GeriPal Alex Smith, Eric Widera

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