GeriPal - A Geriatrics and Palliative Medicine Podcast

Our focus today is on the search for the geriatrician identity, a continuation of the conversation we started with Jerry Gurtwitz on the Future of Geriatrics.  Today's conversation is prompted by multiple articles in JAGS: (1) an article by Jerry Gurwitz with a title the same as this podcast; (2) an article by Helen Fernandez on "Med-Geri", a new combined 4 year internal medicine residency and geriatrics fellowship track; and (3) an article by Mary Tinetti titled, "Mainstream or Extinction: Can Defining Who We Are Save Geriatrics?"  Of note, Mary's article is a follow up to her 2017 article in JAGS in which she wrote:
Those outside the field have difficulty understanding what geriatrics is and what geriatricians do. We contribute to this lack of clarity. We are experts in complexity but are often bad at communicating simply. Our well-intentioned efforts to be inclusive and comprehensive lead to the creation of long, complex descriptions of what we do that further compromises understanding while eroding interest in, and support of, our field.
Today we tackle this problem, discussing:
A "funny if it wasn't so painful" video and JAGS article in which geriatricians from Johns Hopkins roamed the streets of Baltimore asking lay people "What is a geriatrician?"  The responses (something to do with Ben and Jerry's ice cream? Jury-atrician?) will make you laugh and cry at the same time.

4 different types of geriatricians as described by Jerry in his JAGS paper: the complexivist, the healthful longevitist, the syndromist, and the contextualist.

As with the 4Ms, Ken couldn't help but add a 5th, the "identityist", arguing that maybe Geriatricians worry too much in public about their identity, and should instead focus in public on what unites them: shared sense of purpose and mission to focus on whole person care and what matters most to older adults. Ken gave a rousing talk on being a Geriatrician at the Society of General Internal Medicine that received a lengthy standing-ovation (and a Cubs Jersey with his name on it). 

Innovative new programs such as Med-Geri and GeriPal fellowship as ways to bring more people into the profession.

How to balance our effort between recruiting specialist geriatricians to the profession and teaching all clinicians geriatrics principles and skills.  

A paper in JAGS by Richard G. Stefanacci and Ankur Patel in JAGS making the argument that a geriatrician "yields per-patient annual net cost savings of approximately $3495 (specialist consultation avoidance +$1500; ED reduction +$45; hospitalization reduction +$1950)..." and "The reason fee-for-service fails geriatricians is not that their skills are wrong for primary care—it is that the payment model is wrong for their skills. Payvider programs operating under capitation invert every structural disadvantage of fee-for-service. Under capitation, there are no RVUs. There is no penalty for spending 40 min with a complex patient. There is no revenue loss when the patient is dual-eligible rather than commercially insured—the capitated payment is the same regardless of original coverage source. And every unnecessary specialist referral, every avoidable hospitalization, every ED visit that could have been managed in-house represents a cost to the organization rather than a revenue stream."

Stay until the end when Mary has one of the best answers yet (in over 400 podcasts!) to Eric's "if you had a magic wand" question.
Enjoy!
-Alex Smith

I had the privilege of learning from fellow Greenwall Faculty Scholar Lisa Harris about a term she termed, "dangertalk."  As an ob/gyn and abortion provider, Lisa found the debate around the legality of abortion so polarizing that it created a false dichotomy: you're either for or against.  Any talk about misgivings, uncertainty, ambiguity, or ambivalence was silenced.  Talking about these issues in the face of polarization was deemed dangerous and undermining to one side or another. "How could you?" For Lisa's work in finding common ground and embracing nuance she was awarded the 2023 Bernard Lo Award for forging connections across divisions.
In today's podcast we focus on the equivalent experience of moral uncertainty, distress, and residue among prescribers of medical aid in dying.  We are joined by Carly Zapata and Dani Chammas, prescribers of medical aid in dying in California. We discuss:
Their journey prescribing medical aid in dying, and reasons for choosing to prescribe

The legality of prescribing in California.  We compare California to Canada, as we have previously on this podcast. We discuss new limited survey data suggesting that legal barriers may not explain the remarkable 20 fold differences in use of medical aid in dying between California and Canada; rather, Canada has 6x the number of providers per capita as California, and much greater awareness of the legality of medical aid in dying. We talk about cases that are not as clear - e.g. people who have voluntarily stopped eating and drinking.  

Moral issues, including ambiguity and ambivalence, distress and residue. For example the moral distress created when a patient requests medical aid in dying due to what is clearly a systems failure (see this Atlantic article for clear examples from Canada).  We ask if they sometimes feel frustrated that more people who are in favor of medical aid in dying are not prescribing, instead leaving prescribing responsibility to a relatively small group of clinicians.  

How core ethical ideas might lead to very different conclusions about medical aid in dying, and ways Dani teaches ethics to trainees.  

Psychological models that can help navigate this complex terrain with patients and families, including formulations and countertransference.  


And I can't believe I haven't played, "I will follow you into the dark" previously - but google couldn't find it - really?  In 400+ GeriPal podcasts?  Great song.  So fitting.  My son Renn plays guitar on the audio only version.
-Alex Smith
 
Additionally, some take home points, sent by Dani after recording:
(1) Holding the dialectic: On one hand, people deserve the highest level of attention to their personhood and their suffering—an effort that, at times, can soften or even resolve a desire for hastened death. And on the other hand, some people will authentically experience this as the most values-aligned way of dying, given their circumstances.
(2) Learning to accept that while laws create the safety rails, within those boundaries, morality is pluralistic. Both patients and clinicians bring deeply held moral frameworks to these decisions—and those frameworks deserve to be acknowledged and respected.
(3) We have to be willing to ask the hard questions—and to show up for one another as we do. Because this work, more than almost any other, has taught us the profound impact of not feeling alone when navigating grey terrain.
I view the discussion as an invitation for our field to not necessarily to become more certain, but to be willing to wrestle with the hard questions—while still showing up with rigor and compassion.
And to remember that our patients are people before they are cases. If we can stay close enough to truly know them, we're much more likely to respond in ways that honor both their suffering and their dignity—whatever path that ultimately leads to.

