We love getting requests from listeners for podcast topics.  This request came from geriatricians we met at the annual American Geriatrics Society meeting in Chicago.  They wanted to know more about what a geriatrician should do in a pre-operative risk assessment.  So we invited Vicky Tang and Houman Javedan, two geriatricians and leaders in the pre-operative assessment and prehab space, to talk with us.

As is our style, we backed up to some bigger questions, including:

-Why do patients need a geriatric assessment pre-operatively?-Why are our surgical colleagues asking us? Is it due to liability concerns? -Why do we do them?  Recognizing we may have different motivations than our consultants (hint: stealth geriatrics) -How does the comprehensive geriatric assessment fit int? Do the 4Ms fit into pre-operative assessment if at all? (an entertaining disagreement ensued) -Must a geriatrician do this? -What is the Geriatric Surgery Verification Program? -What’s the most important part of 

Many links from our guests below.

And please forgive my Spanish on the song, I tried! Thanks to sons Kai and Renn on Ukulele and Bass for making it sound better.

-Alex

From Vicky:

1. Systematic review of Prehab https://pubmed.ncbi.nlm.nih.gov/39655991/

2. Geriatric Surgery Verification Program https://www.facs.org/quality-programs/accreditation-and-verification/geriatric-surgery-verification/ 

3. shared decision making in surgical patients https://pubmed.ncbi.nlm.nih.gov/40551447/ 

From Houman:

Geriatric Surgical Co-management Evidence

1.    Trauma survival with geriatric assessment 2022- https://pubmed.ncbi.nlm.nih.gov/36102764/ 2.    Hip fracture survival benefit meta-analysis 2014- https://pubmed.ncbi.nlm.nih.gov/23912859/ 3.    Elective abdominal surgery benefits POSH program 2018- https://pubmed.ncbi.nlm.nih.gov/29299599/ 4.    POSH Program for Spine 2021- https://pubmed.ncbi.nlm.nih.gov/33382460/ 5.    Elective orthopedic joints ED readmission decreases 2024 - https://pubmed.ncbi.nlm.nih.gov/39715294/ 6.    The need for geriatricians, tools and education models (aka Ms) are not enough - https://pubmed.ncbi.nlm.nih.gov/30916758/

Sub Topics

7.    Utility of minicog and where our improved local mortality of 18% and delirium of 11% reported - https://pubmed.ncbi.nlm.nih.gov/27147687/

8.    Geriatrician performed CGA-FI best at predicting mortality in rib fractures 2025 - https://pubmed.ncbi.nlm.nih.gov/39800638/

9.    Geriatrician performed CGA-FI predicting mortality better than age in hip fractures 2024- https://pubmed.ncbi.nlm.nih.gov/39007664/ 

10.  Multidomain frailty assessment and surgery showing severely frail patients at risk of mortality even with low risk procedures (eg. Cystoscopy) - https://pubmed.ncbi.nlm.nih.gov/31721994/

11.  Different outcomes for hip fracture surgery in the severely frail - https://pubmed.ncbi.nlm.nih.gov/38892908/

12.  Complexity of aging physiology- example of prostaglandin based free water excretion in collecting duct of aging kidney first paragraph on page 360- https://pubmed.ncbi.nlm.nih.gov/36948780/ 

What is a “good death”? How should we define it, and who gets to decide? Is the concept of a “good death” even useful?

Twenty-five years ago, Karen Steinhauser published a groundbreaking study in JAMA that transformed my understanding of what it means to have a good death and questioned the usefulness of the term itself. This study examined the factors that are important at the end of life for patients, families, physicians, and other healthcare providers.

In today’s podcast, we are honored to have Karen join us to discuss this pivotal study and the nature of a “good death”. We are also joined by Rasa Mikelyte and Edison Vidal, co-authors of a recent study comparing the perspectives of people with dementia in the UK and Brazil on what constitutes a good death.

