Our guests today present an important rejoinder to the argument that we should refocus away from advance care planning (ACP).  Sarah Nouri, Hillary Lum, and LJ Van Scoy argue that diverse communities are asking for ACP.  Sarah Nouri gives an example from her work in the LGBTQ+ community of a trans woman who was buried as a man because existing laws/rules did not protect her wishes.  Others cited the call from communities to meet them where they are - be they senior centers, Black-owned businesses, or churches (we have a podcast planned in the fall with Fayron Epps and Karen Moss on the church setting).  It does seem that if communities, particularly historically marginalized communities, are interested in ACP, that fact should carry some weight in how resources are allocated to research and health care financing.  We additionally have a debate/discussion about which outcomes of ACP matter most, including Terri Fried’s commentary in JAGS that caregiver outcomes matter more than goal concordant care (the “holy grail”), completion of advance directives, or changes in health care services use.  Did the caregiver feel heard and understood?  Did they have PTSD? Complicated grief? Depression?  Group visits are one way of reaching diverse communities to which advance care planning has not traditionally been targeted.  In a group visit there is a social norming effect - “if my neighbor is doing it, perhaps I should be doing it to?”  Please tune in to hear more, and listen to the whistle of the “Friendship train!”   -@AlexSmithMD    Links: Community Based Participatory Research and ACP in Latinx communities: https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.18236 Community based ACP in the Black Community: https://link.springer.com/article/10.1007/s11606-023-08134-2 ACP in the Chinese American Community: https://www.sciencedirect.com/science/article/pii/S0885392423000982 Group ACP in primary care: https://www.annfammed.org/content/14/2/125.short and https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16694 Project Talk Website: www.ProjectTalkTrial.org Project Talk Trial Protocol Paper: https://journals.sagepub.com/doi/pdf/10.1177/1049909116656353 Hello Article (including Black churches): https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2765685 Communication Quality Analysis: https://www.tandfonline.com/doi/abs/10.1080/19312458.2022.2099819 Conceptualizing Surrogate Decision Making: https://www.tandfonline.com/doi/abs/10.1080/19312458.2022.2099819 What counts as a surrogate decision: https://journals.sagepub.com/doi/abs/10.1177/10499091231168976   For e-training modules on ACP group visits: https://cuelearning.org Click on the Register link (upper right corner). A pop-up box will appear and enter your email address and set up your password. For Registration Code, enter: ENACT (not case sensitive). The ACP Group visit implementation guide is available here: www.coloradocareplanning.org. Scroll down to “Innovations in ACP page”

Hot off the press is a brand spanking new updated 2023 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.  The Beers Criteria is one of the most frequently cited reference tools in geriatrics, detailing potentially inappropriate medications to prescribe to older people. We’ve invited two members who helped update the criteria including Todd Semla and Mike Steinman.   We discuss a little history of the Beers criteria, including the original Beers Criteria that was published by the late Dr. Mark Beers, and how it has evolved over the last three decades.  We also discuss specifics about how to use and not use the Beers Criteria, how medications are selected for inclusion in the criteria, and specifics about certain medications. And of course, take a deep dive by downloading the JAGS paper on the updated Beers Criteria or any of the great links from AGS including the: 2023 AGS Beers Criteria App  Beers pocket card

We’ve had multiple GeriPal episodes about treatments for dementia, including aducanumab (here, here, and here) and lecanemab (here).  As today’s guest, Kristine Yaffe notes, part of the reason for that emphasis is that in the US we prioritize treatment, whereas other countries are ahead of us in prioritizing prevention.  Deb Barnes and Kristine Yaffe published a landmark paper in Lancet Neurology finding that up to half of dementia risk is due to modifiable factors.  If we focused on prevention, from a public health standpoint, we would achieve far more than spending millions billions on treatment. Today we talk about steps we can and should take to reduce the risk of dementia, including: Education and cognitive games (I reveal my embarrassingly poor average time on the NYT mini cross word) Physical activity Sleep Depression Smoking Social isolation Blood pressure control (listen also to our podcast on Sprint Mind with Jeff Williamson) We also delve into an exciting new trial Kristine led with others on the impact of risk factor reduction on cognition - here’s a link to press about the trial from a fall meeting presentation - article forthcoming.  And because we can’t resist, we dip into aducanumab and lecanemab at the end.  -@AlexSmithMD

