Hospice and Palliative Medicine Fellowship Training in Mental Health: A Survey of Program Directors

Abstract

Context:

Psychological and psychiatric care is a core domain of palliative care. Despite a high burden of mental health comorbidity among individuals with serious illness, the Accreditation Council of Graduate Medical Education gives little guidance about training hospice and palliative medicine (HPM) fellows in this domain of care. Currently, there is a lack of empiric data on HPM physician fellowship training in mental health topics.

Objectives:

To characterize HPM physician fellowship training practices in the psychological and psychiatric aspects of palliative care.

Methods:

A cross-sectional survey study querying HPM fellowship training directors nationally.

Results:

95 programs participated (51% response rate). 98% of programs offered didactics on mental health topics. Topics universally deemed as important by program directors were commonly taught, but there was variability in both the perceived importance and the didactic coverage of several topics. Only 15% of programs offered core rotations in psychiatry. Most programs offered psychiatry electives, but such electives were only rarely utilized by fellows. Interdisciplinary team (IDT) rounds infrequently included doctoral mental health clinicians.

Conclusions:

Beyond a few commonly identified and taught key topics, there is variability in clinical and didactic exposure to mental health training among HPM fellowships. Standardizing key learning objectives and guiding educators in how to achieve these objectives could improve the preparedness of the physician workforce in HPM to meet the mental health needs of patients with serious illness.

Introduction

Mental health comorbidities are common among individuals with serious illnesses receiving palliative care and negatively impact health outcomes. Approximately 40% of people with serious illness in palliative care settings evidence clinically significant mood and/or anxiety symptoms.^1–7 While less robust epidemiologic data exist for other mental health disorders, serious mental illness (e.g., psychotic disorders),^8,9 trauma-related disorders,^10,11 and substance use disorders^12–14 are also impactful in the palliative care setting. Mental health comorbidities are associated with negative palliative care outcomes including poor quality-of-life, higher physical symptom burden, decreased survival, and differential healthcare utilization patterns.^15–18

Palliative care clinicians frequently manage mental health comorbidities in the setting of serious illness. Such comorbidities may drive referral to palliative care among patients with serious illness and are among the most frequent concerns raised by patients to palliative care clinicians.^4,19,20 In recognition of the role palliative care clinicians play in managing psychological and psychiatric serious illness care, the National Consensus Project for Quality Palliative Care’s Clinical Practice Guidelines include psychological and psychiatric aspects of care as a core domain of palliative care.²¹

Although mental health constitutes a core domain of palliative care, training of palliative care physician fellows in this domain of care is poorly described. The Accreditation Council on Graduate Medical Education (ACGME)’s Milestones for physicians completing hospice and palliative medicine (HPM) fellowship offer sparse guidance.²² Pertinent Milestones include psychosocial and spiritual assessment (Patient Care 1), management of psychosocial and spiritual distress (Patient Care 2), and family/caregiver support for bereavement (Patient Care 4). management of non-pain symptoms (Medical Knowledge 3). However, such milestones do not guide program directors or fellows in specific mental health skills and knowledge. The lack of specific guidance around mental health training of HPM clinicians is also reflected in ACGME program requirements; these requirements allude to the psychosocial component of HPM and suggest that the interdisciplinary team (IDT) must include “psychosocial clinicians,” but do not mandate any actual clinical or didactic mental health training for fellows.

Existing educational mandates for HPM fellowship allow for significant variability in the content and form in which fellows are trained in mental health topics. To date, there has been no empiric study of the didactic and clinical training that physician HPM fellows receive in this domain of care. Accordingly, we sought to characterize didactic training and clinical exposure to psychiatric and psychological care provided in HPM fellowships and to identify the barriers to such training. We hypothesized that most programs would provide didactic training but that there would be significant heterogeneity in the content of didactic training and in opportunities for clinical experiences building psychiatric and psychological skills.

