAPC)

Nine different online courses including training in pain management, communication, and advance care planning

All healthcare professionals

Online access free with institutional membership

Center for Palliative Care, Harvard Medical School

Practical Aspects of Palliative Care: virtual one-day course reviews primary palliative care skills

All healthcare professionals

Online (link)
$285

Palliative Care Education and Practice: six-month course with 12 days in person

Physicians and nurses who want to advance skills or lead programs

Online and in-person (link)
$8895

EPEC: Education in Palliative and End of Life Care

Core curriculum consists of 16 distance learning modules

All healthcare professionals

Online (link)
$30 per module

Four Seasons Consulting Group

Palliative Care Immersion Course: 5-day course with focus on all aspects of palliative care, including business.

All healthcare professionals

Currently online (link)
$2750

Vital Talk

Multiple virtual and in-person courses focused on communication, many open-source online resources, and VitalTalk Tips app

All healthcare professionals

Online and in person (link)
Varies

HPM Fellowship Training

HPM fellowships are Accreditation Council for Graduate Medical Education-approved, one-year graduate medical training programs. Surgeons may enter fellowship after completing three clinical training years or finishing residency.6 Residents entering fellowship before completing residency need to begin the application process during the end of their second post-graduate year (PGY) to start fellowship after PGY-3. Residents must have a guaranteed categorical position to complete residency immediately following HPM fellowship.7 HPM fellowships participate in the National Resident Matching Program Medical Specialties Matching Program. Application for fellowship is completed through the Electronic Residency Application Service in the Summer prior to the anticipated starting year of training. Applicants submit rank lists in the Fall, with match results available before the end of the calendar year.8 Mid-career competency-based pathways are currently in the early phases of development at several programs nationwide. The American Academy of Hospice and Palliative Medicine serves as a centralized clearinghouse for information about these innovative programs.

HPM Board Certification

HPM fellowship training is required for board eligibility and certification. HPM board certification is offered through the American Board of Surgery (ABS) and nine other primary specialty boards. The ABS also supports candidates from other surgical specialty boards. The American Board of Internal Medicine oversees HPM board examination administration for all specialties. Residents completing fellowship after PGY-3 are HPM board-eligible immediately following fellowship but may defer the HPM board exam until completing residency. Application access requires contacting the assigned ABS administrator in the Spring, with the exam held in the Fall of even years. Consistent with other surgical specialties, ABS application requires the HPM Program Director's signature. HPM certification is not granted by the ABS until the resident is certified by the primary surgical specialty.7

Considerations for Maintaining Technical Skills

Consideration should be given to optimal timing of HPM fellowship within one's career trajectory. Due to limited numbers of dually trained HPM-surgeons, interested candidates may need to seek mentors beyond their home institution. Surgeons planning to complete an HPM fellowship should be cognizant of opportunities to operate during fellowship, or lack thereof. Residents completing fellowship during surgical training can build case volume upon return to their residency program. Practicing surgeons entering fellowship should consider their operative volumes in the year prior to fellowship. Maintaining technical skills is essential for surgeons planning to operate after HPM fellowship. Discussing the intent and ability to moonlight or do locum tenens work during fellowship with the HPM Program Director prior to matching may facilitate post-fellowship return to an operative surgical practice.

Career Development and Integration

Palliative care training can enhance surgical practice. Surgeons seeking to practice specialty palliative care face weighty considerations regarding professional identity and career satisfaction. Many surgeons trained in HPM desire a clinical practice evenly divided between the two fields.9 However, barriers to dual-specialty practice can be so challenging that surgeons are forced to choose between specialties. This frequently entails either exclusively delivering specialty palliative care as an integrated component of surgical practice or foregoing operative surgery. While the latter option contradicts advice to continue operating to maintain skills and standing among surgical peers, it is important to honor individuals' unique professional choices and respect the enduring value and applicability of surgical experience outside the operating room.

Surgeons practicing specialty palliative care may be funded through surgery, medicine, or geriatrics departments, a cancer center, by inter-departmental cost-sharing, or other models. Depending on their surgical specialty, surgeons may find it most feasible to practice palliative care in an outpatient (e.g., clinic, embedded office hours in an oncology practice, hospice agency) or inpatient (e.g., consult service, embedded within a surgical or trauma service) setting. Surgeons desiring dual roles should consider service models that are feasible and attractive based on their interests and credentials, and the needs and norms (e.g., schedules, cross-coverage) of the groups and system they will practice in. Individual and institutional flexibility, shared vision and values, and clear expectations with benchmarks for productivity, compensation, and academic responsibilities will increase the likelihood of a successful appointment and professional fulfillment.

Conclusion

Surgeons have many rewarding options for integrating Hospice and Palliative Medicine into their careers, ranging from incorporation of primary palliative care in surgical practice to HPM specialization. Surgeons are encouraged to explore career opportunities in palliative care and join the growing community of practice passionate about advancing surgical palliative care.

Summary of Learning Points

  • Palliative care skills enhance surgeons' abilities to assess, address, and relieve patient suffering.
  • Hospice and Palliative Medicine Fellowship training is currently required for HPM board-eligibility and certification.
  • A range of accessible resources offers surgeons at any stage of education or practice the ability to enrich understanding of the field of palliative care and develop palliative care skills.
About the Authors

Halle B. Ellison, MD, FACS, is an assistant professor of surgery and palliative care at Geisinger, Danville, PA. 

Lee Ann Lau, MD, FACS, is an assistant professor of hospice and palliative medicine at the Medical College of Wisconsin, Milwaukee, WI.

Allyson C. Cook, MD, is an assistant clinical professor of palliative medicine, surgery, and critical care medicine at University of California, San Francisco, CA.

Red Hoffman, MD, ND, FACS, is an acute care surgeon at Mission Hospital, an associate hospital medical director at Care Partners, in Asheville, NC, and adjunct assistant professor of surgery at University of North Carolina, Chapel Hill, NC. 

Ana Berlin, MD, MPH, FACS, is an assistant professor of surgery and medicine at Columbia University Irving Medical Center, NY.