I haven’t worked with many adolescents and young adults (AYA, roughly teens to twenties).  But when I have, I find that they’re often some of the hardest patients to care for.  Why?  We talk about why it’s so hard with Abby Rosenberg (chief of PC at DFCI and Boston Childrens), Nick Purol (clinical social worker at DFCI and Boston Childrens), Daniel Eison (pediatric PC doc and co-host of PediPal).  We are grateful to Andrea Thach (PC doc at Sutter East Bay) for bringing this topic to our attention and for asking questions as a guest host.  Here are just a few of the explanations for why it’s so hard: They are closer in age to some of us (younger clinicians).  Countertransference hits hard. There’s an in-between space between adolescence and adulthood - and there’s something that we identify with in that in-between space, tugging at our heart strings Everyone has been a teenager.  Everyone has lived through their early 20s.  Every member of the interdisciplinary team.  Adolescence and young adulthood is a romanticized time of life in our culture.  We remember bucking the rules, figuring out who you are, hair on fire, feeling invulnerable, trying to figure out who you are - and now those adolescents are stuck in the hospital, with doctors and parents telling them what to do, having their autonomy crushed by the medical institution, realizing they’re not invulnerable. We talk about these issues and more - what resources to leverage, how to cope as a team.  We in geriatrics and adult palliative care clinicians have so much to learn from our colleagues in pediatrics - and though many of these lessons are specific to adolescents and young adults - many of the lessons are valuable for the care of patients in older life stages. Links to resources for working with AYA, from Nick Purol): The Courageous Parents Network has a wealth of information/resources/videos/articles on many overlapping issues and topics related to caring for children/adolescents/young adults with serious illness (from both the provider and clinician perspective): https://courageousparentsnetwork.org

We have a special extra podcast this week.  During the last AAHPM - HPNA meeting in Montréal, we went around asking attendees what one thing that they are most worried about and one thing they are most hopeful for when thinking about the future of our field.  We couldn’t fit everyone’s responses in but came up with the big themes for questions and edited them into this weeks podcast / YouTube video.  Eric and Alex   DISCLAIMER While we filmed in Montreal during the Annual Assembly, all opinions expressed in this podcast are independent of AAHPM and HPNA, or the Annual Assembly.  Furthermore, direction to external websites is not an endorsement from AAHPM or HPNA, or the Annual Assembly.  Palliative Care the Next Generation: How the Service May Grow and Evolve https://hospicenews.com/2023/04/14/palliative-care-the-next-generation-how-the-service-may-grow-and-evolve/ AccentCare, a portfolio company of private equity firm Advent International, is another example. The company has expanded its palliative care services through partnerships with hospitals and other managed care providers, according to AccentCare CEO Stephan Rodgers. “We’ve got a very large palliative care practice,” Rodgers told PCN. “What we’ve seen to make it really work is you either have to be in the hospital, where we’ve taken over palliative care in the hospital, or you have to be contracted with managed care and get it at some kind of risk, because community-based palliative care is very difficult to make operate right now from a profitable [perspective].”

In 1990 11% of homeless persons were older than 50.  Today half are over age 50.  Today we talk with Margot Kushel about how we got here, including: That sense of powerlessness as a clinician when you “fix up” a patient in the hospital, only to discharge them to the street knowing things will fall apart. Chronic vs acute homelessness What is the major driver of homelessness in general?   What is the major driver of the increase in older homeless persons? Why do we say “over 50” is “older” for homeless persons, why not 65?  To what extent is the rise of tech in San Francisco to blame for our local rise in homelessness?  What are the structural factors and individual factors that contribute to homelessness? How has the history of redlining and the federal tax subsidy of wealthy (mostly white) people in the form of a mortgage interest deduction contributed to racial inequalities in homelessness? What can we do about it?  What are the highest yield interventions and policy changes? What should we call it - homeless or unhoused? We were fortunate to make it to the end of this podcast before Margot lost power.  It’s storming again in the Bay Area at the time we record this.  So much harder than for the older homeless people on the streets with no power to lose.  A mad world out there (song hint). Key references:  -Margot Kushel’s UCSF Grand Rounds  -JAMA IM paper on mortality among older homeless persons -NEJM perspective arguing that interventions to address homelessness shouldn’t be evaluated on cost savings.   -@AlexSmithMD

Social connections impact our health in profound ways, whether it is the support we receive from family and friends in navigating serious illness, the joy from shared social activities, or connecting with our community. Experiencing social isolation, the objective lack of contact with friends, family, or the community, or loneliness, the subjective feeling of lacking companionship or feeling left out, may be signs that our overall social life is struggling. But, should we as clinicians care about the social lives of our patients? Are there meaningful ways of assessing loneliness and social isolation in clinical settings and connecting patients with interventions? How can public health and policy experts address these needs, particularly in light of the COVID-19 pandemic which turned our social lives upside down? On today today’s podcast, we are joined by guest host and UCSF geriatrician Ashwin Kotwal as we welcome three renowned scholars in the field: 1) Dr. Julianne Holt-Lunstad, Professor of Psychology and Neuroscience at Brigham Young University, an international expert on loneliness, social isolation, and social interventions, who has served on the National Academy of Sciences committee on social isolation and loneliness and advised the UK Loneliness Campaign, 2) Dr. Thomas Cudjoe, Assistant Professor of Medicine at Johns Hopkins University, who has conducted groundbreaking work on the measurement of social isolation and mechanisms of impact on health, and 3) Dr. Carla Perissinotto, Professor of Medicine at UCSF, who has pioneered the clinical and policy approach to addressing loneliness and social isolation.   We talk about:   Their personal and clinical inspiration for studying loneliness and social isolation, and hurdles encountered in bringing these needs to the clinical world.  The Listening "EAR" approach that simplifies assessment of loneliness and social isolation in clinical settings, and other practical pointers.  Check out some of their recent work, including: Dr. Holt-Lunstad’s and Dr. Perissinotto’s powerful perspective piece in the New England Journal of Medicine which provides a clinical framework for addressing loneliness and social isolation.  Dr. Cudjoe’s recent work demonstrating the impact of social isolation on dementia risk, populations at risk, and how our social lives "getting under our skin." Dr. Kotwal's work showing how social isolation impacts end-of-life health care use, including hospice and acute care. We touch briefly on (and build on) topics discussed in prior podcasts such as loneliness during the pandemic. Tune in to hear Alex’s acoustic rendition of Outkast’s Hey Y’All!   -Ashwin Kotwal

