Visual Abstract.
ABSTRACT
Background
Pediatric hospice and palliative medicine (PHPM) is a growing subspecialty worldwide; however, formal graduate medical education pathways remain limited in low- and middle-income countries, including most of Latin America, constraining workforce development and access to specialized care.
Objective
To describe an educational innovation that provides formal fellowship training in PHPM to physicians in Latin America.
Methods
From 2023 to 2026, Unidad Nacional de Oncología Pediátrica (Guatemala), St Jude Children’s Research Hospital, and the University of Utah developed and implemented a PHPM fellowship program in Latin America. The curriculum emphasizes culturally responsive training and ACGME International (ACGME-I) core competencies. Program outcomes, feasibility, and acceptability were assessed using mixed methods. Quantitative data were collected via anonymous ACGME-I program evaluation surveys completed by 10 participants over 2 years, representing a 100% response rate from fellows (n=2) and a 57% response rate from core faculty mentors (n=8 of 14 eligible). Qualitative data were obtained from written reflections and monthly structured debriefings with faculty (n=14) and fellows (n=2) from March to August 2025.
Results
Three fellows completed or are completing training, and the program received ACGME-I initial accreditation in February 2026. Graduates demonstrated early workforce impact, including expansion of PHPM services in Chile and planned implementation of the Dominican Republic’s first non-oncologic public PHPM program. All survey respondents agreed that the program provided a high-quality curriculum and effective career preparation. Qualitative analysis identified themes of strong mentorship, clinical relevance, and feasibility.
Conclusions
This trilateral PHPM fellowship is an internationally partnered, regionally grounded training that demonstrates early feasibility, acceptability, and educational value.
Introduction
More than 21 million children worldwide need access to pediatric hospice and palliative medicine (PHPM) services, yet only 5% to 10% currently receive it.1 Access to PHPM varies widely in Latin America; only 12 countries have enacted laws related to palliative care, and no country offers systemic access (Table 1).2 PHPM services in Latin America are provided by interdisciplinary teams in a mix of inpatient, outpatient, and rarely, hospice, settings.2
Table 1.
Current PHPM Access in Latin America and the Caribbean
| Total pediatric palliative programs | 375 |
| Estimated number of children requiring PHPM per year | 150 000 |
| Estimated annual new pediatric cancer diagnoses | 29 000 |
| Estimated annual pediatric deaths from cancer | 10 000 |
| Specialized PPC teams per million children <15 years | 0.8 |
| Countries with some PHPM presence | 20 out of 33 |
| Countries with generalized PHPM provisiona | Argentina |
| Chile | |
| Countries with isolated PHPM provisionb | Brazil |
| Mexico | |
| Minimal PHPM provision | Colombia |
| Costa Rica | |
| Cuba | |
| Dominican Republica | |
| Ecuador | |
| El Salvador | |
| Guatemala | |
| Haiti | |
| Honduras | |
| Nicaragua | |
| Panama | |
| Paraguay | |
| Peru | |
| The Bahamas | |
| Trinidad and Tobago | |
| Uruguay | |
| No PHPM provision | Antigua and Barbuda |
| Barbados | |
| Belize | |
| Bolivia | |
| Dominica | |
| Grenada | |
| Guyana | |
| Jamaica | |
| St Kitts and Nevis | |
| St Lucia | |
| St Vincent and the Grenadines | |
| Suriname | |
| Venezuela |
With notable gaps.
PHPM services exist, but only in certain geographic areas.
Abbreviations: PHPM, pediatric hospice and palliative medicine; PPC, pediatric palliative care.
Note: All data and access categories cited from the 2025 Palliative Care Atlas of the Americas.2 In the 2025 Palliative Care Atlas of the Americas, PHPM program is defined as providing a system of specialized palliative care services or teams for children in the country that has geographic reach and is delivered through different service delivery platforms.