In addition to exploring the nature of a good death and their individual studies, we will discuss:

• Whether an external criterion for a good death exists, or if it is entirely dependent on the perspective of the dying individual.

• The role of culture and spirituality in defining a good death.

• The role of healthcare providers in the discussion about the nature of a good death.

Key references we discuss include:

• Our previous GeriPal podcast, “Should the Concept of ‘The Good Death’ Be Buried?” with VJ Periyakoil.

• Karen’s 2000 JAMA article, “Factors Considered Important at the End of Life by Patients, Family, Physicians, and Other Care Providers.”

• Rasa and Edison’s article, “Comparing the Views of People with Dementia in the UK and Brazil about a Good Death.”

• A short video from the EPEC project that Edison mentioned during the recording of an interview with Cicely Saunders, where she shares her advice for anyone going into medicine or palliative care and her views about the principles of palliative care.

Lastly, if you would like to join Eric, Edison, and I in Brazil on April 6, 2026, for the São Paulo Geriatrics & Gerontology Congress, click here to register.

-Alex Smith

A podcast on medical billing and coding??? Ok, hear us out as we were skeptical too. We’ve invited the Billing Boys, Chris Jones and Phil Rodgers, who convinced us of the following:

1. Billing is complicated, but it isn’t hard. 

2. Effectively billing helps pay for the interprofessional team members who often can't bill

3. We should know our worth and bill for it. Just because a visit didn’t feel HARD to a well-trained provider doesn’t mean it wasn’t complex or valuable.  Many of us have long suffered from low professional self-esteem when it comes to money, and it’s high time we stop that.

4. While exclusively billing on time may have been right 20 years ago, we must now understand complexity and advance care planning (ACP).

We can't cover everything in the 45 minutes we are together, so here are some of the resources we reference in the podcast:

• Chris’s and Phil’s consulting contact info via Lightning Bolt Partners

• CAPC resources:

• CAPC’s Billing and Coding Toolkit

• CAPC’s Monthly office hours in Inpatient and Community-Based PC Billing and Coding run by Andy Esch, Phil Santa Emma, and Chris Jones

• CAPC’s 2025 Annual Billing and Coding Update done by Phil and Chris each year

• Advance Care Planning resource from the Medicare Learning Network

• Top Ten Tips for Using Advance Care Planning Codes 

• CPT 2025 Professional Edition. This is the book that has the Complexity Grid in it. The answers are all here! And your coders will likely share. 

On today’s podcast, we talk about an innovative specialized primary care model for older veterans called the Geriatric Patient Aligned Care Team (GeriPACT) program.  It’s designed with smaller patient panels and enhanced social worker and pharmacist involvement, and its approach is aimed at improving care and outcomes for our aging population.

We unpack the intriguing findings of a recent JAMA Network Open study authored by one of our guests, Susan “Nicki” Hastings, looking at GeriPACT that compares it to a traditional Patient Aligned Care Team (PACT).  While GeriPACT successfully delivered more attention to geriatric conditions, it surprisingly didn't translate into expected improvements like more time at home or better self-rated health.

We discuss the potential reasons behind this with our other two guests, one a geriatrics fellow, Kristie Hsu, and the other a recurring guest and host of the podcast, Ken Covinsky.  Was it just that it didn’t work, or were there other things going on, from the intensity of "usual care" to the challenges of measuring complex health outcomes and the possibility that 18 months simply wasn't long enough to see the full benefits?

Despite what was ostensibly a negative trial, we highlight some reassuring aspects and future hopes for GeriPACT and how we can all incorporate some of these components into the care of our patients. We'll also pose critical questions for future research, emphasizing why continued development and evaluation of new care models are essential for the health of our older population.

With all the attention focused on Alzheimer's biomarkers and amyloid antibodies, it’s easy to forget that comprehensive dementia care is more than blood draws and infusions. On today’s podcast, we buck this trend and dive into the complexities and challenges of comprehensive dementia care with the authors of two pivotal articles recently published in JAMA.

