Palliative Care Education in Cardiovascular Disease Fellowships: A National Survey of Program Directors

Abstract

Background

Palliative care (PC) is an essential component of high-quality cardiovascular disease (CVD) care.

However, little is known about the current state of PC education in CVD training including attitudes towards integration in training and implementation among program leadership.

Methods

We developed a nationwide, cross-sectional survey querying educational approaches, perspectives, and barriers to PC education in general CVD fellowship training. The survey was distributed to 392 members of the American College of Cardiology Program Director (PD) listserv representing 290 general CVD fellowships between 1/2023 and 4/2023. We performed descriptive and chi square analyses of survey data.

Results

Fifty-six program representatives completed the survey (response rate = 19.3%). Respondents identified as current PDs (89%), associate PDs (8.9%), and former PDs (1.8%), representing a diverse range of program sizes, types, and regions of the country. Respondents reported use of informal bedside teaching (88%), formal didactics (59%), online or self-paced modules (13%), in-person simulation (11%), and clinical rotations (16%) to teach PC content. Most programs covered PC topics at least annually, although there was variability by topic. We found no associations between program demographics and type or frequency of PC education. Most respondents reported dissatisfaction with the quantity (62%) or quality (59%) of PC education provided. Barriers to PC education included an overabundance of other content to cover (36%) and perceived lack of fellow (20%) or faculty (18%) interest. Comments demonstrated the importance of PC education in fellowship, a lack of a requirement to provide PC education, difficulty covering all topics, and suggestions for how PC skills should be taught.

Conclusions

In a national survey of CVD educational leadership on approaches to PC education in CVD training, respondents highlighted both challenges to implementation of formal PC curricula in cardiology training and opportunities for comprehensive PC education.

Lay Summary

Palliative care improves the quality of life for patients and their caregivers by providing a focus on their entire well-being. This includes management of symptoms such as pain, lack of energy, and depression. as well as conversations about concerns and decisions related to the expected course of heart disease. The addition of palliative care education into cardiology training programs would facilitate the ability of heart specialists to provide this care.

Graphical Abstract

Visual Take Home: National Survey of Cardiovascular Disease Fellowship Program Directors on Palliative Care Education in Training Programs

BACKGROUND

Palliative care (PC) is an essential component of patient-centered cardiovascular disease (CVD) care.¹ Specialty PC is a medical subspecialty that is concerned with improvements in quality of life, reduced symptom burden, and support of patients and families during serious illness.² Despite advances in medical therapies, CVD is associated with high morbidity and mortality.³ With aging of the population, increasing complexity of illness, and advancement in CVD therapeutics, there is a growing need for patient-centered decision making, including communication about prognosis, advance care planning to promote goal-concordant care, and complex symptom management.⁴ Multiple models of PC interventions for CVD, including inpatient, outpatient, home-based, and telehealth PC, have been associated with improvements in patient-centered outcomes including symptom burden, depression and anxiety, satisfaction with care, quality of life, and advance care planning.^5–10 Further, PC has been associated with higher rates of death at home,^11,12 which aligns with most patients’ wishes for end-of-life,¹³ as well as reduced healthcare utilization for patients with CVD.^10,11,14,15 As a result, PC has been recommended in the ACC/AHA guidelines for patients with a variety of cardiovascular diseases, including heart failure (Class I indication) and valvular disease (Class I indication).^16–18 However, delivery of high quality and timely PC services can be challenging, particularly given the national shortage of specialty-trained PC clinicians.^19–21

While most acknowledge the importance of addressing PC needs in CVD, cardiovascular clinicians report feeling unprepared to deliver comprehensive, high-quality PC.^22–24 Requirements exist for PC educational experiences in medical school and internal medicine residency, however most CVD fellows report inadequate training to lead goals of care conversations or engage in effective advance care planning.^25–27 While cardiology trainees find PC competencies to be integral to their practice of cardiology, fewer than 10% of current or former fellows report receiving PC training, required or elective, during fellowship.²⁵ Further, PC topics particularly relevant to CVD care, such as critical illness conversations and cardiac device deactivation, are only superficially addressed.²⁶ Little is known about the format, frequency, or content of PC education within CVD fellowships. The purpose of this study was to better understand the scope of current PC training in CVD fellowship programs nationwide.

METHODS

We conducted a nationwide, cross-sectional survey of adult general CVD program directors (PDs) in the United States. Eligible PDs were identified through a listserv maintained by the American College of Cardiology (ACC). Participation invitations were sent by an ACC coordinator via electronic mail; an initial invitation was sent in January 2023, and 4 reminders were sent through April 2023. Eligible PDs were also invited during a PD meeting held at the ACC Scientific Sessions in March 2023.