A growing body of literature supports the idea that interinstitutional partnerships and targeted workforce development are key to building sustainable hospice and palliative medicine capacity in low- and middle-income countries.3-6 Despite increased global recognition of the need for PHPM, access remains deeply uneven across Latin America, with training programs often relying on isolated initiatives rather than systemic integration.7 PHPM clinicians in Latin America are required to receive some palliative training, but the depth and quality of this training vary considerably and is rarely offered in clinical settings.6 Countries such as Mexico,8 Colombia,9 and Brazil4 have limited clinical pediatric palliative training opportunities; Argentina offers some non-clinical pediatric palliative education.10,11 However, these programs have not been formally evaluated or published, and most nations in the region lack formal graduate medical education (GME) pathways in PHPM. Systemic barriers, including limited funding, faculty shortages, and low institutional prioritization, further hinder the establishment of formal training for subspecialization in PHPM.6,7
This article describes the development, implementation, and evaluation of a clinical PHPM fellowship in Latin America, launched in 2023 in Guatemala. To our knowledge, this is the first PHPM fellowship designed to meet ACGME International (ACGME-I) standards. We explore how cross-institutional collaboration supports culturally responsive training and identify key factors influencing the program’s sustainability and potential for replication.
KEY POINTS
What Is Known
Pediatric hospice and palliative medicine (PHPM) training pathways remain scarce in most low- and middle-income countries, especially across Latin America, limiting workforce growth and access to specialized pediatric palliative care.
What Is New
This article reports a partnership implementing the first regionally grounded PHPM fellowship in Latin America, delivering a culturally responsive, ACGME International–aligned curriculum and demonstrating early feasibility and acceptability.
Bottom Line
Early program outcomes, including graduates expanding national PHPM services, highlight that internationally partnered, locally embedded training models are a potential way to build sustainable palliative medicine capacity in resource-limited regions.
Methods
Program Development
The fellowship was launched in July 2023 through a collaboration between the Unidad Nacional de Oncología Pediátrica (UNOP) and Universidad Francisco Marroquín (UFM) in Guatemala, with academic support from St Jude Children’s Research Hospital (SJCRH)/LeBonheur Children’s Hospital (LCH) and the University of Utah/Primary Children’s Hospital (UU/PCH). Partner institutions were selected based on long-standing academic relationships in training pediatric hematology/oncology fellows (SJCRH and UNOP), leadership in global health capacity building (SJCRH),12 and existing relationships with other pediatric divisions in Guatemala (UU/PCH and UFM). Spanish proficiency among US faculty facilitated collaboration with colleagues in Latin America. Barriers were similar to those faced by any team collaborating across time zones and languages, but were manageable with careful planning. The program was designed to address a critical gap: UNOP has provided clinical PHPM services since 2005 but lacked a formalized educational structure to train future leaders. The fellowship was developed to align with the duration and Milestones of ACGME-accredited programs in the United States, and an application for ACGME-I accreditation was submitted in November 2025. This setting provided both clinical depth and the interdisciplinary infrastructure needed to support a high-quality fellowship, while also presenting challenges common in resource-limited environments.
International collaboration was central to the development process. Partners contributed complementary strengths: UNOP offered clinical volume, cultural knowledge, and regional leadership, while SJCRH and UU provided academic oversight, mentorship models, and curricular frameworks derived from high-resource settings, in addition to clinical exposure to palliative care in non-oncologic settings.
Our program sought to build on the success of existing international GME opportunities in low- and middle-income countries, such as the partnerships between the St Jude Global Academy and 5 Latin American institutions to train pediatric hematologists/oncologists,13-16 the African Pediatric Fellowship Program in South Africa,17 and radiology18 and oncology19 fellowships in Ethiopia, which are now self-sustaining and locally led. We also utilize virtual learning platforms, such as those available in South Asia through Project ECHO, to offer remote mentorship and case-based learning.20,21
Implementation and Intervention
Curriculum Structure and Duration:
The 12-month program provides a multisite clinical experience covering the full illness trajectory, including prenatal, outpatient, inpatient, and home settings. Fellows manage a spectrum of oncologic, cardiac, neurologic, and genetic conditions. The curriculum focuses on ACGME-I Milestones in Patient Care, Medical Knowledge, Interpersonal and Communication Skills, Professionalism, and Systems-Based Practice22 (Table 2). UFM also requires specific instruction in ethics and philosophy.
