GeriPal - A Geriatrics and Palliative Medicine Podcast

In prior podcasts we talked about racism and COVID, lack of diversity in the palliative care workforce, racial and ethnic differences in end of life care, and implicit bias in geriatrics and palliative care. Today our focus is on structural, institutional, and interpersonal racism, and how these different but related constructs negatively impact the care of older adults and people with serious illness. We are joined by Deborah Ejem, a medical sociologist and Assistant Professor in the School of Nursing at the University of Alabama Birmingham, and Deep Ashana, a pulmonary critical care physician and Assistant Professor of Medicine at Duke University. We discuss: What are the differences between structural, institutional, and interpersonal racism? Examples of how these forms of racism operate in the care of seriously ill patients, including from one of our guest's personal experiences. The importance of attention to religion and spirituality Clinician reluctance to engage in advance care planning with minoritized patients as a driver of disparities How abandoning support for advance care planning might foreground implicit biases inherent in the heuristics (or nudges, or short cuts in thinking) inherent to time-pressed in-the-moment decision making. Lack of diversity in the participants represented in AAHPM State of the Science presentations, as well as lack of focus on disparities (no link - see upcoming presentation by Deboarh Ejem at the virtual conference). Co-opting of disparities issues by the Alzheimer's Association in their argument for CMS/Medicare coverage of aducanumab (see this Twitter thread by Jonathan Jackson here and article by Daniel George here). Action Item: Please submit a comment to CMS about aducanumab coverage today. Feel free to express your outrage at the lack of diversity in the trials. We could have continued talking with our guests for hours. We will continue to address the issue of racism in future podcasts. -@AlexSmithMD

Patients with end stage liver disease and decompensated cirrhosis have an average life expectancy of 2 years without transplant. Outcomes are worse among those who are frail. Symptoms are common, including pain, ascites, encephalopathy, and pruritus. Patients with end stage liver disease are often some of the most disadvantaged patients we care for. Caregiver burden is immense; divorce is common. Some will go on to receive a transplant, but many will not. Many are confused about the diagnosis and feel poorly supported. Prognosis is fraught, as the worse your prognosis (i.e. lower your chance of survival), the higher you move on the transplant list. Advance care planning is rare (or serious illness communication for those of you who don't consider this advance care planning). Outcomes of in-hospital CPR are worse for patients with end stage liver disease than outcomes for patients with advanced cancer. Though integration of geriatrics and palliative care into the care of patients with end stage liver disease holds obvious potential, major barriers remain. In this week's podcast, we talk with Jen Lai, Ricky Shinall, Nneka Ufere, and Arpan Patel about end stage liver disease from a geriatrics and palliative care perspective. We talk about the tension patients face between putting on the "best face" to be listed for transplant (e.g. full code, goals focused on extending life). We talk about the potential and limitations of the MELD score for prognosis, and how frailty further stratified risk for older patients with end stage liver disease. We discuss what is needed in terms of improved communication around the time of diagnosis, creating a safe space for serious illness communication, and resources for patients and caregivers (including this Canadian information resource). And we have a round robin about treatment of common and challenging symptoms – yogurt makes a surprise appearance. And…Radiohead! Great request…thank you Nneka! -@AlexSmithMD

More Health Policy this week! Today, we discuss "SNPs" but this is not a podcast about haircuts during the pandemic. We take a deeper dive into the world of Medicare Advantage and what it means for vulnerable patients facing serious illness and those at the end of life. We are joined by UCSF geriatrics fellow Alex Kazberouk to talk to Dr. Claire Ankuda (Assistant Professor at Icahn School of Medicine at Mount Sinai and Palliative Care Physician) and Dr. Cheryl Phillips (President and CEO of the Special Needs Plan Alliance and past president of the American Geriatrics Society). We discuss: Special Needs Plans (SNPs) for older adults – what they are and what they mean for our patients What happens when a Medicare Advantage patient enrolls in hospice and how that may change with the new "Hospice Carve-In" This is part two of a two part series on Medicare Advantage and healthcare financing. On our prior episode, we heard Dr. Don Berwick's and Dr. Rick Gilfillan's critique of Medicare Advantage plans. This week, we bring up a rebuttal to their critique and also talk about quality data and reporting for Medicare Advantage patients. Alex plays The Purchaser's Option by Rihannon Giddens (she has so many terrific songs!). Astute online viewers will also spot an appearance of the Team Canada Tokyo 2021 Olympic Jacket and Cheryl's dog.

