Geripal-podcast

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,

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 tal

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 parti

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 c

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,

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 Rh

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 Imperati

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

Today’s podcast may be a stretch for our listeners.  Please stick with us.  No matter what your position on medical aid in dying (I’m ambivalent) or abortion (I’m pro-choice), this is a bioethics podcast, and I hope that we can all agree that the ethical issues at stake deserve a critical re-think.  All three of today’s guests are well established bioethicists.   Let me start by quote/paraphrasing one of today’s guests, Mara Buchbinder, who puts her finger on the issue we talk about today:   “Typically when we think about conscience in medical ethics we think about it in terms of  a negative claim of conscience, where a clinician refuses (or objects) to provide care.  But what we know from my research and those of others, people also articulate a positive claim of conscience: they feel compelled to provide a service - whether it’s abortion provision or medical aid in dying -  because of a deeply held conviction that this is the right thing to do.”   I’ll continue by quoting Lisa Harris, who wrote in the NEJM

From discussing “taking away the keys to the car” for a cognitively impaired older adult to decisions to limit life sustaining treatments at the end of life, conflict and disagreement permeate everything that we do in medicine.  How well though are we taught to handle conflict and disagreement?  I’d say not well as I don’t think I’ve ever received a formal talk on the issue. On today’s podcast we take a deep dive into the topic of Negotiation and Dispute Resolution training with Lee Lindquist and Alaine Murawski.   We’ve had Lee on before to talk about her Plan your Lifespan project.  We invited her back along with Alaine to talk about their work around negotiation training, including their work on NegotiAge, an online, AI based training intervention designed to teach negotiation skills to caregivers. For an ever deeper dive into the subject of negotiation and dispute resolution, check out the following links (and for any caregivers interested in participating in the randomized clinical trial of the NegotiAge

We’ve talked at length on prior podcasts about the failures of aducnumab, Biogen, and the FDA’s decision to approve it.   But wait, there’s a shiny new anti-amyloid drug, lecanemab!  (No it’s not just the French version of Aducanumab).   In an article in the NEJM (a published article this time, wonder of wonders!) lecanemab was shown to slow the rate of cognitive decline by 0.45 points on an 18 point cognitive scale compared to placebo.  Wow!  Wow?  Wait, what?   On today’s podcast we talk with Jason Karlawish, who we’ve had on previously talking about his book The Problem of Alzheimer’s and with Aaron Kesselhim, to discuss FDA approval of Aducanumab, as well as frequent guest and host Ken Covinsky.   They debate today’s central question: is it time for geriatricians to get on board with lecanemab?  Along the way we address: Is this degree of slowed cognitive decline meaningful to patients or care partners? What about the burdens, risks, and harms? Every 2 week visits for infusions, regular monitoring for

Eric and I weren’t sure what to call this podcast  - storytelling and medicine? Narrative medicine?  We discussed it with today’s guests Heather Coats, palliative care NP-scientist, and Thor Ringler, poet.  It wasn’t until the end that the best term emerged - storycatching.  Because that really is what this is about.  Clinicians “catching” patient life stories.    What’s in a story?  Well, as we learned, everything.  Our patients aren’t “the 76 year old with heart failure in room 202,” as Heather Coats astutely noted.  They’re people, and what makes us people if not our life’s stories?  Our loves, our triumphs, our failures, our work, our families.   Thor Ringler helped start the My Life My Story project at the Madison VA in Wisconsin.  It’s since spread to over 70 VAs.  VA “gets” the importance of storytelling in medicine, without the need for reams of research to back it up.  As Thor notes, capturing patient stories has face validity as positively impacting the patients who share their stories and have them

What would it take to transform dementia care?  While a lot of hope and money is being put into new monoclonal amyloid antibodies like lecanemab, the evidence is that while they are great in reducing amyloid in the brain for those with early Alzheimer’s disease, the effects are at best modest in slowing down the decline in cognition and function (more to be said on that in an upcoming podcast). In order to truly transform dementia care we need to think much broader than the amyloid hypothesis.  So on today's podcast we invite four brilliant individuals to talk about their perspective on how to change how we as a society and health care system partner with individuals with dementia. These amazing guests include: Susan McFadden, PhD, retired professor emerita (psychology and gerontology) at the University of Wisconsin, Oshkosh, an experienced researcher and practitioner in the field of dementia, and creator of the Fox Valley Memory Project. Her most recent book is Dementia Friendly Communities: why we need th

Assisted Living Communities (no longer preferable to call them Assisted Living Facilities, as we learned on the podcast) are…what, exactly?  That’s the central question on today’s podcast.  The problem is the tremendous heterogeneity in services offered and quality of care.  If you’ve seen one Assisted Living Community you’ve seen one Assisted Living Community.  To address this question, we talk with Sheryl Zimmerman, author of a recent study in JAMA Network Open that used a Delphi process to ascertain what experts thought were the essential services an Assisted Living Community should offer to residents.  The experts settled on a range of key services, from more palliative care focused (e.g. end of life care and advance care planning) to more geriatrics focused (e.g. toenail trimming) to things in between (e.g. staff training in person centered care).  The problem, as Kenny Lam and Ken Covinsky, authors of an accompanying editorial, state on the podcast: there is an inherent tension between the motives of