Do we need an RCT to establish the worth of chaplaincy? Einstein once said, “Everything that can be counted does not necessarily count; everything that counts cannot necessarily be counted.” A friend of GeriPal, and prior guest, Guy Micco commented today that we need an RCT for chaplaincy is like the idea that the humanities need to justify their value in medical training: “It’s like being told to measure the taste of orange juice with a ruler.” On the other hand, all of our guests agree that chaplains are often the most vulnerable to being cut from hospital and health system budgets.  These studies are important. Today we have a star-studded lineup, including Lexy Torke of Indiana University, who discusses her RCT of a chaplaincy intervention for surrogates of patients in the ICU, published in JPSM and plenary presentation at AAHPM/HPNA.  To provide context, we are joined by Karen Steinhauser, a social scientist at Duke who has been studying spirituality for years (and published one of the most cited papers in palliative care on factors considered important at the end of life, as well as one of my favorite qualitative papers to give to research trainees).  We are also joined by LaVera Crawly, a physician turned chaplain, now VP of Spiritual Care at Common Spirit Health (and author of another of my favorite and most cited papers on palliative care in the African American Community). We dive into the issues of measuring spirituality, chaplaincy, the need for an expanded vocabulary around spirituality, spiritual assessments, spiritual history, LaVera’s journey from physician to chaplain (listen to her compelling answer to the magic wand question at the end). For further context, please check out our prior podcast on spirituality, and this discussion of the RCT by Lexy that I helped moderate for Transforming Chaplaincy. Thanks to my son Kai for playing the guitar part in 5/4 with strange chords on Riverman by Nick Drake! -Alex

Two weeks ago on the GeriPal podcast we talked about why and how to write for the general public.  This week we’ve invited three guests to share their stories about storytelling that’s written for healthcare providers. The first guest is Liz Salmi.  Liz wrote a fabulous perspectives piece in the NEJM titled “Deciding on My Dimples” which talks about her experience as a patient doing shared decision making during neurosurgery for resection of an astrocytoma.   In addition to this being a fascinating story, Liz brings in a great perspective as a patient, advocate, researcher, and a punk rocker. Our second guest is a recurring star of GeriPal, Anne Kelly.  She just published an essay for JAMA Piece of My Mind titled “The Last Visit”.  In this piece Anne describes her experience with the expressions of love she and her mother shared in the last days of her mothers life. Lastly, but certainly not least, we’ve invited Preeti Malani.  Preeti is the editor for JAMA’s Piece of My Mind section.  We’ve asked Preeti to come on to describe what happens behind the curtain when evaluating these stories, including what makes those few that get accepted stand out. We’ve also love to hear from you on twitter and facebook your own experiences writing for the medical world (and please include links!)

In November of 2022, Ava Kofman published a piece in the New Yorker titled “How Hospice Became a For-Profit Hustle.”  Some viewed this piece as an affront to the amazing work hospice does for those approaching the end of their lives by cherry picking stories of a few bad actors to paint hospice is a bad light. For others, this piece, while painful to read, gave voice to what they have been feeling over the last decade - hospice has in some ways lost its way in a quest of promoting profit over care. On today’s podcast, live from the American Academy of Hospice and Palliative Medicine Annual Meeting, we invite two thought leaders in the field, Ira Byock and Joseph Shega, to discuss among other things: Is hospice losing its way?Is there a difference between for-profit and not-for-profit when it comes to quality of care?What is our role as hospice and palliative care providers in advocating for high-quality hospice care? If you are interested in signing the position statement “Core Roles and Responsibilities of Physicians in Hospice Care”, click here. For a deeper diver into these issues, check out some of the following links:     Ira’s Stat new article “Hospice care needs saving” GeriPal’s episode on the growing role of private equity in hospice care Acquisitions of Hospice Agencies by Private Equity Firms and Publicly Traded Corporations. JAMA IM 2021 Hospice Acquisitions by Profit-Driven Private Equity Firms. JAMA Health Forum. 2021 Association of Hospice Profit Status With Family Caregivers’ Reported Care Experiences.  JAMA IM 2023 A shout-out to my NPR episode on 1A titled the “State of Hospice Care”   DISCLAIMER While we filmed in Montreal during the Annual Assembly, all opinions expressed in this podcast are independent of AAHPM and HPNA, or the Annual Assembly.  Furthermore, direction to external websites is not an endorsement from AAHPM or HPNA, or the Annual Assembly.    ---------------------------