Table 2.
Fellowship Curriculum Modules
| PHPM Core Clinical Competency | Fellowship Curriculum Modules |
|---|---|
| Symptom management |
|
| Psychosocial and spiritual care |
|
| Communication and ethical decision-making |
|
| Care coordination |
|
| Care of the imminently dying |
|
| Bereavement |
|
| Scholarly work |
|
Abbreviations: PHPM, pediatric hospice and palliative medicine; UFM, Universidad Francisco Marroquín.
Rotations and Clinical Settings:
The program combines hands-on clinical experience with international academic collaboration. In Guatemala, fellows manage patients daily in outpatient and inpatient settings, including monthly on-call shifts and rotations at a free-standing pediatric hospice, Hogar Estuardo Mini. Established in 2015, this facility is a cornerstone of the program and the first pediatric hospice in Latin America. In addition to clinical training at UNOP, fellows complete 2 to 4 months of observational training at SJCRH/LCH and UU/PCH to gain exposure to palliative care in high-resource, oncologic and non-oncologic settings (see online supplementary data), alongside participation in international seminars (Cure4Kids and UU HPM Grand Rounds). The curriculum follows ACGME-I Milestones, integrating fellows into interdisciplinary teams to master symptom management and culturally sensitive care. Through case discussions and mentored research, fellows are exposed to diverse family perspectives on illness, dying, and death. The program received initial AGCME-I accreditation as an advanced specialty in February 2026.
Mentorship and Fellow Evaluation:
Fellow evaluation mirrors the evaluation process for ACGME HPM fellows. Fellows are supervised by faculty during each clinical rotation, enabling the program director to formally evaluate their progress biannually using ACGME-I Milestones. In addition to midpoint and end-of-year evaluations, faculty conduct monthly oral and/or written assessments of fellow clinical performance, communication skills, and professionalism. A scientific oversight committee composed of representatives of all 3 institutions meets at least biannually to discuss fellow scholarly progress. Fellows complete a final written examination in Spanish (rather than HPM boards), administered by UFM, and drawn from a standardized question bank, developed following comprehensive review of multiple existing resources and educational materials used within the St Jude Global Palliative Care Program and its partner institutions. Subject matter experts from all 3 institutions reviewed each question to confirm accuracy, alignment with ACGME-I learning objectives, and appropriateness for diverse cultural and clinical contexts.
Recruitment and Selection:
The fellowship is open to certified pediatricians from Latin America and is advertised through regional listservs and international conferences. The selection process involves a review of applications, pediatric and English proficiency assessments, 3 letters of recommendation, a personal statement of interest, a comprehensive CV, and interviews with faculty from all 3 partner institutions. Candidates are evaluated on their commitment to PHPM, research interests, leadership potential, and the availability of local infrastructure in their home countries to support the growth of new services. Recruitment data showed 13 applicants in the first year, 8 in the second, and 3 in the third, with 1 fellow selected annually through a ranked metric system and group discussion.
Funding:
Funding for this program is provided by donors to SJCRH and American Lebanese Syrian Associated Charities and distributed to fellows through the Ayúdame a Vivir Foundation,23 which collaborates with UNOP locally. Funding includes a monthly trainee stipend that covers food and lodging expenses and a scholarship to attend one conference during the fellowship.
Visa Logistics:
Our administrative team took a proactive approach to securing visas amid fluctuating government regulations, and SJCRH provided official letters of acceptance for candidates seeking visas. Fellow travel to the United States was coordinated using both temporary tourist or student visas (B and J visas). Some Latin American countries also require visas for travel to Guatemala. However, participation is subject to regional travel restrictions, and candidates from countries facing significant visa barriers for Guatemala or the United States were unable to join the program.
