Pilot Program Improves Palliative Care Training for Hematology/Oncology Fellows

Although palliative care is a crucial part of the journey of cancer care for a significant number of patients, current training within this area in hematology and oncology fellowship programs often falls short in equipping fellows to adequately provide this care, according to Jessica Bauman, MD. Thus, Bauman and her coinvestigators conducted a pilot educational study to test a longitudinal, integrated palliative care rotation that they hope could serve as a model for other institutions in the future.1

“Patients with hematologic or oncologic diagnoses have considerable needs in terms of their supportive care, symptom management, and communication [with providers],” Bauman said. “It is recommended by the Accreditation Council for GraduateMedical Education [ACGME] that hematology/oncology fellows acquire basic palliative care skills, which include symptom management and communication, as well as end-of-life care. Due to the direct needs for patient care, it becomes particularly important for those who are training in hematology/ oncology to learn these skills.”

During the 2024 American Society of Clinical Oncology Annual Meeting, Bauman presented findings from the pilot study, which included 19 second-year hematology/ oncology fellows who identified patients from their hematology/oncology practice with palliative care needs and referred them to a palliative care clinic. The fellows then followed those patients in the palliative care clinic with a palliative care attending physician and in the hematology/ oncology clinic. The feasibility of the rotation was measured by tracked visits, acceptability was assessed through a survey and semistructured interviews, and fellows were assessed on their palliative care knowledge via a pre- and postrotation survey and knowledge assessment.

Findings from the study demonstrated that over the 3-year pilot, 51 patients were referred by fellows to palliative care. Fellows participated in 95% of the total palliative care visits (n = 132). Palliative care knowledge (P < .01) and preparedness to provide palliative care (P < .01) both improved significantly from before the rotation to after, according to the knowledge assessment; fellows also showed improvement in 14 of 26 survey items regarding palliative care skill confidence (P < .05).

All fellows who completed the postrotation acceptability assessment (n = 17) agreed or strongly agreed that the rotation changed clinical practice and that it helped them feel more engaged with caring for their sickest patients. Fellows also rated the rotation as valuable or extremely valuable at a rate of 94%, and 88% agreed or strongly agreed that the structure of the rotation was effective.

In an interview with Oncology Fellows, Bauman, chief of the Division of Head and Neck Medical Oncology, an associate professor in the Department of Hematology/ Oncology, and the director of the Hematology/Oncology Fellowship Training Program at Fox Chase Cancer Center in Philadelphia, Pennsylvania, discussed the design of the palliative care education program, its effect on fellows who participated, and the future of palliative care education for hematology/oncology fellows.

Where do current palliative care training approaches for hematology/ oncology fellows fall short?

As a result [of general ACGME palliative care education guidelines], every fellowship incorporates these requirements in different ways. Some may incorporate a rotation, and some may incorporate a lecture set based on various palliative care skills, but it is very different from one place to the other. [Because of] that variability and…the vast amount of information and skills that hematology/oncology fellows need to acquire, thinking about palliative care skills may not necessarily be front and center for many fellowships in terms of training and the literature suggests considerable variability. Given the variability, it’s important to [consider] ways to enhance or augment palliative care education within hematology/oncology fellowship.

What inspired the creation of the palliative care rotation pilot study, and how was it conducted?

For a long time at Fox Chase, we have had a palliative care rotation built into our fellowship. It was both an inpatient and outpatient rotation, but we learned over time that fellows were not as engaged in the learning. We realized that we wanted to change the way we were providing education on the palliative care skillset. We capitalized on the outpatient model that we have in terms of the primary education for our fellows here. Our fellows standardly are in outpatient clinics where they’re caring for patients with hematologic or oncologic disorders longitudinally in 6-month blocks. Because of that, they get to know patients and are very involved in their management, decision-making, and symptom management. Fellows are a part of [patients’] care teams, and we thought that it would be helpful if they are not only learning about the hematology/ oncology decision-making, but it could [also] augment their education and skillset to have simultaneous learning per patient in terms of palliative care skills that are more communication and symptom management oriented. The model that we created is for them to identify a patient [whom] they’re caring for in their continuity clinic for hematology/oncology who has a palliative care need, to refer that patient to the palliative care team, and for them to then see the patient with the palliative care team. This allowed [fellows] to not only learn from their hematology/oncology attendings but also learn—through the same patient [who] they already cared for—more palliative care skills to integrate into their patient management.

Each fellow referred anywhere from 2 to 4 of their own continuity patients to the palliative care team, and then followed those patients longitudinally, both with their hematology/oncology attending [and] with their palliative care attending. Most of the visits were in the outpatient setting, [because] so much of hematology/oncology is outpatient, but if those patients were admitted, [fellows] would also be involved in the inpatient management.

What was the rotation’s effect on palliative care training for fellows, and how was it received by them?

The [assessment of the] rotation was 2-fold. One question was whether it was feasible. We wanted to determine whether [fellows] would refer patients [to palliative care]. Will patients buy in, and will [fellows] be able to follow those patients over time? The second question that we asked was: Is this associated with a change in knowledge and/or a change in skill set?

We found that this was a feasible rotation; of the 19 fellows who participated, all of them were able to refer anywhere between 2 and 4 patients, for a total of 51 patients who were referred over the course of this program. Among those 51 patients, there were 132 palliative care visits, and 95% of those visits were attended by the fellow. Most visits were successful in [terms of] our fellows being able to see the patient, both in their hematology/oncology clinic as well as the palliative care clinic.

In terms of change in knowledge, we saw…an improvement in palliative care knowledge and in the confidence to deliver palliative care [over the course of the 6-month rotation]. Before and after [the rotation], we had [fellows] rate how confident they were in a host of different types of palliative care skills, including communication, prognostication, and symptom management. We saw improvement in 14 of the 26 items, which included pain and symptom management, prognostication, and working with an interdisciplinary team.

After the rotation, we also asked fellows to evaluate the rotation and we conducted exit interv iews. The vast majority thought that the rotation was valuable; they thought that it changed their clinical practice and that it helped them engage more in taking care of their sickest patients, which are important findings.

In a world where we are seeing increasing physician burn out, seeing the value that this rotation brought to them was remarkable. In their exit interviews, many fellows commented on how this rotation increased the meaning of their work, which I believe is particularly valuable as we consider antidotes to burnout.

What are the next steps regarding research in palliative care training for hematology/ oncology fellows?

It would be great to use this [program] as a model and incorporate it into other fellowships nationwide. One of the challenges of that is that not every [institution] has a well-integrated palliative care team in the outpatient setting. Additionally, not all fellowship curricula are the same and thus not every [institution] will be able to do this in the same way.

As a result, a next step would be considering how other fellowships might be able to adopt this kind of rotation how it impacts patient care and fellowship education. Furthermore, we didn’t ask for feedback from patients [who] were a part of this to evaluate this program…. thus [discerning] the patient perspective of this educational program will be important in a future study.

Reference

Bauman JR, Albert M, Chwistek M, et al. A longitudinal, palliative care educational pilot in hematology-oncology fellowship training. J Clin Oncol. 2024;42(suppl 16):9007. doi:10.1200/JCO.2024.42.16_suppl.9007