GeriPal - A Geriatrics and Palliative Medicine Podcast

There are a lot of old myths out there about managing urinary tract symptoms and UTI’s in older adults.  For example, we once thought that the lower urinary tract was sterile, but we now know it has its own microbiome, which may even provide protection against infections. So giving antibiotics for a positive urine culture or unclear symptoms may actually cause more harm than good.   On today’s podcast, we are gonna bust some of those myths.  We’ve invited some very special guests to talk about the lower urinary tract - Christine Kistler and Scott Bauer.   First, we talk with Christine, a researcher and geriatrician from the University of North Carolina, who recently published a JAGS article titled Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline.  We discuss with her how we should work-up and manage “urinary tract infections” (I’ve added air quotes to “UTI” in honor of Tom Finucane’s JAGS article titled “Urinary Tract Infection”—Requiem for a Heavyweight in which he advocated to put air quotes around the term UTI due to the ambiguity of the diagnosis.) Then we chat with Scott Bauer, internist and researcher at UCSF, about how to assess and manage lower urinary tract symptoms in men.  We also discuss Scott’s recently published paper in JAGS that showed that older men with lower urinary tract symptoms have increased risk of developing mobility and activities of daily living (ADL) limitations, perhaps due to greater frailty phenotype.    

In the US, geriatrics “grew up” as an academic profession with a heavy research base.  This was in part due to the tremendous support of the National Institute on Aging.  Clinical growth of geriatrics programs has lagged academic research, despite the rapid aging of the population.  Palliative care, in contrast, saw explosive growth in US hospitals.  In contrast to geriatrics, the evidence base for palliative care lagged clinical growth, in part because palliative care has no centralized “home” at the National Institutes of Health.  The National Palliative Care Research Center (NPCRC)and Palliative Care Research Cooperative (PCRC)were founded in part to meet this need. Today we interview Kate Courtright, a critical care and palliative care physician-researcher who conducts trials of palliative care.  Kate’s journey is in a way emblematic of the lack of centralized funding for palliative care: she’s received funding from three separate NIH institutes, the NPCRC, and been involved in the PCRC. We talk with Kate about how despite how far we’ve come in palliative care research, we still don’t have answers to some fundamental questions, such as: Who should get specialized palliative care?  Should eligibility and access be determined by clinician referral? By diagnosis?  By prognosis?  By need? If we move away from clinician referrals as the means by which people get access, how do we keep the clinicians engaged, and not enraged?  Can nudges help?  (see our prior podcast on Nudges with Jenny Blumenthal-Barby and Scott Halpern) When should people get palliative care?  What does “early” really mean?  We can’t possibly meet the needs of all people with newly diagnosed serious illness How do we move from efficacy (works in highly controlled settings) from effectiveness (works in real world settings?  What’s the role of implementation science? What is a pragmatic trial? What outcomes should we measure? We cover a lot of ground!  Working on a mystery.  Going wherever it leads.  Runnin down a dream… -@AlexSmithMD

We are two and a half years into the COVID pandemic.  We’ve lived through lockdowns, toilet paper shortages, mask mandates, hospital surges where ICU’s overflowed, a million COVID deaths, prolonged school closures, development and roll out of novel vaccines, an explosion of social isolation and loneliness, and the invention of the “zoom meeting.”  But what have we really learned over this seemingly endless pandemic other than how to make a quarantini?  Well, on today’s podcast we invite Monica Gandhi to sum up the evidence to date about how best to prevent getting COVID (or at least the severe outcomes of the disease) and how to treat it, including the role of Paxlovid in symptomatic disease. Monica Gandhi is a professor of medicine and associate division chief of HIV, Infectious Diseases, and Global Medicine at UCSF & San Francisco General Hospital.  In addition to her research publications, she is a prolific writer both on social media and on media outlets like the Atlantic and the Washington Post.  Some call her an optimist or maybe a pragmatist, but I’d call her someone who inherently understands the value in harm reduction when it’s clear harm elimination just ain’t gonna happen. So take a listen and if you want a deeper dive into some of the references we discuss on the podcast, here is a list: Medscape article on how “COVID-19 Vaccines Work Better and for Longer Than Expected Across Populations, Including Immunocompromised Individuals” Stat news article about variants/COVID becoming more predictable A good twitter criticism of the CDC 1 in 5 COVID survivors have long COVID study NIH study about long COVID published the day before in Annals of Internal Medicine Evusheld and how it works against BA4 and BA5 Our World in Data COVID graphs