So you want to write a book. So you want to write a book!  So…you want to write a book?!? Today we talk with two geriatricians: Rosanne Leipzig, author of Honest Aging: An Insider's Guide to the Second Half of Life; and Louise Aronson, author of Elderhood: Redefining Aging, Transforming Medicine, and Reimagining Life. (You can hear our prior podcast on Louise’s book here).  We talk with them about writing for the lay public, including: Why write a book for the lay public? Why write about aging? Was there pushback from publishers (hint: hell yes) What terms to use to describe the “old age” time period? How did they start writing a book? How do you find time to write and also be doctors and academic professors? Revisions and working with editors Writing an Op Ed - how to start, what to write, where to send it  TheOpEdProject as a resource for learning more We look forward to the books and op-eds our listeners will write!   In all seriousness, you don’t actually have to want to write a book to be interested in this podcast.  You don’t have to want to play professional basketball to appreciate The Last Dance, which documents the final season of Michael Jordan with the Chicago Bulls.  These are inherently interesting interviews because the motivations, process, and struggle of monumental undertakings are interesting in and of themselves. Enjoy! -@AlexSmithMD

Psychedelics are having a moment.  Enthusiasm is brimming.  Legalization is moving forward in several states, following the lead of Oregon and Colorado.  FDA is considering approval, shifting away from Schedule I restrictions, paving the way for use in clinical practice.  Potential use in palliative care, chronic pain, and for mood disorders is tantalizing. Early data on efficacy in patients with anxiety and demoralization are promising.  Research is exploding.  Two of our guests today, Stacy Fischer and Brian Anderson, are involved in large multicenter trials of psychedelics for patients with advanced cancer (Fischer) or life-limiting illness (Anderson).  Theora Cimino conducted an observational study (publication in the works) of marginally housed/homeless persons many of whom had experience with psychedelics. And yet there are reasons for caution.  In our prior podcast with Ira Byock on psychedelics in 2019 we talked primarily about the potential of psychedelics.  Today we largely focus on reasons for caution, including: We know almost nothing about psychedelics in older adults - only about 1% of patients in published trials were older adults, much less older adults with multiple chronic conditions, multiple medications, and frailty.  Bree Johnston and Brian Anderson wrote a terrific summary of the evidence (or lack thereof) in older adults. There is a marked lack of diversity in published trials.  Most participants are White and well-resourced.  Psilocybin, the most commonly used psychedelic, increases heart rate and blood pressure, which may potentially lead to cardiovascular events. The efficacy of psychedelics without therapy, and the impact of variations in therapy type, training, duration, is unknown. Ethical issues, including colonization of psychedelics by big pharma. Psychedelics have been used by communities around the globe for hundreds of years (or more).  We cover these issues and more in today’s podcast. Note, I butchered the chorus on the YouTube version - please listen to the podcast for my souped up version with drums and bass! -@AlexSmithMD

Gabapentin is the 10th most prescribed drug in the United States and use is increasing.  In 2002, 1% of adults were taking gabapentinoids (gabapentin and or pregabalin).  By 2015 that number increased to 4% of US adults. There are a lot of reasons that may explain the massive increase in use of these drugs.  One thing is clear, it is not because people are using it for FDA approved indications.  The FDA-approved indications for gabapentin are only for treating patients with partial seizures or postherpetic neuralgia. However, most gabapentin prescriptions are written off-label indications. On today's podcast we talk all about the Gabapentinoids - Gabapentin and Pregabalin - with Tasce Bongiovanni, Donovan Maust and Nisha Iyer.   It’s a big episode covering a lot of topics. First, Nisha, a pain and palliative care pharmacist, starts us off with discussing the pharmacology of gabapentin and pregabalin, including common myths like they work on the GABA system (which is weird given the name of the drug).   Tasce, a surgeon and researcher, reviews the use of gabapentin in the perioperative setting and the research she had done on the prolonged use of newly prescribed gabapentin after surgery (More than one-fifth of older adults prescribed gabapentin postoperatively continue to take it more than 3 months later).  Donovan discusses the growth of “mood stabilizers/antiepileptics” (e.g. valproic acid and gabapentin), in nursing homes, particularly patients with Alzheimer's disease and related dementias. This includes a JAGS study recently published in 2022 showing that we seem to be substituting one bad drug (antipsychotics and opioids) with another bad drug (valproic acid and gabapentin). Lastly, we also addressed a big reason for the massive uptake of gabapentinoids: an intentional and illegal strategy by the makers of these drugs to promote off-label use by doing things like creating low-quality, industry-funded studies designed to exaggerate the perceived analgesic effects of these drug.  This long and sordid history of gabapentin and pregabalin is beautifully described in Seth Landefeld and Mike Steinman 2009 NEJM editorial. I could go on and on, but listen to the podcast instead and for a deeper dive, take a look at the following articles and studies: Gabapentin in the Perioperative setting: Prolonged use of newly prescribed gabapentin after surgery. J Am Geriatr Soc. 2022 Perioperative Gabapentin Use in Older AdultsRevisiting Multimodal Pain Management JAMA IM. 2022 Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort.  JAMA Surgery 2018 Gabapentin and mood stabilizers in the Nursing Home Setting: Antiepileptic prescribing to persons living with dementia residing in nursing homes: A tale of two indications. JAGS 2022 Trends in Antipsychotic and Mood Stabilizer Prescribing in Long-Term Care in the U.S.: 2011-2014 JAMDA 2020 Efficacy of Gabapentinoids: Gabapentinoids for Pain: Potential Unintended Consequences. AFP 2019 Gabapentin for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews Review. 2017 The Illegal Marketing Practices by Pharma promoting ineffective: The Neurontin Legacy — Marketing through Misinformation and Manipulation NEJM 2009 Narrative review: the promotion of gabapentin: an analysis of internal industry documents. Annals of IM. 2006

