University of Colorado
Fellowships for the Future
The Colorado Palliative Medicine Fellowship Program is an investment in the future of quality palliative care. Launched in July 2007, the fellowship is open to candidates who have completed a residency program approved by the Accreditation Council for Graduate Medical Education (ACGME) and are board-certified or board-eligible in their primary discipline. Although it is most likely to attract primary care specialties such as family and internal medicine, an applicant that falls under the co-sponsorship of 10 participating sub-specialty boards would be considered.
“One of the strengths of our fellowship program is that it provides the opportunity to practice and teach palliative care in diverse settings,” Program Director David Nowels said. Fellows work with a palliative care team in inpatient, ambulatory, home-based care and long-term care, as well as hospice and homecare environments. Core knowledge and skills are developed through weekly conferences, which include lectures, interactive workshops, role play and patient exercises. In addition, fellows hone their teaching skills through structured practice with family and internal medicine residents, medical students, nurses and other interdisciplinary providers.
Upon completion of the first year, fellows are qualified to practice palliative medicine, with the additional goal to teach in an academic setting, Nowels said. An optional second year of mentored research is available for fellows interested in pursuing research in an academic environment.
Partnering with the Community
Housed in the department of family medicine, where Nowels is an associate professor, the fellowship offers a broad range of clinical training opportunities through community partnerships, including hospitals, hospices, and nursing homes, as well as assisted living, ambulatory, and long-term care facilities in the Denver Metro area. Financial support for the fellowship reflects the collaborative nature of the venture.
“We cobbled together funding for the start-up,” Nowels explains. “Our community partners provided some of the initial money for the first slot.”
Though finding funding for the program continues to prove challenging, additional support comes from the US Department of Veterans Affairs; the division of general internal medicine, department of medicine and the department of family medicine at UC School of Medicine; and the Denver Hospice. The program offers a joint fellowship: one year in geriatrics and one in palliative medicine. The second fellow, slated to graduate June 2010, will be the first fellow to complete the combined geriatric/palliative medicine fellowship in collaboration with University of Colorado Hospital and Denver VA Medical Center.
An Institutional Commitment
Palliative care came to University of Colorado Hospital in 2000, to help improve quality of care for patients with severe illness. Palliative Care Consult Services began with five physicians volunteering their time, and in 2005, the hospital added an advanced practice nurse. Members of the “Care Team” have since grown to include physicians, nurses, social workers, chaplains, volunteers, and, when appropriate, pharmacists. A request for consultation by the “Care Team” may come from patients or their families, from nurses or other staff members, or from the physician in charge of the case.
Reasons for a palliative care consult include:
- the need for advice and assistance with pain and other symptom management
- ethical and legal decision making
- psychosocial, emotional, and spiritual support
- establishing goals of care
The economics of fielding an interdisciplinary team are complex. The funding stream for palliative care is less clear than it is for hospice care, as the hospital carries all expenses beyond physician reimbursement. “In order to have a successful palliative care service, it really does take an institutional commitment. It can’t survive on physician billing alone,” adds Dr. Jean Kutner, professor and head of the division of general internal medicine at the University of Colorado School of Medicine, and one of the founders of Palliative Care Consult Services at University of Colorado Hospital.
An Educational Mission
Driving the need for specialists trained in palliative medicine is the increased acceptance by the medical community at large. In 2006, Hospice and Palliative Medicine was officially recognized by the American Board of Medical Specialties. The first board exam was offered in 2008.
Because palliative care requires an interdisciplinary approach, there are training needs across the spectrum, from physicians to nurses to social workers, Kutner says. “From a physician standpoint, we have medical students, we have residents, and we have fellows rotating on the service. The fellows are palliative care fellows, geriatric fellows, pain fellows, and oncology fellows. From the nurse’s standpoint, our College of Nursing offers a certificate program in hospice and palliative care that’s very popular. There’s a school of social work in town that has also recognized the need.”
Officials at the Colorado Palliative Medicine Fellowship Program have applied for accreditation through ACGME, and expect to know the status of the application in May 2010. While educating both clinicians and families remains an ongoing process, Kutner has seen a sea of change in both the teaching and practice of palliative medicine. Someday soon, Kutner says, it will be a standard of care.