Survey questions covered 3 main topics: 1) modalities of PC education; 2) frequency of PC education; and 3) PD satisfaction with and barriers to PC education [Supplement]. Topic selection was guided by literature and guideline review as well as study team discussion. The final survey consisted of 12 closed-ended, 2 open-ended, and 6 mixed questions. “Frequency” and “Satisfaction” questions utilized a 5-point Likert scale.²⁸ The remaining questions were asked as binary yes/no. Respondents additionally provided institutional demographic information, including program size, type, location, and availability of specialty PC services. Prior to distribution, the survey was reviewed by members of the ACC’s Geriatrics Council, Palliative Care Workgroup, and PD Council. It was also piloted among a small group of PDs. All procedures and measures were approved by the University of Pennsylvania Institutional Review Board. Survey completion was accepted as informed consent.

Survey responses were recorded in Qualtrics (Qualtrics, Provo, UT, 2022) and organized in Microsoft Excel (Version 16.76, 2023). All questions were mandatory except for the fellowship institution name and location. All provided responses were included in analyses; 6 respondents completed less than half of the survey. Numerical data are reported as frequencies. Chi-square analyses were conducted to determine whether PC teaching modality (formal didactics, bedside teaching) or frequency (one topic from four PC competencies at least annually) varied as a function of program demographics, including program size, type, region, and availability of training programs/service lines (PC fellowship, advanced heart failure and transplant fellowship, PC inpatient service, and PC outpatient service). A significance level of p=0.05 was used for all analyses. Quantitative analyses were performed in Stata (version 18, StataCorp., 2023, College Station, TX). Free-text responses were assembled and sorted into common topics and themes.

RESULTS

Description of fellowship programs

Study invitations were sent to 392 members of the ACC PD Section across 290 CVD programs accredited by the Accreditation Council of Graduate Medical Education (ACGME).²⁹ The survey was completed by 56 program representatives (response rate = 19.3%). Respondents identified as current PDs (89%), associate PDs (8.9%), and former PDs (1.8%). Programs represented a diverse range of sizes, types, and regions of the country (Table 1). The most common program size was 11-15 fellows (39%). Most programs were university based (63%) and located primarily in the Northeast (32%) and South (29%). Most respondents reported that their institutions had access to inpatient PC consultation (93%), outpatient PC services (77%), and a PC fellowship program (68%). Fewer programs reported dedicated cardiovascular PC services, either an inpatient consult service (45%) or outpatient clinic (27%). Thirty-three (59%) programs had an advanced heart failure fellowship program.

Table 1:

Program Demographics

Characteristic (n=56)	N (%)
Program Size (# of fellows)
1-5	1 (2)
6-10	9 (16)
11-15	22 (39)
16-20	9 (16)
21-25	9 (16)
26+	6 (11)
Program Type
University-Based	35 (63)
University-Affiliated	11 (20)
Community-Based	10 (18)
Region
Northeast	18 (32)
Midwest	9 (16)
South	16 (29)
West	12 (21)
Available Services or Programs
Inpatient PC Consultation	52 (93)
Outpatient PC Service	43 (77)
Dedicated Inpatient Cardiac PC Consultation	25 (45)
Dedicated Outpatient Cardiac PC Service	15 (27)
Hospice and Palliative Care Fellowship	38 (68)
Advanced Heart Failure Fellowship	33 (59)

Modalities and frequency of palliative care education

Formal PC didactics (lectures, conferences, journal clubs) were reported by 59% of respondents with content provided by a PC specialist (46%), cardiologist (18%), or another clinician (14%). Respondents also reported alternative formal educational modalities, including online or self-paced modules (13%), in-person simulation (11%), and clinical rotations (16%) as shown in Table 2. Most commonly, PC education was provided through informal bedside teaching (88%). Most programs covered PC topics at least annually. The topics that were most commonly covered at least annually were provider self-care and wellness (64%), communication skills (64%), and withdrawal and deactivation of devices (54%) (Table 3). Management of spiritual and existential distress was the least likely topic to be covered at least annually (28%). We found no associations between program demographics (size, region, type, availability of PC or heart failure fellowships) and modality or frequency of PC education (p>0.05).

