GeriPal - A Geriatrics and Palliative Medicine Podcast

Alex Smith, Eric Widera
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A geriatrics and palliative medicine podcast for every health care professional. Two UCSF doctors, Eric Widera and Alex Smith, invite the brightest minds in geriatrics, hospice, and palliative care to talk about the topics that you care most about, ranging from recently published research in the field to controversies that keep us up at night. You'll laugh, learn, and maybe sing along. CME and MOC credit available (AMA PRA Category 1 credits) at www.geripal.org

  1. -2 j

    Video-Enhanced Advance Care Planning: Joshua Lakin and Kei Ouchi

    Can simple, evidence-based video decision aids—paired with structured clinician training—improve Advance Care Planning (ACP) documentation and goal-concordant care? That's the question we pose in this week's podcast with Dr. Joshua Lakin and Dr. Kei Ouchi. We break down the methodologies behind two major clinical trials in which they were involved that implemented this video-enhanced approach. The first study, published in JGIM, was a multicenter, parallel randomized trial of 598 seriously ill older adults in emergency departments (EDs). It tested whether watching a 5-minute video and having a short, 10-minute structured clinical conversation during acute ED visits could establish longitudinal care preferences. The researchers found that this intervention not only increased ACP documentation at 3 months (45.6% vs. 31.3%), but also significantly increased goal-concordant care in a subset of study participants who died in the hospital. The second study, published in JAMA Network Open, was a multicenter, stepped-wedge trial involving 13,800 older adults with advanced cancer across 29 outpatient oncology clinics. Practices in the trial received patient video tools and VitalTalk clinician training. The bundled intervention led to a statistically significant increase in electronic health record (EHR) ACP documentation (25.3% vs. 20.8% with usual care). Both studies provide strong evidence that combining video-enhanced ACP with clinician training improves documentation of these discussions. What I loved most, though, is that the JGIM paper offers some of the first evidence that combining these approaches directly helps patients receive care aligned with their true values.

  2. 23 juil.

    Longevity Treatments - Snake Oil or Breakthrough? John Newman & Mahtab Jafari

    The longevity industry is booming. Influencers are promoting this and that as promoting healthy aging, longevity, and healthspan, and it's hard for us, much less our patients, to make sense of it.  To be sure, we should always start by recommending exercise, nutritious foods, good sleep habits, and meaningful social interaction.  We wanted to go beyond that to talk about the promise and potential and risks/harms of "biohacks." Today we talk with Mahtab Jafari, PharmD, and John Newman, MD, PhD, and to discuss: How we clinicians should think about this movement, knowing many of our patients (and ourselves) also prize living as long as we can as healthy as we can, and at the same time acknowledge that a high quality of life, growth, and a meaningful life are possible with support in states of disability or dementia. How animal models can leading to promising therapeutics but must be tested in humans What it takes for a drug to obtain approval for longevity or healthspan indications when we cannot realistically wait around 40 years for a result We ask them to rate the evidence for many treatment on the scale of very promising, meh, or snake oil/avoid, including creatine, metformin, GLP1, SGLT2i, NAD+, testosterone/estrogen, red light therapy, rapamycin, and rodeola rosea. And I get to sing Wake Me Up by Avicii - an uplifting song with lyrics that could have multiple meanings - makes you think! -Alex Smith

  3. 2 juil.

    Who Should Deliver Palliative Care in Liver Disease? Chris Woodrell, Manisha Verma, Marie Bakitas

    Who's better at delivering palliative care to patients with liver disease: palliative care specialists, or hepatologists who have received liver disease-specific palliative care training?  That's the question we take a deep dive into on this week's podcast by breaking down the PAL-LIVER trial, published this year in JAMA Internal Medicine. We've invited three of the trial's authors, Manisha Verma, Chris Woodrell, and Marie Bakitas, to discuss this cluster-randomized clinical trial spanning 19 U.S. medical centers. We'll discuss: Why was this trial done? Do we really need to run a separate palliative care trial for every single organ disease? What kind of specialized palliative care training did the hepatologists receive? What exactly is meant by the finding that hepatologists were not statistically superior, but were shown to be statistically non-inferior? Lastly, we discuss whether these results change anyone's practice, and whether healthcare systems should decide which type of palliative care model to fund (primary vs. specialty.) —- References we discussed Developing palliative care interventions in liver disease using formative and summative qualitative evaluation. Hepatology 2026  Palliative Care for Advanced Liver Disease: Hepatology and Palliative Care Specialists Experiences. J Pain Symptom Manage 2026

  4. 18 juin

    Why you should care about the shakeup at NIH: Sean Morrison, Ken Covinsky, Stacy Fischer

