Clinical Scholars Program
Training Site Application Form
To help meet the demand for physicians with clinical experience in Hospice/Palliative Medicine (HPM) to work
in hospices and hospital-based palliative care programs, AAHPM will offer a focused clinical experience for
physicians. AAHPM is seeking applications from potential clinical training sites and plans to approve a minimum
of 8 training sites in 2007. Applications will be reviewed by a site selection committee and criteria will include
depth of educational opportunities for trainees; past experience in providing visiting physician preceptorships and/
or clinical experiential training for residents and medical students; past experience in physician trainee evaluation
and mentorship; evaluations from former trainees; and geographic location.
Benefits to Training Site
• National recognition as a leader in hospice and palliative medicine education and training
• AAHPM support and program development assistance
• Opportunity to collaborate with other sites in the development of educational tools and assessments
• $3000 per trained physician for one week and the follow-up described below
Program Eligibility Requirements
• Provide hospital-based palliative care clinical consultation or inpatient acute hospice/palliative care unit, in
operation for at least 24 months
• Have a diverse patient population including cancer and non-cancer diseases
• Have at least two physicians and one nurse, board certified in hospice and palliative care, who provide direct
patient care services
• Have an inter-disciplinary team which includes nursing, social service, chaplaincy
• Have experience in providing clinical palliative care training to physicians (any training level)
• Have sufficient manpower resources to provide at least one week of continuous mentorship to a minimum of
8 visiting physicians per year.
• Schedule a minimum of one continuous week of clinical training for a minimum of 8 physicians per year, with
a maximum of 3 physician visitors at one time. Some physicians may elect to complete two weeks of training
and training sites must have the flexibility to accommodate such requests.
• Provide direct clinical experiences to the physician including the ability to see new inpatient consultations or
inpatient ward patients; complete a history/physical examination; develop a plan of care; and provide daily
• Provide opportunities for either direct observation of key communication skills or a simulated patient
experience suitable for evaluation
• Utilize a standardized set of trainee evaluation materials
• Provide direct feedback to the trainee regarding their clinical knowledge and skills
• Provide 12-15 hours of mentorship in the form of quarterly consults, phone calls, three case reviews, and
preparation of a final written evaluation.
• Lead up to 6 discussion group conference calls with trainees to discuss common issues/questions following
4700 W Lake Avenue / Glenview, IL 60025 / 847-375-4712 / www.aahpm.org
AAHPM Support Services
• AAHPM will conduct all necessary marketing and will make applications available.
• An examination for non-ABHPM certified physicians will be developed and conducted to ensure that
applicants have mastered the body of knowledge of HPM.
• AAHPM will handle inquiries, receive applications and funds, select eligible physicians, and match applicants
to sites best suited to their needs
• AAHPM will host an annual one-day training meeting for all site program directors
• Participant evaluations and feedback from sites will be gathered, organized, and distributed to identify
opportunities for improvement.
Training sites will be paid a sum of $3000 per trainee per week of clinical training. An additional $1500 will be
paid to the site for a second week of training, if recommended or desired. Training sites may not independently
bill trainees for any portion of the training or mentoring required for the AAHPM Clinical Scholars Program.
Deadline for applications: June 1, 2007
Notification of selection: July 15, 2007
By June 1, 2007, applicants should complete and save this application as a WORD document and attach it to an e-
mail message to email@example.com.
I. CONTACT INFORMATION
Palliative Care Program or Hospice Name:
Daytime Phone: Fax: Email:
II. PROGRAM INFORMATION
A. Provide a brief summary (maximum 250 words) of your program’s current work and commitment to
mid-career physician education.
B. Briefly (maximum 250 words) describe why your program wishes to participate in the AAHPM
Clinical Scholars Program and how this program fits into the overall goals of your HPM program.
C. Check all of the training sites that will be available to trainees in your program.
1) Home Hospice
2) Residential Hospice (non-acute)
3) Inpatient Acute Hospice or Palliative Care Unit
4) Palliative Care Consultation Service – Acute Hospital
5) Palliative Care Outpatient Clinic
D. Provide the following information regarding fellowship programs:
1) Do you have a HPM fellowship program? Yes No
2) Is your program accredited by the PMRC? Yes No
3) How long have you been training fellows? years
4) How many fellows are in your program this year?
E. Describe the physician education activities provided in the past year:
1) Do you provide didactic training to medical students or resident physicians? Yes No
2) Do you provide clinical training to medical students or resident physicians? Yes No
3) Do you have a written curriculum for medical students or resident physicians for your clinical training?
F. Do you offer visiting preceptorships for community physicians? Yes
1) How many physicians have visited your program in the past three years?
2) What is the average duration of training for visiting physicians? days
3) How much do you charge for visiting physicians? $
4) Do you have a written curriculum for visiting physicians for your clinical training? Yes No
III. CURRICULUM INFORMATION
Please provide the following information about the curricula currently used in your clinical training. Feel free to
attach your curricula to this submission or answer the questions below, copying A-E for each training year.
A. Indicate the training year for this curriculum (e.g., M1, M2, M3, M4, Residency, Visiting Physician).
B. Describe the learning objectives of this curriculum.
C. Provide clinical activities and corresponding location (e.g., Hospital PC consultation service located at Omaha
D. Describe the evaluation method(s) for this curriculum.
E. List any additional learning activities which supplement the clinical experience (e.g., weekly journal club).
IV. FACULTY INFORMATION
Complete the table below for key staff who will have direct contact with visiting physicians. Indicate by placing
an “X” in the appropriate box which staff have completed specialized training in palliative care education
methods such as the Harvard PCEP Course or completed specialized training in communications teaching or had
actual experience in running a communications encounter such as OSCE or equivalent.
Physician % ABHPM Completed Completed training in Completed training
FTE Board EPEC pc education methods in communications
HPM Certified Trainer (e.g., Harvard PCEP teaching (e.g., OSCE
Course Course) Training)
Example: John Smith, MD 50% X X OSCE Training
Nurse % HPNA Completed Completed training in Completed training
FTE Board ELNEC pc education methods in communications
HPM Certified Trainer (e.g., Harvard PCEP teaching (e.g., OSCE
Course Course) Training)
Example: John Smith, RN 50% X X Harvard PCEP
Other Faculty % Board Certification Completed training in Completed training
FTE pc education methods in communications
HPM (e.g., Harvard PCEP teaching (e.g., OSCE
Example: John Smith, SW 50% Harvard PCEP
V. LETTER OF COMMITMENT
Provide a letter from the administrative director of your hospice or palliative care program attesting to:
a. your program’s commitment to training a minimum of 8 visiting faculty per year
b. sufficient resources exist to continue your current clinical and educational work and provide the necessary
staff time to provide a rich training environment
c. your program will abide by the AAHPM visiting physician evaluation criteria and participate as necessary in
data collection and requested meetings by the AAHPM project director.
d. no additional training fees will be levied to the visiting physicians in this program for training at your site.
For programs that currently provide clinical training for visiting physicians, provide contact information for two
individuals you have trained in the past 24 months.
For programs that do not currently provide clinical training for visiting physicians, provide contact information
for two medical students or residents you have trained in the past 12 months.
VII. SUBMISSION INSTRUCTIONS:
Applicants should submit the following as WORD documents attached to an e-mail message by June 1, 2007 to
1. Completed application form
2. Letter of commitment
3. Curricula attachments for Section III as appropriate