Methods

Survey Design

Given the lack of a previously described tool, we designed a 21-question survey tool to evaluate clinical and didactic components of mental health training in HPM programs. Our survey design process followed an adapted version of Artino et al.’s seven-stage process for educational survey design.²³ (1) We initially utilized existing literature reviews conducted by the authors to clarify our constructs and ensure no existing tools existed that we could leverage. These reviews included both published work^24–27 and in-progress work on behavioral health and serious illness. (2) Because of the small size of the target population, we elected not to formally conduct interviews with HPM fellowship program directors. Instead, the lead author (DS) utilized the expertise of two associate fellowship program directors (NS and MC), a senior palliative care researcher (MCR), and members of the Weill Cornell palliative care interdisciplinary team to ascertain that our constructs were appropriately aligned with the perspectives of clinicians, researchers, and educators in palliative care. Constructs of interest included the distinction between didactic and experiential training, the language used to describe didactic content topics, and the broad structural components of the survey (see domains below). (3) Using data from steps 1 and 2 and emulating the structural features of surveys used to examine integration of palliative care training in psychiatry fellowships (in a sense, the converse of this study), ^28,29 we drafted survey items. (4) We designed survey items in seven major domains: eligibility screening, program characteristics, mental health didactics, mental health clinical experiences, key topics, barriers to training, and interprofessional experiences (see appendix 1). We utilized best practices in questionnaire designs and layout as described by the Association for Medical Education in Europe.²³ The survey was constructed using RedCap, a secure, web-based software platform designed to capture and manage data for research.³⁰ Following the initial survey design process, (6) we conducted expert validation with the cohort described in step 2 as well as a psychiatrist with expertise in behavioral health integration not otherwise engaged in the study. In addition, the lead author is a psychiatrist and palliative care physician with content expertise in workforce development and behavioral health-serious illness care cross-training. (7) While we conducted internal pilot testing among all co-authors and members of the co-authors’ research teams and divisions, we elected not to pursue external pilot testing because of concerns about the loss of data from our small sample population. None of the individuals involved in the pilot testing process participated in the final study.

Sample Assembly

We sought to survey a single program director from each HPM fellowship nationally. We initially obtained contact information for fellowship programs in using FREIDA^™, the American Medical Association’s directory of residency and fellowship programs.³¹ We cross checked our program contact list against the ACGME’s directory of accredited HPM fellowship programs and clarified discrepancies via program websites.³² Furthermore, we conducted internet searches for those programs for whom our contact information were generic graduate medical education emails to attempt to obtain the program directors’ contacts from the program websites. For programs for which we were unable to obtain email contact information, we also attempted calling by phone.

Survey Distribution and Administration

We utilized RedCap’s automated distribution system to anonymously distribute the survey to program directors on 10/4/2022. In keeping with the anonymous nature of the survey, we were unable to connect specific responses to specific individuals, but using RedCap, we were able to send an automated reminder email to nonresponders after 2 weeks. Because we attempted to correct contact information for email bounce-backs, our final reminder emails were sent on 11/21/2022 and the survey was closed 11/30/2022.

Data Analysis

We utilized descriptive statistics to analyze survey results. Results are presented using frequencies and percentages. We used Wilcoxon Rank Sum testing to determine whether the number of didactic topics taught was associated with fellowship programs providing clinical rotations in psychiatry. Incomplete data were included if respondents answered screening, program characteristics, and at least one other survey section.

Human Subjects Protection

This study was reviewed by the Biomedical Research Alliance of New York (BRANY) Institutional Review Board and deemed exempt with acknowledgement by the Weill Cornell Institutional Review Board.

Results

We reached out to 193 programs. Of these we received delivery error messages and were unable to find alternative contact information from 5 programs. 2 programs emailed us that they were not currently training fellows. Of 186 active programs that we were able to contact, 97 responded. One respondent did not complete the program demographics and was excluded, and one respondent did not meet the screening criterion of being a program director. As such, our analytic sample size was 95 (51% response rate).

Fellowship Program Characteristics

We asked programs about their general characteristics (see table 1). Responding programs were largely urban (n=80, 84%) and university-based (n=67, 71%). Most programs trained 1–2 physicians annually (n=50, 53%) followed by 3–4 fellows (n=31, 33%). Most programs were physician-only (n=71, 75%); those fellowships that either trained other disciplines themselves (n=12, 13%) or co-existed with fellowships aimed at other disciplines (n=12, 13%) most frequently also trained nurse practitioners (n=9, 9%) or social workers (n=6, 6%).

