GeriPal - A Geriatrics and Palliative Care Podcast

In today’s podcast we set the stage with the story of Dax Cowart, who in 1973 was a 25 year old man horribly burned in a freak accident. Two thirds of his body was burned, most of his fingers were amputated, and he lost vision in both eyes. During his 14 month recovery Dax repeatedly demanded that he be allowed to die. The requests were ignored. After, he said he was both glad to be alive, and that the doctors should have respected his wish to be allowed to die. But that was 1973, you might say. We don’t have such issues today, do we? Louise Aronson’s recent perspective about her mother in the NEJM, titled, “Beyond Code Status” suggests no, we still struggle with this issue. And Bill Andereck is still haunted by the decision he made to have the police break down the door to rescue his patient who attempted suicide in the 1980s, as detailed in this essay in the Cambridge Quarterly of HealthCare Ethics. The issues that are raised by these situations are really hard, as they involve complex and sometimes competing ethical values, including: The duty to rescue, to save life, to be a “lifeguard” Judgements about quality of life, made on the part of patients about their future selves, and by clinicians (and surrogate decision makers) about patients Age realism vs agism The ethics of rationale suicide, subject of a prior GeriPal episode Changes in medical practice and training, a disconnect between longitudinal care and acute care, and frequent handoffs The limitations of advance directives, POLST, and code status orders in the electronic health record The complexities of patient preferences, which extend far beyond code status The tension between list vs goals based approaches to documentation in the EHR And a great song request, “The Cape” by Guy Clark to start and end. Enjoy! -@AlexSmithMD

Serious illness communication is hard. We must often deliver complex medical information that carries heavy emotional weight in pressured settings to individuals with varying cultural backgrounds, values, and beliefs. That’s a hard enough task, given that most of us have never had any communication skills training. It feels nearly impossible if you add another degree of difficulty, whether it be a crying interpreter or a grandchild from another state who shows up at the end of a family meeting yelling how you are killing grandma. On today’s podcast, we try to stump three VitalTalk expert faculty, Gordon Wood, Holly Yang, Elise Carey, with some of the most challenging communication scenarios that we (and some of our listeners) could think up. During the podcast, we reference a newly released second-edition book that our guests published titled “Navigating Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope.” I’d add this to your “must read” list of books, as it takes readers through the VitalTalk method that our guests use so effectively when addressing these challenging scenarios. If you are interested in learning more about VitalTalk, check out their and some of these other podcasts we’ve done with three of the other authors of this book (and VitalTalk co-founders): Our podcast with Tony Back as well as Wendy Anderson on “Communication Skills in a Time of Crises” Our podcast with James Tulsky on “The Messiness of Medical Decision-Making in Advanced Illness.” Any one of our podcasts with Bob Arnold, including this one on the language of serious illness or this one on books, to become a better mentor. Lastly, I reference Alex’s Take Out the Trash video, where he uses communication skills learned in his palliative care training at home with his wife. The results are… well… let’s just say less than perfect. By: Eric Widera

We’ve talked about Brain Death before with Robert (Bob) Troug and guest-host Liz Dzeng, and in many ways today’s podcast is a follow up to that episode (apologies Bob for mispronouncing your last name on today’s podcast!). Why does this issue keep coming up? Why is it unresolved? Today we put these questions to Winston Chiong, a neurologist and bioethicist, and Sean Aas, a philosopher and bioethicist. We talk about many reasons and ways forward on this podcast, including: The ways in which advancing technology continually forces us to re-evaluate what it means to be dead - from the ability of cells/organs to revive, to a future in which organs can be grown, to uploading our consciousness to an AI. (I briefly mention the Bobiverse series by Denise Taylor - a science fiction series about an uploaded consciousness that confronts the reader with a re-evaluation of what it means to be human, or deserving of moral standing). The moral questions at stake vs the biologic questions (and links between them) The pressures the organ donation placers on this issue, and questioning if this is the dominant consideration (as Winston notes, organ donation was not central to the Jahi McMath story) What we argue about when we argue about death - the title of a great recent paper from Sean - which argues that “we must define death in moralized terms, as the loss of a significant sort of moral standing,” - noting that those why are “dead” have something to gain - the ability to donate their organs to others. Winston’s paper on the “fuzziness” around all definitions of brain death, titled, Brain Death without Definitions. As we joke about at the start - talking with philosophers and bioethicists, you almost always get a response along the lines of, “well that’s a good question, but let’s examine a deeper more fundamental question.” Today is no different. And the process of identifying the right questions to ask is absolutely the best place to start. Eventually, of course, everything must cease. -@AlexSmithMD