You know when you walk out of a patient's room and have that sense, “This isn’t going to go well.” The patient is sick and getting sicker, and refuses to let you talk with family or other members of her inner circle.  Should you stop at “no?”  Today we talk with Anne Rohlfing, Lynn Flint, and Anne Kelly, authors of a JGIM article on the reasons we shouldn’t stop at “no.”  We owe it to the patient to explore the reasons behind the “no,” commonly not wanting to be a burden to their family.  In such cases, we owe it to the patient to use persuasion, for example, “I hear that you don’t want to be a burden.  And I’m worried that there may come a time when you have trouble making decisions for yourself.  We will have to reach out to your daughter then to help with decisions. Imagine her hearing for the first time that you’re sick, that you’re hospitalized, that you’re in the ICU, and that you can’t make your own decisions?  That’s a huge amount of news all at once. It would help her to prepare if we could start talking with her now.”  We also talk with Emily Largent, a bioethicist and former ICU nurse, who argues in a Hastings Center Report for an expanded vision of patient consent.  Consent is often viewed as “all or nothing” for any specific decision.  Emily and colleagues have argued for a wider view of consent that continues to involve patients whose consent may fall in the gray zone - able to express some goals and values, hopes and fears - but not able to think through the complexities of a major decision.  I’d hazard that maybe half the patients I care for at the intersection of geriatrics and palliative care fall in the gray zone.  Emily’s expanded notion of consent is grounded in the concept of “relational autonomy.”  Relational autonomy was was first introduced to bioethics by feminist scholars, who observed that most people do not make decisions as isolated islands. Rather, most of us live and make decisions in relationship to one another.  Emily’s notion also borrows from pediatric bioethics, in which parents can look to young children for assent and input on decisions, empowering them to some extent.  Invoking this principle, Emily argues for an expanded role for patients in the gray area and their inner circle working together along a spectrum of cooperative decision-making. My favorite line from Emily’s paper: “Geriatric assent has not been widely adopted in clinical care, but bioethicists should advocate for this, as adoption of partial-involvement strategies can prolong the period in which individuals are (appropriately) engaged in decisions about their health care.” Enjoy! -@AlexSmithMD

Think about the last time a patient yelled at you in anger.  How did you react?  The last time this happened to me I immediately went on the defensive despite years of training in serious illness communication skills.  Afterwards, I thought there must be a better way. Well on today’s podcast we invite two of our favorite palliative care psychiatrists, Dani Chammas and Keri Brenner, to teach us about going beyond simple communication skills like naming the emotion when interacting with the angry patient (see our podcast on avoiding the uncanny valley for a deeper dive into the dangers of becoming too rote and scripted).  As Keri put it in the podcast, we must go beyond “a hammer and a nail” philosophy to approaching anger by developing a toolkit for anger that is vast and varied. Dani and Kery present three steps for interacting with an angry patient:  Look within: What is this anger bringing up in me? How is this anger making me feel, think, and react? Ask why: What is underneath the anger for this particular patient? Creating a “formulation” for the patient Act mindfully: Decide what can we do, and how we can respond therapeutically (and no there is no mnemonic for this step) Here are some other great references we discussed in the podcast: Shalev D, Rosenberg LB, Brenner KO, Seaton M, Jacobsen JC, Jackson VA. Foundations for Psychological Thinking in Palliative Care: Frame and Formulation. J Palliat Med. 2021;24(10):1430-1435. doi:10.1089/jpm.2021.0256 Rosenberg LB, Brenner KO, Jackson VA, et al. The Meaning of Together: Exploring Transference and Countertransference in Palliative Care Settings. J Palliat Med. 2021;24(11):1598-1602. doi:10.1089/jpm.2021.0240 Brenner KO, Rosenberg LB, Cramer MA, et al. Exploring the Psychological Aspects of Palliative Care: Lessons Learned from an Interdisciplinary Seminar of Experts. J Palliat Med. 2021;24(9):1274-1279. doi:10.1089/jpm.2021.0224 Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298(16):883-887. doi:10.1056/NEJM197804202981605 What's in the Syringe?: Principles of Early Integrated Palliative Care And for those interested in other podcast we did with Dani and Keri, check out the following: Therapeutic Presence in the Time of COVID Improving Serious Illness Communication by Developing Formulation What is Emotional PPE?