    Emergency Podcast! Our guests Sean Morrison, Ken Covinsky, and Stacy Fischer believe that you should care deeply about the proposed shakeup at the National Institutes of Health.  Major proposed rules changes at the Office of Management and Budget, would affect a huge range of government grants, from Headstart to Transportation to the National Science Foundation, as well as the National Institutes of Health (NIH), the subject of today's podcast. You dear listeners should all care.  You should care because you care for older adults, or you're a researcher who studies palliative care, or you're a chaplain who visited with the family of a patient who died today.  You should care because these rule changes are so sweeping that they would remove standard components of the scientific review process and instead put them in the hands of political appointees. You should care because if rules like this were in place in the 1980s, we might not have developed treatments to stop the HIV/AIDS epidemic.  You should care because if these rules go into effect we will not be able to work with researchers in other countries studying outbreaks of Ebola or Hauntavirus.  You should care because these rules silence federal research into groups of people we care for daily. And if you're not a researcher, your voice is even more important here.  As Sean says, researchers who protest these proposed rule changes might come across as self-serving.  Clinicians who are not researchers -  who can say that these rules will negatively impact the science that improves care of older adults living with chronic conditions and their families - your voices may resonate even more. What can you do? Most of these rule changes are open for public comment here until July 13, 2026.  Every comment will be read and requires a response.  It's ok to respond anonymously.  Personalized stories matter more than form responses. Tips: 1: Say (or just describe to keep anonymous) who you are and why you are qualified to comment. Telling the story of how patients and families you care for or study is enough.  Get your partner and parents to respond too.  Simply being a concerned citizen is perfectly fine. 2: List the exact provision #s that concern you, and explain what they would do. You do not need to quote the rule directly. Just explain what you understand it to mean in plain terms. Political Appointees Take Control of Grant Awards (§200.205); Peer Review Is No Longer Binding (§200.205(d)); Active Grants Can Be Terminated at Any Time, for Any Reason (§200.340);  DEI, Gender Research, and Related Topics Banned as Grant Conditions (§200.300);  Prohibition on International Scientific Collaboration (§200.220);  Conference Attendance Now Requires Express Agency Pre-Approval (§200.432);  Publication Costs and Open Access Fees Presumptively Unallowable (§200.461) 3: Explain the concrete harm. What would happen to your patients and their families if this provision takes effect? 4: Closing: State clearly what you want OMB to do. This can be as simple as: "I urge OMB to withdraw these specific provisions: §200.340, §200.202, §200.205." or "I urge OMB not to finalize this rule." Submit your comment in opposition here: The deadline is July 13, 2026.  You can also email your congressperson or senator.   Times they are a changin'.

  5. 11 juin

    How We Limit Non-beneficial Life Sustaining Treatments: Jason Batten, Liz Dzeng, Teva Brender

    Today's podcast is a natural follow up to our podcasts on Slow Codes and Unilateral DNR orders.Today we talk about a new study about how clinicians talk about potentially non-beneficial life-prolonging treatments, published in JAMA Network Open. Do they adhere to society guidelines, which allow as permissible approaches only shared decision-making and following institutional policy.  Or do they take alternative approaches, like not offering interventions, not mentioning interventions, or simply stating a plan to limit interventions? Turns out doctors are using these alternative approaches frequently. Our guests are Jason Batten, Liz Dzeng, and Teva Brender, all clinicians, all of whom have been thinking about and wrestling with the ethical reasoning behind these approaches. We all admit to using these approaches.  Are the alternative approaches wicked games (song hint), and our response should be to stop these behaviors, beginning with ourselves? After all, if you ask patients or surrogates, they're likely to say they want all the options and may not universally welcome recommendations.  Or, as with slow codes, does the fact that these alternative approaches are in common use suggest that the guidelines should be revised?  You listen and decide! -Alex Smith   Additional links: Dzeng 2023 JAMA IM: The larger ethnographic study from which data was drawn with data drawn from high- medium- and low-intensity hospitals. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2806959 Brender 2025 JAMA NO: Factors that exacerbate or mitigate moral distress related to potentially non-beneficial treatments.https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2835316 Dzeng 2015 JAMA IM: Study illustrating that more senior physicians feel more comfortable not offering or recommending against futile CPR. Relevant quote: "Experienced physicians at all sites generally were comfortable engaging in best interest decision making and, when clinically appropriate, not offering or making explicit recommendations against offering resuscitation." https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2212265 Weiss Goitiandia AJOB 2025: Reasons why some clinicians would hesitate to go to the ethics committee / futility process for these discussions: https://www.tandfonline.com/doi/10.1080/15265161.2025.2457734?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed Axelrod AJOB 2025: Discusses some of the systemic consequences of using physiologic futility as a standard and how it might contribute to a healthcare system that imposes aggressive treatments on vulnerable patients. https://www.tandfonline.com/doi/full/10.1080/15265161.2025.2530715#d1e152