Investor money and venture capital funding is pouring into Medicare Advantage (MA) plans. Enrollment in MA plans has more than doubled from 12 million members in 2011 to 26 million in 2021. What does this mean for us and our patients? Do these plans deliver better care for vulnerable older adults? Or are they a money making machine driving up healthcare costs in the name of profit? On today's podcast, we are joined by UCSF geriatrics fellow Alex Kazberouk to talk with Dr. Don Berwick (founder of the Institute for Healthcare Improvement, former administrator of Center for Medicare and Medicaid Services) and Dr. Richard Gilfillan (former CEO of Geisinger Health Plan and Director of the Center for Medicare and Medicaid Innovation). Their recent two part post on the Health Affairs Blog about the Medicare "Money Machine" has stirred up a debate about challenges and misaligned incentives within Medicare Advantage. We talk about: What Medicare Advantage is all about - its history, operations, potential benefits, and what it means for us and our patients Rick and Don's Health Affairs post on the downsides of MA plans and the Medicare "Money Machine" Policy solutions to improve the system without throwing the baby out with the bathwater We also touch upon prior podcast topics such as the area deprivation index and population health. As a special, Alex plays a superb rendition of this song which is definitely not a Rickroll. This is part one of a two part series on Medicare Advantage and healthcare financing. We have a follow-up with Claire Ankuda and Cheryl Philips on Special Needs Plans and the Medicare Advantage Hospice Carve-In coming soon.

Three months ago we did a podcast with Randy Curits about his recent diagnosis of ALS in March and what it was like for someone who studies and cares for people living with serious illness, to now be someone who is living with serious illness. It was one of our favorite podcasts we've done, but also got us to think "wait, how come we've never done a podcast on ALS?" We fix that on today's podcast. We've invited Elizabeth Lindenberger and Kara Bischoff to talk about what every geriatrician and palliative care clinician should know about ALS. Topics include: prognosis in ALS, disease modifying therapies (and when/if to discontinue, advance care planning in ALS, the role of embedding geriatrics/palliative care in ALS clinics, interventions in ALS (noninvasive ventilation, PEG tubes, and trachs), and symptom management as the disease progress. So take a listen and if you want to take a deeper dive, take a look at these articles: Embedded Palliative Care for Amyotrophic Lateral Sclerosis: A Pilot Program and Lessons Learned Top Ten Tips Palliative Care Clinicians Should Know About Amyotrophic Lateral Sclerosis

It's GeriPal's 200th episode. Yup, we started the podcast in 2016 and over the years we have grown from basically podcasting for Alex's mom to now getting over 25,000 plays per month. So to celebrate our 200th, and given that the last two years kinda sucked in a lot of ways, we are going to pivot to appreciative inquiry. We have invited leaders in geriatrics and palliative care to quickly share: One thing that you are grateful for in Geriatrics and Palliative Care (other than GeriPal!) One thing you are hopeful for in 2022 The guests we had were an awesome group that included Rachelle Bernacki (@rbernack), Kim Curseen (@Curseen), William Dale (@WilliamDale_MD), Helen Fernandez (@hfernandez01), Lynn Flint (@lynnmomdoc), Anne Kelly, Allison Kestenbaum (@ARKestenbaum), Christopher Langston (@calangst), Nancy Lundebjerg (@nlundebjerg), Mary Lynn McPherson (@mlmcpherson), Sean Morrison, Christine Ritchie (@RitchieCS), Christian Sinclair (@ctsinclair), Wendy-Jo Toyama(@WJSvetanoff), James Tulsky (@jatulsky), and Haider Warraich (@haiderwarraich). We also invite you to join us in this discussion. Go to either our Twitter account or youtube channel and share your answers to these two questions. Eric

Geriatric Oncology has arrived. Yes, Louise Walter has been leading the fight to improve cancer screening in older adults for years. But when it came to geriatricizing the way we assess and treat older adults with cancer, the evidence was thin. In our prior podcast with Supriya Mohile and William Dale on geriatric assessment in oncology, we couldn't say for certain if a geriatric assessment was helpful for patients with cancer. Well now we can. We are joined by Melisa Wong, a geriatric oncologist, and Louise Walter, a geriatrician and leader in cancer screening for older adults, to talk about the shifting landscape of geriatric oncology, including: How to think about cancer screening in older adults, moving beyond a one-size-fits all age-based approach to individualize cancer screening decisions. We also talk about the importance of thought pieces in driving a field forward. 2 landmark trials of the geriatric assessment in oncology, one in JAMA Oncology (first author Daneng Li) and the other in the Lancet (first author Supriya Mohile) (William Dale senior author for both studies). In both studies, grade 3+ toxicity was reduced in the geriatric assessment arm. Melisa Wong's study in JAGS finding a constriction of life space for older adults with cancer, and discussion of patient centered outcomes beyond traditional outcomes such as grade 3+ chemotherapy toxicity. Links of Interest: Association of Community Cancer Center site on Geriatric Oncology Cancer and Aging Research Group And as a bonus, you get to hear Louise on piano and vocals and I cover Wouldn't It be Loverly, from My Fair Lady. -Enjoy!