Anti-Asian hate incidents rose dramatically during COVID, likely fueled by prominent statements about the “Chinese virus.” VIewed through the wider lens of history, this was just the latest in a long experience of Anti-Asian hate, including the murder of Vincent Chin, the Chinese Exclusion Act, and the internment of Japanese Americans during WWII. For those who think that anti-Asian hate has receded as the COVID has “ended,” just two days prior to recording this episode a Filipino woman was pushed to her death on BART in San Francisco. These incidents are broadcast widely, particularly in Asian News outlets. Today we talk about the impact of anti-Asian hate on the health and well being of older adults with Russell Jeung, sociologist, Professor of Asian Studies at San Francisco State, and co-founder of Stop AAPI-Hate, Lingsheng Li, geriatrician/palliative care doc and T32 fellow at UCSF, and Jessica Eng, medical director of On Lok, a PACE, and Associate Professor in the UCSF Division of Geriatrics. We discuss: What is considered a hate incident, how is it tracked, what do we know about changes over time The wider impact of Anti-Asian hate on older Asians, who are afraid to go out, leading to anxiety, social isolation, loneliness, decreased exercise, missed appointments and medications. Lingsheng (and I) recently published studies on this in JAMA Internal Medicine, and JAGS. Ongoing reports from patients about anti-Asian hate experiences Should clinicians screen for Anti-Asian hate? Why? Why not? Proposing the clinicians ask a simple follow up question to the usual “do you feel safe at home?” question used to screen for domestic violence. Add to this, “do you feel safe outside the home?” This question, while providing an opportunity to talk about direct and indirect experiences, can be asked of all patients, and opens the door to conversations about anti-semitism, islamophobia, or anti-Black racism. See also guides for how to confront and discuss anti-Asian hate in these articles in the NEJM and JGIM. And to balance the somber subject, Lingsheng requested the BTS song Dynamite, which was the group’s first English language song, and was released at the height of the COVID pandemic. I had fun trying to make a danceable version with electronic drums for the audio-only podcast. Maybe we’ll get some BTS followers to subscribe to GeriPal?!? -@AlexSmithMD

(We couldn’t resist when Miguel Paniagua proposed this podcast idea and title. And no, you’ll be relieved to hear Eric and I did not imitate the interview style of Zach Galifiniakis). We’ve talked a good deal on this podcast about what happens before death, today we talk about what happens after. Our guest today is Thomas Lynch, a poet and undertaker who practiced for years in a small town in Michigan. I first met Thomas when he visited UC Berkeley in the late 90’s after publishing his book, “The Undertaking: Stories from the Dismal Trade.” We cover a wide range on this topic, weaving in our own stories of loss with Thomas’s experiences, stories, and poems from years of caring for families after their loved one’s have died. We cover: The cultural shift from grieving to celebration, the “disappearance” of the body and death from funerals The power of viewing the body and participating in preparing the body, including cremation The costs of funerals The story of why Thomas became an undertaker A strong response to Jessica Mitford’s scathing critique of the American Funeral Industry published in “The American Way of Death” Our own experiences with funerals and burial arrangements for our loved ones Shifting practices, with a majority of people being cremated after death, a dramatic increase This podcast was like therapy for us. And I got to sing Tom Waits’ Time, one of my favorites.