  6. 4 juin

    Elder Mistreatment Prevention and Solutions: Carrie Rubenstein, Julia Hiner, & Tony Rosen

    Today we revisit a topic we last discussed in a 2020 podcast with Laura Mosqueda: elder mistreatment.  Our guests today are geriatricians Carrie Rubenstein and Julia Hiner, and Tony Rosen, an emergency medicine doctor. They talk about where we are now, in 2026, with elder mistreatment, including: Terminology: elder mistreatment vs. abuse and neglect The need to incorporate prevention and solutions into how we talk about mistreatment This is not rocket science. Studying elder mistreatment is much harder than rocket science. Highlighting the reasons they focus on elder mistreatment, including inspiring words for why this led them to geriatrics and aging research Should we screen for elder mistreatment? The US Preventive Services Task Force doesn't see enough evidence to recommend screening. Our guests may differ… Which clinicians should assess for elder mistreatment? Hospitalists? ED docs? Primary care providers? Tony published a study in JAGS showing older adults who experienced elder mistreatment were as likely to visit primary care as those who did not, also great accompanying editorial by Mara Rosenberg and Lena Makaroun gets a shout out. Early evidence that supporting caregivers can reduce elder mistreatment (in one small study of the COACH intervention, rates of mistreatment were reduced to zero) Borrowing from pediatrics: many/most hospitals and emergency departments can call a Child Protective Services Team. Tony is piloting a parallel team for older adults - the Vulnerable Elders Protection Team (see JAGS paper).   We talk about key members of interdisciplinary teams across sites, systems, and counties. Social workers get a big shout out. A one year fellowship in capacity assessment and elder mistreatment at UT Houston, directed by Julia. An Elder Abuse Curriculum for Medical Residents and Geriatric Medicine Fellows https://pmc.ncbi.nlm.nih.gov/articles/PMC10842324/ Kudos to my son Renn for recording 5 overlapping cello parts on Eleanor Rigby! -Alex Smith

  7. 28 mai

    CCRCs, ALFs, and Private Equity: John Burton, Bill Applegate, & Melissa Aldridge

    Two retired luminaries in geriatrics join us today to share their personal experiences. First, John Burton, a geriatrician and Director of the Division of Geriatric Medicine at Johns Hopkins for some 35 years, shares his journey moving into a Continuing Care Retirement Community (CCRC) during Covid.  You can read about John's early experiences in his JAGS commentary titled, "Waiting for the Other Shoe to Drop."  The tone is bleak.  John's experience since Covid, as you'll hear, is very positive.  Many of the concerns he raised about isolation have been addressed. Second, we hear from Bill Applegate, Geriatrician, retired faculty at Wake Forest, and former Editor in Chief of JAGS (Bill recruited Eric and me to join JAGS as editors about 10 years ago). Bill had a distinctly negative experience in two assisted living facilities (ALFs), which you can read about in his JAGS essay, titled, "My Journey Through Assisted Living Facilities." Bill is seriously concerned about the lack of national oversight, poor staffing, and financial motivations behind for-profit and private-equity owned ALFs. Finally, we hear from Melissa Aldridge, a former banker turned health services researcher, about the rise of private equity purchases of Assisted Living Facilities nationally.  This is a follow up to our prior podcast on private equity gobbling up hospices with Melissa, Lauren Hunt, and Krista Harrison. Melissa is concerned that private equity has a very short time frame to turn acquisitions profitable, and cutting staff is often their first move.  Further, private equity is financing these acquisitions with debt that is increasingly hard to trace and regulate. We talk about how private equity moving from purchasing fast food chains, toy stores, and hotels into CCRC, ALF, nursing home, and hospice ownership is a major concern.  This is not the same as Blackstone buying the Hilton and turning a profit.  These institutions provide healthcare, daily care needs, and community for a huge swath of older adults.  These concerns should trigger a higher level of scrutiny, oversight, and regulation than other industries. What can you do about this, dear listeners?  Listen to the end to find out! Thanks to Jerry Gurwitz for suggesting this podcast.  We appreciate your suggestions. Keep 'em coming. -Alex Smith

  8. 21 mai

    Search for Geriatrician Identity: Mary Tinetti, Helen Fernandez, Jerry Gurwitz, Ken Covinsky

    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

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A geriatrics and palliative medicine podcast for every health care professional. Two UCSF doctors, Eric Widera and Alex Smith, invite the brightest minds in geriatrics, hospice, and palliative care to talk about the topics that you care most about, ranging from recently published research in the field to controversies that keep us up at night. You'll laugh, learn, and maybe sing along. CME and MOC credit available (AMA PRA Category 1 credits) at www.geripal.org

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