We’ve invited David Reuben and Greg Sachs to talk about their two respective trials, published in JAMA — D-CARE and IN-PEACE — aimed at improving the evidence for care models supporting individuals diagnosed with dementia. D-CARE tested the comparative effectiveness of health system-based dementia care, a community-based program, and usual care, while IN-PEACE assessed the addition of palliative care to dementia care programs for individuals with moderate to severe dementia.

Despite their pragmatic trial designs and high expectations, both studies' primary outcomes were negative, although there were some intriguing positive secondary outcomes. We discuss how some critical questions about the integration of these findings into practice, and how they fit in with previous research that did show benefits (see this past podcast on using health navigators to improve dementia care).

If you want to learn more about comprehensive dementia care, check out these past podcasts:

• Our previous podcast on comprehensive dementia care with Lee Jennings and Chris Callahan

• Our podcast on the GUIDE Model with Malaz Boustani and Diane Ty

• Our podcast on Transforming the Culture of Dementia Care with Anne Basting, Ab Desai, Susan McFadden, and Judy Long

Lastly, here is the link to Greg Sachs' NEJM article that describes his maternal grandmother decline from Alzheimer's disease.

In today’s podcast we talk with Eric Wong, geriatrician-researcher from Toronto, and Thiago Silva, geriatrician-researcher from Brazil, about the comprehensive geriatrics assessment.  We spend the first 30 minutes (at least) discussing what, exactly is the comprehensive geriatric assessment, including:

• What domains of assessment are essential/mandatory components of the comprehensive geriatrics assessment?

• Who performs it? Is a multidisciplinary team required? Can a geriatrician perform it alone? Can non-geriatricians perform it?

• Who is the comprehensive geriatrics assessment for? Who is most likely to benefit? Eric Widera suggests not as much benefit for very sick and very healthy older adults, more benefit in the vast middle.

• Why do the comprehensive geriatrics assessment? What are the interventions that it leads to (we cover this more conceptually, rather than naming all possible interventions)

• How does the comprehensive geriatrics assessment relate to the 4Ms (or 5 Ms)?

• How long does it take to conduct a comprehensive geriatrics assessment?

• What’s the evidence (BMJ meta analysis) for the comprehensive geriatrics assessment? 

• What are the outcomes we hope for from the comprehensive geriatrics assessment?  

That final point, about outcomes, bring’s us to Eric Wong’s study, published in JAGS, which evaluates the cost effectiveness of the comprehensive geriatrics assessment performed by a geriatrician across settings (e.g. acute care, rehab, community clinics).

As an aside, as the editor at JAGS who managed this manuscript, I will say that we don’t ordinarily publish cost effectiveness studies at JAGS, as the methods are opaque to our clinical audience (e.g. raise your hand if you understand what ‘CGA provided in the combination of acute care and rehab was non-dominated’ means).

We published this article because its bottom line is of great interest to geriatricians.  In Eric’s study, geriatricians performing CGA were more cost effective than usual care in Every. Single. Setting.

And of course cost effectiveness is only one small piece of the argument for why we do the comprehensive geriatrics assessment in the first place (no patient in the history of the world has ever asked for a test or treatment because it’s cost effective for the health care system).

I’ll close with a couple of “mic drop” excerpts from Thiago’s accompanying editorial:

Finally, it is instructive to compare the cost-effectiveness of geriatric services and CGAs with other interventions. A recent analysis of lecanemab for early-stage Alzheimer's disease found that gaining one QALY would cost approximately $287,000 (USD). In contrast, Wong et al. estimated that adding community-based CGA would cost about $1203 (CAD) per quality-adjusted life month (QALM) (equating to roughly $10,105 (USD) per QALY, using $1 USD = $0.7 CAD), making geriatrician-led CGA nearly 30 times more cost-effective. Put simply, for each dollar spent to improve quality of life for a year through CGA, one would need to spend almost $30 to achieve the same benefit with lecanemab. 