Geriatric anesthesia is a thing. The average age of people getting surgery is increasing. Anesthesiologists and surgeons feel that with new techniques and approaches they can perform surgery on patients at ever older ages, patients who they previously would have excluded from surgery. One of the key advances in geriatric anesthesia is the use of spinal anesthesia, a form of regional anesthesia that also includes epidurals and peripheral nerve blocks. When older adults experience a hip fracture, there's a growing consensus that spinal anesthesia offers superior outcomes compared to general anesthesia. It's surprising therefore, to talk with Mark Neuman about the results of his randomized trial in NEJM, which finds essentially no difference between general anesthesia and spinal. Importantly, as a primary outcome Mark selected walking ability based on feedback from older adults - this is the outcome our patients care about most. But he finds no difference in primary outcome or secondary outcomes, including (surprisingly) delirium. We break down potential reasons, with thoughtful commentary from Liz Whitlock and Cindy Hsu, two anesthesiologists with experience caring for older adults with hip fracture. Liz is a friend of the pod and researcher who we interviewed previously about "pumphead." Cindy is...my wife. She also helps me out with the accompaniment on piano as it's tough for me to play guitar with a broken clavicle. Thank you dear wife! We had fun learning to play/sing Drivers License by Olivia Rodrigo. Ah...teen angst...the angst!!! -@AlexSmithMD

The great resignation is upon us. One in five health-care workers has left their job since the pandemic started. Geriatrics and palliative care are not immune to this, nor are we immune to the burnout that is associated with providers leaving their jobs. In today's podcast, we talk with Janet Bull and Arif Kamal about what we can do to address burnout and increase resiliency, both from an institutional and individual perspective. Janet Bull is the Chief Medical Officer and Chief Innovations officer at Four Seasons Hospice and Arif Kamal is an oncologist, palliative care doctor and researcher at Duke. We discuss Arif's and Janet's article published in JPSM on the prevalence and predictors of burnout among hospice and palliative care clinicians, as well as Arif's Health Affairs article on the policy changes that are key to promoting sustainability and growth of specialty palliative care workforce. In that later article, Arif found that among many things: Burnout was reported by approximately one-third of physicians, nurses, social workers, and other respondents in the specialty of hospice and palliative care The presence of burnout was associated with increased odds of intending to leave early If you want to learn more about what you can do to promote wellness on your team, check out this article Arif published with other colleagues in JPSM titled the "Top Ten Tips Palliative Care Clinicians Should Know about Implementing a Team Wellness Program." Eric

I don't consider myself spiritual. For some in palliative care, this would be considered heresy as we are told "everyone is spiritual." But, hey, I'm not. So there. However, despite not being spiritual, I do believe that spiritual care is fundamental to the care I give patients and families. I also recognize it is the one palliative care domain I am most uncomfortable with and the one that as a field, we actually don't support very well (odds are, if your palliative care team doesn't have a full interdisciplinary team, the discipline you are likely missing is chaplaincy). So, on today's podcast, we break down spiritual care in palliative care with three leaders in the field: Allison Kestenbaum, Katy Hyman, and Paul Galchutt. We ask these experts a veritable smorgasbord of questions on spiritual care that includes: What the heck is spirituality and is the term itself inherently religious? What is the difference between a "spiritual care history" vs "spiritual screening" vs a "spiritual assessment" and why does it matter What do you do if your spiritual screen or assessment uncovers something? How do we ask our patients if they would like to see a chaplain? Should we ask or just like any of our other team members just have them stop by? What does spiritual care for the non-religious look like? What are some specific communication tips to take a deeper dive into patient/family/caregiver suffering. Can you research spirituality? Also, for all you palliative practitioners and researchers, here is a link to freely join the Hospice-Palliative Spiritual Care Research Network (HPSCRN) with Transforming Chaplaincy The HPSCRN is a space to connect, inform, explore, and coordinate for all interprofessionals.