GeriPal - A Geriatrics and Palliative Medicine Podcast
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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The Chaplain and the Doctor: A Podcast with Betty Clark and Jessica Zitter
11/20/2025
The Chaplain and the Doctor: A Podcast with Betty Clark and Jessica Zitter
In this week’s episode, we delve into the powerful documentary with two extraordinary guests: Betty Clark, the chaplain at the heart of the film, and Dr. Jessica Zitter, the physician and filmmaker who brought this story to the screen. The film provides a deeply moving look into the ways personal stories and biases shape our interactions in healthcare. Through our conversation with Betty and Jessica, I gained a valuable insight: the narratives we carry within ourselves—whether conscious or unconscious—act as invisible forces that influence how we engage with patients and colleagues. I also learned that recognizing these stories and the biases they may produce, rather than avoiding them, can foster more genuine and empathetic care. They also may lead to deep friendships, as is clearly shown between Betty and Jessica. I love both this podcast episode and the film itself, as they shine a light on the deeply human—and oftentimes flawed—experience of working in healthcare. They remind us of the vital role of storytelling in shaping how we care for patients, and the often-overlooked yet essential contributions of chaplains in healthcare settings. Betty and Jessica’s reflections underscore how chaplains bring compassion and humanity to the medical team, offering emotional and spiritual support to patients and providers alike. If you’re interested in watching The Chaplain and The Doctor during its festival tour, or would like to host a screening at your own institution, I encourage you to visit the film’s website at . This episode of the GeriPal Podcast is sponsored by , an amazing group doing world class palliative care. They are looking for physician faculty to join them in the inpatient and outpatient setting. To learn more about job opportunities, please click here: ** NOTE: To claim CME credit for this episode, **
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A Strategic Path Forward for Hospice & Palliative Care: Ira Byock, Kristi Newport, Brynn Bowman
11/13/2025
A Strategic Path Forward for Hospice & Palliative Care: Ira Byock, Kristi Newport, Brynn Bowman
In June of 2025, hospice and palliative care pioneer Ira Byock . In a nutshell, he expressed concerns that the quality of hospice care in the United States has become highly variable, with disturbing frequency of unethical practices and avaricious owners. He also raised concern that the rapid increase in palliative care program growth during the first two decades of this century has stalled, leaving us with understaffed programs that are often inadequately trained. Along with Ira, we’ve invited Kristi Newport, a palliative care doctor and Chief Medical Officer of the , and Brynn Bowman, Chief Executive Officer of the , to discuss these issues and outline a strategic path forward for the field. In particular we talk about Ira’s four-part solution to transform the field and restore its integrity: (1) publishing clear clinical and programmatic standards, (2) making meaningful data publicly available to ensure transparency and accountability, (3) fostering quality-based competition among providers, and (4) embracing the authentic brand of hospice and palliative care—expert care that alleviates suffering and fosters well-being. So take a listen and dive a little deeper with these resources, and dont forget, you too can get involved in AAHPM (): Ira’s paper titled “” Our previous podcast on “” Our previous podcast on with Melissa Aldridge, Krista Harrison, & Lauren Hunt - a state-by-state look at palliative care capacity offers insight into how palliative care professionals across the country are feeling this year and what they’re focused on and by Chris Comeaux and Cordt Kassner
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Palliative Care in Sickle Cell: Craig Blinderman, Stephanie Kiser, Eberechi Nwogu-Onyemkpa
11/06/2025
Palliative Care in Sickle Cell: Craig Blinderman, Stephanie Kiser, Eberechi Nwogu-Onyemkpa
Today’s topic on palliative care for sickle cell disease may raise eyebrows with some of you. You might think, wait, now we’re doing sickle cell? On top of , , and ? Where does it end? Do we have staff for all of this? Well I implore you, dear listeners, to keep an open mind and listen to this podcast. Our guests do a fabulous job of stating the case for palliative care in sickle cell disease, to the point that we ask: why haven’t we been doing this all along? Our guests today are Craig Blinderman, Stephanie Kiser, Eberechi Nwogu-Onyemkpa, three palliative care docs who have been advancing the practice in palliative care for sickle cell for a long time. Our discussion ranges from what is sickle cell; to outcomes; to social determinants and discrimination; to PCAs, ketorolac, and bupenorphine; and to the importance of the interdisciplinary team. I would also encourage you to check out Eberechi’s NEJM Perspective on Involving which includes a table of the challenges and action items needed to move the field forward. I’d also encourage you to sample this AAHPM on the same topic (we learned that a flight is similar to a flight of drinks - a quick sampling). As Eberechi notes at the start, we should be grateful for the community of people who are advancing palliative care in sickle cell. Thank you for being a friend (song hint!). -Alex Smith
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Medical Billing and Coding in Geriatrics: Peter Hollmann, Ken Koncilja, and Audrey Chun
10/30/2025
Medical Billing and Coding in Geriatrics: Peter Hollmann, Ken Koncilja, and Audrey Chun
Last month, the “Billing Boys”—Chris Jones and Phil Rodgers—joined the GeriPal podcast to . This month, we’re back with part two, shifting the focus to geriatrics. While billing and coding may not be the most exciting topic, they’re essential for ensuring fair reimbursement for the complex care we provide and for supporting the work of our interprofessional teams, many of whom can’t bill directly for their services. When we underbill or leave money on the table, we not only shortchange ourselves but also devalue the critical role of geriatrics in the healthcare system. This time, we’re joined by experts , , and to dive into key questions: Why does billing matter, and who does it benefit? What’s the difference between CPT, E&M, and ICD-10 codes (if you need a refresher, check out our chat with the Billing Boys )? We explore how to think about billing for complexity versus time, and unpack new and impactful codes like the Cognitive Assessment and Care Plan Services code (99483), advance care planning (ACP) billing codes, and G2211, which acknowledges the added work of managing patients with chronic conditions. We also highlight the new APCM G-codes for 2025, a set of HCPCS codes that could provide substantial financial support for interdisciplinary teams in geriatrics. Finally, we discuss the advocacy behind these codes. The plays a vital role on the AMA’s RUC committee, helping to improve reimbursement for the complex care of older adults. Tune in to this week’s GeriPal podcast for expert advice, practical strategies, and insights that will help you optimize your billing practices and sustain the future of geriatrics! Here are some of the resources we also talked about: 👉 NOTE: Eric and Alex are giving UCSF Geriatrics Grand Rounds on Wednesday November 5, 4-5pm Pacific Time. The topic is, "What we've learned from nearly 400 GeriPal podcasts." Join us! This will be highly interactive. If you'd like to join via Zoom, you can use this link: . Or join in person, grand rounds are open to all! We will be speaking at the main UCSF Campus, 500 Parnassus Ave, in the Health Sciences West Building, 3rd floor, room 303. You can ask for directions when you arrive at UCSF, or email Alex to arrange for someone to meet you at the front ().
