Alex Smith, Eric Widera

A geriatrics and palliative care podcast for every health care professional. We invite the brightest minds in geriatrics, hospice, and palliative care to talk about the topics that you care most about, ranging from recently published research in the field to controversies that keep us up at night. You'll laugh, learn and maybe sing along. Hosted by Eric Widera and Alex Smith.
Medicare Advantage, Special Needs Plans, and the Hospice Carve-In: A podcast with Dr. Claire Ankuda and Dr. Cheryl Phillips
6d ago
45 mins
Medicare Advantage and the "Medicare Money Machine": Guests Dr. Don Berwick & Dr. Rick Gilfillan
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 patientsRick 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.
Jan 13 2022
47 mins
Amyotrophic lateral sclerosis (ALS) - What every Geriatrician and Palliative Care Clinician Should KnowCelebrating GeriPal's 200th with Leaders in Geriatrics and Palliative CareGeriatric Oncology: Podcast with Melisa Wong and Louise Walter
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 OncologyCancer 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!
Dec 16 2021
44 mins
Geriatric Anesthesia: Podcast with Mark Neuman, Liz Whitlock, and Cindy Hsu
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
Dec 10 2021
41 mins
Burnout and Resiliency: A Podcast with Janet Bull and Arif Kamal
Dec 2 2021
43 mins
Spiritual Care in Palliative Care: A Podcast with Allison Kestenbaum, Katy Hyman, and Paul Galchutt
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 matterWhat 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.
Nov 24 2021
48 mins
Every deep drawn breath: Podcast with Wes Ely
Nov 18 2021
52 mins
The Messiness of Medical Decision Making in Advanced Illness: A Podcast with James TulskyReducing Prolonged Admissions: Podcast with Kenny Lam, Jessica Eng, Sarah Hooper, and Anne FabinyMeaningful Activities: Podcast with Anna Oh and Theresa Allison
Most studies in geriatrics have used metrics such as survival time or disability in activities of daily living as their outcome measure.  Many palliative care interventions are evaluated on the basis of ability to change symptoms such as pain.  But these outcomes represent a thin view of the human experience.  What older adults and those with serious illness often care about most is being able to do the activities that animate their lives with meaning and purpose.  Participating in meaningful activities is central to quality of life, and yet is poorly captured in most outcome scales. In this week’s podcast, Ken Covinsky joins Eric Widera and I to talk with Anna Oh and Theresa Allison, two researchers who have taken very different approaches to studying meaningful activities.  Anna conducted a quantitative study, getting a 30,000 foot view of older adults with dementia, disability, and depression’s ability to participate in meaningful activities.  Most people think that a good quality of life isn’t possible for people with these conditions. Anna’s study, published in JAMA IM, finds that most older adults with these conditions are still engaging in meaningful activities. Theresa’s qualitative study, published in JAMDA, delves deep into the lived experience of older adults with dementia and their caregivers. She finds that while they have had to adapt to support participation in meaningful activities, the underlying sources of meaning have remained the same.  Interestingly, caregiver stress was higher when the people with dementia they cared for stopped participating in meaningful activities.  Helping people with dementia and caregivers adapt to continue to engage in meaningful activities is a creative activity that is at the heart of good geriatric and palliative care. -@AlexSmithMD
Oct 28 2021
42 mins
“Real world” eligibility for aducanumab: A Podcast with Tim Anderson and Marco Canevelli
The FDA label for the amyloid antibody aducanumab (Aduhelm) started off exceedingly broad, basically including anyone with Alzheimer's disease, but was subsequently narrowed to to patients with mild cognitive impairment (MCI) or mild dementia due to Alzheimer disease (AD).  Should, though, the label be even more restrictive to mirror the populations studied in the two still unpublished trials of the drug, EMERGE and ENGAGE?  Or should CMS consider restricting coverage for aducanumab to populations meeting trial eligibility criteria and requiring additional evidence on clinical outcomes in groups excluded from the trials? In today's podcast, we talk with Tim Anderson and Marco Canevelli, the authors of two recent articles published about the real world eligibility of aducanumab: Tim Anderson was first author of a JAMA research letter that found that more than 92% of Medicare beneficiaries with Alzheimer's Dementia and 85% of those with MCI would have been excluded in the clinical trials of aducanumab based on their age or comorbid conditions.  Marco was first author of a JAGS letter to the editor that systematically applied the EMERGE and ENGAGE exclusions to 911 patients with cognitive complaints who went to A geriatric outpatient unit in Milan (Italy). Only six patients (i.e., 0.66%) of these patients would potentially be candidates to aducanumab. For more podcasts on aducanumab, check out these two: All things Amyloid, including Aducanumab and Amyloid PET scans with Gil RabinoviciAducanumab (Aduhelm) for the Treatment of Alzheimers: A Podcast with Aaron Kesselheim and Jason Karlawish
Oct 21 2021
46 mins
Primary Palliative Care for Cancer: Podcast with Yael Schenker and Bob Arnold