Health care professionals are human, and as humans we experience loss both in and out of work.  You’d imagine though that our professional expertise and experiences in helping patients and families cope with loss and grief would be helpful in managing our own personal losses.  Turns out, it’s maybe not. That was the lesson I learned from reading a new book edited by Matt Loscalzo along with Marshall Forstein called “Loss and Grief: Personal Stories of Doctors and Other Healthcare Professionals”.  It’s a collection of personal stories of a small number of health professionals, including Craig Blinderman and Susan Block, who have been struck by personal illness and loss. On today’s podcast, we’ve invited Matt Loscalzo and Craig Blinderman to talk about their book and the process they used to create these stories, which all stood out for their openness in talking about things that we as healthcare professionals often keep so very private.   We also brought in Vickie Leff to talk about the work she does with Well

Dr. Faith Fitzgerald once quipped that prognostic modeling is the “punctilious quantification of the amorphous.”  She has a point.  Prognosis is inherently uncertain.  As Alex Lee says on our podcast today, all prognostic models will be wrong (in some circumstances and for some patients); our job is to make prognostic models that are clinically useful.  As Sei Lee notes, the argument for developing prognostic models has won the day, and we increasingly use prognostic scores in clinical decision making.  What makes prognostic models for mortality different from models used for anticoagulation or risk of renal injury?  James Deardorff replies that there is something inherently different about predicting mortality.  Death is different.  For some reason clinicians who might be perfectly comfortable using an anticoagulation risk calculator might be skeptical of a mortality risk calculator (see this recent terrific JAMA IM study from Nancy Shoenborn on this issue).  And yet, the only thing that may be worse than a

The Department of Health and Human Services helps to guide billions of dollars in investment and direction in research, policy, and health care. The Assistant Secretary for Planning and Evaluation (ASPE), within the HHS, is the principal advisor to the Secretary of HHS on health policy, ranging from legislation to strategic planning to research. How does this relate to aging policy and research? How does coordination occur between the federal, state and local level in aging health policies? And, who within ASPE guides aging policy and connects policy to every day health challenges experienced by patients and clinicians?    On today today’s podcast, we are joined by guest host and UCSF geriatrician Ashwin Kotwal as we welcome Dr. Tisamarie Sherry (Deputy Assistant Secretary for the Office of Behavioral Health, Disability, and Aging Policy (BHDAP), appointed by the Biden administration). This office is tasked with providing aging policy research and recommendations within ASPE, including long term care and the

When I’m on service these days there is inevitably a moment when a resident says “Patient so-and-so is on X” - and I have absolutely no idea what X is.  Modern subspecialist practice advances at such a remarkably rapid pace, it can be hard to keep up. In this context, we’re excited to hear from infectious disease experts and nephrologists about updates in the care of older adults.  Sonali Advani and Lona Mody talk about their recent JAGS article highlighting three recent articles that every clinician caring for older adults should be aware of in the treatment of infectious diseases (hint: I’ve never finished a course of antibiotics, and maybe your patients don’t need that full course either).  Devika Nair and Rasheeda Hall talk about their JAGS article highlighting updates from nephrology in the care of older adults, including a link to this new eGFR calculator that does NOT include race.  We have a discussion about the decision to remove race, a social construct, from clinical risk calculators (though I’m

Earlier this year palliative care was the correct response to the following clue on the game show Jeopardy: From a Latin word for “to cloak”, it’s the type of care given to seriously ill patients to provide comfort without curing What struck me most was not that palliative care was a question, nor that it made it seem that palliative care isn’t provided alongside care directed at curing, nor was it that hospice was the first buzzed in response, but it was that palliative care was the $2000 question in the Double Jeopardy round!  The fact that palliative care was the hardest of questions told me that we have a massive messaging problem in our field. So what do we do about it?  Well, on today’s podcast we talk with Marian Grant and Tony Back, who with support form the John A Hartford Foundation and the Cambia Health Foundation, have done a deep dive into the research on layperson perceptions of palliative care, hospice, and advance care planning.  The result is a new toolkit to help us fix our messaging &

Have you had difficulty managing a particular type of cancer pain?  For me it’s radiation induced mucositis/esophagitis.  Janet Abrahm is one of the world’s experts in pain and symptom management for patients with cancer joins us to talk about (among other things): Ketamine for hyperalgesia and allodynia, how to treat dissociative side effects Lidocaine: worth the hype? Strengths and weaknesses of buprenorphine for cancer pain Fentanyl patch: often missed issues Hypnosis: uses and how to get training via the American Society of Clinical Hypnosis Janet is the author of the 4th edition of the book Comprehensive Guide to Supportive and Palliative Care for Patients with Cancer, along with co-authors Molly Collins and BR Daubman. This book is terrific, truly comprehensive, and is a go to resource for when I’m “stuck” taking care of patients with cancer.   And yes, this would be a great one for CME.  Eric and I are working on it…maybe by 2023?   Finally, can you believe this is our 236th podcast and, I believe,