What is a healthy diet and how much does it really matter that we try to eat one as we age? That’s the topic of this week's podcast with three amazing guests: Anna Pleet, Elizabeth Eckstrom, and Emily Johnston. Emily Johnston is a registered dietitian, nutrition researcher, and Assistant professor at NYU. Anna Pleet is an internal medicine resident at Allegheny Health Network who has a collection of amazing YouTube videos on aging and the Mediterranean diet. Elizabeth Eckstrom is a geriatrician, professor of medicine at OHSU, and author of a new book, the Gift of Aging. I love this podcast as while we talk about the usual topics in a medical podcast, like the role of screening, energy balance, and evidence-based for specific diets, we also talk about what a Mediterranean diet actually looks like on a plate and pepper our guests with questions about their favorite meals to convince Alex and me to eat more like a Sardinian. Eric PS. NEJM just published a great summary of diets summing up adherence to the Mediterranean diet and the following improved health outcomes: death from any cause, cardiovascular diseases, coronary heart disease, myocardial infarction, cancer, neurodegenerative diseases, and diabetes

We are dusting off our crystal balls today with three amazing guests who have all recently published an article on prognosis over the last couple months: Kara Bischoff, James Deardorff, and Elizabeth Lilley. To start us off we talk with Kara Bischoff about the article she just published in JAMA Network on a re-validation of the Palliative Performance Scale (PPS) in a modern day palliative care setting. Why do this? The PPS is one of the most widely used prognostic tools for seriously ill patients, but the prognostic estimates given by the PPS are based on data that is well over a decade old. ePrognosis now includes the modern validation of the PPS. Next, we talk with James Deardorff about whether we can accurately predict nursing home level of care in community-dwelling older adults with dementia. Spoiler alert, he published a study in JAMA IM on a prognostic index that does exactly that (which is also on eprognosis.org) Lastly, we invite Liz Lilley to talk about her paper in Annals of Surgery about prognostic allignment, including why as palliative care and geriatrics teams we need to take time to ensure that all disciplines and specialities are prognostically aligned before a family meeting.

The US Preventive Services Task Force (USPSTF) concluded back in 2000 that there is insufficient evidence to recommend for or against routine screening for dementia in older adults. Are there, though, populations that it may be helpful in, or should that change with the advent of the new amyloid antibodies? Should it? If so, how do we screen and who do we screen? On this week’s podcast we talk with three experts in the field about screening for dementia. Anna Chodos is a geriatrician at UCSF and the Principal Investigator of Dementia Care Aware, a California-wide program to improve the detection of dementia in older adults who have Medi-Cal benefits. Joseph Gaugler is the Director of the Center for Healthy Aging and Innovation at the University of Minnesota, director of the BOLD Public Health Center of Excellence on Dementia Caregiving, and Editor-in-Chief of the Gerontologist. Lastly, Soo Borson is a self-described primary care leaning geriatric psychiatrist, developer of the Mini-Cog, and co-leads the CDC-funded BOLD Center on Early Detection of Dementia. In addition to the questions asked above, we also cover the following topics with our guests: What is dementia screening? Who should get it if anyone? What should we use to screen individuals? What happens after they test positive? And if you are interested in learning more about the Guiding an Improved Dementia Experience (GUIDE) Model for dementia, check out this podcast.

Emergency podcast! We’ve been asked by many people, mostly junior/mid career faculty, to quickly record a podcast on ageism and the elections. People are feeling conflicted. On the one hand, they have concerns about cognitive fitness of candidates for office. On the other hand, they worry about ageism. There’s something happening here, and what it is ain’t exactly clear. We need clear eyed thinking about this issue. In today’s podcast, Louise Aronson, author of Elderhood, validates that this conflict between being concerned about both fitness for the job and alarmed about ageism is exactly the right place to be. We both cannot ignore that with advancing age the prevalence of cognitive impairment, frailty, and disability increase. At the same time, we can and should be alarmed at the rise in ageist language that equates aging with infirmity, and images of politicians racing walkers or a walker with the presidential seal. Ken Covinsky reminds us that we should not be making a diagnosis based on what we see on TV, and that if a patient’s daughter expressed a concern that their parent “wasn’t right,” we would conduct an in depth evaluation that might last an hour. Eric Widera reminds us of the history of the Goldwater Act created by the American Psychological Association in the 1960s which states that psychiatrists should refrain from diagnosing public figures, and the American Medical Association code of ethics which likewise discourages armchair diagnosis (rule established in 2017). We frame today’s discussion around questions our listeners proposed in response to our Tweets, and are grateful for questions from Anand Iyer, Sandra Shi, Mike Wasserman, Ariela Orkaby, Karen Knops, Jeanette Leardi, Sarah McKiddy, Cecilia Poon, Colleen Christmas, and Kai Smith. We talk about positive aspects of aging, cognitive screening, the line between legitimate concerns and ageism, ableism, advice for a geriatrician asked to comment on TV, frailty and physical disability, images in the press, historical situations including , and an upper age limit for the Presidency, among other issues. Of note, we talk about candidates from all parties today. We acknowledge concerns and speculation that others have raised about candidates across the political spectrum, current and former. We do not endorse or disclose our personal attitudes toward any particular candidate. Fitness for public office is a non-partisan issue that applies to all candidates for office, regardless of political party. There’s something happening here, and what it is ain’t exactly clear. Strong recommendation to also listen to this terrific podcast with another geriatrician all star, Jim Pacala, on MPR! -@AlexSmithMD

