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

• 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.

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.

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.

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 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

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.

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.

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.

1. Wancata LM, Hinshaw DB, Suwanabol PA. Palliative care and surgical training: Are we being trained to be unprepared? Annals of Surgery. 2017;265(1):32-33. doi:10.1097/SLA.0000000000001779
2. Bonanno AM, Kiraly LN, Siegel TR, Brasel KJ, Cook MR. Surgical palliative care training in general surgery residency: An educational needs assessment. American Journal of Surgery. 2019;217(5):928-931. doi:10.1016/j.amjsurg.2019.01.008
3. American Academy of Hospice and Palliative Medicine. Profile of Active Hospice and Palliative Medicine Physicians, 2016.; September 2017. Available at: http://aahpm.org/uploads/Profile_of_Active_HPM_Physicians_September_2017.pdf. Accessed February 21, 2021.
4. Hall, DE, Beal EW, A. Angelos P, Dunn GP, Hinshaw DB, Pawlik TM. Ethics, Palliative Care, and Care at the End of Life. In: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Kao LS, Hunter JG, Matthews JB, Pollock RE. eds. Schwartz's Principles of Surgery, 11e. McGraw-Hill; Accessed February 21, 2021. https://accesssurgery.mhmedical.com/content.aspx?bookid=2576&sectionid=216218388.
5. Mosenthal AC, and Dunn GP, eds. Surgical Palliative Care: Integrating Palliative Care. New York, NY: Oxford UP; 2019.
6. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Hospice and Palliative Medicine. Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/540_HospicePalliativeMedicine_2020.pdf?ver=2020-06-29-164052-453. Accessed January 22, 2021.
7. The American Board of Surgery. Hospice and Palliative Medicine Training and Certification. Available at: https://www.absurgery.org/default.jsp?examoffered_hpm. Accessed February 21, 2021.
8. American Academy of Hospice and Palliative Medicine. HPM Fellowship Program Directors' Guide A Resource Guide for Starting and Running a Hospice and Palliative Medicine Fellowship Program. Available at: http://aahpm.org/uploads/HPM_FD_Guide_Final_081220.pdf. Accessed January 22, 2021.
9. Berlin, A. "So You Want to do Surgical Palliative Care? Training Pathways and Practice Models" American College of Surgeons Clinical Congress, Boston, MA, October 2018.