Table 2:

Delivery Method for Palliative Care Education in Cardiovascular Disease Fellowships^*

Education Type (n=56)	N (%)	No Response (n, %)
Didactics (lectures, conferences, journal clubs)	33 (59)	0 (0)
Taught by PC Specialist	26 (46)	0 (0)
Taught by Cardiologist	10 (18)	0 (0)
Taught by Advanced Practice Provider	4 (7)	0 (0)
Taught by Internal Medicine Physician	2 (4)	0 (0)
Taught by other professionals (free text option)	0 (0)	0 (0)
Online or Self-Paced Modules	7 (13)	0 (0)
Simulation (in-person)	6 (11)	0 (0)
Taught by PC Specialist	6 (11)	0 (0)
Taught by Cardiologist	4 (7)	0 (0)
Taught by Advanced Practice Provider	2 (4)	0 (0)
Taught by other professionals (free text option)	0 (0)	0 (0)
Clinical Rotation with Specialty PC	9 (16)	0 (0)
Inpatient consult service offered	9 (16)	0 (0)
Outpatient clinic offered	5 (9)	0 (0)
Bedside Teaching	49 (88)	6 (11)
Taught by PC Specialist	23 (41)	6 (11)
Taught by Cardiologist	37 (66)	6 (11)
Taught by Advanced Practice Provider	5 (9)	6 (11)
Taught by Internal Medicine Physician	3 (5)	6 (11)
Taught by other professionals (free text)	3 (5)	6 (11)

^*Respondents could choose more than one type of instructor.

Table 3:

Frequency of Palliative Care Topics Covered in Cardiology Fellowships*

	Never (n, %)	Less than annually (n, %)	Annually (n, %)	Monthly (n, %)	Weekly (n, %)	Don’t Know (n, %)	No Response (n, %)
PC Competencies (n=56)
Communication	10 (18)	7 (13)	26 (46)	4 (7)	2 (4)	1 (2)	6 (11)
Prognostication	11 (20)	7 (13)	23 (41)	4 (7)	3 (5)	2 (4)	6 (11)
Timely referral to specialty PC	10 (18)	7 (13)	21 (38)	8 (14)	2 (4)	2 (4)	6 (11)
End-of-life care and hospice referral	10 (18)	7 (13)	20 (36)	6 (11)	4 (7)	3 (5)	6 (11)
Caregiver support and bereavement	10 (18)	10 (18)	19 (34)	3 (5)	3 (5)	5 (9)	6 (11)
Ethical and legal concerns	9 (16)	10 (18)	23 (41)	5 (9)	1 (2)	2 (4)	6 (11)
Cultural sensitivity, social determinants, LGBTQ concerns at end-of-life	11 (20)	9 (16)	22 (39)	3 (5)	1 (2)	4 (7)	6 (11)
Provider self-care and wellness	6 (11)	8 (14)	27 (48)	3 (5)	2 (4)	4 (7)	6 (11)
Complex symptom management (n=56)
Pain	13 (23)	13 (23)	16 (29)	4 (7)	1 (2)	3 (5)	6 (11)
Shortness of breath	8 (14)	8 (14)	14 (25)	10 (18)	7 (13)	3 (5)	6 (11)
Existential or spiritual distress	18 (32)	12 (21)	11 (20)	2 (4)	1 (2)	6 (11)	6 (11)
Cachexia, fatigue, exercise intolerance	13 (23)	14 (25)	14 (25)	3 (5)	2 (4)	4 (7)	6 (11)
Anxiety, depression	9 (16)	11 (20)	23 (41)	2 (4)	1 (2)	4 (7)	6 (11)
High-Risk Procedures (n=56)
Shared decision making	2 (4)	5 (9)	18 (32)	18 (32)	5 (9)	2 (4)	6 (11)
Deactivation or withdrawal of devices	6 (11)	7 (13)	27 (48)	6 (11)	0 (0)	4 (7)	6 (11)
Lifespan Concerns (n=56)
Palliative Care for Adult Congenital Heart Disease	5 (9)	9 (16)	23 (41)	7 (13)	3 (5)	3 (5)	6 (11)
Geriatric Syndromes
Multimorbidity	15 (27)	9 (16)	16 (29)	4 (7)	1 (2)	5 (9)	6 (11)
Frailty, falls, mobility	14 (25)	10 (18)	18 (32)	2 (4)	1 (2)	5 (9)	6 (11)
Cognitive impairment	14 (25)	13 (23)	16 (29)	2 (4)	1 (2)	4 (8)	6 (11)
Polypharmacy	15 (27)	9 (16)	17 (30)	1 (2)	4 (7)	4 (8)	6 (11)
Family Support	12 (21)	12 (21)	17 (30)	3 (5)	2 (4)	4 (8)	6 (11)

Satisfaction with and barriers to palliative care education

Most respondents reported dissatisfaction with the quantity (62%) or quality (59%) of PC education provided in their fellowship programs. Skills in complex symptom management (38%), advance care planning (20%), and communication skills (19%) were reported to be especially under-developed at the end of training. Barriers to implementing PC education were prevalent (71%). Most frequently, PDs reported an overabundance of other content to cover (36%) or lack of fellow (20%) or faculty (18%) interest. A few respondents reported that PC education does not belong in a cardiology fellowship curriculum (7%) and/or believe that PC content should be covered in residency (18%). Free-text responses demonstrated the importance of PC education in fellowship, lack of a requirement to provide PC education, difficulty covering all topics, and suggestions for how PC skills should be taught (Table 4). Two respondents reported unique PC educational models.