In May we did a podcast on KidneyPal (the integration of palliative care in renal disease), which made us think, hmmm… one organ right next door is the liver. Maybe we should do a podcast on LiverPal? (or should we call it HepatoPal?) On today’s podcast, we do that by inviting four palliative care leaders who are integrating palliative care into the care of those with liver disease: Kirsten Engel, Sarah Gillespie-Heyman, Brittany Waterman, and Amy Johnson. It’s a jampacked 50 minutes, filled with pearls on taking care of patients with liver disease. We cover: How each of their LiverPal teams are structured Why and how LiverPal differ from general palliative care or other palliative care specialty areas (KidneyPal, PalliPulm, etc) How to prognosticate in liver disease and how they communicate this with patients How to think about expectations of transplants and limitations of it How to manage complications and symptoms ranging from ascites, hepatic encephalopathy, pain, itching, cramps, and depression Also, if you want to take an ever deeper dive, check out our 2022 podcast on End Stage Liver Disease with Jen Lai, Ricky Shinall, Nneka Ufere, and Arpan Patel

“Anxiety is a lot like a toddler. It never stops talking, tells you you’re wrong about everything, and wakes you up at 3 a.m.” I’m not sure who wrote this quote, but it feels right to me. We’ve all had anxiety, and probably all recognize that anxiety can be a force of action or growth but can also spiral to quickly take over our lives and our sleep. How, though, do we navigate anxiety and help our patients who may end up in the anxiety spiral that becomes so hard to get out of? On today’s podcast, we’ve invited Alex Gamble and Brianna Williamson to talk to us about anxiety. Alex is a triple-boarded (palliative care, internal medicine, and psychiatry) assistant professor of medicine at Stanford. Brianna is one of UCSF’s palliative care fellows who just completed her psychiatry residency. We start by defining anxiety (harder said than done), move on to talking about when it becomes maladaptive or pathologic, and how DSM5 fits into all of this. We then walk through how we should screen for anxiety and how we should think about a differential. Lastly, we talk about both non-pharmacologic and pharmacologic treatments. It’s a lot to cover in 45 minutes, so for those who like to take a deeper dive, here are some of the references we talked about: Alex Sable-Smith’s great BATHE video on YouTube: Two books that Alex Gamble often recommends to patients can help build up your capacities to sit with anxiety (per Alex, both are from an Acceptance and Commitment Therapy framework) Things Might Go Terribly, Horribly Wrong: A Guide to Life Liberated from Anxiety The Reality Slap

