GeriPal - A Geriatrics and Palliative Medicine Podcast

The only certainty in medicine is uncertainty. It touches every aspect of clinical practice, from diagnosis to treatment to prognosis. Despite this, many clinicians view uncertainty as something to tolerate at best or eliminate at worst. But what if we need to rethink and reframe our relationship with uncertainty in medicine? In this episode, we sit down with Jonathan Ilgen and Gurpreet Dhaliwal, co-authors of the New England Journal of Medicine article, "Educational Strategies to Prepare Trainees for Clinical Uncertainty." Together, we explore the nature of uncertainty in clinical practice, its effects on trainees and seasoned clinicians, and strategies to embrace it as a fundamental part of medical reasoning rather than a regrettable byproduct. Jonathan and Gurpreet share insights from research and clinical experience, offering practical methods to help trainees and clinicians recognize, manage, and even embrace uncertainty. Key topics we discuss include: The paradoxical nature of uncertainty: When perceived as a threat, it can provoke anxiety or fear; yet when framed as an opportunity, it can inspire hope and optimism. Why uncertainty is inevitable in medical practice and its impact on clinicians. Is uncertainty a state or a trait? The distinction between epistemic uncertainty (knowledge gaps) and aleatoric uncertainty (randomness in outcomes). How experienced clinicians utilize strategies such as forward planning and monitoring to navigate uncertainty. Communicating uncertainty with patients: how to do it effectively without eroding trust. How to integrate uncertainty into medical education. During the conversation, we explore the emotional responses to uncertainty and how these reactions can influence clinical practice and decision-making. Importantly, Jonathan and Gurpreet emphasize the importance of openly communicating uncertainty with colleagues, supervisors, and patients—a practice that, contrary to common belief, actually strengthens trust, fosters transparency, and encourages collaboration. By normalizing and embracing uncertainty, clinicians can better manage the complexities of medicine and build confidence in their ability to care for patients in the face of the unknown.   👉 We're thrilled that Meg Wallhagen, Professor of Nursing at UCSF, has recorded an intro to this week's podcast.  Any listener who contributes $1000+ is invited to record an intro to a GeriPal podcast! You can donate here, any amount is appreciated. Also, Meg is looking for practicing or student clinicians (physicians and nurses) who are willing to participate in a study on how a simulation of hearing loss promotes a greater appreciation of the experience of hearing loss. Participation should take no more than one to one and one half hour and you will receive a gift card in acknowledgement of your time.  If interested, please contact her directly at [email protected]. For more info, click the following link to open the flyer (PDF format):  Information_Flyer_Practitioneer   ** NOTE: To claim CME credit for this episode, click here **

In a recent episode of the GeriPal podcast, we explored whether the field of palliative care is in need of saving—and, if so, how to save it—with guests Ira Byock, Kristi Newport, and Brynn Bowman. Today, we shift focus to one actionable way to improve palliative care: through quality improvement (QI) collaboratives, registries, and benchmarking.  To guide this discussion, we've invited three leading experts in the field—Drs. Steve Pantilat, David Currow, and Arif Kamal—who bring invaluable experience as pioneers in developing QI collaboratives and registries. Together, they authored a recent paper in JPSM titled "The Case for Collaboration to Optimize Quality," which underscores the importance of these efforts. In this episode, Dr. David Currow shares lessons from Australia's Palliative Care Outcomes Collaborative (PCOC), a national model for standardized data collection and benchmarking that has driven measurable improvements in palliative care. Meanwhile, Drs. Steve Pantilat and Arif Kamal reflect on the history of the Palliative Care Quality Collaborative (PCQC), a U.S.-based initiative formed in 2019 by merging the National Palliative Care Registry (NPCR), the Palliative Care Quality Network (PCQN), and the Global Palliative Care Quality Alliance (GPCQA). Although the PCQC had ambitious goals, it ultimately closed earlier this year. Together, the panelists unpack the reasons behind its closure and discuss the lessons future registries can take away from its challenges. Throughout the conversation, we tackle some of the field's biggest questions about registries and QI collaboratives: What data should be collected to create meaningful quality indicators? How can we minimize the administrative burden of data collection on clinicians? And how do we balance the risk of becoming narrowly focused "symptomatologists" with the need to maintain holistic, person-centered care? By addressing these questions, the panel highlights the immense potential of QI initiatives to enhance palliative care while remaining true to the field's core mission: ensuring that patients and their families feel deeply cared for during life's most vulnerable moments.  