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Rethinking Slow Codes: Gina Piscitello, Parker Crutchfield, Jason Wasserman
10/23/2025
Rethinking Slow Codes: Gina Piscitello, Parker Crutchfield, Jason Wasserman
I’m going to begin with a wonderful quote from a recent editorial in by our guests Parker Crutchfield & Jason Wasserman. This quote illustrates the tension between the widely held view in bioethics that slow codes are unethical, and the complexity of real world hospital practice: “Decisive moral positions are easy to come by when sitting in the cheap seats of academic journals, but a troubling ambivalence is naturally characteristic of live dilemmas.” Gina Piscitello, our third guest, recently surveyed doctors, nurses and others at 2 academic medical centers about slow codes. In a , she found that two thirds had cared for a patient where a slow code was performed. Over half believed that a slow code is ethical if they believed the code is futile. Slow codes are happening. The accepted academic bioethics stance that slow codes are unethical is not making it through to practicing clinicians. Our 3 guests were panelists at a session of the annual meeting last year, and their panel discussion was apparently the talk of the meeting. Today we talk about what constitutes a slow code, short code, show code, and “Hollywood code.” We talk about walk don’t run, shallow compressions, and…injecting the epi into the mattress! We explore the arguments for and against slow codes: harm to families, harm to patients, moral distress for doctors and nurses; deceit, trust, and communication; do outcomes (e.g. family feels code was attempted) matter more than values (e.g. never lie or withhold information from family)? We talk about the classic bioethics “trolley problem” and how it might apply to slow codes (for a longer discussion see this ). We talk about the role of the law, fear of litigation, and legislative overreach (for more see this ). We disagree if slow codes are ever ethical. I argue that Eric’s way out of this is a slow code in disguise. One thing we can all agree about: the ethics of slow codes need a rethink. Stop! In the name of love. Before you break my heart. Think it over… -Alex Smith
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GeriPal Live! at NPCRC Foley Retreat: Dio Kavalieratos, Prasanna Ananth, Alexi Wright
10/16/2025
GeriPal Live! at NPCRC Foley Retreat: Dio Kavalieratos, Prasanna Ananth, Alexi Wright
This is the second GeriPal podcast we’ve recorded live using this format, see this to our prior podcast at the Center to Advance Palliative Care (CAPC) meeting in Philadelphia. Also look for our upcoming podcast recorded live from the . Today we join you from beautiful Banff, Alberta, Canada at the National Palliative Care Research Center () annual Kathleen Foley retreat. This meeting was bittersweet. I’ve been fortunate to attend every meeting in one capacity or another since 2006. The made an enormous impact on the growth and capacity for palliative care research nationally. Personally, NPCRC funding was essential support as I was a new faculty member and had not yet secured longer term career development funding. More than anything, though, I will miss the community. I treasure those meals, hikes, sing-alongs with others dedicated to improving care of people with serious illness through research. On today’s podcast, we invited Dio Kavalieratos, Prasanna Ananth, and Alexi Wright to join us to talk about three articles that spoke to them. For each I leave you with a teaser of a hard question that was raised that we couldn’t really answer. Prasanna chose an article by Abby Rosenberg about . We talked about why palliative care clinicians get fired, with Prasanna, a pediatric oncologist, raising the issue that it’s more problematic when you’re the oncologist providing primary palliative care and you get fired than if the consultant specialty palliative care provider is fired. Dio chose an article about the . We talked about the needs of palliative care internationally, and Alexi raised the question: should the highest standard of palliative care (e.g. in the US) apply to palliative care in every country, a la the Partners in Health model pioneered by the late Paul Farmer? Or should we “settle” for access to affordable opioids? Alexi chose an article about . Alexi used it as a springboard to talk about other populations at compounded risk for poorer care in the current political environment. We hope you enjoy this one as much as we did, dear listeners. We’re always trying to improve, and welcome your suggestions for how to improve upon this new “live” format. So far we’ve heard we need to be better at summarizing the articles for the audience/listeners, and finding ways to involve our live audience to a greater extent than the occasional question. Please let us know if you have other suggestions! Final note - check out the wonderful NPCRC created about their impact on the field of palliative care (Eric and I were filmed recording GeriPal). -Alex Smith This episode of the GeriPal Podcast is sponsored by , an amazing group doing world class palliative care. They are looking for physician faculty to join them in the inpatient and outpatient setting. To learn more about job opportunities, please click here:
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GeriPal Live! at CAPC: Karen Bullock, Kim Curseen, Matt Gonzales
10/09/2025
GeriPal Live! at CAPC: Karen Bullock, Kim Curseen, Matt Gonzales
Eric and I had the pleasure of doing a GeriPal Live! Podcast as the closing keynote for the recent in Philadelphia PA. For this podcast, we invited 3 guests to each select an article of interest to them, and engage in a discussion about the article, including questions from the CAPC attendees in the audience. Our guests chose the following articles (in the order discussed) Matt Gonzales used AI to select an article by Ravi Parikh on , published in JAMA Network Open, finding 44% in the intervention arm received palliative care consults, vs 8% in the control arm. We discussed use of AI to select the article, nudges, sludge, and the impressive though still less than 50% rate of PC consults. Kim Curseen selected an article by Harry Han in JPSM that , finding that clinical fellows spent 5 weeks in outpatient care and 24 weeks in inpatient care, on average. We discussed the mismatch between outpatient training, and the needs of people with serious illness who spend most of their lives outside the hospital, and training in inpatient care, where most hospitals have robust services and needs. Training in non-onc palliative care was particularly low. Karen Bullock selected in response to . We discussed the need to view all issues in geriatrics, hospice, and palliative care through an equity lens, particularly in view of the disparate impact on historically marginalized communities of concerning practices and trends in hospice and palliative care (e.g. ). And at the end, we sang a tribute to the , with the whole Assembly singing along! Stay tuned for future GeriPal Live! Podcasts, including recordings at the Foley Retreat in Banff, and the . -Alex Smith
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Pre-Operative Geri Assessment: Vicky Tang and Houman Javedan
09/25/2025
Pre-Operative Geri Assessment: Vicky Tang and Houman Javedan