I have to start with the song. On our last podcast about urinary incontinence the song request was, “Let it go.” This time around several suggestions were raised. Eric suggested, “Even Flow,” by Pearl Jam. Someone else suggested, “Under Pressure,” but we’ve done it already. We settled on, “Oops…I did it again,” by Britney Spears. In some ways the song title captures part of the issue with urinary incontinence. If only we lived in a world in which much of urinary incontinence was viewed as a natural part of aging, the normal response wasn’t embarrassment and shame, but rather an ordinary, “Oops…I did it again.” And if only we lived in a world in which this issue, which affects half of older women and a third of older men, received the research and attention it deserves. We shouldn’t have therapeutic nihilism about those who seek treatment, yet urinary incontinence is woefully understudied relative to its frequency and impact, and as we talk about on the podcast, basic questions about urinary incontinence have yet to be addressed. I don’t see those perspectives as incompatible. Today we talk with George Kuchel and Alison Huang about: Urinary incontinence as a geriatric syndrome and relationship to frailty, disability, and cognitive decline Assessment of incontinence: the importance of a 48 hour voiding diary, when to send a UA (only for acute changes) How the assessment leads naturally to therapeutic approaches Non-pharmacologic approaches including distraction, scheduled voiding, and pelvic floor therapy “Last ditch” pharmacologic treatments. Landmark studies by Neil Resnick and Joe Ouslander. Enjoy! -@AlexSmithMD

I always find cachexia in serious illness puzzling. I feel like I recognize it when I see it, but I struggle to give a clear definition or provide effective ways to address it. In today's podcast, we had the opportunity to learn from a renowned expert in palliative care, Eduardo Bruera, about cachexia and anorexia in serious illness. Eduardo established one of the first palliative care programs in 1984, created the Edmonton Symptom Assessment Scale (ESAS), and significantly contributed to the evidence base for palliative care symptoms that many of us rely on daily. During our discussion with Eduardo, we delved into how we can define cachexia and anorexia, why they occur in conditions like cancer, how to assess for them, and explored the interventions that are helpful and those that are not in the treatment of these conditions.

As Eric notes at the end of today’s podcast, we talk about many difficult issues with our patients. How long they might have to live. Their declining cognitive abilities. What makes their lives meaningful, brings them joy, a sense of purpose. But one issue we’re not as good at discussing with our patients is sexual health. On today’s podcast Areej El-Jawahri, oncologist specializing in blood cancers at MGH, says that sexual health is one of the top if not the top issue among cancer survivors. Clearly this issue is important to patients. Sharon Bober, clinical psychologist at DFCI, notes that clinicians can get caught in an anxiety cycle, in which they are afraid to ask, don’t ask, then have increased anxiety about not asking. Like any other conversation, you have to start, and through experience learn what language is comfortable for you. Don Dizon, oncologist specializing in pelvic malignancies at Brown, suggests speaking in plain language, starting by normalizing sexual health issues, to paraphrase, “Many of my patients experience issues with intimacy and sexual health. Is that an issue for you? I’m happy to talk about it at any time.” All guests agree that clinicians feel they need to have something they can do if they open Pandora's box. To that end, we talk about practical advice, including: The importance of intimacy over and above physical sexual function for many patients Common causes and differential diagnoses of sexual concerns in patients with cancer and survivors Treatments for erectile dysfunction - first time the words “cock ring” have been uttered on the GeriPal Podcast - and discuss daily phosphodiesterase 5 inhibitor therapy vs prn The importance of a pelvic exam for women experiencing pain What is “pelvic physical therapy?” Treatments for vaginal dryness and atrophy ACS links, NCCN links, Cancersexnetwork, and a great handout that Areej created And I get to sing Lady Gaga, also a first for GeriPal! And let me tell you, there’s nothing like the first time (sorry, I couldn’t help it!).