Table 1,

Program Characteristics

Characteristics of Responding Programs

	n=95
Program Setting, n (%)
Urban	80 (84%)
Rural	4 (4%)
Other	11 (12%)
Type of Institution, n (%) (n=94)
University	67 (71%)
Community or hospice-based	14 (15%)
Mixed	10 (11%)
Other	3 (3%)
Program Size, n (%)
1–2 physicians annually	50 (53%)
3–4 physicians annually	31 (33%)
5–6 physicians annually	9 (9%)
6–10 physicians annually	5 (5%)
Fellowship trains non-physician clinicians, n (%)
No	71 (75%)
Yes	12 (13%)
Institution has other palliative care training which does	12 (13%)
Other disciplines trained in fellowship, n (%)
Nurse Practitioners	9 (9%)
Social Workers	6 (6%)
Physician Assistants	5 (5%)
Chaplains	2 (2%)
Physicians	1 (1%)
Other	1 (1%)

Among respondents, approximately one fifth (n=19, 20%) had trained psychiatrist fellows in their fellowship, however, the vast majority (n=86, 91%) would be willing to consider psychiatrists for fellowship training.

Didactics

We asked programs about whether they provided didactics on mental health topics and the content of these didactics (see table 2). Almost all fellowship programs identified mental health topics as components of their didactic curriculum (n=93, 98%). We asked fellowships to identify topics for which there was dedicated didactic content. Of 13 topics (see table 1), programs taught a median of 8 topics (IQR 6–9). The most taught topics were delirium (n=89, 94%) and substance use disorders (n=86, 91%). Other commonly taught topics included depressive disorders (n=82, 86%), anxiety disorders (n=82, 86%), dementia (n=81, 85%), bereavement (n=81, 85%), and decisional capacity (n=80, 84%). Less frequently taught topics were general psychopharmacology (n=48, 51%), trauma-related disorders (n=34, 36%), serious mental illness (n=15, 16%), and personality disorders (n=14, 15%). Program directors identified a range of disciplines contributing to mental health didactics including palliative care physicians and/or nurses (n=88/93, 95% of programs offering didactics), followed by palliative care social workers (n=55, 59%) and psychiatry faculty (n=50, 54%).

Table 2,

Mental Health Training in Hospice and Palliative Medicine Training Programs

Didactic and Clinical Mental Health Training in HPM Fellowships

Program has had psychiatry trained fellows, n (%)	19 (20%)
Program would consider psychiatry-trained fellows, n (%)	86 (91%)
Curriculum covers mental health didactics, n (%)	93 (98%)
Didactic Session Topics Covered, n (%)
Delirium	89 (94%)
Substance use disorders	87 (92%)
Depressive disorders	82 (86%)
Anxiety disorders	82 (86%)
Dementia	81 (85%)
Bereavement	81 (85%)
Decisional capacity	80 (84%)
General psychopharmacology	48 (51%)
Trauma-related disorders	34 (36%)
General psychotherapy	20 (21%)
Serious mental illness	15 (16%)
Personality disorders	14 (15%)
Other	4 (4%)
Who teaches mental health didactics, n (%) (n=93 programs with didactics)
Palliative care physician or nurse faculty	88 (95%)
Palliative care social worker	55 (59%)
Psychiatry faculty	50 (54%)
Psychology faculty	34 (37%)
Other	20 (22%)
Does fellowship offer psychiatry or mental health rotations?, n (% yes)
Yes, as an elective	63 (66%)
Yes, as part of the core clinical experience	14 (15%)
No	24 (25%)
Length of required mental health rotations?, n (%) (n=14 programs with required didactics)
Less than one week	2 (14%)
One to two weeks	10 (71%)
Three or four weeks	2 (14%)
Percentage of fellows who complete elective in psychiatry or mental health, n (% yes) (n=62 responding programs with electives)
0–10%	46 (74%)
11–30%	13 (21%)
31–50%	1 (2%)
51–75%	1 (2%)
76+%	1 (2%)
Mental health services available within clinic for fellows’ outpatients, % yes	66 (69%)
Mental health clinicians are routinely involved in interdisciplinary rounds, n (%)
Social workers	90 (95%)
Chaplains	78 (82%)
Psychiatrists	9 (9%)
Psychologists	23 (24%)
Social work trainees	27 (28%)
Chaplain trainees	24 (25%)
Psychiatry trainees	9 (9%)
Psychology trainees	8 (8%)
Art/music therapists	17 (18%)
Other	7 (7%)