While we have previously discussed brain death criteria on the GeriPal Podcast, we have yet to explore the complex landscape families face regarding organ donation. In this episode, we dive into the nuances of Donation after Brain Death (DBD) and Donation after Circulatory Death (DCD), and clarify the essential role of healthcare providers who are not part of an organ procurement organization.
In this episode of the GeriPal Podcast, we step into a space in serious illness care that is often misunderstood, overlooked, or reduced to a simple "call the organ donation network" checklist item.
Joining us are three experts to help us understand the process and our role in it: 
Samantha (Sam) Taylor, a Donation Support Specialist and expert trainer on the donation request conversation

Dr. Nikole Neidlinger, an abdominal transplant surgeon and medical director for the organ and tissue donation program at the University of Washington

Dr. Toby Campbell, palliative care physician and host of the Extraordinary Conversations podcast, which is focused on organ donation for its first season.

We'd also like to send a big thank you to Toby as he was the one who recommended doing this podcast, and we'd encourage all of our listeners to check out Extraordinary Conversations.  I personally love episodes like this as it opens up a black box that I otherwise dont think about (similar to our Undertaker podcast with Thomas Lynch where we talk about what happens after someone dies).

In this episode of the GeriPal podcast, we dive into the fascinating world of geriatric dermatology, or "GeriDerm," with two exceptional guests: Dr. Daniel Butler from the University of Arizona and Dr. Eleni Linos from Stanford University. 
First, we tackle the big question: how do we keep our skin healthy as we age? I see this on a daily basis with my own skin, but I'm unsure what to do about it, including whether we all need to use sun protection and moisturizers, and if so, which ones?  
Then we explore the lag time to benefit in dermatology by examining whether we need to treat every actinic keratosis and basal cell carcinoma aggressively, or whether there are cases where we can opt for watchful waiting. 
We also explore chronic itch with Daniel, covering the three main sources of itch and how our management should change accordingly. Importantly, antihistamines were not a prominent part!
We finally asked Eleni whether artificial intelligence (AI) and digital tools can revolutionize the way we diagnose and manage skin conditions, especially in older adults. 
For a deeper dive into the topic, check out these two papers that we talk about on the podcast
Daniel's JAMA paper on Chronic Pruritus

Elani's JAMA IM paper on Active Surveillance as a Management Option for Low-risk Basal Cell Carcinoma

Eric and I were delighted to be invited to Brazil to give a series of presentations in Sao Paulo at their annual geriatrics meeting.  We met people doing important, interesting, and innovative work in Brazil and throughout Latin America. We got the audience to sing along, including (in another talk) the magnificent Brazilian song Sozinho by Caetano Veloso in Portuguese, with my son Renn playing guitar.
For our final talk, a podcast in front of a live conference audience, we asked our 3 guests, Eduardo Ferriolli, Marlon Aliberti, & Edison Iglesias to select a recent article to discuss.  We talked about:
Intrinsic capacity (selected by Eduardo).  What is it? What is it used for? How do you measure it?  (hint ICOPE).  Eduardo emphasized that intrinsic capacity is a positive aspect of aging, focused on potential rather than deficit.  We asked him to work intrinsic capacity into George Kushel's famous analogy using the golden gate bridge to describe phenotypic frailty (pillars), deficit accumulation frailty (cable supports), and resilience (withstand stress of wind and cars).  Eduardo says intrinsic capacity would be the car, and would vary by type of car and intended purpose.  I loved Eduardo's selected article, which percentiles intrinsic capacity, in order to use within individuals to assess how they're tracking over time, and at a public health level, to identify regions or groups of people with lower intrinsic capacity.  He draws the analogy to growth curves in pediatrics - if you're consistently at 80% - then drop off - your primary care provider should take notice and investigate/intervene.

Geriatric syndromes in hospitalized older adults (selected by Marlon).  If intrinsic capacity is for primary care, our guests argue that the comprehensive geriatric assessment, which takes a long time to administer, should be reserved for specialist geriatrics.  And yet, this paper finds that a limited shorter version of the comprehensive geriatrics assessment can document geriatric syndromes in hospitalized older adults.  Accumulation of multiple geriatric syndromes is associated with increased mortality, and presents an opportunity for risk stratification, goals of care discussions, and intervention. 

Advance care planning across Latin America (selected by Edison).  Back around 2005, when Edison first heard about advance care planning, he says, "it sounded like science fiction."  In Brazil, as with Latin America, medicine was highly hierarchical and patriarchal.  Doctors knew best.  The doctor decided.  If there was no patient choice, why would there be a system to protect the decisions of patients made in advance?  In the intervening years, Edison and others have worked to incorporate and adapt advance care planning to the Latin American context, which is much more focused on family-centered relational autonomy than individual, and incorporates spirituality to a much greater extent.  Edison has been mindful too of not repeating the mis-steps of the advance care planning and advance directive movements in the US.

We took questions from our audience and sang "Imagine" in Portuguese together. Enjoy!
-Alex Smith