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Showing posts from January, 2013

The Geriatrics Scholarship Award Summit: Getting Interns and Residents Excited about Academic Geriatrics

I am excited to announce the third annual Bechtel Geriatrics Scholarship Award Summit open to interns and residents in Internal Medicine or Family Medicine. The goal of the award is to stimulate interest in a career in academic geriatrics by recognizing residents’ scholarly or research achievements in aging or geriatrics.  Each award carries with it a cash prize of $500 plus a stipend to cover travel and lodging in San Francisco to present their work at a special award summit.

To be eligible, applicants must have worked on a scholarly or research project during their medical training (i.e. medical school, masters program, and/or residency training) defined as:
Scholarly Projects: projects may include but are not limited to: curricular design project; community, clinical or educational program development; quality improvement projects; leadership projects; or public policy projects
Research Projects: projects may have been conducted prior to housestaff training (e.g., medical school, c…

What's in a Name: The Branding Issues of Geriatrics and Palliative Care

One common issue that comes up in both palliative care and geriatrics is how to address the lack of name recognition our fields have in the general public.  The reality is very harsh, as both terms have really little to no meaning for most health care consumers.  For instance, in a 2011 survey conducted by CAPC, 70% of participants were "not at all knowledgable" about palliative care.

To drive home this point, some very inspired researchers at Johns Hopkins Division of Geriatric Medicine and Gerontology, including Jean Campbell, Samuel Durso, Lynsey Brandt, Thomas Finucane, and Peter Abadir, have published an entertaining yet disturbing picture of what a random sample of individuals think the word "geriatrician" means.

The authors went through downtown Baltimore with a video camera and a consent form.  They interviewed 82 individuals, of which only 8 (10%) heard of the term “geriatrician.”   The other 90% never heard the term but did give their best guess about wh…

What is in the Palliative Care Syringe?

Remember the landmark trial at MGH by Jennifer Temel that demonstrated palliative care for patients with early stage lung cancer not only improves quality of life, but prolongs survival?  The major question we were left with, as Jennifer says quoting Diane Meier in the accompanying audio interview, is "what is in the palliative care syringe?"  What exactly did they DO to improve quality of life and prolong survival?

Well, now we have some important clues.  In a study published online yesterday in JAMA: Internal Medicine (formerly Archives of Internal Medicine), she mentored a junior researcher named Jaclyn Yoon to examine chart notes from palliative care clinic visits during the MGH trail.  They also examined chart notes from oncologist for those times when the disease progressed.

They found:
During the first few patient visits, palliative care clinicians focused on building a relationship, treating symptoms, understanding of prognosis, and establishing preferences for info…

The Do No Harm Project

I would like to introduce the Geripal community to a wonderful new project that two of my friends and colleagues at the University of Colorado have pioneered. It is called The Do No Harm Project.

Their goal is to emphasize trainee scholarship that highlights the wisdom of Bernard Lown’s credo: ‘do as much as possible for the patient and as little as possible to the patient.’

On their site, they argue, “Harms from overtesting, overdiagnosis, and overtreatment are a serious threat to the health of our patients and the long-term solvency of our health care system. Harms of overuse have not traditionally been taught to medical trainees and there are few incentives to pay attention to overuse: performance measures and payment incentives reward doing more, the legal system punishes underdiagnosis, and there is a dominant cultural belief that more care is better.”

The project is simple - residents submit vignettes where they have witnessed unnecessary harms from overtesting, overdiagnos…

The Need for Medical-Legal Dialogue in Care of Older Adults

“They are just so judgmental and hard to talk to. They’ve got their own agenda and it’s not always about what is right.”  I had asked my students, a group of health care providers and researchers who had come for a year of legal training, about their impressions of lawyers and of the legal system more generally. While some of the students noted positive attributes of lawyers such as in advocating social justice and fairness, there was a consistent thread of cynicism about the motivations and roles of lawyers.

Given that most providers think of lawyers or law only in the context of malpractice suits, this cynical impulse is not surprising, even for a group of health care professionals who voluntarily entered the legal world to become better acquainted with its rules and norms. Yet in the era of a rapidly aging population, daily unspooling of health reform, and growing appreciation of the link between social determinants and health, there is an urgent need to bridge this professiona…

Six Awkward Concerns in My Not-Yet-Opened Notes

The VA has just taken a big bold leap forward: access to progress notes has been added to MyHealtheVet.

I'm impressed and think this is great. I also however can't help thinking of several awkward issues, related mainly to geriatrics, that crop up regularly in my own progress notes.

So I've written a blog post on this issue, and it's live today on The Health Care Blog.