“The take home message of this study is NOT that primary palliative care does not work.”  So says Yael Schenker of the negative study of an oncology nurse-led primary palliative care intervention for people with advanced cancer. And we pushed Yael and Bob Arnold (senior author) on this point - we have several negative studies of primary palliative care (see links below to podcasts)  - is it time to start to question the effectiveness of primary palliative care?  We certainly all agree on the problem: we have only enough palliative care specialists to care for some small proportion of the population of people with serious illness.  But when we move away from specialist palliative care to primary palliative care do we lose something critical? Perhaps we cannot train primary providers (front line nurses and doctors generally) to deliver palliative care that is “good enough” to impact outcomes. That’s one interpretation.  Another is that we need a “stronger dose” of primary palliative care.  In Yael and Bob’s study nurses averaged 2.2 visits, hardly robust longitudinal palliative care.  Patients who had 3 visits had better outcomes. Unpacking negative studies is just as interesting as unpacking positive studies.  Knowing what doesn’t work is just as important as knowing what does. Links: Negative multi-national study of primary palliative care in nursing homes Negative ICU primary palliative care intervention Project ENABLE Podcast on palliative care’s diversity problemSystematic review of palliative care
Oct 14 2021
46 mins
Time Limited Trials in the ICU: A Podcast with Dong Chang and Richard Leiter
Time-limited trials. We’ve all probably used them before. We meet with patients and families.  We agree to either start or continue a particular treatment to see if it helps in some specific way over some defined period of time. If it works as hoped, great, we continue the treatments.  If not, we stop them.  At least that is how it’s supposed to go.  On today’s podcast we talk all about these time-limited trials with Dong Chang and Ricky Leiter.  Dong was the lead author of a JAMA IM article looking at the outcomes of training staff to use time-limited trials as the default communication and care planning approach for critically ill patients in intensive care units.   Ricky is the lead author of the accompanying editorial and palliative care physician extraordinaire.    We discussed with Dong and Ricky about the results of the JAMA IM study, which were pretty darn impressive.  The intervention resulted in significant reductions in duration of ICU stay (7.4 v 8.7 days), fewer invasive procedures, but no change in mortality, and no change in family satisfaction rating (which was high before and after the intervention).  We discuss potential reasons why the intervention worked, some limitations of the study, the role uncertainty plays in decision-making, and so much more (including nudging from our last podcast).  If you want to read more about time-limited trials, check out these articles as well:  Paula Spans NY Times article on Time limited trials titled “I need to know I tried” The JAMA IM study and editorial on time-limited trialsTim Quill and Robert Holloways article in JAMA on Time-Limited Trials from 2011And lastly our nudging podcast that we brought up several times
Oct 7 2021
47 mins
Is nudging patients ethical? Podcast with Jenny Blumenthal-Barby and Scott Halpern
I’m going to start this introduction the way Eric ended our podcast. You are a GeriPal listener.  Like us, you care deeply about our shared mission of improving care for older adults and people living with serious illness.  This is hard, complex, and deeply important work we’re engaged in.  Did you know that most GeriPal listeners have given us a five star rating and left a positive comment in the podcasting app of their choice?  We will assume that you are doing the same right now if you haven’t done so already, though we suppose you are free to choose not to if you don’t believe in the mission of helping seriously ill older adults. Ha! Gotcha. Today we talk with Jenny Blumenthal-Barby and Scott Halpern, two experts in the ethics and study of “nudging,” or using heuristics, biases, or cognitive shortcuts to nudge a person toward a particular decision, without removing choice.  Jenny just published a terrific book on the topic, “Good Ethics and Bad Choices: The Relevance of Behavioral Economics for Medical Ethics.”  Scott published several landmark studies including this study of changing the defaults on an advance directive (e.g. comfort focused care is checked by default) and a paper on how nudging can be used in code status conversations (e.g. “In this situation, there is a real risk that his heart may stop—that he may die—and because of how sick he is, we would not routinely do chest compressions to try to bring him back. Does that seem reasonable?”). Examples of nudges are comparing to norms (most listeners have given us a 5 star rating), the messenger effect (I’m a believer in the GeriPal mission too, we’re on the same side), appealing to ego (you’re a good person because you believe in an important cause), and changing the defaults (you’re giving us a five star rating right now unless we hear otherwise).   We distinguish between nudges and coercion, mandates, and incentives.  We talk about how clinicians are constantly, inescapably nudging patients.  We arrive at the conclusion that, as nudging is inevitable, we need to be more thoughtful and deliberate in how we nudge.   Nudges are powerful.  At best, nudges can be used to promote care that aligns with a patient’s goals, values, and preferences. At worst, nudges can be used to constrain autonomy, to promote “doctor knows best” paternalism, and to “strongarm” patients into care that doesn’t align with their deeply held wishes.   What will send your head spinning later are the thoughts we raise: what if nudging people against their preferences is for the common good? And also: what if the ease with which people are nudged suggests we don’t have deeply held preferences, goals and values? Hmmm....  Hey, have you completed your five star rating of GeriPal yet? -@AlexSmithMD Other citations: -Randy Curtis and Robert Burt on unilateral DNR and informed assent -GeriPal podcast with Angelo Volandes about using video to improve choices