Table 4:

Themes from Open-Ended Questions

Theme	Exemplary Quotes
The importance of palliative care education in CV fellowship	• “Not really considered”; “Never brought up as an issue.” • “[Trainees] are already exposed [to palliative care] during residency.” • “We should definitely incorporate more formal training on this topic.” • “Palliative care…should be covered in the fellowship curriculum, however it should not be exhaustive since we…depend on palliative care specialists to help navigate complex goals of care discussions.”
How palliative care skills are taught in CV fellowship	• “Palliative care is primarily a learned clinical skill - not really something we focus on in lectures. The fellows do get learning in this way; just not formally.” • “Many of these [skills] are covered during practice, instead of in a didactic setting.” • “Basic info is provided for all. The option for elective is available for those interested to gain more experience and focus.”
Time is a barrier	• “It’s getting overwhelming when everything is important to cover (gen cards, DEI, QI, PS, Wellness).” • “Time is the major barrier - given all educational demands.” • “Have not seen the space and time to implement since they have received such training, most of them, during IM residency.”
Connection to heart failure care	• “We don’t yet even have a HF-specific rotation yet, so the more formal exposure suggested here doesn’t happen.” • “We do not have alignment with the director of HF and transplant in terms of the need for palliative consultation on all patients being considered for advanced therapies, and this represents a barrier in terms of education.”
Lack of a mandated focus on palliative care education	• “Palliative care is NOT a COCATS area of focus/rotation, so while an honorable idea, just isn’t something we’ve dedicated much time to.” • “Required online content that is systematized would be great.”
Some programs have developed innovative approaches	• “We have started a robust palliative care curriculum that has started this year-clinical case conferences, didactic sessions, interactive shared decision-making sessions, hired actors as patients, and in fellows’ clinic, precepted serious illness conversations. This is the first year, but well received. Hope to expand it to our procedural specialties, where it is very needed. This new general cardiology curriculum is [in] collaboration with our palliative care division, cardiologists trained in [PC], and [PC] APP. Has been an important addition to the curriculum.” • “Every year, all of our first-year fellows participate in a 2-day workshop called CardioTalk,42 run by cardiology and palliative care specialists focusing on communication skills specific to goals of care and shared decision making, using standardized patients.”

DISCUSSION

Our survey, more than 5 years after prior surveys,^25,26 demonstrated continued paucity of PC education in CVD fellowship training across the diverse group of centers included in this study. We found a wide variety in how PC education and training is provided. While many PDs reported offering some didactic instruction or bedside teaching, the majority were dissatisfied with the how PC is taught in their programs. Respondents highlighted the difficulty of incorporating PC into an already full curriculum as well as uncertainty as to the most effective format by which to teach PC concepts. PC is a critical clinical skill for cardiologists given the persistently high morbidity and mortality associated with CVD,³ and new approaches to PC education in training are needed to prepare the next generation of cardiologists to provide compassionate, patient-centered care that addresses not only the physical complications of heart disease, but also the psychosocial and spiritual impacts of CVD.

Prior surveys of CVD fellows and faculty demonstrated insufficient PC education in fellowship training and trainee discomfort with PC competencies such as goals of care conversations.^25,26 Our current survey adds to this literature by showing PC education in CVD fellowships remains insufficient more than 5 years after previous surveys. In addition, this study was the first to survey program directors, rather than fellows or general faculty, to gauge how fellowship PC education is designed and implemented into training. Finally, this survey included questions on the methodology and frequency of teaching specific PC competencies, as well as structural barriers to incorporating PC education in CVD fellowships.