The landscape of options for treating people with kidney failure is shifting. It used to be that the “only” robust option in the US was dialysis. You can listen to our prior podcast with Keren Ladin talking about patients who viewed dialysis as their only option, and structural issues that led to this point (including this takedown of for profit dialysis companies by John Oliver). One of the problems was a lack of an alternative robust option to offer patients. As one of our guests says, you have to offer them something viable as an alternative to dialysis. Today we interviewed Sam Gelfand, dually trained in nephrology and palliative care, Kate Sciacca, a nurse practitioner (fellowship trained in palliative care), and Josh Lakin, palliative care doc, who together with a social worker and other team members started KidneyPal at DFCI/BWH, a palliative care consult service for people with advanced kidney disease. As a team, they provide a robust alternative to dialysis for patients with kidney failure: conservative kidney management. And “conservative,” as they note, can mean not only a “conservative approach,” as in non-invasive/less aggressive, but also an effort to “conserve” what kidney function remains. We get right down to the nitty gritty of kidney supportive care techniques they incorporate in clinic, including: Communication about the choice between dialysis and conservative kidney management: what are the tradeoffs? Function often declines after initiating dialysis, at least among nursing home residents. Dialysis may extend life, but those “additional” days are often spent in the hospital or dialysis, away from home. Symptoms are common in both options, though more anxiety and cramping in dialysis, more pruritus and nausea in conservative kidney management.. Introducing the idea of hospice early, at the time of diagnosis with kidney failure. Listen also to our prior podcast with Melissa Wachterman on hospice and dialysis. Approaches to treating fatigue Approaches to treating pain - the second most common symptom (!) - and the answer isn’t tramadol (or tramadon’t) - rather think buprenorphine patch or methadone, and how to dose gabapentin and pregabalin. Also, don’t count out the NSAIDS! Approaches to treating itching/pruritus Approaches to treating nausea Our guests were deeply grateful to their colleagues Dr. Frank Brennan, Dr. Mark Brown, and clinical nurse consultant Elizabeth Josland of the renal supportive care team at St. George Hospital in Sydney, Australia (down under) for teaching them the ropes of palliative care in kidney failure. And we got to learn some new vocabulary, including the meaning of “chunder.” Enjoy! -@AlexSmithMD

Who gets to decide on what it means to have a disease? I posed this question a while back in reference to Alzheimer's disease. I’ll save you from reading the article, but the main headline is that corporations are very much the “who” in who gets to define the nature of disease. They do this either through the invention of disease states or, more often, by redrawing the boundaries of what is considered a disease (think pre-diabetes). On today's podcast, we invite Adriane Fugh-Berman to discuss the influence of industry, whether it be pharma or device manufacturers, on healthcare. Adriane founded PharmedOut, a Georgetown University Medical Center project that “advances evidence-based prescribing and educates health care professionals and students about pharmaceutical and medical device marketing practices.” I’ve listened to a lot of Adriane’s talks. It is clear to me that she is not anti-medicine or even anti-pharma but is very much against both the visible and hidden influences that pharma and device manufacturers use to sell their products. This could be through overt marketing like advertisements or drug rep visits, or more covert measures like unrestricted grants to advocacy organizations, funding of CME, paying “key opinion leaders,” or the development of “disease awareness campaigns.” So take a listen and dont worry, while GeriPal podcasts offer CME, we never take money from industry. By: Eric Widera

On today’s podcast, we’ve invited four hospice and palliative care social media influencers (yes, that’s a thing!), all of whom focus their efforts on educating the general public about living and dying with a serious illness. Their work is pretty impressive in both reach (some of their posts are seen by millions of viewers) and breadth of work. We’ve invited: Julie McFadden (aka Hospice Nurse Julie): Julie is a social media superstar, with 1.5 million subscribers on TikTok, another 400,000 subscribers on her YouTube channel, and another 350k followers on Instagram. She covers topics on death, dying, and hospice from a hospice nurse perspective, and she also has a book coming out called “Nothing to Fear: Demystifying Death to Live More Fully,” which is now available for pre-order. Matt Tyler (aka Pallidad for those on Twitter): Matt is the Hospice and Palliative care doctor who created How To Train Your Doctor, which helps patients living with serious illness find tips on “owning” their healthcare plan on his Instagram and YouTube pages. He was also the one who we have to thank for suggesting this podcast! Hsien Seow & Samantha (“Sammy”) Winemaker: Hsein and Sammy's goal was to start a revolution with their podcast “The Waiting Room Revolution,” which is now in its 7th season! The hope was by going directly to those living with a life-changing illness, we could directly tackle the question that comes up so many times - “Why didn’t anyone tell me that sooner…” They also just published a book,” Hope for the Best, Plan for the Rest,” and Sammy is a TikTok star in her own right, with some posts having over a million views. We covered a lot of topics in the podcast from:: What motivated them to create public-facing social media channels? Why focus on the public rather than other health care providers? How do they deal with professional barriers and the barrage of comments? Advice for others who might want to dabble in social media outreach So, take a listen and check out their social media sites to get inspired. Just don't let Alex make me do another TikTok dance… Eric Widera