Ultimately, the question is not whether geriatricians represent a worthwhile investment (they are) but how healthcare systems can ensure that every older adult requiring specialized, comprehensive care can access it. Wong et al.'s modeling study provides a valuable contribution by showing that geriatricians placed in acute and rehabilitation settings offer the most cost-effective deployment given current workforce limitations. Despite some caveats, the overarching message remains clear: geriatric expertise not only enhances care quality but can also align with health-economic objectives, especially in high-acuity environments. However, we cannot allow an inadequate geriatric workforce to become a permanent constraint, forcing painful decisions about which older adults and which settings will miss out on optimal geriatric care. Instead, we should continue to strive to increase the number of geriatricians through robust training programs and payment model reform to ensure that cost-effective care can be provided for this large and growing vulnerable population.

 -Alex Smith

On a prior podcast we talked with Todd Semla and Mike Steinman about the update to the AGS Beers Criteria of potentially inappropriate medications in older adults (Todd and Mike co-chair the AGS Beers Criteria Panel).  One of the questions that came up was - well if we should probably think twice or avoid that medication, what should we do instead?

Today we talk with Todd and Mike about their new recommendations of alternative treatments to the AGS Beers Criteria, published recently in JAGS, and also presented at the 2025 AGS conference in Chicago (and available on demand online).

We had a lot of fun at the start of the podcast talking about the appropriate analogy for how clinicians should use the AGS Beers Criteria.  In our last podcast, the analogy was a stop sign. You should come to a stop before you prescribe or refill a medication on the Beers list, look around at alternatives, and consider how to proceed.  You might in the end decide to proceed, as there are certainly situations in which it does make sense to start or continue a medication on the Beers list.

Today’s analogy had somewhat higher stakes, involving a driver, a pothole in the road, and a cyclist on the side who you’d hit if you swerved.  Really upping the anti!!!

The podcast is framed around a case Eric crafted of a patient with most of the medications and conditions on the Beers list. We used this as a springboard to discuss the following issues (with links to prior GeriPal podcasts):

• Insomnia (Doxepin is an alternative, trazodone and melatonin are not?!?)

• Diabetes management 

• PPI for GERD

• Treatments for pain, including NSAIDS, COX2, and gabapentinoids

• Cannabis

• Deprescribing,org - terrific Canadian website (no tariff to use)

And I hope that the prescribing landscape is indeed getting better (thanks to Kai on guitar)!

-Alex Smith

Health care trainees rotate through a variety of different settings. ICUs, hospital wards, and outpatient clinics. If they're lucky, they might even spend time in a nursing home. But on today’s podcast, we’re adding one more setting to that list: your local art museum.

In this thought-provoking episode, we explore how art museum teaching is being integrated into the education of medical professionals—and why it's making a profound difference. Our guests, Amy Klein, Laura Morrison, and Gordon Wood, share their journey of integrating art into medical training, along with practical strategies you can use if you're inspired to do the same.

You'll also hear how engaging with museum-based medical education can help health care professionals deepen empathy and emotional awareness, practice the skill of multiple perspective-taking, and grow more comfortable with ambiguity and uncertainty.

Resources mentioned in the podcast include:

• A story about one medical student's experience with a day in the museum using multiple museum-based education exercices

• A Journal Article published in the Journal of Palliative Medicine titled “Museum-Based Education: A Novel Educational Approach for Hospice and Palliative Medicine Training Programs” 

• A journal article on “Twelve Tips for Starting a Collaboration with an Art Museum.”

• A handout from the 2025 AAHPM/HPNA preconference gives examples of museum-based education exercises and resources for further training. 