We love getting requests from listeners for podcast topics. This request came from geriatricians we met at the annual American Geriatrics Society meeting in Chicago. They wanted to know more about what a geriatrician should do in a pre-operative risk assessment. So we invited Vicky Tang and Houman Javedan, two geriatricians and leaders in the pre-operative assessment and prehab space, to talk with us. As is our style, we backed up to some bigger questions, including: -Why do patients need a geriatric assessment pre-operatively?-Why are our surgical colleagues asking us? Is it due to liability concerns? -Why do we do them? Recognizing we may have different motivations than our consultants (hint: stealth geriatrics) -How does the comprehensive geriatric assessment fit int? Do the 4Ms fit into pre-operative assessment if at all? (an entertaining disagreement ensued) -Must a geriatrician do this? -What is the ? -What’s the most important part of Many links from our guests below. And please forgive my Spanish on the song, I tried! Thanks to sons Kai and Renn on Ukulele and Bass for making it sound better. -Alex From Vicky: Systematic review of Prehab Geriatric Surgery Verification Program shared decision making in surgical patients From Houman: Geriatric Surgical Co-management Evidence 1. Trauma survival with geriatric assessment 2022- 2. Hip fracture survival benefit meta-analysis 2014- 3. Elective abdominal surgery benefits POSH program 2018- 4. POSH Program for Spine 2021- 5. Elective orthopedic joints ED readmission decreases 2024 - 6. The need for geriatricians, tools and education models (aka Ms) are not enough - Sub Topics 7. Utility of minicog and where our improved local mortality of 18% and delirium of 11% reported - 8. Geriatrician performed CGA-FI best at predicting mortality in rib fractures 2025 - 9. Geriatrician performed CGA-FI predicting mortality better than age in hip fractures 2024- https://pubmed.ncbi.nlm.nih.gov/39007664/ 10. Multidomain frailty assessment and surgery showing severely frail patients at risk of mortality even with low risk procedures (eg. Cystoscopy) - 11. Different outcomes for hip fracture surgery in the severely frail - 12. Complexity of aging physiology- example of prostaglandin based free water excretion in collecting duct of aging kidney first paragraph on page 360-
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What Makes a Good Death? Karen Steinhauser, Rasa Mikelyte, Edison Vidal
09/18/2025
What Makes a Good Death? Karen Steinhauser, Rasa Mikelyte, Edison Vidal
What is a “good death”? How should we define it, and who gets to decide? Is the concept of a “good death” even useful? Twenty-five years ago, Karen Steinhauser published a groundbreaking study in JAMA that transformed my understanding of what it means to have a good death and questioned the usefulness of the term itself. This study examined the factors that are important at the end of life for patients, families, physicians, and other healthcare providers. In today’s podcast, we are honored to have Karen join us to discuss this pivotal study and the nature of a “good death”. We are also joined by Rasa Mikelyte and Edison Vidal, co-authors of a recent study comparing the perspectives of people with dementia in the UK and Brazil on what constitutes a good death. In addition to exploring the nature of a good death and their individual studies, we will discuss: Whether an external criterion for a good death exists, or if it is entirely dependent on the perspective of the dying individual. The role of culture and spirituality in defining a good death. The role of healthcare providers in the discussion about the nature of a good death. Key references we discuss include: Our previous GeriPal podcast, “ Karen’s 2000 JAMA article, “.” Rasa and Edison’s article, “” A short video from the EPEC project that Edison mentioned during the recording of where she shares her advice for anyone going into medicine or palliative care and her views about the principles of palliative care. Lastly, if you would like to join Eric, Edison, and I in Brazil on April 6, 2026, for the -Alex Smith
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Medical Billing and Coding with the "Billing Boys"
09/11/2025
Medical Billing and Coding with the "Billing Boys"
A podcast on medical billing and coding??? Ok, hear us out as we were skeptical too. We’ve invited the Billing Boys, Chris Jones and Phil Rodgers, who convinced us of the following: Billing is complicated, but it isn’t hard. Effectively billing helps pay for the interprofessional team members who often can't bill We should know our worth and bill for it. Just because a visit didn’t feel HARD to a well-trained provider doesn’t mean it wasn’t complex or valuable. Many of us have long suffered from low professional self-esteem when it comes to money, and it’s high time we stop that. While exclusively billing on time may have been right 20 years ago, we must now understand complexity and advance care planning (ACP). We can't cover everything in the 45 minutes we are together, so here are some of the resources we reference in the podcast: Chris’s and Phil’s consulting contact info via CAPC resources: This is the book that has the Complexity Grid in it. The answers are all here! And your coders will likely share.
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Is Geriatrics-focused Primary Care (GeriPACT) Better? A Podcast with Nicki Hastings, Kristie Hsu, and Ken Covinsky
09/04/2025
Is Geriatrics-focused Primary Care (GeriPACT) Better? A Podcast with Nicki Hastings, Kristie Hsu, and Ken Covinsky
On today’s podcast, we talk about an innovative specialized primary care model for older veterans called the Geriatric Patient Aligned Care Team (GeriPACT) program. It’s designed with smaller patient panels and enhanced social worker and pharmacist involvement, and its approach is aimed at improving care and outcomes for our aging population. We unpack the intriguing findings of a recent , looking at GeriPACT that compares it to a traditional Patient Aligned Care Team (PACT). While GeriPACT successfully delivered more attention to geriatric conditions, it surprisingly didn't translate into expected improvements like more time at home or better self-rated health. We discuss the potential reasons behind this with our other two guests, one a geriatrics fellow, , and the other a recurring guest and host of the podcast, . Was it just that it didn’t work, or were there other things going on, from the intensity of "usual care" to the challenges of measuring complex health outcomes and the possibility that 18 months simply wasn't long enough to see the full benefits? Despite what was ostensibly a negative trial, we highlight some reassuring aspects and future hopes for GeriPACT and how we can all incorporate some of these components into the care of our patients. We'll also pose critical questions for future research, emphasizing why continued development and evaluation of new care models are essential for the health of our older population.
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Do Dementia Care Management Programs Work? A Podcast with David Reuben and Greg Sachs
08/28/2025
Do Dementia Care Management Programs Work? A Podcast with David Reuben and Greg Sachs
With all the attention focused on Alzheimer's biomarkers and amyloid antibodies, it’s easy to forget that comprehensive dementia care is more than blood draws and infusions. On today’s podcast, we buck this trend and dive into the complexities and challenges of comprehensive dementia care with the authors of two pivotal articles recently published in JAMA. We’ve invited David Reuben and Greg Sachs to talk about their two respective trials, published in JAMA — and — aimed at improving the evidence for care models supporting individuals diagnosed with dementia. D-CARE tested the comparative effectiveness of health system-based dementia care, a community-based program, and usual care, while IN-PEACE assessed the addition of palliative care to dementia care programs for individuals with moderate to severe dementia. Despite their pragmatic trial designs and high expectations, both studies' primary outcomes were negative, although there were some intriguing positive secondary outcomes. We discuss how some critical questions about the integration of these findings into practice, and how they fit in with previous research that did show benefits (). If you want to learn more about comprehensive dementia care, check out these past podcasts: Lastly, here is the that describes his maternal grandmother decline from Alzheimer's disease.
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Comprehensive Geriatric Assessment: Benefits, Cost-Effectiveness, and Who It Helps Most - Eric Wong and Thiago Silva
08/21/2025
Comprehensive Geriatric Assessment: Benefits, Cost-Effectiveness, and Who It Helps Most - Eric Wong and Thiago Silva
In today’s podcast we talk with Eric Wong, geriatrician-researcher from Toronto, and Thiago Silva, geriatrician-researcher from Brazil, about the comprehensive geriatrics assessment. We spend the first 30 minutes (at least) discussing what, exactly is the comprehensive geriatric assessment, including: What domains of assessment are essential/mandatory components of the comprehensive geriatrics assessment? Who performs it? Is a multidisciplinary team required? Can a geriatrician perform it alone? Can non-geriatricians perform it? Who is the comprehensive geriatrics assessment for? Who is most likely to benefit? Eric Widera suggests not as much benefit for very sick and very healthy older adults, more benefit in the vast middle. Why do the comprehensive geriatrics assessment? What are the interventions that it leads to (we cover this more conceptually, rather than naming all possible interventions) How does the comprehensive geriatrics assessment relate to the 4Ms (or 5 Ms)? How long does it take to conduct a comprehensive geriatrics assessment? What’s the evidence () for the comprehensive geriatrics assessment? What are the outcomes we hope for from the comprehensive geriatrics assessment? That final point, about outcomes, bring’s us to Eric Wong’s study, , which evaluates the cost effectiveness of the comprehensive geriatrics assessment performed by a geriatrician across settings (e.g. acute care, rehab, community clinics). As an aside, as the editor at JAGS who managed this manuscript, I will say that we don’t ordinarily publish cost effectiveness studies at JAGS, as the methods are opaque to our clinical audience (e.g. raise your hand if you understand what ‘CGA provided in the combination of acute care and rehab was non-dominated’ means). We published this article because its bottom line is of great interest to geriatricians. In Eric’s study, geriatricians performing CGA were more cost effective than usual care in Every. Single. Setting. And of course cost effectiveness is only one small piece of the argument for why we do the comprehensive geriatrics assessment in the first place (no patient in the history of the world has ever asked for a test or treatment because it’s cost effective for the health care system). I’ll close with a couple of “mic drop” excerpts from Thiago’s accompanying : Finally, it is instructive to compare the cost-effectiveness of geriatric services and CGAs with other interventions. A recent analysis of lecanemab for early-stage Alzheimer's disease found that gaining one QALY would cost approximately $287,000 (USD). In contrast, Wong et al. estimated that adding community-based CGA would cost about $1203 (CAD) per quality-adjusted life month (QALM) (equating to roughly $10,105 (USD) per QALY, using $1 USD = $0.7 CAD), making geriatrician-led CGA nearly 30 times more cost-effective. Put simply, for each dollar spent to improve quality of life for a year through CGA, one would need to spend almost $30 to achieve the same benefit with lecanemab. Ultimately, the question is not whether geriatricians represent a worthwhile investment (they are) but how healthcare systems can ensure that every older adult requiring specialized, comprehensive care can access it. Wong et al.'s modeling study provides a valuable contribution by showing that geriatricians placed in acute and rehabilitation settings offer the most cost-effective deployment given current workforce limitations. Despite some caveats, the overarching message remains clear: geriatric expertise not only enhances care quality but can also align with health-economic objectives, especially in high-acuity environments. However, we cannot allow an inadequate geriatric workforce to become a permanent constraint, forcing painful decisions about which older adults and which settings will miss out on optimal geriatric care. Instead, we should continue to strive to increase the number of geriatricians through robust training programs and payment model reform to ensure that cost-effective care can be provided for this large and growing vulnerable population. -Alex Smith
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What instead? Alternatives to Beers: Todd Semla and Mike Steinman
08/14/2025
What instead? Alternatives to Beers: Todd Semla and Mike Steinman
On a we talked with Todd Semla and Mike Steinman about the update to the of potentially inappropriate medications in older adults (Todd and Mike co-chair the AGS Beers Criteria Panel). One of the questions that came up was - well if we should probably think twice or avoid that medication, what should we do instead? Today we talk with Todd and Mike about their new recommendations of , and also presented at the 2025 AGS conference in Chicago (and available ). We had a lot of fun at the start of the podcast talking about the appropriate analogy for how clinicians should use the AGS Beers Criteria. In our , the analogy was a stop sign. You should come to a stop before you prescribe or refill a medication on the Beers list, look around at alternatives, and consider how to proceed. You might in the end decide to proceed, as there are certainly situations in which it does make sense to start or continue a medication on the Beers list. Today’s analogy had somewhat higher stakes, involving a driver, a pothole in the road, and a cyclist on the side who you’d hit if you swerved. Really upping the anti!!! The podcast is framed around a case Eric crafted of a patient with most of the medications and conditions on the Beers list. We used this as a springboard to discuss the following issues (with links to prior GeriPal podcasts): (Doxepin is an alternative, trazodone and melatonin are not?!?) management PPI for GERD Treatments for pain, including NSAIDS, COX2, and - terrific Canadian website (no tariff to use) And I hope that the prescribing landscape is indeed (thanks to Kai on guitar)! -
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Art Museum-Based Medical Education: Amy Klein, Laura Morrison, and Gordon Wood
08/07/2025
Art Museum-Based Medical Education: Amy Klein, Laura Morrison, and Gordon Wood
Health care trainees rotate through a variety of different settings. ICUs, hospital wards, and outpatient clinics. If they're lucky, they might even spend time in a nursing home. But on today’s podcast, we’re adding one more setting to that list: your local art museum. In this thought-provoking episode, we explore how art museum teaching is being integrated into the education of medical professionals—and why it's making a profound difference. Our guests, , , and , share their journey of integrating art into medical training, along with practical strategies you can use if you're inspired to do the same. You'll also hear how engaging with museum-based medical education can help health care professionals deepen empathy and emotional awareness, practice the skill of multiple perspective-taking, and grow more comfortable with ambiguity and uncertainty. Resources mentioned in the podcast include: A Journal Article published in the Journal of Palliative Medicine titled “” A journal article on “.” A AAHPM/HPNA preconference gives examples of museum-based education exercises and resources for further training. Alex’s summary of some prompts we discussed for the “Personal Responses Tour”, which is a reflective exercise where participants choose artwork based on a personal prompt, then share with a small group. The prompts include: Find a work of art that reminds you of a patient Find a work of art that reflects a challenging clinical situation Find a work that speaks to an experience you have had in your palliative medicine training that taught you about the impact of bias or racism Find a work that connects to the path you took into palliative care or geriatrics Find a piece that makes you think about community Find a piece that reflects your idea of what a “good death” is Lastly, stay on the “look out for” the 2026 Art Museum-Based Education preconferences session at the AAHPM/HPNA annual meeting on March 4, 2026 in San Diego!
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We Need a Care Revolution: Victor Montori
07/31/2025
We Need a Care Revolution: Victor Montori
In his book, “,” Victor Montori decries the industrialization of healthcare. We’ve become a healthcare factory, beholden to health systems motivated by profit. In particular, he laments the loss of the “care” aspect of healthcare. Clinicians are under the clock to churn through patients. Patients are tasked with doing work outside of the clinic. Patients are tasked with hours and hours of work to self manage, obtain and manage medications, track weights and fingersticks, not to mention scheduling visits and waiting around for the visit to start. Now we have an app for that. For what, you ask? Well, for everything! Digital burden is real. Think about what we ask patients to do: charge your device, remember your password, 2 factor authentication, each interface is different, wait…where do you enter your fingersticks again? Victor is an endocrinologist who often provides care for older patients with multiple chronic conditions, polypharmacy, and complex social situations. He’s “one of us.” Some might argue that these circumstances call for incremental change. Not Victor. He argues that we need a revolution. In particular, he argues that the revolution must come from patients to be successful. On this podcast we discuss: Why do we need a revolution? What made him get to this point of arguing for a revolt? Why should the revolution be patient led, rather than clinician led? What role do clinicians have to play? What is (a term Victor coined with Carl May and Francis Mair in 2009)? How does shared decision making fit into the revolution? What’s the matter with guidelines? What’s the role of standardization? We suspect that most geriatrics and palliative care providers feel like they’ve escaped many of the issues Victor describes, trading less glamorous and remunerative work for more satisfying time spent caring for patients; focusing on what matters, goals of care, and attention to emotion and social well-being. Are we deluding ourselves? If you’d like to join the revolution, please check out Victor’s website, And I believe this is the first Peter Gabriel song request! I think Peter Gabriel’s album So was the first cassette tape I purchased. About time, 350+ podcasts in. My son Kai turns this very non-guitar friendly song into an acoustic jam for the audio-only podcast version; you get my weaker attempt on YouTube :) Finally, a quick plug for the in Portland OR. Victor and I had a terrific time bonding at this year’s lecture series. While not strictly geriatrics and palliative care focused, the lectures seem targeted at a broad audience, with something for everyone. And yes, I made them sing parody songs :) -Alex Smith
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System Wide Goals of Care Implementation: A Podcast with Ira Byock, Chris Dale, and Matt Gonzales
07/24/2025
System Wide Goals of Care Implementation: A Podcast with Ira Byock, Chris Dale, and Matt Gonzales
Most health care providers understand the importance of goals-of-care conversations in aligning treatment plans with patients’ goals, especially for those with serious medical problems. And yet, these discussions often either don't happen or at least don't get documented. How can we do better? In today’s podcast, we sit down with Ira Byock, Chris Dale, and Matthew Gonzales to discuss a multi-year healthcare system-wide goals of care implementation project within the Providence Health Care System. Spanning 51 hospitals, this initiative was recently described in NEJM Catalyst, showing truly impressive results, including an increase from 7% to 85% in goals of care conversation documentation for patients who were in an ICU for 5 or more days. How did they achieve this? Our guests will share insights into the project’s inception and the strategies that drove its success, including: Organizational Alignment: Integrating GOC documentation into the health system’s mission, vision, and strategic objectives. Clinical Leadership Partnership: Collaborating with clinical leaders to establish robust quality standards and metrics. Ease of Documentation: Upgrading the electronic health record (EHR) system to streamline the documentation and retrieval of GOC conversations. Communication Training: Conducting workshops based on the Serious Illness Conversation Guide to equip clinicians with the skills needed for impactful GOC conversations. Join us as we explore how these strategies were implemented and learn how you can apply similar approaches in your own healthcare setting.
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Death Anxiety: Dani Chammas & Keri Brenner
07/17/2025
Death Anxiety: Dani Chammas & Keri Brenner
What is death anxiety? We spend the first 15 minutes of the podcast addressing this question. And maybe this was unfair to our guests, the fabulous dynamic duo of palliative psychiatrists Dani Chammas and Keri Brenner (listen to their prior podcasts on and the ). After all, we invited them on to our podcast to discuss death anxiety, then Eric and I immediately questioned if death anxiety was the best term for what we want to discuss! Several key points stood out to me from this podcast, your key points may differ: The “anxiety” in “death anxiety” is not a pathological phenomenon or a DSM diagnosis; it references an existential concern that is fundamental to the human experience . To me,” awareness of mortality” might be a better term, but in fairness, the idea of “death anxiety” was coined well before the formal establishment of “anxiety disorders.” The ways in which death anxiety manifests in our patient’s choices and behaviors varies tremendously, and our responses as clinicians must be individualized. There is no “one size fits all” approach. In one example Dani discusses, a pain level of 1.5/10 might be overwhelming, because for a patient in remission from cancer any pain might signal return of cancer. Some manifestations of death anxiety can be debilitating, others lead to tremendous personal growth, connection to others, and a drive toward finding meaning in their illness experience. Death anxiety impacts us as clinicians, not only through countertransference, that word that I still can’t define (sorry Dani and Keri!), but also through our own unexamined fears about death. As clinicians who regularly care for people who are dying, we might find ourselves becoming “used to” death. Is this a sign that we are inured to the banality of death, and less able to empathize with the death anxiety experienced by our patients or their families? Or could it reflect our acceptance of the finitude of life, prompting us to live in the present moment? Perhaps it is something else entirely. The key is that looking inwards to understanding our own unique relationship with mortality can deepen our ability to authentically accompany the experiences of our patients. I mean, don’t fear the reaper, right? Sorry, no in my version, but you do get my son Kai, home from college, on guitar for the audio only podcast version. Here are some resources for listeners wanting to learn more about this topic: Books: Yalom ID. . New York, NY: Basic Books; 1980. Yalom ID. . San Francisco, CA: Jossey-Bass; 2008. Solomon S, Greenberg J, Pyszczynski T. . New York, NY: Random House; 2015. Becker E. . Free Press; 1973. Articles: Emanuel LL, Solomon S, Chochinov HM, et al. . J Palliat Med. 2023;26(2):235-243. Chochinov HM, McClement SE, Hack TF, et al. . J Palliat Med. 2023;26(12):1404–1410. doi:10.1089/jpm.2022.0052. Clark D. . BMJ. 2002;324(7342):905–907. doi:10.1136/bmj.324.7342.905. Vess M, Arndt J, Cox CR, Routledge C, Goldenberg JL. . J Pers Soc Psychol. 2009;97(2):334–350. Menzies RE, Zuccala M, Sharpe L, Dar-Nimrod I. . J Anxiety Disord. 2018;59:64–73. doi:10.1016/j.janxdis.2018.09.00 Brown TL, Chown P, Solomon S, Gore G, De Groot JM. . Psychooncology. 2025;34(1):45–56. doi:10.1002/pon.70068. Tarbi EC, Moore CM, Wallace CL, Beaussant Y, Broden EG, Chammas D, Galchutt P, Gilchrist D, Hayden A, Morgan B, Rosenberg LB, Sager Z, Solomon S, Rosa WE, Chochinov HM. . J Palliat Med. 2024 Oct;27(10):1379-1389. doi: 10.1089/jpm.2024.0070. Epub 2024 Mar 28. PMID: 38546453.
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Individualizing Blood Pressure Goals in Older Adults: A Podcast with Mitra Jamshidian, Simon Ascher and Mark Supiano
07/10/2025
Individualizing Blood Pressure Goals in Older Adults: A Podcast with Mitra Jamshidian, Simon Ascher and Mark Supiano
What’s the ideal blood pressure target for older adults with hypertension? Should we aim for a systolic BP of 120 mmHg in all older adults, as suggested by the ? Or should we be more flexible—especially for those who are frail or among the oldest old? This week on the GeriPal Podcast, we explore the nuances of managing blood pressure in older adults with our guests Dr. Mark Supiano, Dr. Mitra Jamshidian, and Dr. Simon Ascher. Now, some of our astute GeriPal listeners may say, “wait, didn't you already talk about this with Mark Supiano in a 2017 podcast titled ” Yes, we sure did, but we decided to revisit this topic as Mitra Jamshidian and Simon Ascher published a new Their key finding: most community-dwelling older adults in the SPRINT trial experienced greater benefits than harms from more aggressive blood pressure targets—even those who were older, frail, or on multiple medications. Join us for an in-depth discussion on balancing risks, benefits, and patient preferences in hypertension management for older adults. Plus, we might just sneak in a little Frank Sinatra for good measure.
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Should Palliative Care be in the Survivorship Business? A Podcast with Laura Petrillo, Laura Shoemaker
07/03/2025
Should Palliative Care be in the Survivorship Business? A Podcast with Laura Petrillo, Laura Shoemaker
In this week’s episode, we dig into two deceptively simple questions: When does someone become a cancer survivor, and should palliative care be in the business of caring for them? Spoiler: It’s more complicated than it seems. We’ve invited two palliative care doctors to talk about survivorship with us: , a physician-researcher at Mass General Hospital and Harvard Medical School, and , an outpatient palliative care doctor at the Cleveland Clinic. This episode is a must-listen for those navigating the evolving landscape of cancer care, and asking not just how we treat cancer, but how we support people who are living with it. If you want some further reading on survivorship, check out some of these articles: A NEJM article titled “” A ASCO publication that includes a section on survivorship - A webinar on survivorship -
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Health and Wealth Shocks: Lauren Hunt, Rebecca Rodin, Tsai-Chin Cho
06/26/2025
Health and Wealth Shocks: Lauren Hunt, Rebecca Rodin, Tsai-Chin Cho
famously characterized the end of life functional course of people with dementia as a slow dwindle over time. later found that people with dementia do indeed have persistent severe disability throughout the last year of their lives. But from our clinical work, many of us are familiar with people with dementia who experience sudden shocks to their health, think hip fracture, think hospitalization for pneumonia. Those disruptive events or shocks often portend a major decline in function from which people with dementia never fully recover. And they’re often a sign of (or cause of?) worsening prognosis. Today we talk about disruptive events, or health and wealth shocks. We start with Lauren Hunt, who described the and of hip fracture and hospitalization for pneumonia in a pair of publications in JAGS, comparing people with dementia who experience these events to people without dementia. We then turn to social events, starting with Rebecca Rodin, who studied the effect of widowhood on mortality and function for people with dementia, cancer, and organ failure, published in . Finally, we turn to Tsai-Chin Cho, who studied the impact of a wealth shock (loss of 75%+ of wealth in a short time period) on cognitive decline in 4 countries. Tsai-Chin’s article, published in found a tantalizing hint that countries with stronger safety nets had lower incidence of wealth shocks, and less of a deleterious impact of the wealth shock on cognitive function. Wait, so one key message is that social health is linked to physical and cognitive health?!? And the government can do something about that?!? Yes indeed, we like to hammer that home regularly, dear listeners. And I enjoyed singing Leonard Cohent’s Who By Fire, about the many ways people might die…you know…typical uplifting GeriPal song lyrics! -Alex Smith Additional links mentioned by Tsai-Chin Cho: - -
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Transgender Health, Aging, and Advocacy: A Podcast with Noelle Marie Javier and Jace Flatt
06/19/2025
Transgender Health, Aging, and Advocacy: A Podcast with Noelle Marie Javier and Jace Flatt
Happy Pride Month GeriPal listeners! Transgender issues are in the news. Just today (June 17th) as we record this podcast: Ezra Klein released a wonderful , the first openly transgender member of congress A judge ruled that focused on minority groups, including transgender people, were illegal and ordered the government to restore funding. It’s Pride month, and our guests remind us of the in the Stonewall riots, which started the modern fight for LGBTQI+ rights and liberation. Today’s guests are Noelle Marie Javier, a geriatrician and palliative care doc who tells her story of transitioning as a faculty member at Mt. Sinai in New York, and Jace Flatt, who started their journey as a gerontology researcher at UCSF and is now faculty at UNLV. Jace was in the news recently for having because they included transgender participants. We cover many topics, including: Terminology: gender identity, sexual orientation, gender expression, transgender, nonbinary, intersex, what’s in LGBTQI+ Gender affirming care Major health and medical issues associated with aging as a transgender person Allostatic load Accelerated aging What can clinicians do - pointers, pearls, and attitudes Dementia Caregiver issues Hormone replacement therapy at the end of life Sexual orientation and gender identity (SOGI) data, what is it, how to collect it respectfully and safely Mentioned: Harvey Chochinov’s , and our prior podcast on s with Carey Candrian and Angela Primbas So pleased to sing True Colors by Cyndi Lauper, with Kai on guitar for those of you listening to the podcast. -Alex Smith Many links! -: Jace Flatt’s research site. - - gender affirming trans health services -: organization for health professional advancing LGBTQ+ equality - - -: focus on impact of Medicaid cuts -s: resource guide
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What You Should Know About Radiation Oncology: A Podcast with Anish Butala, Emily Martin and Evie Kalmar
06/12/2025
What You Should Know About Radiation Oncology: A Podcast with Anish Butala, Emily Martin and Evie Kalmar
If you’re anything like me, you might find the process of what happens to patients when they visit a radiation oncologist somewhat mysterious. During my training, I didn’t receive much education about radiation oncology, and I’m not entirely sure what some of the terms mean (hypofractionated means fewer sessions, right?). Well, today’s podcast aims to clear up all these uncertainties. We’ve invited , and , a palliative care doctor and past president of the Society for Palliative Radiation Oncology (SPRO), to explain everything we should know about radiation oncology. Additionally, , who suggested today’s topic, will join us as one of our guest hosts. Tune in and we will walk you through the patient’s journey from the initial planning visit to the final treatment, discuss common indications like bone and brain metastases, hear about when to consider steroid therapy, and highlight radiation therapy emergencies.
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Implementing Palliative Care in Nursing Homes
06/05/2025
Implementing Palliative Care in Nursing Homes
The need for better palliative care in nursing homes is significant. Consider this: the majority of the 1.4 million adults residing in U.S. nursing homes grapple with serious illnesses, and roughly half experience dementia. Many also suffer from distressing symptoms like pain. In addition, about 25% of all deaths in the United States occur within these facilities. Despite these substantial needs, specialized palliative care beyond hospice is rare in nursing homes. Furthermore, only about half of nursing home residents nearing the end of life receive hospice care. So, how can we improve palliative care for individuals in nursing homes? Today's podcast explores this crucial question with three leading experts: Connie Cole, Kathleen Unroe, and Cari Levy. Our discussion delves into: The specific palliative care needs of nursing home residents. How to think about primary and specialized palliative care in this setting. The obstacles hindering referrals to palliative care services. Practical strategies to overcome these barriers and enhance care. We also take a dive into these 2 articles that Connie first authored: If you are interested in learning more, check out some of our other palliative care in nursing home podcasts including:
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Lucid Episodes: Andrea Gilmore-Bykovskyi & Andrew Peterson
05/29/2025
Lucid Episodes: Andrea Gilmore-Bykovskyi & Andrew Peterson
Have any of you watched the movie “”? At the end, one of the characters, who has dementia, experiences an episode of lucidity. When I watched it, between tears (I’m a complete softie) I remember thinking, “Oh no! This will give people false hope! That their loved one is ‘in there.’ If only they could find the right key to unlock the lock and let them out.” Today we talk about lucid episodes and what they might mean to the person with dementia, their family and loved ones, to philosophers, to clinicians, to neuroscientists. Our guests are Andrea Gilmore-Bykovskyi, a nurse researcher, and Andrew Peterson, a philosopher. We had a wide ranging discussion that touched on (among many things): A consensus definition developed at an NIH conference, organized by the recently retired NIA program officer (we will miss you Basil!). Andrew complicates this , stating is raises more questions than answers. Hospice nurses know that terminal lucidity “is a thing” and have pretty much all seen it Family and caregiver of lucid episodes and what they meant to them, including early glimpses into a Andrea is doing using video to capture episodes and show them to family. Potential for experiences to elicit “false hope”, misunderstanding/misinterpreting, and changing say code status from DNR to full code (). ’s work on brain activity during CPR and near death episodes Ethical issues these lucid episodes raise Should clinicians treat people with dementia as always lucid? Having some level of awareness? Parallels between how we treat people with advanced dementia, who may or may not be lucid, and , who may or may not be conscious, or experiencing paradoxical lucidity on their way to full consciousness. I try to say please and thank you to the AI I interact with other than Alexa, who is obviously way behind. The , featuring Anne Bastings, Jason Karlawish, Elizabeth Donnarumma, and Justin Clapp Was Andrew’s song choice, “I can see clearly now” better than Eric’s suggestion “Silent Lucidity” by Queensryche? Enjoy! -Alex Smith
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Music as Medicine: Jenny Chen, Tyler Jorgensen, & Theresa Allison
05/22/2025
Music as Medicine: Jenny Chen, Tyler Jorgensen, & Theresa Allison
As you know, dear listeners, I love music. We start each podcast with a song in part to shift the frame, taking people out of their academic selves and into a more informal conversation. Well, today’s guests love music at least as much if not more than me, and they each make a strong case for music as medicine. Jenny Chen is a palliative care fellow at Yale who regularly sings for her seriously ill patients. Look for Jenny to potentially appear on the show (no lie). Tyler Jorgensen not only plays music for his patients, starting out with just pulling up a tune on his iPhone, he and others at UT Austin and Dell med now wheel a record player into patients rooms and play vinyl, taking patients back to the sounds and routines - think taking the record out of the sleeve, placing the needle in the groove - of younger days. You can here Tyler and I having a great time singing together and sharing stories around his podcast . And Theresa Allison is a geriatrician and ethnomusicologist who studies the role of music for people with dementia. The ability to appreciate, recognize, and engage with music is preserved even until late stages of dementia, and Theresa is examining how music can be useful from the time of diagnosis, not only for the person with dementia, but their caregivers. Many links today, including: - Movie and movement - - book by Hilary Moss -Tyler Jorgensen’s article on -Tyler’s reflection/story comparing - something I arrived at independently and tell all new trainees! This is not highly scripted orchestral music, people, it’s Jazz. -S (and prognosis) in palliative care -Review of (Theresa Allison author) -Theresa Allison’s paper on -
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Nudges for Prognosis and Comfort Care in the ICU: Kate Courtright, Scott Halpern, & Jaspal Singh
05/15/2025
Nudges for Prognosis and Comfort Care in the ICU: Kate Courtright, Scott Halpern, & Jaspal Singh
Our main focus today was on to consider a more palliative approach to care. Our guests are all trained in critical care: Kate Courtright, Scott Halpern, and Jaspal Singh. Kate and Scott have additional training in palliative medicine. To start. we review: What is a nudge? Also called behavioral interventions, heuristics, and cognitive biases. Prior podcasts on the , and a different trial conducted by Kate and Scott in which the . What is sludge? I’d never heard the term, perhaps outside of Eric’s pejorative reference to my coffee after adding copious creamers, flavoring, and sweeteners. Sludge is apparently when you create barriers or extra work for someone. For example, putting the healthy food at the back of the grocery store is sludge; making an applicant for health insurance climb the flight of stairs to the office - weeding out those less fit - is also sludge. Prior-auth forms? Sludge. Examples of nudges, some based in health care, others in coffee. This specific , published in JAMA Internal Medicine, was conducted in 17 ICUs in North Carolina. Many were community hospitals. Participants were critically ill and intubated. Clinicians were randomized to 4 groups: Usual care Prognosis nudge - EHR prompt asking, do you think your patient will be alive in 6 months? This is called a focusing effect Comfort care nudge - EHR prompt asking if they’d offered comfort-focused care. This is called accountable justification - an appeal to standards of care for critically ill patients endorsed by multiple professional societies. Both the prognosis and comfort care nudge. A few key points of discussion: Is an EHR prompt a nudge or sludge? The intervention was a negative study for the primary outcome, hospital length of stay. Why? The prognosis nudge did nothing. What to make of that? Would you think an EHR nudge to consider prognosis might move the needle, at least on some outcomes? The nudge toward offering comfort care led to more hospice and early comfort-care orders. Is this due to chance alone, given the multiplicity of secondary outcomes examined? Or is it a tantalizing finding that suggests a remarkably low cost EHR based nudge might, on a population level, lead to critical care clinicians offering comfort care and hospice more frequently? ! -