It’s been a while since we’ve done a Covid/bioethics podcast (see prior ethics podcasts here, here, here, and here).  But Covid is not over and this pandemic keeps raising challenging issues that force us to consider competing ethical considerations.   This week, we discuss an article by bioethicists Govind Persad and Emily Largent arguing that the NIH guidance for allocation of Paxlovid during conditions of scarcity.  They argue that the current guidelines, which prioritize immunocompromised people and unvaccinated older people on the same level, should be re-done to prioritize the immunocompromised first, and additionally move up older vaccinated individuals or vaccinated persons with comorbidities.  The basis of their argument is the ethical notion of “reciprocity” - people who are vaccinated have done something to protect the public health, and we owe them something for taking that action.  Eric and I attempt to poke holes in their arguments, resulting in a spirited discussion. To be sure, Paxlovid is no longer as scarce as it was a few months back.  But the argument is important because, as we’ve seen, new treatments are almost always scarce at the start.  Evusheld is the latest case in point.  Sometimes, you can’t always get what you want… -@AlexSmithMD

A patient is on morphine and you want to convert it to another opioid like hydromorphone (dilaudid).   How do you do that?  Do you do what I do, pull out a handy-dandy opioid equianalgesic table to give you a guide on how much to convert to?  Well on today’s podcast we invited Drew Rosielle on our podcast who published this Pallimed post about why opioid equianalgesic tables are broken and why we shouldn't use them, as well as what we need to move to instead. But wait, before you throw out that equianalgesic table, we also invited Dr. Mary Lynn McPherson, PharmD extraordinaire who published this amazing book, Demystifying Opioid Conversions, 2nd Ed., which advocates for an updated, wait for it… equianalgesic table!  Oh boy, what should we do?  Should we throw out the equianalgesic table like some are advocating we do with advance directives (see here), or should we just modernize it for the times with updated data?   Listen to this spicy podcast with these wonderful guests to make up your own minds (I’m sticking with the equianalgesic table for now). If you want to take a deeper dive into some of the references, here you go: Pallmed Post on why “Opioid Equianalgesic Tables are Broken” Pallimed post on “Simplifying Opioid Conversions” Dr. Akhila Reddy and colleagues study looking at converting hospitalized cancer patients from IV hydromorphone to PO morphine, PO hydromorphone, or PO oxycodone. Our previous podcast with Mary Lynn titled “All the Questions You Had About Opioids But Were Afraid To Ask”  

In today’s podcast we talk with Dr. Rajagopal (goes by “Raj”), one of the pioneers of palliative care in India.  Raj is an anesthesiologist turned palliative care doctor.  He is also author of the book, “Walk with the Weary: Lessons in Humanity in Health Care,” and was featured in this Atlantic article.  Raj is the founder of Pallium, an organization dedicated to improving palliative care throughout India.  We are joined by guest-host Tom McNally, a rehab and pediatric palliative care doc at UCSF. In this podcast, we cover a great deal of ground, including: Early challenges Dr. Raj faced in pain management: access to opioids, corruption, a system that doesn’t see addressing suffering as a priority Prognosis communication and the subtle ways we may communicate it without intention Social pain and loneliness Community-based palliative care networks  Raj’s reflections on the state of palliative care in the US How definitions bind us, for example the division between chronic pain and palliative pain in much of the US Ways listeners can learn more and contribute (see this link in the US) Because the song request was the short theme-song for Pallium, I recorded it two ways.  The intro is the upbeat guitar driven version.  The outro is the synthesizer (new toy!) slowed down version. Enjoy! -@AlexSmithMD 

Think about the last time you attended a talk on communication skills or goals of care discussions.  Was there any mention about the impact that hearing loss has in communication or what we should do about it in clinical practice?  I’m guessing not.  Now square that with the fact that age-related hearing loss affects about 2/3rd of adults over age 70 years and that self-reported hearing loss increases during the last years of life.   Screening for addressing hearing loss should be an integral part of what we do in geriatrics and palliative care, but it often is either a passing thought or completely ignored.  On today's podcast, we talk to Nick Reed and Meg Wallhagen about hearing loss in geriatrics and palliative care.  Nick is an audiologist, researcher, and Assistant Professor in the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health. Meg is a researcher and professor of Gerontological Nursing and a Geriatric Nurse Practitioner in the School of Nursing at UCSF. We talk with Nick and Meg about: Why hearing loss is important not just in geriatrics but also for those caring for seriously ill individuals How to screen for hearing loss Communication techniques we can use when talking to individuals with hearing loss The use of assistive listening devices like pocket talkers and hearing aids Their thoughts on the approval and use of over the counter hearing aids If you want to take a deeper dive into this subject and read some of the articles we discussed in the podcast, check out the following: Hearing Loss: Effect on Hospice and Palliative Care Through the Eyes of Practitioners COVID-19, masks, and hearing difficulty: Perspectives of healthcare providers Association of Sensory and Cognitive Impairment With Healthcare Utilization and Cost in Older Adults Over-the-counter hearing aids: What will it mean for older Americans? Addressing Hearing Loss to Improve Communication During the COVID-19 Pandemic  