• Alex’s summary of some prompts we discussed for the “Personal Responses Tour”, which is a reflective exercise where participants choose artwork based on a personal prompt, then share with a small group. The prompts include:

• Find a work of art that reminds you of a patient

• Find a work of art that reflects a challenging clinical situation

• Find a work that speaks to an experience you have had in your palliative medicine training that taught you about the impact of bias or racism

• Find a work that connects to the path you took into palliative care or geriatrics

• Find a piece that makes you think about community

• Find a piece that reflects your idea of what a “good death” is

Lastly, stay on the “look out for” the 2026 Art Museum-Based Education preconferences session at the AAHPM/HPNA annual meeting on March 4, 2026 in San Diego!

In his book, “Why We Revolt,” Victor Montori decries the industrialization of healthcare.  We’ve become a healthcare factory, beholden to health systems motivated by profit. In particular, he laments the loss of the “care” aspect of healthcare.

Clinicians are under the clock to churn through patients.  Patients are tasked with doing work outside of the clinic. Patients are tasked with hours and hours of work to self manage, obtain and manage medications, track weights and fingersticks, not to mention scheduling visits and waiting around for the visit to start.

Now we have an app for that. For what, you ask? Well, for everything! Digital burden is real. Think about what we ask patients to do: charge your device, remember your password, 2 factor authentication, each interface is different, wait…where do you enter your fingersticks again?

Victor is an endocrinologist who often provides care for older patients with multiple chronic conditions, polypharmacy, and complex social situations.  He’s “one of us.”

Some might argue that these circumstances call for incremental change.  Not Victor.  He argues that we need a revolution. In particular, he argues that the revolution must come from patients to be successful.

On this podcast we discuss:

• Why do we need a revolution? What made him get to this point of arguing for a revolt?

• Why should the revolution be patient led, rather than clinician led? What role do clinicians have to play?

• What is minimally disruptive medicine (a term Victor coined with Carl May and Francis Mair in 2009)?

• How does shared decision making fit into the revolution?

• What’s the matter with guidelines? What’s the role of standardization?

• We suspect that most geriatrics and palliative care providers feel like they’ve escaped many of the issues Victor describes, trading less glamorous and remunerative work for more satisfying time spent caring for patients; focusing on what matters, goals of care, and attention to emotion and social well-being.  Are we deluding ourselves?

If you’d like to join the revolution, please check out Victor’s website, patientrevolution.org

And I believe this is the first Peter Gabriel song request! I think Peter Gabriel’s album So was the first cassette tape I purchased.  About time, 350+ podcasts in.  My son Kai turns this very non-guitar friendly song into an acoustic jam for the audio-only podcast version; you get my weaker attempt on YouTube :) 

Finally, a quick plug for the Sommer Lecture series in Portland OR.  Victor and I had a terrific time bonding at this year’s lecture series. While not strictly geriatrics and palliative care focused, the lectures seem targeted at a broad audience, with something for everyone.  And yes, I made them sing parody songs :)

-Alex Smith

Most health care providers understand the importance of goals-of-care conversations in aligning treatment plans with patients’ goals, especially for those with serious medical problems. And yet, these discussions often either don't happen or at least don't get documented. How can we do better?

In today’s podcast, we sit down with Ira Byock, Chris Dale, and Matthew Gonzales to discuss a multi-year healthcare system-wide goals of care implementation project within the Providence Health Care System. Spanning 51 hospitals, this initiative was recently described in NEJM Catalyst, showing truly impressive results, including an increase from 7% to 85% in goals of care conversation documentation for patients who were in an ICU for 5 or more days.

How did they achieve this?  Our guests will share insights into the project’s inception and the strategies that drove its success, including:

1. Organizational Alignment: Integrating GOC documentation into the health system’s mission, vision, and strategic objectives.

2. Clinical Leadership Partnership: Collaborating with clinical leaders to establish robust quality standards and metrics.

3. Ease of Documentation: Upgrading the electronic health record (EHR) system to streamline the documentation and retrieval of GOC conversations.

4. Communication Training: Conducting workshops based on the Serious Illness Conversation Guide to equip clinicians with the skills needed for impactful GOC conversations.

Join us as we explore how these strategies were implemented and learn how you can apply similar approaches in your own healthcare setting.