Evaluation Methods
Participants:
Former and current fellows, clinical faculty, program administrators, and educational leaders from all partner institutions evaluated the program, including UNOP and UFM in Guatemala, and SJCRH/LCH and UU/PCH in the United States.
Data Sources:
Data were collected from multiple sources to ensure a comprehensive assessment of the program. These included anonymous, official ACGME-I evaluation surveys (n=10) over 2 years (2023-2025) from fellows and faculty at all 3 institutions, in-depth written reflections from faculty and fellows, structured debriefing sessions, and a review of administrative meeting notes recorded between 2021 and 2023.
Data Collection:
The research team facilitated the collection of in-depth reflections at the conclusion of the fellowship. Semistructured debriefing sessions were conducted monthly and following each rotation to elicit perspectives on program processes, perceived outcomes, and contextual factors influencing implementation. These sessions focused on curriculum development, clinical supervision, interdisciplinary collaboration, research mentorship, and institutional coordination.
Data Analysis:
Qualitative data from written reflections, debriefing sessions, and meeting notes underwent thematic analysis to identify recurring patterns, program strengths, and opportunities for improvement. Quantitative data from anonymous surveys were summarized descriptively to assess participant satisfaction and self-reported outcomes across various training domains. Two authors (S.M.J., K.G.) conducted inductive thematic analysis of debriefing summaries and participant reflections to identify themes related to program implementation and educational quality (Table 3). Themes were reviewed with the author team and considered alongside quantitative program evaluation data (Table 4). Trustworthiness was supported through triangulation of data sources and methods and prolonged engagement via longitudinal mentorship and monthly debriefings.
Table 3.
Qualitative Themes
| Informant Type | Qualitative Themes |
|---|---|
| Faculty perspectives (n=14 across 3 institutions over 2 years) |
|
| Fellow perspectives (n=2 over 2 years) |
|
Table 4.
Fellowship Program Evaluation—Quantitative Survey Results (N=10)
| Evaluation Criteria | Agree, n (%) | Strongly Agree, n (%) | N/Aa, n (%) |
|---|---|---|---|
| Program offers a quality curriculum | 0 (0) | 10 (100) | - |
| Goals and objectives are clear | 2 (20) | 8 (80) | - |
| Evaluation process is appropriate | 2 (20) | 8 (80) | - |
| Educational conferences are high-quality | 2 (20) | 8 (80) | - |
| There is adequate patient exposure | 2 (20) | 8 (80) | - |
| The role of fellow is clear | 1 (10) | 9 (90) | - |
| The continuity clinic is a valuable experience for the fellows | - | 8 (80) | 2 (20) |
| There are research opportunities | 1 (10) | 9 (90) | - |
| Workload for the fellows is appropriate | 0 (0) | 10 (100) | - |
| There is time for fellows to attend weekly lectures and attendance is encouraged | 0 (0) | 10 (100) | - |
| There is appropriate training to prepare for a career as a physician | 0 (0) | 10 (100) | - |
| Overall, fellows are well-trained and prepared to take care of patients when they complete the fellowship | 0 (0) | 10 (100) | - |
| The program leadership is acceptable | 0 (0) | 10 (100) | - |
N/A selected by faculty who did not have continuity clinic experience at their rotation site.
This study and the associated evaluation methods were reviewed and qualified for exemption by the UNOP Department of Research and Education.
Results
Quantitative and Qualitative Findings
A total of 10 participants completed the anonymous ACGME-I program evaluation surveys over 2 years, representing a 100% response rate from fellows (n=2) and a 57% response rate from core attending faculty (n=8) who worked most closely with the trainees. Seven faculty per year received the survey, and were eligible to complete this survey if they were formal mentors at any of the 3 sites, including 1 faculty mentor per site in the United States and 5 faculty members in Guatemala. These quantitative data were supplemented by qualitative feedback from a broader group of 14 faculty members across all 3 sites, as well as from our 2 fellows, through written reflections and monthly structured debriefing sessions from March to August 2025.