This study emphasizes the challenges of implementing formal PC curricula into cardiology training, while also highlighting different models of comprehensive PC education. The current approach to PC education in CVD fellowships relies on the individual programs’ interest, which is inconsistent, and therefore, a more targeted approach to overcome reported barriers is needed (Figure 1). The current training guidelines, Core Cardiovascular Training Statement (COCATS), only specify that fellows “know the principles, modalities, and appropriate indications” for PC.³⁰ Compared to the specific numbers of procedures and months of clinical exposure required for other areas of CVD fellowship, the PC recommendation provides little guidance to programs about how to teach and assess PC skills during fellowship. This was reflected in the PDs free text responses, as they highlighted the challenges of time in an already full training program and lack of national guidance on how to implement PC education. Specific, measurable, and standardized PC competencies should be included in COCATS to ensure cardiology trainees enter clinical practice with the PC knowledge and skills needed to provide holistic and person-centered care to vulnerable patients with CVD (Figure 2).

Figure 1 –

Proposed Solutions to Improve PC Education in Cardiovascular Disease Fellowships

Figure 2 –

Proposed Competencies and Methods for Implementation for Palliative Care from Medical School Through Subspecialty Cardiovascular Disease Fellowship

Panel A – PC exposures and skills mapped across medical education level

Panel B – Methods for implementation of PC education in a 3-year CVD fellowship

This survey further demonstrates the need for curriculum mapping across the whole of medical training, as PC education is offered inconsistently prior to CVD fellowship. Multiple PDs expected that PC was taught during internal medicine residency, citing this as a reason not to prioritize PC education in their own programs. The ACGME requirements for internal medicine training only specify that programs include “clinical experiences” in PC.³¹ This varies widely by residency program, and it likely does not include training in cardiovascular-specific PC needs, such as cardiac device deactivation. PC education should be considered a core competency that is taught throughout medical training: exposure in medical school, communication skills in residency, and cardiovascular-specific PC skills in fellowship.³² For those interested in developing additional expertise, development of a subspecialty fellowship in palliative cardiology could create a generation of leaders to study, practice, and teach palliative cardiology, as has been modeled in nephrology and oncology combined fellowships.^33,34

Another key finding of this study is that some programs struggle to collaborate with their PC colleagues or others who may provide PC education. This highlights a potential resource for content expertise that, if cultivated, could address concerns about cardiology programs’ ability to develop their own PC education.³⁵ For example, PC issues such as existential crisis could be taught by chaplains, frailty and geriatric syndromes by geriatricians, and end-of-life care and caregiver bereavement by social workers.^36,37 Further, utilization and expansion of online modules, such as ACC’s Palliative Care for the Cardiovascular Clinician,³⁸ Vital Talk,³⁹ and Centers to Advance Palliative Care modules,⁴⁰ could reduce the burden of PC curriculum development on individual programs.

To increase PC education initiatives in CVD fellowship, PDs will need to advocate for resources at the division and institutional level, for example by offering workshops or practice with standardized patients. An additional opportunity lies in providing uninterrupted time, protected from clinical responsibilities, to allow fellows to engage in PC didactics, communication skills building, and role plays with feedback utilizing a proven, actionable tool such as GUIDE provided by Vital Talk.^39,41–43 Most programs in this survey reported reliance on bedside teaching, often provided by cardiologists, yet inconsistent quality of such teaching may lead to inconsistent education among graduating fellows, or worse, perpetuation of misconceptions about PC. Formalized existing resources for PC education can also provide the lifelong education and mentoring necessary for cardiologists beyond fellowship, which is critical to the success of bedside teaching.

This study has notable strengths, including the diversity of program types across 23 states. This study also has some limitations. The low response rate is not uncommon for this type of study,^44–46 although this may affect generalizability of findings. Further, though analyses showed no differences in PC education modality or frequency by program demographics, the small sample size may limit the power to detect differences. The survey content was not formally validated, though it was piloted among multiple independent groups for appropriateness and interpretability. Since survey responses were anonymous, we cannot ascertain if there were duplicate responses, however data were closely examined to exclude this possibility. Finally, although PDs generally direct fellowship curricula, it is possible that respondents may not be aware of all PC educational initiatives at their institutions; therefore, they may have underestimated their fellows’ exposure to and interest in PC education.

Patients with CVD have high morbidity and mortality with increasingly complex PC needs, and formal PC education in fellowship training is lacking. Arming cardiology fellows with more consistent and robust primary PC education will ensure that they are best positioned to provide patient-centered, holistic care.

Application to Patients.

• Patients with cardiovascular disease and symptoms such as shortness of breath, fatigue and pain can benefit from palliative care interventions to improve their quality of life

• Patients with cardiovascular disease are often faced with decisions regarding complex interventions and discontinuation of therapies. Cardiologists who are educated to provide shared decision making are best prepared to facilitate this process.

• Communication regarding prognosis and goals of care is an essential component of patient-centered care, yet many cardiologists feel ill-prepared to engage in these types of conversations.

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