Comics. Cartoons. Graphic Novels. Graphic Medicine.  I’m not sure what to title this podcast but I’ve been looking forward to it for some time.  Heck, I’m not even sure to call it a podcast, as I think to get the most out of it you should watch it on YouTube. Why, because today we have Nathan Gray joining us.  Nathan is a Palliative Care doctor and an assistant professor of Medicine at Johns Hopkins. He uses comics and other artwork to share his experiences in palliative care and educate others about topics like empathy and communication skills.  His work has been published in places like the L.A. Times, The BMJ, and Annals of Internal Medicine.   We go through a lot of his work, including some of the comics you can see on our blog post. However if you want to take a deeper dive, check out his website “The Ink Vessel” or his amazing twitter feed which has a lot of his work in it.  

In celebration of National Poetry Month, we are delighted to share with you the second podcast in our series on poetry and medicine.  In the first podcast, we talked with Guy Micco and Marilyn MacEntyre about poetry and aging. In this second part in our series, we welcome Mike Rabow and Redwing Keyssar to talk about palliative care and poetry.   As with aging, poetry operates on multiple levels within the palliative care space.   Poetry puts us in our patient’s shoes. As Redwing’s poem says, “why not live as long as possible?”   Poetry holds us in that liminal space so many of our patients are in. Paradox.  The impossiblity which is life, which is everything, and death, which is the end of life. As Mary Oliver tells us In Blackwater Woods, and I’m paraphrasing here, we must to hold it to our bones, knowing our lives depend on it, and when the time comes, to let it go. To let it go.   Or as in Mark Nepo’s poem Adrift, I am so sad and everything is beautiful. Poetry helps us grapple with our own experiences of illness.  Redwing, who is a cancer survivor, shares poems about her experiences with cancer.  Mike Rabow shares his award winning poem about coming out to the world about his diagnosis with multiple sclerosis.   We talk not only about reading poetry, but also writing poetry, and using poetry in medical education as a healing modality. And along the way, we really felt like we got to the heart of things.  To the deeper emotions - of loss and grief, of wonder and transcendence - that are at the heart of the complex care we provide. -@AlexSmithMD  Links to Redwing’s poetry workshops: Food for Thought Poetry for Resiliency  Loss, Losing  and Loosening, poetry for grief and loss   Wounded Healer poetry sessions  Advance Care Planning Links to Redwing Keyssar’s poetry collections  Redwing’s website: www.redwingkeyssar.com Institute for Poetic Medicine Mike Rabow’s Comprehensive Care Team randomized trial of outpatient palliative care Look also for a forthcoming article by Mike and Redwing in Journal of Pain and Symptom Management on poetry as a healing modality, to be published mid May (will add link when out). In addition to Redwing’s own songs and poems, other poems read by Mike and Redwing during the podcast: In Blackwater Woods by Mary Oliver Therapy by John Wright Adrift by Mark Nepo Talk Before Sleep by Elizabeth Berg Late Fragment by Raymond Carver  

Buprenorphine.  It’s been around for a long time but is acting like the hot new kid in town.  Just look at this year’s AAHPM meeting, where it felt like every other session was talking about how hot buprenorphine is right now.  But does this drug really live up to the hype? On today’s podcast we talk with three experts on buprenorphine on why, when, and how to use it in serious illness. Our experts include Katie Fitzgerald Jones (palliative nurse practitioner and doctoral student at Boston College), Zachary Sager (palliative care physician at the Boston VA and Dana-Farber Cancer Institute), and Janet Ho (physician at UCSF in addiction medicine and palliative care). We try to cover a lot in a 45 minute podcast, but if there is one take-away, it's that all of us who prescribe opioids should learn how to use buprenorphine and that we should all sign up for a DEA X-waiver at www.getwaivered.com or at www.buprenorphine.samhsa.gov (now you can treat up to 30 patients without completing the additional educational training, so signing up takes about 5 minutes).  And if you want to learn more about buprenorphine from these amazing palliative care clinicians and others, check out of some of these articles: Learn more about caring for those with substance use disorder:  Adapting Palliative Care Skills to Provide Substance Use Disorder Treatment to Patients With Serious Illness  Learn about using the low dose buprenorphine patch:  Low-Dose Buprenorphine Patch for Pain - Fast Fact Learn about how to initiate buprenorphine:  Sublingual Buprenorphine Initiation: The Traditional Method  - Palliative Care Network of Wisconsin Low Dose Initiation of Buprenorphine: A Narrative Review and Practical Approach Good review on buprenorphine for pain Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion