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<?xml version="1.0" encoding="UTF-8"?><rss version="2.0" xmlns:content="http://purl.org/rss/1.0/modules/content/" xmlns:wfw="http://wellformedweb.org/CommentAPI/" xmlns:dc="http://purl.org/dc/elements/1.1/" xmlns:atom="http://www.w3.org/2005/Atom" xmlns:sy="http://purl.org/rss/1.0/modules/syndication/" xmlns:slash="http://purl.org/rss/1.0/modules/slash/" > <channel> <title>A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</title> <atom:link href="https://geripal.org/feed/" rel="self" type="application/rss+xml" /> <link>https://geripal.org/</link> <description></description> <lastBuildDate>Wed, 20 Nov 2024 21:44:15 +0000</lastBuildDate> <language>en-US</language> <sy:updatePeriod> hourly </sy:updatePeriod> <sy:updateFrequency> 1 </sy:updateFrequency> <generator>https://wordpress.org/?v=6.6.2</generator> <item> <title>Coping with Serious Illness: Danielle Chammas and Amanda Moment</title> <link>https://geripal.org/coping-with-serious-illness-danielle-chammas-and-amanda-moment/</link> <dc:creator><![CDATA[Alex Smith]]></dc:creator> <pubDate>Thu, 21 Nov 2024 08:00:41 +0000</pubDate> <category><![CDATA[All Posts]]></category> <category><![CDATA[End-of-Life]]></category> <category><![CDATA[CME Eligible]]></category> <category><![CDATA[Podcasts]]></category> <guid isPermaLink="false">https://geripal.org/?p=6976</guid> <description><![CDATA[The post <a href="https://geripal.org/coping-with-serious-illness-danielle-chammas-and-amanda-moment/">Coping with Serious Illness: Danielle Chammas and Amanda Moment</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></description> <content:encoded><![CDATA[<div class="wpb-content-wrapper"><div class="vc_row wpb_row vc_row-fluid no-bottom-margins"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"> <div class="wpb_raw_code wpb_raw_html wpb_content_element vc_custom_1732138468630" > <div class="wpb_wrapper"> <iframe title="Libsyn Player" style="border: none" src="//html5-player.libsyn.com/embed/episode/id/34044701/height/90/theme/custom/thumbnail/yes/direction/backward/render-playlist/no/custom-color/00548f/" height="90" width="100%" scrolling="no" allowfullscreen webkitallowfullscreen mozallowfullscreen oallowfullscreen msallowfullscreen></iframe> </div> </div> <div class="vc_tta-container" data-vc-action="collapse"><div class="vc_general vc_tta vc_tta-tabs vc_tta-color-sky vc_tta-style-flat vc_tta-shape-square vc_tta-spacing-1 vc_tta-o-no-fill vc_tta-tabs-position-top vc_tta-controls-align-left"><div class="vc_tta-tabs-container"><ul class="vc_tta-tabs-list"><li class="vc_tta-tab vc_active" data-vc-tab><a href="#summary" data-vc-tabs data-vc-container=".vc_tta">Summary</a></li><li class="vc_tta-tab" data-vc-tab><a href="#transcript" data-vc-tabs data-vc-container=".vc_tta">Transcript</a></li><li class="vc_tta-tab" data-vc-tab><a href="#cme" data-vc-tabs data-vc-container=".vc_tta">CME</a></li></ul></div><div class="vc_tta-panels-container"><div class="vc_tta-panels"><div class="vc_tta-panel vc_active" id="summary" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#summary" data-vc-accordion data-vc-container=".vc_tta-container">Summary</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> Denial. Substance use. Venting. Positive reframing. Humor. Acceptance. All of these are ways we cope with stressful situations. Some we may consider healthy or unhealthy coping strategies, but are they really that easy to categorize? Isn’t it more important to ask whether a particular coping behavior is adaptive or not for a particular person,in a particular time or situation? We are going to tackle this question and so many more about coping on this week’s podcast with <a href="https://www.ucsfhealth.org/providers/dr-danielle-chammas">Dani Chammas</a>, a recurring GeriPal guest, psychiatrist, and palliative care doc at UCSF, and <a href="https://pallcare.hms.harvard.edu/faculty/node/74">Amanda Moment</a>, a Palliative Care Social Worker at Brigham and Women’s Cancer Center. There are so many take-home points for me on this podcast, including this one on a framework for assessing coping in serious illness: <ol> <li style="font-weight: 400;" aria-level="1">nonjudgmentally observe their coping</li> <li style="font-weight: 400;" aria-level="1">wonder about the impacts of their coping</li> <li style="font-weight: 400;" aria-level="1">prioritize helping patients maintain their psychological integrity</li> <li style="font-weight: 400;" aria-level="1">mindfully think through how we can serve their coping in ways that they can tolerate, always calibrating based on the person, the moment, and the setting in front of us.</li> </ol> Here are some more resources we’ve discussed in the podcast <ul> <li style="font-weight: 400;" aria-level="1">Dani’s NEJM article on coping: “<a href="https://www.nejm.org/doi/abs/10.1056/NEJMp2402142">Should I Laugh at That? Coping in the Setting of Serious Illness</a>”</li> <li style="font-weight: 400;" aria-level="1">Dani’s GeriPal podcast with us on “<a href="https://geripal.org/improving-serious-illness-communication-by-formulations/">Improving Serious Illness Communication By Developing Formulations</a>”</li> <li style="font-weight: 400;" aria-level="1">A great journal article on “<a href="https://journals.sagepub.com/doi/10.1177/10499091241300614">Formulation in Palliative Care: Elevating Our Potential for Therapeutic Communication</a>”</li> <li style="font-weight: 400;" aria-level="1">A study on how palliative care may work by enhancing patients’ ability to access adaptive coping – “<a href="https://ascopubs.org/doi/10.1200/JCO.2017.73.7221">Role of Patient Coping Strategies in Understanding the Effects of Early Palliative Care on Quality of Life and Mood</a></li> </ul>   ** NOTE: To claim CME credit for this episode, <a href="https://geripal.org/coping-with-serious-illness-danielle-chammas-and-amanda-moment/#cme">click here</a> **   <hr /> </div> </div> </div></div><div class="vc_tta-panel" id="transcript" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#transcript" data-vc-accordion data-vc-container=".vc_tta-container">Transcript</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=9745">00:09</a> Welcome to the GeriPal Podcast. This is Eric Widera. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=12857">00:12</a> This is Alex Smith. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=14017">00:14</a> And Alex, who do we have with us today? Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=15945">00:15</a> We are delighted to welcome back Dani Chammas, who is a psychiatrist and palliative care doc at UCSF in the division of palliative medicine. Dani, welcome back to GeriPal. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=25417">00:25</a> Excited to be back. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=26913">00:26</a> And we’re delayed to welcome Amanda Moment, who is a palliative care social worker at the Brigham and Women’s Hospital in Boston. Amanda, welcome to GeriPal. Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=35593">00:35</a> Thanks for having me. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=37145">00:37</a> We are going to talk about coping and part of this came up from, and we’ll get into it, a New England Journal piece that Dani wrote. Should I laugh at that? Coping in the setting of serious illness. But before we jump into that topic, which is a pretty hefty topic, Dani, I think you have a song request for Alex. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=57035">00:57</a> Indeed, I’m going to request It’s Okay by Nightbirde. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=61035">01:01</a> Why did you pick this song by this song? Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=65035">01:05</a> I love this song as a piece of art, but I also chose it because the artist was a young woman who wrote and sang this song during her journey with terminal cancer, and she has since died. But the song lives on, and it was, in my opinion, a big piece of her unique coping to create and share this song. So it felt very fitting to just today’s discussion. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=86583">01:26</a> How did you find this song? This is not on pop radio, right? Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=91575">01:31</a> I didn’t know I was gonna get out in this early. I watch America’s Got Talent with my children, and Nightbirde auditioned with this song and got Simon Cowell’s Golden Buzzer. And my kids love watching the moment when the glitter falls on her face. So we watched it a lot of times. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=110207">01:50</a> Oh, wow. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=111705">01:51</a> Yeah. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=112273">01:52</a> I watched American Idol for years, my wife and I. I have to say, I watched this video of America’s Got Talent and I was bawling. My wife was like, what’s going on over there? Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=124793">02:04</a> It’s like, oh, garlic. It’s the onions. This is great. [laughter] Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=130929">02:10</a> So here’s a little bit. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=140875">02:20</a> (singing) Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=205095">03:25</a> Thank you, Alex. Nice song, Dani. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=208271">03:28</a> Thank you. Beautiful choice. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=210063">03:30</a> Thanks. Yeah, I could feel the America’s Got Talent glitter dropping on us. [laughter] Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=218055">03:38</a> All right, Dani, I’ve got a question. So you just published not too long ago. I forget when it was New England Journal. Should I laugh at that? Coping in the setting of a serious illness about a patient encounter you had with somebody who used an. A coping style that we see not infrequently. Do you want to describe kind of in your own words again? You probably haven’t read in a while what that patient encounter was like. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=246087">04:06</a> Yeah, yeah. I. I remember it well because on paper it was very sad case. Young man, terminal cancer coming in for the first time. And I remember reading the chart and expecting heaviness. Expecting a lot of heaviness. It’s really hard for us all when someone so young is going to die. And he came in and started cracking jokes, these dark humor, pseudo appropriate, pseudo inappropriate jokes from the start. And I was taken aback. And then he was just so cracking up at how taken aback I was. And so he kept them coming. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=285991">04:45</a> And what was his sticker? What did his sticker say again? Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=288999">04:48</a> It was mist. He gave me stickers that said it was metastasized when I got here. Yeah. Or the first thing he said when I met, he was like, what’s the difference between my dad and cancer? I was like, what? He was like, well, at least my dad didn’t beat me. And I was, like, so taken aback. It was not what I was expecting to see in the room. And I was wondering, like, what do I do right now? Do I. Do I laugh with him? I’m a pretty. You guys know me. I love to joke, like, I could go down this rabbit hole, but is that going to be in service of him, or is that going to really be colluding with something that’s not in service of him? And so the narrative piece is really the process of, in my own mind, trying to verbalize how I assess somebody’s coping and how I decide in the moment how I’m going to relate to it. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=337411">05:37</a> Yeah. And that’s the whole point of this podcast. So hopefully we’ll walk through that narrative. But maybe for listeners like me, I struggle in actually defining what coping is. It’s one of those words that we say a lot, but I am not sure I completely understand what I am saying when I use that word. Amanda, what is coping? Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=365005">06:05</a> Well, Dani and I have been talking a lot about how coping is basically everything that we see in terms of how people express their reactions to what’s happening in front of them. Coping is something that we see our patients do. Coping is something that we do as we’re taking care of people and as we’re moving through the world. So kind of all of the behaviors that we see, it’s some form of coping. And there’s a lot of thoughts that people have about, you know, what is adaptive coping, what is kind of maladaptive coping. And we can talk a little bit about that, but it’s basically someone’s reaction to what’s happening in front of them and all the ways that it manifests. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=409405">06:49</a> Too simple or too simplistic. But really, when I think about coping, it’s just like, how do we deal? Right. Like, how do we help ourselves maintain psychological integrity in the face of the stressors that we have to manage? Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=424805">07:04</a> And you use the words adaptive and maladaptive. And just to put that in plain English for our listeners, is that like good coping and bad coping, healthy and unhealthy? Coping, healthy and unhealthy. That’s probably better. Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=438075">07:18</a> Yeah. And I think a lot of people, they come from their own lens when they’re identifying whether they think that someone else is coping is healthy or unhealthy. And so it’s, you know, it’s something that is an incredibly subjective thing. But I think because we only view it from our own lenses, we think we’re saying something objective when it’s incredibly subjective as we’re identifying it. So trying to kind of build language for how are we assessing that coping. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=466311">07:46</a> Yeah. I would say, though, one of my hopes for this time together is that we take ourselves outside of this false dichotomy, that coping is good or bad, that there’s a right or wrong way to cope with serious illness because it’s just not the case. Right. We can ask ourselves, is it serving the patient? How is it serving the patient? How is it hindering the patient? There are ways that we can assess coping, but I think that this idea that people are doing it right, right or wrong really gets us into trouble. Because like Amanda said, everything we see is coping. Everything. Right. Somebody writes a beautiful poem. Coping. Somebody shouts at my front Desk staff because they’re pissed off about their appointment time. Coping, it is all coping. And it just helps me to let go of good and bad and remind myself the person in front of me is doing the best that they can with the resources, internal and external they have available to them to deal with the circumstances they’ve been dealt. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=528735">08:48</a> But aren’t there some bad ones? Like denial is. What is it? Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=534575">08:54</a> Denial is not just a river in Egypt. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=537855">08:57</a> Listen. But sometimes denial serves people. Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=542415">09:02</a> Sometimes it can be really healthy to not dwell on something that you have no control over. Say so say you are waiting for scan results to come back and you got a day between today and tomorrow where you don’t have your scan results. And in that time period, avoidance and kind of denial of engaging with hard things in that time period might be really healthy. It might be a way for you to cope and get through that time period without completely falling apart or not being yet ready to confront a reality. So I don’t think that denial by itself is positive or negative. Kind of, to Dani’s point, is it sort serving somebody in the moment that it’s happening? Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=587527">09:47</a> And I might get in trouble for saying this about math. Oh, no. I’m scared to say it, but I am going to say it anyways. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=595975">09:55</a> This is for our TikTok, so you can do it a little dance as you describe the benefits of meth. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=601711">10:01</a> About meth. About meth. No. So I know the thing is, coping serves a purpose. It’s there for a reason. Whether we think there might be more adaptive coping we can get somebody in contact to or not, it’s there for a reason. There’s a reason the person is using the math. It’s got a function. And so we don’t want to take a sledgehammer to what’s keeping people intact. Even if it’s something that we don’t think is the best for them, we want to respect what it does and then we can think through, okay, how’s it serving? How’s it hindering? Can I adjust it? Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=636865">10:36</a> So for each person, that particular coping mechanism may be a mixture. There may be ways in which it’s healthy for them and there may be ways in which it’s hindering or harmful to them. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=648357">10:48</a> Yeah, right on, Alex. And if I were to one up that I would say that that ratio changes both depending on time and depending on circumstance. And so we see a lot of people who their coping is that they’re doers, they just have to do. And when they’re in their treatment phase, that’s really serving them. They’re doing. They’re doing. They know which. The clinical trials and the this and that. And then, you know, the. They’ve got it all, the infusions and this, that. And then we see them on the other side of treatment when they’re in remission, and it’s just not serving them anymore. Right. They kind of come apart in that space because with nothing to do, they have to really look at what’s going on with them. So it can be different over time, and it can be different over circumstance. If you like to compartmentalize, well, gosh, when you’re going to Disneyland with your kids for a memorable trip, compartmentalize, put that cancer in the box and take pictures with Mickey. But if we’re going to have a family meeting, that’s a different circumstance. We’re going to have to be able to open the box. So help serves and hinders in everybody. And that balance changes based on time and circumstance. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=718035">11:58</a> So going back to the case that you presented at the start, so you’re seeing this person use a whole lot of humor. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=725931">12:05</a> Yeah. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=726923">12:06</a> What did you do? Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=728955">12:08</a> Okay, so internally, this was the question in my head, is it serving? Is it hindering? Because a part of me worried, are we about to use humor for an hour together to avoid talking about the fact that this young man’s going to die or not? And so I let him educate me. I sort of called out the coping. I said, you know, I don’t usually start my appointments in laughter. And it seems like humor has been really important for you. And he kind of described that it has been important. And I said, what led you here? Like, how do we end up here? And he looked at me and he said, Dr. D. Because he didn’t call me Dr. Shaw. He said, Dr. D, this story isn’t going to end in a rainbow. This story isn’t going to end well. My only choice is to make the rainbow right now. And then I knew, and then I knew that he is using this humor to deal with the truth of his illness, not to avoid it. He gets where this is going. And so I let myself laugh with him. And my goodness, did we laugh together. And I think that’s why by the end of the appointment, we were able to go to equally deep places that were pretty dark and pretty heavy together. Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=798315">13:18</a> I was going to say, like to build on that, too. To your point, Alex, about the denial piece, it’s. It’s amazing how often when we’re taking care of somebody in the hospital, if you have Say, you know, a family member who is not showing up for visits with the medical team or who is. Is so fiercely pushing back on discussions about how sick somebody is. It’s often assigned to us that they absolute understand it and that’s why they’re pushing back on it so heavily that that’s actually a sign that people have awareness and insight and how they’re choosing to cope with it looks this way, but they wouldn’t have to push so hard if they didn’t know what they were pushing against. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=843375">14:03</a> I like that it kind of flips it on its head the way we think about it. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=847175">14:07</a> Yeah. It’s kind of like when I think about miracles, I used to always worry, oh man, they’re just in denial. But then you recognize eventually over time, oh wait, we’re in prognostic agreement. Like it would take a miracle. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=861017">14:21</a> A miracle, yeah, that’s right. It’s not in the capacities of what we can do medically. Yeah. Oh, I was just going to say the other piece because we talked about then holding. If we conceptualize everything as coping, it helps us hold empathy. It helps us empathize with the person regardless of how they’re behaving. And I think that the other thing that we can hold empathy for is that when you have a serious illness, it will stress your ability to engage with your normal coping more for some, less for others. But it takes a toll on our ability to hit our adaptive coping. And we see this all the time on a micro level in our normal lives. Stress makes us cope worse. My 4 year old is a beast. Putting her shoes on in the morning every day. She wants her socks one way, she wants the shoes one way. If I’m rested, if I’m calm, if I’m regulated, I can take a deep breath, I can tell myself, you know what, Dani, one day you’re going to miss her at this age. One day and I’ll work with her. But if I’m overwhelmed, if I’m stressed, if I’m not regulated, I might pick up those shoes, throw them out the front door and walk away. Because it’s the best that I have to offer her in that moment. And so if we take a step back and think about the level of stress that people experience managing a serious illness, I think it helps us have grace with the fact that even the coping that we’re seeing might be very different from what we would have seen had we known them earlier in their lives. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=952815">15:52</a> Yeah. Our ability to cope is seriously tested and stressed in the setting of serious illness. And all that comes with it. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=962999">16:02</a> Well, is it our ability to cope because we’re coping, right. I’m hearing we’re coping no matter what. We’re just using different coping styles under different stresses. Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=972495">16:12</a> Like what we can access sometimes narrows when we’re under stress. So we may have a broad range of things that we can access in our day to day lives and then sometimes under stress that can narrow. So like I have, I have, I do inpatient work. So I have people who, you know, on in their normal lives, they go hiking, they do yoga, they like to swim, you know, and suddenly they’re hospitalized for weeks at a time and they can’t the kind of coping that they normally would. So they’re having to draw on aspects of coping that they very rarely had to cultivate, you know, or may have only done for periods of time that were much shorter than that. So oftentimes people are having to build new coping techniques at a time when their resources are lower. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1018875">16:58</a> So it’s logistically true, Right. Sometimes that we lose the capacity and then it’s emotionally true. Right. Sometimes like, you know, yes, throwing the shoes out the door and walking away is coping. That’s how I managed without screaming at my 4 year old who was coping. But I wasn’t able to take a deep breath and be in a Zen place. There was less in the repertoire that I could touch. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1040208">17:20</a> Yeah, not as healthy. Potentially harmful elements of that coping mechanism for your relationship with your four year old. I want to ask about how you determine that sort of mixture of healthy versus unhealthy or whatever terms we want to use is for each patient. And Dani, you just flat out like basically asked this patient called it out and spoke to the moment. And I don’t usually start my patient encounters with humor. How can our listeners probe and get a better understanding for that patient in front of them whether this coping style is adaptive or maladaptive or the mixture they’re in. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1084455">18:04</a> I’ll take this one, but I know I’m going to sound like a broken record with Alex and Eric. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1089335">18:09</a> Is it going to be formulation, holding space? Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1093103">18:13</a> Yes, formulation, holding space or countertransfer? Eric, you got it. It’s formulation really. It’s formulation. And it’s a hard question to answer because we formulate using different data with different patience. So sometimes my patient is my biggest ally in formulating and I can go back into. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1119479">18:39</a> Some of our listeners remarkably may not have heard your prior episodes. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1123351">18:43</a> That’s true. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1124343">18:44</a> What is formulation? Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1125951">18:45</a> Formulation. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1126991">18:46</a> Some of the listeners haven’t heard my prior Episodes. But Eric and Alex. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1131535">18:51</a> Yeah, Alex, what is formulation? Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1133407">18:53</a> What is formulation? Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1136055">18:56</a> Eric said it. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1136943">18:56</a> I said, holdings, space. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1140705">19:00</a> I’ll. I’ll take you off the hook only because I love you. So formulation is essentially, it’s our assessment of what is under the surface for the thoughts, behaviors, feelings that we’re seeing on the surface for our patients. So it’s the why. It’s our hypothesis, our theory, our framework for understanding the psychological why behind what is manifesting on the surface for somebody. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1169291">19:29</a> So when the person comes in with stickers, they’re using humor. The question Dani is asking is, why? Why? Why am I seeing this behavior? Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1180395">19:40</a> Well, and so, and I had a piece of it, right? I’m like, okay, they’re using this to cope. But I wanted to go farther into the why, right? Why are they using it to cope? Like how? Like, what is it serving? What is it hindering? Are they using it to tolerate their situation? Are they using it to stay in the weeds and not look at their situation? And so we ask ourselves that. And sometimes our data comes from the patient. Sometimes it comes from just our intuitive sense of what’s going on. Sometimes it comes from our idt. Thank goodness we have an idt, and we can keep each other in check and think about these things together. Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1221515">20:21</a> I think family members are a lot of how we make formulations about how people are coping. Because sometimes my patients are really ill and it’s hard to get much of a history from them. And so sometimes it’s the family members saying, prior to illness, here’s how he or she coped prior to illness, here’s what things looked like. And so we really kind of pull in a lot of data both from what we’re seeing in front of us and from people who’ve known the patient for a lot longer. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1250483">20:50</a> Yeah, like if you take, for example, Eric and Alex, a patient who is just asking questions, questions, questions, questions. What about the Billy? What about the this? What about the that? You can’t get out the room. There’s so many questions. That’s a form of coping. We’ve all agreed everything we see is a form of coping and we can formulate what is behind that. Well, maybe they’re an engineer and understanding makes them feel rooted. And the more that we can help them understand and have a sense of control, the better that they’re going to be able to traverse what is being asked for them. Well, gosh, then I’m going to lean into that coping. I will do things that give them control. Say, here’s a notebook I want you to take it and write down your questions as they come up, like a literal form of notebook. Write down your questions for me. I’m going to come back at this time tomorrow. As much information and control I can give, I’m going to give because I think that this coping is helping them stay rooted. But take that same behavior and let’s say it’s somebody else. And the whole team’s been trying to tell them this, Your husband’s going to die. This doesn’t look good. And. And the wife doesn’t want to think about it, doesn’t want to hear it. So instead she’s like, but what about the Billy? I saw the Billy. Well, that went down by one. And I want you to answer this. And you’re like, oh, gosh, she’s trying to avoid the big picture. And you try to go big picture. And she says, no, I heard that there’s a clinical trial at the Mayo Clinic, and I’m wondering about this. And so you get the sense that these questions, even though they’re coping, even though they’re keeping her psychologically intact, aren’t serving her. They’re not helping her do the work, you know, she needs to do to get where you have to get. And so then you might lean away from it, and you have to calibrate again. We don’t take a sledgehammer to it. We don’t want to crumble her to pieces. So you calibrate how much she can tolerate you leaning away and what you can do. So you start to wonder with her. You know, gosh, there’s a lot of moving pieces going on. Like, I wonder what your hopes are. I wonder what your fears are. And she gets back to the details, and you lean away again, like. But you’re not, like, ripping her out of it, but you’re calibrating based on your assessment what you want to do with it. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1378855">22:58</a> I mean, a. That sounds like just amazing palliative care, and it also sounds like a skill that’s probably also very hard to teach during a palliative care fellowship. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1391815">23:11</a> Well, go ahead, Annie. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1392847">23:12</a> Well, I was gonna say. I love that you say this, though, because we have. So we have these original Temel studies that said our presence. Palliative care’s presence early on does something good, right? It improves outcomes. And there have been subsequent studies by Greer. Amanda, you might know the literature better than me, but what they found is that one of the most meaningful ways that palliative care presence improves outcomes is that we help patients access adaptive coping yeah. So we’re doing it. I think you’re right, though. We’re not. We don’t have the spotlight on it. We haven’t thought deeply about what it is we’re doing that’s helping with this. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1431201">23:51</a> No address. Empathy Nurse. Acronym insert. You must be frustrated here. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1438201">23:58</a> You want to get me in trouble, Eric, you always get me in trouble when you put me on a rant about my feelings about acronyms. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1444081">24:04</a> So I’m going to go back to the Jennifer Tomel study. The part that I loved about that study is that there was a qualitative study that came out afterwards looking at what did they do, like what was in that syringe in the Jennifer Tamil big New England Journal study. And if you look what they did early on, the very first things were relationship rapport building and how was somebody coping with their illness? So is this fundamental part about how people are coping, and I am not sure how much we’re teaching trainees, if anything, in palliative care, like to really dive into that coping part. Hell, I couldn’t even answer how to define coping. What do you think, Amanda? Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1491345">24:51</a> Yeah, I mean, I think so as an idt, kind of member of the team. That’s often what I’m honing in on when I’m working with trainees is what kind of coping are you seeing? Because, you know, especially if I’m working with an MD fellow, they may be thinking, you know, in really complex ways about how do we get this person’s pain under control? How do we get this nausea better? And a lot of what I’m talking to the fellows that I work with about is what are you seeing in the room? What do you think is happening in the room? What are you seeing in terms of the relationship between this patient and their family? What are you seeing in terms of how we as a team are interacting with them? How much do you think we understand and have replacement rapport with them? So these are the kinds of things that I’m talking, you know, to our fellows about. And I. I think it’s a part of. It’s a part of some of the learning, but maybe not as explicit a part of the learning as it. As it needs to be. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1545917">25:45</a> Amanda, imagine if every fellow, as you know, they write their pain assessment and their nausea assessment, if every note had a coping assessment and they had to take the time to think through it. Because I agree with you, Erica, it’s foundational. Some would argue it’s the most meaningful thing we do. Why aren’t we explicitly. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1564005">26:04</a> Yeah. And it was one of the seven major themes from the Jennifer Temel study and what they did early on in the disease trajectory, again, they did not address advanced care planning on that. Like, first part of their visits, they addressed how people are coping. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1578261">26:18</a> Yeah. And when we asked Jennifer Temel and we asked Vicki Jackson, we asked. Well, we actually. We will ask Vicki Jackson. I think we’re having her on a forthcoming podcast. We asked Areej Al Jawahari, what’s the secret sauce in these palliative care interventions? They all said they think it’s coping. And Joe Greer is going to be on as well in a forthcoming podcast. And so now the question is, how do we unpack that coping? What is it? How is it that palliative care clinicians are accessing, inquiring, probing, boosting, supporting, giving resources to people to engage in more healthy coping or expand their repertoire of their ability to cope? Those are all kind of fundamental questions. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1625005">27:05</a> I think the repertoire idea, too. Sorry, Eric, I’m jumping in. But I love the expand the repertoire idea because if we do decide that something isn’t serving, you don’t want to take something away if you don’t have a replacement on the other side. Right. There’s some kind of glue that’s helping keep somebody together. If you’re going to remove it, you better have a new adhesive. And so we do need to build it. And one of the beautiful things about palliative care is that sometimes we’re the replacement. Like, sometimes our accompaniment is the coping. That somebody is. I have a patient right now. She gets so sad when she goes to social gatherings, because anytime somebody says something to her that feels invalidating, like, they say, oh, how are you doing? But she has cancer. So she’s like, why’d they ask me that question? Or even if they’re too intense, like, oh, you must be in a rough spot. And she’s like, no, I’m still a person. Every time they make a misstep, it hurts too much for her. So her coping was that she stopped going to social gatherings. That was it. That’s what she could do. And I wanted to get her out back to social gatherings. I had to give her something new. So now the strategy that we use together is she goes whenever they say something irritating, she pictures me in her head rolling my eyes with her, having a laugh. She writes it down in a little sticky note on her phone, and she saves it for her next appointment. And at the next appointment, she’s like, let me read you the bloopers reel. And we Laugh about it. But because of that, she’s able to go to these social gatherings again. Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1715617">28:35</a> So we all need a little Dani in our heads. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1720705">28:40</a> One part of me, not all. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1722297">28:42</a> Well, it is interesting too, because Alex used the word healthy coping and it sounds like healthy coping. I’m getting this. Like, healthy coping is not necessarily a thing. Right? So I can imagine I just delivered some bad news and somebody is using acceptance as they’re coping. You know what I recognize, you know, I’m going to die. It’s okay. I don’t need any treatment. Like, just let me go peacefully. That’s most important. I go back. But, but, sir, you just have high blood pressure. Like, this is. You’re not going to die from this. Like, so acceptance could be not the best coping mechanism in all forms of bad news or how we deliver things. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1768111">29:28</a> Oh, my goodness. Imagine if a patient came and said, like, my boss is, you know, sexually harassing me. You would not accept. You would not think acceptance was the most adaptive coping. And that’s why I like to use the word adaptive, because it changes based on person situation. You wouldn’t think that the most adaptive coping. Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1785875">29:45</a> That’s why context is so critical for coping. Context is important for a lot of reasons. So is how someone’s coping, is it serving them in the context of, say, their illness? Context also can be other things. Coping is also. It also happens within a person’s family system, whatever role they play in their family system. So if they are usually the one person who always handles everything for their family and then they get an illness, they’re going to handle it, you know, because it’s the role they’re used to playing within their family system. And sometimes it’s really hard for people to break out of those roles when they are encountering illness. It’s also culturally contextualized. So you have someone who comes from a particular cultural background, and coping may be very common in that cultural background. You can’t divorce coping from context. So when we think about our learners, when we think about us as providers trying to assess coping and engage with coping, we always have to make sure that we’re thinking about multiple layers of context. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1853747">30:53</a> I love that too, because like in the last week, my coping style has been avoidant when it comes to news. Yeah, we just had a big election if people didn’t know. So I just, I have tuned out. I just listen to music now on my ride in and out. I don’t listen to like NPR or anything. It’s just avoidant. But that’s just with this one aspect of my life, I just cannot. One day I plan to listen to news again, but right now, I think it’s the right thing for me. I actually feel pretty good with it. It’s probably at some point gonna be not so good if I completely tune out of the entire world, but. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1894163">31:34</a> Yeah, that’s right. Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1896195">31:36</a> That’s right. In this moment in time, in this context that is serving you. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1900291">31:40</a> Yeah. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1901115">31:41</a> I remember Susan Block when I was a fellow at Brigham Women’s Hospital. And Dana Farber, she said one of her teaching sessions, you know, there are some patients who are so fragile, and the only coping support they have is denial. Don’t take that away from them because they may crumble psychologically when you pull that away. And that’s sort of. We talk about doing a lot of prognosis. I do a lot of prognosis research. We talk in palliative care a lot about prognostic disclosure, prognostic awareness. And there are cases in which we probably shouldn’t push too hard there because we may undermine that sole support. And until we get to a place where we can provide more supports, we need to get them through. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1953575">32:33</a> And does you want to talk about talking about talking about it? Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=1956335">32:36</a> Yeah. So a lot of times when we’re in sensitive territory, one of the most kind of therapeutic ways in is to talk about talking. So rather than delving directly into content, talking about the idea that I think, you know, I’m feeling like it might be time to have a conversation maybe about what’s the head, or maybe about what’s worrying you, or maybe about what’s worrying us as your medical team. How would you feel if we were to have a conversation like that? Who would you want to be there? How would we need to put some guardrails in place to make sure that you felt safe enough to have some of these conversations or at what point? This is one of my favorite questions to ask when someone says, no, I don’t want to talk about that right now. You know, how would you know when it would be time to talk about that? At what point would you imagine a conversation like that could be helpful? And then you start building a roadmap, you together with the person you’re working with, so that when you enter into that sensitive space, you’re doing it together, you’re doing it in a partnership, and you’re doing it with parameters already created. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2022945">33:42</a> I love that. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2023977">33:43</a> I love the talking about talking about it. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2026745">33:46</a> Yeah. It takes invitation. That whole idea of inviting people in the conversation, one step so much better. And deeper. Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2035435">33:55</a> I was talking to someone today whose wife is doing poorly, getting sicker and sicker. And today was a day of getting scans. And when we sat down, it was pretty tearful. And I said, you know, some people in this circumstance want to think a little bit about the what ifs. What if the scan comes back and the news isn’t good? What if, you know, what if I have to start thinking about how to talk to my kids about what’s going on here. There are other people who say, in this time of uncertainty for these next few hours, I think I just need to avoid the worst case scenarios and just wait for the information to come back. And if the information comes back, then I can make a decision about which way I want to go. He said, I think that second one is me. I don’t know that I’m ready to move into the what ifs just yet, but I think if I get this data back, I think I’ll know whether it’s time or not. So we talked about talking. We set some parameters, and we talked about how he would know when it was time. So now we have an agreed upon kind of plan to move forward together if by tomorrow he has that data. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2102775">35:02</a> The beauty, too, is, I think, Amanda, now you brought us into this domain of tools, right? Talking about, talking about it is a tool. And what, you know, medical practice assessment precedes plan. And so that’s why we wouldn’t talk about talking about it with everybody. Some people would feel really like, babied and kind of belittled that we did it like that. But that’s why it’s so foundational to have a formulation that roots us into why we’re choosing the tools, the communication tools, the interventions that we’re choosing. Where is it coming from? I had someone run a case by me just this week, and they said, the patient said to me, I know I’m going to die. I’ve put that in a small box. And I put the box down here at the base of my skull and I’ve closed it and I’d like to leave it there. And the person who was coming to me for consultation said, well, how do I get them to open up the box? And my first question was, why? Like, why do you want them to open up the box? And I’m not saying it would be right or wrong to open up the box, but they hadn’t thought through it. Did they want to open up the box because of something in them, as the clinician, some idea they had about what palliative care should look like, what coping should look like, or was there a formulation about the patient, whether they felt like opening the box would be helpful? Because I couldn’t really advise them one way or the other until we had gotten to that point. I have strategies for opening it, I have strategies for keeping it closed. Right. But we have to understand why we’re choosing to do what we’re doing and who it’s in service of. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2189105">36:29</a> So in that situation, hypothetically, if Dani or Amanda were in the room, what would you your next step after the person said, I’m going to put this right here in the back of my head. Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2201605">36:41</a> So part of what I think about when you’re at that assessment point about how might this be serving, how might this not be? Sometimes I will say to people, it sounds like having that box back here feels like a safe way to be. It feels like it’s helping you kind of get through your day to day stuff. Are there things that are important for you to be thinking about or talking about that keeping it in the box is preventing you from getting to like, are there important conversations? Is there work that would be important for you to do that we’re not tending to because the box is closed back here. That’s more kind of talking about talking without totally being explicit about it. But it’s trying to understand, is there anything you’d be doing differently? If we have this box out and we were looking at things and some people will say, no, look, I’ve already done my will, I’ve already told my kids, I want you to take this piece of furniture and I want you to take the other one. So putting it back here means it’s helping keep my anxiety about death in check. But there’s nothing concrete I would need to do by pulling that box out. There are other people who say, yeah, there are things that would be important to me, but it’s not time to look at those yet. And those may be the scenarios in which you might be able to kind of expand that toolkit a little bit with somebody about how and when that work would be important to get to. I don’t know, Dani, if you have other thoughts about that. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2285949">38:05</a> Well, I was going to say with this specific case, with this trainee, they got at the. The trainee essentially said, I want to fill out the advance directive with them. But as we looked further into it, the trainee felt like the template for doing an advanced directive that we in medicine had taught him because we do like algorithms and templates, was that he needed to open up like the feelings, the hopes, the fears. We taught him to do hopes and fears. He was trying to do what we told him to do. And so. So I was like, well, let’s throw that template out of the window for this patient. You just need the advance directive. You know, that he knows he’s dying, so go there and make it really transactional. All right. I know you want to keep it in the box. Let’s keep it in the box. I just have to check through a couple things with you to make sure everything’s aligned the way you would want it, and then we can move on. Would you want this? Yeah. No. Yeah. And do it. But we know why we’re doing it, right? It’s not like we’re doing it because we want to avoid going to those feelings, which you can imagine a clinician doing, getting super logistical, because they don’t want to go there. We’re doing it because we think it’s in service of this patient. That’s where we left it. I’ll have to tell you how it turns out when I hear back. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2355569">39:15</a> I love it, too, because there’s. There’s no necessarily right answer here. Like, there’s no ABIM test we could take that says, oh, option B is clearly the correct answer on this board test. Is that you. You’re coming up with an idea of what may be the underlying reasons. Maybe you’re inquiring, what, what, like why. Why does he feel it’s so important to keep this under a lockbox in the back of his brain? And then you’re coming out like, what do I want to do with this information? Is this adaptive? It Is it not? Is it helping him in this current situation? Is it not? And then thinking about next steps, where do we go from here? Does that sound right? Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2395955">39:55</a> Yeah. Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2396555">39:56</a> And I think also being mindful, especially when we are. When somebody’s in the medical system, we are one of a tapestry of providers that people are working with. It also may be that they’ve opened that box with five other people and they just don’t want to open it with the sixth, you know, So I think also kind of keeping in mind that we are. We’re one point of interaction with people in a larger. In a larger network. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2423447">40:23</a> I’m going to channel my inner Amanda moment right now and give you wisdom that she’s dropped on me and pretend that it’s my own. But I think the other. The other thing to remember is that we are people in the room, too. Like, we have our own coping styles, and that can really help us and get in the way if we’re not in touch with that. So, you know, I, for example, humor is one of my copings. It’s so easy for me to go there. And that’s why there’s a ton of laughter in my clinic, really. It’s one of the most powerful ways I palliate. And I have to be careful not to get in trouble. Right. I have to be careful not to accidentally collude in a case where humor isn’t working so well for somebody or if there’s a couple. Right. Oftentimes we really relate to the way one person in the couple copes and not so much the other one. And we do the relationship a disservice by leaning too much into relating to one or the other. So it almost feels a little bit like love languages. You know, we all have love languages. These are our coping languages. And when there’s there aligned, there’s pros and cons. We can go there together. We can. In a good way or in a not so good way. And when they’re not aligned, there’s pros and cons. I know some colleagues who, if that patient had come in cracking jokes, it would have been a very uncomfortable room. Humor isn’t their go to coping. Like, it would have felt strange. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2511725">41:51</a> I’m getting. This is so complicated. Like, you know, people have many different coping styles and each coping mechanism that they have to employ may have maybe adaptive for them and maladaptive in different proportions. And that they may be able to access some of these under some circumstances, but not stressful circumstances, that there’s a dyadic interaction with the provider, who also has their own coping styles that may relate, resonate, or have dissonance with the style of the patient or the caregiver or the couple. To get even more complicated. This is complicated. Couldn’t we just come up with on the spot a mnemonic like Cope that it summarizes. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2556059">42:36</a> You had me. You had me. My mouth was ready to say, you pretty much nailed it. And then you lost me. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2565459">42:45</a> I was going to say, can we just make a drug to. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2568465">42:48</a> That’s right. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2570145">42:50</a> Cobaminumab. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2572905">42:52</a> It’s gotta be some sort of benzo. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2575145">42:55</a> No, I mean, I mean, if I were to paraphrase what you said, because you did nail it. What you said is humanity is complicated. And you’re right, humanity is complicated and we do it ourselves and we do our patients a disservice if we try to pretend that it’s not. And I’m not going to say anything more about mnemonics. But I was baiting you. I know you, you were. You’re just trying. But I do think, I do think your point also, Eric, is right. There’s not one way, there’s not one answer. We can’t give you a. This is what you do with denial. I actually tried to write a paper about the different. I was like, I want to define the different coping mechanisms for palliative care so they know what’s projective identification, they know it’s denial. They know this. And the journal said, as long as you say what to do with each one. I’m sorry, I have a hard line there. Like, I can’t go there. And eventually we, like agreed to part ways because they want us to know what to do. But you, we. There’s no one right answer. But there is a consistent way of approaching, which I think you guys are both getting at, right? You non judgmentally observe someone’s coping. You wonder about the impacts of those coping. You prioritize maintaining their psychological integrity above all else. And then you mindfully think through how to serve their coping in ways that they can tolerate, that are calibrated based on person, moment and setting. Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2658445">44:18</a> And I will put in a plug too, for the importance of understanding our own coping. What are we comfortable with? What are we not, to Dani’s point about love languages, what’s our coping language that we feel most at ease with? Because we are likely to see someone who has a coping mechanism that’s different from ours as maladaptive coping, quote, unquote. And so understanding what ours is is the first step because we’re the lens through which we see our patients and their coping. So I want to put in a plug for that. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2691497">44:51</a> And is that like when you’re under stress, what are. Because I have all of these different coping styles like the ones you go to under stress or how should I think about that, Amanda? Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2702561">45:02</a> Well, let me turn it on you really quick though and give you one more quiz because this is a word we’ve spoken about. There’s a psychological word behind this. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2711809">45:11</a> Counter transference. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2713041">45:13</a> Yes. Eric, you’re on fire today. Yeah, countertransference. A little bit of what Amanda is talking about is countertransference. When somebody doesn’t cope the way that we would want them to cope, we experience countertransference. And yeah, there’s a range of how we cope, but there are certain crayons that are in our crayon box and there are certain crayons that aren’t So I can’t tell you which of your crayons you’re going to pull on, but I can tell you avoidance. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2741823">45:41</a> Avoidance. It’s mostly avoidance. It’s different shades of avoidance in my. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2746303">45:46</a> Crayon box have a total different. My. My mom’s cousin, our family is Lebanese. This gets at Amanda’s point about culture. My mom’s cousin had cancer, and they literally did not tell the woman she had cancer at all once she died believing that she had an infection that she was going to get better from. And my family thinks this was a huge success. They do this a lot in Lebanon. And they were like, she wasn’t even scared and Americanized doctor that I am, I was mortified. I was like, this is so wrong. I had a huge countertransference to it because it was so far from my crayon box of what I thought was in the realm of acceptable coping. And I need to do a lot of looking within to understand, like, okay, where are the hard lines? What’s coming from me? What’s coming from them? Amanda, you could probably go deeper into countertransference than I ever could. Amanda <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2800653">46:40</a> But no, I mean, I think it’s foundational to how we enter any of the spaces where we meet patients. And one of the things that we talk about is you can look for where countertransference is coming up, where you are practicing differently or having kind of strong reactions to people in rooms. And, you know, I think about our families who are maybe kind of loud grievers. You know, we have some families who, you know, context wise, culturally, you know, grieving loudly as a part of the process. And in our kind of like Western medical world, you know, a lot of people feel really uncomfortable with that and feel like, let’s get that behind closed doors. Like, they’re out in the hallway crying. Like, let’s get that behind closed doors. And so, once again, that’s our discomfort. This is a family that’s grieving in the way that feels right to them, but that’s our discomfort. So recognizing when we have our own flares of discomfort that often comes from a place of countertransference. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2862025">47:42</a> Well, we could go on for hours, I think. I thought that was brilliant. We’re going to have some show notes, so we’re going to have a link to the Formulation podcast that we did. Dani actually just published a great paper on Formulation two, which we’ll have a link. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2876473">47:56</a> Amanda was an author on that. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2877921">47:57</a> Amanda was an author, too. Great. That was a fantastic paper. I had to read it twice to Understand what? Like the full concept. So I’m finally getting it, Dani. I am getting it. So we’ll have links to this on our show. Notes. Check out the website. Amanda, Dani, thank you for being on the podcast. Before we end, I think Alex, what’s the song called again? Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2897935">48:17</a> It’s okay is the song. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2899671">48:19</a> It’s okay. Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2907775">48:27</a> I moved to California in the summertime I changed my name Thinking it would change my mind Alex <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2921425">48:41</a> I thought that all my problems they would stay behind I was a stick of dynamite and it was just a matter of time oh, dang. Oh, my Now I can’t hide Said I knew my myself But I guess I lied it’s okay it’s okay it’s okay it’s okay if you’re lost we’re all a little lost it’s all right it’s okay it’s okay it’s okay it’s okay if you’re lost we’re all a little lost it’s all right it’s all right it’s all right it’s all right it’s all right it’s all right. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2971905">49:31</a> Wonderful. Amanda, Dani, thank you for being on the podcast. Dani <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2976105">49:36</a> Thanks for having us. Eric <a href="https://grain.com/share/recording/54282899-ae97-41e6-8b2f-f3557cd9ff8d/2rfRGTOFDDTOgsTSdB1Ct4EcJzEVYGM3QP2UuMyr?referrer=docx&t=2978105">49:38</a> And to all of our listeners, thank you for your continued support. </div> </div> </div></div><div class="vc_tta-panel" id="cme" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#cme" data-vc-accordion data-vc-container=".vc_tta-container">CME</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> <h3 style="text-align: center;">***** Claim your CME credit for this episode! *****</h3> Claim your CME credit for EP335 “Coping with Serious Illness” <a href="https://ww2.highmarksce.com/ucsf/index.cfm?do=ip.claimCreditApp&eventID=13907">https://ww2.highmarksce.com/ucsf/index.cfm?do=ip.claimCreditApp&eventID=13907</a> Note: If you have not already registered for the annual CME subscription (cost is $100 for a year’s worth of CME podcasts), you can register here <a href="https://cme-reg.configio.com/pd/3315?code=6PhHcL752r">https://cme-reg.configio.com/pd/3315?code=6PhHcL752r</a> For more info on the CME credit, go to <a href="https://geripal.org/cme/">https://geripal.org/cme/</a> Disclosures: Moderators Drs. Widera and Smith have no relationships to disclose. Guests Danielle Chammas and Amanda Moment have no relationships to disclose. Accreditation In support of improving patient care, UCSF Office of CME is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Designation University of California, San Francisco, designates this enduring material for a maximum of 0.75 AMA PRA Category 1 credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. MOC Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.75 MOC points per podcast in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. ABIM MOC credit will be offered to subscribers in November, 2024. Subscribers will claim MOC credit by completing an evaluation with self-reflection questions. For any MOC questions, please email <a href="mailto:moc@ucsf.edu">moc@ucsf.edu</a>. </div> </div> </div></div></div></div></div></div></div></div></div></div> </div>The post <a href="https://geripal.org/coping-with-serious-illness-danielle-chammas-and-amanda-moment/">Coping with Serious Illness: Danielle Chammas and Amanda Moment</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></content:encoded> </item> <item> <title>Falls and Fractures: A Podcast with Sarah Berry</title> <link>https://geripal.org/falls-and-fractures-a-podcast-with-sarah-berry/</link> <dc:creator><![CDATA[Alex Smith]]></dc:creator> <pubDate>Thu, 14 Nov 2024 08:00:19 +0000</pubDate> <category><![CDATA[All Posts]]></category> <category><![CDATA[Podcasts]]></category> <guid isPermaLink="false">https://geripal.org/?p=6964</guid> <description><![CDATA[The post <a href="https://geripal.org/falls-and-fractures-a-podcast-with-sarah-berry/">Falls and Fractures: A Podcast with Sarah Berry</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></description> <content:encoded><![CDATA[<div class="wpb-content-wrapper"><div class="vc_row wpb_row vc_row-fluid no-bottom-margins"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"> <div class="wpb_raw_code wpb_raw_html wpb_content_element vc_custom_1731552308703" > <div class="wpb_wrapper"> <iframe title="Libsyn Player" style="border: none" src="//html5-player.libsyn.com/embed/episode/id/33923757/height/90/theme/custom/thumbnail/yes/direction/backward/render-playlist/no/custom-color/00548f/" height="90" width="100%" scrolling="no" allowfullscreen webkitallowfullscreen mozallowfullscreen oallowfullscreen msallowfullscreen></iframe> </div> </div> <div class="vc_tta-container" data-vc-action="collapse"><div class="vc_general vc_tta vc_tta-tabs vc_tta-color-sky vc_tta-style-flat vc_tta-shape-square vc_tta-spacing-1 vc_tta-o-no-fill vc_tta-tabs-position-top vc_tta-controls-align-left"><div class="vc_tta-tabs-container"><ul class="vc_tta-tabs-list"><li class="vc_tta-tab vc_active" data-vc-tab><a href="#summary" data-vc-tabs data-vc-container=".vc_tta">Summary</a></li><li class="vc_tta-tab" data-vc-tab><a href="#transcript" data-vc-tabs data-vc-container=".vc_tta">Transcript</a></li><li class="vc_tta-tab" data-vc-tab><a href="#cme" data-vc-tabs data-vc-container=".vc_tta">CME</a></li></ul></div><div class="vc_tta-panels-container"><div class="vc_tta-panels"><div class="vc_tta-panel vc_active" id="summary" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#summary" data-vc-accordion data-vc-container=".vc_tta-container">Summary</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> Falls are very common among older adults but often go unreported or untreated by healthcare providers. There may be lots of reasons behind this. Patients may feel like falls are just part of normal aging. Providers may feel a sense of nihilism, that there just isn’t anything they can do to decrease the risk of falling. On this week’s podcast, we try to blow up this nihilism with our guest Sarah Berry. Sarah is a geriatrician at Hebrew SeniorLife in Boston where she does research on falls, fractures, and osteoporosis in older adults. We pepper Sarah with questions ranging from: <ul> <li style="font-weight: 400;" aria-level="1">Why should we care about falls?</li> <li style="font-weight: 400;" aria-level="1">What are ways we should screen for falls?</li> <li style="font-weight: 400;" aria-level="1">What are evidence based interventions to decrease the risk of falls?</li> <li style="font-weight: 400;" aria-level="1">What about Vitamin D and falls???</li> <li style="font-weight: 400;" aria-level="1">How should we assess for fracture risk?</li> <li style="font-weight: 400;" aria-level="1">What are some evidence-based ways to decrease fracture risk?</li> <li style="font-weight: 400;" aria-level="1">When should we prescribe vs deprescribe bisphosphonate therapy? How does life expectancy fit in with all of this?</li> </ul> If you want to do a deeper dive into some of the articles we discuss, take a look at the following: <ul> <li style="font-weight: 400;" aria-level="1"><a href="https://pubmed.ncbi.nlm.nih.gov/38536167/">An awesome JAMA review by Sarah on fall risk assessment and prevention in community-dwelling adults</a>.</li> <li style="font-weight: 400;" aria-level="1">The <a href="https://ifar-frail.hsl.harvard.edu/web/home">Fracture Risk Assessment in Long term care (FRAiL)</a> website</li> <li style="font-weight: 400;" aria-level="1">James Deardorff’s JAMA IM article on “<a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2786013">Time to Benefit of Bisphosphonate Therapy for the Prevention of Fractures Among Postmenopausal Women With Osteoporosis</a></li> <li style="font-weight: 400;" aria-level="1">Sarah’s article on “<a href="https://www.sciencedirect.com/science/article/pii/S1525861022007812?via%3Dihub">Controversies in Osteoporosis Treatment of Nursing Home Residents</a>”, which includes this helpful flow chart on starting/stopping osteoporosis drugs in nursing homes</li> </ul> ** This podcast is not CME eligible. To learn more about CME for other GeriPal episodes, <a href="https://geripal.org/cme/">click here</a>.   <hr /> </div> </div> </div></div><div class="vc_tta-panel" id="transcript" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#transcript" data-vc-accordion data-vc-container=".vc_tta-container">Transcript</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1040">00:01</a> Welcome to the GeriPal Podcast. This is Eric Widera. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=3457">00:03</a> This is Alex Smith. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=4441">00:04</a> And Alex, who do we have with us today? Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=6801">00:06</a> In studio, visiting professor coming to us from Boston. She is a returning GeriPal guest. This is Sarah Berry, who is at the Hebrew Senior Life and Beth Israel Deaconess Medical center and Harvard Medical School. And she is a practicing geriatrician and researcher. Sarah, welcome back to the GeriPal Podcast. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=28119">00:28</a> Thanks so much. Happy to be here. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=30079">00:30</a> So we’re going to be talking about falls and fractures. We’ve got a lot to talk about. I have a lot of questions. But before we do, Sarah, do you have a song request for Alex? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=37783">00:37</a> Ooh, how about Free Fallin’? Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=41295">00:41</a> Free Fallin’? Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=45935">00:45</a> We did this, like one of our first podcasts, I remember, and second verse, I kind of went for it. But today I’m not because it is November 6th and I’m feeling subdued. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=57393">00:57</a> Subdued. We won’t talk about what happened on November 5th. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=60089">01:00</a> November 5th. So here’s a little bit of subdued. Free Fallin’. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=71745">01:11</a> (singing) Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=153355">02:33</a> Sarah, excellent song. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=155179">02:35</a> That was nice choice. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=157555">02:37</a> Is there any other reason you picked that song besides, are you a Tom Petty fan? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=162211">02:42</a> I am a Tom Petty fan, yeah. But it was just the first thing that came to mind when you asked me to talk about falls. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=168835">02:48</a> Well, I want to thank you for joining us because you’ve done a lot of the studies around falls and fractures and like, how we think about, especially like in, in frailer older adults, those in nursing homes. I wonder how did you get interested in this as like a research, academic focus of yours? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=188611">03:08</a> Yeah, you know, when I went into my geriatric fellowship or even during residency, I think that I thought that I was going to be interested in dementia and that maybe that would be my line of focus. But I was really struck early on in my training by the number of patients that had these serious falls, fractures, sort of this feeling that they were never going to get back home or they weren’t going to get back home in the same shape that they were before. And I had a good mentor in residency that really encouraged me. You know, if you want to think about the problem, think about clinical research. And was really fortunate to have great mentorship throughout my career. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=229005">03:49</a> Great. And when you think about like back then, I guess now too, like how big of a problem is falls? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=237525">03:57</a> Yeah, it’s a pretty big problem for older adults, I’d say in community dwellers. About one out of every three older adults falls each year in the nursing home that’s higher. It’s one out of two. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=250325">04:10</a> Wow. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=251605">04:11</a> I think the CDC estimates that every 20 minutes an older adult dies from a fall. A fall related injury. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=259813">04:19</a> Wow. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=260557">04:20</a> And many more are injured. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=262329">04:22</a> Yeah. And the big things that we think about as far as complications, so there, obviously the thing that comes to everybody’s mind is like fractures. But there’s other things too, like increased social isolation because there’s a fear of falling. Is that right? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=276393">04:36</a> Yeah, absolutely. Even the falls that don’t result in a major injury, like the fracture, the head traumas, even the falls without those, tend to result in an increase in fear of falling. Anxiety and institutionalization. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=291121">04:51</a> Yeah. You know, I wonder how much, because it’s probably not brought up a lot in primary care settings. People don’t ask about it, they don’t screen about it. I’m guessing older adults don’t bring it up frequently that they’ve fallen. So it’s a silent, I don’t want to say silent epidemic that’s used too often. But there’s silence around these falls and there’s probably some nihilism about kind of, oh, what can we do about falls anyways? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=317267">05:17</a> No, I think all of that is true. I think there’s just sort of this feeling that maybe it’s because it happens so often. I think both the patients feel that. I think providers feel that way. Right. You see this in people’s notes. You know, it was a mechanical fall and people kind of stop getting curious about why it happened or how they can prevent it. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=338887">05:38</a> So is nihilism the right approach here? Like there’s nothing we can do or do you feel like and we can talk about if so there are things that we can do to prevent falls and prevent the complications of those falls. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=353803">05:53</a> Yeah, there are absolutely things we can do to prevent falls and prevent the complications. Maybe not all falls, but we can certainly reduce the frequency of falls and reduce serious injuries in the setting of a fall. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=366547">06:06</a> All right, before we get to that, I got some other important questions. Interrupt me anytime, Alex, if you got something. Okay, so if I were to believe you that we’re going to get to like, what interventions we can do to decreased risk for falls, how does Sarah screen? Do you just ask people like, have you had a fall lately? How do you screen or assess for risk for falls? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=390113">06:30</a> Yeah, that’s honestly the best way to screen for falls is, have you had a fall in the past year or are you worried about falling? And if the answer is yes, then the patient’s at risk. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=401137">06:41</a> Yeah, that’s like the. One of the biggest risk factors, is that right? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=404033">06:44</a> Absolutely. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=405193">06:45</a> Any other risk factors that we should be worried about? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=407609">06:47</a> Well, there’s lots of risk factors for falls. You know, some of the major ones, things like dementia, cognitive impairment, Parkinson’s disease, you know, abnormalities with gait, balance, frailty, you know, low high body mass index. I mean, there’s a lot, you know, medications that goes on and on. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=429029">07:09</a> Yeah. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=429701">07:09</a> But I do think consistently across studies, across settings, sort of the number one predictor of falls is, have you had a fall in the past year? Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=438141">07:18</a> So if there’s one question our audience should ask. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=441045">07:21</a> Absolutely. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=441547">07:21</a> Older adults, have you had a fall. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=442963">07:22</a> In the last year or are you worried about falling? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=445507">07:25</a> Yeah, yeah. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=447043">07:27</a> Are there professional society recommendations or U.S. preventive services task Force recommendations to screen certain groups, all older adults, for falls? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=457923">07:37</a> Yeah. The CDC has nice recommendations, the steady guidelines, and honestly, it follows pretty close with the American Geriatrics, British Geriatric Society guidelines for screening for falls. But really, they recommend that annually that you ask adults 65 years and older if you’ve had a fall or if you’re worried about falling. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=479791">07:59</a> Okay, you have somebody who says, yes, I have fallen. Alex. I know Alex has fallen. He’s broken in the last year. You have. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=488095">08:08</a> On a bike, I’m always. Yeah, I don’t know if that counts. Fall from bike. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=493655">08:13</a> Okay. Actually, the last bike accident, you didn’t even fall. You stayed on the bike. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=498535">08:18</a> Broke my hand while on the bike. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=500495">08:20</a> Okay, you have somebody who’s screened positive. What do you do? What’s the next step? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=508695">08:28</a> Yeah, so it’s probably assessing their gait and balance is the next step. So, you know, in community dwellers, I do the get up and go test. You know, ask them to stand, ideally, without using their arms, walk about 10ft, turn around, sit down, and they should be able to do that if you’re timing them in 12 to 15 seconds or less, you know, if you don’t have the capabilities or, you know, to do a timed up and go test. You know, don’t let perfect get in the way of good. You know, just have them do that test and see if you’re not worried. You’re a little bit worried. Or you’re a lot worried. If you’re a lot worried, you’ve got your answer. If you’re a little bit worried or unsure, then maybe you move on to another test of balance. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=557315">09:17</a> So again, you’re at this point, you’re trying to assess for risk for falls, using the time to go. Are you also doing an assessment? Assessment? Like Sarah’s doing a timed up and go. Like, are you actually watching their gate and thinking about what, what do I think I can maybe intervene on? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=574815">09:34</a> You know, I, I do. I, you know, I pay attention to. Arm swing is a big one. You pay attention to their assisted device and how comfortable that feels with them, how stable that feels with them. But, you know, honestly, even just a, a gut gestalt, you know, I’m a little worried about this patient. I’m, I’m, I’m not worried about this. Pat, I think is better than nothing when screening patients for gait. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=601955">10:01</a> Great. And so you’re getting the sense now you’re worried that this patient’s moderate to high risk. Timed up and go was long. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=612475">10:12</a> What’s long? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=614115">10:14</a> More than 12 or 15 seconds. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=615554">10:15</a> More than 12 or 15 seconds. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=617195">10:17</a> What does Sarah do next? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=619435">10:19</a> Yeah. So, I mean, again, if you’re really worried, you’ve probably got your answer. And you knew in somebody who’s had a fall and they’ve got gait abnormalities, they probably need to talk with them about falls and about, you know, sort of multifactorial interventions, you know, targeting their greatest risk factors to reduce the risk of falls. If they’re somewhere in between, you know, where you are a little worried or you’re unsure, you might do a balance test. So that is asking them to stand with their feet together, you know, for 10 seconds, and then the semi tandem stance where one foot is halfway in front of the other, and then the full tandem stance, one foot in front or the other, for 10 seconds. And if they have trouble with that, then again, I would consider them high risk and move on to this multifactorial intervention. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=670235">11:10</a> And tell me, what is a multifactorial intervention? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=674035">11:14</a> So it’s really assessing patients for their individual risk factors for falls. So gait is one we’ve already talked about. Vision is another obvious one. Hearing is one. Looking at medications, I think is a really big one. And highly modifiable. Orthostatic vital signs I think can be appropriate. Just a good footwear, maybe another one, again, that’s highly modifiable. But just looking at their risk factors and trying to target those that you can intervene on. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=716111">11:56</a> So Potentially some of these intrinsic issues, including kind of their vision. Are they having orthostasis? Is that why they’re falling? Do they have some other medical condition like Parkinson’s disease that may be contributing to it? Medications. Which medications are you most worried about? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=736969">12:16</a> Yeah, medications in general have been shown to increase the risk of fall. So persons that are taking more than five, seven, you know, there’s been a number of different thresholds that have been proposed, sort of irregardless of what medication it is. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=750929">12:30</a> So just the sheer number. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=752085">12:32</a> Yeah, just the sheer number. But certainly psychotropic medications, you know, and there’s really no evidence when it comes to falls that some of the newer psychotropic medications are any safer than the older ones. Right. We might choose a newer antipsychotic over an older antipsychotic because it has less of the motor side effects. But we really shouldn’t kid ourselves into thinking that it’s safer when it comes to falls. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=780235">13:00</a> So antipsychotics, benzos, I’m guessing on there. All the sleep medicines potentially on there. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=787387">13:07</a> Correct. Correct. Gabapentin is another one that I’m concerned about. I think there’s a few studies in dialysis patients and in hospitalized patients suggesting that gabapentin and pregabalin is associated with an increased risk of falls. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=804723">13:24</a> Yeah. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=805355">13:25</a> How about opioids? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=806985">13:26</a> Yeah, that’s another one. And it’s tough, Right, because, you know, the pain, you were often giving these, you know, medications to patients. You know, there’s some intractable confounding there. Nonetheless, they probably do increase the risk of falls. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=822833">13:42</a> Yeah. And marijuana or Marinol or cannabinoids. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=828929">13:48</a> Yeah, great question. I don’t think we’ve got really solid data on that. And I think in particular, there’s interest sometimes in the nursing home and using that in place of other drugs. And I think it’s something we need more data on. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=846835">14:06</a> Came up on our recent podcast about update on cannabis and marijuana, and one of our guests mentioned that you can use cannabis products for treatment of behavioral symptoms and people with dementia in nursing homes, which was news to us. So, interested about the potential side effects of that? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=869213">14:29</a> Yeah, My suspicion is it’s like a lot of these others, like gabapentin, that it maybe, you know, have a better profile for other things, but perhaps when it comes to falls, it’s no better. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=881189">14:41</a> Yeah. Anything that’s potentially somewhat sedating. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=884189">14:44</a> Correct. Yeah. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=886445">14:46</a> How do you think about blood pressure medicines? Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=888991">14:48</a> Right. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=889647">14:49</a> Yeah, that’s a great question, too. You know, the studies are mixed where some studies suggesting that Blood pressure medicines are associated with an increased risk of falls. Some studies even saying that maybe they’re associated with a decreased risk of falls. I like there was some work from Mary Tonetti’s group looking at a large sample of hospitalized patients with injurious falls and their antihypertensive use. And really what I took away from that study was it matters whether you have a history of falls. So they did a subgroup analysis, and in particular, in adults who had reported a fall in the past year, they seem to be at greater risk of injurious falls with antihypertensives. So, again, going back to that, if you just have one question to ask your patients or when you’re thinking about what that blood pressure target should be, maybe it’s if I’ve had a fall in the past year. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=948339">15:48</a> Did you do a study where you looked at the falls around the time of initiation of antihypertensives? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=955147">15:55</a> Yeah. Yeah. Great memory. It’s been a little while. But we looked at a number of classes of medications and found that when you increase the dose or start the medication, patients were at a particularly high risk of falls. And that’s true not only for antihypertensives, but for the diuretics. It was true for meds like benzos, antipsychotics, and for antidepressants. And that. That included. The most common antidepressant in that study was. Was trazodone, something that we sort of, you know, typically consider to be a safer geriatric drug. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=994287">16:34</a> Hmm. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=995095">16:35</a> Okay. I got another. My last fall med’s question doesn’t increase risk for falls, but may increase risk for complications of falls. How do you think about anticoagulants and falls? Specifically doacs? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1009265">16:49</a> Yes. I think that’s also an area where we could probably use some more research. We looked at it in nursing home residents, and we looked at sort of standard dosing of DOAC. So that would be, like, for apixaban, the 5mg bid versus anything lower than that, we called reduced dose of DOACs. And we found that, at least in nursing home residents, there was no difference in the efficacy of the drugs when you got the lower dose. But there was certainly an increased risk of bleeding. And a lot of this is, as you say, it’s bleeding in the setting of. Some of this is bleeding bleeding, and some of this is bleeding in the setting of a fall. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1052925">17:32</a> Okay. So we have these intrinsic issues, but there’s also, like, extrinsic issues that contribute to falls, including in people’s Homes. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1062461">17:42</a> Yeah. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1063221">17:43</a> How do you think about that? And, and as you’re seeing patients or potentially in nursing homes, like you also work in a nursing home, is that right? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1071197">17:51</a> Yeah, I work in long term care and ask to see a lot of fallers. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1074789">17:54</a> How do you think about those extrinsic factors? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1077517">17:57</a> Yeah, I love it that you asked those question because I think that that’s something that we don’t often think about. I go back to at the beginning of the podcast I mentioned there’s this tendency you’ll see in the chart. Oh, it was a mechanical fall and people just stopped. But if you ask people, people have these chronic risk factors that you mentioned, the Parkinson, Parkinson’s disease, the cognitive impairment, the visual impairment, they have them every day. But there’s generally some trigger something that happened that they fell last Tuesday. Right. And you’ve got to really ask about the situational factors to learn about those. So you know, it could be things like, you know, the throw rugs people talk about or poor lighting. You mentioned, you know, starting a new medication I think is sort of falls into that area as well. Risk takers is another thing. You know, the people that, you know are climbing up on ladders or on washing machines to get things down, they may not volunteer that information, but you know, if you ask them kind of what was happening with the fall, you, you may be surprised and learned. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1142473">19:02</a> Yeah. And if I remember correctly there, I think there was one, it was from BMJ or land. I think it was a UK study. They looked at eyesight, they saw like ophthalmologists, a bunch of people got glasses. And what happened is there was an increased risk for falls. And I think it turned out the most common prescription was like a bifocal lens. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1163165">19:23</a> Yeah, I think with. You’re right. So cataract removal first. Cataract has been shown to reduce the risk of falls. But you’re right, I mean I think giving people proper eyewear is good care, but hasn’t necessarily proved to be effective or at least by itself in reducing falls. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1180677">19:40</a> And I think the interesting thing about bifocals, if you look straight, every everything’s in focus, you look down now you’re look, you’re using your reading glasses basically. So you’re not seeing any of those things that could potentially make you slip fall. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1194009">19:54</a> Right. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1194697">19:54</a> Okay, what are the evidence based interventions that we could do to reduce falls? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1202913">20:02</a> Yeah, so in the community dwellers, I would say the strongest evidence base is for exercise. Right. So it needs to be exercise that includes some gait balance and strengthening it’s been shown to be effective when done in groups. It’s been shown to be effective when you give patients home exercise. I mean, exercise, I think there’s no question is effective in preventing falls and fall related injuries. Getting people to exercise. Right now, that’s the challenge. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1235493">20:35</a> Is Tai Chi part of that? I see a lot of Tai Chi falls articles out there. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1239685">20:39</a> Yeah, Tai Chi is one type of exercise that certainly combines some strengthening and core strengthening and balance. So it’s nice. And yes, there’s good evidence in community dwellers that Tai Chi prevents falls. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1255545">20:55</a> How about in nursing home or long term care settings? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1259769">20:59</a> Yeah, nursing homes it is a little bit more complicated. You know, the evidence that exercise prevents falls, or particularly that it prevents falls in persons with dementia, which is the majority of nursing home residents, I think it’s a little less clear. What seems to be effective in nursing homes is again, doing a multifunction assessment of all the patient’s risk factors and then honing in on the ones that are modifiable and trying to address them. That’s certainly what I do in the nursing home. I often find, again, you’re looking and asked to see somebody after a fall and they’re wearing slippers without a back and no tread. Right. Again, we may not prevent all of the falls that that person has, but we can reduce the number of falls by targeting risk factors like that. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1313075">21:53</a> What if, if there was a simple vitamin everybody could take that would reduce their risk for falls? Vitamin, let’s call it D, Vitamin D. I love vitamins because, like, we get really into them until we realize that they don’t really work. Where are we in that cycle with vitamin D? How? There was a lot of talk about vitamin D about a decade ago, decreasing falls and fractures. Did that hold up? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1341125">22:21</a> Yeah, you’re right. The pendulum really swung pro vitamin D. Then it kind of swung the other way and you’ve got these meta analysis, maybe more meta analysis sometimes than individual studies on vitamin D and often with conflicting results. So it’s hard. What’s a clinician supposed to do? You know, I think some of the uncertainty and the discrepancies in the meta analysis depends on which patient population you’re enrolling. And in general, I would say that the evidence does not support that vitamin D prevents falls for your average, you know, community dweller, you know, persons that are probably replete with vitamin D. But in nursing home residents, there is actually evidence that vital vitamin D reduces falls and in particular that calcium and vitamin D can prevent fractures in nursing home residents. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1395181">23:15</a> And for those studies, did they include, did it matter what your vitamin D level or did everybody have low vitamin D level? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1403445">23:23</a> Yeah, it didn’t matter in those studies. So they were, you know, randomized trials and one they didn’t check the vitamin D level and the other they did, but it was fairly comparable across, across the groups. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1415145">23:35</a> So nursing home long term care. Vitamin D prevents not just falls, but fractures. And it’s interesting to try to think like, what’s the mechanism by which it might. Vitamin D and calcium might prevent falls. Like the fracture part I can get, but the mechanistically, the fall part I have trouble with. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1435297">23:55</a> Yeah, I mean, I am certainly not an expert on this. There’s been a lot of, you know, speculation. I mean, there are vitamin D receptors with muscles, you know, the way that it’s metabolized and with the kidneys, I think there’s a lot of speculation, but I also think there’s a lot of unknowns. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1453523">24:13</a> Yeah. In some ways it’s like it’s a hormone too, because they’ve also done studies on vitamin D at really high levels, which actually shows a higher risk for falls. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1463907">24:23</a> Oh, U shape. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1465083">24:25</a> Yeah, yeah. So right there is this recommended. Like for most people it’s get it through your diet in sufficient quantities. But for the people that you are going to supplement, you don’t want to give too much and you don’t want to give too little, is that right? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1482831">24:42</a> Correct. It’s one time in nursing homes it’s so tempting, I think, to give the higher doses just to reduce the pill burden, which is real and problematic in the nursing home. But I do think it’s one area where we have, have pretty strong evidence that the higher doses of 50,000 international units, for whatever reason, does seem to be associated with an increased risk of falls. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1507987">25:07</a> What does Sarah Berry Do? 800, is that your target? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1511567">25:11</a> 800 international units, whatever’s available. 800 or 1,000 maybe. If I’m particularly worried about somebody and they have some risk factors, they’re obese, dark skin, maybe I’d go with 2000. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1525325">25:25</a> I know we want to get to the fractures part and I have two more questions from my perspective about the falls part. All right, so in the long term care setting or the hospital setting, our first podcast was about bed alarms. First GeriPal podcast. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1541725">25:41</a> Yeah. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1542805">25:42</a> So there’s this tension, right, between safety and fall risk and autonomy and allowing people to take risks. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1552133">25:52</a> And if you just restrain them in bed, Alex, they won’t fall. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1555069">25:55</a> Right. You will reduce your. Well, maybe, maybe you would think that it would reduce the Fall risk. I don’t know whether it actually does, but how do you think about that tension in the long term care setting? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1567965">26:07</a> Yeah, that’s a great question. I’m definitely a believer that fall rates, we can improve them in nursing homes, but they cannot and should not be zero. Right. If we’ve really suppressed them that far, then we probably are restricted people too much. It is a challenge. I’m delighted. Our facility made the decision years ago to be alarm free. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1593355">26:33</a> Oh, really? No bed alarms. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1594867">26:34</a> No bed alarms. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1595579">26:35</a> No bed alarms. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1596555">26:36</a> And we did kind of. It was relatively crude, but analysis looking at rates of falls before and after the bed alarms and didn’t find any difference. And again, it made the nurses happy to get rid of them. They were responding to the, to these false alarms that were going off, particularly in our really thin patients. And also I’m not sure that they were really preventing falls. Right, you were just finding the fall after it occurred. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1624625">27:04</a> Because it is interesting because like you said, one of the most important interventions is exercise mobility, like moving around, which also increases your risk for falls, potentially because you’re moving around, but in the long term it may decrease your risk. But bed alarms is the opposite. It nudges people never to get out of their bed or their chair that the alarm is on because you’re going to have this really annoying sound. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1646701">27:26</a> Yeah, I think you said that. Well, and the nurses, they drive them crazy. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1651917">27:31</a> Okay, my second question is in the outpatient setting, we had a podcast with Tom Gill about that stride study published in New Journal. And my general recollection not having reviewed it recently is that that it was a multi component intervention and that the primary outcome was prevention of injurious falls. And that was not a significant difference and that it did, in a secondary outcome, prevent falls in general. Any thoughts about that study in the outpatient setting and whether that affected your practice? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1687535">28:07</a> Yeah, that’s great. And I think it was discouraged for a lot of us that believe in false prevention strategies. And the way that I interpret it, no, I’m still a big believer in false prevention strategies. What was different about that trial in some of the individual trials that used exercise or visual changes, is that this was a pragmatic trial. People didn’t sign consent. They didn’t say, like, hey, I’m looking to prevent falls. Right. They took primary care practice and they randomize them to get their prevention. So instead of in the trials. Right. You’ve got a highly motivated group that wants to prevent falls, whereas in the pragmatic studies you don’t. And Again, I don’t see that as, that falls prevention doesn’t work. I think it’s just a reminder for us as physicians that you can’t give somebody a multimodal intervention just because they’re at risk of falls. You’ve got to talk to your patients about falls and, and see where they are. We talk a lot about with smoking cessation or weight loss. Right. About readiness and sort of patient activation. Right. You know, if you’ve got a patient and they may have a lot of risk factors for falls. Right. And they may have even had a fall with a bad injury. But if they’re in this pre contemplative stage and they tell you that, you know, I’m never going to fall again, it was just the silly mistake. Don’t worry about me. Right. You know, trying to give them, you know, a multifactorial intervention and a lot. Right. It’s not going to work. Right. We need to instead talk to the patients about how serious these falls are, move them from a pre contemplative state into a state of action, and then just, you know, give them one intervention at a time along the way. And, you know, to me, that was the difference between. It’s not that the stride approach was wrong, but to me that’s why they didn’t find an effect. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1810035">30:10</a> Okay, so we have the falls. We’re doing everything that we can do to reduce the risk of falls, but we also should think about how do we reduce the risk of the complications of falls, in particular fractures. How do you assess for the, like, the risk of fractures, especially like in your population, nursing home patients, or frail older adults or older adults with multimorbidity. Like these people are not part of clinical studies generally. How do you think about that? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1840679">30:40</a> Yeah, you know, I think in general, you know, probably bone mineral density screening isn’t, isn’t going to fully capture risk in sort of your frail older population. So if you have it, great. I’m not discouraging or saying there’s not value in that, but really considering their clinical characteristics. So, you know, in the community, probably the best studied model is, is the FRAX model, you know, which is available. It works up to age 90, beyond age 90, you know, they didn’t have data. And so you’re, you’re sort of on your, on your own or just sort of assume the age of 90. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1883985">31:23</a> And is that just postmenopausal women or men too? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1887441">31:27</a> No, the FRAX works in men too. And you can calculate it with or without bone mineral density and Honestly, it does pretty well even without bone mineral density. And so that’s often what I would recommend in community dwellers that are a little bit more frail. Maybe you’ve got a bone mineral density test, maybe it’s five years old, 10 years, you know, an older test still. Put it in, put in what you have, right. And get kind of a risk and then I kind of take that risk and it’s like, you know, anything in geriatric medicine. There’s a little bit of interpretation with it. You know, I think if you have somebody and they have, they’re kind of on the fence, but they’ve also got Parkinson’s disease and cognitive impairment and they’re on a number of medications that make you nervous, round up and assume that their risk is a little higher than it is. Conversely, if you’ve got a patient and they’re bed bound and immobile or more near the end of their life, you might round that risk down. I recognize that that’s not highly scientific, but I think it’s just of a, anyway, kind of what, what we have for frail older adults in the community. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1960125">32:40</a> And we’ll include a link to the FRAX model in the show notes associated with this podcast. And just for our listeners though, it’s spelled F R A X, correct, right? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1969741">32:49</a> Yeah, correct. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1970845">32:50</a> Okay, what about in a nursing home setting, does FRAX apply or are there better ones? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=1975813">32:55</a> Yeah, I would say FRAX is probably not the one to use in nursing homes because again, FRAX gives you a 10 year risk and you know, calculating a 10 year risk and I mean I recognize that it takes into account the competing risk of death. It also doesn’t consider a lot of, you know, the characteristics of nursing home residents. So yeah, we’ve developed a model, it’s called the frail model, the fracture risk assessment in long term care that predicts the two year absolute risk of hip fracture. We’ve got a website, it’s not nearly as pretty as the FRACS website, but you can put in the patient characteristics and get a two year risk of fracture. I would say short of the website though, in sort of an absolute tool. The real drivers in the nursing home tend to be patients having a history of falls. Right. Having a history of fractures and patients mobility or independence. Right. So the patients that are independent in their activities of daily living and they’re independent in transferring those patients are at highest risk of falls in the nursing home. And then as residents become more dependent, their risk actually goes down. So it’s a little different, right, than in the community dwellers where we usually think of impairment increasing the risk. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2055809">34:15</a> Yeah, kind of. Also that U shaped curve. So like somebody with advanced dementia who is now bed bound, their risk for having a fall is correct. A lot lower. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2065913">34:25</a> A lot lower. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2067049">34:27</a> Then the question is, is there a role for potential medications to help reduce that risk for fracture? So, you know, the ones that we think about, like bisphosphonates, how do you think about bisphosphonates and reducing that risk? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2083725">34:43</a> Yeah. So are we back in the community or nursing? Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2086213">34:46</a> Let’s go back in the community briefly. Then we’ll focus probably most of our energy on this. Frail, older, multimorbid. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2093125">34:53</a> Yeah, yeah. Well, even in, I would say even in community dwellers, you know, there’s good evidence that bisphosphonates reduce the risk of fracture. The time to benefit too, for men too, and probably the time to benefit is about 13 months, a little every year. So in general, my rule of thumb has been if somebody, if I think somebody has about a two year life expectancy, then it probably makes sense to at least consider these drugs. Right. It may not be consistent with their goals of care, it may not be appropriate, but at least to consider them. Right. Somebody that’s got a life expectancy, I think they’re probably going to pass away in the next two years. I probably wouldn’t, but I would say that there’s, you know, post hoc analysis of randomized controlled trials in patients with hip fracture, men and women that got zolendronic acid versus not. And they looked in again in a subgroup analysis of those with cognitive impairment, and it didn’t look like the fracture benefit was really much. You know, it still reduced fractures in people with cognitive impairment. We’ve also done a large observational study where we looked at patients who are hospitalized with a fracture and then to see who got a bisphosphonate after or not. And we did subgroup analysis. People were either frail at the time of their fracture or not using the frailty index. And again, it looked like the bisphosphonates, you know, that the beneficial effect was pretty similar. So I think we actually do have growing evidence that the bisphosphonates are reasonably effective even in patients with cognitive impairment and with frailty. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2201995">36:41</a> And for more on that, also consider listening to our prior podcast with James Deardorff and say, Lee, about the lag time to benefit for bisphosphates. I remember themselves saying they were surprised when the lag time to benefit was 13 months, you know, was about a year. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2216807">36:56</a> Well, let’s ask about that. So in James Derridor study we’ll have a link to in the show notes. I have it written down here because I looked it up. 10 RCTs, they combined nearly 23,000 patients. Included in these 10 RCTs, all were women with osteoporosis. Women with osteoporosis, the lag time to benefit. So it took 12 months to avoid one non vertebral fracture per 100 women and to avoid one hip fracture, the numbing treat was 200 at 20 months. So nearly two years. Does that ring true to you? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2254395">37:34</a> Yeah, that seems reasonable. And again, I think we have that meta analysis was focused on the clinical trials that as you say, they were postmenopausal women, they weren’t necessarily frail, they weren’t the patients that were taken care of and they weren’t men. That being said, I think increased observational data supports that the benefits of the drugs are probably similar, you know, in subgroups. So, you know, if somebody has, I would say a two year life expectancy is sort of what I have in my mind is sort of, you know, for these drugs. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2294565">38:14</a> And why two year? What’s. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2296685">38:16</a> Why not one? Because on eprognosis I think we put it at 13 months or one year or something like that, which is interesting. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2302873">38:22</a> Because that’s also for any non vertebral fracture. And again, hip fracture obviously is longer than that. It’s closer to two years. Yeah, I mean, and the number to treat is 200. Got it. 200. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2311801">38:31</a> Maybe we should move the needle on the. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2313617">38:33</a> How do you think about needle? Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2314945">38:34</a> That reminds me of last night. Okay, wait, back, back to now. The present. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2318553">38:38</a> The present two years versus one year. Sarah, why, why are you thinking more two? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2324785">38:44</a> Yeah, hard to pin me down. So I, I think as you said, sort of 13 months. Right. So somebody’s got to live 13 months before they get a benefit in any fracture. And then hip fractures, which are the more serious ones, are about two years. So I mean, and let’s be honest, I mean, I’m not sure that our prognosis tools are so fine that we can release, you know, but if I would not be surprised that somebody passed away in the next two years, then, you know, I probably wouldn’t be using them. But otherwise I think we should least have a conversation and consider. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2357685">39:17</a> Yeah, I love this because I was, I was reading one of your articles I have a link to. It was, it was controversies in nursing homes about like falls and fractures and osteoporosis meds. And one of the things was not just when to consider starting it and incorporating some of these things that you’re talking about, like life expectancy, Are they bed bound? Like, are they getting up and walking around? Those types of things. But also. So when do we stop these drugs? And importantly, like, we think about this all the time, like in our hospice unit. Should we continue these medications or should we stop? How do you think about stopping these medicines? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2394675">39:54</a> Yeah, it’s tough. But the good thing we know about the bisphosphonates is they have this very long half life. Right. There are randomized control trials, the flex trials, where they looked at women who had taken alendronate for five years and then randomized them to continue for versus stop. And in general, there was not a lot of difference in fractures in those that got the five years versus those. And so we know too that these drugs do are associated with a rare but serious risk of atypical femur fractures that almost never happens until you’ve been on them until five, you know, five years or more. And so, yes, so for all of those reasons, it makes sense to consider, you know, a drug holiday or stopping. I think in my patients, if somebody’s been treated for five years and they’re within, I think they’re within the last few years of their life, right. You’re probably talking about stopping the drug. It’s not a drug holiday. There’s no need to do additional screening or consideration. Right. Similarly, I think, you know, patients who have been treated and they’re, as you said, they’re no longer at risk, are not at the same risk of falls. Right. They’ve become, become not ambulatory, they’re more sedentary, they’re, you know, or bed bound, requiring a lift. Right. That’s probably another time when, you know, if somebody’s been treated, it makes sense to stop. And then I guess what can become a little gray, right, Is, you know, well, somebody’s been treated three years or somebody’s been, you know, a little bit less. And in general, I do try to think, you know, if somebody’s not ambulatory and I think their life expectancy expectancy is two years are left, it is probably appropriate to stop bisphosphonates. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2505187">41:45</a> Can I ask how you, how you have that conversation? Like, what do you say to patients or their family members? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2511835">41:51</a> Yeah, you know, I think sort of reminding them that this drug is still in your system, that you’re probably still benefiting from this drug, but if you were to continue taking this drug, it might have some adverse side effects. Right. And that your risk is not the same as it was before. It is a tough. That is a tough conversation. You know, just to mention because I think sometimes it’s confusing. This recommendation is really specific for the bisphosphonates. Denosumab is a little different. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2547419">42:27</a> How so? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2548499">42:28</a> Yeah, so denosumab is a drug that it works by blocking the osteoclast activity. And as soon as you take the drug away, there’s this increased activation of osteoclast. You break down bone and there’s an increased risk of vertebral fractures in particular and probably other fractures. So denosumab, I mean, the good news is it’s only given every six months. But in general. But the notion of holidays. Right. Don’t apply to it. It’s a short acting drug. I still think it’s reasonable. Stop it. If you think that somebody’s life expectancy, if you think they’re within the last year of life again or they’ve become really immobile. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2592825">43:12</a> Okay, I got last question for you. Unless Alex has another question. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2596441">43:16</a> Well, can I ask my head first so that I can put on my guitar? Returning to the outpatient setting or maybe inpatient or long term care setting as well. Exercise we talked about for falls for fractures, specific types of exercise that you encourage your patients, patients like fracture to prevent. Yeah, fractures improve bone health is tough question. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2619433">43:39</a> Do you know? Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2620361">43:40</a> I don’t know. I think of like weight bearing. Like isn’t the mantra. You gotta grind the bones. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2625905">43:45</a> Yes. So I mean definitely weight bearing exercise is best for the bones. So something like swimming, for instance, is great cardiovascular but doesn’t stimulate bones. But you know, I do think there’s a lot of uncertainty for our more frail older patients, particularly those who’ve had vertebral fractures. They have a lot of kyphosis of like exactly what types of exercises strength and conditioning we should be recommending for them. So love to get PT’s input on that and yeah, thanks, Sarah. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2658101">44:18</a> Last question for me. If you had a magic wand, you can make one thing different around how we either screen, assess or treat falls and fractures for our listeners, what would that be? Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2668735">44:28</a> I’d like physicians, particularly young physicians, to get curious about falls. I think they’re just so common in older adults that we sort of lost our curiosity. But if you’re curious and you ask about them, you can prevent them. Not all of them, but some. Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2685175">44:45</a> Love it. Alex. A little bit more free falling. Tom Petty. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2690655">44:50</a> What a treat. Alex <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2696315">44:56</a> (singing) Eric <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2747343">45:47</a> Sarah, thank you very much. If there was a song that could capture the mood that I’m in on November 6th, that is a song. So thank you for that and thank you to all of our listeners for your continued support. Sarah <a href="https://grain.com/share/recording/2c6f4706-3efa-41de-8dda-354214600e4e/cbozeBmfGDOKblYGg9zjXnkU58zSOe6R94jlo46K?referrer=docx&t=2762039">46:02</a> Thank you. That was fun. </div> </div> </div></div><div class="vc_tta-panel" id="cme" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#cme" data-vc-accordion data-vc-container=".vc_tta-container">CME</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> <h3>This episode is not CME eligible.</h3> </div> </div> </div></div></div></div></div></div></div></div></div></div> </div>The post <a href="https://geripal.org/falls-and-fractures-a-podcast-with-sarah-berry/">Falls and Fractures: A Podcast with Sarah Berry</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></content:encoded> </item> <item> <title>Dialysis vs Conservative Management for Older Adults: Manju Kurella Tamura, Susan Wong, & Maria Montez-Rath</title> <link>https://geripal.org/dialysis-vs-conservative-management-for-older-adults-manju-kurella-tamura-susan-wong-maria-montez-rath/</link> <dc:creator><![CDATA[Alex Smith]]></dc:creator> <pubDate>Thu, 07 Nov 2024 08:00:36 +0000</pubDate> <category><![CDATA[All Posts]]></category> <category><![CDATA[Dialysis]]></category> <category><![CDATA[Nephrology]]></category> <category><![CDATA[CME Eligible]]></category> <category><![CDATA[Podcasts]]></category> <guid isPermaLink="false">https://geripal.org/?p=6953</guid> <description><![CDATA[The post <a href="https://geripal.org/dialysis-vs-conservative-management-for-older-adults-manju-kurella-tamura-susan-wong-maria-montez-rath/">Dialysis vs Conservative Management for Older Adults: Manju Kurella Tamura, Susan Wong, & Maria Montez-Rath</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></description> <content:encoded><![CDATA[<div class="wpb-content-wrapper"><div class="vc_row wpb_row vc_row-fluid no-bottom-margins"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"> <div class="wpb_raw_code wpb_raw_html wpb_content_element vc_custom_1730932923139" > <div class="wpb_wrapper"> <iframe title="Libsyn Player" style="border: none" src="//html5-player.libsyn.com/embed/episode/id/33822138/height/90/theme/custom/thumbnail/yes/direction/backward/render-playlist/no/custom-color/00548f/" height="90" width="100%" scrolling="no" allowfullscreen webkitallowfullscreen mozallowfullscreen oallowfullscreen msallowfullscreen></iframe> </div> </div> <div class="vc_tta-container" data-vc-action="collapse"><div class="vc_general vc_tta vc_tta-tabs vc_tta-color-sky vc_tta-style-flat vc_tta-shape-square vc_tta-spacing-1 vc_tta-o-no-fill vc_tta-tabs-position-top vc_tta-controls-align-left"><div class="vc_tta-tabs-container"><ul class="vc_tta-tabs-list"><li class="vc_tta-tab vc_active" data-vc-tab><a href="#summary" data-vc-tabs data-vc-container=".vc_tta">Summary</a></li><li class="vc_tta-tab" data-vc-tab><a href="#transcript" data-vc-tabs data-vc-container=".vc_tta">Transcript</a></li><li class="vc_tta-tab" data-vc-tab><a href="#cme" data-vc-tabs data-vc-container=".vc_tta">CME</a></li></ul></div><div class="vc_tta-panels-container"><div class="vc_tta-panels"><div class="vc_tta-panel vc_active" id="summary" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#summary" data-vc-accordion data-vc-container=".vc_tta-container">Summary</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> We recently published a podcast on palliative care for kidney failure, focusing on conservative kidney management. Today we’re going to focus upstream on the decision to initiate dialysis vs conservative kidney management. As background, we discuss Manju Kurella Tamura’s landmark <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa0904655">NEJM paper</a> that found, contrary to expectations, that function declines precipitously for nursing home residents who initiate dialysis. If the purpose of initiating dialysis is improving function – our complex, frail, older patients are likely to be disappointed. We also briefly mention Susan Wong’s terrific studies that found a <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2802800">disconnect</a> between older adults with renal failure’s expressed values, focused on comfort, and their advance care planning and end-of-life care received, which focused on life extension; and another study that found quality of life was <a href="https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2790040">sustained</a> until late in the illness course. One final briefly mentioned piece of background: John Oliver’s hilarious and disturbing <a href="https://www.youtube.com/watch?v=yw_nqzVfxFQ">takedown</a> of the for profit dialysis industry, focused on DaVita. And the main topic of today is a paper in <a href="https://www.acpjournals.org/doi/10.7326/M23-3028?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed">Annals of Internal Medicine</a>, Maria first author, that addressed the tradeoffs between initiating dialysis vs continued medical/supportive management. Turns out, in summary people who initiate dialysis have mildly longer lives, but spend more time in facilities, away from home. We also discuss (without trying to get too wonky!) immortal time bias and target emulation trials. Do target trials differ from randomized trials and “ordinary” observational studies, or do they differ?!? Eric is skeptical. Bottom line: if faced with the decision to initiate dialysis, waiting is generally better. <a href="https://www.youtube.com/watch?v=QDYfEBY9NM4">Let it be</a> (hint hint). -Additional link to study with <a href="https://link.springer.com/article/10.1007/s11606-017-4151-6">heatmaps</a> of specific locations (hospital, nursing home, home) after initiating dialysis. -@AlexSmithMD   ** NOTE: To claim CME credit for this episode, <a href="https://geripal.org/dialysis-vs-conservative-management-for-older-adults-manju-kurella-tamura-susan-wong-maria-montez-rath/#cme">click here</a> **   <hr />   </div> </div> </div></div><div class="vc_tta-panel" id="transcript" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#transcript" data-vc-accordion data-vc-container=".vc_tta-container">Transcript</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=11513">00:11</a> Welcome to the GeriPal podcast. This is Eric Widera. Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=12457">00:12</a> This is Alex Smith. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=13905">00:13</a> And, Alex, I am very excited today because there was an awesome article on Annals on conservative management versus dialysis. Kind of how we think about that. This is a topic I love to talk about. So we got a lot to cover. Who do we have with us today? Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=30289">00:30</a> Got a lot to cover. Delighted to welcome Susan Wong, who’s a nephrologist and she’s associate professor of medicine at the University of Washington, though she’s joining us from Leeds, England, where she is a distinguished Fulbright scholar. Susan, welcome to the GeriPal Podcast. Susan <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=46701">00:46</a> Thank you for having me. Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=48269">00:48</a> And we’re delighted to welcome Maria Montez-Rath, who is a biostatistician and director of the Biostatistics Corps at Stanford in the division of nephrology. Maria, welcome to GeriPal. Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=60653">01:00</a> Thank you for having me. Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=62285">01:02</a> And we’re delighted to welcome Manju Kurella Tamura, who is a nephrologist and professor of medicine at Stanford. Manju, welcome to GeriPal. Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=72141">01:12</a> Thank you, Alex and Eric, Nice to be here. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=75645">01:15</a> So we have a lot to cover. Again, we’re going to be talking about conservative management versus dialysis in older adults. But before we do, Susan, I think all the way from Leeds, we have a song request. Susan <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=87187">01:27</a> Yes, maybe appropriate because it’s a British band. Let It Be from the Beatles. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=92915">01:32</a> Why did you choose Let It Be? Susan <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=96155">01:36</a> To reflect continuing medical management versus starting dialysis, which is what Maria’s wonderful paper goes through. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=106635">01:46</a> Great, Alex. Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=110955">01:50</a> (singing) Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=154755">02:34</a> Wow. Susan <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=155915">02:35</a> That was impressive. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=158555">02:38</a> We will see at the end of the podcast if let it be is the appropriate, appropriate message we’ll be talking about with conservative management. Well, I got. I got a lot to cover because I’m. I’m really interested in this topic, especially around older adults, because on the inpatient side, we see this all the time. So, for example, you know, we see somebody coming in from the nursing. A nursing home. Maybe they have, you know, advanced ckd, not yet on dialysis. Their function’s kind of decreasing. Maybe they’re having some issues with cognition. And the question always is, hey, what if we like started dialysis, will any of that improve? And man, it feels like every year those GFR numbers just keep on ticking higher and higher when we’re starting to dialysis. No longer in the less than 10s, but maybe 15s or 16s because we’re having these quasi uremic symptoms. So I wonder if I could turn to either of our nephrologists. Is what I’m seeing real? Are we seeing people like more older adults, more nursing home patients starting dialysis, and even at a higher gfr? Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=236955">03:56</a> You want me to take this, Susan? What you’re describing, Eric, was probably what we saw starting about in the 2000s. There was definitely this idea in nephrology of what we called healthy start dialysis, which is this idea that we should start dialysis before someone develops really florid uremic symptoms. By doing so, we might prevent the mortality associated with kidney failure. There was definitely a practice shift towards starting dialysis at higher levels of EGFR and with less severe symptoms. I would say that that practice has now shifted back the other way now that we have some randomized trial evidence that suggests that that actually probably does not benefit patients. I think the tide is turning, but. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=299233">04:59</a> May not be actually happening in real life. Or do we just have the evidence that it doesn’t help but dialysis centers are still dial. Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=309735">05:09</a> I think the tide is shifting, but probably not enough just to throw some statistics out there for you. About half of patients who are over the age of 65 start dialysis with a GFR of over 9, which is sort of the level below which we have clinical trial evidence for suggesting that there may not be a benefit to starting at that level of GFR. So we’re still seeing about half of the older population starts at that level of GFR. And I think the question for our field is, is that because the estimates that we have of GFR based on creatinine provide misrepresentation or an inaccurate representation of someone’s kidney function. Or is it just this lingering practice of starting dialysis early before really severe complications develop? Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=370481">06:10</a> Or having watched that John Oliver episode about DaVita, we will have a link. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=376993">06:16</a> To it in our show. Notes. Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=378313">06:18</a> Is it because of tremendous financial incentives to get people on dialysis and into dialysis centers? Susan <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=385485">06:25</a> Well, I think that’s always a worry of whether or not financial incentives play into decisions. I think if you asked any nephrologist, they would deny it, and I think they truly believe it. But there’s been really compelling data to suggest that, you know, your financial model does have some influence and Manju did an amazing study on this looking at different populations. Let me back. Actually, Manju, you probably could talk about yourself, but I cite it all the time of veterans who are equally eligible to get their care and Medicare fee for service system versus the VA and that patients who get their care in Medicare are more likely to start dialysis. And patient subgroups who I think were most worried about their prognosis on dialysis or getting started are more likely to get started in Medicare if they get their care in Medicare than if they get their care in the VA. So patients who are over the age of 80, patients with metastatic cancer, all the folks that we get, we’re really worried about. And then there’s also another study done by Margaret Yu, who’s also at Stanford now, who looked at timing of dialysis initiation. Again, veterans who are equally eligible to get their care and Medicare or in the VA, those who get their care and Medicare start dialysis at a higher GFR than if they were getting their care in the va. So there seems to be signal but think these just kind of are food for thought right now. But we couldn’t say proof or causal. Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=481125">08:01</a> And my understanding is that the policy and reimbursement rates have shifted to encourage less facility dialysis and more dialysis at home. For example, with peritoneal dialysis and conservative management. Is that fair to say? Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=496645">08:16</a> Yeah. Both Susan and I practice in the va, so we’re a little bit shielded, I think from sort of the true practice change that’s happening outside of the va. But you’re right, there has been a shift in policy to incentivize patients and providers to choose home therapies. To what extent it’s incentivizing conservative management, I would say it’s probably negligible. But maybe that’s just my own VA centric view. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=528985">08:48</a> Well, the devil’s advocate. So you have, I mean versus a younger, healthier person with worsening ckd. That’s their main thing. They’re having some functional decline. I feel like that’s different than the older adult with multimorbidity. A lot of things may be contributing to their functional decline. A lot of things may be contributing to these symptoms that we may be defining as uremic symptoms, but they also could just be non uremic symptoms from all these other comorbidities. I think that is a big challenge of what we know. If we see somebody’s functional status declining, like how much of that is from their CKD and how Much of that would be reversed from dialysis. Isn’t that a big challenge in older adults? Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=573105">09:33</a> Yeah, Eric, you’re giving me this great segue into how I got interested in this area in the first place. So that was exactly the dilemma that I saw when I was a trainee in nephrology. And we would see the patients that you described at the start of the podcast, older adults with functional decline, cognitive impairment, and kidney failure or advanced ckd. And the question is, is this uremia or is this something else? Is it delirium from something else? And is dialysis the right treatment in this situation? I felt like more often than not, we erred towards dialysis because there it is. It’s right there. It’s easy. That was the lingering question I had was, well, what is it actually doing? The first question I got started with is, what does it do to cognitive function? It got bigger and bigger from there. Well, not just cognitive function. What is actually dialysis? How is it benefiting patients? Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=642815">10:42</a> What did it do to cognitive function? Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=645815">10:45</a> That’s a really difficult question to answer, but it’s probably. We’re probably mixing up two or three different conditions here. There’s definitely uremic encephalopathy, and dialysis does improve uremic encephalopathy. But the truth is that most of us don’t see uremic encephalopathy anymore because we start dialysis before anybody actually develops uremic encephalopathy, except maybe in the acute setting. But then there are all of these older patients who have microvascular brain disease, which you guys could talk about better than, than we can. And dialysis, at least hemodialysis probably harms that. There’s evidence that suggests that there’s cognitive decline and an increased incidence of dementia after patients start hemodialysis. And that’s corroborated by some magnetic resonance imaging studies as well. It’s a mixed bag, and it probably depends on what the underlying cause of cognitive dysfunction is. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=710495">11:50</a> I also have to ask, because we will have a link to this article. One of my favorite articles. I talk about it all. This is my favorite article, Susan, that I talk about of Manju is a New England Journal article that came out 2009. 2009, yeah, 2009. Looking at what happens to older adults in nursing homes when they initiate dialysis. What happens to their function? How many of them are alive and dead at one year? How many of them have improved function at one year? Would you mind just describing what you did in that article? Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=748981">12:28</a> Just briefly, thanks for giving me an opportunity to go back to that. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=754885">12:34</a> Sorry if you have to go way back. Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=757597">12:37</a> No, no worries. I’ll share maybe a small personal anecdote before I tell you about the story. I was while we were waiting to hear back from the New England Journal about this paper, I was nine months pregnant and actually I went into labor about 30 minutes after I got the email that said that our paper had been accepted. And so when my co authors were emailing me and I was of course oblivious because I was in the maternity ward by then. So by the time I finally got a chance to respond to them, I said, well, it’s the second best thing that’s happened to me today, Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=805275">13:25</a> so it will always be linked to my daughter who’s named England. Susan <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=810867">13:30</a> No, I’m kidding. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=811931">13:31</a> I was going to say who’s named Midjum. Midjum. That’s a really interesting first name. Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=818435">13:38</a> Yeah. Going back to your question, what we did was we had an opportunity through one of my mentors, Glenn Church, who had access to the US Renal Data System, which, as I think all of you know, is this registry of patients in the US who are treated with dialysis or transplant that had been linked to a registry called the Minimum Data Set, which I think you guys know and probably most of your listeners know, is this registry of patients in nursing homes. By linking the two, we had an opportunity to trace out the trajectory of patients functional status relative to when they started dialysis. I remember when I was first just exploring the data and looking at it, I was seeing this dramatic drop and I was showing it to people and I was like, what do you think about this? This looks really surprising to me. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=883305">14:43</a> Drop in function when dialysis was initiated. So you saw function before and after dialysis and what you were seeing was this drop? Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=890585">14:50</a> Yeah, there was a dramatic drop. So people, it starts to decline a couple of months before they start dialysis, which I think resonates with Mike. Clinical experience. But then after starting dialysis, they don’t recover. Most patients don’t recover. And I think that’s what was so surprising to people because our clinical instinct is to intervene when we see someone declining with the hope that we will prevent that dramatic decline in function and rescue them from that. And we weren’t seeing that. And I think that’s probably why the paper made it into the New England Journal is. So it went counter to what our instincts, which was to intervene. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=938643">15:38</a> Yeah. I personally loved it because again, you saw this thing. I have face validity. We see people, they’re having some worsening functional decline. Hey, as doctors, we got a fix for that. We got dialysis. Let’s do dialysis and let’s see if their function improves. What I remember from the article is that at one year, nobody improved, but some people maintained. Not a lot, but most people either had a decrease in functional status or were dead at one year. Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=968115">16:08</a> And I’ll just say a couple meta comments. One is people remember figures. Nobody remembers a table. The figure of the functional status decline and then minimal recovery after initiation of dialysis is just a figure that’s seared into my brain. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=988075">16:28</a> Mine is the bar chart looking at 3 months, 6 months, 9 months, 12 months. Seeing like at 12 months. Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=993523">16:33</a> Well, that figure is a hat tip to Chuck McCulloch, who is still at UCSF. Without his help, I wouldn’t have been able to make that. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1002955">16:42</a> That was awesome. I love this entire paper because I do think it started making me question what is the role of dialysis as far as making people’s function improve, helping with their symptoms, their quality of life, and starting to question some of this stuff. So I guess the other question is what do we know about, if we think about other things that we use it for? And I think, Susan, I’m going to turn to you on this one. What do we know around quality of life? Because you’ve, you also did a, you did a study looking at this, right? Susan <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1038555">17:18</a> I guess where I would kind of piggyback from Manju’s work here is that I think she, as well as others, started to gather the evidence that to at least bring us to take pause about how beneficial dialysis really was for older patients with multimorbidity and frailty. And I think that myth first had to be debunked before people could be open to the idea of, well, is there something else? Is there something else we can offer, we should offer? And I think that needing to build that evidence was so important to set the stage to be able to even publish studies that would even counter the idea that actually you could maintain people fairly well by continuing medical management or even adding kidney supportive care in a bigger bucket. We call this, you know, conservative kidney management. So in terms of what we know about conservative kidney management, I would say in the U.S. we, we don’t, we don’t do it well. And so it’s almost like a lost art. You know, before dialysis was invented, ev, you know, everybody was doing their very best at conservative kidney management. And then once dialysis came about in the 1970s, it’s a practice that’s kind of all but disappeared, and yet we’ve developed so many more services, we have so many more medications, we know so much more about the illness that we could provide better support to patients. But this infrastructure hasn’t been built. Most of what we know about conservative kidney management comes from other countries, the UK being one of the most prolific countries in terms of producing research on this. And so what they’ve been showing here is that when you have an established conservative kidney management pathway, you can maintain patients for quite some time, for several years, even after they’ve made the decision to forego dialysis, and that they’ve seen pretty comparable survival rates between those who are conservatively managed and those who receive dialysis. So it’s been a real inspiration, I think, for many clinicians and researchers in the US to figure out, well, how can we do this better in the US and to make kidney management an option for patients? And I apologize if I’m driving the conversation to this Annals paper, but what I really liked about this paper. So we’ve been talking about for some. Or I’ve been talking about it for some time, like, look at what they’re doing around the world, this conservative kidney management. We should really look into it. And there’s always these. There’s a lot of skeptics out there. They say, well, you know, it was done in another country. Is it generalizable to the U.S. they have dedicated programs that have been in existence for a couple of decades. We don’t have that here. You know, can we. You know, none of these studies are random. None of the studies are randomized. They’re all observational studies. You know, how trustworthy is this data? And so, you know, Manju and Maria’s paper, it really addresses many of the points of skepticism that people have about all of the data that’s been published in other countries. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1242895">20:42</a> Well, let’s get to that then. Let’s get to Maria first author Anil’s paper. I absolutely love this paper, got a lot to talk about because it has this interesting study design. But before we do, what got you interested in doing this particular paper? Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1261145">21:01</a> Again, it’s very interesting because it came working with Manju. So I’ve been at the Division of Nephrology for a few years now. And so I’m getting deeper and deeper into pretending to be a nephrologist, even though I’m a statistician. But I do like to dive into the science and learn and understand. And I want to understand not only from the point of view of the doctors that I work with, but also the patients that ultimately we can provide some help. And even though I’m not a medical doctor, I feel like I can help in a way if I can show with data, with statistics, some of these things that are questionable to confirm. And this idea, like, so far, this paper of combining survival and home time actually came from personal experience with my dad, not because of dialysis, but his surgeon wanted to do an amputation. And my dad was really afraid of that and not wanting to do it. And I went into the literature and I couldn’t find anything that explained really what happens. All of the papers are always about survival. And in the case of. My dad was like, he really. He hated being in the hospital, but he was getting all of these infections that basically were putting him in the hospital all the time. It started like every month, and then, like, was. He would go home, and then three weeks later he would be back in the hospital. And then this kept on going back and forth. And then, like I said, like, okay, is there anything that actually can tell me whether it’s going to be beneficial in terms of home time, the time that he’s going to be spending at home, which is what he really wants. And then from there, that’s when talking with Manju and the other doctors that I work with, then we said, why don’t we do this? Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1393995">23:13</a> In particular, looking at dialysis patients versus those who are getting dialysis versus those who are getting conservative management, how much time are they spending alive, and not just alive, but also just those days that they’re doing dialysis to, like the. But the institutionalized days, if you will. Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1415997">23:35</a> Yeah, exactly. We knew, because I don’t know if you noticed, we have a paper that also, I’m first off with, where we actually look at what happens on patients on dialysis in the year after they start dialysis and a little bit before. And we have these. I’m a visual person. So we created these heat maps where you could see for each individual what actually happened in the days and you. And see how much time they were alive, how much time they spent in the hospital, in the nursing home and when you start dialysis. So we had yellow was time spent in a hospital or in the nursing home. And just the amount of time that these patients are spending in an institution was just crazy for me. But then there was always the question, but, okay, what happens if you are not on dialysis? And so this really led to then us working more on this paper and trying to figure that out. I haven’t recreated those heat maps, which I still hope I will be able to do. But at least we were able to put the statistics together and really compare a survival and home time in this Annals paper. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1497963">24:57</a> Okay, but we’re going to do a little bit different than your usual like journal club. We’re going to jump to results and then I’m going to go back to methods. What did you find in this Annals paper? Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1509907">25:09</a> Mendu, why don’t you go? You’ll do a better job than me. Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1513427">25:13</a> Yeah, I have the paper here, so I’m going to just refer, I’m going to cheat and refer back to it. What we found when we did two different analyses and intention to treat analysis and a per protocol analysis. In the intention to treat analysis, we’re comparing people who started dialysis within 30 days of meeting the eligibility criteria for this hypothetical trial to everyone else. So that includes patients who did later go on to start dialysis and some who never started dialysis. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1547345">25:47</a> And eligibility was older than 65 and a GFR less than 12. Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1553233">25:53</a> GFR. That’s right. Chronic kidney disease and a GFR less than 12 and people who had not been referred for a transplant evaluation. So selecting people who were probably not. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1564497">26:04</a> Eligible for a transplant, not acute kidney injury. These are people with chronic kidney and that’s right. Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1569457">26:09</a> Took out people with acute kidney injury. And so in that comparison, the patients who started dialysis had longer survival by nine days but spent two weeks fewer at home. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1583865">26:23</a> Nine days, Nine days. Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1588275">26:28</a> That wasn’t statistic. Actually nine days. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1590891">26:30</a> Out of how many days, like how long did they spend? Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1592875">26:32</a> Over three years. Thank you for reminding me. So over three years of follow up, they spent nine additional. They lived longer by nine additional days but spent two weeks less at home. Then we did what we called the per protocol analysis which is comparing people who started dialysis within 30 days of meeting eligibility to those who never started dialysis. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1616257">26:56</a> Oh, because the other group actually could have started dialysis after 30 days in 3 year, 9 day difference group. Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1623041">27:03</a> Okay, that’s right. Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1623977">27:03</a> So in this comparison, not necessarily that they did not start dialysis, but that we only follow them when they are on dialysis or they haven’t started dialysis yet. Right. So it’s the comparison. There’s no mixing like in the intention to treat analysis. Yeah. If they don’t start dialysis at the beginning of the trial, we follow them as if they never dialysis. It’s just like, okay, but they could have. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1652743">27:32</a> They could have, but they’re, they’re. Now the analysis is saying that we are, this is our intention, that they were not going to do it, but they could have just like any other randomized controlled trial. Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1663071">27:43</a> Exactly, exactly, exactly. But I mean, the per protocol, right. The control group now is one where we really only look at the time when they were still on medical management. And if they initiate dialysis afterwards, that time is not included in the analysis. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1684409">28:04</a> What did you find? Go ahead, Alex. Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1686169">28:06</a> Just to clarify for our listeners, just want to say one more time because we’re getting a little researchy here for our largely clinical audience. Comes from like a time when you know, you’re on the protocol and the protocols here are either you’re on the dialysis protocol or you’re on the medical management protocol. And so per protocol analysis means you only are counted in this study for the time that you’re on that protocol or the other protocol, the dialysis protocol or the medical management protocol. Okay, continue. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1717505">28:37</a> And what did you find in per protocol? Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1720721">28:40</a> So in that analysis, we found that the patients who started dialysis live longer, by 77 days, but still over three years, but still spent two weeks fewer at home. Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1735623">28:55</a> So kind of difference between the intention to treat analysis, meaning like where you started is where you’re counted versus the per protocol analysis, which is is only while you’re in that group in which we assigned you at the beginning. How do you explain the difference? Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1752705">29:12</a> Do you want to take that, Maria? Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1754401">29:14</a> We’ll be more statistical than clinical, I think. But I think even before that, for me, the biggest question here between the intention to treat in the per protocol and I’m a big fan of the intention to treat analysis, and most probably you will have even other statisticians not agreeing with me. But in a lot of things that we do, we really try to get at what happens in the real world. And the intention to treat analysis is really giving us that. Because from what I learned working with Manju and Susan and all the other nephrologists that I work with, it’s just like nothing is set in stone. And so you have patience and the patient comes to you and you’re trying to make a decision right now, like, should I start dialysis or not? And let’s say you’re going to decide like, no, actually now, I don’t know. I do not want to start dialysis. But I hear from them just like, yeah, we don’t really plan for dialysis. And then six months later, they decided something happens and they decided they want to start dialysis. Right. And that’s what happens. That’s the real world and that you only get in the intention to treat. Because if you are, when you’re trying to help the patient, if you want to use these results. It’s about the question that you’re asking right now. If I make a decision right now, what is it that I can expect? And right now you don’t know whether that patient is going to start dialysis in the future or not. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1851597">30:51</a> Well, I guess the other question too though is like if this was a drug like we use intention to treat because the people who, let’s say don’t take the drug are very different than the people that do take the drug. The people who are adherent are generally very different than those who don’t. So if you use like a per protocol analysis in a randomized controlled trial of a drug, it’s going to look different than an intention to treat analysis, isn’t it, Maria? Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1876985">31:16</a> Yes, exactly. Exactly. And then the question then is like what is, what are the results generalizable to? Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1884121">31:24</a> Right? Yeah. Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1884809">31:24</a> Right. Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1885353">31:25</a> We’re going to force you to stay on the dialysis pathway from this point on where no matter what you say or we’re going to force you to stay in the medicine medical management pathway. No matter what you say. That doesn’t make any sense. Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1897447">31:37</a> That doesn’t make any sense to me. Exactly. Exactly. Yeah. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1901471">31:41</a> So let me ask you, going a little wonky question. So you did this. Was this a randomized controlled trial? Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1908895">31:48</a> No, it wasn’t. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1910439">31:50</a> You said you emulated like what was this? This is a. The Annals loves this stuff. Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1917639">31:57</a> Right? Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1917863">31:57</a> Now this is a. What’s the official title? Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1921867">32:01</a> It’s a target trial emulation. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1924315">32:04</a> Target trial emulation. Is that just an observational study with a fancy name that makes it sound more like a randomized control trial or are you doing something different than just the normal observational study? Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=1940115">32:20</a> Yes and no. Because I think that what the target trial emulation does is puts you in a place, is when you are designing the study, right. It puts you in a place where, okay, let’s just pretend that this is a clinical trial, right? And when you’re thinking of a clinical trial, we are in the mindset that, okay, we have protocols that we have to follow, we have standards that we need to follow, like we want to keep those. So in the target trial emulation, that’s let’s basically puts us in that mindset that even though it’s observational data, even though the data has already been collected and we are just repurposing it for this study, we can still follow these strict Protocols that make then the results more reliable. And so for me, it’s a good strategy and it helps me when I discuss these with the researchers that I work with to really say, look, let’s just pretend that this is a clinical trial, let’s follow these protocols and let’s be strict with what we do to make sure that we can trust the results that we get at the end. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2020391">33:40</a> Yeah, it seems like you’re putting all the best practices for an observational trial. Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2024431">33:44</a> Exactly. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2025119">33:45</a> Meshing that together, maybe branding it a little bit. Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2028447">33:48</a> I would say that there are two big pitfalls that you see with studies that don’t use target trial emulation and use an observational framework when they’re trying to do these comparisons. One is they’re defining the intervention using future information, which Maria always tells me is a big no, no. You can’t define the groups by who got dialysis in the future. That’s a big no, no. And two, related to that, a lot of these earlier studies are affected by immortal time bias. And so target trial emulation is an approach to try to handle those design issues that we get with observational studies. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2076155">34:36</a> And in one sentence, if you can, in one sentence, anybody, what is a mortal time bias? Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2081835">34:41</a> I got to turn that over to Maria again. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2083931">34:43</a> Maria. Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2086755">34:46</a> So is when. Let’s go back thinking of the dialysis, right? You don’t really know. You don’t have a starting time for medical management. And so if you’re only waiting until someone starts the medication, then that waiting time is not counted for or medication or treatment. Right. And so like that’s the immortal time bias, where someone would not be eligible to really start the treatment or is eligible, but you don’t know and you are counting that or not counting it in towards your analysis. And so that your follow up time then at the end is basically incorrect. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2130965">35:30</a> Go ahead, Alex. Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2131781">35:31</a> Well, I was just going to try to take a stab to answer your question. Take a stab, Alex, in one sentence, I think more total time bias is when the start time for one group doesn’t begin until some event happens and therefore they have to survive until that event. And you’re counting that survival time in your analysis. And that biases them because they’re immortal in a sense, until that event happens. Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2163809">36:03</a> Yes. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2164259">36:04</a> Is that fair? All right. Yes, that’s fair. My last wonky question, fundamentally though, you’re not randomizing two groups. There’s no emulation for randomization. The biggest issue here is there’s going to be a difference between people who start dialysis and don’t stop dialysis no matter what fancy statistics we use. We. Right. Can we really ignore the need for randomization or like I was asking you Susan earlier, like a randomized controlled trial. Thoughts? Susan <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2199275">36:39</a> So, yeah, a couple of thoughts. So why I like this target emulation trial design is that one tries their very best to account for that kind of selection bias. There’s all this propensity score matching and versus probability waiting and all the, the fancy stuff that Maria does. Is there still residual compounding? Absolutely. And I think that’s always going to be the case. Observational studies, but it gets us as close as one can possibly get to the answer, you know, to answering the question, you know, should there be a clinical trial? There is actually a couple ongoing. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2235293">37:15</a> Oh really? Susan <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2236213">37:16</a> Patients. Yeah. So you know, for a long time people have thought that doing a clinical trial, randomizing patients to dialysis or to conservative kidney management was, was unethical. Others have argued now that there’s so much observational data suggesting clinical equipoise between the two, it’s now unethical to not explore this possibility. So in the UK at the University of Bristol they have, they’re maybe three or four years now into a clinical trial randomizing patients to prepare for dialysis and or to prepare for conservative kidney management. They have at least 380 patients now. I think the study closes to enrollment sometime next year. So we’ll learn. And then right now there’s a Dale Lupu has and I think Woody Moss is maybe, I think they’re copias on that. A PCORI study looking at randomizing patients with late stage 4 or 5 kidney disease to receive kidney supportive care, which is, which is the major element to conservative kidney management and randomizing them to see how that might support their decision making and then kind of long term follow up following I think survival as well as quality of life measures and things. It’s an indirect study of what happens when you do provide patients support for when you want to do dial. It’s as close as we can get I think in the US to try quickly. Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2323065">38:43</a> Just a defense of observational studies because this Annals paper, Maria first author on is an observational study. But observational studies like they’re more real world in some sense when you’re capturing like what happens in the real world and following patients. Patients in this case I believe this was VA patients. Right. So this is like all va. Right. As opposed to randomized trial, you get highly select patients like there are some patients who like you can say it’s equipoise and they’re. But they’re going to say, like, no, you’re not going to tell me, randomized mel dialysis or conservative management. I’m not enrolling in that study. And so you’re going to lose all of these patients. And I. So I worry about that. From randomized trials. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2367109">39:27</a> Do you do observational research, Alex? Conflicts of interest. Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2372157">39:32</a> He’s saying I’m biased. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2375645">39:35</a> I want to acknowledge. We got a couple minutes left. I want to go back to Maria. Maria, the reason you did this, right. You wanted to be able to. Be able to tell patients what to expect. And I’m wondering if we can just take two minutes to think about if you were going to have a discussion about what’s the difference between conservative management and starting dialysis for these people. Let’s say this group of people, older adults, maybe some multimorbidity, GFR is less than 12. How would you talk to them about survival, quality of life, or any other benefits or harms when you’re thinking between these two groups? Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2417325">40:17</a> Yeah. So I’m going to answer not from the medical doctor perspective, because that’s Mendew enthusiasm. But I. Again, going back to my dad, if I had to have a discussion with my dad, how would I argue this? I think what we really want is for people to just don’t assume that dialysis is the answer for these elderly patients. Of course, if they are young, there’s really no question. But the question comes when they are older and what is it that they really want? And if we just stay with survival, then the question is, yes, the patients. If you ask the patient, do you want to live longer? They’re going to say, like, yes, I want to live longer. Do you want to live longer? Nine days for me, that’s really the question. Not even 70 days out of three years with the idea that, okay, I can give you three months of extra survival, but you’re going to spend more time in the hospital, and you’re going to be spending the time going to a dialysis facility pretty much every other day. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2486969">41:26</a> And most of that extra time was dialysis daytime. Maria <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2491105">41:31</a> A lot of it is dialysis time. Right. Because they have to go to a dialysis facility for, you know, three times a week for the most part. And so are the patients. Are you okay? Like, as. As the caregiver or as a family member of the patient? Is that really in the best interest of the patient? Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2513975">41:53</a> Great. I love that. How about for you, Susan? How would you think about having this discussion? Susan <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2521455">42:01</a> I think maybe I’m walking Away with the Annals paper with too simplistic an interpretation. But I take the intention to treat analysis dialysis is confirming that we really should delay dialysis initiation for as long as possible. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2538231">42:18</a> There’s no reason to rush it. Susan <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2539607">42:19</a> There’s no reason to rush. And Manju referred to this ideal trial that randomized patients to early versus late start. And there were some criticism about it. But I think this study locks it in that really, you know, you don’t need a clinical trial. If just anybody walking into your clinic with the resources that we can provide, we can. We should probably try to delay this as much as we can. And then the per protocol analysis, I see that as an opportunity that indeed patients who were started on dialysis did live a little longer. 77 days, but that’s not very long at all, you know, at least in my book. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2579437">42:59</a> 77 out of three years. Susan <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2581373">43:01</a> Yeah, three years. How can we close the gap? And that’s where I think this is where kidney supportive care can close that gap. You know, I think we were very measured in saying it’s continuing medical management because we didn’t know exactly the kind of care that patients were getting. Maybe they were getting kidney supportive care or conserved kidney management as a whole, but maybe not. But even if you didn’t have these formal structures in place like they have in the uk, you know, they. There was not that. The distance was not that wide. So it gives me hope that we can close that distance if we can provide the right infrastructure of care for them. So, yeah, that’s what I’m walking away with this. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2621385">43:41</a> Oh, lovely. Susan <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2622425">43:42</a> My patients. Yeah. It’s just a far more measured framing of what dialysis can offer somebody. It’s not a panacea. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2630369">43:50</a> Manju, how about you? Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2633065">43:53</a> I think Maria and Susan expressed what to say to patients so well. So maybe I’ll express what to say to our colleagues in nephrology and in the policy world, which is that we have equipoise here. There is enough evidence here to suggest that we actually don’t know which path is beneficial and we really need more trials. Although I’m an observational study sort of person, I really do think that the way to move the needle in practice is with trials and I think that we. There’s so many unanswered questions now about how to deliver really good conservative kidney management that we should not wait for just England to do these trials, we should do them here as well. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2681765">44:41</a> Yeah. And I also love. I’m going to go back to that new paper from 2009 which we’ll have linked to. Just don’t assume that function is going to improve post dialysis because they’re in dialysis for three days a week, they’re sleepy afterwards. They’re just function is going to likely get worse for many of these patients. And this is not the fix. So I thought, Manju, I thought your last phrase was going to be let it be, which I was going to argue is my line. [laughter] Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2713699">45:13</a> I should have worked that in. I was not thinking ahead. So should I say we should just let it be? [laughter] Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2720883">45:20</a> Oh, there you go. Alex <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2724395">45:24</a> (singing) Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2769605">46:09</a> Susan, Maria, Manju, thank you for joining us on this GeriPal podcast. Manju <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2773885">46:13</a> Thank you so much. Eric <a href="https://grain.com/share/recording/ecfc6a3c-71f6-4141-b925-4236e6caf162/B0ZfPLzqJNRLdGJUsdjAzHftTPGwWExzmtdxs3DX?referrer=docx&t=2777255">46:17</a> And to all of our listeners. Again, we have a ton of stuff in the show notes. Check it out for the articles and thank you for your continued support. </div> </div> </div></div><div class="vc_tta-panel" id="cme" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#cme" data-vc-accordion data-vc-container=".vc_tta-container">CME</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> <h3 style="text-align: center;">***** Claim your CME credit for this episode! *****</h3> Claim your CME credit for EP333 “Dialysis vs Conservative Management for Older Adults” <a href="https://ww2.highmarksce.com/ucsf/index.cfm?do=ip.claimCreditApp&eventID=14459">https://ww2.highmarksce.com/ucsf/index.cfm?do=ip.claimCreditApp&eventID=14459</a> Note: If you have not already registered for the annual CME subscription (cost is $100 for a year’s worth of CME podcasts), you can register here <a href="https://cme-reg.configio.com/pd/3315?code=6PhHcL752r">https://cme-reg.configio.com/pd/3315?code=6PhHcL752r</a> For more info on the CME credit, go to <a href="https://geripal.org/cme/">https://geripal.org/cme/</a> Disclosures: Moderators Drs. Widera and Smith have no relationships to disclose. Guests Manju Kurella Tamura, Susan Wong, & Maria Montez-Rath have no relationships to disclose. Accreditation In support of improving patient care, UCSF Office of CME is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Designation University of California, San Francisco, designates this enduring material for a maximum of 0.75 AMA PRA Category 1 credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. MOC Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.75 MOC points per podcast in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. ABIM MOC credit will be offered to subscribers in November, 2024. Subscribers will claim MOC credit by completing an evaluation with self-reflection questions. For any MOC questions, please email <a href="mailto:moc@ucsf.edu">moc@ucsf.edu</a>. </div> </div> </div></div></div></div></div></div></div></div></div></div> </div>The post <a href="https://geripal.org/dialysis-vs-conservative-management-for-older-adults-manju-kurella-tamura-susan-wong-maria-montez-rath/">Dialysis vs Conservative Management for Older Adults: Manju Kurella Tamura, Susan Wong, & Maria Montez-Rath</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></content:encoded> </item> <item> <title>COVID Updates: A Podcast with Peter Chin-Hong and Lona Mody</title> <link>https://geripal.org/covid-updates-a-podcast-with-peter-chin-hong-and-lona-mody/</link> <dc:creator><![CDATA[Alex Smith]]></dc:creator> <pubDate>Thu, 31 Oct 2024 07:00:09 +0000</pubDate> <category><![CDATA[All Posts]]></category> <category><![CDATA[COVID-19]]></category> <category><![CDATA[Podcasts]]></category> <guid isPermaLink="false">https://geripal.org/?p=6946</guid> <description><![CDATA[The post <a href="https://geripal.org/covid-updates-a-podcast-with-peter-chin-hong-and-lona-mody/">COVID Updates: A Podcast with Peter Chin-Hong and Lona Mody</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></description> <content:encoded><![CDATA[<div class="wpb-content-wrapper"><div class="vc_row wpb_row vc_row-fluid no-bottom-margins"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"> <div class="wpb_raw_code wpb_raw_html wpb_content_element vc_custom_1730322992551" > <div class="wpb_wrapper"> <iframe title="Libsyn Player" style="border: none" src="//html5-player.libsyn.com/embed/episode/id/33694762/height/90/theme/custom/thumbnail/yes/direction/backward/render-playlist/no/custom-color/00548f/" height="90" width="100%" scrolling="no" allowfullscreen webkitallowfullscreen mozallowfullscreen oallowfullscreen msallowfullscreen></iframe> </div> </div> <div class="vc_tta-container" data-vc-action="collapse"><div class="vc_general vc_tta vc_tta-tabs vc_tta-color-sky vc_tta-style-flat vc_tta-shape-square vc_tta-spacing-1 vc_tta-o-no-fill vc_tta-tabs-position-top vc_tta-controls-align-left"><div class="vc_tta-tabs-container"><ul class="vc_tta-tabs-list"><li class="vc_tta-tab vc_active" data-vc-tab><a href="#summary" data-vc-tabs data-vc-container=".vc_tta">Summary</a></li><li class="vc_tta-tab" data-vc-tab><a href="#transcript" data-vc-tabs data-vc-container=".vc_tta">Transcript</a></li><li class="vc_tta-tab" data-vc-tab><a href="#cme" data-vc-tabs data-vc-container=".vc_tta">CME</a></li></ul></div><div class="vc_tta-panels-container"><div class="vc_tta-panels"><div class="vc_tta-panel vc_active" id="summary" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#summary" data-vc-accordion data-vc-container=".vc_tta-container">Summary</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> In March 2020, we launched our first podcast on COVID-19. Over the past four years, we’ve seen many changes—some positive, some negative. While many of us are eager to move past COVID (myself included), it’s clear that COVID is here to stay. This week, we sit down with infectious disease experts <a href="https://profiles.ucsf.edu/peter.chin-hong">Peter Chin-Hong</a> and <a href="https://sph.umich.edu/faculty-profiles/mody-lona.html">Lona Mody </a>to discuss living with COVID-19. Our conversation covers: <ul> <li style="font-weight: 400;" aria-level="1">The current state of COVID</li> <li style="font-weight: 400;" aria-level="1">Evidence for COVID boosters, who should get them, and preferences between Novavax and mRNA vaccines</li> <li style="font-weight: 400;" aria-level="1">COVID treatments like Molnupiravir and Paxlovid</li> <li style="font-weight: 400;" aria-level="1">Differences in COVID impact on nursing home residents and those with serious illnesses</li> </ul> We wrap up with a “magic wand” question. My wish was for better randomized evidence for vaccines and treatments, though I worry this might not be feasible. In the meantime, there’s significant room to improve vaccine uptake among high-risk groups, particularly nursing home residents. Currently, only 1 in 5 nursing home residents in the US have received the COVID booster, compared to over 50% in the UK. By: Eric Widera   ** This podcast is not CME eligible. To learn more about CME for other GeriPal episodes, <a href="https://geripal.org/cme/">click here</a>.   <hr /> </div> </div> </div></div><div class="vc_tta-panel" id="transcript" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#transcript" data-vc-accordion data-vc-container=".vc_tta-container">Transcript</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=960">00:00</a> Welcome to the GeriPal Podcast. This is Eric Widera. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=3961">00:03</a> This is Alex Smith. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=6289">00:06</a> And Alex, who do we have with us today? Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=7553">00:07</a> We are delighted to welcome back Lona Mody, who is a geriatrician, translational infectious disease researcher, and professor at the University of Michigan and the Ann Arbor Va. Lona, welcome back to GeriPal. Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=21825">00:21</a> It’s great to be here. Thank you. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=23985">00:23</a> And we’re delighted to welcome Peter Chin-Hong, who is an infectious disease physician and medical educator, professor at UCSF and associate dean for regional campuses. Peter, welcome to the GeriPal Podcast. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=36945">00:36</a> A pleasure to be on Alex and Eric. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=39665">00:39</a> Alex, we haven’t had a COVID podcast in a long time. Is that right? Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=42913">00:42</a> It’s been a minute. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=44001">00:44</a> Been a minute. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=45953">00:45</a> So today we’re going to be talking about COVID updates, and I’m super excited. We’ve got a lot to cover from thinking about COVID boosters, to where we are with potential treatments. But before we do, we always start off with a song request. Who has a song request. Is it you, Peter? Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=62995">01:02</a> I do have a song request. I want to hear Kelly Clarkson, and I want to hear her sing. Well, not Kelly herself, but Catch My Breath. And the reason why I’m choosing is because it’s respiratory virus season and we don’t want our patients to catch their breath. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=81155">01:21</a> I love this because Peter gave such a great list of potential songs. All good ones. Yeah. I was voting for Cough Syrup. That was a great one. [laughter] Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=92105">01:32</a> That one would have been quite the challenge. This one’s a little bit more straightforward, I think. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=96265">01:36</a> Cough syrup, though, I’m not sure. I think it may have been the way the kids take cough syrup. Not really. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=101449">01:41</a> I think that was the meaning, too. I got that as well. Waiting for the cough syrup to wear off. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=107945">01:47</a> Little bit different from the way that we mean. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=111481">01:51</a> So wise choice. Wise choice on this. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=113393">01:53</a> Wise choice. Here’s a little bit. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=116245">01:56</a> (singing) Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=180525">03:00</a> That was great. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=182565">03:02</a> Bravo. Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=184405">03:04</a> Awesome. It was fantastic. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=186389">03:06</a> I did hear her once in Central park when I lived in New York. She was, like, playing, and I did not go in to pay for it. I just listened outside. That was my only piece. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=194613">03:14</a> Kelly, amazing singer. I remember that early American Idol is so good. Yeah, I had to take that down about two octaves to see it. Thank you, Peter. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=209515">03:29</a> Lona, I am not sure you remember this, but over four years ago, March, mid March of 2020, we did a podcast on a novel respiratory virus that was coming out of Wuhan. And we asked questions like, what should we be calling this? COVID. SARS. COV2. And, man, things have changed since that first time that we had you on to talk about COVID over the last four years, huh? Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=237935">03:57</a> Yes, it has been four years. Over four years, and it seems like so much has happened. We all have grown so much. The virus has changed so much. The world has changed so much. So, yeah, it’s a good reflection. We know so much now than before. Speaker 5 <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=253487">04:13</a> Yeah. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=254063">04:14</a> And I mean, I’m just reflecting because, like, it feels like back in early 2020, like, it was almost like we were dealing with another virus. Like, Alex and I did some virtual palliative care in New York when the first kind of wave hit New York, and holy smokes, like, the people that we were seeing were so sick. And then when it came to San Francisco again, that. That first year, diffuse lung injuries that we’re seeing, everything else, like, it was devastating. And four years later, it almost feels like we’re dealing with a different virus. And I know that’s probably a stupid statement of me. I probably get a lot of feedback on that statement, but I’d love to hear kind of how you think, both of you, how you think. Where are we with COVID right now? Just from a virus perspective, not treatments or vaccines yet. Peter, does it feel different to you? Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=307875">05:07</a> It feels different, but it also feels the same. The way it feels different is that your neighbor, your cousin, the person at work, isn’t getting as sick in terms of being debilitated anymore or not being as fearful. But it feels the same in that I was on call a lot over the summer, and I took care of a lot of people behind those hospital walls. And, you know, some people are still getting very sick. It’s not the same universal age groups anymore, but there’s a select group, kind of like influenza almost. And when you look at the numbers, actually last year in 2023, even though we’re in a recovery phase, there were more than 75,000 deaths. So I think that dissonance or that disconnect is a little bit, you know, disconcerting to me. Speaker 5 <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=358293">05:58</a> Yeah. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=359535">05:59</a> Why do you think there is such disconnect? Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=362895">06:02</a> I think there is because of. Well, the virus has evolved suddenly. Well, the virus always evolves with the variants, but we’ve evolved even more in terms of getting more immune as a population. So there’s a big force field in society. So that’s changed. And we don’t see hospitals being strained as much anymore. You don’t see body bags, you know, not the same sort of heightened impact on society, but you are seeing some people who are still ill. And I think that disconnect is why people don’t often think of themselves being at risk in the same way, which is more variable in 2024 than in previous years. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=408605">06:48</a> How are you thinking about Lona? Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=410581">06:50</a> Yeah, I think I remember in the early few months the amount of stress that I personally experienced because all of my research has been older adults, nursing home population and the deaths that nursing homes experienced was simply devastating. There were stories about multiple people on the same ward, same unit, all of a sudden having COVID 19 and unfortunately not making it. The impact on. The impact on families. I think that was. That probably deeply impacted me more than I thought it would, considering that there were no early answers. So that was one thing, that early phase that I personally went through, along with several people in that industry. I remember the happiest day was certainly when the vaccine news came out, and I probably jumped several times in my office that, you know, finally we have some good news that are going that’s going to make a difference. I was really happy that day. And then, of course, other treatments and other sort of medications and such came out. We saw the worst and the best of humanity in those times in terms of call schedules, people stepping up or people worried and stressed out. So that was a big portion of the first couple of years of COVID in my life personally. But after that, I think people have become used to the virus. I had heard several virologists mention the same thing as Peter was mentioning that now the immunity is over. 90% of the US population is immune, has some sort of antibodies to the virus. And that’s probably the reason that people feel the need to move forward and not be held back anymore with the worries that are related to the virus. So I think that’s how I’m thinking about it right now. Clearly, scientifically speaking, we need to learn much more than what we know right now about the virus, about the transmission, about the treatment and about the long term sort of implications of a global world that we are in. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=538963">08:58</a> Yeah, I also wonder around that disconnect, how much of it is like we all kind of went through in our own ways some type of trauma, especially early on. That trauma may have been caring for patients who were sicker from respiratory virus than I often have ever seen. I know, Peter, again, the work that you do is different than the work that I do. But like in the nursing home setting, just the sheer amount of how sick people came. And we had Darrell Owens on one of our podcasts very early on we had a nursing home director who basically everybody else called in stopped working in the nursing home. So he was doing everything. Remember that podcast, Alex? Especially in these nursing facilities where you get to know patients over time. And then they were just devastated. In 2020, I do have to say, working still being in a nursing facility, it does actually feel like I have seen people get. And again, this is like these, these n of 1. But like, I am just not as worried when my patients are getting COVID now as I was in 2020. And I think a lot of that is maybe my belief that, you know, immunity works, that this is not a novel virus. Our body is adapting and kind of getting used to this and seeing it over and again. Maybe part of that is just denial based on our own forms of trauma. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=623025">10:23</a> That we all experience trying to get beyond it. And we should mention treatment. The treatments have improved dramatically since the beginning of the pandemic. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=632001">10:32</a> And we got vaccines. So how about we talk about that? So we have vaccines. I was super excited. I posted my Twitter pictures of me getting my vaccines. Number one shot, number two shot, number three shot. This year I have not yet gotten my COVID vaccine. Yes, part of it double two weeks ago, flu shot. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=658577">10:58</a> And you got double COVID, like north, same arm. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=663865">11:03</a> Well, part of it is they. I didn’t sign up for both, so they wouldn’t give me both at the same time. And part of it is like, man, I kind of also like, I don’t think it’s harmful, but I’m 49, okay? For my listeners, I’m 49 years old. I am not sure there’s a lot of evidence that it’s that beneficial. Like, if you look at other guidelines outside of the US like the UK, they actually don’t recommend a healthy 49 year old to get the COVID vaccine. So where are we right now with COVID Lona? Should I call it Boost? Like, what’s the proprietor covered? Boosters, yearly Covered shots. Like what’s the terminology? Since I asked you that same question about terminology in March of 2020, I call them boosters. Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=710219">11:50</a> Right? They are covered boosters, but you know, I think we can vary. I don’t know what Peter calls. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=715859">11:55</a> Well, I think the CDC wants us to call it yelly shots. But you’re right, Luna. I mean, I think colloquially everyone calls it a booster because most people have gotten tons of shots before, so. And the WOOD booster suggests what it’s supposed to do, which is to remind the immune system that what the virus looks like. So for some people they need more reminders. Other people probably don’t need as or it isn’t as urgent that they get that reminder. So that’s kind of where we are. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=749957">12:29</a> And then what vaccines do we have right now? We have three FDA approved vaccines. Is that right? Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=755385">12:35</a> Yeah. So we have three FDA approved vaccines. Two are similar to MRNA, Pfizer and Moderna based on KP2, one of the Flirt variants, descendants of JN1 all Omicron and Novavax, a traditional protein subunit vaccine based on JN1 because it’s more traditional. They had to decide the formula a few months before Pfizer and Moderna did. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=782985">13:02</a> So they’re targeting similar but different strains. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=786865">13:06</a> They’re all targeting the same similar thing. Jan1 was what emerged last winter and January, then spewed a bunch of children out, including these hypertransmissible variants over the summer with the prefix of kp, not Kaiser Permanente. And because MRNA vaccine someone nimbly manufacture, they can say hey, let’s just make a vaccine based on what’s currently circulating. Because the thing in the winter coming up might be more closely derived from that. But turns out that Jan1 and its family are all very similar. So if you got Novavax or if you get Pfizer Moderna, you would probably get the same benefit. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=833995">13:53</a> All right, if. If I was talking to my dad, trying to convince him to get a COVID booster, should I convince them to get Norovax? Should I focus on KP2 with MRNA’s? Does it not matter at all? Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=846635">14:06</a> It probably doesn’t matter. Although I must say that Novavax does have a fan club. They have a. I mean the fans of Novavax have a Facebook page. They advocated for it to come out earlier. So there’s a big sort of cache around novavax. And the reason why is because it’s more traditional. They were no head to head studies, but in the Novak studies they tend to have a fewer side effects Just mildly fewer. Again, not compared to each other. And you know, I think there’s a lot of still people talking about MRNA vaccines. Although personally, if you come back to your question, what you’d recommend to your dad, I would say either is fine. But one of my older relatives had just a really severe reaction to an MRNA shot early on and he got myocarditis, which was very, very rare in an older person. He’s in his 80s. Speaker 5 <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=904965">15:04</a> Yeah. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=906365">15:06</a> Then he, you know, he talked to me, I said, try the Novax. And he tried it and you know, not that it’s again an N of one. Speaker 5 <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=915325">15:15</a> Yeah. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=916093">15:16</a> But he’s continuing to get no vaccine updates. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=919589">15:19</a> Do both of them make you feel like not so great the day after or like, is there any difference or is it the more we use it, you know, you know that post COVID MRNA shot, like you don’t feel great for a day. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=934575">15:34</a> I think that because they’re so spaced out now, a lot of the side effects that we’ve seen like in adolescent males with myocarditis happened after the second shot. Speaker 5 <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=945743">15:45</a> Yeah. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=946527">15:46</a> Because people are getting further apart. It’s not less of that one, two punch. So that’s my hypothesis around that. But yeah, you aren’t hearing people talk about sort of serious side effects anymore. People are talking about, you know, some people. Oh, it wiped me out. Oh, I get on Friday because I want to make sure that over the weekend I can sleep on Saturday. Speaker 5 <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=968733">16:08</a> Yeah. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=969885">16:09</a> Lona, thoughts from your perspective. Do you have any preference when you’re thinking about it? Let’s say for nursing home patients, older. Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=978335">16:18</a> Adults, I think most we use Moderna much more than Novavax and leave it on the patients for their preference. Some patients do have a strong, some strong feelings against the MRNA vaccines, in which case I think the protein based vaccines come in really, really handy. But overall we largely use MRNA vaccine. I have used Moderna or all of mine and in my family I do okay with the vaccine, which means that I probably am not mounting enough response. My husband is that kind of a person who’ll take it on a Friday and he’ll say, okay, I can sleep it up on the weekend. So within the same, you know, we all differ in how we respond to these vaccines, but overall they have been pretty mild. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1023285">17:03</a> I just wanted to interject that there was a really interesting study at UCSF actually where by Eric Frother and Lisa Appel and others showing that the more side effects you had, the more robust the immune responses. But also if you didn’t have side effects you still had a good response. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1041445">17:21</a> So let me ask you a question, because back in December, years ago, when the new vaccine came out, I was super excited. Looking at the New England Journal studies, clearly effective in decreasing bad stuff from COVID in people who have never seen this novel virus before. We’re now three years later. We’ve probably all had some natural immunity. Most of us have had vaccines, 1, 2, 3 doses. What do we know about the evidence right now that yearly boosters in a population that’s no longer like this is no longer a novel virus, but a population that we’re seeing it? I probably saw it this summer and didn’t even know that my body saw it, just got rid of it. What do we know about the evidence? Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1096845">18:16</a> I mean, I think we should probably have better RCTs, as you mentioned, but I feel that a yearly shot definitely is going to be useful and going to be beneficial to patients and all of us general public to reduce the circulation of new variants. So I do think that the virus evolves significantly enough for us to get our COVID shots or COVID boosters or whatever we want to call it at least once a year. I went through this doubt sometime in spring last year about the six monthly thing that’s going to happen. And I was like, I don’t see much in the community right now. Do I really, really want it? And the only reason I took it is that I really don’t want to spend a day in bed. I just cannot afford that anymore. And that was probably the only reason I took it. So I think there is. I can understand public being skeptical about it, especially about the 6 monthly sort of shots that we probably will end up taking, or at least that would be the sort of the soft recommendation coming out. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1161053">19:21</a> So, Q. Six months, twice a year. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1164285">19:24</a> I mean, I think about the shot as. And I love the way that Luna put it too. You know, of course, serious disease, hospitalization and death. I think particularly in our older populations, there is some evidence that at least by antibodies, again, when I’m looking at T cells with cellular immunity, it declines the fastest within six months. And that’s why that six months thing came on board. But to tell you truth, the people I saw in the hospital, and it’s, you know, it’s corroborated by data too. I would say pretty much 100% of the people I saw didn’t get a shot in the last year, even though they’ve gotten like a million shots in the beginning of the pandemic and they were all older in 75. So that’s another thing that I would think about and I worry about the every six months it has to be messaged appropriately because don’t forget the lowest hanging fruit. The eyes on the prize is really for the older patients to get it at least once a year and if you wanted to get the second after six months I’ll be great, like drink for the summer or something like that. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1231025">20:31</a> Well, it’s really interesting because this idea of low hanging fruit. So let’s. I mean if you look at the UK they do not recommend it for non older adults or non immunocompromised. They are not paying for yearly boosters for like a healthy 49 year old. So you would imagine, oh like they just, you know, they’re probably using a lot less of it. If you look at nursing home currently it looks like about half of their nursing home population have had a COVID booster this year. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1261375">21:01</a> So they recommend them for all and will pay for them but just in a narrow population. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1267039">21:07</a> We’re going to just look at this low hanging fruit target all of our messaging. Low hanging fruit us. Everyone over the age of six gets a COVID booster. You want more than one, we’ll give you more than one. Where are we with nursing home population? The group that probably is most at risk? I think it’s less than 20%. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1287924">21:27</a> At the same time, less than 20% are getting the annual boosters have gotten. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1294339">21:34</a> This year’s annual booster. If you look at last year, same thing, same thing between the two group. Significantly less people in the US in nursing homes got COVID boosters than the uk. And I wonder like part of that is like we’re different but part of that is like things are finite, we have finite resources. How much should we just target the people who are actually going to benefit from this versus constant messaging that everybody should be getting these COVID boosters which also feels like, well, do we really have the evidence for that? Thoughts? You could call me stupid for thinking about this, but I worry because I do think I would recommend it for every nursing home patient people who are immunocompromised. Even if we don’t have randomized controlled trial. The harm is so small and I’m fine with the antibody evidence. Peter, am I stupid? Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1350885">22:30</a> Yes. He says you’re not stupid at all. You’re not stupid because the UK is not stupid. So I think there is some truth in what is a lot of truth in what you’re saying. The way I think about it is and it’s really tough this, this messaging. So first of all, historically, the flu vaccine was a targeted population vaccine. So very young and very old. And there is some evidence saying that when you make a vaccine universal that you can get more people in the. You know, again, I’m just quoting one study, more people in the who are actually needed to get it because there’s less confusion and more people are more vulnerable to have access it. So somebody who is not in the system. But with that said, the way I say it is that everybody is allowed to get it. But I really want the people who are 65 and definitely over 75 to get this vaccine because they comprise over 90% of the population who are hospitalized with COVID in the United States and you know, from 2023 onwards. So I think that’s the way I put it. And of course the other benefits too, that decrease long COVID observational studies by 70% has a benefit of reducing infection if it matches the circling variance. Like if you get it now, you can kind of get six to eight weeks maybe of lower risk for holiday parties and things like that. So, you know, there are other benefits as well. Speaker 5 <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1449393">24:09</a> Yeah. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1450057">24:10</a> So a lot of observational studies saying that it benefits. I want to highlight one thing you said too is like flu shots feel very different also because it’s a different virus. But I mean, part of the reason that we’re advocating for twice a year, sometimes even more like the most recent guidelines, you can get more than two shots a year for specific groups is that immunity or I want to say immunity. Right. We had Monica Gandhi on. She taught me the importance of there’s more than antibodies got T cells out there, but antibodies kind of what drop after like two months, like from an antibody response, we start seeing that wane. So when is the right timing that we should be giving these vaccines to our nursing home populations? Because we’re kind of in a lull. We’re going to start seeing it come back in November because it always does. It’s going to peak in December, early January and then it’s going to have that same cycle with the next late spring summer peak lona. Do I perfectly time it? Do I just jump on the bandwagon in September and give it? Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1522755">25:22</a> I think September, October is a good timing to give just because that’s the time when families start making plans, start getting together in November and December and you want the immunity to be there. So I feel the fall timing is reasonably good. The main question is the next timing at the six months. If we do decide to go that route what is the good one? And I think we’ll need to see a couple of years of more pattern. I was looking at the curves from this past year and the spike was in June. CDC now collects data from nursing homes on COVID 19 and nursing homes there was a spike in June and I’m certain that the this is related to the community transmission around that time as well. Which brings us to a couple of different points regarding your original question. One is that among the immunocompromised we should definitely. Among the elderly, we should definitely consider vaccine. Among us healthcare providers who care for the elderly, I think that is a good thing to protect ourselves and our patients. And there is a herd immunity that comes with that and probably is a tipping point that if enough people get the vaccine, then the downstream big outbreaks that we see probably will not be seen. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1598231">26:38</a> So you feel like it actually impacts transmission? Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1601775">26:41</a> Yeah, I do feel that it does impact transmission to some extent. I don’t know, Peter, what do you feel about it? Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1607911">26:47</a> I agree with you, Lona, because even if you just think about symptomatic infection, sure, the studies in households have not proven that it reduces transmission same way that say, you know, a flu vaccine or a time of flu. But, you know, if you reduce the person who is getting the vaccine from getting symptomatic infection, if it’s matching the variant circulating and you just got the vaccine, then you don’t have it to then transmit it to a vulnerable patient that you’re taking care of. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1639207">27:19</a> Oh yeah, I got one more question about vaccine because I want to go on the treatments too. Is that. Do you think we, we can do a randomized controlled trial of these vaccines, given what we know right now, to convince hesitant individuals that, hey, this does it. Because if you look at the observational studies, the effect size is quite large in these studies, so it shouldn’t take a monstrous trial. Am I truly to believe the observational studies? Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1671097">27:51</a> So you’re assuming that the reason that rates are so low among older boosters and among nursing home residents is because of lack of information that we need a randomized trial? Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1682317">28:02</a> Well, you got one person on this zoom call. I’m not going to call him out. Who has not yet had the COVID vaccine. And I do think that if I saw really good evidence that yearly vaccines in immunocompetent individuals who’ve seen COVID before, who’ve got shots before, for me, I do think so, because it kind of, you know, the alternative is like we’re just spending a lot of money on this thing that other countries are not recommending and that’s the other thing is that you’re seeing diversity. Most countries actually do not follow CDC guidelines. So the question is can we do a randomized controlled trial in the US of the vaccines? Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1719109">28:39</a> Yeah, I’m not sure it is going to be ethical anymore to do an RCT of a vaccine. That has shown to be. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1726869">28:46</a> Why not? Most people don’t even take it. Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1729655">28:49</a> Sure there are other designs that can be done. I’m not sure it is possible now in nursing homes for flu. As you know there are many sort of cluster randomized trials that are done for trivalent the different kinds of flu vaccines. That’s probably possible. Not sure if a randomized control trial would be approved from ethical bodies. They would certainly be very strong. But we would probably have to rely on other types of designs, study designs to make. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1755951">29:15</a> Peter, do you think. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1757705">29:17</a> I don’t think you’re going to get buying for randomized control trial for the reasons Luna mentioned but also because it’s going to be so effect expensive. I can imagine pharma or vaccine companies jumping on that bandwagon. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1770849">29:30</a> Oh they’re not good because we’re already giving it. Right. Like there’s no, there’s no economic reason to do a randomized control trial from a pharma company. You can only. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1779985">29:39</a> But there are trials. Well, they are small studies so far but you could like. I love the idea of looking at the flu models in nursing homes, for example, you know, quadrivalent or I mean the high dose flu vaccine or adjuvant flu vaccine. So there are new formulations coming out with a COVID shot like a flu and COVID together so you can look at those kinds of things within populations. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1807919">30:07</a> And I wonder since we have one vaccine targeting JN1 another targeting this KP2, I wonder if there’s any information to be gleaned by the difference in those two too. Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1819875">30:19</a> I think they’re JN1 and JN2. Correct. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1823313">30:23</a> Peter, if I’m KP2 is the child of Jan1. Speaker 5 <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1829547">30:29</a> Yeah. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1830219">30:30</a> Well I want to go to treatments because this brings up the other question. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1832811">30:32</a> About pathways before we go to treatments. Just thinking of our. I want to move on from Eric 49 year old person. Get back to our GeriPal audience. Older adults, people with serious illness. Can we talk briefly about people with serious illness? Is there a lag time to benefit for these vaccines? So for example, we have a hospice unit in our nursing home and those patients typically have days to weeks, maybe months left to live. Should they be getting the vaccine or do the harms, the short term harms, potential harms outweigh the risks for people with limited life expectancy. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1868975">31:08</a> Well, I can start. I really love to hear Luna’s take on this too. Well, I think the vaccine, there are very few harms right now, to tell you the truth. Particularly if somebody has had the vaccine successfully perform. You know, the longest it takes to get up to that top peak antibody is maybe two weeks, but probably in a few days if you’ve been experienced before. Speaker 5 <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1890759">31:30</a> Yeah. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1891191">31:31</a> And it also helps against mi, stroke, some, but those are more long term things. But I think getting seriously ill can happen pretty soon after COVID. So I would say as an ID doc that I would offer vaccines to those individuals because I don’t want them to. I want them to preserve their quality of life, you know, in the period that they have. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1917439">31:57</a> Yeah, Lona. Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1919223">31:59</a> Yeah, I don’t think I would necessarily withhold vaccines, you know, from patients, older adults who are in hospice. Ultimately it comes down to what does a quality of life mean. Some people feel that they are, they are doing fine right now and do not want to get COVID because in two months they have their grandchild, great grandchild’s graduation and they don’t want to risk anything in between. Just as an example. Example. So I, yeah, I may not be the person who makes a policy that, you know, they have to be or they have to reach a 70% target or those kinds of things. But I would not withhold it. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1956947">32:36</a> I think in practice a lot of us don’t do it for people who have less than two weeks to live because if, if anything, because I agree, I think the safety of these drugs is grind, but the possibility of feeling crappy for a day, just getting the shot, I do think we have to think about for our hospice patients. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1973075">32:53</a> So maybe less than two weeks. Maybe don’t recommend it. More than two weeks. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1978907">32:58</a> We’ll see if Peter thinks I’m stupid for that too. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1981123">33:01</a> No, no, I like the two week thing because from a scientific point of view, two weeks is also the time it takes you to get to that level. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1988635">33:08</a> Yeah. Okay. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1991219">33:11</a> Thank you, Alex. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1992227">33:12</a> Can I go to treatments? Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1993523">33:13</a> Yes. To older adults or people with serious illness? Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1996379">33:16</a> Older adults. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1996747">33:16</a> Not Eric, Widera. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1997771">33:17</a> Older adults. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=1999211">33:19</a> I’m giving my co some grief. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2001139">33:21</a> Not a 49 year old. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2002943">33:22</a> I never know how to pronounce this one. Mole. New piv. I never use it. I’ve never used it. I’ve never seen it used. How do you pronounce it? Mol. New Peter. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2014935">33:34</a> Molnupiravir. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2018935">33:38</a> Is it something that we should still use if we’ve never used it? Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2023335">33:43</a> There is still a place in the world for it. And I’ll tell you how I think about it. So of course everybody’s heard about Paxlovid. We’ll talk about that. Yeah, I think if you have access an infusion center, you can’t take Paxlovid because of the 120 potential drugs that people might be fearful of for drug interactions, then remdesivir infusion center is my next go to for three days. If you can’t get either of those two and somebody didn’t get vaccinated or you’re worried about them. A 30% benefit with mopiravir might be worth it to some people. So it’s well tolerated, you know, but got a 30% back. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2066079">34:26</a> I thought panoramic. Wasn’t panoramic. Negative. Was that another study that. Was that the UK panoramic study? They had like Paxlovid and Mal Nu, bit, whatever. Was that a negative study? Was that positive study? Do you know much about panoramic? Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2082335">34:42</a> I don’t. I can’t remember the details about that study, to tell the truth. Except that, yeah, it didn’t show quite as much benefit as people thought. That. That’s my. That’s the punchline I remember. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2094175">34:54</a> Yeah, that’s my. Because it was Lancet last year. I think this comes to goes to Paxlovid is that. And potentially my concern, like with the vaccines too, is that the early on studies were pre omicron, pre. Most of us ever seeing this virus before and you look at like Paxlovid, epic, hr, the first one, high risk patients. Most of us have never been. Everybody not vaccinated. Great drug. Great drug, right? I would say it had a pretty good effect size. It looked like it really worked. Published when a couple months of completion showing in New England Journal showing it works. EPIC sr, standard risk patients, patients who’ve standard risk, not vaccinated or high risk with vaccination. Really no statistical difference between the two groups. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2146121">35:46</a> Well, it comes back to what you’ve been seeing before, from the beginning we started, which is that you, you know, I think the answer is yes and yes. Because when you look at, you know, panoramic or some or EPIC hsr, you’re mixing people both unvaccinated, vaccinated, younger, older, et cetera. Well, SR was mainly, you know, a younger group versus the pure original studies. So the answer is for the right patient, it’s still really worthwhile who, who. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2178203">36:18</a> Would be the right patient in your mind for Paxlovid? Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2181595">36:21</a> Well, the people who I saw in the hospital who may not have been there. Speaker 5 <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2185067">36:25</a> Yeah. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2185459">36:25</a> If they got Paxlovid, because none of them got Paxlovid either. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2188965">36:28</a> So older adults, high risk immunocompromised older adults, certainly nursing home patients. Is that right? Lona, would you agree? Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2199765">36:39</a> I agree. And there is, although not RCTs that are observational studies, that the symptoms and the long term symptoms of COVID are fewer with Paxlovides. I would say that is, I can understand the public skepticism because of the newer studies and conflicting data. But I would say older adults immunocompromised, high risk of hospitalization, should probably get vaccinated. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2222971">37:02</a> Yeah. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2224035">37:04</a> And then again, I feel like this is another one. Like, man, it would be great to have more data, like more, you know, high grade data, high quality data, randomized controlled trials. But we’re just never going to get it because there’s no, there’s no incentive. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2237635">37:17</a> And I guess you mean incentive to the pharmaceutical. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2240163">37:20</a> I guess panoramic. We’re still waiting for panoramic Paxlovid study to come out. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2245247">37:25</a> Yeah. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2245679">37:25</a> No bet. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2246727">37:26</a> Pharmaceutical companies are not going to make money on this. They can only lose. I mean, Pfizer. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2253815">37:33</a> Yeah. So I mean, the way to summarize the way I think about Paxlovid is really the shoulds and the coulds. And again, it’s just like your discussion about vaccines. There are people who need it much more, but that’s getting lost in the average message. And that’s my concern. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2271605">37:51</a> Yeah, I think that’s my concern too. I guess one other question is like, nursing homes are a weird population. It’s not really inpatient. And an inpatient. We use a lot of remdesivir. Do we still use a lot of remdesivir? Is that like Peter, if you’re admitting. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2286797">38:06</a> Somebody 100% because you don’t know where they’re going. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2293069">38:13</a> And remember, most, remember when President Trump had COVID, everyone’s waiting for day seven because you kind of have mild symptoms at the beginning. And I think that’s another myth. My patient has mild symptoms, 85 years old, did maybe didn’t get the last booster, but look, it’s really mild. But remember, you don’t fall off the cliff until day seven. So you can’t really use that as a. And when people first come to the hospital, you don’t know where they’re going. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2321527">38:41</a> Okay. Now nursing homes, not really truly like community based outpatient, not really inpatient. Like, I think our nursing home still has a preference for remdesivir for when the patients get sick, which always confused me. Like, why aren’t we using Paxlovid? Because they are still technically outpatient, lona. Like, what should nursing homes be doing around? Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2343525">39:03</a> I think the short, stiff populations are probably a little bit, you know, different than our long stay populations. But I have largely heard Paxlovid being used more than remdesivir in nursing homes. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2356689">39:16</a> Okay. Same thing with you, Peter. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2359025">39:19</a> People use Paxlovid more, but they’re also worried sometimes about drug interactions. I see. I would say many of these worries are sometimes unfounded. And, you know, I think working with a good pharmacist will help reassure you that, you know, it’s going to be okay. And I oftentimes advise people to have a paxlovid plan. So you kind of know what’s going to happen in case somebody needs paxlovid, but much easier to give than remdesivir. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2389455">39:49</a> All right, I got one last question. Alex, do you have any questions before I ask my question? Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2393679">39:53</a> Last question. Yeah. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2395135">39:55</a> Magic wand. You had a magic wand, Right? Now we are in year what? Year four, year four of COVID What are you hoping in 2025, Lona? 2025. You got a magic wand. Has to be used in some regard regarding COVID. What would it be? Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2411105">40:11</a> I’m hoping with a, with a magic wand that the virus gets even weaker and we have fewer spikes. Summer spikes and spikes. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2421441">40:21</a> Do you think that’s going to happen? Like it’s a coronavirus, right? Like it’s just going to constantly be around with us? I guess it’s a magic wand, so it doesn’t even matter. Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2429121">40:29</a> Maybe the host gets stronger. Maybe the totality of the humanity is stronger in beating the virus. How is that? Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2436723">40:36</a> I love it, Peter. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2439155">40:39</a> I’m going to be more existential about my magic wand, which is. Well, it’s not really existential, but my hope is that we have much more trust in science and medicine and less divisiveness and less misinformation about vaccines because it’s bleeding over into lots of other vaccines for kids, measles, et cetera. So that’s really my hope for 2025. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2463783">41:03</a> Alex, you got a hope? Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2465975">41:05</a> I hope I can catch my breath at the end of this podcast. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2468639">41:08</a> Oh, no, that’s my line. Well, I will say actually, I got a hope. I actually do hope that in 2025 we’ll get some more kind of randomized controlled trial out there because I do think that the antidote to misinformation is actually evidence. So that would be my hope. Alex, Take my breath away. Wait, that’s not Take My Breath. What’s the title of the song? Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2491215">41:31</a> That’s Top Gun. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2492399">41:32</a> That’s Top Gun. Alex <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2493591">41:33</a> That previous Top Gun. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2496335">41:36</a> Hatch my breath Serenade me as I drive my motorcycle with you in the back Alex. Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2502015">41:42</a> It is a cities correct. Speaker 6 <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2504855">41:44</a> I don’t want to be left behind Distance was a friend of of mine Catching breath in a web of lies I’ve spent most of my life Riding waves Playing acrobat Shadow boxing the other half learning how to react I’ve spent most of my time Catching my breath Letting it go Turning my cheek for the sake of the show now that you know this is my life I won’t be told what’s supposed to be right Catch my breath no one can hold me back I ain’t got time for that Catch my breath won’t don’t let them get me down it’s all so simple now. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2568315">42:48</a> Peter Lona, thank you for joining us on this podcast. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2572163">42:52</a> It was so fun. Thanks. Hopefully I can get Lona to paint me a watercolor of a COVID virus. Lona <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2578395">42:58</a> Oh, okay. I can send you a print. I can send you a print. You might like it. Peter <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2582459">43:02</a> Please do. Eric <a href="https://grain.com/share/recording/b364ca16-2cc3-4aab-b581-ed3504902553/xr8XzgBbk3ie0V7ai0kH6vT46pabzis5AzRhRaJU?referrer=docx&t=2583379">43:03</a> And to all of our listeners, thank you very much. Don’t forget, if you’re caring for nursing home patients, give them that booster this year no matter what you do for yourself. And thanks, everybody. </div> </div> </div></div><div class="vc_tta-panel" id="cme" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#cme" data-vc-accordion data-vc-container=".vc_tta-container">CME</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> <h3>This episode is not CME eligible.</h3> </div> </div> </div></div></div></div></div></div></div></div></div></div> </div>The post <a href="https://geripal.org/covid-updates-a-podcast-with-peter-chin-hong-and-lona-mody/">COVID Updates: A Podcast with Peter Chin-Hong and Lona Mody</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></content:encoded> </item> <item> <title>Medical Cannabis Revisited: A Podcast with David Casarett and Eloise Theisen</title> <link>https://geripal.org/medical-cannabis-revisted-a-podcast-with-david-casarett-and-eloise-theisen/</link> <dc:creator><![CDATA[Alex Smith]]></dc:creator> <pubDate>Thu, 24 Oct 2024 07:00:38 +0000</pubDate> <category><![CDATA[All Posts]]></category> <category><![CDATA[Healthcare]]></category> <category><![CDATA[Pain]]></category> <category><![CDATA[Quality of Life]]></category> <category><![CDATA[Podcasts]]></category> <guid isPermaLink="false">https://geripal.org/?p=6939</guid> <description><![CDATA[The post <a href="https://geripal.org/medical-cannabis-revisted-a-podcast-with-david-casarett-and-eloise-theisen/">Medical Cannabis Revisited: A Podcast with David Casarett and Eloise Theisen</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></description> <content:encoded><![CDATA[<div class="wpb-content-wrapper"><div class="vc_row wpb_row vc_row-fluid no-bottom-margins"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"> <div class="wpb_raw_code wpb_raw_html wpb_content_element vc_custom_1729719453497" > <div class="wpb_wrapper"> <iframe title="Libsyn Player" style="border: none" src="//html5-player.libsyn.com/embed/episode/id/33589832/height/90/theme/custom/thumbnail/yes/direction/backward/render-playlist/no/custom-color/00548f/" height="90" width="100%" scrolling="no" allowfullscreen webkitallowfullscreen mozallowfullscreen oallowfullscreen msallowfullscreen></iframe> </div> </div> <div class="vc_tta-container" data-vc-action="collapse"><div class="vc_general vc_tta vc_tta-tabs vc_tta-color-sky vc_tta-style-flat vc_tta-shape-square vc_tta-spacing-1 vc_tta-o-no-fill vc_tta-tabs-position-top vc_tta-controls-align-left"><div class="vc_tta-tabs-container"><ul class="vc_tta-tabs-list"><li class="vc_tta-tab vc_active" data-vc-tab><a href="#summary" data-vc-tabs data-vc-container=".vc_tta">Summary</a></li><li class="vc_tta-tab" data-vc-tab><a href="#transcript" data-vc-tabs data-vc-container=".vc_tta">Transcript</a></li><li class="vc_tta-tab" data-vc-tab><a href="#cme" data-vc-tabs data-vc-container=".vc_tta">CME</a></li></ul></div><div class="vc_tta-panels-container"><div class="vc_tta-panels"><div class="vc_tta-panel vc_active" id="summary" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#summary" data-vc-accordion data-vc-container=".vc_tta-container">Summary</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> Cannabis is complicated. It can mean many things, including a specific type of plant, the chemicals in the plant, synthetic analogs, or products that have these components. The doses of the most widely discussed pharmacologically active ingredients, THC and CBD, vary by product, and the onset and bioavailability vary by how it is delivered. If you believe the evidence for efficacy to manage symptoms like neuropathic pain, how do you even start to think about recommending these products to patients? On today’s podcast, we answer that question with our guests, David Casarett and Eloise Theisen. David is a physician who wrote the book “<a href="https://www.amazon.com/Stoned-Doctors-Case-Medical-Marijuana/dp/1591847672">Stoned: A Doctor’s Case for Medical Marijuana</a>” and gave a TED talk on “<a href="https://www.ted.com/talks/david_casarett_a_doctor_s_case_for_medical_marijuana?subtitle=en">A Doctor’s Case for Medical Marijuana</a>” that was watched over 3 million times. Eloise is a palliative care NP at Stanford and co-founder of The<a href="https://www.radiclehealthcare.com/rhcn-who-we-are"> Radicle Health Clinician Network</a>. So, take a listen and check out the following resources to learn more about medical cannabis: <ul> <li style="font-weight: 400;" aria-level="1"><a href="https://www.radiclehealthcare.com/radicle-institute">Radicle Health’s curriculum and modules for healthcare professionals on cannabis</a></li> <li style="font-weight: 400;" aria-level="1">NEJM Catalyst article on<a href="https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0373"> integrating medical cannabis into clinical care</a></li> <li style="font-weight: 400;" aria-level="1">David’s TED talk on “<a href="https://www.ted.com/talks/david_casarett_a_doctor_s_case_for_medical_marijuana?subtitle=en">A Doctor’s Case for Medical Marijuana</a>”</li> <li style="font-weight: 400;" aria-level="1">A <a href="https://www.sciencedirect.com/science/article/pii/S0885392422007606?via%3Dihub">JPSM systematic review of current evidence for cannabis in palliative care</a></li> <li style="font-weight: 400;" aria-level="1">Our past <a href="https://geripal.org/cannabis-in-older-adults-a-podcast-with-bree-johnston-and-ben-han/">GeriPal episode with Bree Johnston and Ben Han on cannabis in older adults</a></li> </ul>   ** This podcast is not CME eligible. To learn more about CME for other GeriPal episodes, <a href="https://geripal.org/cme/">click here</a>.   <hr /> </div> </div> </div></div><div class="vc_tta-panel" id="transcript" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#transcript" data-vc-accordion data-vc-container=".vc_tta-container">Transcript</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1000">00:01</a> Welcome to the GeriPal podcast. This is Eric Widera. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=3598">00:03</a> This is Alex Smith. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=4534">00:04</a> And, Alex, who do we have with us today? Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=6150">00:06</a> Today we are delighted to welcome David Casarret, who is a palliative care doctor and Researcher in Chief of Palliative Care at Duke and author of Stoned: A Doctor’s Case for Medical Marijuana. His TED talk on this issue has received over 3 million views. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=21310">00:21</a> 3 million. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=22246">00:22</a> 3 million. David, welcome to the GeriPal podcast. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=26290">00:26</a> Thanks. You got me laughing already. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=30394">00:30</a> And we are also delighted to welcome Eloise Theisen, who’s a palliative care nurse practitioner at Stanford and CEO and co-counder of Radical Health Clinician Network, which helps patients use cannabis to treat chronic and age related illness. Eloise, welcome to the GeriPal podcast. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=47970">00:47</a> Thanks so much for having me. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=49658">00:49</a> And I just want a big shout out to Alex Gamble, who said, we have to get Eloise on a podcast to talk about this topic. I am super excited to have you on, Eloise. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=59990">00:59</a> Thank you so much. Yes. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=61478">01:01</a> So we’re going to be talking about medical cannabis, kind of revisiting it, because we actually had one in 2021 with Ben Han and Bree Johnston talking about cannabis, including increasing use in older adults and less perceived risk amongst older adults using medical cannabis. But before we get back into this subject, Eloise, I think you have a song request. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=87020">01:27</a> Yep. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=87884">01:27</a> Man. The amount of songs you could choose. [laughter] Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=90012">01:30</a> From the podcast, both of you had some great suggestions. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=94732">01:34</a> Yeah. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=95156">01:35</a> So thank you for all those terrific suggestions. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=97548">01:37</a> Puff the Magic dragon. [laughter] Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=99108">01:39</a> Material here for songs related to medical marijuana or marijuana in general. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=103476">01:43</a> Eloise, what to pick? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=105172">01:45</a> Well, David had a good one, but I picked How to Get You Into my Life by the Beatles. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=115966">01:55</a> Why did you pick this song? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=118350">01:58</a> The song was actually, Paul McCartney came out and said the song was actually about marijuana that he wrote back in the day. And if you listen to the lyrics, it really does talk about how much he enjoys using it and wants to get it into his life every day. And I think it represents the euphoric component of cannabis that we often don’t discuss and fear. There’s a lot of euphoria phobia out there, so I think it’s a great song. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=143384">02:23</a> Terrific. All right, here’s a little bit. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=146000">02:26</a> (singing) Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=210000">03:30</a> That’s great. So, again, so many other songs. I think, Alex, you’re going to finish with the entire album of the Chronic by doctor Dre. After? [laughter] Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=223000">03:43</a> …trying to get Alex to do some rap. [laughter] Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=226880">03:46</a> One of these days… Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=230056">03:50</a> I’d like to start off just hearing from both of you why you got interested in this subject. And, David, I’m going to start off with you because you wrote an entire book about this. What? Wait, Alex is giving me…is that a… Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=245224">04:05</a> It’s a gummy. Do you want one? You don’t want the gummy? Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=250240">04:10</a> No, it’s okay. Alex. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=255862">04:15</a> It’s going to get really, really interesting. [laughter] Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=259190">04:19</a> For our listeners. These are vitamins. [laughter] David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=264270">04:24</a> That’s what they all say. Yes. Eric, do you want me to go first? Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=269798">04:29</a> Yeah, go ahead, David. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=271094">04:31</a> Yes. This is back in, I don’t know, like 2014 maybe. Pennsylvania was thinking about legalizing medical cannabis, and I got involved in some of those advocacy efforts, worked with a lot of really strong, powerful moms of kids with epilepsy who were really pretty inspiring because they just would not take no for an answer and were not awed or overwhelmed or intimidated by lawmakers in Harrisburg. They just kept at it. So that kind of raised my awareness. And then I met a patient in clinic once who asked me a lot of really intelligent questions about medical cannabis, what it does. She had pancreatic cancer, bad neuropathic pain. And, you know, I tried to give her some advice and actually did some research and looked up what I could. And midway through our encounter together, she told me that she was actually using medical cannabis. And she was kind of asking me what I knew about it as a test to figure out whether I was worth sticking with. And this is. This is pre legalization. So she was. I don’t know where she was getting it, probably from her grandson. But that. That was really eye opening to me, both because I was learning there’s a lot of. Not a lot, but back then, some science, certainly more science than I realized. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=344536">05:44</a> Existed because she handed you a packet of RCT’s, right? Or studies? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=349576">05:49</a> She did, and she had my email address. So for a period of a couple weeks, every night, I would get home and check my email and there’d be more pubmed references. She was a retired professor at Penn. And so I was interested in this. I was still kind of skeptical, and so I don’t think I’ve had told the story widely, but my initial pitch to Random House, which is my publisher at the time, was that I was going to write an expose on the crappy science behind cannabis. And then I started looking into it and realized actually, the science wasn’t perfect, but it wasn’t crappy at all. And there’s actually some decent stuff there. So I was in the awkward position after I got the book deal, going back to my editor at Random House, Nikki Papadopoulos, and saying, well, actually, could we change the frame a little bit more positive? And she, to her credit, was. Was really open and supportive of that. But that was, that was it. It was a little bit of advocacy. And then one patient who really knew more about a topic than I did, which unfortunately happens much more often. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=413970">06:53</a> I loved your book. I read in one sitting last night. It was absolutely fabulous. Tons of interviews, bringing in real patients, talking about the science, both. What do we know works, what do we think as far as risks, side effects that we have to worry about? I also love the idea. Like, you were talking with one patient who was in hospice, and he got a lot out of medical cannabis. He actually joined a hospice. Right, that allowed it, but then they were worried about giving somebody medical cannabis, so they no longer included that as a potential benefit. But they would give somebody morphine, Benzo, this comfort kit, admission, which, honestly, many of those things don’t have a great amount of evidence. But the one thing that he felt like he really got the most benefit from, from his pain, was cannabis, and that was not something that was allowed. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=471930">07:51</a> Yeah. Which is eye opening to me as it is, I think, to many of us. And you could say the same thing about insurance companies. Insurance companies will pay for a lot of drugs that have really not a whole lot of evidence at a lot of costs. But to this day, I haven’t heard of an insurance company that’s willing to cover cannabis. It’s going to change gradually, especially if we talk about rescheduling cannabis. But right now. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=493124">08:13</a> Yeah. Or if a pharma company can make a really good pill, they’ll pay for it. Eloise, how’d you get interested in this? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=502620">08:22</a> Yeah, I was in a pretty significant car accident about 1314 years ago that left me disabled and in chronic pain. And so I, like many patients, ended up on multiple medications after a certain amount of time. We were trying to treat the side effects of one medication, and I ended up on polypharmacy at a pretty young age and ended up with serotonin syndrome. That put me in the emergency room. And it was at that moment that I thought, okay, there’s got to be something else out there that can help me. And I started to use cannabis, and it helped me get off all of my medications. And I returned to school to become a nurse practitioner. I’d been a nurse at the time, and I went back to do my clinicals in an oncology clinic locally. And every day, patients were asking me about it. I’d close the door, and they’d whisper and say, what do you think about marijuana? And I’d be like, I don’t know why we’re whispering. And then I started to wonder, do I have this green aura about me? I had come so far in my own research and curiosity for myself, but never thought it would go any further. And I decided at that point to hang a shingle and start a clinic with a physician. That allowed us to actually teach patients how to use it, what to expect to talk about dosing and drug to drug interactions. And I kind of just took off from there. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=588470">09:48</a> That’s great. And for the listeners not watching YouTube, I’d see maybe it was the big weed magazine thing that you have in the background, Eloise, that got them talking, because it is very stigmatized. Right. This is something that. And we learned this on our last, last podcast with Ben Hot. You know, two decades ago, usage in older adults was nearly zero for cannabis, marijuana. But now I think it was like 5% when he checked it last. The numbers are increasing, which will probably be only continuing to increase with the baby boomer generation becoming older. Is that your feeling, too? Does that have face validity? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=629668">10:29</a> Yeah, I think what we saw in California was, prior to legalization, there was curiosity, but also a lot of their healthcare professionals didn’t know enough about it, so they didn’t discuss it with them. And the process was you’d go and you’d get a letter from a recommendation from a doctor, and then you’d go into a dispensary, and it was really overwhelming. And then in 2018, when adult use was allowed in California, I think it gave people more permission, but the stigma is still there. I mean, I had a woman who completely got her life back. She was in chronic pain, and she started using cannabis, and she was able to go back to yoga and be active. And she was absolutely terrified to tell her adult children, because she spent her whole life telling them to say no to marijuana. And I said, they have to know that you’re doing better. Aren’t they asking you, what are you doing, mom? What’s changed? And she said, oh, I just told them I’m doing some alternative stuff. And she never confessed. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=687950">11:27</a> It still is. I actually do some consulting work with a company called the Farmstand that’s based in a community called the Villages in Florida. And it’s to the degree that any retirement community could be described as a party town, this is a party town made the news not too long ago for having a really high incidence of STD’s. For instance, Friday night, Saturday night parties are of community wide. But I gave this talk, and one of the questions I asked a group of maybe 150 residents was, do you talk to your healthcare provider about your medical cannabis use? After I asked many people how many used it, and I would say less than one in ten were willing to talk to their healthcare provider. This is a community that really loves to live well and is out there and doing what they want to do and enjoying life as much as they can. And yet, stigma about cannabis really, really held them back. It was really, really impressive to me. So I think stigma is still a huge issue. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=744360">12:24</a> So one in ten people who said they were using it told their healthcare provider, and the other nine out of ten did not. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=751088">12:31</a> Yeah, if you believe the results of an informal. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=753704">12:33</a> Sure, sure. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=754840">12:34</a> Yeah. It was something like one in ten, and a lot of people weren’t. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=758376">12:38</a> So how do you both bring it up? And maybe Eloise, like, in your Stanford perspective as a nurse practitioner, not in, like, your cannabis clinic perspective, I’m guessing. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=769560">12:49</a> They come there for some. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=772440">12:52</a> Yeah, that’s kind of a no brainer, right? Yeah, I mean, I think one of the things I’m proud of is that, you know, Stanford was seeking someone with my knowledge for their clinic because patients wanted alternatives to the medications, the pharmaceuticals that were being offered. And so I have free range to talk to my patients about cannabis, and it’s in my bio. So sometimes they are seeking me out and asking to meet with me personally, or they read my bio, and then it comes out during the conversation where they’ll admit other times. I. You know, one of my favorite stories was a gentleman with pancreatic cancer who had intractable nausea and vomiting and nothing worked. And you know, I thought, well, here’s someone I would actually bring it up with. But he was a DA for the last 25 years, and he did the marijuana convictions in his county. And I thought, oh, my gosh, you know, am I going to bring this up to this, this guy? But I just decided, I said, you know, his meeting over video with him and his wife, and I said, you know, I have a suggestion. I don’t know how you’re going to feel about it. And they both got these big grins on their face because they just knew that I was going to say, you know, what do you think about cannabis? And they were relieved because their friends were bringing over bags of this stuff, and they’re like, we don’t know what to do with it. So I was able to guide them. I put them on a transdermal cannabis patch. His nausea and vomiting stopped. His quality of life went up. I mean, it was really kind of, you know, when it works, it can be quite magical. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=862180">14:22</a> David, do you talk about it with your patients? Do you recommend it or prescribe it? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=868700">14:28</a> Yeah, I mean, it’s a slightly different situation for me, more than slightly. Medical cannabis is not legal in North Carolina, so there are definitely some limits. I mean, I haven’t heard of anybody getting in trouble with state medical board for recommending it. I generally, except in rare circumstances, don’t recommend it to a particular patient. I always, always, always, almost always ask what people are using. Are there any medications or alternative remedies you’re using that aren’t in the medical chart that we should know about? Because if I’m recommending benzos or opioids, I want to know what else they’re using. It’s not me being big brotherish. I want to know what the milieu is that I’m throwing these scheduled drugs into. So I ask all the time, and then usually, short of getting the recommendation, I’m happy to talk with patients about what the evidence shows if they’re using it for neuropathic pain, happy to discuss what we know. One large scale meta analysis found benefits and they didn’t. Here’s what we know, here’s what we think we know, and that’s usually the way I approach it. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=937280">15:37</a> So let’s break that down. What do we know? Where is the evidence the best for the use of medical cannabis? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=947580">15:47</a> I would say chronic pain, but not specifically malignant chronic pain. There’s concrete evidence that it can help with chronic pain in older and adults. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=959740">15:59</a> Yeah, yeah, that would probably be at the top of my list, too, although it’s kind of humbling. I mean, I used to say chronic pain for sure, especially neuropathic pain, both because the evidence I thought was good and also because that’s where we get tripped up. Um, opioids don’t work so well. A lot of people don’t like gabapentin lyrica. Sometimes we do methadone here. Buprenorphine maybe, but there. The studies I mentioned before, Mark Ware did a big meta analysis that found some benefit from neuropathic pain. But there was a Cochrane review that was almost identical in methods. Maybe it occluded. One other study, I think, that came out a couple of years later that found no benefit. So I’m still convinced it for neuropathic pain, but the data are messier than I like. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1004712">16:44</a> How much is it? Because cannabis could mean a lot of things, so it could just mean THC, it could be the CBD, it could be a combination of both. It could be the entire plant with everything else in it, and then it could be. How are you actually delivering it? Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1020920">17:00</a> So many different things. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1022192">17:02</a> Are you vaping it? Transdermaling it? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1026070">17:06</a> Yeah, it’s a little repositories. Palliative care works. And then another study says that palliative care doesn’t work, but not like what’s in the syringe. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1036150">17:16</a> Yeah. And we don’t really look at dosages when we’re doing these studies. So I think that’s one of the challenges we have, is that, you know, you can look at these studies that will say, well, they smoked anywhere from, you know, one to ten joints a day, and we don’t know the THC content or the other cannabinoid content. So I think it’s. We need more studies that really hone in on the dosages of the different. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1058160">17:38</a> Cannabinoids, because the amount of THC to CBD is going to vary potentially dramatically. Right. From one source to another. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1069480">17:49</a> Yeah, yeah. And we’re not. And even the evidence on CBD, I think, is promoted as. It’s going to be like a dimmer switch for THC. Right. It’s going to help lessen some of those unwanted effects. But if you. The evidence is all over the place. It’s like, some say it makes the THC less sedating, some says that some CBD can make it more sedating. So it’s really hard to know. What should I try? Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1098200">18:18</a> And reading your book, David, I get a sense that many of the unwanted, well, I wouldn’t say unwanted, maybe for medical marijuana, a medical cannabis, the unwanted effects, the euphoria, the high feelings that’s coming from THC. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1116920">18:36</a> That’s true. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1117776">18:37</a> The sedation versus CBD may not have as many of those or if any of those side effects. Is that right? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1126120">18:46</a> Yeah, I mean, I usually say that CBD isn’t psychoactive, and then I have to correct myself and say, well, in really high doses, for instance, there have been a couple of studies showing that CBD in really high doses, 500, 600 milligrams, can reduce social anxiety. So there’s probably some psychoactive effect of CBD, but compared to THC, it’s essentially zero. At least I appreciate Eloise’s thoughts. That’s my take on it. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1150898">19:10</a> What’s your take, Eloise? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1152530">19:12</a> I usually say it’s non euphoric because it is psychoactive. Yeah. And THC is known for the euphoric effects and it’s also biphasic. So in small doses that it can be euphoric, but in large doses it can be dysphoric and people can have that paranoia and anxiety, very unpleasant experience. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1173380">19:33</a> Yeah, that’s a funny thing, right? Some people helps. We’ll get into anxiety in a brief second. Some people may feel less anxious, some people may get very anxious. And then, David, I also learned from your book, if they start withdrawing from their marijuana or as the kinetic get out of your system, you may actually feel more anxious. So you’re actually treating the anxiety from using a lot of cannabis, is that right? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1200260">20:00</a> Yeah, I think so. I mean, I think, you know, people talk about withdrawal syndrome and it is an official DSM for diagnosis, but I’m not sure it’s. I mean, I haven’t seen it the way you see, you know, alcohol withdrawal, for instance, or opioid withdrawal, but there probably something. There’s something there. And for people who use cannabis for sleep, which we haven’t talked about, but I’ve certainly heard of people who get into the habit, like with Ambien or anything else, who use it every night for weeks and you miss a dose and you really have trouble getting to sleep. So there certainly is some tolerance that builds up. I wouldn’t want to make too much of that because in the overall scheme of things, it’s not like withdrawal or tolerance to other psychoactive drugs. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1245830">20:45</a> Okay, so maybe some evidence for chronic pain, maybe neuropathic pain, it’s not going to bring your pain down to zero, right? It’s gonna maybe, like other agents, maybe reduce it by a couple points out of a ten point scale. Is that sound about right? And is it the THC or the CBD or the combination. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1268480">21:08</a> It depends. I mean, there’s other cannabinoids that are coming out, too, that are showing some evidence, like CBG seems to play a pretty significant role in neuropathic pain and anxiety. There’s also CBD, a and THCA, which are considered the raw forms that can help with pain and anxiety, which aren’t as well studied or available. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1290240">21:30</a> Yeah. And are all those are naturally occurring cannabinoids? Like, if you smoke it, you get those or vaporize it. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1298688">21:38</a> CBD A and t. Any of the cannabinoids that have an a afterwards are considered raw, and then they become neutralized through heat. So either they’re heated in an oven or they’re smoked, and then I. THCA becomes THC through that heating process. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1316310">21:56</a> But that is an important point. I mean, when you look at the cannabinoids in the cannabis plant, we all focus on THC. That’s kind of the popular kid at the party. That’s the cannabinoid that’s been the best studied. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1326390">22:06</a> That’s Marinol right there. Right. We have a pill for that. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1329782">22:09</a> Exactly. But there are a whole bunch of others, some of which we’re starting to understand, some of which just sit in test tubes somewhere. But we know what they are, what they do. But there are well over 100 cannabinoids that have been isolated so far, of which we talk mostly about THC and CBD. But that’s really tip of the iceberg. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1346842">22:26</a> Hmm. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1348010">22:28</a> And then what? Before, because I want to talk about dosing and preparations, but before we do that, other things that we have a pretty good feeling that medical cannabis may help it. So we talked about pediatric seizures. That was the pediatric part, so pretty good evidence. Right. Pain. Anything else? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1368160">22:48</a> I would say one of the common reasons in palliative that people want to meet with me is they use cannabis for appetite stimulation. And I would say the evidence is pretty low. And often I don’t see great results, particularly in females versus males. There’s not a lot of evidence to back that up. It’s just what I have observed over the years. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1388944">23:08</a> But, yeah, yeah, I got to say, I’ve never seen any effect from Marinole, just that THC component. David, your thoughts on anorexia, cachexia? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1400430">23:20</a> Yeah, pretty much the same. I mean, I think in theory there’s a reason it should work, and there’s some regulation of some appetite related hormones like ghrelin. So we know from lab research that there should be an effect, and there’s some effect on appetite. I think anybody who’s used cannabis recreationally. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1418758">23:38</a> Knows that gets the munchies. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1420846">23:40</a> Yeah, I just don’t think it’s enough of an effect to wipe out the cachex syndromes that we get in heart failure, lung disease, or cancer. It’s like trying to kill an elephant in the fly swatter. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1431826">23:51</a> What about nausea, vomiting? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1433770">23:53</a> It’s kind of hit or miss, I would say. What do you think, David? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1436722">23:56</a> The same. I think. I haven’t seen a whole lot of evidence, but again, I think there’s enough background biochemistry evidence that it can alter serotonin metabolism number one. And number two, honestly, I’ve just heard so many anecdotal reports, and I realize that’s anecdotal medicine. It’s not evidence based medicine. But you hear patients telling you again and again and again, look, chemotherapy is a whole different ballgame. If I can have a joint in the parking lot before I drive home some of that placebo effect, but I’ve got to believe there’s something real there. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1474780">24:34</a> And then spasticity or cramps in M.S. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1480780">24:40</a> I don’t see a lot of those patients. What about you, David? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1484036">24:44</a> I don’t. But a big company out there, GW Pharmaceuticals. Yeah, and hundreds of millions of dollars in trials and FDA approvals. So the official answer would probably have to be, if you believe the whole. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1500788">25:00</a> Drug development approval process, what drug is that? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1503920">25:03</a> Satabx. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1506200">25:06</a> And then any other conditions that we think it works in besides the one we’ve talked about right now. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1512048">25:12</a> Yeah, I would add sleep to that. There isn’t a whole lot of randomized controlled trial data that I’ve seen. But if you look at some of the sativax studies, they looked at side effects. And one side effect that comes up often was the side effect of being sleepy, which, if you’ve used it, you don’t really need a researcher to tell. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1531168">25:31</a> You how much of that is like a benzo. Yeah, it makes you sleepy, but it doesn’t help with sleep architecture. People feeling more wakeful during the day, rested. Do we have any evidence around those. Those outcomes? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1547260">25:47</a> No. I mean, if I know it’s not doing much for sleep architecture, and it makes you fall asleep more quickly, depending on the preparation. I work with a company called Curio. It’s based in Maryland, now in multiple states, but has a product that has a sustained release form. So you get an initial dose and then a little bit later, two or three in the morning to help you stay asleep. For those folks who. Whose problem is actually sustaining sleep, not initiating. And a lot of rave reviews, but I don’t have any idea what architecture. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1579630">26:19</a> Well, let’s get to the nitty gritty. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1582270">26:22</a> I do want to add one thing. Neuropsychiatric symptoms in dementia patients. That’s where I’m seeing cannabinoids have a significant impact for those patients. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1593470">26:33</a> Which kind of symptoms? Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1594662">26:34</a> Like behavioral symptoms? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1596830">26:36</a> The behavioral symptoms, yeah, the agitation, anxiety. Calms them down. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1602446">26:42</a> Yeah. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1602806">26:42</a> I discovered that one of the interviews I did for stoned was with a filmmaker in Israel whose debut film, I think, was based on time he spent in a nursing home helping older adults to use cannabis. And he said that the result was just magical. And there’s actually a paper published in the dementia Congress that happened in Brazil just a month or two ago that reported on exactly what Eloise is saying. Reduction in agitation symptoms, which, especially in a world where we’re under pressure to reduce or eliminate the use of antipsychotics, for instance, for those patients, having an alternative is really potentially very cool. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1641056">27:21</a> So how do you get, I know in your book, for those, again, I’m going to plug stone, I think, in Israel, for somebody who couldn’t actually smoke it themselves, the filmmaker actually blew the smoke in his face. Is that right? Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1658646">27:38</a> Interesting delivery mechanism. That’s something we teach in palliative care fellowship. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1665750">27:45</a> And speak for yourself, we do things a little bit differently at Duke. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1671790">27:51</a> What’s the delivery that you recommend or how it’s done? Eloise, what do you do? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1677790">27:57</a> Well, often the dementia patients can get paranoid and refuse their medication. So gummies tend to work the best because it’s a sweet little treat that they like, and it provides a longer lasting effect for them. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1691630">28:11</a> Alex is going for his vitamin. I’m using air quotes. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1695870">28:15</a> It might. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1698550">28:18</a> Let’s talk about that preparation. It’s because you can smoke it, you can use vaporizers, you can use gummies. David, you talked about, you tasted a beer and tea that had cannabis in it, and there’s differences. Right? Like, some of them give you more of immediate effect, some of them a more prolonged delayed effect, which also potentially changes how we think about kind of the euphoric symptoms. How do you think about all these different preparations? I’m going to turn to you, Eloise. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1735100">28:55</a> Yeah, I think it depends when we’re doing our initial intake and assessment on a patient. In a lot of the nausea and vomiting cases, I will often try to do a transdermal patch. If they’re reticent to inhale for any reason, the tinctures, the drops, oil drops, can often have a strong smell and taste, and so they might have want to avoid those because it can make them vomit or make them more nauseous. And there are suppositories out there, too, although they tend to be expensive and a little bit more invasive than most people want to go. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1770314">29:30</a> Do you ever recommend smoking or vaporizing? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1774770">29:34</a> I do, yeah. I think that there’s, you know, there’s short term benefit. So if it’s a. If it’s an acute issue that we’re trying to resolve, then inhalation, you know. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1784730">29:44</a> Might make sense generally through vaporizing, because I always worry about burning plant matter, and inhaling it can’t be good for the lungs. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1796290">29:56</a> They’ve actually done quite a bit of studies looking at inhaling cannabis through a joint. It does show long term it can cause airway inflammation and chronic bronchitis, but short term benefits show that it can actually open up the airways. Again. There might be some benefit over risk initially, but you’re right, you are burning it to the point of combustion. You’re producing tars and carcinogens, and it can certainly irritate the throat and the lungs. So if they have mucositis or radiation, they’re not going to be a good candidate. Vaporization is hard because most of the products on the market here in California are called vape pens or wax pens, and they’re oils that are battery operated and probably burned to the point of combustion as well. So you’re not really getting that vaporized benefit. And if you really wanted to vaporize it, you’re going to have to invest hundreds of dollars into a vaporized device and the vaporizer. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1855706">30:55</a> David, you did a lovely discussion about how a vaporizer works, and it depends on temperature, right? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1862650">31:02</a> Yeah, it’s basically what Eloise said, that the theory is that if cannabinoids vaporize at a lower temperature than combustion occurs, then you want to heat flower plant bud to the temperature that’s above the vaporization point, but not high enough to get matter to burn. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1882824">31:22</a> Yeah. And THC may be a little lower than CBD, so you can also potentially change your ratio. In theory, yeah, in theory. Okay, I got to ask about transdermal because I thought THC wasn’t significantly absorbed transdermal, and there’s questions about CBD. Thoughts on that? David, I’m going to turn to you first. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1905970">31:45</a> Yeah, I heard Eloise say that she recommends patches, so I’m going to maybe keep quiet. I mean, I love the idea of transdermals. I mean, with the caveat that some people really want, want a sense of control, and they don’t really like the idea of sticking a patch on. They want to be able to manage their own symptoms. So there’s a big aspect of patient preference there. But it’s really interesting. I mean, the lab studies I’ve seen, Eloise really make me not so optimistic that you’d actually get meaningful amounts of THC or CBD absorbed. But I mean, there are a lot of products out there and people swear by it. So tell me, what’s the truth? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=1946520">32:26</a> Yeah, I mean, I think definitely what I see in practice is that transdermal gives some patients more control. So there are those that are still really reticent to even try cannabis because they’re afraid of the high, right? They’re afraid they’re going to lose control or they’re going to hallucinate. If you offer them a transdermal patch, which typically can work in like 1520 minutes and last for six to 12 hours, if they’re having an unwanted effect, they can remove that patch and actually undo their experience. The only cannabis delivery method I know of where you can actually undo the potential euphoric effects in real time. There’s really only one company out here in California that I recommend. It’s becoming really hard to find in a very adult centered market because medicinal products just don’t fly off the shelf. And they’re expensive, so it can be cost prohibitive for a lot of patients. But they’re directed to go usually on like a, on the wrist, where there’s a thinner layer of skin and the blood supply is closer to the skin or on top of the foot. So it does, you know, they obviously put chemicals in the patch to help the penetration, the permeability of the skin, and it bypasses the liver. So there’s less drug to drug interactions, there’s less intensity with the THC. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2022920">33:42</a> So the bypassing of the liver is important from a bioavailability standpoint. Right. The liver will chew this stuff up and youre not going to see a lot of it. Then. How do edibles and gummies work, if thats the case? David? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2036728">33:56</a> Well, yeah, you definitely lose some in the first pass effect, but its not like opioids, where that first pass effect really takes out a lot of effectiveness because the cascade of metabolism for cannabis cannabinoids is pretty complicated. And theres some metabolites that are as active as THC is the same as for CBD. So it’s maybe less of a differential, at least in my mind. But, yeah, in theory, cannabinoids like opioids, if they’re absorbed buccally, you miss that first pass effect. It feels to me like, from what I’ve seen and heard, it’s less a matter of dose. It’s not like you lose a lot of effective dose with oral administration going through the GI tract. It’s more of a delay. And that kind of manifests as uncertainty. Like, you eat a gummy and you might start feeling something in ten minutes, it might be 40 minutes, depending on your diet and other things. And some people don’t care about that. Other people really want to know. Like, I want to know that I’m going to get some relief. I’m going to begin to feel this. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2101166">35:01</a> So like a vaporizer gives you more of a quicker onset. So you know what’s happening? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2106630">35:06</a> Yeah, it’s like a PCA pump. Like, you hit that button and you get a double. Now it’s the same thing. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2112558">35:12</a> Yeah. It’s more predictable. It’s a little easier to control. I mean, edibles in some patients, I’ve had them report four hour delay before they feel the effects. So it’s unpredictable. And then THC gets converted into a different metabolite that’s actually much stronger than the delta nine THC. So it’s a much more intense experience, which is why people can have tachycardia and the paranoia and anxiety. And I end up in the emergency department. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2139900">35:39</a> And then how do you think about THC versus CBD ratios? Louise, I’m going to turn this one. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2146260">35:46</a> Yeah. I really like to kind of focus on one dominant cannabinoid at a time, just so I can isolate the experience and get a sense of how they’re responding. And then maybe I’ll add in some different cannabinoids and layer them on top. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2159100">35:59</a> So give me an example. So do you just, like, focus on THC first or do you focus? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2164524">36:04</a> Well, it depends. Yeah. So if you came to me and you had neuropathic pain, particularly, that bothered you mostly at night when you laid down, it was impacting your sleep. I would start with low doses of THC. If you came back to me and said, it’s really helping my pain, but I’m waking up and I’m feeling pretty groggy in the morning. I might add in some CBD to see if we can decrease some of that early morning groggy effect. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2188738">36:28</a> Yeah. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2189514">36:29</a> Or I might add in CBG, which can also help a little bit with the pain and sleep, but maybe not, as, you know, intense of a euphoric effect. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2200254">36:40</a> And when you’re talking about low doses of THC, like, what are the doses and how are you prescribing it? Let’s say I’m coming in with neuropathic pain. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2209750">36:49</a> I would first present to you what I think your options are. So it might be a topical, which we actually haven’t really even touched on. There’s. There’s some evidence that topicals can help for neuropathic pain. They work quickly. They don’t last very long. So if you’re just having a hard time falling asleep, I might say, let’s try a topical. If you’re new to cannabis, might have you get the tinctures or the drops so that we can just start with, like, half a milligram of THC and slowly ramp you up from there. It is sort of dependent on what’s in the market in the area where the patient’s at. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2241830">37:21</a> What about Marinol as a starting place? Do you ever go there? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2246510">37:26</a> Not unless I’m totally desperate and a patient can’t afford it. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2249622">37:29</a> It’s just. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2253530">37:33</a> Marinol is synthetic THC, so it’s actually a full agonist at the cannabinoid receptors, whereas plant based THC is a partial agonist. So similar to, like, buprenorphine, where it’s a partial agonist. We don’t see as many side effects. When we do with our full agonist opioids. It’s similar to plant based THC and marinol. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2272610">37:52</a> So with Marinol, you get too many side effects. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2276042">37:56</a> You can. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2276984">37:56</a> You can. Yeah. That’s your major concern? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2279680">37:59</a> Yeah. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2280312">38:00</a> Interaction with dronabinol usually is cleaning out the medicine cabinet. Whenever I see it on a patient’s chart, I ask whether it’s helping, and they say no. And I ask if they have side effects, and they say yes. And I ask if we should stop it. And they say no. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2290864">38:10</a> It’s like gabapentin. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2293080">38:13</a> Yeah. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2296400">38:16</a> Any other pearls around dosing, David, any from your perspective? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2301090">38:21</a> I don’t think so. I think we’ve talked about some of the big ones. I mean, just to hammer home. What is a mantra for all of us, I think, is if there’s potential benefit, you don’t want to scare people away, so start low. It’s not usually something like a pain crisis where you really need to get drugs into people. Now, if you gradually ramp up over a couple of days, it’s not going to be the end of the world. So that’s often the advice I give. If somebody has a bad experience but wants to try again, I would ask them how fast they ramped up and what their initial dose was. And, you know, if it was initially a 20 milligram THC, gummy, maybe you should cut that in order first. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2340234">39:00</a> Or they, or they ate a brownie a half an hour later, didn’t feel anything, ate three more brownies, and then they passed out 2 hours later. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2350450">39:10</a> Yeah. Yeah. For real, I would say. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2352418">39:12</a> Sounds like a college story. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2353650">39:13</a> No, there was actually in Colorado, I think there was that Atlantic article or New Yorker. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2360562">39:20</a> Yeah, that was a great article. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2363338">39:23</a> Right. As opposed to vaporizing, eating the brownie, you don’t know exactly when it’s gonna kick in. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2369810">39:29</a> Yeah. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2370290">39:30</a> And then if you don’t know, you may take it more of it because it hasn’t kicked in yet, and then you kind of overdone it. Is that right? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2377498">39:37</a> Happens a lot. Yeah. I was just gonna add, with CBD dosing, I think that there’s a big misconception out there, and people actually need hundreds of milligrams to get any kind of relief on its own. If they’re really afraid of THC and they’re like, I just want CBD. They usually need hundreds of milligrams to get any relief from anxiety, sleep, or pain. So most people give up on it before they get any results. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2404380">40:04</a> Do you use these medications as a primary treatment or let’s say for pain, for example, which is probably the most, or maybe the most common indication? I could be wrong about that. Is it an adjunct or is it something that you’d start with? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2420430">40:20</a> It’s patient preference. Often people come to cannabis when they failed everything else, so it’s usually a last resort for them. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2429110">40:29</a> Yeah. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2429710">40:29</a> Yeah. And if nothing else is working, I did have a patient when I first started at Stanford who fired me because he was on high doses of methadone and lorazepam and, like, he had all these really heavy, you know, benzodiazepines and opioids, and he said, would you prescribe Zolpiden for sleep? And I said no, but some of my patients use THC to help them sleep. Do you want to consider that? And he said no, and then asked for a new provider, which I thought was pretty funny. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2463430">41:03</a> Well, so we talked about benefits. Let’s talk about potential risks. What do we know of the risks? Because, I mean, I’m just thinking back to what David was saying, that the person who felt after getting chemotherapy, he needed to smoke that joint before he got into the car to drive home. To drive home. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2485310">41:25</a> I believe that was the phrase. Oh, yeah. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2487358">41:27</a> Not to have somebody drive him, but to drive home. What do we know about the side effects, including cognitive side effects, of these drugs? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2494640">41:34</a> Yeah, we can get the obvious ones first. So driving, operating heavy machinery, not really a good idea. When I was working on stone, actually, one of my patients who’s at the VA, had bad neuropathic pain, and he was telling me that he used cannabis in the morning. He also told me that he took his kids to school and I put two and two together. And so we went to this deserted parking lot and he fired up a joint. And then I laid out this obstacle course. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2523290">42:03</a> Obstacle course of bananas, by the way, because. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2526970">42:06</a> And he just. Many, many bananas died that day. That was kind of a learning intervention for him, showing that it does affect so driving, for sure. Although it’s interesting, maybe I’ll make this point and then we can. Eloise and I can trade back and forth. But the interesting thing about cannabis and driving, to me is that people who are too stoned to drive often know they’re too stoned to drive. They have not always, but they have more insight, as opposed to people who are impaired by alcohol. They think they’re fine and they think they’re invincible. And so people do have the ability to self regulate a little bit. There really aren’t great tests for whether you’re too impaired to drive, although there’s some that are coming online, but it’s pretty impressive. Like, people who are stoned, they drive really, really slowly or ride a bike really, really slowly. Everything seems to be coming really quickly and really have a hard time focusing on what’s important, which is keeping the car on the road. So I think that definitely is a concern. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2587830">43:07</a> And that’s the THC component. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2589830">43:09</a> Yeah. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2590910">43:10</a> And then are there longer term cognitive side effects from these drugs? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2595838">43:15</a> Yeah, there’s definitely evidence that if you look at somebody who’s smoking daily, again, we don’t have good data on how quantifying those dosages or how much THC or CBD or other cannabinoids are in there. We definitely see it much more in adolescents who will demonstrate, if they’re using it daily and significant use, that it affects their overall cognitive as they get older. But they’ve also shown that if you stop and abstain from it after four weeks, there doesn’t seem to be any long term damage from it, but it’s as long as you’re using it. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2632240">43:52</a> One cool study that came out of the UK, I don’t know, like five or six years ago, that tracked people who used recreational cannabis, all different kinds, high THC, low THC, some with CBD, some without, and found that those cognitive effects that Eloise just described are attenuated in people who used THC with a lot of CBD, even after you adjust for THC dose. So that’s one study, 100 people. I wouldn’t hang too much on that, but it is possible that there’s some that what you’re actually using matters. And there may be varying cognitive effects depending on whether you’ve got CBD or other cannabinoids on board. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2669350">44:29</a> And Eloise, any other side effects you talk to your patients about? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2673430">44:33</a> Yeah, I’m definitely cautious in anybody with a history of any cardiac history, especially if they have a new onset of AFIB, because we know that THC particularly can increase heart rate, can also cause orthostatic hypotension. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2686894">44:46</a> So sometimes mild increase in blood pressure, too. Is that right? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2691070">44:51</a> Initially with smoking, it can cause an increase in blood pressure, but if you’re using it more consistently, it can actually lower blood pressure. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2700430">45:00</a> And then mental health disorders, schizophrenia, like, how do you think about that? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2705894">45:05</a> I definitely worry about. It’s not my area of expertise. I usually want them to see someone who is more appropriate for them. But you really should be looking at family history, personal history. And if they have used it, do they experience paranoia or anxiety? Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2724440">45:24</a> Yeah. And I guess one question, too, when we think about potentially using this in older populations, maybe even in those with dementia, like that THC component at Maranal, we see this, is that it can cause delirium, it can cause confusion. So kind of the opposite effect that they were looking at. How do you think about that? Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2744530">45:44</a> I don’t see it. We have some good studies with sativex that David mentioned earlier, which is a CBD, THC, whole plant preparation. It’s not approved in the United States, approved in like 33 other countries, and they’ve used it for the neuropsychiatric behaviors and dementia patients. Really low dose, you know, two to five milligrams. It’s not causing those issues. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2771050">46:11</a> David, any other thoughts? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2773170">46:13</a> I think in the secret often is with older adults, like anything else, start. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2778730">46:18</a> Low, go slow, go low. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2780994">46:20</a> Yeah, I think if you start with 1 THC in whatever preparation, I think you can maybe ramp that up. But from what I’ve seen and heard, I think you can avoid a lot of those side effects as long as you’re careful. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2792848">46:32</a> David, you mentioned at the beginning the scheduling of cannabinoids. I wonder if you want to say anything about that and where you think it needs to go in order to develop the evidence. Base for sensible prescribing. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2807520">46:47</a> Yeah. I don’t know. I mean, I’m not. I haven’t really had a hand in the. In the process of rescheduling. So everybody knows the thesis right now is that there’s interest in rescheduling cannabis. So it’s not as restrictive Loe schedule three, right? I think. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2826190">47:06</a> Correct. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2827470">47:07</a> Which would make it available through prescriptions and drugstores and a lot of politics, as you can imagine. And I know a lot of people inside the Beltway are trying to figure out what that looks like, I guess, from my perspective. Yeah, whatever. But I feel like. And this is why the stuff that radical is doing is so cool. It’s not like cannabis is a new drug that we really need to get clinical trials before we get it into people. We’ve got millions of people using this stuff. Why don’t we do a better job at learning from the people who are actually using it? I don’t think rescheduling is really going to significantly increase data. It’s a good idea. Fine, whatever. But I feel like we’re really missing the boat if we’re not learning every time somebody takes a gummy for sleep or lights up a bong for chemotherapy induced nausea and vomiting, we should be learning from that. I’m not saying we don’t need randomized controlled trials, but in terms of real world evidence, there’s a lot out there that we’re just leaving on the table. So I think that really should be a priority. And I know radical is involved in doing a lot of that work. So quick shout out. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2890032">48:10</a> Okay, I got my last kind of lightning around question for each of you. You’ve convinced listeners that they need to learn more about cannabis, medical cannabis, not recreational, but medical. Where could they learn more about this? I’m going to do the first plug because I read a New England journal catalyst article, which I’ll include in the show notes, which was absolutely fabulous coming from Montefiore. They set up a medical cannabis clinic, has some great slides and information. So I’m going to encourage listeners to go to the show notes and look at that New England journal catalyst video. David, what would you recommend? David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2927720">48:47</a> I would suggest my book, but it’s kind of out of date. I mean, the jokes are still funny, but David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2935640">48:55</a> I still laugh when I read some of it, though, which is really not the question you’re asking. I don’t know. I mean, there’s so many sources out there. I think the biggest challenge is try to get it from a reliable source. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2948490">49:08</a> And I loved your book, too, because when you go into these, not the clinic. Well, many clinics, but to the dispensary, there’s tons of knowledge that they expound on. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2961370">49:21</a> Yeah. Some of which is correct, and much of it. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2967850">49:27</a> Where. Where can we get good information? Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2970298">49:30</a> Our audience, our clinicians. So where can our clinician audience. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2974100">49:34</a> I actually have a part of. Radical health is an education company that we have on demand, self paced modules for clinicians who have more interest in learning about cannabis. We go through the foundations and advanced sciences, and we look at cardiovascular disease and dementia and some other things. So we have a whole suite of education available. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=2997348">49:57</a> Great. And we’ll have links to that in our show notes. With that, I want to be mindful of the time. I want to thank both of you for joining us. But before we end, Alex, time for a little doctor Dre chronic. Speaker 5 <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=3009680">50:09</a> I was alone, I took a ride I didn’t know what I would find now another road where maybe I can see another kind of mine now. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=3024320">50:24</a> Then. Alex <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=3024720">50:24</a> (singing) Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=3073560">51:13</a> Eloise David, thank you for joining us on this podcast. Eloise <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=3075960">51:15</a> Yeah, thanks for having me. David <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=3077538">51:17</a> You guys are awesome. Eric <a href="https://grain.com/share/recording/efe5950e-0cc4-451a-95a8-0709d29e0643/yqLQ7Jz0tbe1GZ82vKhEw52RaiSiKhe4jghStwjo?referrer=docx&t=3078778">51:18</a> And to all of our listeners, again, check out our show notes for more information. And thank you for your continued support. </div> </div> </div></div><div class="vc_tta-panel" id="cme" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#cme" data-vc-accordion data-vc-container=".vc_tta-container">CME</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> <h3>This episode is not CME eligible.