Amber Barnato is an expert in simulation studies.  A health services researcher and palliative care physician, Amber lauds the ability of simulation studies to isolate one variable in a study.  For example, we spend the first half talking about a RCT simulation study of clinician verbal and non-verbal communication with a seriously ill patient with cancer. In one room the physician under study interacts with a white patient-actor, and in another room interacts with a Black patient-actor.  They found no differences in verbal communication, but clear differences in non-verbal rapport building communication: physicians stood farther away, crossed their arms, didn’t touch the Black patient as frequently.  Amber tells the moving story of how these findings led a clinical colleague, her chief, to question and change his behavior. Of note, we talked about implicit bias in depth in this podcast with Kimberely Courseen.  As we’ve written about on GeriPal when we were a blog (a decade ago!) these simulation studies can be used to study language, such as patient or surrogate choices when we use the terms “allow natural death” vs “do-not-resuscitate.”  This change in framing is a nudge, more evidence that the choices we make to use one phrase or another, or the order in which we present options, are all nudges that influence patient choice - listen to our podcast on the ethics of nudging with Jenny Blumenthal-Barby and Scott Halpern for more.     Additional links to simulation studies: https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201411-495OC https://journals.lww.com/ccmjournal/Abstract/2011/07000/A_randomized_trial_of_the_effect_of_patient_race.9.aspx https://www.liebertpub.com/doi/full/10.1089/jpm.2015.0089 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3687021/ https://journals.sagepub.com/doi/pdf/10.1177/0272989X14522099 Theoretical underpinnings: https://home.csulb.edu/~cwallis/382/readings/482/nisbett%20saying%20more.pdf