Have you had one of those consults in which you're thinking, huh, sounds like the patient's goals are clear, it's really that the clinician consulting us disagrees with those goals?  To what extent is it our job as consultants to navigate, manage, or attend to clinician distress?  What happens when that clinician distress leads eventually to conflict between the consulting clinician and the palliative care team? Today our guests Sara Johnson, Yael Schenker, & Anne Kelly discuss these issues, including: A recent paper first authored by Yael asking if attending to clinician distress is our job, published in JPSM. See also the wonderful conversation in the response letters from multidisciplinary providers (e.g. of course  that's our job! And physicians may not be trained in therapy, but many social workers and chaplains are, and certainly psychologists). A SPACE pneumonic for addressing clinician conflict developed by Sara Johnson, Anne Kelly and others. They presented this at a recent AAHPM/HPNA meeting. See below for what SPACE stands for. We referenced a prior episode on therapeutic presence and creating a holding space with Kerri Brenner and Dani Chammas, and this article by Kerri.  We talked about the role of the consultant, including this classic paper on consultation etiquette by Diane Meier and Larry Beresford. Enjoy! -Alex Smith   SPACE: Navigating Conflict with Colleagues "Between stimulus and response there is a space. In that space is our power to choose our response."   -Viktor E. Frankl SPACE: Conflict Navigation Toolkit Self-awareness: Pause & Notice Before Responding What am I feeling?  Take own temperature. Where am I coming from?  What do I need? Perspective-Taking: Ask-Tell-Ask Where are they coming from? Check your understanding with them. "Tell me how you're thinking about this?" "I hear you are concerned about…is that right?" Agenda: Yours and theirs, then focus on common ground Where are we going together? "It seems like we both want…" Curiosity: Reframe and explore to understand Am I missing anything? Why is this kind, smart & hard-working colleague thinking differently than I am? "To help me better understand, what is your biggest concern about…?"  Empathy: For others: Empathic statements around the situation & silence For self: Your feelings are valid, reflect on it later.  You will misstep in tense moments: apologize, learn from it. Eating helps. Authors:  Ethan Silverman MD University of Pittsburgh Anne Kelly LCSW San Francisco VA Health Care System Jasmine Hudnall DO Gundersen Health System Cassie Shumway MS, RN, OCN, CHPN UW Health Hospitals & Clinics Andrew O'Donnell RN University of Wisconsin Sara K. Johnson MD University of Wisconsin  

In this week's podcast, we sit down with Drs. Sarguni Singh, Christian Furman, and Lynn Flint, three authors of the recent Journal of the American Geriatrics Society article, "Rehab and Death: Improving End-of-Life Care for Medicare Skilled Nursing Facility Beneficiaries."  The authors dive into the challenges facing seriously ill older adults discharged to Skilled Nursing Facilities (SNFs), where fragmented care transitions, misaligned Medicare policies, and inadequate access to palliative care often result in burdensome hospitalizations and goal-discordant care.  The discussion highlights key barriers in Medicare's SNF and hospice benefits, including the inability to access concurrent hospice and SNF care, and explores solutions to improve care. Among the recommendations is leveraging Medicare's Patient Driven Payment Model (PDPM) to reimburse SNFs for providing palliative care, commissioning a Government Accountability Office (GAO) report on SNF utilization at the end of life, and piloting a model that allows time-limited concurrent hospice and rehabilitation care.  Also, check out these two resources if you want a deeper dive: Our past podcast we did, now nearly 6 years ago, on the original NEJM paper, Rehabbed to Death. Joan Carpenter's article titled "Forced to Choose: When Medicare Policy Disrupts End-of-Life Care" in the Journal of Aging & Social Policy   👉 This episode of the GeriPal Podcast is sponsored by IU Health's Geriatrics Department, in partnership with Indiana University's School of Medicine, an amazing group, rich in innovative Geriatric Medicine.  They are looking for physician faculty to join them in the inpatient and outpatient settings.  To learn more about job opportunities, please click the following links: Physician & Advanced Provider Job Opportunity | Geriatrician opportunity at Eskenazi Hospital Physician & Advanced Provider Job Opportunity | Geriatrician opportunity at IU Health Fishers Hospital  

Six years ago we had John Newman on GeriPal to talk about Geroscience (Song choice Who Wants to Live Forever by Queen, perfect selection).  John explained the basics of geroscience, what is it, what are the key theories in geroscience, what is senescence, why people who provide clinical care for older adults should care about geroscience, and potential therapeutics like metformin and rapamycin. Today we bring on three rising stars in Geroscience, Brian Andonian, Sara LaHue, Joe Hippensteel, to talk about one of the key pillars of Geroscience: inflammaging.  We use this terrific paper they published in Geroscience as a springboard.  We discuss: What is inflammaging? Chronic progressive low grade inflammation with aging. I try to get one of them to stake a claim that inflammaging should be the organizing principle of geroscience How does inflammaging operate in rheumatologic conditions like rheumatoid arthritis (Brian), neurologic conditions like traumatic brain injury  (Sara), and critical illness (Joe).  We talk about Post-ICU Syndrome (PICS) and relate inflammaging to our prior podcast with Wes Ely about his book Every Deep Drawn Breath.  We also talk about how inflammaging is not just a factor in chronic conditions like diabetes or inflammatory bowel disease, which make intuitive sense, but also in acute conditions, like sepsis or traumatic brain injury in older adults. The state of the science on clinical and research tests for inflammaging - ready for prime time?  What is the state of the science for therapeutics? Why should some anti-inflammatory therapeutics make us nervous in frail older adults? Inflammation developed evolutionarily for a reason. E.g. tthink of drugs that wipe out the immune system. The outsized discrepancy between non-FDA products marketed to consumers as anti-inflammaging and the state of academic Geroscience.  We announce GeriPal's new lineup of skin care anti-inflammaging products! We discuss lifestyle interventions such as exercise, meditation, caloric restriction and intermittent fasting, and strength/resistance training. \We recognize the efforts of Clin-STAR in bringing together multidisciplinary aging researchers to advance aging research, including our guests. And what a joy to sing Billy Joel!  Here's a link to the documentary I mentioned, which is on my list to see. -Alex Smith