Clinical Experiences

Seventy fellowships (74%) offered fellows either elective or required mental health clinical rotations. The majority offered mental health elective rotations (n=63, 66%) while only a minority included mental health rotations as core rotations (n=14, 15%).

The most common length of core rotations was 1–2 weeks (n=10, 11%).

Most programs offering elective rotations estimated that only 0–10% of their trainees completed psychiatry elective rotations (n=46, 73% of programs with elective offerings).

The most common settings for both core and elective rotations were general inpatient consultation-liaison psychiatry (n=57 (8 core rotations, 50 elective opportunities, 1 both), 60%) and outpatient psycho-oncology (35 (3 core rotations, 32 elective opportunities), 37%), though programs also offered opportunities in outpatient and inpatient general psychiatry, inpatient psycho-oncology, and other settings.

A Wilcoxon Ranked Sum test showed there was no statistically significant difference between the number of didactic topics taught by those programs with or without clinical rotations (z=0.653, p=0.52).

Key Topics

We asked program directors to select the three most important mental health topics for fellows to learn from a list of 12 common mental health topics (with an option to input other topics) (see table 3). Every topic was selected by at least two program directors as being among the most important three topics for fellows to learn. The frequency with which topics were selected aligned with the frequency with which they were taught in didactic content. Delirium was selected most frequently (n=54, 57% of program directors), followed by depression and anxiety (n=45, 47% for each), substance use disorders (n=38, 40%). The topics least selected as highly important were trauma-related disorders (n=9, 9%), general psychotherapy (n=3, 3%), serious mental illness (n=3, 3%), and personality disorders (n=2, 2%).

Table 3,

Frequency of Topics Selected as Top 3 Importance by Program directors, n (%)

Frequency of Topics Identified as “Most Important” by Program Directors (*Respondents could select up to 3 choices)

Delirium	54 (57%)
Anxiety Disorders	45 (49%)
Depressive Disorders	45 (49%)
Substance Use Disorders	38 (40%)
Bereavement	25 (26%)
Decisional Capacity	23 (24%)
Dementia	20 (21%)
General Psychopharmacology	10 (11%)
Trauma-related Disorders	9 (9%)
General Psychotherapy	3 (3%)
Serious Mental Illness	3 (3%)
Personality Disorders	2 (2%)
Other	1 (1%)

Barriers to Training

We asked program directors about barriers to providing mental health training to HPM fellows (see table 4). Program directors had the opportunity to select as many as relevant from 4 barriers (time, lack of qualified faculty, lack of available clinical experiences, and difficulty adapting mental health content to palliative care), as well as to input their own. Time was cited as the most common barrier (n=46, 48%), followed by lack of qualified teaching faculty (n=30, 32%), difficulty adapting content (n=28, 29%), and lack of available clinical experiences (n=18, 19%). Other reported barriers included lack of funding and a lack of interest. Most programs identified a single barrier (n=48, 51%) followed by two barriers (n=23, 24%) and no barriers (n=14, 15%).

Interprofessional Experiences

We asked program directors about opportunities for fellows to collaborate with mental health clinicians in the interdisciplinary team rounds setting and in clinic. Almost all programs included social workers (n=90, 95%) and chaplains (n=78, 82%). However, few IDT rounds included psychiatry (n=9, 9%) or psychology (n=23, 24%) faculty participation. Arts and music therapists were integrated into 17 fellowships’ IDT rounds (18%).

Sixty-six (70%) program directors identified available mental health services for fellows’ clinic patients, however, the nature of those services (e.g., palliative care social work/chaplaincy, psychiatry, psychology) and the relationship to the clinic (e.g., embedded, co-located) were not obtained.