Sep 30 2021
48 mins
Living with and studying serious illness: Podcast with Randy Curtis
Randy Curtis, a paragon of palliative care research, was diagnosed with ALS in March.   Randy is in a unique position as someone who studies and cares for people living with serious illness, who now shares his reflections on being on the other side, to reflect on the process of living with serious illness.  His reflections are illuminating and inspiring. We talk with Randy about his experience being in the patient role, rather than the physician or researcher role.  We ask if knowing the prognosis for his subtype of ALS is helpful to him, and if he’s seeing a palliative care clinician.  We talk with Randy about his legacy, principally his focus on mentoring.  We talk about how his approach to his life, his clinical work, and research has shifted in the face of living with serious illness.  We end by talking about our favorite “Randy Curtis” studies. Thank you Randy for modeling vulnerability and willingness to talk about ALS. Thank you for your mentoring which has nurtured a veritable forest of trainees, and for your research which has improved care for people living with serious illness and their families. And here’s to your song choice: a “good life” indeed, by any measure. Links: -Prior GeriPal podcast with Randy Curtis on an earlier study of the JumpStart patient-priming intervention for goals of care discussion -ICU family meetings: Increased proportion of family speech is associated with increased satisfaction -Alterations in translated ICU family meetings -A communication strategy and brochure for ICU family meetings -Practical guidance for ICU family meetings -Empathy in life support decisions -Cambia Center of Excellence for Palliative Care Research -Cambia Sojourns Scholars Leadership Program   -@AlexSmithMD
Sep 16 2021
42 mins
Palliative Care's Diversity Problem: A Podcast with Lindsay Bell, Tessie October, and Riba Kelsey
Sep 9 2021
46 mins
Grief and Academia: Podcast with Krista Harrison
Much has been written in geriatrics and palliative care about anticipatory grief, about the grief of caregivers, and even the grief clinicians experience following the deaths of their patients.  Krista Harrison, in a Piece of My Mind essay in JAMA, writes about something different.  She writes about coping, as an academic hospice and palliative care researcher, with personal grief from the deaths of her dad and step-dad within 5 months of each other.   There are many reasons this essay likely touched so many people (it seemed to be all over Twitter).  One is that there’s a silence around this experience of death.  Krista’s essay opens up a space to talk about it.  Another is that the experience of grief is in fact universal, whether it’s the loss of a loved one, the loss of a colleague or mentor to illness or a move, the loss of “a return to normal” following COVID.   Krista wanted to add a couple of things not mentioned in the podcast that she found helpful.  First, she treasures videos she has of her loved ones recorded before death.  Second, she made fingerprint imprints of her two dads and keeps the fingerprint impressions in a locket around her neck. We talk with Krista about these and many other things on this week’s podcast.  Let’s keep the conversation going. Links: Making Space for Grief in Academia, JAMA The Hidden Curriculum of Hospice: Die Fast, Not Slow, Health Affairs Live Discharge from Hospice Isn’t Graduating - It’s Getting Expelled, JAGSGriefcast podcast RadioLab: The Queen of Dying PodcastThe Dougy Center Grief Out Loud PodcastOn Being PodcastThe Five Invitations by Frank Ostaseski Resilient Grieving by Lucy Hone  The Art of Losing (poems) When Things Fall Apart by Pema Chodron -@AlexSmithMD
Sep 2 2021
43 mins
#AcademicLifeHacks: A Podcast About Tips and Tricks to Thrive in Academic Medicine
Today’s podcast is on academic life hacks, those tips and tricks we have seen and developed over the years to succeed in academic medicine in fields that are somewhat generalist in nature. While the podcast is meant for fellows and junior faculty, we hope some of it applies to the work that all of our listeners do, even in non-academic settings.   Why are we doing a podcast on #academiclifehacks?   You will notice that at the start of the podcast, we spent a couple minutes to recognize my co-host, Alex Smith, for a particularly important award he received at the 2021 AGS meeting – the  Thomas and Catherine Yoshikawa Award for Outstanding Scientific Achievement in Clinical Investigation.  As part of this award he presented a talk titled "Confessions of an Unfocused Researcher."  We (and when I say we, everyone on this podcast except for Alex who we kept in the dark) thought it would be a good idea both to celebrate Alex’s award and talk about some of the topics he brought up in his talk, as well as other tips and tricks.   So we asked Lynn Flint and Ken Covinsky from UCSF, and Christopher Langston from Archstone foundation to join Alex and me to talk about our shared tips and tricks to succeed in academic medicine.  In particular we focused on several key issues that new faculty need to address as they start their careers including: Academic focus and goals Mentorship (and mentoring up)Academic scholarship & writingCollaboration & NetworkingWork / Life Balance We would also love to see your own academic life hacks by sharing them on twitter and adding the hashtag #academiclifehacks to the tweet.
Aug 26 2021
55 mins