Survey respondents indicated high levels of satisfaction across all educational domains. As shown in Table 4, 100% of respondents “Agreed” or “Strongly Agreed” that the program offers a high-quality curriculum with clear objectives and appropriate evaluation methods. Notably, 100% of participants “Strongly Agreed” that the overall quality of training, career preparation, accessibility of weekly lectures, and the appropriateness of the workload met expectations. The analysis of written reflections and meeting notes revealed several recurring themes across the international partnership (Table 3).
Program Adjustments
Based on data from the structured debriefings, operational meeting notes, and fellow feedback, adjustments were implemented during the first 2 years of the program. These included increasing the duration of clinical rotation time within Guatemala and establishing a proactive process for local institutional review board approval to facilitate fellow-led research projects.
Discussion
The implementation of the PHPM Fellowship in Guatemala offers an early look into the feasibility and value of regionally grounded, internationally supported training in low-resource settings. While the small sample size (n=10 survey respondents) limits broad generalizability, the 100% satisfaction rate regarding curriculum quality and career preparation suggests that the model is effectively meeting its primary educational objectives.
Our findings highlight the impact of bidirectional learning, a theme strongly emphasized by faculty in both Guatemala and the United States. Rather than a one-way transfer of knowledge, the partnership fostered increased cultural awareness and the exchange of communication approaches across settings and cultures. Similarly, the increased clinical confidence reported by fellows supports their stated goals of expanding PHPM beyond oncology, a critical need identified in the 2025 Palliative Care Atlas of the Americas.2 The program’s responsiveness to feedback serves as evidence of a continuous quality improvement framework. The leadership team adjusted the program based on participant experience, reinforcing the argument that cross-institutional collaborations can be both flexible and rigorous.
The potential for a “ripple effect” is already visible through the trajectories of our graduates and the expansion of this model globally. In 2024, St Jude Global, inspired by the Guatemala fellowship framework, successfully launched similar PHPM fellowships in partnership with the Hospital de Amor in Barretos, Brazil, and the King Hussein Cancer Center in Amman, Jordan. As detailed in Table 5, the first fellow from Chile has already influenced national policy by collaborating with the Ministry of Health on clinical guidelines and expanding pain management access. This momentum continues with the current fellow from the Dominican Republic, who is in negotiations to establish the nation’s first non-oncologic pediatric palliative care service in early 2026.
Table 5.
Fellow Outcomes
| Country | Key Outcomes and Future Goals |
|---|---|
| Chile |
|
| Dominican Republic |
|
| Ecuador |
|
Sustainability and Limitations
Despite these successes, sustainability remains a challenge. The program relies heavily on external donor funding, and while this funding framework has sustained the UNOP pediatric hematology/oncology fellowship for over 20 years, we recognize this as an ongoing vulnerability.15,16 We have also observed a decrease in the total number of applicants over the past 3 years. This trend requires further investigation but may be attributed to travel restrictions, the personal sacrifice of studying abroad for a year, or shifting political climates. Furthermore, the shortage of trained faculty remains a bottleneck for scaling; however, as graduates from Chile and the Dominican Republic begin to assume mentorship roles, we anticipate the development of decentralized training hubs that can reduce reliance on a single institution.
Conclusions
This trilateral PHPM fellowship is an internationally partnered, regionally grounded training that demonstrates early feasibility, acceptability, and educational value.
Supplementary Material
Author Notes
*Drs Martínez-Jiménez and Gradick are co-first authors and contributed equally to the work.
Funding: Funding for this program comes from donors to St Jude Children’s Research Hospital and American Lebanese Syrian Associated Charities and is distributed to fellows via the Ayúdame a Vivir Foundation, which collaborates with the Unidad Nacional de Oncología Pediátrica locally. Funding includes a monthly trainee’s stipend that covers food and lodging expenses and a scholarship to attend one conference during or directly after the fellowship concludes.
Conflict of interest: The authors declare they have no competing interests.
Editor’s Note
The online version of this article contains information about specialized rotations at US-based partner institutions.
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