Discussion

To the authors’ knowledge, this is the first study characterizing the mental health training of HPM fellows. Working in the context of the IDT, HPM physicians benefit from close collaboration with clinicians that may bring expertise in certain components of mental health including palliative care social workers and chaplains.³³ However, even in the ideal setting of a well-staffed IDT, palliative care physicians benefit from expertise in the diagnosis and management of mental health comorbidity. Existing evidence suggests that common comorbidities including anxiety and depression may be underdiagnosed and undertreated in the palliative care setting, with gaps identified in screening, in use of medications to manage depression and anxiety, and in integration of mental health into palliative care research. ^7,34–37 Mental health training for HPM physicians may improve care for patients with serious illness, empower palliative care clinicians to address a common and impactful domain of care with confidence, and expand the scope of palliative care to a broader array of patients with serious illness (e.g., patients with neurologic illness for whom mental health symptoms are a core manifestation of their disease).

Our study demonstrated that almost all fellowship programs provide didactic training in some mental health components of palliative care. Not surprisingly, those topics identified as most important (such as delirium, depression, anxiety, and substance use) were also those taught most frequently. We were struck, however, that a minority of programs did not include these topics in their didactic curriculum (e.g., ~15% of programs do not provide teaching on depression and anxiety). These highly valued, highly taught topics may represent an entrée into standardizing mental health training across HPM fellowships.

The topics deemed less important by program directors and taught less frequently were noteworthy. These topics included trauma-related disorders, serious mental illness, personality disorders, general psychopharmacology, and general psychotherapy. Each of the topics was identified by at least a few program directors as highly important suggesting substantial variability in the perceived importance of specific mental health topics in which HPM fellows should receive training. We were particularly surprised by the dearth of training in general principles of psychopharmacology given the extensive use of psychiatric medications in palliative care both for their primary and off-label indications. While this may represent a significant training gap in fellowship didactics, it may also reflect the inclusion of psychopharmacology instruction in didactic content on related topics (e.g., depression, symptom management). Likewise, although psychotherapy may be outside the scope of palliative medicine, understanding of psychotherapeutic principles is an important component of effective palliative care.³⁸ Finally, there is increasing evidence of the prevalence and impact of trauma-related disorders among patients with serious illness and the lack of training in this topic may represent an opportunity for improvement.^11,39

In contrast to didactics, few programs offered core clinical experiences in mental health. Elective experiences were common but rarely utilized by fellows. Furthermore, few fellowships integrated doctoral-level mental health clinicians into interdisciplinary rounds which may suggest a lack of access to mental health expertise for complex case discussion or that trainees and educators access such expertise through different models such as co-consultation or shared rounds.

Data from consultation-liaison and geriatric psychiatry show that program directors in these subspecialties value palliative care and attempt to integrate palliative care content into training, but that there is significant variability in methods of doing so and the types of content covered.^28,29 We replicate these data for mental health training of palliative care clinicians. While requiring further study, these data may speak to cultural siloes between specialized mental health and palliative care training.²⁴ Evidence for it includes the relatively low rate of formalized cross-training between psychiatry and palliative care,^28,29, the dearth of primary palliative care training programs aimed towards or adapted for psychiatrists, the relatively low rate of referral to specialized palliative care services among potentially appropriate patients in mental health settings,⁴⁰ and the relatively low proportion of fellowships that integrate psychiatrists or psychologists into interdisciplinary rounds. Our finding that 9% of fellowships include psychiatrists in IDT rounds is consistent with data from 2014 showing that fewer than 10% of palliative care teams include a psychiatrist as a team.⁴¹ As a caveat, our study is insufficient to characterize the degree of integration or siloing between specialist palliative care and mental health training programs. First, we did not capture the degree with which trainees may learn from mental health specialists through shared rounds^42,43 or other models of cross-specialty collaboration. Furthermore, evidence for siloing may not reflect gaps in clinical care as we lack data on rates of co-consultation with specialized mental health services and the degree to which patients feel their mental health is appropriately addressed by current paradigms of care.

Our study has several limitations. We strove to achieve a balance between survey length and depth, but further data on the relative importance of mental health topics, types of mental health services available in palliative care clinics would have been generative. In particular, our survey instrument did not include important skills and situations in mental health that fell outside the relatively narrow diagnostic lens we utilized. Most notably, we did not ask about training in psychiatric emergencies such as suicidality and agitation, firearm safety, and harm reduction/risk mitigation with respect to substance use disorders.

Though we were able to collect data from approximately half of currently active HPM fellowship programs nationally, our data are susceptible to both response and non-response bias. We tried to limit response bias by maintaining anonymity and by concretely asking about specific training content (e.g. a didactic on depression), rather than asking general questions about mental health training to which respondents might feel compelled to answer affirmatively so as not to identify gaps in their program. However, our data may nonetheless be skewed by non-response bias; it may be that those program directors who did not complete our survey feel less strongly about mental health training for HPM fellows and may direct programs with less training. Our data were heavily drawn from urban, academic programs, though this may be representative of the national landscape of fellowship programs. Finally, our data are derived from a single set of stakeholders: program directors. A more fully informed investigation of training practices and needs will need to include the perspectives of trainees and recent graduates and non-physician palliative care clinicians.

Broadly, our study utilizes a frame of reference situated in psychiatry and psychology. While we feel that the constructs, measurements, and interventions situated in this frame are important components of psychosocial palliative care, they are not singular. The existential, spiritual, and relational components of palliative care abut and often overlap with psychological and psychiatric components; trainees may be learning about psychological distress through frames other than psychology and psychiatry and this was not captured or explored in our survey. In part, this omission reflected the limitations of survey tools which may fail to capture such nuance and complexity. However, we also had particular interest in the exposure of palliative care trainees to this frame, not because it is the only or best way to care for patients with serious illness, but because it offers specific tools and constructs (e.g., psychopharmacology) that may be important contributors to holistic whole-person care.

Our study demonstrates that while many fellowship programs provide didactic content on mental health topics commonly perceived to be important by program directors, few programs provide clinical rotations in psychiatry. Furthermore, there is significant variability in both the perceived importance of and teaching of several impactful mental health topics including psychotherapy, psychopharmacology, and trauma-related disorders. This variability speaks to a need to better guide training programs in designing and implementing training in this domain of care with an eye towards empowering palliative medicine trainees with appropriate “primary mental health skills.” Such guidance should be developed in the context of data regarding the epidemiology of mental health comorbidity among patients with serious illness and the perspective of patients, caregivers, and clinicians around how to best meet the needs associated with these comorbidities.

Conclusion

This is the first study to characterize training of HPM physician fellows in mental healthcare for individuals with serious illness. Most fellowships report didactic training in some mental health topics. Though topics universally perceived as important were frequently taught, there was variability in perceptions about and teaching of several topics. Additionally, few fellowships require clinical experiences in mental health and elective experiences in mental health are rarely utilized by fellows. Furthermore, fellows may have limited exposure to specialized mental health clinicians for case discussion in the context of interdisciplinary team rounds. Research into current practices and gaps in care, into the training needs of fellows, and into the development of disseminable and operationalized training to empower palliative care fellows to function in “primary mental health” delivery may help refine training in this domain of care.

Key Message.

Most HPM physician fellows receive didactic but not clinical exposure to the psychiatric and psychological aspects of palliative care. This component of palliative care training might be advanced through operationalized learning objectives and guidance about methods to achieve these objectives.

Psychiatric Training of Palliative Care Fellows Survey

Screening Question:

Are you the training director of a United States-based, Accreditation Council of Graduate Medical Education (ACGME)-accredited hospice and palliative medicine fellowship training program?

• Yes

• No

Program Demographics:

In what geographic region is your program located?

• Pacific (Alaska, California, Hawaii, Oregon, Washington)

• Mountain (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming)

• West South Central (Arkansas, Louisiana, Oklahoma, Texas)

• West North Central (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota)

• East North Central (Illinois, Indiana, Michigan, Ohio, Wisconsin)

• South Atlantic (Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia)

• Mid-Atlantic (New Jersey, New York, Pennsylvania)

• New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont)

• East South Central (Alabama, Kentucky, Mississippi, Tennessee) In what type of institution is your program situated?

• University program

• Community or hospice-based program Military program

• Mixed

• Other (please specify)

In what setting is your program situated?