As Betty Ferrell says on our podcast today, nurses play an essential role in care of people with serious illness. Who spends the most time with the patient in the infusion center? Doing home care? Hospice visits? In the ICU at the bedside? Nurses. ELNEC (End-of-Life Nursing Education Consortium) celebrates it’s 25th anniversary in 2025. We talk today with Betty Ferrell, who has been a nurse for 47 years, and is the founder and PI of ELNEC. As I argue on the podcast, ELNEC has likely done more to lift the primary palliative care skills of clinicians than any other initiative. Full stop. Some numbers to back it up: ELNEC has trained more than 48,000 providers in a train the trainer model Over 1.5 million clinicians have been educated in ELNEC ELNEC curricula are integrated int 1180 undergraduate and 394 graduate Schools of Nursing ELNEC has been taught in over 100 countries Today we talk about the origin story of ELNEC, the special role of nurses in palliative care, empowering as well as educating nurses, interprofessional ELNEC training, and opportunities and challenges ELNEC faces over the next 25 years. Enjoy! -@AlexSmithMD

Eric asks the question that is on many of our minds - is the future of AI more Skynet from Terminator, in which AI takes over the world and drives humanity to the brink of extinction, or Wall-E, in which a benevolent and empathetic AI restores our humanity? Our guest today is Bob Wachter, Chair of Medicine at UCSF and author of the Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. Bob recently wrote an essay in JAMA on AI and delivered a UCSF Grand Rounds on the same topic. We discuss, among other things: Findings that in several studies AI was rated by patients as more empathetic than human clinicians (not less, that isn’t a typo). Turns my concern about lack of empathy from AI on its head - the AI may be more empathetic than clinicians, not less. Skepticism on the ability of predictive models to transform healthcare Consolidation of EHR’s into the hands of a very few companies, and potential for the drug and device industry to influence care delivery by tweaking AI in ways that are not transparent and already a sort of magical black box. AI may de-skill clinicians in the same way that autopilot deskilled pilots, who no longer new how to fly the plane without autopilot A live demonstration of AI breaking a cancer diagnosis to a young adult with kids (VITAL Talk watch out) Use cases in healthcare: Bob predicts everyone will use digital scribes to chart within two years Concerns about bias and other anticipated and unanticipated issues And a real treat- Bob plays the song for this one! Terrific rendition of Tomorrow from the musical Annie on piano (a strong hint there about Bob’s answer to Eric’s first question). Enjoy! -@AlexSmithMD

Ambivalence is a tough concept when it comes to decision-making. On the one hand, when people have ambivalence but haven't explored why they are ambivalent, they are prone to bad, value-incongruent decisions. On the other hand, acknowledging and exploring ambivalence may lead to better, more ethical, and less biased decisions. On today's podcast, Joshua Briscoe, Bryanna Moore, Jennifer Blumenthal-Barby, and Olubukunola Dwyer discuss the challenges of ambivalence and ways to address them. This podcast was initially sparked by Josh’s “Note From a Family Meeting” Substack post titled “Ambivalence in Clinical Decision-Making,” which discussed Bryanna’s and Jenny’s 2022 article titled “Two Minds, One Patient: Clearing up Confusion About Ambivalence." Bryanna’s and Jenny’s article is particularly unique as it discusses these “ambivalent-related phenomena” and that these different kinds of “ambivalence” may call for different approaches with patients, surrogates (and health care providers): In addition to defining these “ambivalent related phenomena” we ask our guests to cover some of these topics: Is ambivalence good, bad, or just a normal part of decision-making? Does being ambivalent mean you don’t care about the decision? What should we be more worried about in decision-making, ambivalence or the lack thereof? The concern about resolving ambivalence too quickly, as it might rush past important work that needs to be done to make a good decision. What about ambivalence on the part of the provider? How should we think about that? How do you resolve ambivalence? Lastly, the one takeaway point from this podcast is that the next time I see ambiguity (or have it myself), I should ask the following question: “I see you are struggling with this decision. Tell me how you are feeling about it.”