Sometimes you read a book and get a flash of insight - that “ah ha!” moment - about yourself and the ways you interact with others.  That happened to me when reading “Range: Why Generalists Triumph in a Specialized World.”  It helped me to understand and justify my interest in (this won’t surprise you) EVERYTHING related to geriatrics or palliative care.  Also hat tip to Matthew Growdon for recommending the book. Today we talk with Bob Arnold, who has a long list of recommendations for books that have the potential to generate an “ah ha!” moment.  The podcast is ostensibly focused on becoming a better mentor, but as you’ll hear, we discuss techniques that can help you cope with anxiety, stress, your spouse…the list goes on.  In reality, insights from these books can help you be a better teacher, a more curious person, as well as a better mentor or mentee. Bob urges you to buy these books from your local bookstore.  To that end, we’re not including links with the titles below.  Please shop locally. As a bonus, Lauren Hunt, frequent guest on GeriPal, heard we recorded this podcast and wanted to add a couple books to Bob’s list (she saw Bob give a talk about these books at the NPCRC Foley retreat).  Her list will strongly resonate with women in academics. See below for Lauren’s two additions to Bob’s list, with her personal commentary. Enjoy! -@AlexSmithMD   Bob’s booklist: Lori Gottlieb, Maybe You Should Talk to Somebody: A Therapist, Her Therapist, and Our Lives RevealedEthan Kross, Chatter: The Voice Inside Our Head, Why It Matters, and How to Harness ItEric Barker, Plays Well With Others: The Surprising Science Behind Why Everything You Know About Relationships Is (Mostly) WrongStephanie Foo, What My Bones Know: A Memoir of Healing From Complex TraumaJennifer L. Eberhardt, Biased: Uncovering the Hidden Prejudice That Shapes What We See, Think, and DoClaude M. Steele, Whistling Vivaldi: How Stereotypes Affect Us and What We Can DoMarcus Buckingham, Nine Lies About Work: A Freethinking Leader's Guide to the Real WorldMarshall Goldsmith, What Got You Here Won't Get You ThereAdam Grant, Give and Take: Why Helping Others Drives Our SuccessDavid Epstein, Range: How Generalists Triumph in a Specialized WorldDouglas Stone, Thanks for the Feedback: The Science and Art of Receiving Feedback WellDouglas Stone, Difficult Conversations: How to Discuss What Matters MostKerry Patterson, Crucial Conversations: Tools for Talking When Stakes Are HighKerry Patterson, Crucial Accountability: Tools for Resolving Violated Expectations, Broken Commitments, and Bad BehaviorAnne Lamott, Bird by Bird: Some Instructions on Writing and LifeJames Clear, Tiny Changes, Remarkable Results, Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad OnesMichael Bungay Stanier, The Coaching Habit: Say Less, Ask More & Change the Way You Lead ForeverPeter Bergman, You Can Change Other People: The Four Steps to Help Your Colleagues, Employees--Even Family--Up Their GameDoug Lemov, The Coach's Guide to TeachingDoug Lemov, Teach Like a Champion 2.0: 62 Techniques That Put Students on the Path to CollegeDoug Lemov, Practice Perfect: 42 Rules for Getting Better at Getting Better   ​​From Lauren: The Secret Thoughts of Successful Women: Why Capable People Suffer from the Impostor Syndrome and How to Thrive in Spite of It by Valerie Young  I was inspired to read this book after reading a post on the 80,000 hours blog. I had heard of course heard of imposter syndrome in the past but I didn’t make the connection to myself until I read this article and saw my thoughts printed on the page. You would think that after several years of a number of career successes, the imposter syndrome would have abated for me, but rather I found it getting worse! I thought that I should know more of what I was doing by this point in my career, but instead I often felt like I had no idea what I was doing!  So I came across this book and found it very helpful. Young defines people who have imposter syndrome as those who have a “persistent belief in their lack of intelligence, skills, or competence. They are convinced that other people’s praise and recognition of their accomplishments is undeserved, chalking up their achievements to chance, charm, connections, and external factors. Unable to internalize or feel deserving of their success, they continually doubt their ability to repeat past successes.”  I certainly related to the point that instead of successes alleviating feelings of fraudulence, the opposite happens, because it increases pressures to uphold one’s reputation. The pressures can be intense, leaving one wondering if it’s all worth it, and prompting fantasies of leaving the charade behind.  One thing I really liked about this book is that it places the imposter syndrome into the context of a patriarchal, misogynistic, racist society and organizations that create cultures that cultivate self-doubt (ahem academia). Imposter syndrome is a rationale response to a crazy world. We exist in a society and culture that actually judges women to be less competent at work (the studies she details are SUPER disturbing). It is not surprising we would internalize these norms. Also that being underrepresented in a field creates pressures not only to represent just oneself, but an entire gender.  She focuses on women, but these concepts obviously apply to people of color and other disadvantaged social groups. And of course men can have imposter syndrome too.  Another part I liked about the book is digging into the notion that one’s success is due to luck, or being in the right place at the right time. She dispels these notions by pointing out that, first of all, luck is always present, even for people who are enormously talented and second, being the right place at the right time, having the right connections, and having a winning personality can sometimes actually be the result of skills or abilities, often the result of hard-work, hustling, and efforts to develop one’s socioemotional capacity.   This is a self-help book, so throughout she offers some useful rules and self-talk for responding to imposter syndrome thoughts. She details different ways to respond to thoughts based on your competence type. For example, if you are a perfectionist, she recommends reframing to a “good enough” quality standard—a mantra I adopted from colleague during the pandemic and has been incredibly helpful for me over the past few years. For the rugged individualist who equate true competence equals solo, unaided achievement, the reframe is “competence means knowing how to identify the resources needed to get the job done.”  Another really important idea she raises is that women often have difficult choices to make about their career and its impact on other parts of their families and their other social networks that aren’t as pronounced for men in our society. Sometimes it is difficult to disentangle these questions from feelings of imposter syndrome. For example, is reluctance to take on more responsibility at work or relocate because you feel inadequate or is it because of genuine concern about the impact on your family? Moreover, women (generalizing here) tend to place lower value on traditional measures of work success (e.g. money, power, influence) and greater value on connection and meaning. It can require a lot of soul searching to figure out whether one is avoiding career “success” out of fear or that certain paths are just truly not aligned with our values.   Finally, towards the end of the book, she introduces the idea of “faking it till you make it” and having chutzpah—i.e going for it. Of course, she’s not advocating for a George Santos approach (no lying) but just having a little bit more of a mindset that you’ll figure it out once you’re on the job.  I’d definitely recommend this book if you’ve ever struggled with similar feelings or mentor people who might. She’s got a breezy and relatable writing style that’s easy to read, lots of great real-world stories, and piquant quotes.   The No Club:  Putting a Stop to Women’s Dead-End Work by Linda Babcock, Brenda Peyser, Lise Vesterlund, and Laurie Weingart  Summary of the book’s premise:  Work activities fall on a spectrum from promotable and non-promotable (NPT).  Promotable activities are those that advance one’s career. They use the word “advance” quite broadly to encompass various outcomes, like earning a promotion, getting plum assignments, increasing compensation, and enhancing marketability for other jobs. Promotable tasks are visible to others and increase the organization’s currency. Some tasks may be indirectly promotable—they help you develop skills that have the potential to enhance your future success or access to future promotable work.  NPT’s are important to your organization but will not help to advance your career. These tasks have low visibility (think committees and other service).  Too many NPT’s can lead to work/work imbalance where promotable tasks get pushed to the side and advancement slows, or work-life imbalance, where advancement continues but at the expense of time in one’s personal life (or both).  Although not exclusively a problem for women, women are more likely to take on NPT’s at work. This is because they are both asked more often and are more likely to say yes when asked.  They propose both bottom-up (women saying no to more things) and top-down solutions (organizations making efforts to divide up NPT’s more fairly and ensuring everyone is pitching in).  Before I read this book, I didn’t fully grasp the idea that an activity would be helpful to the organization but not to my own career. Sometimes requests for participation in these activities come with a veneer or prestige and lots of feel-good gratitude. I personally feel a lot of guilt and worry about disappointing people when I say no to things. Even declining to review an article for a journal is accompanied by some stomach knots (it’s so hard to find reviewers!) I also place a lot of value in collaboration and working in teams, and the idea of working in a culture where everyone is only looking out for themselves is not appealing to me.  But I’m also worried at the level of overwhelm I experience at times and perhaps some of you have experienced as well. How do we ensure that we are on sustainable path where we can stay in and build the world we want to live and work in?   The book also got me thinking about what is promotable or not in academia, i.e. what is the currency. I think we all know that grants and publications are promotable activities, but even within that there are hierarchies. Some of these hierarchies I think I understand: a data-based paper in a high-impact journal has higher promotability than an editorial in a lower-impact journal. Some of them I’m not sure about: is an NIH project grant more promotable than a foundation grant and if so why (bc higher indirects?)  Also, things like mentorship seem gray to me: senior-authored articles are evidence of independence and potential track to mentoring awards, but people often seem to place mentorship in the NPT category. I think having more transparency and discussion about what is promotable or not would be very useful.    Highly recommend this book for women, men, people in leadership, and employees. It’s extremely well-written, nuanced, and eye-opening.   SPONSOR:    This episode of the GeriPal Podcast is sponsored by UCSF’s Division of Palliative Medicine, an amazing group doing world class palliative care.  They are looking for physician faculty to join them in the inpatient and outpatient setting.  To learn more about job opportunities, please click here: https://palliativemedicine.ucsf.edu/job-openings