• Urban

• Rural

• Other (please specify) __________

How large is your program?

• 1–2 physician fellows annually

• 3–4 physician fellows annually

• 5–6 physician fellows annually

• 6–10 physician fellows annually

• 11+ physician fellows annually

Does your fellowship train non-physician clinicians?

• Yes

• No

• This fellowship does not, but our division/department/institution has other palliative care fellowship training programs for non-physician clinicians

What other disciplines does your fellowship train?

• Physicians

• Nurse Practitioners

• Physician Assistants

• Chaplains

• Social Workers

• Other

Has your program had psychiatry-trained fellows?

• Yes

• No

• Unsure

Would your program consider psychiatry-trained fellows?

• Yes

• No

• Only if also trained in another specialty (e.g. dual family medicine or internal medicine-psychiatry training)

• Unsure

Didactics:

Are mental health topics covered in your fellowship's didactic curriculum?

• Yes

• No

Which, if any, topics below have a dedicated didactic session (select all that apply):

• Depressive disorders

• Anxiety disorders

• Trauma-related disorders (post-traumatic stress disorder; acute stress disorder)

• Serious Mental Illness (e.g. chronic psychotic disorders)

• Substance use disorders

• Personality Disorders/Personality Structure

• General Psychotherapy (psychodynamic psychotherapy, cognitive behavioral therapy etc.) Delirium

• Dementia

• Bereavement

• General Psychopharmacology

• Decisional Capacity

• Other (please specify) __________

Who teaches mental health didactics in your program? (select all that apply)

• Psychiatry faculty

• Psychology faculty

• Palliative care social workers

• Palliative care physician or nurse faculty

• Other (please specify): ____________

Clinical:

Does your fellowship offer psychiatry or other mental health rotations? (select all that apply)

• Yes as part of the core clinical experiences

• Yes as an elective

• No we do not offer psychiatry rotations at this time

Please select which clinical experiences are available to and/or required of fellows:

	Core Rotation	Elective Rotation
Inpatient general consultation-liaison psychiatry	□	□
Inpatient psychiatric unit	□	□
Inpatient psycho-oncology	□	□
Outpatient general consultation-liaison psychiatry clinic	□	□
Outpatient psycho-oncology clinic	□	□
Outpatient general psychiatry clinic	□	□
Other (please specify) ____________	□	□

Approximately how long in total are required psychiatry or mental health rotations?

• < 1 week

• 1 or 2 weeks

• 3 or 4 weeks

• >4 weeks

What percentage of fellows complete an elective in psychiatry or mental health?

• 0–10%

• 11–30%

• 31–50%

• 51–75%

• 75+%

Key Topics:

What do you feel are the most important mental health content areas for hospice and palliative medicine fellow training? (Select up to three)

• Depressive disorders

• Anxiety disorders

• Trauma-related disorders (post-traumatic stress disorder; acute stress disorder)

• Serious Mental Illness (e.g. chronic psychotic disorders)

• Substance use disorders

• Personality Disorders/Personality Structure

• General Psychotherapy (psychodynamic psychotherapy, cognitive behavioral therapy etc.)

• Delirium

• Dementia

• Bereavement

• General Psychopharmacology

• Decisional Capacity

• Other: __________

Key Topics:

Have you experienced any barriers to providing training in mental health topics within your fellowship program?

• Time

• Lack of qualified, available faculty

• Lack of available clinical experiences

• Difficulty adapting mental health faculty or clinical rotations to HPM fellow needs

• Other: ___________

Interprofessional:

Are there mental health services available within clinic for fellows’ outpatients?

• Yes

• No

• Unsure

If yes, what mental health services are available for fellows' outpatients? Select all that apply.

• Social work

• Embedded psychiatrist

• Embedded psychologist

• Integrated model of care (e.g. collaborative care model)

• Other ___________

If your program regularly conducts interdisciplinary team rounds, what mental health clinicians are routinely involved? (select all that apply)

• Social workers

• Chaplains

• Psychiatrists

• Psychologists

• Social work trainees

• Chaplain trainees

• Psychiatry trainees

• Psychology trainees

• Art/Music therapists

• Other (please specify) ___________