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

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:

1. 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.

2. 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.

3. 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

Lynn Flint and Anne Kelly join as hosts in a reprise of last year's ask us anything format. Thank you for sending in your terrific questions! Lynn and Anne condensed them to about 20, and we ran through them rather rapid fire. Also on fire? Our mouths. As with our 300th episode, we did this Hot Ones-style. Every few questions, we had to eat a chicken wing slathered in hot sauce. The hot sauces got progressively hotter, though as we discovered, the ordering may have been a littttttle bit off. Still, by the time we hit the really hot ones, our mouths were on fire, we were blowing our noses, gulping down milk, and terrified of what the next hot wing would bring…

We covered so much in this podcast, including:

• Coffee or tea? What jokes do you make with patients?

• Where do we see ageism?

• Why are we still advocating for advance care planning?

• Concerns about expansion of medical aid in dying

• Should doctors reveal that they're using AI in clinical care (thanks for the question mom!)

• The future of geriatrics and palliative care

• What we'd do differently about the podcast if we could start over, or what we could do that is new going forward. Surprises in terms of who is listening, our audience.

• Ideas for others to build community as we do at GeriPal

• Influence of our own spirituality and religion on our clinical practice

• Lasting practice changes from prior podcasts, or from Covid experience

• Why PC in the ED hasn't taken off

• And more!

Looking back on 10 years and 400 podcasts, Eric and I are filled with gratitude for you, dear listeners. You sustain us. You keep us going. Please stay involved, send us messages about show ideas, and introduce yourself to us at national meetings.

Thank you!

-Alex Smith

Rural populations in the United States face unique healthcare challenges. These communities tend to be older, have higher mortality rates, and experience higher rates of chronic conditions and physical disabilities compared to urban populations. Despite the increased need for palliative care in rural areas, access remains alarmingly limited. Even in hospital settings, where palliative care programs are more common in urban areas, only 35% of rural hospitals report having such programs, compared to 81% of urban hospitals.

In this week's podcast, we explore the challenges and opportunities of delivering palliative care in rural communities with our esteemed guests Karl Bezak, Jeanie Youngwerth, Adie Goldberg, and Gregg Vandekieft. We begin by discussing what inspired each of them to focus on rural palliative care. From there, we dive into what rural palliative care looks like and examine how it differs from care provided in urban settings. Our guests also share insights into the challenges of delivering this care in resource-limited rural environments and explore innovative strategies to ensure patients and families receive the support they need (like providing remote fellowship training for docs living in rural areas!).

We also tackle the role of telemedicine in rural palliative care, both the good part, connecting patients in remote areas with specialists who might otherwise be unavailable, and the bad part, the huge digital divide seen in rural areas.

Join us for what I thought were some valuable insights our guests brought on how we can better serve rural populations and create a more equitable system for palliative care delivery. And if you want to learn more, check out some of these resources:

• University of Colorado's Community Hospice and Palliative Medicine (CHPM) Fellowship, which allows mid-career providers to obtain training while continuing to live and work in their community supported through online and distance learning technology

• Master of Science in Palliative Care Program: Master of Science Degree

• The Rural Health Information Hub's Rural Hospice and Palliative Care Overview

• Stratis Health's Rural Community-based Palliative Care resource center

• The Washington Rural Palliative Care Initiative website

• CAPC's Safety-Net and Rural Care website

• The paper validating the AI Algorithm used to identify patient in rural ED for the TeleGOC Pause Model at UPMC (SafeNET)

• A Google Site where Karl is hosting their most recent data related to the TeleGOC Pause Model

Today we're delighted to talk with Anne Walling, Neil Wenger, and Rebecca Sudore about a pragmatic implementation trial aimed at increasing advance care planning for primary care patients with serious illness in University of California clinics, published in Annals of Internal Medicine. Seriously ill primary care patients were identified using structured data fields (meaning routinely captured without needing to read the chart or use natural language processing).

This study focused on patients without a completed advance directive or POLST form. This was a 3 arm trial that tested a nudge in the patient portal and a mailed advanced directive vs. the nudge plus a link to PrepareForYourCare vs. the nudge plus PrepareForYourCare plus a navigator reminding patients to talk with their doctor and bring any completed advance directives or POLST forms to the PCP visit.

In brief, the study found that at 2 years there were higher rates of advance directive or POLST in the electronic health record (about 20%) in the arm with the nudge plus PrepareForYourCare plus the navigator compared to the other 2 arms (around 13%). Rates of advance care planning discussions with primary care providers were similarly higher in the 3rd arm. Health care utilization, however, did not differ between arms. Please see links to articles describing the intervention in detail and incorporation of stakeholder perspectives.

I'm going to cut to the pushback to this article right up front:

• The study's primary outcomes were advanced directives or completion of POLST forms - haven't we moved beyond thinking completion of forms should be the primary outcome of advance care planning research?

• There was no control condition. Observed increases in advance directive or POLST in the electronic health record may have occurred without any intervention. People with serious illness get sicker with time and the sicker they are the more likely they are to engage in advance care planning, without any intervention. This is particularly true as the study occurred during the hight of the Covid pandemic, when there was a global effort to increase advance care planning. How much did these interventions contribute on top of that rise that might have occurred without intervention?

• Observed documentation - 13-20% - was low. Is it worth the effort of getting buy-in to automate these EHR nudges and spend FTE to hire a navigator? Particularly as health systems, who pushed for focusing on seriously ill patients because they are the most expensive/highest utilizers, did not get what they wanted, i.e. no difference in utilization of acute healthcare services between arms?

Our guests provide a strong defense and additional context, which you can and should listen to on the podcast. And I have to point out, setting aside the advance care planning aspect, the method of identifying upstream primary care patients with serious illness is a major contribution to the field in and of itself. Pioneers in the field, led by Amy Kelley, have been working to identify the seriously ill population for over a decade.

And a fun fact about All You Need is Love - the verses are in 7/4 time!

-Alex Smith