</h3> </div> </div> </div></div></div></div></div></div></div></div></div></div> </div>The post <a href="https://geripal.org/medical-cannabis-revisted-a-podcast-with-david-casarett-and-eloise-theisen/">Medical Cannabis Revisited: A Podcast with David Casarett and Eloise Theisen</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></content:encoded> </item> <item> <title>Guidelines or Goals in Heart Failure: A Podcast with Parag Goyal, Nicole Superville, and Matthew Shuster</title> <link>https://geripal.org/guidelines-or-goals-in-heart-failure-a-podcast-with-parag-goyal-nicole-superville-and-matthew-shuster/</link> <dc:creator><![CDATA[Alex Smith]]></dc:creator> <pubDate>Thu, 17 Oct 2024 07:00:41 +0000</pubDate> <category><![CDATA[All Posts]]></category> <category><![CDATA[End-of-Life]]></category> <category><![CDATA[Quality of Life]]></category> <category><![CDATA[Podcasts]]></category> <guid isPermaLink="false">https://geripal.org/?p=6933</guid> <description><![CDATA[The post <a href="https://geripal.org/guidelines-or-goals-in-heart-failure-a-podcast-with-parag-goyal-nicole-superville-and-matthew-shuster/">Guidelines or Goals in Heart Failure: A Podcast with Parag Goyal, Nicole Superville, and Matthew Shuster</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></description> <content:encoded><![CDATA[<div class="wpb-content-wrapper"><div class="vc_row wpb_row vc_row-fluid no-bottom-margins"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"> <div class="wpb_raw_code wpb_raw_html wpb_content_element vc_custom_1729125448959" > <div class="wpb_wrapper"> <iframe title="Libsyn Player" style="border: none" src="//html5-player.libsyn.com/embed/episode/id/33491307/height/90/theme/custom/thumbnail/yes/direction/backward/render-playlist/no/custom-color/00548f/" height="90" width="100%" scrolling="no" allowfullscreen webkitallowfullscreen mozallowfullscreen oallowfullscreen msallowfullscreen></iframe> </div> </div> <div class="vc_tta-container" data-vc-action="collapse"><div class="vc_general vc_tta vc_tta-tabs vc_tta-color-sky vc_tta-style-flat vc_tta-shape-square vc_tta-spacing-1 vc_tta-o-no-fill vc_tta-tabs-position-top vc_tta-controls-align-left"><div class="vc_tta-tabs-container"><ul class="vc_tta-tabs-list"><li class="vc_tta-tab vc_active" data-vc-tab><a href="#summary" data-vc-tabs data-vc-container=".vc_tta">Summary</a></li><li class="vc_tta-tab" data-vc-tab><a href="#transcript" data-vc-tabs data-vc-container=".vc_tta">Transcript</a></li><li class="vc_tta-tab" data-vc-tab><a href="#cme" data-vc-tabs data-vc-container=".vc_tta">CME</a></li></ul></div><div class="vc_tta-panels-container"><div class="vc_tta-panels"><div class="vc_tta-panel vc_active" id="summary" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#summary" data-vc-accordion data-vc-container=".vc_tta-container">Summary</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> When treating heart failure, how do we distinguish between the expanding list of medications recommended for “Guideline Directed Medical Therapy” (GDMT) and what might be considered runaway polypharmacy? In this week’s podcast, we’ll tackle this crucial question, thanks to a fantastic suggestion from GeriPal listener Matthew Shuster, who will join us as a guest host. We’ve also invited two amazing cardiologists, Parag Goyal and Nicole Superville, to join us about GDMT in heart failure with reduced ejection fraction (HFrEF) and in Heart Failure with preserved EF (HFpEF). We talk about what is heart failure, particularly HFpEF, how we treat it (including the use of sodium–glucose cotransporter-2 inhibitors (SGLT2’s), and how we should apply guidelines to individual patients, especially those with multimorbidity who are taking a lot of other medications. I’d also like to give a shout out to a recent<a href="https://www.acpjournals.org/doi/10.7326/M23-2384"> ACP article on HFpEF </a>with an outstanding contribution from Ariela Orkaby, geriatrician extraordinaire (we also just did a <a href="https://geripal.org/electronic-frailty-indexes-kate-callahan-ariela-orkaby-dae-kim/">podcast with her on frailty</a>).   ** This podcast is not CME eligible. To learn more about CME for other GeriPal episodes, <a href="https://geripal.org/cme/">click here</a>.   <hr /> </div> </div> </div></div><div class="vc_tta-panel" id="transcript" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#transcript" data-vc-accordion data-vc-container=".vc_tta-container">Transcript</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=920">00:00</a> Welcome to the GeriPal podcast. This is Eric Widera. Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=4294">00:04</a> This is Alex Smith. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=5942">00:05</a> And Alex, who do we have with us today? Because I think we have someone special, a guest host. Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=12310">00:12</a> We have a guest host who has requested this episode, Matt Shuster, who’s a geriatrician and palliative care doc. He’s in Boston. He’s a medical director of Hebrew Senior Life outpatient clinic at Newbridge. And also I was in the HVMA primary care program. That’s what it was called at the Brigham way back in the day. And Matt was one of the preceptors of a good friend of mine and classmate Dawn Sherling. And Matt brought today’s topic to us. Matt, welcome to the GeriPal podcast. Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=43472">00:43</a> Thank you. I’m thrilled to be here. Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=46080">00:46</a> We also have Parag Goyal, who is a cardiologist and associate professor of medicine at Cornell. He’s the director of the program for Care and Study of the Aging Heart and director of the Heart Failure with Preserved Ejection Fraction program. Parag, welcome to the GeriPal podcast here. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=66178">01:06</a> Thank you. Thank you. Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=67202">01:07</a> And I know Parag from the Beeson meetings where we sing campfire songs at night. It’s a lot of fun. And Nicole Superville is a cardiologist and assistant professor at Wake Forest and associate director of heart failure for the Atrium Health Southern region. Nicole, welcome to the GeriPal podcast. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=87270">01:27</a> Glad to be here. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=89150">01:29</a> So we’ve got a lot to cover. We’re going to be talking about heart failure in older adults and specifically guidelines or goals when we’re thinking about heart failure. But before we go into that topic, Matt, I think you have a song request. Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=102390">01:42</a> I do. And the song is entitled medication. Pretty obvious reason to pick that. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=108670">01:48</a> What was the reason to pick that? Or will we find it in the lyrics? Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=112830">01:52</a> Well, actually, we will find the lyrics. The band is called the collection. It’s actually a song that the lead singer of that group wrote about depression. But if you look closely in the lyrics, there’s a lot of references to things that have to deal with heart failure and the effects of treatments for heart failure, orthostasis, falls, dyspnea. So pay attention to the lyrics. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=137030">02:17</a> Alex, give us a little snippet. Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=138974">02:18</a> Here’s a little snippet. And for those watching on YouTube, you’re going to see me with the guitar playing this. For those of you who are listening to the audio only podcast, Matt sent me the garageband version with like four different backing tracks. It’s awesome. So I’ll be singing along to that. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=157130">02:37</a> Feeding the beast, Matthew, feeding the beast [laughing] Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=161210">02:41</a> All right, here’s a little bit. Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=167810">02:47</a> (singing) Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=235910">03:55</a> I think I see it. Matthew, I get the lyrics. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=238230">03:58</a> Yeah, that was actually very fitting in terms of just how patients may feel. I feel like I should steal this and put this as an overhead for. Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=247766">04:07</a> A heart failure clinic playing in the background. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=255040">04:15</a> Okay, Matt, I’m going to start off with you. What motivated you to suggest this podcast? Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=261408">04:21</a> Well, I actually have been teaching, doing sessions about polypharmacy for many years. And in fact, as Alex mentioned in the intro, probably more than 20 years ago, Muriel Gillig asked me to help out with the geriatric modules at the Brigham women’s hospital primary care medicine sort of sessions. And I know one of the topics I did was polypharmacy then. And Alex, you may have actually been in one of those. Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=287764">04:47</a> Probably was, yeah. Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=289404">04:49</a> And so it’s been something I’ve thought about for a long time in practice. And in recent years, you know, the pace of new drug discovery and release by the FDA, it seems to have quickened a lot of great drugs, a lot of. A few drugs we scratch our heads about. But in the last couple years, I have a practice at Newbridge that is really old old. The average age is 87. And so there’s lots of folks who have heart failure, and the big majority actually have heart failure with preserved ejection fractions. And I’m starting to see that phrase when they come out of the hospital more and more often, guideline directed medical therapy and what that means, which is often adding two, three, even four more medications on individuals who may be on 5810 more. So it’s been that conflict between, here’s a guideline, here’s some evidence, which I must say, as a generalist, it’s hard to sort through the evidence. And how do I reconcile that with what I know are some of the dangers of polypharmacy? But that’s why I picked this topic. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=359820">05:59</a> And Nicole, as a specialist, does that kind of ring true to you? Is this tension? Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=364828">06:04</a> In a way, it definitely does. In terms of that struggle in terms of here, you’re right. You have the guidelines. You have x amount of medications to choose from. And do I apply just a, hey, one size fits all approach in terms of just checking off those boxes, or do I make it a little bit more tailored in terms of my approach? When I see a patient? I would say it’s particularly more difficult, too, because with patients with heart failure, preserved ejection fraction, you know, a lot of times they have multiple comorbidities, and so they’re already on a lot of different medications, and then, you know, you’re trying to really be selective. I personally, at least, that’s my approach sometimes. In terms of, hey, what do I add on here? Where would I get the most bang for the buck? Can I really add on three or formal medications in that particular setting? And I would imagine, too, that’s probably a struggle for other cardiologists as well. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=429630">07:09</a> Yeah. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=429998">07:09</a> So all these issues, it’s very interesting because this discussion sort of mirrors why I do what I do from a career standpoint. So in training as a cardiology fellow and then as a heart failure fellow, I got very interested in this very specific subtype of heart failure. Heart failure with preserved ejection fraction. And to your point, Nicole, these patients are older. They’ve got a bunch of medical conditions. The idea of polypharmacy or a high medication burden is nearly universal. So as I was training and learning traditional cardiovascular stuff, I was like, seems like polypharmacy and multimorbidity. And I should probably learn more about this incorporated into how I actually think about patients and older adults. And it links back to learning a little bit about frailty and cognitive impairment. But polypharmacy was a big one. And for the past several years, I study polypharmacy because of these issues that we’re actually describing. So, really important topic, and I’m excited for these next 40 minutes or so to talk this through in greater detail. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=494986">08:14</a> Well, can I ask a stupid question? Because heart failure is one of those things. Like, in med school, I think we only got taught about heart failure with reduced deduction factor. We didn’t even call it back then. We just called the heart failure. And the number of meds for that has significantly increased. So that there’s this question that we will get to. And then there’s this other thing of heart failure with preserved ejection fraction, which. Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=520448">08:40</a> I think we used to call diastolic dysfunction. Right. When we were in training, but now has a new name, heart failure with preserved ejection fraction. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=528280">08:48</a> And that’s not what the kids are calling it, Alex, either. Is it a HFpEF? Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=533640">08:53</a> That’s right. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=534576">08:54</a> HFpEF versus HFpEFdev? Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=539242">08:59</a> Yes. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=540720">09:00</a> What is HFpEF? Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=545360">09:05</a> Do we have a lot of evolution there? Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=551560">09:11</a> There’s been a lot of evolution, I would say, in the term or the entity, I would say half path. You’re right. Years ago, it was felt to be mostly just related to diastolic dysfunction. But I think the thought has really evolved far past that to where there’s a lot of ongoing research, and it seems more to be not just a cardiocentric entity, but I would say more of a systemic disease. Probably. The evidence suggests more so of aging. There’s a lot of different components in terms of just an inflammatory component, things that we see in the skeletal muscle changes in that regard. And a lot, of course, that suggests that there are different phenotypes of HFEF. So there’s still a lot, I think, that needs to be explored, and we’re trying to learn more. Hence what makes it particularly challenging, I think, in terms of trying to figure out, you know, try to get to a one size, kind of fit all. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=615452">10:15</a> Approach, and it feels like, I mean, for half ref. Reduced ejection fraction, I get it. It’s a disease of older adults, like, when you look at it. But HFpEF seems like a lot of older adults have it. It is fairly common. Does that sound right, Prague? Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=634700">10:34</a> Yeah. So as the population ages, I think this is one of the main reasons why we’ve seen a much higher prevalence of heff pEf. Part of it is also, I think the field is recognizing that there’s this subtype of heart failure. I’ll share what often happens when patients come to see us. They see doctors for years, they’re short of breath, they have fatigue, they have swelling of the legs, edema, they have all these classic symptoms of heart failure. They get an echocardiogram, which is the right thing to do. And the echocardiogram shows a preserved ejection fraction. Because this is a heart failure syndrome with a preserved ejection fraction, which is easily measured on the echo. People see that. They see it’s preserved. And often patients are told there’s no cardiovascular problem, you don’t have heart failure, you’re older, or maybe it’s from another chronic condition or. And so, unfortunately, I think for a while, this condition, for many people, isn’t diagnosed until you end up seeing a cardiologist or a heart failure doctor who’s really honed in on this to say, actually, this is a heart failure syndrome. So, yeah, it’s great that we’re all recognizing this condition much more frequently, because, again, it does disproportionately affect older adults. And I think one key part is educating the field, not just my fellow cardiologists, but also primary care doctors, geriatricians, that there’s this heart failure syndrome that is kind of sneaky, and it’s kind of difficult to diagnose any. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=725344">12:05</a> Any pearls on the diagnosis of HFpEF. Should I even be using that term, HFpEF, or should I not follow what the kids are doing? Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=734080">12:14</a> No, HFpEF is cool, and it’s fine. Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=738280">12:18</a> I used it to tell the residents that I’m still in the game. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=741962">12:21</a> Yeah. Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=744610">12:24</a> I would say that in primary care, I think we see this so much now in older adults, because there are so many older adults that we’ve sort of gotten used to the idea that our questions really are for what’s the most effective treatment? We use those bnps brain natural agapeptide tests. Those get probably overused in following patients, and we see them very elevated in these folks with normal ejection fractures, and they have edema. So I think there’s recognition. But the confusion for, I believe, is coming from some great therapies that are on board, but the data seems to be really more effective for the reduced ejection fraction population, not the folks that we are seeing more and more. Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=790118">13:10</a> Hey, before we jump to treatment, one more question. Is your impression that HFpEFde is under diagnosed in older adults? Yes, over diagnosed in older adults are about right. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=803296">13:23</a> So I think I would say under diagnosed. And I was going to answer Eric’s question about the pearl. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=808976">13:28</a> Thank you. I thought Alex was trying to bypass my pearl question. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=813080">13:33</a> For me, I think the biggest pearl is if you’ve got an older adult who has. Who has. Who is reporting to you progressive shortness of breath, don’t blame it necessarily on age or deconditioning. That’s the classic misclassification that I end up seeing. If it’s continuing and it’s getting worse and maybe they have some swelling in the legs, there are some subtle findings on the echo, but really think for a second, could this be this really common cardiovascular condition, echocardiogram, maybe even a referral to a cardiologist? If you have access to that, I think, is the way to go. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=850018">14:10</a> Yeah. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=850806">14:10</a> And I would say one thing, you know, because I think Matt mentioned about the BNP levels. I think that’s another pearl I would probably say, to keep in mind, because some of these patients don’t always have elevated bnp levels. Of course, it’s a clinical picture that you’re trying to put together, but when you think about the subtype of people with obesity and HEP pef, sometimes their Bnp levels could be just fine. So I would agree, just in terms of not trying to dismiss a lot of these patients in terms of deconditioning and really trying to sometimes hone in on the diagnosis despite a Bnp level that is not necessarily very high. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=895390">14:55</a> Okay, I got another question. GDMT was mentioned a couple times. What is GDMT? T sounds like a new age band. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=907870">15:07</a> Guideline direction, medical therapy. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=910950">15:10</a> Is that just pharmacological guideline, or does that include all guidelines, non pharm exercise, things like that? Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=917750">15:17</a> So, technically, it’s the pharmacologic therapies. And that term GDMT is just a term coined in the heart failure world, which there were lots of medicines for reduced EF, HFrEF, and only recently has there been now therapies that we call GDMT for heart failure with preserved ejection fraction. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=940270">15:40</a> Okay. And I promise I’m going to turn it over to Matthew. Ask about or Matt about the GDMT. But given that it doesn’t include non pharmacological therapies, I got a question about one of those therapies that we always ask, like, low salt diet. This was actually just brought up to me by a med student the other day. He was describing his, like, 87 year old grandma who was placed on a low salt diabetic diet. And, like, he has to convince her every day to take this, and she would rather die than continue to this diet, and he feels like he has to force her to take it. Where are we with low salt diet? Because I also feel like we target people’s low sodium diets in the hospital. We target their diuretics to this, and then they just go home and they eat something completely different. So we’re not targeting our intervention to what their life actually looks like. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=989360">16:29</a> So I have lots of strong opinions on this, but, Nicole, you can go first, and then I’ll go. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=994120">16:34</a> I too, but I’ll let you go first. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=998120">16:38</a> Hit me. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=999400">16:39</a> So excessive sodium can lead to fluid retention. And I’m not saying. I’m saying excessive sodium. So what I usually counsel on is to avoid very high amounts of salt. So what are the high amounts of salt, pickles, olives, processed meats, eating out? I mean, I think those are the big ones, so I usually recommend avoiding those. But I don’t go personally as far to say low salt diet, because the concern, and there’s some studies supporting this, is that when you suggest low salt diet, caloric intake drops. And when talking about older adults with chronic medical conditions, if you drop that caloric intake and they start losing weight because they’re not eating enough. Okay, great. They’re not eating salt, but they’re also harming themselves in other ways. So I actually explicitly will share this with patients to make sure that they appreciate that balance. I don’t want you to eat too much salt, but I need you to eat enough food to live life. Nicole, I don’t know what you think. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1061078">17:41</a> No, I try to strike that balance as well in terms of, like, the salting. And I will share something just personal. So I have a two and a half year old, and during my last pregnancy, I had gestational diabetes. And boom, boy, was it hard to count those carbs. So I think that gave me a different perspective in terms of when I counsel my patients, I’m probably similar to you. I always tell them, you know, no one’s perfect. You know, you’re gonna go out. You’re gonna probably join friends at a restaurant. I don’t know what you all at. When you went to the Beeson club, was it the Beacon Club? Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1101466">18:21</a> Beeson conference? Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1103098">18:23</a> Yes, the Beacon conference. But we’re not perfect individuals. I tried to tell them, hey, there were days when I just wanted a cheat day, and I was going to have my burger and fries no matter what that sugar was going to be. And so I try to practice with them more mindfulness in terms of, hey, apart from just thinking about the sodium, I want you to get in the habit of getting other clues to, particularly the weight I found very useful. In the mornings, you try to weigh yourself in whatever manner you choose to and then really think about your target dry weight. So you go out, you probably have your steak. If you see tomorrow, that weight jumps up by, like, three pounds. Hey, that ain’t muscle mass. That is probably your body holding on to some fluid. So, you know, get in the habit of, like, hey, maybe adjusting your diuretic, and they can call the office and we kind of work through it together if things aren’t turning around. But I’m probably right there with you as well, that know, we don’t want to be too stringent. There are studies to support that. But again, mindfulness, I think, is a big issue, and that’s how I counsel. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1172086">19:32</a> And I love this. This is like, what Matt brought up is this guidelines versus goals. People’s goals are often much more than, you know, perfect management or heart failure, even living as long as possible. The quality of life matters more. And correct me if I’m wrong, we actually have one study. Was it sodium hf? That may be suggested. Low. Low sodium diet doesn’t really add much. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1196670">19:56</a> I believe it was that one. Right. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1199230">19:59</a> And it’s actually, um. I gotta look back. I think it’s. I’m not even sure it’s explicitly in the guidelines anymore. In terms of low. Oh, yeah, excessively low. I’ll have to double check that. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1209982">20:09</a> Even the aha, I think, you know, because I remember, you know, when we were training, they would always say, like, limited to, like, 2 grams a day. And even the Aha was a little bit more liberal than us physicians. You know, counseling, sometimes through that 2 grams or, like, 1.5, they at some point was doing, like, 3 grams or something. But certainly, I think, again, it’s a practice, I think, of mindfulness and giving patients other tools as well, in terms of trying to keep their fluid status in a great place. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1240360">20:40</a> All right, Matt, I’m going to. You ask the next question, and maybe we can get into GDMT. Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1245490">20:45</a> Well, you know what I’d like to do is just give you a snippet from a case that I’ve used in talking medicine. It’s one of my old, old patients. He’s 91, lives in assisted living, has been diagnosed with HF, HF preserved ejection. HF of 55%. Has the usual collection of chronic diseases, paroxysmal afib, hypertension, chronic kidney disease, adult diabetes, a little anemia, a little edema, a little mild cognitive impairment. Uses a walker, put some stockings on with an eight in the morning, and he’s on. And this is an. I saw him back after he’d seen the cardiologist on torsemide, betoprolol, rivaroxabam, metformin, spironolactone, aspirin, omeprazole, atorvastatin, aricepthenne, and a bunch of vitamins, and was doing okay. His weight was up a few pounds from the year before, but he wasn’t short of breath. He’s pretty sedentary. He had one plus edema. So kind of from a primary care point of view, the guys are doing okay. And assisted living, the quote from the cardiologist and again, I get varied perspectives from different cardiologists. None of us are the same on this, of course. Mister X appears adequately compensated, although weight and edema slightly increased. Recommend adding SGLT, two inhibitor, and consider nephrolysin inhibitor arb if blood pressure tolerates to meet GDMT. And I think that phrase and seeing that kind of said to me, well, this is something worth exploring. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1351790">22:31</a> So there’s a lot of medicines. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1354582">22:34</a> I would actually say there’s a lot to unpack there. Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1359350">22:39</a> And it was the idea that, well, after eliciting that long list, it almost reads as if the goal is now to add two more medicines. Yet there’s so much multi morbidity going on. And how do you know you’re doing more benefit than harm? Orthostasis lecture like, you know all the things that can go wrong. And I think as a primary care doctor, I want to know the number needed to treat. I as far as the benefit for a patient like this versus the number needed to harm. And it’s hard to get that data. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1391164">23:11</a> Yeah. How much is it going to help? And importantly too, when we think about prognosis, when is it going to help? Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1397540">23:17</a> When. Yeah, what’s the lag time to benefit? Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1400740">23:20</a> So I’m going to add another piece to this that I think about practically when taking care of patients. Some of it is certainly the GDMT itself, the actual heart failure medicines that we as a field are often promoting because of substantial benefits. It’s more substantial, you could argue, in reduced HF, but I do think also meaningful in HFpEF. But the other angle I want to add here, I’m a heart failure cardiologist who researches deep prescribing. And so my colleagues, my colleagues, when I would go to conferences, that’s an oxymoron. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1437632">23:57</a> They’re all contradiction, paradox. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1440648">24:00</a> Hey, I like you and I respect you, but I don’t understand, what do you prescribing? We’ve spent the last 20 years trying to get everyone to take more meds, not necessarily less. And my view, which is actually consistent with our field, is not that I necessarily want to de prescribe heart failure medicines or cardiovascular medicines, but I want to prescribe the right meds for the right patient at the right time. And I want to get rid of the stuff that doesn’t make any sense. Why do I bring this up? The few things that you outline, the vitamins. I don’t know. I still haven’t seen any data that supports a bunch of vitamins. That people take aspirin. Why is the person on aspirin? Do they have coronary artery disease? Or is this for primary prevention, which has also fallen out of favor? He’s on metformin. You might argue that you could replace the metformin with an STL inhibitor. So now we’re not adding a medicine. We’re actually substituting or replacing. So I just wanted to add that layer of how I think about these things, because I agree. I don’t know if we want to keep add on therapy, add on therapy. If we can be a little bit more holistic and think through what are the medicines that are going to provide the greatest bang for your buck and get rid of the stuff that probably isn’t going to do anything. To me, that’s the first step in conjunction with understanding the patient’s priorities. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1518680">25:18</a> I would agree with that. I feel like, especially in that age group, I do think more so sometimes of making substitutions rather than add on. And let me even say most times to me, I think of them as well as suggestions. I actually reach out sometimes to the primary care physician to say, like, hey, let’s talk about this. Because sometimes they have much more longstanding relationships with these patients than me meeting them for a slice in time and trying to shuffle the deck, so to speak. But another layer I would add to it is also maybe more patient centric. I don’t know. I think at the age of 91, a patient should have a say, really, in terms of, hey, I can present you with some of the reasons I think we should make a switch, but what do you think? Do you think you want to go down that path of changing your medications? It sounds like to me, that patient felt like, hey, maybe he was doing okay. His quality of life was fine. It even seemed like they were suggesting that, hey, the physician themselves was suggesting that, hey, he’s doing okay. But I may propose this to you in terms of adding on these two medications. So I think I make the patient, at this point, weigh in as well. I think that’s another layer. And then look for areas of substitution as opposed to adding on. Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1607860">26:47</a> Okay, I’m going to interject here. One of our first podcasts, over 300 podcasts ago, was with Nate Goldstein, who studies heart failure management in older adults, and particularly older adults nearing the end of life. And he said, the best palliative treatment for heart failure is treatment for heart failure, which to me, seems like it would push you to really consider these meds, and that would pair that with, I was reading some, doing some preparatory reading for this, and there was a great article on annals of internal medicine that Matt sent to us that we can share in the show notes associated with the podcast, and he pointed out that actually, treatment in the most frail patients had great benefit, which flies in the face of, like, well, the sicker you are, maybe the less you should consider it. Maybe it’s the sicker you are, more you should consider it. So I just have these, like, you know, these thoughts echoing around in my head as we’re talking about de-prescribing, which, of course, I’ve drunk that Kool Aid, but they’re kind of intention in. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1670668">27:50</a> Contrast, you know, that’s certainly one way to think about it. I think, personally, the challenge with HFpEF, as I was saying, is I think there are a lot of different phenotypes, and a lot of times, these patients have a lot of comorbidities. So I think the approach in which, you know, somebody, the approach people might take to it, I think, is different. For example, you know, you might see some of these algorithms that tell you, hey, address the blood pressure first, prioritize the SGLt two inhibitor. Prioritize the MRA. What if somebody has atrial fibrillation? If it’s somebody who has coronary artery disease? Then you prioritize different things. So, I mean, I think, especially when you’re dealing with the geriatric population in particular, I think it’s okay to be a little bit more methodical. And again, probably trying to, at least from Parag’s perspective, I wouldn’t say it’s necessarily de prescribing, but I think thinking about ways to substitute. But I’ll open it up to you, Parag. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1735070">28:55</a> No, I agree. Everything you outlined, I wanted to address Alex’s point. I have a. I have a comment for both. So, the first is, there’s actually an AHA, scientific statement on palliative pharmacotherapy that just came out in the last few months that I had the privilege of participating in. One of the points in there was exactly what you’re describing, which is, well, if you manage the symptoms with heart failure therapy, some of which is GDMT, then you actually might help them feel better. And that’s actually a very patient centric, symptom based approach that you want to use at end of life. Naturally, you want to balance that with treatment burden and pill burden. But often I do continue some of those therapies at end of life. The second point is, you made a comment about frailty. What’s interesting as someone who thinks not just about polypharmacy, but all multiple geriatric condition of the setting of heart failure, which, by the way, really common cognitive impairment, really common frailty, really common is that there’s probably a bi directional arrow between heart failure and these geriatric conditions. So, on the one hand, you want to. From my standpoint, you want to think practically, okay? If they’re frail, if they’re falling, if they have cognitive impairment, they’re at higher risk of adverse drug events. We’ve got to think through how to accommodate some of these limitations. A pill organizer, having family. But at the same time, if we can actually initiate these therapies and treat heart failure itself, you might be treating and eliminating what? Or mitigating the contribution from heart failure itself. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1830190">30:30</a> Yeah. In the hospice unit that I work in, what we see sometimes is people are on, like, 20 different medicines. We come in, we pretty much stop a lot of them, or most of them, but maybe give them a little bit of afterload reduction and continue the diuretics, which they often were forgetting, and then they look great, and we’re all high. And this idea of prioritizing the ones that are going to be most important. And for me, it’s a little bit easier in my head to think about that. With reduced ejection fraction for heart failure, HFpEF makes it a little bit more challenging for me. And I think, Nicole, you said that I should think about it more as a systemic disease, like, all of these things in your body that are leading towards. So it could be obesity, metabolic syndrome, all of these things, and aging, which I would imagine makes it very hard to answer. The question that Matt brought up is, like, what’s the number to treat? Like, what’s the right thing for this patient? Because there could be a lot of things that are causing. Is that part of the problem with Heff PEF? Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1900480">31:40</a> I think that’s one of the challenges. I mean, we are part of our huge initiative called Heart share, for example, where, well, the NIH is investing almost 50 million over the next few years, really trying to get down to that very question. In terms of just the different phenotypes. We’re trying to build a huge repository, both a registry as well as a deep phenotyping cohort, trying to just figure out the different phenotypes and maybe more targetable interventions for HFpEF. Certainly there’s been a lot of progress, I would have, say, over the years, but I still feel like, again, just with the work that Sanjeev Shah and others have done. It really speaks to. This is not just a cardio centric entity, it is a disease of aging. And maybe there are multi organs involved in terms of us learning more and trying to approach patients a little differently. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1958260">32:38</a> Which, by the way, the multi organ, multi morbidity, even polypharmacy aspect, sodium glucose transport inhibitors, which we’ve talked about, STL inhibitors are a really nice medicine for them. Why? Because you’re treating multimorbidity. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1976430">32:56</a> My question is, all of this talk about individualizing care for people with Hep PEF, can I just click the easy button and just start them on an SGL too? Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=1988570">33:08</a> I kind of do. I put almost everyone sglt. It’s very well tolerated. What do I describe to them? Well, it treats heart failure, it improves metabolic health. Metabolic health probably plays a role in the pathophysiology of Heft Pep. It treats diabetes, it prevents progression of chronic kidney disease. I mean, that’s a huge part. A proportion of my patients. From a health profile standpoint, I would. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2014154">33:34</a> Have to say the SGLT, two inhibitors, I feel like they’re one of the most forgiving classes of medications. I think they’re well tolerated. So that one, I think is the easy button that we push in terms of adding those on. And then you get a little bit more details with the nuances of other things based on the kidney function when you’re thinking about your aldactone or your rns and that sort of thing, in terms of blood pressure and so forth. So I think the sglt two s for sure. I feel like that’s a very forgiving. Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2048070">34:08</a> Class, but I think that’s one of the frustrations, is that I’m obviously not an expert in trials, but from my understanding, there haven’t been regimen versus regimen sorts of trials done in this field. And I want to ask both of you, as a primary care doctor, what’s most dramatic to me is when I see the harms from too much medication, the orthostasis, the fall, the hip fracture, that’s much easier to see than the 8% improvement in hospitalization and morbidity by adding drug eggs. Should I feel confident that the studies that have shown these benefits actually were adequately, including folks in the old, old group, 80, 85 and above? Of course, to lump everyone from 65 on is the same group of patients. It’s the same as lumping ten year olds with 25 year olds. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2103218">35:03</a> To me, Casey, this is a great topic and a great question and something I struggle with a lot and think about a lot so the reality is, over the last 20 years, real world older adults have just been excluded from clinical trials. I think it’s been better for HFpEF. Part of it is the average age is older, and part of it is, I think, as a field, not just in cardiology but broadly across the country, we recognize we’ve got to include older adults. We have to stop systematically actually excluding these patients. In the past, there were age cutoffs where patients of beyond a certain age weren’t incorporated. So we’re doing a better job. Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2146380">35:46</a> And dementia cutoffs. Right. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2148364">35:48</a> So we’re doing a better job. But I do still think those who are more frail have more cognitive impairment, have more advanced kidney disease, the, a little bit sicker older adults are not really in these studies. And so I think the question for me is not necessarily oldest old, but the more physiologic or biologically aged, how do you manage medicine in those people? And my approach has been understanding what their goals are, understanding what their staging of the disease is. If they’ve got six month life expectancy, I’m going to think about things a little bit differently. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2191484">36:31</a> How so? Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2192860">36:32</a> Well, I don’t know if at six months I’m going to be as aggressive with blood pressure control, for example. I think that’s probably the most obvious. Some of these medications take, you don’t get benefit within the first few weeks. It might take six months, it might take a year, it might take a couple of years. And so I think about that aspect. So I think going slowly and being thoughtful and trying a medicine and seeing again or communicating with them, I mean, this is the nuance in medicine that we all need. The challenge is, it’s easy to say, oh, yeah, talk to them in a few days, talk to them in a week, have them come back every other week, because the time constraints and the way our, our healthcare system is built, the people at the greatest risk are these more vulnerable people. And so what happens is people just say, well, they’re older, they’re more vulnerable. I can’t risk it. I can’t start a medicine and see them six months later. So it’s hard, is what my summary is. It’s really hard. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2253640">37:33</a> Yeah. And I don’t think there’s, that’s probably not a perfect answer, I think, you know, to any of this. And again, that’s why I think, to me, it’s a shared decision making sort of approach when you’re dealing with patients who are elderly and I’m talking about 80, 90 years old, which it seems like you’re referring to, Matt? I think it’s just a shared decision making. And really, as you pointed out, Parag really centered sometimes mostly with the patients and what their goals are. So to me, that’s when you’re really moving away from just the guidelines to probably like a more goal oriented sort of approach in terms of that subset of patients who are really, most of the times, as you’re rightly pointing out, not included in most of these sort of trials. So I think it’s a more tailored approach that I take and I think, you know, try to prioritize with the patient what’s important to them. Is it adding on these kind of free, more medications to your regimen? Is that going to impact what you perceive, for example, your quality of life? Because a lot of these times, sometimes we’re talking about medications that the outcomes or the benefits are not necessarily driven by mortality. Sometimes it’s just driven by heart failure rehospitalizations. If you’re seeing a patient who’s like 80 something years old and they have not been in the hospital for years on end, are they truly getting a huge benefit from just layering on medication after medication? So it’s a complex, I think, conversation, but I think when we’re moving into particular age ranges, I make it a little bit more patient focused on what their goals are and what brings them. Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2362020">39:22</a> Quality of life, you know, for shared decision making is so important, but it presumes that the, on the clinician end that you have the right information to share and that’s, you know, feel a lot of uncertainty and I, what I’m going to be doing. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2379394">39:39</a> So, Matt, do you refer, I guess, the majority of those patients to the heart failure specialists in terms of making those decisions? Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2391410">39:51</a> Most of them have come to me, have already been seeing a cardiologist or come out of a hospital if they’re a patient that has been mine for a long time and has developed what I believe is heart failure, particularly with preserve jet fraction. I mean, I will use traditional meds, symptom based, and be thinking about adding these new drugs in a sort of one by one. And I have the luxury in my clinic to see them back every few weeks and. Really? Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2418892">40:18</a> Yeah. So what’s the typical knee jerk reaction for most of your patients who presumably feel like, hey, I’m limping around here doing just fine, but I, whoa, I saw this heart failure cardiologist and they want to add on three more medications to my regimen. Like, what’s their typical reaction? Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2439680">40:39</a> You know, it’s a delicate conversation. They may have a long relationship with that cardiologist, so it requires some collaboration. And, you know, this is back and forth between the PCP and the cardiologist. And again, it’s a luxury to have the time to do that. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2456936">40:56</a> Well, Matt, do you say to your patient who comes in, well, I can start you on this SGL two inhibitor, where in this one study, 16% had worsening heart failure or cardiovascular death. The folks who didn’t get it had 19.5% chance. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2474450">41:14</a> Right. Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2475330">41:15</a> Right. That is not the conversation I’m gonna have. Right. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2479130">41:19</a> Why not? That’s evidence right there. I can show the graph. Got it on my phone right there. Evidence based medicine. Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2487690">41:27</a> Yeah, that’s the struggle. And if I said that the patient looked back at me and say, aren’t you the doctor? I’m paying you to tell me what to do here? Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2497760">41:37</a> Or, that doesn’t sound like a lot, or, hey, that sounds great. Nicole, Parag, what do you think? How do you convert this, like, into meaningful numbers versus just setting potentially false hope that this will, and this is the hard thing about medicine. Right. There’s very few things that have a number to treat of one. And odds are most things have a much larger number to treat, and it’s not going to help this individual patient. Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2523872">42:03</a> This one patient. Right. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2525832">42:05</a> The number needed to treat thing. I don’t know. I might say something controversial here. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2531608">42:11</a> Oh, boy. Like that. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2533016">42:13</a> Give it to us, Parag. We love it. We love talking about it. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2535794">42:15</a> I think it’s helpful. Right. Lower number need to treat means that the statistical likelihood that the person in front of you may derive benefit. But there’s a fundamental problem here, which is that these are all population based studies, and the results are the average effect. You have no idea what the effect will be in any single individual patient. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2557650">42:37</a> And a lot of either direction, helpful or hurtful. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2560762">42:40</a> Correct. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2561626">42:41</a> And in a lot of these studies, subgroup analyses are done, and arguments could be made that there are very specific subgroups that are actually driving the results, but those are usually determined after the fact. And so all of that is to say, this is kind of a mess. I don’t think the answer is necessarily, hey, 3% improvement. And so that’s how you’re going to have to make a decision. I think we got to move somehow in the direction of either sort of precision or personalized medicine. How you operationalize that, how you manifest that, I think, is to be determined. I’ll throw out one strategy, which is work that we’re doing, which is n of one trials. Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2601898">43:21</a> Oh, great. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2602604">43:22</a> Which are kind of, you know, they’re trial and error. They’re basically formalizing what we all do in medicine. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2607860">43:27</a> Give me a brief, one sentence of what n of one trial is. Then I’m going to ask Nicole and Matt, another pearl from each of you when you think about heart failure. So I am going to call this your pearl. Parag, what’s this net of one trial? Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2623356">43:43</a> So the idea of n of one trial is in a single individual. You test multiple interventions and try to determine in that single individual what is most effective. That’s what we do in medicine every day, but it’s very formal. We start in med, we see them three months later. How do you feel? I think formalizing that can help us better understand how patients are feeling with the addition of a medicine. Are they having a side effect? One possible idea for future personalized medicine. We’ll see. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2651908">44:11</a> Great. Love it. So you start gabapentin for pain. You dc it three weeks later because it’s not working. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2659960">44:19</a> Then you try lyrica. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2661568">44:21</a> Oh, God. We won’t go into Gabapentin anymore. Listen to our gabapentin episode from a couple months ago. Nicole. Pearl. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2670120">44:30</a> So I would also say one thing that we probably don’t have time to discuss is, and I know we spent a lot of time on pharmacotherapy, but we are looking into non pharmacological things that can be very useful in this population in terms of things like exercise training and those sort of things that may be just as beneficial from a quality of life perspective, especially even things we did not touch on apart from exercise and pharmacologic stuff, monitoring devices that sometimes help patients stay home in terms of things like cardiomem. So I think there’s a lot going on in the heart failure space and tools that we have to use. I think we’ve touched the tip of the iceberg and may make things a little bit more confusing for Matt on the primary care. Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2716204">45:16</a> And even, and just to follow that up with all Dlane Kitsman’s work and others in cardiac rehab, I was rather shocked to read that CMS doesn’t cover. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2726548">45:26</a> Cardiac rehab, not for patients with HFpEF, and so hence why we have rehab FPF ongoing. Another study looking at the benefits of physical rehabilitation in patients with HFpEF. So I think more to come. Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2743188">45:43</a> Okay. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2743932">45:43</a> All right, Matt, take us home. One pearl. Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2746668">45:46</a> My pearl is an amazing piece of in home technology called a scale. And a rule of two plus two. If your weight is up more than two pounds, more than twice in a week or in two days, call us and let us know. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2762868">46:02</a> Yes. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2763980">46:03</a> Love that. Well, I want to thank all three of you. Oh, go ahead, Parag. Parag <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2768076">46:08</a> I approve. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2772650">46:12</a> We have all agreed on one thing at the end of this podcast. This is lovely. Alex, do you want to take us home with a little bit more medications? Alex <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2785250">46:25</a> (singing) Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2853620">47:33</a> Matt, great song selection. Parag. Nicole, thanks for joining us. Matthew <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2859540">47:39</a> Thank you. Nicole <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2860236">47:40</a> Thanks for having me. Eric <a href="https://grain.com/share/recording/f312f0e1-0dcf-45e8-b0b4-2d23c7bb416c/pdLEWuya9tPvp1rGDUn8gnWoIbIZCgg0dvd2zW4f?referrer=docx&t=2861812">47:41</a> And thank you all to all of our listeners for your continued support. </div> </div> </div></div><div class="vc_tta-panel" id="cme" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#cme" data-vc-accordion data-vc-container=".vc_tta-container">CME</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> <h3>This episode is not CME eligible.</h3> </div> </div> </div></div></div></div></div></div></div></div></div></div> </div>The post <a href="https://geripal.org/guidelines-or-goals-in-heart-failure-a-podcast-with-parag-goyal-nicole-superville-and-matthew-shuster/">Guidelines or Goals in Heart Failure: A Podcast with Parag Goyal, Nicole Superville, and Matthew Shuster</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></content:encoded> </item> <item> <title>Intentionally Interprofessional Care: DorAnne Donesky, Michelle Milic, Naomi Saks, & Cara Wallace</title> <link>https://geripal.org/intentionally-interprofessional-care-doranne-donesky-michelle-milic-naomi-saks-cara-wallace/</link> <dc:creator><![CDATA[Alex Smith]]></dc:creator> <pubDate>Thu, 10 Oct 2024 07:00:59 +0000</pubDate> <category><![CDATA[All Posts]]></category> <category><![CDATA[CME Eligible]]></category> <category><![CDATA[Podcasts]]></category> <guid isPermaLink="false">https://geripal.org/?p=6921</guid> <description><![CDATA[The post <a href="https://geripal.org/intentionally-interprofessional-care-doranne-donesky-michelle-milic-naomi-saks-cara-wallace/">Intentionally Interprofessional Care: DorAnne Donesky, Michelle Milic, Naomi Saks, & Cara Wallace</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></description> <content:encoded><![CDATA[<div class="wpb-content-wrapper"><div class="vc_row wpb_row vc_row-fluid no-bottom-margins"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"> <div class="wpb_raw_code wpb_raw_html wpb_content_element vc_custom_1728522096799" > <div class="wpb_wrapper"> <iframe title="Libsyn Player" style="border: none" src="//html5-player.libsyn.com/embed/episode/id/33399027/height/90/theme/custom/thumbnail/yes/direction/backward/render-playlist/no/custom-color/00548f/" height="90" width="100%" scrolling="no" allowfullscreen webkitallowfullscreen mozallowfullscreen oallowfullscreen msallowfullscreen></iframe> </div> </div> <div class="vc_tta-container" data-vc-action="collapse"><div class="vc_general vc_tta vc_tta-tabs vc_tta-color-sky vc_tta-style-flat vc_tta-shape-square vc_tta-spacing-1 vc_tta-o-no-fill vc_tta-tabs-position-top vc_tta-controls-align-left"><div class="vc_tta-tabs-container"><ul class="vc_tta-tabs-list"><li class="vc_tta-tab vc_active" data-vc-tab><a href="#summary" data-vc-tabs data-vc-container=".vc_tta">Summary</a></li><li class="vc_tta-tab" data-vc-tab><a href="#transcript" data-vc-tabs data-vc-container=".vc_tta">Transcript</a></li><li class="vc_tta-tab" data-vc-tab><a href="#cme" data-vc-tabs data-vc-container=".vc_tta">CME</a></li></ul></div><div class="vc_tta-panels-container"><div class="vc_tta-panels"><div class="vc_tta-panel vc_active" id="summary" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#summary" data-vc-accordion data-vc-container=".vc_tta-container">Summary</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> In fellowship, one of the leaders at MGH used to quote Balfour Mount as saying, “You say you’ve worked on teams? Show me your scars.” Scars, really? Yes. I’ve been there. You probably have too. On the one hand, I don’t think interprofessional teamwork needs to be scarring. On the other hand, though it goes against my middle-child “can’t we all get along” nature, disagreement is a key aspect of high functioning teams. The key is to foster an environment of curiosity and humility that welcomes and even encourages a diversity of perspectives, including direct disagreement. Today we talk with DorAnne Donesky, Michelle Milic, Naomi Saks, & Cara Wallace about the notion that we should revolutionize our education programs, training programs, teams, incentive structures, and practice to be intentionally interprofessional in all phases. The many arguments, theories, & approaches across settings and conditions are explored in detail in the book they edited, “<a href="https://global.oup.com/academic/product/intentionally-interprofessional-palliative-care-9780197542958?q=intentionally%20interprofessional&lang=en&cc=us">Intentionally Interprofessional Palliative Care</a>” (discount code AMPROMD9). Of note: these lessons apply to geriatrics, primary care, hospital medicine, critical care, cancer care, etc, etc. And they begin on today’s podcast with one clinical ask: everyone should be a generalist and a specialist. In other words, in addition to being a specialist (e.g. social worker, chaplain), everyone should be able to ask a question or two about spiritual concerns, social concerns, or physical concerns. Many more approaches to being interprofessional on today’s podcast. But how about you! What will you commit to in order to be more intentionally interprofessional? If we build this dream together, standing strong forever, nothing’s gonna stop us now… -@AlexSmithMD Interprofessional organizations that are not specific to palliative care are doing excellent work <ul> <li style="font-weight: 400;" aria-level="1">National Center for Interprofessional Practice and Education: <a href="https://nexusipe.org/">https://nexusipe.org/</a></li> <li style="font-weight: 400;" aria-level="1">National Collaborative for Improving the Clinical Learning Environment <a href="https://ncicle.org/">https://ncicle.org/</a></li> <li style="font-weight: 400;" aria-level="1">Interprofessional Education Collaborative (home of the IPEC Competencies) <a href="https://www.ipecollaborative.org/">https://www.ipecollaborative.org/</a></li> <li style="font-weight: 400;" aria-level="1">American Interprofessional Health Collaborative (sponsor of the biennial meeting “Collaborating Across Borders”) <a href="https://aihc-us.org/index.php/">https://aihc-us.org/index.php/</a></li> <li style="font-weight: 400;" aria-level="1">Health Professions Accreditors Collaborative <a href="https://healthprofessionsaccreditors.org/">https://healthprofessionsaccreditors.org/</a></li> </ul>   <img decoding="async" class="alignnone wp-image-6051" src="https://geripal.org/wp-content/uploads/2022/11/LOGO_for_Palliative_Medicine.jpg" alt="" width="300" height="56" /> This episode of the GeriPal Podcast is sponsored by <a title="https://palliativemedicine.ucsf.edu/" href="https://palliativemedicine.ucsf.edu/" target="_blank" rel="noopener" data-saferedirecturl="https://www.google.com/url?q=https://palliativemedicine.ucsf.edu/&source=gmail&ust=1727963112478000&usg=AOvVaw1GTLryJpxJNfSpmV_4DqFt">UCSF’s Division of Palliative Medicine</a>, an amazing group doing world-class palliative care. They are looking to build on both their research and clinical programs and are interviewing candidates for the <a title="https://aprecruit.ucsf.edu/JPF05240" href="https://aprecruit.ucsf.edu/JPF05240" target="_blank" rel="noopener" data-saferedirecturl="https://www.google.com/url?q=https://aprecruit.ucsf.edu/JPF05240&source=gmail&ust=1727963112478000&usg=AOvVaw3rlpeh9LADWlkarXY4Fysa">Associate Chief of Research</a> and for<a title="https://aprecruit.ucsf.edu/JPF05235" href="https://aprecruit.ucsf.edu/JPF05235" target="_blank" rel="noopener" data-saferedirecturl="https://www.google.com/url?q=https://aprecruit.ucsf.edu/JPF05235&source=gmail&ust=1727963112478000&usg=AOvVaw1DtbVOjJDFm8hlD2SYJ9nu"> full-time physician faculty to join them in the inpatient and outpatient setting</a>. To learn more about job opportunities, please click here: <a title="https://palliativemedicine.ucsf.edu/job-openings" href="https://palliativemedicine.ucsf.edu/job-openings" target="_blank" rel="noopener" data-saferedirecturl="https://www.google.com/url?q=https://palliativemedicine.ucsf.edu/job-openings&source=gmail&ust=1727963112478000&usg=AOvVaw121ITGs40ew6piXM1zVpaq">https://palliativemedicine.ucsf.edu/job-openings</a>   ** NOTE: To claim CME credit for this episode, <a href="https://geripal.org/intentionally-interprofessional-care-doranne-donesky-michelle-milic-naomi-saks-cara-wallace/#cme">click here</a> **   <hr /> </div> </div> </div></div><div class="vc_tta-panel" id="transcript" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#transcript" data-vc-accordion data-vc-container=".vc_tta-container">Transcript</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=25358">00:25</a> Welcome to the GeriPal podcast. This is Eric Widera. Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=52562">00:52</a> This is Alex Smith. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=53898">00:53</a> And, Alex, who do we have with us today? Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=56554">00:56</a> We have a tremendous interprofessional team here with us today. We’re welcoming back to GeriPal, Naomi Saks, who’s a palliative care chapter, an assistant professor in the Division of Palliative medicine at UCSF. Naomi, welcome back to GeriPal. Naomi <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=69566">01:09</a> Thank you. Good to be here. Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=71478">01:11</a> We’re delighted to welcome Michelle Milic, who is a pulmonary in critical care and palliative care doc and associate professor of clinical medicine at Georgetown. Michelle, welcome to GeriPal. Michelle <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=82350">01:22</a> Thanks for having us today. Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=83902">01:23</a> And we’re delighted to welcome DorAnne Donesky, who is a palliative care nurse practitioner at Queen of the Valley Medical center in Napa and professor emeritus at the UCSF School of Nursing. DorAnne, welcome to GeriPal. DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=96850">01:36</a> Good to see you. Thanks. Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=99010">01:39</a> And Cara Wallace, who is a hospice social worker and endowed chair and professor in the St. Louis University School of Nursing. Cara. Cara <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=107858">01:47</a> Hi, everybody. Glad to be here. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=110378">01:50</a> So I’m gonna correct you, Alex. This is not an interprofessional team that we’re talking about. This is an intentionally interprofessional team. Cause that’s our topic for today, and we’re going to describe what that is. But before we do, Cara, do you have the song request for Alex? Cara <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=128790">02:08</a> I do. Our song request is nothing’s gonna stop us now by starship. And this song really feels like an invitation to me, which is something that we’re trying to do with this conversation with this textbook and this project that we’ve done together. We’ve built a lot of momentum around intentionally interprofessional, palliative care and talking with authors and talking about people interested in the textbook and in those conversations. It’s starting to feel like nothing’s gonna stop us now. Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=158290">02:38</a> Love it. This song brings me back to my youth all right, here’s a little bit. Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=165090">02:45</a> (singing) Looking in your eyes I see a paradise this world that I found is too good to be true standing here beside you want so much to give you this love in my heart that I’m feeling for you let them say we’re crazy I don’t care about that. Put your hand in my hand, baby don’t ever look back let the world around us just fall apart maybe we can make it if we’re hard, too hard and we can build this dream together standing strong forever nothing’s gonna stop us now and if this world runs out of lovers we’ll still have each other nothing’s gonna stop us nothing’s gonna stop us us now. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=227200">03:47</a> Man flashbacks to 8th grade dances. [laughing] Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=232800">03:52</a> Move your hands up, please. [laughing] Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=239360">03:59</a> Don’t you need a duet for that, Alex? Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=241704">04:01</a> Yeah, I do. That’s true. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=244460">04:04</a> We’ll see. Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=245092">04:05</a> Maybe I’ll overdub something on the audio version. We’ll see. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=249404">04:09</a> Yeah, maybe a little interprofessional. Intentionally interprofessional duet going on there. Okay. DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=260100">04:20</a> With that song, as you were singing it, I was thinking about another really important person who isn’t here today, which is Barbara head, who was our senior editorial advisor for this book and unfortunately passed away on hospice right before the book was published, but not before she had written the introduction. And as you were singing that, it just brought her to my heart and I wanted to acknowledge her, so I got it. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=287616">04:47</a> Because most of our listeners may have not seen this book, may have just figured out that we’re going to be talking about a book. So you published this book intentionally. Interprofessional palliative care has a ton of great authors, an inter professional list of amazing authors. Does somebody want to just give me, like, a couple liner? Like, what is this book? I’m going to call on you, DorAnne, since you’re the first to speak. DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=315710">05:15</a> Okay. Yeah. This was a complete epiphany moment at annual assembly one year when I happened to be talking to an Oxford editor, and she said, what do you want to write about? And I said, interprofessional practice. And she said, okay, great, write the book. And I said, but how can I do that without an inter professional team? That seems really silly, like trying to tickle yourself and then wonder why you’re not laughing. It’s like, we need to be together. And so all of our listeners are. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=347926">05:47</a> By the way, they’re trying to tickle themselves right now, and it’s not very good. DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=352550">05:52</a> Nobody’s laughing. So the first thing that the editor and I did was put together the team, because even if I had started down the direction, it would have been a nursing book with other people’s input. I wanted it to be fully, intentionally interprofessional. So before the first word was written on even the proposal to Oxford that they had invited, we had our team together. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=377550">06:17</a> And why was that so important? DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=380910">06:20</a> It just seems obvious to me. So maybe one of my colleagues can say why it just doesn’t make sense to be doing inter professional with, without an interprofessional team. Naomi <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=390850">06:30</a> I can chime in a little bit. So everyone in our whole field, plus the World Health Organization, the national Consensus Project, everyone says that interprofessional collaboration is what we’re supposed to be doing. It’s all what we signed up for when we signed up on the dotted line to be in healthcare and palliative care. We’re supposed to be the leaders and what we found and from our own experience. And then by doing this book in such a collaborative way, that across the country, the idea of what interprofessional is multidisciplinary, transdisciplinary. We’re all talking about different things, and we really, as we came together with this book, with the editors and the authors, we all came together on a vision, a revolutionary vision, that actually, we have to be as intentional about learning collaboration as we are about pain and symptom management as we are about facilitating complex family meetings. The collaboration is actually the center. It’s like the jewel of what we do. And it not only leads to better outcomes for patients, it leads to our better sustainability. We can do this work longer. We also know that people get their whole, their whole selves assessed when we have a full team. And so we really wanted to put this book out as a love letter to this idea of. No, actually, we love collaboration, but we really have to be intentional about it. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=474150">07:54</a> That’s really interesting, because what I think back to a lot of palliative care teams. Sorry, I just cursed. But if you think back to, like, even studies in palliative care, we just did a podcast on this, is that when we think about interprofessional teams, as far as evidence base, a lot of our evidence base of interprofessional teams is a doctor and a nurse, or a doctor and a social worker. And I guess that was intentional. But is that interdisciplinary, or is that intentionally interdisciplinary? Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=510780">08:30</a> Interprofessional. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=511756">08:31</a> Interprofessional. Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=512268">08:32</a> We heard a lot of terms, dang it. We do need to learn what these terms might mean and how they’re different. Multidisciplinary, interprofessional. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=518924">08:38</a> Back to your question. Yeah, let’s get to both of those. Let’s ask the first question. Is your thoughts of, like, we talk a big game in palliative care? Are we walking the walk? Cara <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=528240">08:48</a> I’ll take this one. I’m thinking about, you know, I come from the hospice world where we had our, you know, idts. We sat around as our interprofessional team, and I thought, this is what I do, right? So I got invited to write this textbook or an edit this textbooks with Dorian, and I was like, oh, yeah, I got this. This is what I’ve always done. I’m a researcher now. I build interprofessional teams. Like, I’ve got this. I’ve got this in the bag. This is what I do. And I think you mentioned when we talk about collaboration, and it sometimes just pockets and two people or three people. What I really learned in doing this textbook was there are ways to do it better. There are ways to be more intentional. I am shocked at how much growth there was for me personally on the subject area. And not only that, but how much more we have to learn as a field in this topic and how little there is out there, actually, in terms of how to do this well. So that was really a big eye opener for me, and I think that’s one of my, I think, biggest takeaways. But I think, really, response to that question is, are we doing this? Yeah, we’re doing it. Okay. We don’t want the message to be that we’re not doing this well, but there’s so much room to do it better. And I learned that at every turn in this textbook, I would come to a conversation with my ideas and have great ideas, and the product was always better. When Michelle had given her perspective and Naomi had given her perspective and Dorian had given her perspective, and we always landed somewhere different. And that’s why it was so important that every chapter had to be touched by multiple professions at every step in the process of this textbook. Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=627602">10:27</a> And just to put some numbers to the response, though palliative care is assumed to be interprofessional. This is from the last chapter of your book or near the end. The National Palliative Care Registry. In 2018, survey data revealed that only 41% of survey adult practices had the full complement of funded core team members, which is up from 25% of 2016. So moving in the right direction, but still less than half have the full complement of core team members. Michelle <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=656980">10:56</a> And I’d like to add something to that as well, too. I think we’ve all been in a situation where things just connected and there was a vibe and a sense of this collaboration that felt like it’s the secret sauce of palliative care. What is it? What is that that allows us to work well together and to really understand and be additive and be invitational to each other? I think one of the big things that I picked up from doing this work is that there is more of a formula to that. There is intentionality to it. There’s curiosity, there’s humility, there’s invitations in every direction that really allows for each person that is at the table to bring their area of expertise, their perspective, their impressions, and that all of that is additive. If nothing, if not, leads to something greater, like the alchemy that we always talked about, that we developed while doing this work. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=714950">11:54</a> I also wonder, as you’re thinking about writing this book and creating this book, a lot of the things you talk about apply not just in palliative care, but to other specialties, too. I think geriatrics very proud of interprofessional care. If you have on dialysis, there’s an interprofessional team caring for you. How did you decide to focus just on palliative care? And is there a bigger, can more disciplines learn about working with teams? Working in teams? When reading this book, absolutely. Naomi <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=754244">12:34</a> We all happen to be in hospice or palliative medicine, and we know that we all think about this as a thing. We actually all don’t just think about being next to amazing colleagues. We think about how. How do we actually collaborate with them, how do we move through differences? How do we synergize our expertise in a way that we co create a care plan. So this is applicable to anybody in healthcare and actually any kind of team. The ideas that we’re talking about here can really apply palliative care, again, especially for me, for others in my field as a chaplain and other. And I know social workers and others have told me that we can work at the height of our practice in palliative care in a way that we are not always invited to in general healthcare or being a staff chaplain or being not part of a team. And so I think it’s really important to think about the ways that we’re thinking about operationalizing this, which we have a model, a generalist specialist model, and this idea of transdisciplinary care, where we flatten the hierarchy and we all work together at the height of our practice communication. Is constant, and we co create a plan together. And so we do that with a number of different methods that we talk about in the book that are really applicable to lots of different settings in healthcare and in teams. Cara <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=841420">14:01</a> You mentioned, too, earlier about how we’re not taught how to do this. Right. And I think if we think about our educational systems, we’re still really siloed. And I think that that’s just a really important thing to think about, is how do we better teach interprofessional and groups before we get to the place where we’re having to practice it with no idea about how to actually do that. Right? Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=865600">14:25</a> Yeah. I guess the question is, when you’re teaching this stuff, like, there are important, like, there’s, I guess, Venn diagrams, right? Like, it’s really important for a particular discipline to learn the core skills for that discipline. And you can’t just put everybody in the same room together for four years and assume that, like, they’re gonna a work as a team, but they’re also gonna develop those skills that they need for their each discipline when they also have to, like, learn how to work together. How should one do that? DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=899270">14:59</a> You know, you mentioned something that I think is extremely important, which is making sure that each clinician is grounded in their own profession first. And we made some errors early on with our. It was published under the paper teen talk from UCSF, where we didn’t make sure that all the learners were grounded in their own profession, and chaos resulted. So we really see people as having two co equal professional identities. One is as a palliative care specialist, and one is as their own profession that they’re trained in. Both are really important, and that palliative care specialty is shared similar skills among all of us. And so, once people are grounded in their own profession, then they can be much more confident and comfortable in working with each other. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=954916">15:54</a> And can I ask you that paper on team talk? Like, what was. What was the issue? DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=960900">16:00</a> Oh, we had this bright idea that we just wanted everyone to come together and strip them of their professional identities, and we’re just all going to be good communications learners together. And it was actually kind of interesting to see how each of the professional learning groups had very different responses. One group was very angry because they had never been at the table as an equal learner, and it became really obvious that they had some anger they needed to work out. Others were very disrespectful of the other learners, not realizing who was in the room, and they were just talking smack about each other. And then others just simply bowed out and just said, forget, and I’m gonna. I’m gonna get on my phone here and do something else. So we now do the opposite and are very careful to make sure people are grounded in their own profession. And even among the four of us, I don’t want anyone to think that this was not a time of sometimes discomfort and pretty serious disagreement. But then we would go back to being grounded ourselves in what was important to us, both personally as well as professionally. And then we would seek for alignment. We aren’t always agreed. We don’t all agree on every single word that was written in the book, but we got to the place of alignment where we could support each other and move forward with the book, because. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1048027">17:28</a> You have a whole chapter on tension in professional teams. And I think if anybody has worked in a professional team, you know, it’s all not like, you know, puppies and kitties and roses. Like, there is tension. And in some ways, if I remember your chapter, it’s like tension is part of working in a team. Is that right? DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1072110">17:52</a> I’m curious what Michelle has to think about. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1073814">17:53</a> Yeah, Michelle. Michelle <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1076310">17:56</a> I think it is a part of working in a team, and just from the physician’s perspective, you know, in traditional training, we’re taught to take the lead in a lot of conversations and a lot of actions and a lot of actionable activities at bedside. Just very recently, I was on call in the ICU just about a week ago, and I was the doctor in charge, and there were, you know, 15 people in the room, but I had the one that was signing the supervision orders of what happened during this, you know, Perry code situation. And it was so interesting to see how, you know, I’m evaluating the room. I’m looking around, I’m running through my checklist in my head, and one of the nurses said, would you like to have, or can we. I was almost like, can we offer you this next suggestion? And I just. It kind of caught me where I was at that moment that this had this sense of awareness of this was. It was an invitation. It wasn’t a, you need to start this new medicine. It wasn’t. It was an invitation. It was an ask. It was almost a permission and this sense of deferential communication. And I just looked at her and I said, you are five steps ahead of me. Thank you. This is exactly what we need. And it’s being self aware in those moments and realizing that everyone on that team is bringing something important and valuable and showing respect in that moment, whether it’s a crisis, an emergency situation or something that you really have time to plan and to prepare for. For instance, a family meeting or an update or communication with families. DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1177180">19:37</a> I just want to jump in there. But that story reminds me of my own training, which was several decades ago as a nurse. We had a whole class session on how to frame our suggestions to physicians in question so that we wouldn’t offend them. So this is a systemic issue, I think, that Michelle is talking about. I just want to mention that this is more than just interpersonal personalities. We kind of buck in the system here, but I’m so grateful that Michelle notices that and calls it out. Naomi <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1211950">20:11</a> I think also, I was going to say, and to add to what Doran and Michelle were saying in that chapter specifically, they talk about power differentials and hierarchies and how that’s such a constant thing that we have to work on. A lot of it we don’t even have control over. It’s also our training is quite different. What we’re doing in the name of geriatrics or palliative care or even care is different depending on our training and our approaches, like Chaplin’s very self reflective other people, it’s quite, you know, measuring and assessing. So really, a lot of it is that we’re speaking different languages. And just an example of, like, the power differential and hierarchy. There’s a lot of times just because I’m called the chaplain, and people project all different things, whether I’m not clinical, whether I’m not skilled, whether I’m a nice church lady that came over from across the block to visit and hold people’s hands, whatever they think I am, that’s as much power as I have in that moment. So often I have attending a physician, attending colleagues who know me really well. I’ve worked in palliative care for years, and there’s some times where I’m in the family meeting, I’m facilitating the family meeting, and then I’m reporting out to the referring doctors, and I say, what happened? And they look at me, and they just look next to me at the doctor. And I have a number of doctors that are identified as male and white. And I just turned to them and I said, can you just please tell them what I just said? Because they can’t hear me. And so that kind of thing happens all the time. And so this whole idea that. That we are all doing our best, but Doran is the person that let me know about this theory, contact theory in the 1950s. We knew this long time ago, you can’t just put a lot of compassionate, smart people together in a room and think they’ll collaborate. There’s so many other forces that are influencing it. Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1325620">22:05</a> Yeah. And just to name a few of the more of those from the book, this is on the clinical education and training chapter. In many settings, physicians have the ultimate legal and professional responsibility for overseeing patient care, which shapes physicians physician vision and expectations for collaboration, or lack thereof, of the core palliative care professions. Physicians are typically granted the most power and authority by the systems and then goes on to talk about billing and who can and who cannot bill, and talking about physicians can write orders that members of other professions are expected to carry out. This language grounds the hierarchical paradigm in interprofessional relationships because of the scope of practice alone, and then also talking about how this is sort of ingrained in our trainees, as you’ve mentioned. And it’s very difficult to unlearn what you have learned in order to learn a new way, which is why we need an entire book about it. DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1382310">23:02</a> I want to just make a little shout out in defense of physicians, because I do get a little worried that sometimes interprofessional conversations end up being complaints about power and hierarchy that we then project onto doctors. So, as a non physician, I want to shout out that I see you, I hear you. And I just want to mention that I was practicing full time as an RN with nursing wages for 16 years of my life before Michelle got her first job. So, you know, we talk about the financial and this and that, but physicians have put a whole lot of their early life and dollars into training. And when you talk about licensure, physicians are paying thousands of dollars for licensure to maintain their certifications, and licensure is where we pay hundreds of dollars. We take one exam once for licensure and maybe another one or two for certification, and then we just have continuing education after that, where Michelle is taking a board certification literally every two years for the rest of her life at the cost of thousands of dollars. So I want physicians to know that we see you, we hear you, we really appreciate you, and we’re simply advocating that you see your role as a role, and you’re really, really valuable, as is everybody. When there’s a code situation and somebody needs to make a discussion, we don’t have time for a committee meeting, and the physician role is to make that decision, and our role is to back off and make it happen. And then hopefully we debrief afterwards and we make it much better. So I’m really hoping that physicians who are listening also hear us as very invitational we see you, we love you, we need you desperately, and we also recognize the commitment, dedication, money, time you have put in to your training. And we’re all in this together ultimately. And we also need you to bring all of us along. Cara <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1515354">25:15</a> To me, Dorian, this brings up for me the intentionality behind understanding, right. Some of those things that aren’t apparent to us at face value and how hard it is to really make time for that. But how important it is, like how important it is to make time to say what do you see as you know, your primary role here? What is your field of practice and what you bring to this space? What are your strengths? What are your challenges? How do those overlap with my strengths and challenges? How do those overlap with my scope of practice? Where are those points where we do overlap that we could have conversations about how to coordinate those within those areas of practice? Those conversations take time and intention. I don’t think it’s naturally baked into the way that we practice to have those conversations and understand the background and training and all of the thing that shapes how we practice and how we show up in those spaces. So that’s what that’s bringing up for me, Dorian, as you’re telling that story, is that we don’t understand all of this unless we ask and make space and time to have some conversations about it. Michelle <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1585586">26:25</a> And I’m going to add to that too, that that goes in every direction. Writing with and editing one of the chapters on the scope of social work practice and even seeing in the literature how little is acknowledged and recognized as a full scope of social work practice was really eye opening. I think sometimes based on our work location, our limitations in the system, we focus our work in a very small, narrow part of our actual spectrum of what we are capable of doing and what we could do at the endless boundaries of our disciplines. But I think we end up, because of the system and how we work, we sort of narrow our own minds and our vision as to what each of us can bring and can do. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1633270">27:13</a> I love that because we actually had a palliative care. We’ve never had a palliative care pharmacist until now, actually several years ago. And so I didn’t know what I was missing until we got a palliative care pharmacist. And it took a while to figure out, like what’s the role of a palliative care pharmacist on our team? And now I can’t imagine not having a healthcare pharmacist and as a doctor, I feel like I should know about drugs and how to prescribe them. But there’s this, again, there’s this overlap in skills and knowledge and expertise, but we have very distinct expertise. And I wonder how in practical, real life scenarios, how does one do this? And Naomi, you mentioned this concept of generalist specialist model. What is that? And is that the solution? Naomi <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1692190">28:12</a> It’s one idea. What we know is that collaboration hasn’t been operationalized very much. So we took this idea of, and it’s really an invitation from the national consensus project that every member of the team should be screening in all domains. So this is a practical, really basic idea that can be applied to clinical practice. It actually can be applied to research and education, too. So it’s this idea that we all are generalists in every domain. So that means that we all screen for every domain in our interactions. And a screening is one to two simple sentences to identify need in that or distress in that domain. So, for instance, I do a psychosocial screen, I do a physical screen, I do screens in all the other domains. All my team members are taught how to do spiritual, existential, religious screens. Not because they’re going to unpack the box and they’re expected to intervene on everything, but they can recognize it, and then they are taught what to do with it. Whether they have a social worker, a nurse, a physician, an NP on the team, they know what to do with that information. If they don’t, they know how to get to community resources. So that’s one idea. And then the other part of this is that we’re all specialists in specific domains. And that’s the part where we go deep. And unfortunately, since what Alex mentioned is that across the country, most teams are not fully staffed with the core or even all the expanded, amazing team members that we would like in palliative care or geriatrics or medicine. So what happens is you don’t actually get to see the full advanced practice of these colleagues. And so, number one, you don’t know what they do. You think they’re nice, they kind of, they’re there a couple days a week. They come. They mostly go in themselves because they have a huge caseload. They can’t always collaborate. They don’t always get to do all the generalist palliative care skills that all of us, as specialists do, which is advanced care planning, lead a family meeting, give anticipatory guidance at the end of life. Those are skills that we all have, but you don’t get to do those if you’re not staffed fully and you’re not on the team all the time. DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1825170">30:25</a> I also wanna make a shout out for pain and symptom management with social work and chaplains. I have found so often, I’ve been shocked because I don’t know what. I don’t know. And we’ll have a patient with very severe symptoms that are just not responding to the normal treatments. And a social worker or a chaplain will say, wait a minute, can I go in? And they have interventions that if the pain or other symptoms have social, psychological, cultural, or spiritual or existential domains, they intervene, and suddenly the medication requirements plummet and the patients are much more comfortable. So we totally forget that all of us are symptom managers as well. And we often don’t give our chaplain and social work colleagues opportunities to do that. Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1881220">31:21</a> Eric, should we? Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1882508">31:22</a> Yeah. Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1882988">31:22</a> Just in terms of very practical words to say or questions to ask, could we just ask? Naomi, when you say you’re asking about the social domain, what’s your go to question? Naomi <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1893100">31:33</a> So my social workers that I work with are exceptional, and they’ve taught me how to look at strengths and stressors in their social environment, with their family, in this moment. What do they turn to to cope? What do they turn to for strength? And also who are their people? Who are the care partners? And then to identify acute needs, suicidal ideation, financial needs, but also psychosocial needs. So they’ve taught me how to do that within a few sentences. And all of us in the team are looking at that. Sometimes a social worker doesn’t do this psychosocial screen when they’re in the room with us. Maybe another member of the team might do it because we’re all looking with the same eyes, and it’s all this. We’re dancing together with that. Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1935642">32:15</a> That’s great. Thank you. And somebody other than Naomi want to volunteer how they ask about the spiritual domain. DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1942210">32:22</a> We are still developing these questions. Sometimes I ask about what brings a patient, meaning what brings them joy when they feel at peace. Can they describe their experience? We’re still in development. We’re all learning together. Michelle <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=1959610">32:39</a> I’d like to add to that, too. We’re doing some research in our ALS clinic, and the screening question that we have is, do you experience non physical pain that is deep and uncontrolled? And so it’s just a sense of where is that in them? And we recognize it, we screen for it. But if we don’t have the full cadre of practitioners and support system, then we’re oftentimes we see what we’re missing and we don’t have a chaplain there. So that’s part of why we’re doing looking into some research in that area. But pain, that is deep and uncontrolled to me. Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2001580">33:21</a> The concept that every member of the inter professional team should be generalists and able to ask questions and regularly, routinely ask questions about all domains is probably the concept that pushes the most on the field in the way that it is now. There are many concepts in this book that have pushed on the field. That is one that’s very practical. Everyday clinical encounter, changing that. I think. I’m interested to hear what our listeners think about this and whether they feel this is practical. If they feel like they’re overstepping their boundaries, how does this, you know, what questions work? What questions ought they use? Those sorts of things. So thank you for sharing those questions. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2047208">34:07</a> And whether or not I’m gonna. I’ll be at a listener whether or not it’s efficient. So does everybody need to screen for the same questions? I can imagine as a patient, it gets really annoying when people are asking similar questions. And this even comes down to how we structure our teams. Are we all going it at once? Are we doing it separately? How do we think about efficacy versus efficiency in how we structure these teams? Guessing you all are going to say this is what the intentionality comes from. We do our teams. Thoughts on that? I’ll ask you, Michelle, how do you think about that? Michelle <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2086089">34:46</a> I’m actually going to toss this one to DorAnne because this is something that we. That we talked about in the. In one of the chapters, so go ahead. DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2096080">34:56</a> Well, on our team, which is a community hospital, not an academic institution, we have our morning palliative care huddle when we all review all of the patients who have been referred to our team and that we’re following. And so we often have one person go in to do the initial contact, the initial consult, and it can be anybody from any of the professions. And then the next morning is when they report out, and that’s when we can discuss about what, what the next step, what the interventions are. So everybody is not going in and asking the same questions. One person has done the initial consult, and then we discuss as a team and then decide, do we need to go in, you know, more than one of us, or who is the next, who is the right person to. To follow up from there? Naomi being at an academic institution, and she’s actually doing some research in this area, so I’m sure it looks a little different with an academic setting. Naomi <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2155822">35:55</a> Yeah. The number one question I get when I get this all excited about transdisciplinary and a flat hierarchy and we’re all dancing, is, do we all have to go in together? That’s my number one question I get. And I’m like, no, but in any revolution, you got to actually start with, all right, who are these people? What do they do? We go in together. Sometimes we all listen to the initial consult. Sometimes, till we trust each other, we build some communication, we build some vulnerability with each other. We kind of get to know it. And then absolutely, we divide and care, or sprinkle and sparkle or separate, split and sparkle. We call it in our team, and we all go off and do what’s needed, but we’re all looking. We constantly come back to each other, communicate throughout the day, and then we work together. So there’s nothing that says about this that we all have to screen every time or that we all have to be together. These are just seeds that we’re saying, you know what? If you want to enculturate this, you actually have to think about it, to do it very intentionally. And then once it’s seated and you keep inviting every new member of the team, you teach them how to screen in all domains. Every member of the team is invited into this transdisciplinary way of working. Then you can, and you mature in it. Then you can continue to just do work the best work you can in whatever ways you can. Cara <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2233570">37:13</a> I think, too, about how social workers are. Often we become palliative care specialists on the job, right. There are very few palliative care fellowships for social workers, very few specialized programs who teach palliative care as a specialty area. It’s generally one class, if you get it right. And so often social workers, new social workers who land in hospice and palliative care are taught by the system, right. How to become a specialist. And if that’s not the. And this is not always true, right. I think social workers, the goal is that we want to operate at the top of our degree and bring all of our training with us. But sometimes the job is what it is, and it makes it really difficult to change it, especially when we’re still developing as specialists. I think this model that Naomi’s talking about, where the system has a role in how we operate and how we train, especially for those of us who become specialists on the job, how can we think about this from a systemic level all the way, obviously from education and beyond? But I just think that’s an important component as well, to consider I am. Naomi <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2307200">38:27</a> Going to share something a little vulnerable, too, though, because we’re friends here and it’s just between us. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2312360">38:32</a> Yeah. Nobody else is listening. Naomi <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2314320">38:34</a> I have to say that for some of us who may be perceived at lower status or not, our complete role profession is not understood. It really does help to be part of a menu together initially when we see people, so that they know that it’s just part of the work that we do. And so it doesn’t mean we all have to go together. But it is great to be conscious that we all influence our status and perception to patients and care partners and the institution, the more that we can hold up each other as equal experts and skilled people in the field. And sometimes that means introducing ourselves together. That does really help. So just wanted to share that. That is part of our. Our experience. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2358386">39:18</a> Well, do you also think our training needs to change? Because, like, a lot of fellowship training for palliative care physician fellows is like, we’re training them how to facilitate and lead family meetings, and they’re doing that throughout the entire year. How do you do an intentionally interprofessional palliative care family meeting and should that change? Cara, what do you think? Expert on education? Cara <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2384250">39:44</a> No. Well, I mean, I really think. I think understanding that other people can lead family meetings is what is right. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2391876">39:51</a> Doesn’t need to be the fellow. Cara <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2393612">39:53</a> It doesn’t have to be the fellow. And how often do fellows get to observe the social worker or the chaplain lead a family meeting? Is that happening in our training spaces? I don’t know, but I think it should be. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2405180">40:05</a> Yeah. Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2406148">40:06</a> Could I ask. I know we’re kind of running up against it already because there’s so much to talk about here, about what are the qualities of high functioning teams? And to read from the book, again, this is from the chapter on critical care. Several characteristics, including humility, strong communication, trust, equity, compassion, self reflection, grace, vulnerability, and openness to engage are especially important for the combined for high functioning teams, et cetera, and goes on to talk quite a bit about humility, which I completely agree is a strong component. But I want to sort of, like, buck the idea for a little bit of that and say that high functioning teams are those that can disagree. Right. And then maybe advocate for tension not being all bad, and that those who can live in that tension and that disagreement while still feeling like this is a safe space to disagree are often some of the most high functioning teams because it welcomes those, those divergent points of view from which the best course often emerges. Any thoughts about qualities of high functioning teams. DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2472320">41:12</a> I’d add curiosity to that list. I find that curiosity and humility together when there’s tension occurring, to be curious about what happened, what is that person’s experience? And recognizing that there’s more than just my experience often takes care of it. And once again, looking for alignment, recognizing we may not ever agree, but it’s okay, we can find a path forward that works for us. Naomi <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2499450">41:39</a> I agree. Alex, what you’re saying, I think some of the most amazing experiences and growth experiences I’ve had on teams and with members is when we disagree, we step on each other’s toes and we talk about it afterwards, and we’re like, oh, my God, we’re bigger than we ever could have been. And we’re like, oh, yeah, you’re mine. You’re my person. You’re my ride or die after that. And so I absolutely agree. The things that, and a lot of people study, this interprofessional collaboration, the things they talk about are clear roles, that you have to understand what the goals are, that you have to be able to be real, that the vision has to be transparent, that there has to be mutual trust, there has to be a place you can say no. Not so often are we taught that we actually can say no to a colleague. We always think we have to say yes. So. And this idea that we actually do have to prove this case, this case is not yet proved. There’s not a lot of evidence out there that this leads to better healthcare outcomes. We wish there was, but we do have to make a financial case. We’d love to have research that supports this that says, okay, actually, we are better not just as caregivers, not just for patients, but we’re better as an institution if we work this way. And so these are the things that we still need to grow that just haven’t been. I really think one argument that is really important is if we’re all working at the height of our practice, then our capacity is actually bigger. We can go off on our own, and one person on the team can lead a family meeting, the other person can introduce palliative care. The other person could be doing something else. So that also might be a future case. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2592580">43:12</a> Okay, I got a question. We’re running out of time. As Alex puts on his guitar, one practical recommendations for the people who are listening or part of teams that they can do today or tomorrow. I guess it’s a Saturday. If you’re not on Saturday, Monday. To improve intentional interprofessional collaboration. Cara? Cara <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2614590">43:34</a> Yeah, I would say who’s missing from the room when decisions are made. Thinking about not just the clinical actions, but thinking about interprofessional at every level, which includes leadership, administration, or national societies, really thinking beyond just, just the clinical moment. Michelle <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2632884">43:52</a> Michelle, I feel that approaching every situation and every person you’re working with and being self aware of this is treating and approaching situations with courtesy, value, and respect. So recognizing that when we have our as trainees, a scut list of things to do when we burst into the room and we need to check with one more thing with that patient, and we’re interrupting speech therapies evaluation, which is going to help add to information that will help our care plan, that we pause, we acknowledge what’s happening, we value what’s happening in that moment and find a respectful time to perhaps collaborate or come back and approach things in that. DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2672826">44:32</a> Way DorAnne, I’m going to go metaphorical and trust your open hand. If you are feeling called to this type of practice, stop working so hard, stop efforting, stop stressing yourself, and trust that you will be led forward as you open yourself to this type of practice. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2693364">44:53</a> And Naomi, bring us home. Naomi <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2695692">44:55</a> All right, I’ll bring us home. I would say enjoy integrating collaboration, like any skill or competency in palliative care, and think about it as a value that you want to continue. And the second is continue to learn how to make a case of why to leadership and to institutions of why interprofessional collaboration is the best kind of care. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2714976">45:14</a> Because we can build this dream together. Naomi. [laughing] Cara <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2718520">45:18</a> Standing tall forever nothing’s gonna stop us now, you guys. [laughing] Alex <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2727480">45:27</a> (singing) Looking in your eyes I see a paradise this world that I found is too good to be true standing here beside you want so much to give you this love in my heart that I’m feeling for you let them say we’re crazy I don’t care about that. Put your hand in my hand, baby don’t ever look back let the world around us just fall apart maybe we can make it if we’re hard, too hard and we can build this dream together standing strong forever nothing’s gonna stop us now and if this world runs out of lovers we’ll still have each other nothing’s gonna stop us nothing’s gonna stop us us now. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2788670">46:28</a> Heck, yeah. Nothing’s going to stop us now thank you. Thank you, Michelle. Thank you, Naomi. Thank you, DorAnne, Thank you, Cara, for joining us on this podcast. Naomi <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2800430">46:40</a> Thank you for having us. DorAnne <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2801902">46:41</a> Thank you. Michelle <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2805686">46:45</a> And thank our authors all of the time on this project. We could never have gotten to this place without every single person contributing to that book. Eric <a href="https://grain.com/share/recording/1c7f1df9-da7f-4e6d-8136-3cc901d7669c/RBKZv5u6EAUB6DJHGtRgpN7HWNvJETBl5zUnxNg9?referrer=docx&t=2816370">46:56</a> And we will have a link to the where to buy this book on the show notes. So go to the GeriPal website and you can find out where to buy it. Eric And thank you to all of our listeners for your continued support. </div> </div> </div></div><div class="vc_tta-panel" id="cme" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#cme" data-vc-accordion data-vc-container=".vc_tta-container">CME</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> <h3 style="text-align: center;">***** Claim your CME credit for this episode! *****</h3> Claim your CME credit for EP329 “Intentionally Interprofessional Care” <a href="https://ww2.highmarksce.com/ucsf/index.cfm?do=ip.claimCreditApp&eventID=14012">https://ww2.highmarksce.com/ucsf/index.cfm?do=ip.claimCreditApp&eventID=14012</a> Note: If you have not already registered for the annual CME subscription (cost is $100 for a year’s worth of CME podcasts), you can register here <a href="https://cme-reg.configio.com/pd/3315?code=6PhHcL752r">https://cme-reg.configio.com/pd/3315?code=6PhHcL752r</a> For more info on the CME credit, go to <a href="https://geripal.org/cme/">https://geripal.org/cme/</a> Disclosures: Moderators Drs. Widera and Smith have no relationships to disclose. Guests DorAnne Donesky, Michelle Milic, Naomi Saks, and Cara Wallace have no relationships to disclose. Accreditation In support of improving patient care, UCSF Office of CME is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Designation University of California, San Francisco, designates this enduring material for a maximum of 0.75 AMA PRA Category 1 credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. MOC Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.75 MOC points per podcast in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. ABIM MOC credit will be offered to subscribers in November, 2024. Subscribers will claim MOC credit by completing an evaluation with self-reflection questions. For any MOC questions, please email <a href="mailto:moc@ucsf.edu">moc@ucsf.edu</a>. </div> </div> </div></div></div></div></div></div></div></div></div></div> </div>The post <a href="https://geripal.org/intentionally-interprofessional-care-doranne-donesky-michelle-milic-naomi-saks-cara-wallace/">Intentionally Interprofessional Care: DorAnne Donesky, Michelle Milic, Naomi Saks, & Cara Wallace</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></content:encoded> </item> <item> <title>Images of the Dying: A Podcast with Wendy MacNaughton, Lingsheng Li, and Frank Ostaseski</title> <link>https://geripal.org/images-of-the-dying-a-podcast-with-wendy-macnaughton-lingsheng-li-and-frank-ostaseski/</link> <dc:creator><![CDATA[Alex Smith]]></dc:creator> <pubDate>Thu, 03 Oct 2024 07:00:30 +0000</pubDate> <category><![CDATA[All Posts]]></category> <category><![CDATA[Death]]></category> <category><![CDATA[End-of-Life]]></category> <category><![CDATA[Podcasts]]></category> <guid isPermaLink="false">https://geripal.org/?p=6913</guid> <description><![CDATA[The post <a href="https://geripal.org/images-of-the-dying-a-podcast-with-wendy-macnaughton-lingsheng-li-and-frank-ostaseski/">Images of the Dying: A Podcast with Wendy MacNaughton, Lingsheng Li, and Frank Ostaseski</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></description> <content:encoded><![CDATA[<div class="wpb-content-wrapper"><div class="vc_row wpb_row vc_row-fluid no-bottom-margins"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"> <div class="wpb_raw_code wpb_raw_html wpb_content_element vc_custom_1727904729922" > <div class="wpb_wrapper"> <iframe title="Libsyn Player" style="border: none" src="//html5-player.libsyn.com/embed/episode/id/33305172/height/90/theme/custom/thumbnail/yes/direction/backward/render-playlist/no/custom-color/00548f/" height="90" width="100%" scrolling="no" allowfullscreen webkitallowfullscreen mozallowfullscreen oallowfullscreen msallowfullscreen></iframe> </div> </div> <div class="vc_tta-container" data-vc-action="collapse"><div class="vc_general vc_tta vc_tta-tabs vc_tta-color-sky vc_tta-style-flat vc_tta-shape-square vc_tta-spacing-1 vc_tta-o-no-fill vc_tta-tabs-position-top vc_tta-controls-align-left"><div class="vc_tta-tabs-container"><ul class="vc_tta-tabs-list"><li class="vc_tta-tab vc_active" data-vc-tab><a href="#summary" data-vc-tabs data-vc-container=".vc_tta">Summary</a></li><li class="vc_tta-tab" data-vc-tab><a href="#transcript" data-vc-tabs data-vc-container=".vc_tta">Transcript</a></li><li class="vc_tta-tab" data-vc-tab><a href="#cme" data-vc-tabs data-vc-container=".vc_tta">CME</a></li></ul></div><div class="vc_tta-panels-container"><div class="vc_tta-panels"><div class="vc_tta-panel vc_active" id="summary" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#summary" data-vc-accordion data-vc-container=".vc_tta-container">Summary</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> Can death be portrayed as beautiful? In this episode, we share the joy of talking with <a href="https://www.wendymacnaughton.com/about">Wendy MacNaughton</a> (artist, author, graphic journalist) and <a href="https://frankostaseski.com/">Frank Ostaseski</a> (Buddhist teacher, author, founder of the <a href="https://www.mettainstitute.org/">Metta Institute</a> and Zen Hospice Project) about using drawings and images as tools for creating human connections and processing death and dying. You may know Wendy as the talented artist behind <a href="https://www.chroniclebooks.com/products/meanwhile-in-san-francisco?srsltid=AfmBOoqppXSgr7fwIyrHFdO1T_a96xeaQt1GgbCTjEb9OpzLH918miuK">Meanwhile in San Francisco</a> or <a href="https://www.saltfatacidheat.com/">Salt Fat Acid Heat</a>. Our focus today, however, was on her most recently published book titled <a href="https://bookshop.org/p/books/how-to-say-goodbye-wendy-macnaughton/18777984?ean=9781639730858">How to Say Goodbye</a>. This beautiful book began as a very personal project for Wendy while she was the artist-in-residence at Zen Hospice. As BJ MIller writes in the foreword, “May this book be a portal — a way for us to move beyond the unwise territory of trying to ‘do it right’ and into the transcendent terrain of noticing what we can notice, loving who we love, and letting death — like life –surprise us with its ineffable beauty.” Some highlights from our conversation: <ul> <li style="font-weight: 400;" aria-level="1">The role of art in humanizing the dying process.</li> </ul> <ul> <li style="font-weight: 400;" aria-level="1">How the act of drawing can help us sloooow down, pay attention to the people and world around us, and ultimately let go… </li> <li style="font-weight: 400;" aria-level="1">The possibility of incorporating drawings in research and even clinical care. </li> <li style="font-weight: 400;" aria-level="1">The wisdom and experiences of hospice caregivers (who are often underpaid and undervalued).</li> <li style="font-weight: 400;" aria-level="1">How to use the “Five Things” as a framework for a “conversation of love, respect, and closure” with someone who is dying.</li> </ul> And finally, Wendy offers a drawing lesson and ONE-MINUTE drawing assignment to help us (and our listeners) be more present and connect with one another. You can read more about this blind contour exercise from Wendy’s <a href="https://www.wendymacnaughton.com/drawtogether-strangers">DrawTogether Strangers project</a>. The rules are really quite simple: <ul> <li style="font-weight: 400;" aria-level="1">Find another person.</li> <li style="font-weight: 400;" aria-level="1">Sit down and draw each other for only one minute. <ul> <li style="font-weight: 400;" aria-level="2">NEVER lift up your pen/pencil (draw with a continuous line) </li> <li style="font-weight: 400;" aria-level="2">NEVER look down at your paper</li> </ul> </li> </ul> That’s it! While the creative process is what truly matters, we think that the outcome is guaranteed to be awesome and definitely worth sharing. We invite you to post your drawings on twitter and tag us @GeriPalBlog! Happy listening and drawing, Lingsheng <a href="https://x.com/lingshengli">@lingshengli </a> Additional info: <ul> <li style="font-weight: 400;" aria-level="1">For weekly lessons on drawing and the art of paying attention from Wendy, you can subscribe to her Substack <a href="https://club.drawtogether.studio/">DrawTogether with WendyMac</a> and join the <a href="https://club.drawtogether.studio/s/dt-grown-ups-table">Grown-Ups Table (GUT)</a>! </li> <li style="font-weight: 400;" aria-level="1">To learn more about Frank’s teaching and philosophy on end-of-life care, read his book <a href="https://fiveinvitations.com/the-book/">The Five Invitations </a></li> </ul>   <img decoding="async" class="alignnone wp-image-6051" src="https://geripal.org/wp-content/uploads/2022/11/LOGO_for_Palliative_Medicine.jpg" alt="" width="300" height="56" /> This episode of the GeriPal Podcast is sponsored by <a title="https://palliativemedicine.ucsf.edu/" href="https://palliativemedicine.ucsf.edu/" target="_blank" rel="noopener" data-saferedirecturl="https://www.google.com/url?q=https://palliativemedicine.ucsf.edu/&source=gmail&ust=1727963112478000&usg=AOvVaw1GTLryJpxJNfSpmV_4DqFt">UCSF’s Division of Palliative Medicine</a>, an amazing group doing world-class palliative care. They are looking to build on both their research and clinical programs and are interviewing candidates for the <a title="https://aprecruit.ucsf.edu/JPF05240" href="https://aprecruit.ucsf.edu/JPF05240" target="_blank" rel="noopener" data-saferedirecturl="https://www.google.com/url?q=https://aprecruit.ucsf.edu/JPF05240&source=gmail&ust=1727963112478000&usg=AOvVaw3rlpeh9LADWlkarXY4Fysa">Associate Chief of Research</a> and for<a title="https://aprecruit.ucsf.edu/JPF05235" href="https://aprecruit.ucsf.edu/JPF05235" target="_blank" rel="noopener" data-saferedirecturl="https://www.google.com/url?q=https://aprecruit.ucsf.edu/JPF05235&source=gmail&ust=1727963112478000&usg=AOvVaw1DtbVOjJDFm8hlD2SYJ9nu"> full-time physician faculty to join them in the inpatient and outpatient setting</a>. To learn more about job opportunities, please click here: <a title="https://palliativemedicine.ucsf.edu/job-openings" href="https://palliativemedicine.ucsf.edu/job-openings" target="_blank" rel="noopener" data-saferedirecturl="https://www.google.com/url?q=https://palliativemedicine.ucsf.edu/job-openings&source=gmail&ust=1727963112478000&usg=AOvVaw121ITGs40ew6piXM1zVpaq">https://palliativemedicine.ucsf.edu/job-openings</a>   ** This podcast is not CME eligible. To learn more about CME for other GeriPal episodes, <a href="https://geripal.org/cme/">click here</a>.   <hr /> </div> </div> </div></div><div class="vc_tta-panel" id="transcript" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#transcript" data-vc-accordion data-vc-container=".vc_tta-container">Transcript</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1000">00:01</a> This episode of the GeriPal podcast is sponsored by UCSF’s Division of Palliative Medicine, an amazing group doing world class palliative care. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=8654">00:08</a> UCSF’s Division of Palliative Medicine are looking to build on their research and clinical programs and are interviewing candidates for the associate chief of research position and for full time physician faculty to join them in the in-patient and out-patient settings. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=25358">00:25</a> To learn more about job opportunities, please go to palliativemedicine.ucsf.edu/job-openings. Or if you’re like me and you have difficulty remember what a backslash or forward slash is. Just go to the show notes of this episode and click on the link and onto the show. Eric Welcome to the GeriPal podcast. This is Eric Widera. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=53210">00:53</a> This is Alex Smith. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=54346">00:54</a> And Alex, who do we have with us today? Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=56090">00:56</a> Today we are delighted to welcome Wendy MacNaughton, who is a trained as a social worker and is an author and illustrator and author of how to say Goodbye, a book of visual journalism. She has a TED talk. She launched these draw together groups for kids, for adults, for strangers, and she has a sub stack, draw together with Wendy Mac that you can find and join and is co founder of Women Who Draw. Wendy, welcome to the GeriPal podcast. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=86766">01:26</a> Really happy to be here. Thanks for having me. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=88948">01:28</a> And we’re delighted to welcome Frank Ostaseski, founding director of Zen Hospice Project, a buddhist teacher, founder of the Meta Institute, recipient of the Humanities Award for AHPM in 2018, and author of The Five Invitations: Discovering What Death Can Teach Us About Living Fully, something that we hope to talk about today. Frank, welcome to the GeriPal podcast. Frank <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=112652">01:52</a> Nice to be here with you all. Great to be here. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=117216">01:57</a> And we have Lingsheng Li who is a geriatrics and palliative care doc and illustrator and is currently a T32 research fellow at UCSF. You can find her illustrations online at her Twitter account, particularly those about the anti-asian hate study that we did recently and had a podcast about, as well as in annals of internal medicine. She has illustrations of clinician moral distress and coping. Lingsheng, welcome back to GeriPal. Lingsheng <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=146644">02:26</a> It’s so nice to be here. Thank you. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=148236">02:28</a> Alex and Lingsheng will be kind of a guest host today, a little bit of both. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=152316">02:32</a> I got some questions for Lingsheng, but before we jump into the topic at hand, which I think we’re calling images of the dying, maybe illustrations, maybe drawing. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=161996">02:41</a> We’ll get into that. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=162628">02:42</a> We’ll get into all that. I got questions. Somebody has a song or a question. Lingsheng is it you? Lingsheng <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=167580">02:47</a> It’s me again. And the song we have today is photograph by Ed Sheeran. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=172588">02:52</a> Why did you pick photograph by Ed Sheeran? Lingsheng <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=175500">02:55</a> It’s a beautiful song, and the reason why we chose it is really inspired by Wendy and Frank’s work, thinking about how images, photos can really be a way to preserve the memories of those we love, whether they’re present with us or not. And also just thinking about the big picture of what it’s important to show love to each other. And it’s hard, and it hurts sometimes, but it’s one of the best things that we can do for another person. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=200680">03:20</a> I got another question. Are you an Ed Sheeran fan? Lingsheng <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=204250">03:24</a> I would say yes. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=205266">03:25</a> Oh, yeah? Lingsheng <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=206450">03:26</a> Yes. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=207850">03:27</a> I just saw him play at Bottle Rock. He was with the offspring, so I heard him play with the offspring. If anybody knows what the offspring sounds like. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=215754">03:35</a> Good show, Alex. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=216610">03:36</a> You want to take it away? Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=235280">03:55</a> (singing) Lingsheng <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=311280">05:11</a> That was really beautiful. Thank you, Alex. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=330560">05:30</a> That was really beautiful. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=332216">05:32</a> Thank you. Thank you, Wendy. I’ll have a more professional version on the audio-only versuib. This one will go on the YouTube. Frank, let’s start with you. About 25, maybe even 30 years ago, at the Zen center in Green Gulch in Marin. I was on a retreat with Guy Micco, who’s been on this podcast several times, and he was teaching a class on death while I was in medical school. And you were a guest at that retreat, and you brought photographs of patients from the Zen center and had us view them, think about them, talk about them, and perhaps even write about them. I wonder why you did that. What is it about the images of the dying that helps teach medical students? Frank <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=388320">06:28</a> Well, I think a number of things. I mean, they were being eight by ten black and white photos, if you remember, and they were all taken by one person, actually, who was a volunteer at the hospice. And he originally came to suggest that this could be his gift to the hospice, to take these photos. And I said, you can’t take any photos. I said, maybe in six months or a year, then you could take photos. First you have to be a volunteer and see what it’s like to be present at the bedside. And so after about a year, I said, okay, now. And he took these beautiful photographs, which you saw. And actually they’re pictures of living people who then died. And so that’s really an important part, because it’s to help the clinicians that we were training to first of all, humanize the dying process, to see these people as living beings, not the dying, which is a kind of generalization, a term we use, which I’m not so happy with. So that’s the first part. I first did it with Bill Moyers, actually. Bill Moyers and his journalists, and they were hard nosed journalists who just come back from, oh, I forget, South Africa, I think. And I was, the only way to really get them into the subject was to have them look at photographs. And they’re like clinicians, they’re very keen observers. And so they look for the details and things like doctors do. And so this allowed us for, it allowed people to see themselves in the people that they were serving. And when we see ourselves and the people we’re serving, then the way in which we care for them fundamentally shifts. Yeah. So that’s a long answer to a short question, but that’s how we get started. Yeah. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=495950">08:15</a> I want to follow up and ask a little bit more about the founding of the Zen hospice project and the Meta Institute. I wonder if you could say a little bit more about the meta Institute in particular and what it is that clinicians today can do to learn, to be more present and learn about the need to be thoughtful and compassionate in the care that they provide people with serious illness. Frank <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=523222">08:43</a> Well, briefly. I mean, we started Zen hospice way back in the early to mid eighties, in the midst of the AIDS epidemic. Yeah, I won’t say much more about that, except that it seemed to me that there was a natural match between people who were cultivating what I might call the listening mind or the listening heart through meditation practice, and people who really needed to be heard at least once in their life, folks who were dying. And so that was our plan. We didn’t honestly have much more of a plan than that. And we worked with primarily people who were unhoused, unsheltered, living on the streets, of San Francisco. They had triple diagnoses, often life threatening illness, but also mental illness and usually some kind of addiction. So they were tough and diverse clientele to work with. I worked with those people for almost 20 years. The Metta Institute was an outgrowth of that. It was to share what they taught us with clinicians, and we trained hundreds and hundreds of clinicians. I’ve forgotten how, how many now over 15 years, I think it was. And it wasn’t just about tacking on new skills to the same old you. It was about you transforming. And we believe that as you transform, the way in which you did the work would transform. Any institutions in which you worked would transform. And so that was our intention. And, you know, I think we had some good success with it. Yeah. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=609810">10:09</a> And I want to ask if our listeners, is the meta Institute still going and if our listeners wanted to participate? Most of our audience are clinicians who care for either older adults or people with serious illness, and often both who are interested in learning more. Where can they go? Frank <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=627698">10:27</a> Well, the meta institute isn’t offering that, those extensive year long trainings anymore, but people can still find me, and I’m doing trainings with colleagues. My friend Joan Halifax and I often teach together. And so they can go to frankaustdeseski.com or mettainstitute.org and find out about upcoming workshops and that sorts of thing. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=649454">10:49</a> Yeah, and we’ll have links to both of those on our website. But it also made me think. I remember visiting the Zen hospice. It was a beautiful victorian. I remember you walked in. In addition to the place, which was beautiful, there was a cook that was making, like, you smelled food. The people there were very generous. And I’m also hearing it was a place where a lot of people came in to volunteer and somewhat different. Like, I also want to bring in my skills as a photographer and take pictures. And it sounded like there was a, you first had to volunteer first. When do you also spend some time at the Zen hospice? What got you interested in going there? Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=698678">11:38</a> I think it was probably nine years ago now. I was invited to be an artist in residence there. I think the seeds that Frank planted with that experience with the photographer then grew. And I think there was one person who was there before me. Josh Kornbluthe was an artist in residence. He’s a performer and a writer, and I was the second person. And I draw from life. I spend a lot of time with people. And kind of, like Frank was saying, you kind of have to hang out a little while before you before you start another role. Right. You really have to get to know somebody before you start being nosy. I think it’s like, kind of a polite thing. I spend a lot of time with people, and I draw them from life, and I have conversations. Some call them interviews, but I think of it more as, like, hanging out in conversations, and I write down everything that people say, and I take the words and the pictures and put them together to tell a story. And I had recently lost my aunt, and she was the first person who I lost. I’d been at the bedside as she was dying, and that really had cracked my heart open. And within, honestly, a day or two of that happening, somebody from Senhos called and invited me to do this. And it was like the universe kind of saying, this is what’s happening. And it was an incredible experience. I was there for on and off for a year, twice a week for about six months. I won and ended up producing a little book called how to say goodbye. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=794238">13:14</a> And when you were there. So we’re going to be talking about the book, how to say goodbye. When were you. When you were there and you’re doing these. Were you doing these illustrations at that time? And did you have an idea? I’m going to have this book that I’m going to put out there in the world while you were volunteering at Zen Hospice? Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=810744">13:30</a> No. So something first, like, just for language sake, like, illustrations is an interesting word because typically it’s used. Illustrations are drawings or some kind of art form that’s used to illuminate, like, text, for example. Right. And I actually start with the drawings, like, the drawings themselves. I don’t call them illustrations. They’re kind of like the content. They’re the meat. They’re the point of it. And I had no idea what was going to come of it. For me, drawing is not even about the outcome of the drawing. It’s about the process of looking. Frank, what you were saying about listening and learning to listen, I think we have so much in common with that. I’m just focused on the eyes part, you know, and learning to look and learning to see. And I went in there with no agenda of an outcome, just to look. And I think up until the time when my aunt was passing, I had been very afraid of the idea of death in my family. It was something we didn’t talk about. People just kind of disappeared, and it was set. That was it. And when I was with my aunt, I use drawing as a way to look at things that make me uncomfortable. It gives me kind of, in a way, like an excuse to look closely, and it also keeps my hands moving so that I can kind of concentrate, have, like, a little. A little bit of an activity while I’m looking. And I brought that intention over to Zen Hospice to really look and also give the opportunity for people who may not have felt seen at some time to have that opportunity as well. Frank <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=907310">15:07</a> Hey, Wendy, can I jump in and ask a question? Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=909446">15:09</a> Yeah, I’ll just keep talking. Go. Frank <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=911622">15:11</a> I’m curious about, like, how you develop the quality of that attention, because you came in a room and you weren’t speaking to people most of the time. You were watching, you were observing. What was that like for you, and what was it like with the person you were sitting with? Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=928490">15:28</a> Such a good question, Frank, because it was different at Sun Hospice than it was in other situations. Frank <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=933402">15:33</a> Sure. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=934298">15:34</a> And I think one thing that made it so different is it felt like, well, I always wanted to ask permission, and I didn’t feel comfortable if there was a new resident there. I wouldn’t draw them without talking to them, explaining what I was doing, getting them. You know, if. And if some people weren’t ready and they said no, then that’s fine, you know? And then sometimes that would change over time because I just kept coming back. But then once somebody was open to being drawn, sometimes I’d sit and they would be lying in bed, and I’d just sit in the chair, and we’d be quiet together, and I draw. Sometimes we’d have a conversation, and I’d be drawing. There was one time that I drew somebody, and she said, well, I’d like to draw you, too. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=991000">16:31</a> Oh. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=992960">16:32</a> Her name was Katherine. Her portrait in the book is one of my favorites because she’s actually looking directly at me. And that transformed the experience. Right. So we both had this mutual experience, simultaneous of looking, paying attention to each other, noticing the details, and being really absorbed in each other and also being seen at the same time. It’s really powerful. Frank <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1014476">16:54</a> Beautiful. That really goes to what I was saying earlier about this mutual exchange that occurs you also, as an artist or a keen observer, and I noticed in your illustrations or in the drawings that you often were also drawing the mundane things in the room, the flower vases that sometimes had dead flowers in them, or a painting that was on the wall, the scene that the person who was in the bed was looking at. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1042319">17:22</a> It does show their perspective, doesn’t it? I think. Well, to your point about spending time in a place, I think when we first enter a place, we see the things we expect to see, we’re bringing our own perspective to something we’re seeing ourselves. It takes time and attention to really settle in and see and notice what’s actually going on. And the residents there, I mean, some are only there for a very short amount of time, but some are there for a very long amount of time. So it was a real gift to spend time in a place. And while I could never truly put myself in their shoes, at least to be next to them, you know, to be sitting. Sitting with them together and see from that perspective. Yeah, but those details, frank, like, that’s what made Zen hospice what it was, because everything was so considered. It really was. And it was such a sensual place in that way. Frank <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1099092">18:19</a> Very much so. But it also. You’re also speaking to the ordinariness, which is part of the dying process. We tend to think of it as the dramatic experience of life, the great adventure. And it does have some of that, but it’s also quite ordinary. All of us will go through this, and we will each experience it in our own unique way. And that’s one of the beautiful things about your book, is it expresses the unique way that people meet that experience, that sometimes very ordinary experience. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1128760">18:48</a> I so appreciate you saying that. And I think that that can only really be experienced with time, because I remember when I went in at first and hostess, look, I’m as human as they come. I went in there with kind of my pencils blazing, you know, I’m like, all right, we’re gonna do this. You know, it’s gonna. I don’t even know. I didn’t have any expectation of outcome, but it was gonna be grand, you know? And then over time, it’s mundane and it’s slow. Lingsheng <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1162386">19:22</a> Right. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1162930">19:22</a> It’s, like, pace, and. And I can imagine that. I mean, I think there was a part of me that kind of wanted to vominose this certain part, you know, because it was like, this is not. This is slow sometimes, like the days. It’s like another kind of. Another kind of time zone in there, right? And I think that ended up, once I kind of was able to step into the pace of the residents. Right. That changed the way that I saw and changed the drawings that I did. I don’t think I’ve ever been in a place like it. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1199298">19:59</a> And I gotta say, it also just reminds me of the entire idea of, like, slow medicine, too. Is that the pace of everything that we do in the hospital, the pace that our trainees kind of go through, it’s fast, and there’s something totally different about standing over someone, asking all these history questions versus just pulling up a chair and just sitting there. And sometimes in silence. So much so that when our fellows, like, join us in our hospice unit, we actually have to have a talk about how things are just. It’s okay to be slower here. It’s okay just to sit in silence with someone and pay attention just to the things that you see and hear around you. Frank <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1240974">20:40</a> Yeah, beautifully said, alex. I mean, I would say that we needed to go at the speed of nature. That’s how I used to describe it. And it sort of takes you out of what we might call TikTok times and puts you into a slightly different kind of time. And you’re describing that beautifully, and it has a different rhythm to it. And we slow ourselves to the pace of the person that we’re in contact with, the person that we’re serving in that moment. And what’s important about this for your listeners is that we begin to see that dying is not just a medical event, and we need to stop treating it as if it were just that. We need to bring the best of what medicine has to offer, of course. And dying is too big, too profound for any one model, including the medical model. And so I think it’s much more about relationships, our relationship with each other, with God, or whatever image of ultimate kindness we hold in our life with the experience of suffering and the experience of dying itself. Yeah. Much more about relationships has been my experience. And so we have to teach clinicians the art of relationship. Lingsheng <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1305390">21:45</a> Now. Wendy, I have. Where we have your beautiful book in front of us, and I actually opened it to a page of the person you were describing earlier. I think her name is Katherine. She’s the one with the piercing blue eyes and the flower shirt. And I think she was the one that was drawing you as well. And, you know, I read your book multiple times. The first time, I read it really fast because I was so excited to get a hold of it, and I just wanted to see what was the content, what was inside, what drawings were there. And then the next few times, the last time I read it was actually this morning. I slowed down. I realized that, you know, each page you can just kind of hold in your hand, you can just look at the pictures, look at the details, the lines, the flower petals, the strawberries in a bowl. And that’s just so beautiful. And I want, you know, I approach it from the perspective of someone who loves drawing. I’m also a geriatrician and a palliative care physician, so I’ve talked to families and patients about death and dying. I’ve counseled patients and families about, you know, kind of what to expect afterwards or what to expect in the days and the weeks before someone dies. And I wonder, what is your. Who is your intended audience for this book? Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1381760">23:01</a> I mean, it’s a great question. I think a lot of times we make things that we wish we had a, you know, and that it’s something that we really deeply need, that it will probably be of service to someone else, too. I would say it answers some questions that I had, but I think it’s what I would have liked, and it is what I still need and what I learned in that residency and with caregivers and the residents. I am still practicing today. You know, my mom has Alzheimer’s and my uncle has Alzheimer’s. And I’m trying to practice what I learned and what I included in that book with. With them in my life now. Lingsheng <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1428380">23:48</a> That’s really beautiful. Thank you. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1431340">23:51</a> All right. Like, shay, I got a question for you. What I’m hearing is like that this. This idea of slowing down, sitting with someone and paying attention to these things and potentially drawing, being able to bring that in. And art, bringing different aspects of this encounter with the patient. Encounter is probably too medical of a word, but I’m going to use it anyways, potentially to a different level, different spot. You are a artist, a drawer. You bring this stuff into your research. Have you ever thought about doing the same as Wendy? Sitting down, bringing that in with a patient encounter? Lingsheng <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1468904">24:28</a> It’s actually just a dream of mine to be able to do this with patients and their loved ones, to have the luxury of time and, you know, first to have that rapport and trust, like Wendy and Frank are saying, to be able to sit down and not just ask them questions, but really to observe and to listen. You know, I’ve always loved drawing, like I said before, and it wasn’t until recently that I started thinking about incorporating it into my academic and research work. More specifically, using drawing and visual art as a way to represent data, to analyze data, but also as an outcome, as an intervention, to be able to share with patients and families and to connect them on a deeper level. And I think what’s powerful about art is that it’s really a universal language. A lot of my interest is working with chinese speaking patients and families, especially those who are monolingual, meaning they’re nothing. English is not their primary language. So just a way to show them that we care without actually saying those words, but to ask them really hard things without forcing them into a conversation about death and dying. It’s really meeting them where they are and going back to Wendy’s book for a little bit, because I have a question I wanted to ask you. Describe this book as wisdoms from caregivers. Was that your intention when you wrote this book and when you drew the pictures, or did that evolve from something else? Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1562790">26:02</a> When I first went into Zen hospice, that was absolutely not what I thought was going to come out of it. I thought that I focus on the residents, on the people who were dying, and share some of their stories. And I think the dynamics of the space. And over time, it became clear that this is like sometimes, you know, with art making, like, people plan things. Good luck with that. You know, if you’re really open to it, the situation’s going to offer you what it has, you know, and for your skills. And so the caregivers became the center for me and what we can learn from them. And I also never intended to make a book. It’s what I know how to do. I know how to put together stories. And I did that. And I did self publish a book because it felt so personal to me. This process felt like I could not take it into, like, the publishing rigmarole. Like, it would be so wrong to have a marketing meeting about it. Like, that just felt bizarre. So I, my aunt, who I had drawn before and included drawings of her in this project, she had left me a little bit of money, and I took that, and I self published the books. And then I gave those as gifts. And I asked just if it was helpful to pass it on and it would have its own organic distribution as opposed to, like, the publishers kind of way of doing things. But when we ran out, I ran out and people asked for more. At that point, enough time had passed so that I felt like there was some distance, emotional distance. And I was kind of ready to just let it exist outside of my body, you know, be out in the world. And that’s how it ended up becoming the book that is available now. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1673180">27:53</a> Part of that book is a forward by BJ Miller, who we’ve had on this podcast many times. And I’m going to read it because I’m actually going to turn to Frank with this question, too. BJ says, this book is not pretty. Pretty is strategic and tidy. This book is beautiful, which is to say, true death is like that, full of sights and sounds and smells, of dying bodies doing bodily things. It’s not always pretty. It’s always beautiful. And it also just reminded me that the time that I had spent seeing Zen hospice, this beautiful victorian, again, they just walk inside. It’s beautiful inside. The people are beautiful. Not everything is pretty around you, but there is beauty to it. And I wonder, Frank, as you set up Zen Hospice, founded it, as you created these things, like the artist in residence, was that an important part of it? Why did you even do artists in residence? Frank <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1741190">29:01</a> Well, actually, I didn’t. It was something that BJ started when he was there for a short time as the director. He did it, and I think it was a brilliant idea. We did emphasize beauty all along. Beauty was a central part, one of the healing mechanisms. That’s part of the process of being with dying. I was involved in a project where we gave all the patients instamatic cameras, and we had the patients photograph their experience, including patients who were severely confused, demented, had Alzheimer’s, etcetera. And so we got their perspective, which was really interesting. And oftentimes they were shot up because the patient was lying down. And so we got pictures, partial pictures of people’s faces. We got pictures of just their shoulders, because that’s all the patient was seeing, or the commode across the room from them. And so it began to also help us understand how to set this thing up differently from the patient’s perspective, from the resident’s perspective. So I think this is an interesting project that I would encourage Lee or others to do. Give the patient some cameras, give the patients. Let the patients, not just the caregivers, but let the patients share their wisdom with you as well. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1815390">30:15</a> Yeah, I love how that goes back to the conversation before Frank, about having it be much more of a conversation and centering, like the person who’s actually dying, the person centering their experience, not our objectification of their experience. Right. It’s challenging with art making, because that’s what a storyteller does. Right. And I think there’s limitations to the traditional kinds of stories that have been done. And I’m really excited by examples like that, that you use where we kind of break those rules. Right. So that actually we’re hearing the voice of the person, not talking about the person. Lingsheng <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1860420">31:00</a> Wendy, going back to something you said about conversations, too, in the book, you mentioned this framework for talking to people that you love who may be dying. And that’s the five things. Wonder if you can talk about that. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1874390">31:14</a> Yeah. That was shared with me by Roy Reimer, who is still working with a Zen caregiving project. And he shared with me these five things that, as he explained to me, have been used in many different cultures. Frank, you know this way better than I do, so please interrupt me if I am wrong here, if I get anything off, but many cultures all over for a very long time, I forgive you. Please forgive me. Thank you. I love you and goodbye. And these are five things that are starting points for conversations and ways of opening up conversations so that we can be fully present with somebody and say goodbye. Did I get that right, Frank? Frank <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1920936">32:00</a> Pretty good. I mean, they have their origins in the hawaiian culture. Actually, I believe the word is o. Pono. Pono. And they were made popular by Ira Bayak, you know, great hospice palliative care physician, and in his book, the four things that matter most, actually. Then he repeated it in several other books. Yeah. Please forgive me. I forgive you. Thank you. I love you. And you added, say goodbye. Yeah. I would add one more. And I’m saying this because I just went through a heart attack about a month ago, and I was with my son, and we didn’t quite know what was happening with me, et cetera. And I added, I’m proud of you. And I think that’s a really different thing for it’s a parental message that’s really important. In addition to I love you is I’m proud of you. And I would. So I, when I’m working with parents or people who have that role in someone’s life, I add that I’m proud of you. I think that’s important. Yeah. So, yes, they were made popular by Ira Bayak. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1992532">33:12</a> Ira, absolutely. Much respect and gratitude for Ira Bayok. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=1997132">33:17</a> And we’ve had Ira on this podcast, I think most, couple times least, maybe most recently talking about psychedelics. I have another question. I know, link shing. Looks like you have another question, too. But quickly. I remember also when I was in med school, I was doing research with Jeff Burak, HIV AIDS doctor, and doing research into experience of hospice and dying. And we interviewed this guy who lived in a single room occupancy hotel in San Francisco, and he had advanced lung cancer, and he was worried about the cleanliness of his place. He was worried about whether he could get the next another meal, safety when he went out in the hallway. And then we visited him again when he was at Zen Hospice. And although his disease was more advanced and his symptoms were worse, they were better controlled and his needs were taken care of. He was clean, he was well fed, and he was almost beatific in the bed there to get back to that beauty and talking about making amends with his son, from whom he’d become estranged. And he even used the words that he wanted to focus on getting his spiritual house in order. And this was just such a remarkable transformation. And one of the things that did this about the Zen hospice was the environment itself. When we talked about that beauty. And the other piece that was critically important were the people who worked there, who volunteered there, who. Wendy, I noticed you included in your book. I wonder if you could say a little bit more about those caregivers and what you observed in your time at Zen Hospice. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2106044">35:06</a> Wendy, they’re great people and hard workers. I mean, it’s. Do you mean about as people or what? Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2114654">35:14</a> Yeah, I mean, in addition to including the images of the people who are dying, there are also images of the people who care for them in the book. As I recall. I did read it several weeks ago. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2127190">35:27</a> Yeah, I mean, they’re a huge presence in the house, and they’re really important part of the resident’s day to day life. They are. We’re a very dedicated group of people who had incredible depth of care and experience and commitment. It is an incredibly underpaid, I think, a field, you know, with the kind of level of deep work that’s going on there. So the level of commitment there and care is just. Was so moving to me. Nurses are great. I developed a lot of friendships with the folks there. So, yeah, an essential point of view of the residents. And also, it was their words that I was sharing. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2173538">36:13</a> Right. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2174138">36:14</a> I just want to acknowledge that this question almost seemed, like, shocking to you. Like, yeah, they’re important, part of it. From the medicine side of things. We never mentioned caregivers. And, like, you try to find a caregiver’s name in a hospital chart, you just can’t. Home caregivers. Really? Yeah, yeah. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2195428">36:35</a> Doesn’t make any sense. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2196900">36:36</a> I dare anybody to try to look up somebody’s caregiver’s name in a hospital chart. They’re just knocking. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2201460">36:41</a> That doesn’t make any sense. I’m actually shocked by that. I’m sorry. I’m naive. It’s not my field. But that’s insane. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2207772">36:47</a> No medicine completely relies on caregivers. But we do support them. We don’t. We do nothing, though, to support them. We don’t talk to them, send them home thinking, okay, they got it now. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2221240">37:01</a> The built environment was important, the philosophy was important. And I think. Frank, interested in your thoughts on this? What I think the magic of Zen Hospice and why it is the pinnacle of any hospice I’ve seen in my, however long career, is the people, and not only their dedication to it, but also what they got out of it that kept them renewed to keep going back. Frank? Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2247650">37:27</a> Yeah. Frank <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2248210">37:28</a> I mean, let me say something. I’m not at all romantic about dying. I think it’s maybe the hardest work they will ever do in this life. I think it doesn’t always turn out well. It’s not always beautiful. It’s messy, and it can be cool and mysterious. But most of all, it’s normal. We all go through it. As we said earlier, we should say at this juncture, because I don’t want Zen Hospice to become some, you know, perfect model. It’s not, in fact, Zen Hospice, the facility that we had that wendy’s been speaking about and did her drawings and doesn’t exist anymore. They, unfortunately, that facility closed. That residence closed, so it doesn’t exist anymore. Zen hospice project is also morphed. It’s now become the Zen caregiving project. It’s put its emphasis much more on educational work, which is fantastic. So everything comes and goes, not only of us, but also projects. And I think when we hold that, when that is not just an intellectual understanding, but when that we hold that in our bones, the way in which we are with things changes fundamentally. And so it wasn’t that it was just a lot of nice people taking care of each other. It was people taking care of each other who understood something fundamental about the impermanence of life and brought to that a kind of fearless receptivity. And that’s what was particularly unique in the situation that you were describing. That doesn’t mean there’s no fear. There was lots of fear. It means that fear isn’t the only thing in the room. And we’re able to meet that fear with some degree of calmness, with some degree of equanimity, with some compassion and wisdom. That was the heart of Zen hospice, and it doesn’t need to exist just at Zen Hospice. Let me emphasize that there have been many, many people who have studied with me who have modeled that program and created hospices elsewhere in the country. And so let’s not get too. I want to make sure I don’t get too romantic about this. Holding in permanence is not easy. It’s just the cognitive understanding. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2384084">39:44</a> Is there a role for that in what you were doing there, Wendy, too, because you are taking these drawings? I was going to say illustrations. I cracked myself in my head of these individuals. Did anybody ask for them? Or did family members ever like this very intimate portrait of them to share? And kind of like the photograph song that we were hearing before putting it in their back pocket. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2413308">40:13</a> No, I think honestly, maybe a couple of the caregivers were interested, but at this point, the residents of family members didn’t really, excuse my language, give that much of a shit. Like it was like there was other stuff going on and this was an experience we had. I think that to Frank’s point, you’re calling me out on all of my work, Frank, like, you know what? You know, what I’m trying to do here with this is I’m trying to hold on so much to so many things. I’m trying to get it down on paper. And I feel like my, as an artist, the best work as an artist I can do is stay in the presence of the experience of making the art. That is the time where I’m like, that’s. That’s the best of the making of the work and the outcome, the piece of work there, that’s evidence of the experience. But so much of our culture and myself included as an artist, is about that object and holding on to that experience in this thing, publishing the book, the book becomes a thing. It has all this thing. Not like it’s really about the experience of the making of the looking, of the listening of the conversation. And I think from my perspective, the experience of making this book for me was a positive experience. The fact that it is this, I hope that it comes out as a book that I’m holding. I hope that it is useful and it’s very ironic. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2497270">41:37</a> Thanks so much. I think in our podcast with Thomas lynch, the undertaker from Michigan and poet, he talked about how some of the first images taken were images, photographs of people who were dying. And that was part of the use case for the camera is that you could have them with you after death. And so there’s this tension here about. Fascinating, yes, to hold on. And yet these are images of people who are dying and itself shows impertinence because they are living and they are dying at the same time. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2529696">42:09</a> Frank, what’s your take on this? Frank <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2533530">42:13</a> I’m really thinking about your clinicians here. And they may not have Wendy’s skills to do what she did. However, the metaphor that she’s giving us is very, very important here. To slow down, to be present, to be available, to be keenly observant with the people in which we’re serving. That’s essential. And that observation has to include ourselves as well as the person that we’re serving. Otherwise, you know, it doesn’t work. Well, what this, what we’re pointing here to is that this precariousness that I’m speaking of really introduces us to the preciousness of life. And then we don’t want to miss a moment. Then it’s not just about taking care of someone who’s dying. It’s caring for life. It’s the light, the preciousness of life that we want to be part of that we all want to jump in with both feet to the preciousness of life and not miss a moment of it. And so that’s why we say that being with dying is the most life affirming thing that we could possibly do. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2591910">43:11</a> I wonder before, because I know we’re getting at the top of the hour. I think Link Shing has a because the question is, what do we as clinicians, as the people are listening to this podcast, how do we bring in or can we bring any of this into our lives, in our practices? Link Shen, you had an idea, didn’t you? Lingsheng <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2608614">43:28</a> I did. And I just want to give a shout out to wendy’s grown ups table community. I’m a part of that. A lot of my friends are as well. And I know you give weekly lessons to people thinking about drawing. And it just, it’s not just about these lessons. It’s really about the experience. And one thing, one message that you said on your website from draw strangers is that drawing is looking, and looking is loving. And I just, I think that’s so beautiful is, I think, you know, for our listeners on GeriPal, many of us are clinicians, social workers, nurses, physicians, researchers. What is one small, short drawing assignment that you would give us? Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2649500">44:09</a> Oh, fun. Lingsheng <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2650716">44:10</a> To, you know, kind of help us be present and be mindful and to experience a little bit joy and a really busy workday so that we don’t go on Twitter and doom scroll or do other things. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2663250">44:23</a> Nothing good ever comes of that. So, okay, quick, quick little drawing lesson here. Most people think about drawing as something that we do to produce an outcome. I invite people to let go of the outcome and think about drawing as an action, an activity. And that is the only thing that matters. You can throw it away afterwards. Doesn’t really matter. It’s just about the experience of making the drawing. That’s the point. Once you understand that doesn’t really matter, it takes a bunch of pressure off. You have a very different experience in your body, in your breathing, in your observation, in your relationship to the thing you’re observing, everything changes. Okay? That’s the lesson. Here’s the assignment. So I would invite people to do something. This is one of the first things you learn in art school. It is technically called a blind contour drawing, but I think it’s magic. It allows us to see with fresh eyes, see beyond our cognitive bias, and actually look at what is in front of us. Pay attention to details, notice things we’d otherwise overlook, and connect with things in a new way. So you need a piece of paper, and ideally, you need another person. I would invite you to each have a pen and a piece of paper to put that paper down in front of you. Hold your pen, look up at each other, because you’re going to draw each other. Set a timer for 1 minute, and draw each other. However, you’re going to do two rules. The first rule is, you’re never allowed to keep your pen up off the paper. Draw with one continuous line. Rule number two, never, ever, ever look down at the paper upon which you are drawing. You cannot look at what you’re drawing. You can only look at the person’s face. Imagine your pen and your eyes are connected. Three, two, one. Go. Lingsheng <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2779430">46:19</a> I love that. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2780494">46:20</a> Love it. And we did this in our division link Shang had us do this, and we did this with the palliative care research fellows. I know we’re out of time. Okay, we got to move. This wonderful exercise. Highly recommended. Lingsheng <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2794320">46:34</a> Maybe we can ask our listeners to also share their drawings on Twitter. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2799144">46:39</a> Yeah, well, I thought the whole point is not to share. Right? [laughing] Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2803400">46:43</a> Right. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2804256">46:44</a> Is to be there, connected. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2806448">46:46</a> I’ll tell you that. You’ll be so surprised by how awesome these drawings are, because once we let go of expectations and let our care and observation take over, we end up creating the most awesome, unexpected, free drawings you’d ever seen. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2823830">47:03</a> Well, Frank and Wendy, I know I could talk another hour. I love all of our topics. Would love to have you on again. But maybe before we end, maybe I’ll save this one and put as a photograph put in my back pocket. Alex. Alex <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2855960">47:35</a> (singing) Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2932220">48:52</a> Wendy and Frank, thank you for joining us on this podcast. Wendy <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2935860">48:55</a> Thank you so much. Frank <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2937340">48:57</a> Nice to be with you all. Eric <a href="https://grain.com/share/recording/202b8c44-29e7-42bc-9ce6-1e7ac4d03a2b/yhnPheAaWm3S2ROu4J1pH7h6ec249dt7zXXUryPf?referrer=docx&t=2939100">48:59</a> And for all of our listeners, we’ll have links to the book and everything else we talked about in our show notes, so check those out and thank you for your continued support. </div> </div> </div></div><div class="vc_tta-panel" id="cme" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#cme" data-vc-accordion data-vc-container=".vc_tta-container">CME</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> <h3>This episode is not CME eligible.</h3> </div> </div> </div></div></div></div></div></div></div></div></div></div> </div>The post <a href="https://geripal.org/images-of-the-dying-a-podcast-with-wendy-macnaughton-lingsheng-li-and-frank-ostaseski/">Images of the Dying: A Podcast with Wendy MacNaughton, Lingsheng Li, and Frank Ostaseski</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></content:encoded> </item> <item> <title>Stepped Palliative Care: A Podcast with Jennifer Temel, Chris Jones, and Pallavi Kumar</title> <link>https://geripal.org/stepped-palliative-care-a-podcast-with-jennifer-temel-chris-jones-and-pallavi-kumar/</link> <dc:creator><![CDATA[Alex Smith]]></dc:creator> <pubDate>Thu, 19 Sep 2024 07:00:46 +0000</pubDate> <category><![CDATA[All Posts]]></category> <category><![CDATA[Palliative Care]]></category> <category><![CDATA[CME Eligible]]></category> <category><![CDATA[Podcasts]]></category> <guid isPermaLink="false">https://geripal.org/?p=6905</guid> <description><![CDATA[The post <a href="https://geripal.org/stepped-palliative-care-a-podcast-with-jennifer-temel-chris-jones-and-pallavi-kumar/">Stepped Palliative Care: A Podcast with Jennifer Temel, Chris Jones, and Pallavi Kumar</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></description> <content:encoded><![CDATA[<div class="wpb-content-wrapper"><div class="vc_row wpb_row vc_row-fluid no-bottom-margins"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"> <div class="wpb_raw_code wpb_raw_html wpb_content_element vc_custom_1726693014309" > <div class="wpb_wrapper"> <iframe title="Libsyn Player" style="border: none" src="//html5-player.libsyn.com/embed/episode/id/33113737/height/90/theme/custom/thumbnail/yes/direction/backward/render-playlist/no/custom-color/00548f/" height="90" width="100%" scrolling="no" allowfullscreen webkitallowfullscreen mozallowfullscreen oallowfullscreen msallowfullscreen></iframe> </div> </div> <div class="vc_tta-container" data-vc-action="collapse"><div class="vc_general vc_tta vc_tta-tabs vc_tta-color-sky vc_tta-style-flat vc_tta-shape-square vc_tta-spacing-1 vc_tta-o-no-fill vc_tta-tabs-position-top vc_tta-controls-align-left"><div class="vc_tta-tabs-container"><ul class="vc_tta-tabs-list"><li class="vc_tta-tab vc_active" data-vc-tab><a href="#summary" data-vc-tabs data-vc-container=".vc_tta">Summary</a></li><li class="vc_tta-tab" data-vc-tab><a href="#transcript" data-vc-tabs data-vc-container=".vc_tta">Transcript</a></li><li class="vc_tta-tab" data-vc-tab><a href="#cme" data-vc-tabs data-vc-container=".vc_tta">CME</a></li></ul></div><div class="vc_tta-panels-container"><div class="vc_tta-panels"><div class="vc_tta-panel vc_active" id="summary" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#summary" data-vc-accordion data-vc-container=".vc_tta-container">Summary</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> If palliative care was a drug, one question we would want to know before prescribing it is what dose we should give. Give too little – it may not work. Give too much, it may cause harm (even if the higher dose had no significant side effects, it would require patients to take a lot of unnecessary additional pills as well as increase the cost.) So, what is the effective dose of palliative care? On today’s podcast, we talk about finding an evidence-based answer to this dosing question with three leaders in palliative care: <a href="https://www.dfhcc.harvard.edu/insider/member-detail?tx_hcc_persondetail%5Baction%5D=show&tx_hcc_persondetail%5Bcontroller%5D=Person&tx_hcc_persondetail%5Bperson%5D=292&cHash=963a8230264de98452e125a5592d1f27">Jennifer Temel</a>, <a href="https://medicine.duke.edu/profile/christopher-jones">Chris Jones</a>, and <a href="https://www.pennmedicine.org/providers/profile/pallavi-kumar">Pallavi Kumar</a>. All three of our guests were co-authors of a<a href="https://jamanetwork.com/journals/jama/fullarticle/2819643"> randomized control trial on “Stepped Palliative Care” published in JAMA this year</a>. We talk about what stepped palliative care is, how it is different from usual care or intensive palliative care, why these palliative care dosing questions are important, and dive deep into the results of their trial. We also discuss some of the other important trials in palliative care, including<a href="https://geripal.org/palliative-care-for-cancer-podcast-with-jennifer-temel-and-areej-el-jawahri/"> Jennifer Temel’s landmark NEJM study on outpatient palliative care</a> and another study that gave an intervention<a href="https://geripal.org/fast-food-style-palliative-care/"> we dubbed “fast-food palliative care” in an older GeriPal blog post.</a> ** NOTE: To claim CME credit for this episode, <a href="https://geripal.org/stepped-palliative-care-a-podcast-with-jennifer-temel-chris-jones-and-pallavi-kumar/#cme" target="_blank" rel="noopener">click here</a> **   <hr /> </div> </div> </div></div><div class="vc_tta-panel" id="transcript" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#transcript" data-vc-accordion data-vc-container=".vc_tta-container">Transcript</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=27720">00:27</a> Welcome to the GeriPal podcast. This is Eric Widera. Alex This is Alex Smith Eric And Alex, who do we have with us today? Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=34416">00:34</a> We are delighted to welcome back Jennifer Temel, who is a thoracic oncologist at Massachusetts General Hospital in Boston. Jennifer, welcome back to the GeriPal podcast. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=44656">00:44</a> Thanks. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=46160">00:46</a> And we’re delighted to welcome Chris Jones, who’s a palliative care doc at Duke in North Carolina. Chris, welcome to the GeriPal podcast. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=54264">00:54</a> Thank you. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=55710">00:55</a> And we’re delighted to welcome Pallavi Kumar, who is a palliative care doc and oncologist at the University of Pennsylvania. Pallavi, welcome to GeriPal. Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=64846">01:04</a> Thank you. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=66510">01:06</a> So we’re going to be talking about a model of outpatient palliative care, a stepped model for palliative care. But before we jump into that topic, Jennifer, do you have a song request for Alex? Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=80270">01:20</a> I do have a song request for Alex. I have requested Galileo by the Indigo girls. And the reason I requested it is because it is one of the two most famous Indigo girls song, with the other being closer to fine. And most people think closer to fine is better, but they are wrong. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=96422">01:36</a> Galileo, Alex, did you do closer to fine already? I feel like we’ve done that one. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=102190">01:42</a> Probably. Probably. I think I did. I was in an Indigo girls cover band in college at the University of Michigan. Saw them play a couple times. Actually got a pick from one of them. I think it was Emily. At some point. I carried around my wallet for years until it fell out. And then we got in. Our band, strangely, got in. We played like a talent show. And then we got invited to play at the Elks. Or was it the Masons? I think it was the Masons lodge. And boy, did they not know what to make of us. So this is a fun song. Thank you for requesting it. It’s taken me back quite a few years. Here we go. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=149170">02:29</a> (singing) Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=216170">03:36</a> I have a trial that’s going on that’s showing that there’s association between the length that Alex plays a song on a podcast intro and his enjoyment of that song. [laughter] Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=228160">03:48</a> That was a lot of fun. Thank you for taking me back. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=238200">03:58</a> So I’m really excited because I am very eager to talk about this study. So there’s a study published in JAMA just a couple months ago this year on stepped palliative care and a stepped model. And I wonder if we can, before we talk about, like, why is a step model important? Can someone describe for me what a stepped model is? Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=265600">04:25</a> I can take that on. So, basically, with a stepped care model, the goal is to tailor care delivery to the patient’s needs while at the same time utilizing less clinician resources. How it works is that all patients will have access or encounters with the specialty trained clinician, a psychologist, a social worker, a palliative care clinician. But they’ll have infrequent contact, and they’ll be closely monitored for the condition that the specialist is treating them for. And if that low frequency contact sort of solves the problem, that is, their depression gets better or their depression doesn’t get worse, they stay with that low frequency contact. But if their depression, for example, worsens, then they step up to more frequent contact with, for example, the psychiatrist. So it’s really trying to, again, solve two problems, be a more patient centered approach by having the care tailored to what the patient needs. But also when there’s limited resources, like psychiatrists or palliative care clinicians trying to sort of triage care to patients who need it most. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=332462">05:32</a> Yeah. And so let’s just, let me get this. So you, Jennifer, probably have, like, the most cited, probably should be the most cited randomized controlled trial of palliative care and lung cancer patients that everybody, every palliative care article I’ve seen, whether or not it works, always includes, it was outpatient palliative care in lung cancer patients. I know there’ve been studies afterwards, too. That was not a stepped model of care. Right. What was that? Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=362660">06:02</a> That’s a great question. So when I started this research 20 years ago, I’m aging myself in national radio, tv, whatever you want to call this, the prognosis of lung cancer was pretty uniform. So, for example, everyone who was diagnosed with an advanced or metastatic lung cancer had a prognosis on the order of months. When we started this work, we made up an interval, but the interval we made up was monthly encounters with palliative care, because many patients didn’t survive more than four or six months. Thank goodness. In the 20 years since then, lung cancer therapies have improved, and lung cancer is a cancer population where there’s really varying prognosis based on cancer characteristics. So, unfortunately, some people still do live for six, eight months. But there are subgroups of patients that have better responses to therapies and can live a year or two years, or in some cases, many years. That was really the impetus for our team thinking about, how do you take a population who has high palliative care needs, but has really varying palliative care and supportive care needs based on their treatment, their different prognosis, et cetera? That’s why we thought about applying a step care model to patients with advanced lung cancer. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=445880">07:25</a> I guess, Chris, from your perspective. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=451000">07:31</a> From. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=451336">07:31</a> A clinical perspective, why is it important to test this stepped care model versus implementing more? What we know was evidence based before? All of this is. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=461912">07:41</a> Yeah, it’s a really interesting thing, because the 2010 article was solving the problem of, hey, send us patients, we promise we won’t kill them. Right? That was the initial. And now when I think about the clinic at Duke, when we’re really running on all cylinders, we can get ourselves up to a five, six, seven week wait for a new palliative care referral. And there’s a mortality number of people who just can’t make it to get to our clinic. So the problem of, hey, look at us, we promise we’ll be helpful. We won’t kill your patient. We’ve solved that problem, and we’ve solved it so well at some institutions that we now have this tremendous capacity problem problem. So that’s the thing that I’ve really liked about the stepped model. I’ve been the implementation arm of a couple of different studies, and I was in one where it was basically read this script, and we’re going to call it a palliative care intervention. I was like, oh, this is so hard to do, but this. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=524672">08:44</a> Did this happen in an ICU, by any chance? Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=528080">08:48</a> There might have been a GeriPal podcast or a Christian Sinclair article about this. Yes, but the idea in the positive here is that this model says you do palliative care. We’ll keep an eye on the patients, and we’ll let you know if they need more of you. Now, the rate limiting step in my mind is I don’t have anybody to keep an eye on those patients in the clinic. So implementing stepped wedge would be hard. Now we can talk later on about the different models of paying for care coordination. That would actually be a way to solve this problem. But I love this because of the capacity problem that we’re suffering with. Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=566440">09:26</a> Yeah. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=566776">09:26</a> Any other thoughts? Pahlavi? Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=568640">09:28</a> I think it’s also just patient centered. Right. So time is a precious resource and I don’t know, in your respective cities, but parking at our beautiful parking garage costs like $30 for the day. So saving people time and money and just the burden of being here for a visit that they may not actually need that day, I think it’s hard to put a value on that. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=591990">09:51</a> I love. I don’t think a lot of doctors quite understand that. Sometimes patients feel like, I don’t really need to see my doctor, but they’re telling me to come, so I’m going to do this for them. Yeah, I have a question. Go ahead, Alex. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=609750">10:09</a> I have a lot of questions, but first question is, when I first looked at this, I was like, wait, there’s no usual care arm. There’s no usual care arm. And then I got an invitation to speak at the, what is the Montreal Congress to palliative care. And they want me to debate Vicki Jackson about this issue of we no longer should have usual care arms and palliative care trials. Like, have we moved beyond the point where it’s ethical to have a usual care arm for patients with advanced lung cancer? I don’t know who wants to take that one? Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=648142">10:48</a> And Alex, when you’re saying usual care, do you mean usual care not being palliative care or like. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=653550">10:53</a> Yeah, or like palliative care if they get a consult for whatever reason, but not trn consult, like standardized, you know, randomized to palliative care versus whatever they’re doing before. If they get palliative care consult, they get one. If they don’t, they don’t. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=667190">11:07</a> First of all, Alex, I just want to compliment you on that, um, really heroic effort on a french accent. Great. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=672726">11:12</a> He loves doing a french accent, by the way. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=674654">11:14</a> Oh, really? Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=675126">11:15</a> Get him started. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=676530">11:16</a> I mean, it wasn’t. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=678370">11:18</a> Don’t. I just started him. Will the rest of the podcast, he’ll. Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=683306">11:23</a> Be doing a frank, not palliative. I’m just putting it out there. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=692450">11:32</a> I would be shocked if anyone on this call said anything other than, of course, usual care cannot be the control arm that just, it’s not ethical. We know that patients with serious cancer, like advanced lung cancer, need to be seeing palliative care. And I’m hinting at something we talked about before the recording started, but now that we’re going with it, Alex had asked about non inferiority and why that was the design and the reason non inferiority was the design. If we accept that frequent contact with palliative care is the standard of care, and we’re trying to do something that entails less contact or less palliative care, that’s the rationale for it being a non inferiority design, because we have to make the argument it’s no worse. It would have been hard to hypothesize that less contact with palliative care would have been better. So again, that’s the rationale for non inferiority. But I definitely do not think it is ethical to have non palliative care. As Eric said, usual care, be a control arm when we’re trying to improve on early longitudinal palliative care models. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=756870">12:36</a> And most of our listeners are like clinician, practicing clinicians caring for older adults, people with serious illness. Can you, one of you, explain in lay terms what a non inferiority trial is and how it differs from. I guess we would say that most trials are superiority trials. Is this superior to that? But we don’t actually put the word superior in there. So what’s a non inferiority trial? Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=781050">13:01</a> You guys want me to take this one? Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=782890">13:02</a> Desperately, yes. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=784890">13:04</a> I feel like I want to make my statisticians proud. So it’s basically. So there are really. This is so unpleasant for a palliative care conversation, but sort of the three designs are superiority, non inferiority, and equivalence. Probably at some point in the next couple of months, we’ll talk about equivalence palliative care trial, and that one’s probably a little more easy or easier to understand. So, superiority, you’re just saying one arm is statistically better than the other. For an equivalence trial, you basically have the sample size and the power to look at whether one is better or one is worse. Basically that either one is better or worse. An equivalence trial is kind of in the middle. You don’t need quite as much patience and quite as many patients and quite as much power as equivalents, but you need more patience and more power than superiority. So you’re basically saying that the experimental arm is no better or no worse, that it is equivalent, that within a margin of sort of variation in your p value, that the two arms are identical slash similar, and the difference in. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=853884">14:13</a> The design of those studies is it mainly just the sample size? The power, yes. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=860164">14:20</a> So the power has to be higher for a non inferiority and then higher for an equivalence trial than it does for a superiority trial, and that increases the sample size. So, for example, for a lot of palliative care studies looking at superiority, it’s usually say 200, 150 to 250 patients. This trial was obviously 450 patients. We have an equivalence trial which will be published soon. That was 1250 patients. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=888724">14:48</a> Oh, wow. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=889436">14:49</a> Wow. We are going to have to have you back. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=892844">14:52</a> I just misquoted my study. This study was 510 patients. Just ignore me. But you know what I mean. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=898500">14:58</a> You’re creating like the all hat study now of palliative care. Once you get to four digits of patients, like, we can never, we cannot aspire to five digits. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=906852">15:06</a> It’s just 400 or 500 patients. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=911260">15:11</a> Well, can we talk about this study? Let’s talk about what you did and who was included. Let’s start off with who was actually included in this study, this 410 ish patients? Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=922580">15:22</a> It was 510. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=923668">15:23</a> I’m sorry, 500, 510. Yeah, you’re right. You said, you said 500. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=927788">15:27</a> But now someone else should answer. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=930510">15:30</a> Pallavi, give us a little background. Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=933518">15:33</a> Yeah. So adults with lung cancer. So that includes people with non small cell lung cancer, small cell lung cancer and mesothelioma being treated with non curative intent. So I think that was one of the key eligibility criteria. English or spanish speakers. And they had to be within. Oh, I’m going to get this wrong. Within eight weeks of diagnosis of advanced disease. Jennifer. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=960810">16:00</a> So within twelve weeks. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=962690">16:02</a> So early-ish, is that similar to your knee? Jim, paper on early palliative care? Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=968682">16:08</a> Yeah, so that is a great question. So in the New England Journal of Medicine paper, it was eight weeks. In these more recent studies, we’ve expanded it to twelve weeks, just because when we do multi site trials, there’s definitely a learning curve. Enrolling patients in palliative care studies. And our research coordinator teams at multiple sites were saying eight weeks is kind of tighten to enroll patients or, you know, have the time to approach and enroll patients. So for most of our multi site trials, we’ve expanded the eligibility window to twelve weeks from eight. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=998960">16:38</a> So everybody was diagnosed with an advanced lung cancer sometime in the last twelve weeks and then they were randomized. Either this stepped early, stepped palliative care versus early palliative care, which is the. Maybe not the usual care like Alex was saying, but it’s the evidence based care that we have from prior trials. Is that right? Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1023400">17:03</a> We called it the early intensive palliative care. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1026192">17:06</a> Early intensive palliative care, because the usual care is the usual probably thing that happens is we wait for a palliative care consult. It’s not case finding. And then when they come in, we’ll see them, and there may be more intensive palliative care. We see them every month. Does that sound about right, Chris? Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1045961">17:25</a> Yeah, I think a month is pretty uncommon, at least in our clinic. Like, yeah, if I could hang the stars, if I was taking care of 25 people, I’d see them every day and they’d all feel great, right? Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1057441">17:37</a> Or overwhelmed. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1059049">17:39</a> Yeah, well. Or they’d have so much time, toxicity, they’d drop out of cancer care. Those would be the two options. You decide if you’d want to see me every day. But no, that you named it right. That four weeks. We probably do six to eight weeks on our typical care patients. If we have somebody who’s hit a level spot. Jennifer mentioned earlier this idea of prognostication and the people who are the pd l one expressors. I learned more about people’s dogs and about their grandkids. Cause they were fine. There were a couple of people on my patient panel who were early intensive palliative care, and they did wonderfully for a long time outside of this study. I wouldn’t have seen them that often. So that’s where that full time toxicity question comes up. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1108840">18:28</a> So they were fine until they were not fine eventually, and some of them. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1112608">18:32</a> Were fine until the study ended, because we have some people in our clinic who are 4567 years stable metastatic non small cell lung cancer, stable on immunotherapy. It’s amazing. Back at that capacity question, right? If we’re still getting people in, but instead of living six months, they’re now living six years. That’s a lot of appointments that we have to account for over time. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1140450">19:00</a> So let’s talk about what was in the syringe in both groups. When we’re thinking about a palliative care trial. I was thinking about, okay, what do they mean by palliative care? What was in this stepped wise or intensive palliative care group? What was the team made of? Because, I mean, I can think of it like a spectrum. On one hand, in palliative care, it’s like primary palliative care, people who’ve got a little bit of teaching. On the other hand, you got a full interprofessional team. You got palliative care psychologists and social workers and pharmacists and MP’s and physicians and nurses, you know, the chaplains. Yeah, the full model that we love to talk about, that actually rarely happens in the real world. Pahlavi, who was, what was the team made out of? Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1185940">19:45</a> It’s interesting. I think it actually varies a little bit, even among our three sites in terms of the intensive arm. So at our cancer center, we have physicians, advanced practice providers. We do have access to palliative care social work in the outpatient setting, and we have a nurse. We don’t have pastoral care actually readily available for our ambulatory patients. And so that’s sort of our interpretive team or interdisciplinary team here. And then the sept arm, I think we were pretty clear that they could not be receiving home palliative care services. That was an exclusion criteria. And then they, I think that was an exclusion criteria in both arms, actually. We did not want them to already have seen home palliative care. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1226564">20:26</a> And that includes home hospice care. Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1228956">20:28</a> Yes, definitely. And then we also didn’t give them access to palliative care social work on the stepdarmouse. They had access to the cancer center resources, but they didn’t have access to sort of regular contact with palliative care mental health professionals. Was that the same at MGH for. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1248060">20:48</a> We don’t, you know, our palliative care team here in the outpatient setting is only physicians and advanced practice providers. I would say generally, though, to answer your question, Eric, you know that palliative care content and clinicians were identical in both study arms. So those were intentionally not varied, because then you’re not just comparing the cadence and the frequency, you’re comparing different interventions. So, for example, the intervention visits had to be delivered by a physician or advanced practice provider. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1279420">21:19</a> So I got a question for you, Chris. You brought up ICU study. It was titled like, had the word palliative care in the title, I think. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1291512">21:31</a> Blog post, if we’re talking about the same study, was like, fast food palliative care, in and out palliative care, something like that. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1297944">21:37</a> In and out. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1298336">21:38</a> Palliative care doesn’t work. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1299720">21:39</a> It was nationally representative. So it was not in and out because I can’t get those burgers here. It was just fast food generally. You’re right. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1306976">21:46</a> So this study showed that in people with chronic critical illness, having palliative care lead one and a half sessions in an ICU around prognosis and goals. I’m not even sure goals of care was a huge part of it, didn’t actually help, but actually worsen potentially some PTSD outcomes. And the entire community of palliative care said yes, not a palliative care study. Sure, it has palliative care in the title. Sure, there was a palliative care led prognosis, meaning. But it was not a full interprofessional palliative care team. They didn’t include all these palliative care NCCN guidelines or. Sorry, I always forget that. Yeah. Not all the domains of palliative care were included. I wonder, when you think about that trial versus this, which you can also make the argument that this was not a full palliative care consult team. How do you think about that? I’m bringing it up since you brought up that trial. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1372918">22:52</a> I know, I know. I’m happy to. And I’m going to have to call the first author and tell them that I love them still. Cause I still do. But the idea of do this thing and we’re gonna call it palliative care versus do palliative care, and I. We’re what? We’re nine years after that original article. Right. Or the article that, the fast food article, to use the parlance from the blog post. So I think we’re in a different spot now. I think we’ve. That article really helped me to realize if you’re overly prescriptive about what a palliative care intervention is, it’s less likely to work. Palliative care is zigging and zagging and following the patient where they are. So being told, you are an expert at this, we trust you do palliative care. It makes it hard to report what’s in the syringe, but it’s putting the stuff in the syringe that the patient needs. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1425176">23:45</a> Yeah, I love that, too, because I think that one for me really is, can our interventions need to target the patient population that we’re managing? So in chronically critically ill patients, the idea that one visit is going to do anything is just. No, I think it was a great trial. I think we learned a lot from it. Palliative care. I actually think it’s a great palliative care trial. And I wonder, Jennifer, from this study, were there other things that putting this together that was prescriptive that these palliative care physicians, advanced practice nurse that they were always going to do, or was it, we’re going to let you be do your thing, but this is who the team members are going to be. Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1469844">24:29</a> Yeah. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1470220">24:30</a> So the team members were prescribed that at least intervention visits had to be physicians or advanced practice providers. As Pahlavi said, you could refer to other providers. The intervention, I would say, was somewhere in the middle of scripted versus not scripted. I mean, the pro of scripted is we have fidelity, we know exactly what happened. The con of scripted is exactly what Chris says. You come in with an agenda, that’s not what the patient’s agenda is. So we trained all the palliative care clinicians on the model that we mostly deliver here at MGH. That early visits, when people who often look and feel like all of us, even though they’re on chemotherapy or immunotherapy. It’s about establishing a relationship and rapport. It’s about instilling coping skills. And if they have symptoms, you address symptoms, and at some point, you might elicit goals and values, and at some point, you might talk about end of life care. But it’s a very different model. It’s an outpatient model where establishing relationships, as Chris said, getting to know what their grandchildren are doing, getting to know what they like to do, so that when the hard times come 3612 months later, you have that trust and relationship to make those conversations happen, easier to facilitate them. What was very scripted was when palliative care visits occurred in step and how they occurred. So again, the step model is patient centered. We monitored patients to know when they should step up to more frequent palliative care, and we did that with a quality of life measure. And that was very intentional. We did not just rely on a physical symptom measure, which many of our colleagues are doing. And the reason for that is the nature of our palliative care intervention. It’s not just about physical symptom management. It’s about coping. It’s about psychological support. And so we thought a quality of life measure, which incorporates physical well being, functional well being, emotional well being, social well being, and physical symptoms, was the right trigger to say someone needed more palliative care. Additionally, in case patients didn’t step up, we did have sort of events where they were scheduled to see palliative care. So if their cancer treatment changed or they were admitted to the hospital, they were always triggered to have a palliative care visit, just because we know those tend to be very physically and emotionally taxing events in a cancer patient’s life. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1607950">26:47</a> How soon after from a hospitalization, all. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1610926">26:50</a> The palliative care visits were triggered? Generally, we gave palliative care because of the reason, exactly what Chris said. Sometimes we can’t get people in with palliative care. You sort of had a month after all of those events. So once the team saw that you had cancer change in your cancer treatment or admitted to the hospital, you were scheduled to see palliative care within a. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1627894">27:07</a> Month of that event, did they also see inpatient palliative care? Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1631500">27:11</a> Yes. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1632780">27:12</a> And that was, was that a trigger in the stepped group, that everybody who got admitted saw inpatient palliative care? Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1638604">27:18</a> So that’s a great question. So in stepped palliative care, it was sort of up to the team in the, what Chris and Pallavi are calling intensive. I haven’t called it that before, but I might steal it. Then inpatient visits were mandated. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1650540">27:30</a> Oh, truly intensive. Like you’re seeing everybody. Every four weeks, they get admitted, they’re going to see inpatient palliative care. After admission, they also see palliative care. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1663820">27:43</a> I know we’re getting you confused. And the early integrated palliative care was every month. And if hospitalized, and then the step quality of life is monitored, if their quality of life dropped, they stepped up. But for patients who weren’t stepped up after a change in cancer treatment or hospitalization, they would have palliative care visits. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1681772">28:01</a> And, Ken, I asked Pallavi, maybe you know this, so you’re doing these quality of life surveys. I’m trying to figure out how would this be implemented in, outside of a research setting? How are the, how are the folks getting these quality of life surveys? How are you getting them back? Great question. Is this practical outside of a research setting? Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1703710">28:23</a> It depends. Which is not a great answer, but. So it actually changed over the course of our study because, you know, before COVID everything was in person, and we’d have these lovely research assistants and coordinators running around sitting with patients while they did the surveys, getting them back in real time, or hounding them to send them back by mail or email. And then we started pushing a lot more surveys electronically to patients, which, of course, has its challenges, because not everyone’s as tech savvy as, you know, our highly educated patients who have access to technology. So it even changed over the course of the study. Pragmatically, I think as more and more cancer centers and health systems move towards collection of pros, I think it is going to be more feasible. But pros, patient reported outcomes. I’m so sorry. Jargon. I think bigger cancer centers and health systems can probably implement these, but I think it’s tough in a community based practice to reliably collect these without boots on the ground. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1760690">29:20</a> Yeah. Chris, do you use them in your practice? Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1764100">29:24</a> So it’s an interesting question. We had some, something that was required of all patients. And the thing, if they didn’t fill it out, they couldn’t join the video visit. So people would be three minutes late because they’d be feverously clicking these boxes and we didn’t ask for them and we didn’t read them and we didn’t look at them. So not what we’re talking about within this trial, but there was a patient reported outcome. I begged our tech people, I said, get rid of this. This is a barrier to getting the patient in the door. Now, if I had somebody who could catch these things, similar to what the research assistants are doing, or if I had a dashboard that Mister Smith three months ago was this and now is this, that would be so useful to me. So I think that’s the future. Is being able to automate some stuff through the portal and then have a dashboard on the clinician side of look, these are the domains that the patient declined in between these two visits. Well, I’m not going to wait for them to bring it up. I’m going to bring it up in our next scheduled visit. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1827440">30:27</a> Yeah. Or if you have a team huddle. Oh, these ones are in the red. We need to. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1832240">30:32</a> We aspired within our group. Now we have two nurses for 8.5 ftes. So we’re like super tight in terms of our support staff, but we aspire to have like ten patients or so that we call the hot list. So these are the patients who are. We’re actively changing methadone. They’ve been in the hospital twice in the last six weeks. We want our nurses to keep up with those patients, but it’s just, it’s really hard to implement when the prior authorizations all need to get done. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1860980">31:00</a> It’s real world. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1862284">31:02</a> So let’s hear. I was going to say, did it work? But that’s not the question, right, Jennifer? Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1866468">31:06</a> That’s not the question. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1869220">31:09</a> Was it, did it not work? I’m not even going to say, was it equivalent? Because that’s not the question either. I just learned. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1875220">31:15</a> I feel comfortable saying it worked, and I’ll tell you why. Because quality of life was non inferior. So quality of life was, if we want to talk about just the as good as the more intensive model, but we used significantly fewer palliative care resources. So basically, to achieve the same quality of life benefit as the intensive arm patients saw palliative care, significantly fewer. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1898808">31:38</a> Half is less, right? Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1900192">31:40</a> About half. Is that good English? I’m not sure. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1902184">31:42</a> About half. Good enough for Jerry. That’s GeriPal grammar. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1904632">31:44</a> People understand, though. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1906920">31:46</a> Jerry Pal Grammar, that’s about half as much. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1912390">31:52</a> And the quality of life included symptoms, right? Their symptoms weren’t worse. Quality of life wasn’t worse. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1919950">31:59</a> The quality of life tool includes sort of the four domains that I mentioned, physical, functional, emotional and social well being, and that it also has a lung cancer specific subscale. So it’s the fact measurement system. So there’s like a fact lung effect, brain effect, colon. And so they always have those four domains and then a cancer specific. So, for example, the lung cancer specific one has questions about cough and shortness of breath anorexia. So the quality of life measure encompasses all of those domains. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1949800">32:29</a> And the secondary. Now, no worsening in depression symptoms, or I guess, equivalency as far as depression symptoms, use of coping strategies, prognosis, communication about serious illness or end of life care. Just no difference between any of those outcomes. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1966666">32:46</a> No difference in any of our patient reported outcomes. That is correct. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1970402">32:50</a> All right, I’m going to turn. This is the tough one. There was a difference, though, in hospice utilization, right? Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=1980690">33:00</a> Correct. There was a difference in length of stay in hospice. So the length of stay in hospice in both study groups was longer than, I think, any other study that’s ever been published, but officially, it was longer in the intensive arm than the step arm. And I have not asked Chris or Pallavi on their opinion as to why that is. So I’m very excited to hear their thoughts on why they think that was. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2003020">33:23</a> Pallavi, I want to hear from you first. Why do you think so? I’m looking at the data right now, adjusted mean days, 20 days versus 35. Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2013476">33:33</a> Days, which hats off to the intensive arm. 35 days is amazing and many, many times the national average. Right. So my thoughts, and this is speculation on my part, but I do wonder if there was a slightly more sort of orderly transition to hospice on the intensive arm, because we had these social visits, these rapport building visits, we had a chance to address that sort of low level existential distress that I think we can pick up that may not be picked up in the fact l, but may be picked up in these very organic clinician patient interactions. And so I wonder if the. And this is where I think qualitative data from caregiver bereaved caregivers would be super useful. On the lower touch arm, the stepped arm, was it a slightly more chaotic or sort of, you know, not as smooth transition to hospice? Maybe it happened a little bit later because it just wasn’t as smooth and we hadn’t had months and months of monthly visits to talk about it. The what ifs. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2081100">34:41</a> All right, Chris, my theory, and you can tell me if this is a dumb theory or not. My theory is that more people were seen by inpatient palliative care. And that’s where a lot of hospice referrals happen for these individuals when they’re really declining and they get discharged with, with hospice. So you’re seeing. Because everybody in the intensive care got inpatient palliative care or they were supposed to. That’s the reason. Stupid theory. Do we know of any data and I haven’t seen. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2111628">35:11</a> It’s an interesting question. I don’t know if we captured where the hospice referral came from. What my thought is, I like Paul Lavie’s thought. My thought is probably driving alongside hers, which is that patients sometimes need to be told, I love you, I know you. It’s time now for hospice. And if you wait for the hospitalization, for the inpatient team to be the one to say that you’re going to get hospice, but you’re going to get it for a shorter time because things have already decompensated, where if we can do that in the office without the hospitalization, that’s when people have longer times on hospice is when it can be controlled. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2153666">35:53</a> So you’re saying the exact, exact opposite. Jennifer, do we have any data to suggest which theory fits closer? Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2166620">36:06</a> We are investigating it right now. I think one thing that’s a bit tricky about it is just to be careful to not make inferences about subgroups. So we’re looking at people who are sort of on the low touch versus who stepped up. And it gets a little confusing. You’re slicing and dicing the population. The data on hospitalizations by study group we are just starting to analyze right now. So you’ll have to have us all come back in a couple of months so we can tell you if there’s a difference in hospitalizations and palliative care exposure. My guess is it’s not that I don’t think that we’re going to see differences in hospitalizations between groups or exposure so much to palliative care during hospitalizations. My guess is it’s more what Pahlavi was saying, that the sort of less intensive palliative care was able to do everything else except a super early referral to hospice. I don’t want us to forget that 20 days in hospice is still something that is still pretty amazing. And so even though there was a difference, it’s probably worth the discussion. Is that difference matter? Is that something we have to chase, or can we say the length of Stan hospice or step palliative care was 20 days? That’s amazing. And it’s good enough. I don’t know. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2240798">37:20</a> Pallavi. Good enough. Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2242470">37:22</a> Good enough. In terms of the length of stay. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2245374">37:25</a> When you’re thinking about this study, I’m trying to put this together in my mind. We have this study that shows less intensive palliative care compared to intensive palliative care actually was non equivalent in pretty much everything we measured except length of stay in hospice. Like, how much weight do I put in that hospice use secondary outcome? Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2268790">37:48</a> I don’t know that we know exactly the right dose of hospice to get max benefit. Like, when do you plateau? Right. We know that is usually better, but we’re looking at short times being hours to days. So I don’t know how clinically meaningful that week difference was to families. That’s really who we’re talking about, who got the support they needed to take care of their dying loved one. Here’s what I really want to know. I want to know how are we going to better predict who’s going to step up? That’s what. And someone’s got to say it this hour. AI, right? This 2024 is the year of AI. How we can we predict who’s going to step up? So I can give those people that intensive care just, you know, from the get go. I don’t know. I don’t know that there. I don’t know we’re going to know the answer to that. But that’s really what I wanted to know after we looked at the results. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2317000">38:37</a> Yeah, speaking of, like, a practical approach, one thing that was mentioned in discussion, I’m not sure if this was like, the reviewers asked you to do this using prognosis is a trigger. And, you know, we’re kind of like, we do e prognosis. We do a lot of prognosis stuff. And I completely agree, like, quality of life should be the trigger. Like a decrement in quality of life is the ideal trigger, not prognosis, not a shorter prognosis. And it’s a lot easier to calculate prognosis likely from, you know, the labs and the medical record than it is to, like, get patients to stomp onto a survey about quality of life. So there’s some trade offs there. I don’t know if any of you. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2354482">39:14</a> Have thoughts about that or are both important. Like, quality of life is really important, but also, like, when somebody’s prognosis suddenly changes through the much worse, is. Shouldn’t that be a trigger as well? Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2366210">39:26</a> Yeah, I mean, I think if I think about the next step, which is actually what I’m going to call the next study, isn’t that cute? Next step I think exactly what you are saying is what we need to do. We need to combine stepped care with AI prognostic models. Polybe knows this. I’m not sure if Chris knows it as well, but we have, and if anyone is on the study section is listening to this, you are meeting next week, so hopefully this will convince you. We have a proposal that’s been to NIH several times using an AI prognostic model to identify palliative care needs, and it has been trashed multiple times for a wide variety. I know this is so inappropriate, but I’m just going with it now. Maybe a reviewer is listening because of concerns about the ethics of using AI to identify palliative care needs. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2415390">40:15</a> Huh? Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2416590">40:16</a> What’s the concern there? Because we’re using AI to do everything right now it feels like we sure are a reviewer. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2423670">40:23</a> We sure are. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2431710">40:31</a> I feel like Kamala Harris about drama. Next question. And what’s the risk of someone seeing palliative care earlier than they were supposed to? I don’t know, but I’m hoping the third tries of charm, but I make promises. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2452910">40:52</a> I have another question about relating to your prior study. One the landmark reason, let’s just call it, you know, speaking of, can we say it on this podcast? AI the need. Jim, paper on early palliative care. The big reason it made headlines wasn’t the improvement in quality of life, which was great. It was the length in survival, you know, in the patients randomized to early palliative care. Now, I notice survival wasn’t a component of this study. I wonder what the reasons for that are. And I might it be that my hypothesis is that those small gains that might be seen in a palliative care arm in terms of survival are dwarfed by the gigantic differences that we’ve seen in the intervening ten years in cancer directed therapy. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2498420">41:38</a> Yeah, that’s exactly right. You really could not look at survival in an unselected metastatic lung cancer population in this five to almost ten year period. Now, there are just too many sort of predictive and prognostic factors that we would not be able to control for. So that is exactly correct. But it goes to how you kicked off this podcast. We don’t need a usual care arm anymore, and we don’t need to show the value and benefits of early palliative care. It has been shown, done. Close that chapter. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2529270">42:09</a> Well, in wait, can I just add, what was the survival in this group? Do we know how long people lived? Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2537000">42:17</a> We made a very thoughtful decision to not look at it, because if we do, people are going to ask for the differences between study groups, and that is a flawed analysis. And I don’t think we should be looking at data that we don’t feel like we have the rigor to make inferences about. So we are not looking at it. Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2556480">42:36</a> You’re saying it’s a flawed analysis because as what you said earlier, there’s so many components, what goes into survival for these different groups that it would be hard to make comparisons that were fair. You couldn’t digest for all those factors because you didn’t collect them or you don’t have access to them or whatever. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2572722">42:52</a> Correct? Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2573730">42:53</a> Yeah, sorry, Alex, you were going to say something? Alex <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2576530">42:56</a> No, I was just going to say that that case is shut, that palliative care should be usual care in advanced lung cancer and that for non cancer illnesses, for other conditions, there are still questions where usual care might be appropriate. Is that fair to say? I’m workshopping what I’m going to say at the “Congress du caretive” [speaking in French]. Thank you. Thank you. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2606420">43:26</a> You’re welcome. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2607860">43:27</a> Yeah, I mean, I think Alex is a great point. So we have this for lung cancer. Do we need to repeat all of this for different kind of cancers? Is it really open and shut for other conditions or do we need randomized controlled trial for different conditions, different stages of conditions? I think palsy. I sure hope not, Chris. No, hope not. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2630378">43:50</a> Because if you, you know, if we go back and you think about palliative care as cross cutting. Right. And if we go back to every single underlying condition that we can help with and if we’ve got to build that house from the dirt, we’re going to be talking about this in 2086. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2650014">44:10</a> Well, we have. Because every ten years we’re going to have to update it too, to keep up with. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2653358">44:13</a> We still haven’t gotten to Huntington’s disease, but you know, we’ll get there by 20, 116. Right. Like at some point we have to say we don’t hurt people. We know that the question of, as a limited resource, who are the right people for us to help, that’s in my mind probably still open. But I think when we have an opening like an ASCO guideline, we should drive the truck through there and then. I love the idea that really this trial was about is how much is enough? Because if we give somebody a lot, that means at least at my institution, some other people are not going to get any. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2689130">44:49</a> So I want to be mindful of the time. I want to ask kind of what’s next? What do we do with this? And I wonder from each of you. I’m going to start off with you, Chris, kind of what is next? What do you think the next thing we should either do in your own clinics with this data, or maybe from a research perspective, you can take either one of those. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2708022">45:08</a> Yeah. And as the non researcher in the group, if I could kind of hang the stars around this, what I would do is build some patient reported outcomes that allow me to know my patients, who I see on kind of the routine refill every ten weeks, every twelve weeks, who is suffering in that group, and I don’t know, so that I can pull them in in an earlier. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2731372">45:31</a> Slot, see, like a dashboard with how they’re doing. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2734236">45:34</a> Exactly. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2735340">45:35</a> So similar to this study, except kind of automated, no researcher research assistance needed, and then you’re looking at that dashboard. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2744468">45:44</a> I would love to build that. Yeah. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2746172">45:46</a> Pahlavi? Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2748580">45:48</a> I think I would like to see us operationalize these critical clinical points and use them as triggers for sort of, kind of an automated palliative care consultation. So if a patient with advanced lung cancer needs palliative radiation, a change in therapy, or an unplanned hospitalization, to me is actually the number one sentinel event that always alarms me. I feel personally ashamed when my patients get admitted to the hospital. So when that happens, I think that should trigger sort of reconnecting with palliative care. So I think that’s actually fairly easy to operationalize and shouldn’t require a great deal of manpower. I think the quality of life assessment was really brilliant in this trial, and I, on my wish list, would be a way to operationalize it that doesn’t add to clicks or headaches or make clinicians want to pull their hair out. But I do think that’s really important. And then my third wish is that if we were operating in a stepped care model, is giving folks access to people like palliative care social work, because we know so much of what’s in the syringe is coping support and that rapport building. We have found that when we partner with our palliative care social worker, even if we’re trading visits, patients feel cared for and they don’t have to have a financially toxic visit every time they can do a virtual visit with a social worker and still feel connected to the team. So those are three things I’d love to implement, like today. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2832360">47:12</a> And Jennifer, next steps. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2835640">47:15</a> I would like us to continue to maximize palliative and supportive care for patients with newly diagnosed advanced cancer and used fewer palliative care resources. So my next step is to try to integrate digital apps and videos and other things that deliver palliative and supportive care. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2854342">47:34</a> AI palliative care versus human palliative care. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2857782">47:37</a> There you go. That’s it. That’s the end of the podcast. Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2863790">47:43</a> Very fitting. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2865470">47:45</a> Well, we could talk much more about everything. I just want to thank all three of you. But before we end, and Alex, I think a little bit more is it Galileo? Speaker 6 <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2881130">48:01</a> Offer thanks to those before me. That’s all I’ve got to say. Cause maybe you squandered big bucks in your lifetime. Now I have to pay. But then again, it feels like some sort of inspiration to let the next life off the hook. And she’ll say, look what I had to overcome from my last life. I think I’ll ride above how long till my soul gets it right? Can any human being ever reach the highest light except for the resting soul? Galileo, king of night vision, king of inside. Chris <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2947680">49:07</a> Alex Smith, Indigo guy, everybody. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2954120">49:14</a> Follow me. Chris, Jennifer, thank you for being on this podcast. That was wonderful, wonderful study. We’ll have links to the study and to some of the other things we talked about, like the ICU study in our show notes today. Thank you all. Pallavi <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2967840">49:27</a> Thank you. Jennifer <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2968736">49:28</a> Thank you. Bye. Eric <a href="https://grain.com/share/recording/9974bb10-1fb1-47b2-9a31-c5a4d493c7d6/dUf5iUZduEsiHtpWGKZYqIXOU6jCkKjKg9Pm5kRo?referrer=docx&t=2970608">49:30</a> And thank you to all of our listeners for your continued support. </div> </div> </div></div><div class="vc_tta-panel" id="cme" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#cme" data-vc-accordion data-vc-container=".vc_tta-container">CME</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> <h3 style="text-align: center;">***** Claim your CME credit for this episode! *****</h3> Claim your CME credit for EP327 “Stepped Palliative Care” <a href="https://ww2.highmarksce.com/ucsf/index.cfm?do=ip.claimCreditApp&eventID=13848">https://ww2.highmarksce.com/ucsf/index.cfm?do=ip.claimCreditApp&eventID=13848</a> Note: If you have not already registered for the annual CME subscription (cost is $100 for a year’s worth of CME podcasts), you can register here <a href="https://cme-reg.configio.com/pd/3315?code=6PhHcL752r">https://cme-reg.configio.com/pd/3315?code=6PhHcL752r</a> For more info on the CME credit, go to <a href="https://geripal.org/cme/">https://geripal.org/cme/</a> Disclosures: Moderators Drs. Widera and Smith have no relationships to disclose. Guests Jennifer Temel, Chris Jones, and Pallavi Kumar have no relationships to disclose. Accreditation In support of improving patient care, UCSF Office of CME is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Designation University of California, San Francisco, designates this enduring material for a maximum of 0.75 AMA PRA Category 1 credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. MOC Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.75 MOC points per podcast in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. ABIM MOC credit will be offered to subscribers in November, 2024. Subscribers will claim MOC credit by completing an evaluation with self-reflection questions. For any MOC questions, please email <a href="mailto:moc@ucsf.edu">moc@ucsf.edu</a>. </div> </div> </div></div></div></div></div></div></div></div></div></div> </div>The post <a href="https://geripal.org/stepped-palliative-care-a-podcast-with-jennifer-temel-chris-jones-and-pallavi-kumar/">Stepped Palliative Care: A Podcast with Jennifer Temel, Chris Jones, and Pallavi Kumar</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></content:encoded> </item> <item> <title>Well-being and Resilience: a Podcast with Jane Thomas, Naomi Saks, Ishwaria Subbiah</title> <link>https://geripal.org/well-being-and-resilience-a-podcast-with-jane-thomas-naomi-saks-ishwaria-subbiah/</link> <dc:creator><![CDATA[Alex Smith]]></dc:creator> <pubDate>Thu, 12 Sep 2024 07:00:29 +0000</pubDate> <category><![CDATA[All Posts]]></category> <category><![CDATA[CME Eligible]]></category> <category><![CDATA[Podcasts]]></category> <guid isPermaLink="false">https://geripal.org/?p=6895</guid> <description><![CDATA[The post <a href="https://geripal.org/well-being-and-resilience-a-podcast-with-jane-thomas-naomi-saks-ishwaria-subbiah/">Well-being and Resilience: a Podcast with Jane Thomas, Naomi Saks, Ishwaria Subbiah</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></description> <content:encoded><![CDATA[<div class="wpb-content-wrapper"><div class="vc_row wpb_row vc_row-fluid no-bottom-margins"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"> <div class="wpb_raw_code wpb_raw_html wpb_content_element vc_custom_1726102060853" > <div class="wpb_wrapper"> <iframe title="Libsyn Player" style="border: none" src="//html5-player.libsyn.com/embed/episode/id/33015512/height/90/theme/custom/thumbnail/yes/direction/backward/render-playlist/no/custom-color/00548f/" height="90" width="100%" scrolling="no" allowfullscreen webkitallowfullscreen mozallowfullscreen oallowfullscreen msallowfullscreen></iframe> </div> </div> <div class="vc_tta-container" data-vc-action="collapse"><div class="vc_general vc_tta vc_tta-tabs vc_tta-color-sky vc_tta-style-flat vc_tta-shape-square vc_tta-spacing-1 vc_tta-o-no-fill vc_tta-tabs-position-top vc_tta-controls-align-left"><div class="vc_tta-tabs-container"><ul class="vc_tta-tabs-list"><li class="vc_tta-tab vc_active" data-vc-tab><a href="#summary" data-vc-tabs data-vc-container=".vc_tta">Summary</a></li><li class="vc_tta-tab" data-vc-tab><a href="#transcript" data-vc-tabs data-vc-container=".vc_tta">Transcript</a></li><li class="vc_tta-tab" data-vc-tab><a href="#cme" data-vc-tabs data-vc-container=".vc_tta">CME</a></li></ul></div><div class="vc_tta-panels-container"><div class="vc_tta-panels"><div class="vc_tta-panel vc_active" id="summary" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#summary" data-vc-accordion data-vc-container=".vc_tta-container">Summary</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> Well-being and resilience are so hot right now. We have an endless supply of CME courses on decreasing burnout through self-care strategies. Well-being committees are popping up at every level of an organization. And C-suites now have chief wellness officers sitting at the table. I must admit, though, sometimes it just feels off… inauthentic, as if it’s not a genuine desire to improve our lives as health care providers, but rather a metric to check off or a desire to improve productivity and billing by making the plight of workers a little less miserable. On today’s podcast, we talk with <a href="https://pallcare.hms.harvard.edu/faculty/node/49">Jane Thomas</a>, <a href="https://palliativemedicine.ucsf.edu/people/naomi-tzril-saks">Naomi Saks</a>, and <a href="https://sarahcannon.com/about/newsroom/ishwaria-subbiah-md-joins-scri-as-executive-director-for-cancer-care-equity-and-professional-wellness">Ishwaria Subbiah</a> about the concepts of wellness, well-being, resilience, and burnout, as well as what can be done to truly improve the lives of healthcare providers and bring, I dare say it, joy into our work. For more on resources for well-being, check out the following: <ul> <li style="font-weight: 400;" aria-level="1">Cynda Rushton, PHD, MSN, RN — Transforming Moral Distress into Moral Resilience <a style="background-color: var(--wpex-surface-1);" href="https://www.youtube.com/watch?v=L1gE5G8WnTU">https://www.youtube.com/watch?v=L1gE5G8WnTU</a></li> <li style="font-weight: 400;" aria-level="1">Tricia Hersey: Rest & Collective Care as Tools for Liberation <a style="background-color: var(--wpex-surface-1);" href="https://www.youtube.com/watch?v=7OuXnLrKyi0">https://www.youtube.com/watch?v=7OuXnLrKyi0</a></li> <li style="font-weight: 400;" aria-level="1">Beyond resiliency: shifting the narrative of medical student wellness <a style="background-color: var(--wpex-surface-1);" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10500407/">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10500407/</a></li> <li style="font-weight: 400;" aria-level="1">Fostering resilience in healthcare professionals during and in the aftermath of the COVID-19 pandemic <a style="background-color: var(--wpex-surface-1);" href="https://www.cambridge.org/core/journals/bjpsych-advances/article/fostering-resilience-in-healthcare-professionals-during-and-in-the-aftermath-of-the-covid19-pandemic/0ADCA3737D12CAF308567A7F59EFC267">https://www.cambridge.org/core/journals/bjpsych-advances/article/fostering-resilience-in-healthcare-professionals-during-and-in-the-aftermath-of-the-covid19-pandemic/0ADCA3737D12CAF308567A7F59EFC267</a></li> <li style="font-weight: 400;" aria-level="1">The Greater Good Science Center studies the psychology, sociology, and neuroscience of well-being and teaches skills that foster a thriving, resilient, and compassionate society. <a style="background-color: var(--wpex-surface-1);" href="https://ggsc.berkeley.edu/?_ga=2.230263642.712840261.1724681290-1268886183.1680535323">https://ggsc.berkeley.edu/?_ga=2.230263642.712840261.1724681290-1268886183.1680535323</a></li> </ul> ** NOTE: To claim CME credit for this episode, <a href="https://geripal.org/well-being-and-resilience-a-podcast-with-jane-thomas-naomi-saks-ishwaria-subbiah/#cme" target="_blank" rel="noopener">click here</a> **   <hr /> </div> </div> </div></div><div class="vc_tta-panel" id="transcript" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#transcript" data-vc-accordion data-vc-container=".vc_tta-container">Transcript</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=9590">00:09</a> Welcome to the GeriPal podcast. This is Eric Widera. Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=12486">00:12</a> This is Alex Smith. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=13782">00:13</a> And Alex, who do we have with us today? Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=15518">00:15</a> We are delighted to welcome Jane deLima Thomas, who was a co-fellow with me back in the day in palliative care. She’s a geriatrician and palliative care doc and is associate chair for professional development in the department of Psychosocial Oncology and Palliative Care at the Dana Farber Cancer Institute and Harvard Medical School. Jane, welcome to the GeriPal podcast. Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=37842">00:37</a> Thank you so much for inviting me. Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=39802">00:39</a> And we’re delighted to welcome Ishwaria Subbiah, who is an oncologist and palliative care doc and is executive director of Cancer Care Equity and Professional Wellness at the Sarah Cannon Research Institute in Nashville, Tennessee, and also oversees wellness for us. Ishwaria, welcome to GeriPal. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=59388">00:59</a> Such a pleasure to be here. Thanks for having me. Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=61674">01:01</a> And we’re delighted to welcome back to the podcast Naomi Saks, who is a palliative care chaplain, assistant professor in the Division of Palliative Medicine at UCSF and Director of Individual and Collective Well-being for the Hospice and Palliative Medicine fellowship at UCSF. Naomi, welcome back to GeriPal. Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=78906">01:18</a> Great to be here. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=80378">01:20</a> So we’re going to be talking about wellness and resiliency, or even if those are the terms that I should be using now, because everything seems to be changing. But before we do, I think somebody has a song request for Alex. Who has a song request? Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=94140">01:34</a> I do. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=95156">01:35</a> Naomi, what song? Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=97660">01:37</a> Beautiful, by Christine Aguilera Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=99084">01:39</a> Oh, Beautiful. Beautiful. Thank you. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=114332">01:54</a> Why’d you pick this song, Naomi? Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=117430">01:57</a> Because it really talks about this beautiful experience of our beloved, which is ourselves, the part that we often cut out of the equation. And so I just thought it was really beautiful. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=129990">02:09</a> Thank you. Alex… Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=132870">02:12</a> (singing) Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=196270">03:16</a> That is a lovely song. It’s been a while since I heard it. Thank you, Naomi. Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=201382">03:21</a> Beautiful words can’t bring me down. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=204900">03:24</a> Okay, I’m going to start off with the question that I had earlier. I think we titled this wellness and resiliency, but I see a lot of words that are being bantered around. I even heard in people’s titles. So wellness, well being, resiliency, burnout. How should I have titled this? Naomi, I’m going to turn to you. Thoughts on kind of where we are. I know you work with our fellows a lot on this. How do you talk to them about these terms and these definitions? Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=240870">04:00</a> So, really good question one, I always let people name their own experience. So that is one of the things I’ve learned, and all the people I work with teach me is actually, we ask people what they call it, what they call their experience. But there’s been a big shift, I would say, in the last five or ten years of programs that focus on this idea that if you just were good enough and better, we’re going to burn you out and ask you to do yoga afterwards, and if you were just strong enough and more organized, you could take care of yourself. So people are not so excited about this idea of resilience in the old fashioned way, this idea that it’s up to you. If you were just. If you could make it, if we. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=284154">04:44</a> Could just make you a little bit more resilient, you can increase your Rvus so you can see more patients. So we’re going to mandate you take this mandatory resiliency training after work on this online module, right? Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=299040">04:59</a> So we know that we in healthcare, and all of our colleagues are some of the most resilient people that ever existed. I mean, in other work, hard work environments as well. But that’s where it extended to this whole idea of well being or flourishing, or wholeness or sustainability. This is this idea that 80% of burnout or moral injury is actually systemic, and only 20% is actually how we relate to that. And that’s how the names have really changed. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=327032">05:27</a> 80 2080 20. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=329312">05:29</a> And that’s really how this field of professional well being, healthcare professional well being, clinician well being, has evolved, is that there is an important place in our overall professional well being for personal resilience and our individual coping strategies, recovery methods from day to day. But we can’t lose sight of the system level, the x individual outside of the individual, the system level factors that inform our day to day workplace experience. And so, in that way, the frameworks developed out of the national academies, Mayo, Stanford, they really all align around personal resilience. Being an important part of our professional well being. But allowing the space in that same breadth to say it is actually mostly organizational factors, organizational culture of wellbeing, efficiency, of day to day work, life and practice being the other main components that complement personal resilience. So we’re not going to meditate our way out of this one, is what we’re saying. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=401600">06:41</a> But meditation or there’s some personal aspect that still matters. That right. So it’s not 100% systemic or systemic. Systematic, absolutely. Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=415320">06:55</a> Connection. There’s all these gold standards from positive psychology that are still so important, and also from all the wisdom traditions, spiritual traditions, existential meaning making connection, pro social emotions, this gratitude, these emotions that make us feel good inside, and then they help us connect to other people. All those things are still important. This whole idea of mindfulness taking a pause, perspective taking, all those things are really important in changing how we experience what was going on, because it isn’t actually what’s happening, it’s what we tell ourselves about what’s happening. Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=450580">07:30</a> Jane, as long as I’ve known you, you’ve struck me as somebody who has been really adept at finding a within yourself the balance and being attuned to what you need in order to have a fulfilling career, fulfilling personal life. And, I don’t know, back in the day, you know, to push on the terminology, we used to call this work life balance that’s probably falling out of favor. I don’t know. Yeah, probably. I’m seeing some nods. Probably not the term we use anymore. I’m wondering how you think about this issue. Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=484590">08:04</a> So, first of all, it’s such a lovely compliment, and I want to just savor that for a minute, because I actually think it may reflect the phenomenon of how people look from the outside. Like, it sounds like the way that you experienced me. And sort of what I was conveying was that I had great work life balance. And internally, that was not my experience. My experience was that it was wild and that, you know, I think as a single mother and as a junior faculty person somewhere like Dana Farber, it was easy to feel like I was falling short in a bunch of different directions. Not that I had it all under control. And I do think that one contributor to our sense of sort of unease or the frantic feeling is that we compare what’s happening to us internally, the mess behind the scenes. Honestly, if you saw. I’m in my dining room right now, if you saw what was happening, I’m in the middle of packing. And so chaos, like, behind the computer, is chaos. And it’s like, a little. Little example of what I’m talking about. So, we compare that to what we see from the, you know, on the outside of the people that we know and we work with. So that’s. That’s just one note that maybe we can explore further. But to take the compliment at face value, I do think that something that I’ve really aimed for over years is to pay attention. Is to pay attention to what’s happening internally, is to pay attention to what’s happening around me and pay attention to what’s happening in the people that I’m responsible for, including my trainees or my coworkers or the people who are in the program that I led for some years. And I think everything that we’re talking about in this time and that we will talk about probably has to start with this idea of paying attention. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=598490">09:58</a> And I just want to acknowledge, too, because I’m going to compliment you, too, Jane. I’ve known you since we did PSAP together, I think, back in 2007 ish. But even today, the first thing that you asked me is how my son was doing. And we didn’t even ask how my son was doing. You said, how was Kai doing? My son’s name? And I just. It shows that you don’t just. You’re not paying attention just to, oh, how’s work going for you, Eric? It’s this larger acknowledgement as me, as a human, human being in this crazy world that we live in. And then there’s more to me than work that feels, Jane, like something that, I don’t know, I wish I did more and could pay attention to more. It feels like a practice of yours in some way. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=645790">10:45</a> There’s something to be said for being seen as a whole person, even in the workplace environment, because it’s you, truly. There’s no such thing as drawing a line between work and home. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=657820">10:57</a> Yeah. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=658252">10:58</a> You’re thinking about things outside of work during the work day. You try to keep it down as much as possible, but there are still things that weigh on your mind, and rightfully so, because you are one person, you’re a whole person. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=670484">11:10</a> So it’s not really work life balance. It’s more like work life, like integration. We’re putting it all together. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=675772">11:15</a> I just think of it as coexistence. Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=679900">11:19</a> Quick plug for the show severance on Apple, where the main character has severed his work life from his personal life. In fact, his brain is divided in two, and the work life person doesn’t know what happens in the personal life and the personal life part of his brain. Doesn’t know what happens in the work life. That is the opposite. And obviously, it leads to a lot of problems, which shows why this is problematic. I love the extreme. Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=708558">11:48</a> Yeah, I kind of think about it as remembering. That’s why a lot of the people I work with call it wholeness. You know, our training was invented in 1889. It’s pretty much the same. It was even before the weekend was invented. And we’re asked to banish huge parts of ourselves off in our training. And then it continues. We’re told not to pee when we need to pee, not to eat when we’re hungry. And we’re actually told that it’s not professional to be emotional. These kinds of things, they run deep and they get into our DNA. So it takes a while to rehydrate and to remember that. That actually, we will not show up less than whole. And that’s a revolutionary act. Like, we love this work so much that we will no longer banish parts of ourselves off. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=755300">12:35</a> I think that’s a beautiful concept. And I wonder how. What do we do to achieve that? Naomi? Because it’s certainly not the way I’ve been trained. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=765780">12:45</a> It’s. We don’t see. We don’t often see that kind of. I don’t want to call it behavior, because it’s. It’s part of just being a human. We don’t often see that modeled. Right? We don’t often see that. We don’t often bear witness to that, at least in. When we look at those who are further along professionally than us. And so in that way, it’s. There’s something to be said for bringing just enough authenticity. It’s not that you bring all of your problems to work, or you bring all of your work problems to home. Those people who may not have, those who may not share a bit of the whole picture on how they’re doing at work, especially leaders, they’re going through things. It’s not that their life is not a bed of roses for them. And so in that way, there’s really a missed opportunity there for mutual gain from getting some validation of what’s actually on your mind and still using that opportunity kind of reset and focus on what you wanted to accomplish that day versus having whatever’s weighing on your mind just persist throughout the day. Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=838920">13:58</a> I’d love to hear Naomi’s perspective on this. I feel like this is maybe in her wheelhouse, but building off of what Ishwaria just said, the idea that we have the capacity, the facility, to bring our whole selves to work but then also the discipline to know which facets of ourselves to bring to whatever the situation is that we’re entering. So whether it’s an encounter with a patient or whether it’s a family meeting or a clinical practice meeting or a feedback session with a fellow, the idea that we have both the ability to be very full and open and also selective and disciplined about how it is that we. What parts of ourselves that we bring into each particular moment. And, Naomi, I don’t know if that resonates at all for you. Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=890030">14:50</a> I definitely think, and I love Jane, how you keep coming back to the moment, because that’s all we have. We don’t have a past and we don’t have a future. And the moment, especially in our body, which is something we’re not usually trained to do, is to really to check in with ourselves, to scan and see where we’re triggered to, where we need a little attention, are we tasting our food? Those kinds of things. But I would say, even for me and for the colleagues I work with, the first thing is saying, we work for institutions that were not built to take care of us. In fact, we live in systems that are oppressive. They’re often racist. They often do not invite our whole selves there. The work of Tricia Hersey with rest is resistance. This whole idea that our worth is not equal to our productivity. Like, just even having that and normalizing it, and, like, after 13 years of training or 15 or whatever, chaplains, nurses, social workers, patient care assistants, everyone is working in these systems that are not built to take care of them. And I think that’s just, like. It’s actually a relief just to say that. I think it’s important. And I would say we still don’t know how to do this. We are bright and amazing and compassionate and dedicated humans, and we still do not know how to completely sustain in these systems and flourish in systems that depend on us to overwork and actually have censuses and groups of patients that are more than we can handle until we get more resources. That is the basic business plan and strategy of the institutions we work in, is basically to say, we’re going to make you work so hard and have so many patients, then we’ll finally give you resources, like, just that. And then it comes back to exactly like, okay, today, how am I going to sit here? How am I going to continue to be in this? So that I think it’s both. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1007898">16:47</a> I really love what everyone’s saying because it is interesting. Part of it is, how do I stay resilient in a broken system. And when the system does acknowledge wellness, it sometimes feels authentic because it’s their solution to decreasing productivity. Rvus. It’s like the development of an EHR. It’s really not about helping the patient or physician. It’s all about rv in billing. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1035372">17:15</a> Billing. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1036860">17:16</a> Right. Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1037388">17:17</a> Feels inauthentic. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1039940">17:19</a> And I wonder, AIshwaria, coming from your perspective, like, you’re leading wellness for two organizations, including your work, you have a leadership role in that. Like, how do you think about this from a systems perspective? Because I think it’s really easy for somebody like me to say, oh, like the C suite, they’re just bad people and they don’t care about us. And it feels like I can, you know, talk with my colleagues and, like, we can share stories about, like, war stories, but they’re people too. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1078040">17:58</a> Yeah. There’s something to be said for thinking of stepping back and recognizing that the system is an inanimate entity, that the system and the culture that comes with it are perpetuated by people. And so in that way, it’s not the letterhead or the four walls and the roof that are perpetuating the present, it’s the people. And so in that way, if we’re looking to advance the workplace experience in any setting, in any setting, in any role, and definitely within healthcare and definitely within oncology and medicine and geriatrics, is, you’re going to have to recognize that efforts to optimize will be centered on partnership and aligning as quickly as possible on the shared goals to the earlier point made. Systems should care for our wellness because it’s the right thing to do. But it may be that staffing shortages, high turnover, high cost of recruiting, training up a new physician nurse app, really any role that that’s the driver for the inanimate system to suddenly pay attention to, why are people leaving? And so in that way, that effort to maintain the systems momentum was a driver behind having a leadership presence in many organizations across the, in many healthcare settings across the country. For a team that’s tagged with professional. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1184252">19:44</a> Well being, is that usually the cause? I hear more and more places have chief wellness officers. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1191200">19:51</a> It’s a role that’s built to be one where that leader sees eye to eye with the chief financial officer, with the chief information officer, with pick any other C suite member. And that role is meant to drive that organizational culture of wellness. So that the norm isn’t you’re going to have to demonstrate the need for these three ftes yourself, and then we’re going to give you one like, that’s. That’s organizational culture, wellness. It’s not whether we have a mindfulness moment between the 14th and 15th meeting of the day. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1234148">20:34</a> Yeah, it’s. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1235884">20:35</a> Do we ask somebody to do the work of five and then give them one fte? Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1242220">20:42</a> It feels like from a, you know, the chief wellness officer, it. It could be viewed as two different ways. We are offloading wellness on this individual who doesn’t have a lot of power to make change, but we can scapegoat all our problems on this chief wellness officer. They can put together some pizza parties and stuff like that while we deal with the real business at hand. Versus what you’re talking about, too, is this integration of the chief wellness officer into that c suite where they actually have the funding, they have the ability to change things. And it’s not just we’re pushing all off these duties on this person so we can say we’re doing something on wellness. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1286640">21:26</a> It allows a role like a chief wellness officer or really any executive role in professional well being, allows for the quantification of professional well being through the validated measures out there and measures that not just share what the burnout rate is, but measures that go into the driver dimensions of burnout so that you, as a chief wellness officer, can say, oh, it’s not because I haven’t done any meditation retreats that our people are burned out. It’s because, look, they have finding very low meaning in work. Their EHR helpfulness score ranked painfully low. And so, in that way, by having objective measures of well being, you’re taking a lot of the perceptions out, especially one surrounding that there’s a resiliency deficit that needs to be corrected in order for burnout to no longer be a problem. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1348820">22:28</a> Yeah. Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1349868">22:29</a> Jane, I remember back in fellowship where a couple of instances when we push back on leadership about stuff because our work was just becoming unbearable. And I remember we did it once with Susan block over the IPCo and another time with Andy Billings over coverage issues. It’s been a long time since then. That was like 2005. Over your career, have there been times when you’ve advocated either for yourself or for your colleagues with upper level leadership? And now that you’re in upper level leadership, what’s your view of this as you’re helping people who are coming up through the system grow and develop professionally? Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1393920">23:13</a> There are a lot of parts to that question. Alex. Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1396680">23:16</a> Sorry. Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1397568">23:17</a> No, no, it’s fine. So, I guess I’m going to choose the part that I want to answer. Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1404824">23:24</a> Good. Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1405960">23:25</a> Which is, you know, I have had a few different kinds of leadership roles, and one was, as clinical director for our clinical service at Dana Farber and Brigham and women’s, overseeing the clinical operations for our whole fairly large group. I backed into that role. It wasn’t sort of a strategy to be like, oh, I really want to do a clinical leadership role. And then found myself in that role during the pandemic and learned some things about myself that I didn’t know. Namely, I actually like working in a crisis. I can make decisions quickly. Like, there were some things that I was like, oh, look at that. And also, by the fall of 2020, I was pretty sure that I didn’t want to be a leader anymore. And so I’ve spent the last couple of years actually backing out of leadership roles because that position of being sort of caring deeply about what’s happening for people who are doing the face to face patient encounters and doing that kind of work, and the administrators who are making decisions and sort of being in between those forces. And then, and sometimes even on the role of the administrators making decisions, especially in the context of a pandemic, became so heavy that it was. It was hard to keep my balance. The role that I have now is one where I don’t have people who report to me. I don’t manage anybody, but I get to sit in on some leadership meetings and make my voice heard. And my role is to try and be as thoughtful and as observant as I can be about what’s happening with people in our group, in our department of about 200 people, and figure out where the places where people are really thriving, where are the places where that’s less the case? And what are the interventions that I could imagine that might help the places, you know, for the people who are in the spots where they’re not doing as well? The very long winded answer to your question, that has a little bit to do with leadership. But also for me, I found the level, the happy point, where I could be in a position where I could be helpful, where I could use the skills of observation and desire to help someone grow without getting banged around quite so much in the big institutional politics and decision making over life and death, things like what happens in a pandemic. Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1558088">25:58</a> That’s great. Yeah. It sounds like you’ve found within yourself what you need in order to be able to thrive in your role, and you’re helping others identify those areas where they’re thriving and not thriving. That’s true. Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1570288">26:10</a> That’s it. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1571000">26:11</a> I hope we all have a jane in our workplace and in our departments and in our practices, our clinics, labs like we need. Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1580006">26:20</a> Maybe we just take this fivesome on the road, but there’s. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1584542">26:24</a> There’s. There are things we can teach one another to heighten our self awareness. Right. The way that we’re reacting in a moment to something we’re observing, to be able to recognize that in the moment and past likely validate it. Right. Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1598630">26:38</a> It’s. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1599134">26:39</a> You’re reacting appropriately to what you’re facing. Now. Let’s find a way to reconcile with that a little bit here, a little bit afterwards, and then let’s preserve some of that cognitive bandwidth for, okay, what can we do next to help that patient, that family? What can we do next to help that colleague? And so there’s something to be said for having peers who are peer leaders in the workplace, who have that level of observational awareness on what others are going and to help them recognize in the moment that this is affecting me in the way that it should, because I’m a good person and I should be reacting this way. Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1642590">27:22</a> Jane, I really relate to what you say. You know, us in palliative care, we’re fueled by death anxiety, by a lot of loss. We’re supposed to be the people, the comfort business people. We’re supposed to go into the center of human existence and just make it better. And during COVID that kind of broke apart for me. I was always in leadership positions. I was a director of our palliative care team. I was a spiritual care director, and I kept it together pretty well. This idea of I was supposed to be the compassion person. I was supposed to always come in and bring calm. And actually, that broke apart. During COVID there was no calm. There was no way to keep it together. And I actually couldn’t take care of the people that I was supposed to. And at first, it was so painful, and then it was just a beautiful relief. There was a moment of, like, a death, and then, actually, there was this moment of, like, actually, I can be. I can show up much more fully now than I ever have been before, and I don’t. I don’t keep parts of myself away. And I also don’t assume that I’m gonna be the person to be able to swim into the death anxiety, to swim into the loss, to people’s fear of aging, to people’s fear of dying. And I didn’t think I needed to make it better. But chaplains, especially during COVID were the ones that were just sent in there. We were often the only ones left in the hospital. We went into the rooms. And there was, like, a feeling of, oh, right, we’re valued now. And that was really great. And we never let a good emergency go to waste. So we got more ftes that way, too. But at the same time, I had such compassion for our leadership, for me being in that position. And I continue to know that, like, this is, like, nobody’s getting out of this, like, in a perfect way. But I just really relate to sort of your own personal journey, because I think I’ve had my own with this. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1752076">29:12</a> Naomi, what do you think it was about COVID pandemic that broke so many of us? Because I do feel like that the same thing happened to me is that part of my goal of the last two years was actually to give up some of my leadership roles, fellowship, leadership roles. Other things focus more. And it’s probably just until recently where I, like, I’m finding those things that bring me joy again and attending things I haven’t done in a while, like our works in progress meetings, which I never really attend. It’s more research meeting, but I kind of get joy out of it. I go to M and M’s again because I still kind of get joy out of it. So trying to find those things because I hear this over and over again, I think Covid broke a lot of us. Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1796650">29:56</a> Yeah. For me personally and also for a lot of people, my friends and colleagues, we couldn’t keep it knitted together. That was the bad news and the good news, and it was so unknown, and everyone was so traumatized. And right down from leadership down to the whole. Anyone in the whole organization didn’t know what to do. And we all were kind of acting from our feet, doing the best we could. And then I couldn’t. I didn’t have enough energy to also knit a Persona, professional identity, or even a sense of, I actually can fix this, or I’m a leader, and I’m going to take care of people. And it was horrible because I was like, this is not what I signed up for. But then there was just after I let just surrendered to that. Same with me, Eric. Joy just comes into my life now. All I want to do is like, okay, let’s have fun. Like, let’s. Let’s just do some crazy thing at work. Let’s have fun. Let’s go out. There’s some just joy that’s bursting inside of me from that experience of this identity, this professional identity breaking open. But it was hard for a while. I couldn’t get help. I couldn’t get anyone to. We couldn’t make it better. There was just no way. Yeah, it was a dark night. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1867940">31:07</a> You know, Naomi, you hit on something as you were sharing that. That. That really resonated with me, and that’s. You can’t be everything for everybody, and it’s not. This was an element of my professional growth, especially as I hit that mid career stage. At the start of the pandemic. It was having to reconcile with the fact that I was getting responsibilities and needs shared of others that I could meet. From a skill set standpoint, it’s within my scope of practice and palliative care and oncology. But there physically wasn’t the time, and there wasn’t that energy to be able to do everything for. It was pushing ten boulders up a mountain instead of just, you know, one. It’s just not. You cannot be everything for everybody. Even if you’re trained to do it. You just can’t. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1927650">32:07</a> Yeah, I felt like the first year, I actually had a ton of energy. Like, it was a sprint, and then, like, I ran out of energy and just. I had nothing like. And the fact that it just kept on going. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1942704">32:22</a> Just kept on going. Any Hollywood virus movie, there’s a resolution in, like, three months, it’s done, and the world goes on. Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1952800">32:32</a> I had family members pounding on my chest in the lobby, wanting to get up to their patient’s room and screaming at me and calling upstairs that their loved one was dying. There are stories that are stuck in here that need definitely. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1965536">32:45</a> Look, let me ask you about this thing, because we’re talking about wellness and resiliency, but I think the other big thing that we saw a lot was moral injury. We want that family to visit their loved one as they’re dying, but we have no control. There’s some things that are completely out of our control. We know it’s not the right thing to do, so we feel this injury deep in our souls. Do you think that played a role? And how do you think about moral injury, Naomi? Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=1995978">33:15</a> Well, you know, for palliative care, like, our baseline is, okay, we can’t save you, but we can at least give you a nice death as best as we can. Like, that’s, like. That’s the assumption. I know that’s a myth, too, but it’s kind of what we hold in our hearts. We can’t. We can’t cure you, but at least we can give you a nice death. And so that was gone. And so moral injuries, this whole idea that I think of, and Cinder Rushton was the one that really put this on the map. For us. But it’s really this idea that I know the right thing to do, but the system won’t, or the. Or the situation won’t let me do it. And so I really feel like that idea is really this idea of, like, how there’s also moral resistance. Now it’s called moral resistance, which is this, and moral resiliency, which is this idea of how to be. How to be fluid and to be, and to respond and to have perspective taking when we don’t have control. And Covid was just. Just an amazingly startling example of what we didn’t have control. We’re not making this any better. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2057230">34:17</a> Yeah. Individuals had no control. Systems had no control. Like a loss of control in every layer as we think about next steps and how to help with wellness, well being, resiliency, however we want to call it. I wonder if we can use this time, because we’re getting close to the top of the hour. We can think about, like, on those different levels, the individual levels, the system levels. What are the things that we can do to improve the well being, the wellness of individuals? I’m going to go ahead. Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2095918">34:55</a> What have you seen to be effective at your institution or other institutions? Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2101590">35:01</a> Jane, I’m going to start off with you. Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2104150">35:04</a> I was hoping you’d start with AIshwaria. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2107710">35:07</a> I was thinking about that from a big systems wellness perspective, but I’m going to mix it up a little bit. You’ve worked with a lot of trainees, a lot of people on the service. Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2119370">35:19</a> I have. So I have a few thoughts about this. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2124090">35:24</a> Go ahead. I’m ready. Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2127890">35:27</a> One is part of what I really try and help people do is, as has been commented on a little bit during this time, is to see and to validate people’s experience. And so if I’m precepting a fellow and we come out, and sometimes it’s that, I’ll see that there’s a struggle. I can help give words to that, or I can share my own. And so that person isn’t so alone. Whatever it is, it’s to give it form, give it a name, give it some shared currency. And in that is a sort of nurturing of what I think of as authenticity or belief in your own experience. Experience and a practice of understanding that something’s happening and then going after it and trying to figure out and define what that is and articulate what that is. So maybe I’ll just start there. There are some other things that I think of along those lines, but this idea of authenticity and sort of hand in hand with that goes a shift. And this is sort of like the second piece of going from should to want to. And so, like, we have all of these shoulds that are imposed. Sometimes they’re internal. We grow up. I should be a good person. I should be generous. I should be whatever it is and learning to figure those out and sort of parse. What are the ones we should actually listen to and what are the ones that we can actually let go of and the external ones as well. We should be writing. We should be doing this. We should be doing that. What are the things that I. That, as you were saying, Eric, that bring me joy that I can pursue because they feed me, as well as whatever the reward system that I’m in. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2229502">37:09</a> What’s that person? Is it Marie Kondo or something like, you get rid of the things that don’t bring you joy? Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2236350">37:16</a> Yes. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2238270">37:18</a> Bring the closet cleaning philosophy to life. Good to know. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2245710">37:25</a> Naomi, I wanted to get your thoughts. I loved your title. What was your title again? Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2252330">37:32</a> Individual and collective well being. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2254386">37:34</a> Individual and collective. When you think about individual and collective well being, what works in each of those two categories? Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2262266">37:42</a> Yeah. So, obviously, as a chaplain, the internal life is sort of my playground. And so I think the first thing is actually that 20%. Are we paying attention? Are we noticing? Are we taking dearest care of ourselves? Do we taste our lunch? Do we let ourselves actually sleep long enough? Do we say no, even when it’s hard? Are we not pathological, altruist? Are we allowed to actually take care of ourselves? And then do we take moments of mindfulness, moments of respite? So that’s really important. And then there’s all those gold standards that I mentioned earlier, meaning making connection, prosocial emotions, processing grief. Like, we are not ever included to do that. But then there’s the bigger systemic thing of actually baking in well being. Not as a check mark, not as an extra, but making sure that it’s in clinical practice, education, training, and research and DEI and this equity and inclusivity aspect. And so that means that everything from do we take a break after we go into a family meeting? And it’s really intense, do we actually give ourselves a moment to cry, to actually changing workflow, to actually advocating for hiring more people or creating research teams that show outcome and financial base, interprofessional teams. So when we were working on this book, intentionally interprofessional, we found such strong evidence that the team itself, simply being in a team, is protective. It’s completely protective. So those kind of things are really important to look at it both internally and then also this whole larger view. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2361970">39:21</a> That goes to you, Ashwari, as you’re thinking about this from a, a systems perspective, what have you seen that works? Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2370138">39:30</a> You know, it’s recognizing that one of my favorite quotes is from Christine Sinski over at the AMA. It’s not you, it’s the system. And so it’s us within healthcare as a whole, pausing for half a second and validating ourselves and our reactions as this is us reacting to the stimulus that’s presented. I am not the one. I don’t need to be fixed. There are things I can do better, there are things I can learn more and do more of, and I’ll do that. But the present is not because I, as an individual healthcare professional, am not enough. And so in that way, the system level solutions are validating professional well being as an organizational responsibility and infusing that culture of wellness into every single discussion, conversation, initiative, it build, quality improvement, whatever. You know, every single table has to have at least one leader who would already be there anyway, who has that lens of impact of what we’re proposing on the workplace experience of those who will touch that initiative. What is the task load burden? Actual task load burden? What are we going to take off their plate if we’re going to put these additional seven tasks onto their plate? For a, you know, to meet some quality measure, do we really need a 15 character password? If ten would do, do we really need the computers to timeout after 15 minutes? If we can safely do it, extend the timeout period to 60 minutes. So the well being as an organization is recognizing that it’s not the catastrophic losses that we may have on occasion that affect our day to day professional well being. It’s the accumulation of the micro trauma, the micro injuries that we are taught to just get over, take a deep breath, shake it off and move on. No, the injury accumulates, and it accumulates to the point where you can’t tell why you’re feeling so heavy when you walk into work or when you get out of bed. It’s the organization’s priority and responsibility to ensure that work that’s being done. A metric of impact and a metric of outcome is centered on the people. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2539626">42:19</a> Yeah. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2540850">42:20</a> And it’s possible. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2542490">42:22</a> Yeah, it’s one of those challenges too. It’s like the organization, like every organization, things build up over time. Meetings build up, all of these additional things build up. We were just in an m and m where there was a bad outcome. Like we have these, we look at these outliers and then there’s a desire to change our practices based on these outliers, which adds more things. Somebody had a hyperglycemic event, so we’re going to check daily, three times a day, blood sugar sugars on everybody. So instead of it, I like what you’re thinking about this, is that there should be some potential pushback. We’re thinking about, what does this mean for. But everybody in this system, the patient, the providers, is this the right path forward? Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2588660">43:08</a> Exactly. And you shouldn’t, as a system, hesitate to de escalate. De implementation should be in the same breath as innovation and any other buzzword. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2601700">43:21</a> Yeah, because we often talk about even like, interprofessional collaboration, how great it is. But there could also be excessive collaboration where you have so many meetings at conference calls, you can’t get anything done in your life anymore. Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2614760">43:34</a> I found that after Covid, everyone just sneaks a Zoom meeting and, like, that’s not real time. I’ve never had so many meetings in my whole life. I don’t know about all of you. Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2624208">43:44</a> Yeah. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2624792">43:44</a> Things that would be hallway conversations at the coffee shop, at the cafeteria are now a meeting. That sense of community in the workplace has changed substantially, and we don’t know the mid or long term impact, and we truly don’t know how it’s going to affect professional well being. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2646610">44:06</a> Do we have time for one lightning round question for each of you? Is that okay? It’s a magic wand question. I see nobody saying no. So I’m going to take this opportunity to extend this podcast just slightly. So if you had a magic wand around wellness or resilience, you can focus on individual listening to this podcast. A system, our society. What would you use that magic wand on? Ishwari, I’m going to start off with. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2672268">44:32</a> You when I think of the pandemic. My magic wand is for each person to feel control of shaping their professional life and their professional legacy. That the work that you do doesn’t have to be every single thing you do, every single. But the work that you do, if you sit back and reflect, has to align with your. Why? Why did you go into this field of work? And is the work you’re doing as a whole making you feel like, hey, that’s what I set out to do. And if the answer is no, for crying out loud, change the. Change your job internally, within your organization. Actively explore what opportunities there are to evolve your focus and your functions. If not, find the place that does. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2729280">45:29</a> Yeah. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2730520">45:30</a> Nothing has to be wrong in order to move, and that’s something that we have to really be comfortable with in healthcare as healthcare professionals is. But to change, you don’t have to be on fire before you decide that something needs to change. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2747864">45:47</a> I love that. Naomi, what’s your magic wand? Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2752250">45:52</a> Well, we had a beautiful ed resident that was rotating with us last week, and she said, naomi, what would it look like if this system was built for me and for my well being? And I go, that is a great question. So my big fat magic wand would be reconceptualizing this whole problem and actually reconceptualizing healthcare into healing and centerpiece love, compassion at the center of that, and rethink about this whole idea of how, how do we invite people and train people and what are we inviting to them in this healing art that we’re doing? And it would completely reconceptualize. We talk about the fourth aim of well being, being part of it. I would get rid of the first three aims and reconceptualize that and say, really? Is that for the best and good for everybody? That’s the wand I would want to use. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2801006">46:41</a> I love that. Jane, you’re the last one. I gave you the last one this time. Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2805950">46:45</a> I know, and I’m still going to complain about the order. Who can follow Naomi with those answers? I love what both of them have said. Naomi is like, basically reconfiguring healthcare completely and reprioritizing it. And it’s amazing. I want to go there. But what Ishwaria said is something that I’ve done a lot of thinking about as well, and to sort of pull palliative care and this topic of wellness and sort of career and work and fulfillment together, you know, if the gold standard in healthcare or in palliative care is goal concordant care, and that’s we’re aiming to figure out what people’s values are, who they are, what’s happening in the context of their illness, and then create a plan that matches who they are in that journey, then what I would aim for, for people that I work with, for myself or anybody in healthcare, is goal concordant careers. So the idea that we, we take who they are, what they are, figure out their priorities, that they do this for themselves, that they know themselves well enough that they can learn their own priorities, their own goals, their own passion and mission, and that their careers reflect that. And I think when we have people who are working in situations where they can do that, where they can use the best parts of themselves, where their sense of mission and the difference they want to make, they can actually do that. They’re effective. Then thinking about wellness, it starts to skyrocket. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2894328">48:14</a> Yeah. And I think both for the person and I just want to bring in one thing Ishwaria said earlier is systems are made of people. Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2901816">48:21</a> Yeah, exactly. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2904040">48:24</a> With that, I want to thank all three of you. But before we end, Alex, do you want to give us a little bit more of Christina Aguilera? Alex <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2912600">48:32</a> (singing) Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2976040">49:36</a> Ishwaria, Naomim Jane — thank you for joining us on this podcast. Jane <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2979968">49:39</a> Thank you. Naomi <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2980856">49:40</a> Thank you. Wonderful to be here. Ishwaria <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2983216">49:43</a> You are the best. Thank you. Eric <a href="https://grain.com/share/recording/ef834790-d4ca-4531-8df9-1c3d7394c209/SMYUm8TWVPdKvFTixx1cUPpidb0amk6OtyeAUa0p?referrer=docx&t=2984624">49:44</a> And thank you to all of our listeners for your continued support. </div> </div> </div></div><div class="vc_tta-panel" id="cme" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#cme" data-vc-accordion data-vc-container=".vc_tta-container">CME</a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> <h3 style="text-align: center;">***** Claim your CME credit for this episode! *****</h3> Claim your CME credit for EP326 “Well-being and Resilience” <a href="https://ww2.highmarksce.com/ucsf/index.cfm?do=ip.claimCreditApp&eventID=13632">https://ww2.highmarksce.com/ucsf/index.cfm?do=ip.claimCreditApp&eventID=13632</a> Note: If you have not already registered for the annual CME subscription (cost is $100 for a year’s worth of CME podcasts), you can register here <a href="https://cme-reg.configio.com/pd/3315?code=6PhHcL752r">https://cme-reg.configio.com/pd/3315?code=6PhHcL752r</a> For more info on the CME credit, go to <a href="https://geripal.org/cme/">https://geripal.org/cme/</a> Disclosures: Moderators Drs. Widera and Smith have no relationships to disclose. Guests Jane Thomas, Naomi Saks, and Ishwaria Subbiah have no relationships to disclose. Accreditation In support of improving patient care, UCSF Office of CME is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Designation University of California, San Francisco, designates this enduring material for a maximum of 0.75 AMA PRA Category 1 credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. MOC Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.75 MOC points per podcast in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. ABIM MOC credit will be offered to subscribers in November, 2024. Subscribers will claim MOC credit by completing an evaluation with self-reflection questions. For any MOC questions, please email <a href="mailto:moc@ucsf.edu">moc@ucsf.edu</a>. </div> </div> </div></div></div></div></div></div></div></div></div></div> </div>The post <a href="https://geripal.org/well-being-and-resilience-a-podcast-with-jane-thomas-naomi-saks-ishwaria-subbiah/">Well-being and Resilience: a Podcast with Jane Thomas, Naomi Saks, Ishwaria Subbiah</a> appeared first on <a href="https://geripal.org">A Geriatrics and Palliative Care Podcast for Every Healthcare Professional</a>. ]]></content:encoded> </item> </channel> </rss>