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Psilocybin in Serious Illness: A Podcast with James Downar, Ali John Zarrabi and Margaret Ross
05/08/2025
Psilocybin in Serious Illness: A Podcast with James Downar, Ali John Zarrabi and Margaret Ross
We’ve covered psychedelics on the podcast before—first in 2019 with , and then again in 2023 with Stacy Fischer, Brian Anderson, and Theora Cimino, focusing on the . In today’s episode, we’re taking a closer look at the current state of the science around one specific psychedelic: psilocybin. We'll discuss three recent clinical trials involving patients with serious illness, joined by our guests , , and . We begin with a refresher on psilocybin—what it is, how it might work, what conditions it may help treat (including demoralization), and how it’s typically administered. What makes this episode especially compelling is our deep dive into the three studies, which highlight two different approaches to using psilocybin: daily microdosing, similar to traditional antidepressants, and a more intensive model known as psilocybin-assisted therapy. This latter approach involves three structured phases—preparation, the dosing session, and post-session integration with trained therapists.
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HIV, Aging, and Palliative Care: Peter Selwyn and Meredith Greene
05/01/2025
HIV, Aging, and Palliative Care: Peter Selwyn and Meredith Greene
Peter Selwyn, one of today’s guests, has been caring for people living with HIV for over 40 years. In that time, care of people with HIV has changed dramatically. Initially, there was no treatment, then treatments with marginal efficacy, complex schedules, and a tremendous burden of side effects and drug-drug interactions. The average age at death was in the 30s. Now, more people in the US die with HIV rather than from HIV. Treatment regimens are simplified, and the anti-viral drugs are well tolerated. People are living with HIV into advanced ages. The average age at death is likely in the 60s. Nearly half of people living with HIV are over age 55. One in 10 people with newly diagnosed HIV is an older adult. Our second guest, Meredith Greene, is a geriatrician and researcher who focuses on care of older adults living with HIV, in the US and Africa. On today’s podcast we discuss: Implications of aging with HIV for clinical care Loneliness and social isolation among older adults living with HIV Persistence of stigma Need to consider HIV in the differential diagnosis for older adults Screening for HIV Screening for osteoporosis in people living with HIV Dementia and cognitive impairment risk in people living with HIV When to stop anti-virals near the end of life Toward the end we speak to the moment. More older adults live with HIV in SubSaharan Africa and the global South than anywhere else in the world. Funding for research and clinical care is at risk, as USAID and PEPFAR (which is under USAID), are shuttered. Millions of lives are at stake. Meredith wore a shirt that said . Eric gave me the hook during my live cover of One, by U2, a song released in 1992 whose proceeds went entirely to AIDS research. I couldn’t help it, forgive me dear listeners, I had to do a longer than usual cut at the start! -Alex Smith Useful links: Peter's article on the evolution of HIV: Peter’s book PEPFAR: Articles: Management of Human Immunodeficiency Virus Infection in Advanced Age About Act-up for those who might know the Silence=Death t-shirt reference:
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Potentially Unsafe Low-evidence Treatments: Adam Marks, Laura Taylor, & Jill Schneiderhan
04/24/2025
Potentially Unsafe Low-evidence Treatments: Adam Marks, Laura Taylor, & Jill Schneiderhan
More and more people are, “” Self-identified experts and influencers on (podcasts!) and social media endorse treatments that are potentially harmful and have little to no evidence of benefit, or have only been studied in animals. An increasing number of federal have a of endorsing such products. We and our guests have noticed that in our clinical practices, patients and caregivers seem to be asking for such treatments more frequently. Ivermectin to treat cancer. Stem cell treatments. Chelation therapy. Daneila Lamas wrote about this issue in the -after we recorded - in her story, a family requested an herbal infusion for their dying mother via feeding tube. Our guests today, Adam Marks, Laura Taylor, & Jill Schneiderhan, have coined a term for such therapies, for Potentially Unsafe Low-evidence Treatments, or PULET. Rhymes with mullet (On the podcast we debate using the French pronunciation, though it sounds the same as the French word for chicken). We discuss an for the American Journal of Hospice and Palliative Medicine, including: What makes a PULET a PULET? Key ingredients are both potentially unsafe and low evidence. If it’s low evidence but not unsafe, not generally an issue. Think vitamins. If it’s potentially unsafe, but has robust evidence, well that’s most of the treatments we offer seriously ill patients! Think chemo. What counts as potentially unsafe? They include what might be obvious, e.g. health risks, and less obvious, e.g. financial toxicity. What counts as low-evidence? Animal studies? Theoretical only? Does PULET account for avoiding known effective treatments? Do elements of care that are often administered to seriously ill patients count? Yes. Think chemotherapy to imminently dying patients, or CPR. How does integrative medicine fit in with this? Jill Schneiderhan, a family medicine and integrative medicine doc, helps us think through this. How ought clinicians respond? Hint: If you’re arguing over the scientific merits of a research study, you’re probably not doing it right. Instead, think , REMAP, and uncover and align with the emotion behind the request. Does the approach shift when it’s a caregiver requesting PULET for an older relative who lost capacity? How about parents advocating for a child? For more, Laura suggests a book titled, . And I am particularly happy that the idea for this podcast arose from my visit to Michigan to give , and the conversations I had with Adam and Laura during the visit. We love it when listeners engage with us to suggest topics that practicing clinicians find challenging. And I get to sing Bon Jovi’s Bad Medicine, which is such a fun song! -Alex Smith
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