The Covid epidemic laid bare two major structural issues.  First, Black and Latinx persons experienced much higher rates of mortality than other groups.  Second, as we discussed in last week’s podcast, older adults, particularly those in nursing homes, were far more likely to die than younger individuals.  These are structural issues because the fundamental causes of these issues were not biological issues, they were social.  These worse outcomes were not due to differences in genes, they are due to structural racism and ageism.  In today’s podcast we talk about the intersection of racism and ageism.  We use the Covid pandemic and lack of diversity in trials for recently approved Alzheimer’s drugs aducanumab and (to a lesser extent) lecanemab as springboards for discussion.  Our guests Tim Farrell, Ramona Rhodes, and Nancy Lunderbjerg wrote an article in JAGS on this issue, and Sharon Brangman wrote a separate JAGS article on the need to achieve diversity in study populations. In a third piece, Ramona Rhodes wrote about efforts to improve diversity, equity, and inclusion at JAGS (in the journal itself, including content and editorial leadership).  The article was titled, “Change is coming” - which also gives you a hint as to today’s song request. One final note: at the start of today’s podcast we thank one of our generous donors, Meg Wallhagen, and ask her why she donated to GeriPal.  A prior guest on GeriPal, Meg is a tireless advocate and researcher for hearing impairment issues affecting older adults.  She has a study that is open to recruitment for any adult - hearing impaired or not - please see the blurb below to learn more and participate. Enjoy! -@Alex Smith From Meg Wallhagen: The Federal Drug Administration (FDA) now allows hearing aids to be sold Over-the-Counter (OTC-HAs) to adults with mild to moderate hearing loss. We – Meg Wallhagen from UCSF and Nick Reed from John Hopkins University - are interested to learn what people like you know about OTC-HAs and if you would consider buying them. The survey should only take about 10-20 minutes to complete. If you are willing to consider taking the survey, please click on the following link to learn more.  https://ucsf.co1.qualtrics.com/jfe/form/SV_9ZbReHYH72m82gK

In April 2022, the National Academies of Sciences, Engineering and Medicine (NASEM) issued a report on how the United States delivers, regulates, finances, and measures the quality of nursing home care. It’s massive with over 600 pages detailing everything from the history of nursing home care in the United States to the latest issues that nursing homes have had to face with COVID-19. On today's podcast we invited Jasmine Travers, Alice Bonner, Isaac Longobardi, and Mike Wasserman to talk about the report.  Jasmine was one of the committee members for the NASEM report, and Alice and Isaac are chairing and directing a coalition called Moving Forward tasked with taking the goals identified in the NASEM report and identifying specific and practical initiatives, test concepts, and promote their adoption for lasting improvements. We could have gone on for a couple hours for this podcast, but alas time ran out.  But if you want to learn more, check out these links: The report by NASEM titled “The National Imperative to Improve Nursing Home Quality”The website for the Moving Forward We will also link to the JAGS articles co-authored by seven committee members that focus on specific recommendations of the NASEM report when they get published (stay tuned).

Acute Care for Elders (ACE Units) have been around for over a quarter of a century. Randomized trials of ACE units date back to 1996 when Seth Landefeld and colleagues published a study in NEJM showing that they improve basic activities of daily living at discharge and can reduce the frequency of discharge to long-term care institutions.  But if ACE units are so great, why do so few hospitals have them? On today's podcast we talk about ACE units with geriatricians Kellie Flood and Stephanie Rogers.  They recently published a paper in JAGS looking at the current landscape of ACE units in the US. In the podcast we go over these issues and more: What are ACE units and what structural elements go into them (see the picture below for a nice summary)? Which patients are eligible to go to an ACE unit?What are the benefits of an ACE unit?If ACE units are so great, why are they not so common? What does the future look like for ACE units and how does it differ (if at all) from Age Friendly Health Systems? If you want to do a deeper dive in ACE units, check out some of the following articles: The original NEJM paper on ACE units from 1996 Kellie Flood’s paper in JAMA IM showing that not only ACE units deliver better care, but also help with the hospitals bottom line