In the post, I describe the following six awkward topics that might make patients (or caregivers) upset, if they were to read about my concerns in the progress notes. Here's my quick list:
Possible cognitive impairmentPossible elder mistreatment (a subject just recently raised on this very blog)Possible abuse or diversion of prescription drugsPossible substance abuse, especially alcoholConcerns about ability to manage safely at home or while drivingConcerns voiced by family or caregivers
As we know, these are issues of importance to the health of older adults. Unfortunately, to date they've gener…

Screening for Elder Abuse and Neglect – the USPSTF Report

The United States Preventive Services Task Force (USPSTF) released its updated standards for screening older or physically or mentally dysfunctional adults for abuse and neglect. The conclusion? “Recommendation I - current evidence is insufficient to assess the balance of benefits and harms of the service.”

What does this mean? There are varying interpretations – but the wrong interpretation is that we should forego screening for abuse and neglect in vulnerable older patients. As the CDC report notes, few studies have evaluated the accuracy and outcomes of specific screening strategies in older adults. Yet elder abuse in its various forms affects in the range of 2% to well above 10% of older adults. This can include physical, psychological, or sexual abuse, financial exploitation, and neglect. One study found that 1 in 10 older adults may have been abused, yet only 1 in 5 of these cases were reported.

No doubt there are potential harms of screening for elder abuse, such as sham…

An Evidence-Based Intervention to Reduce Post-Hospital Syndrome

There's an interesting Perspective in the NEJM titled "Post-Hospital Syndrome — An Acquired, Transient Condition of Generalized Risk," by Harlan Krumholz, a cardiologist at Yale.

In his article, Krumholz proposes that during the month after hospitalization, many people find themselves in an acquired, transient, vulnerable state, which may "derive as much from the allostatic and physiological stress that patients experience in the hospital as they do from the lingering effects of the original acute illness." He notes that approximately a fifth of Medicare patients are rehospitalized within 30 days, often for conditions different from the index admission.

How might this post-hospitalization syndrome emerge? He goes on to describe the many stressors we know affect patients during hospitalization, including interrupted sleep, psychoactive medications, deconditioning, inadequately managed pain, and delirium.

What to do? He writes that "Recognition of the post-…

Congratulations to the 2013 Hastings Center Cunniff-Dixon Physician Awardees

We would like to extend our heartfelt congratulations to the 5 physicians just been named as recipients of the 2013 Hastings Center Cunniff-Dixon Physician Awards.  This one of a kind national award recognizes excellence in the care of patients at the end of life.   This year's awardees are a truly exceptional lot, all of whom demonstrate the very best of what our field has to offer.


The awardees include:

Senior Physician Award:

Charles G. Sasser, M.D., FACP, FAAHPM, director of palliative care services at Conway Medical Center in Conway, South Carolina. He is a pioneer in palliative care who has been a model and mentor to generations of palliative care providers. Under his leadership, Conway established the first interdisciplinary team for palliative care services in South Carolina -- a team that included nurses, social workers, pastors, and physicians. Colleagues praise the value he places on doctor-patient discussions and his mentorship of colleagues from all specialties and pr…

Metal on Metal Hip Replacements: A Tragic Failure of the FDA Regulatory Process

Hip replacements are a miracle of modern medicine.  They restore mobility to persons with disabling hip arthritis and free them from often severe pain.  While hip replacements are major surgery, especially in the generally older patients who require them, the success rate is high.  Hip replacements are remarkably durable, still working without the need for revision in the vast majority of patients a decade or longer after surgery.

Standard devices for hip replacements use a metal ball that fits into a plastic socket.  These devices have worked well for many years.

But then a new device came along--a metal ball fitting into a metal socket.  The DePuy "metal on metal" hip replacement was supposed to be the newest and greatest thing--more durable and allowing patients a more active life style.  Thousands of patients received the metal on metal hip implant instead of the standard hip replacement.

Unfortunately, the results were catastrophic.  These metal on metal hip replaceme…

If Air Travel Worked Like Health Care

I was lucky enough to attend UCSF's School of Medicine Leadership Retreat today which was facilitated by the design firm IDEO (if you have't heard of them before, 60 minutes just profiled the company's founder, David Kelley, the video of which can be found here.)  

To get us started with the process, we had homework that forced us to research unrelated fields and industries to help solve the challenges that we face in our own institution.  This led one group to wonder - what if other companies looked at health care as a model?  What would that company look like?

We'll, we have an answer below.  The original source is from a National Journal article by Jonathan Rauch written in 2009.  It was put to video by Mary & Peter Alton.



My favorite line comes at the end.  It beautifully encapsulates the stale defense of the status quo and highlights the need to look outside of health care for solutions to what ails us:
"Sir. Please. Calm down and be realistic. I'…

Evidence-Based Practice of Palliative Medicine

I just got my hands on a copy of a fabulous new book by Drs Goldstein and Morrison and felt compelled to write a quick review about it.  The title of the book is "Evidence-Based Practice of Palliative Medicine" and it's 528 pages is chock-full of useful palliative care topics.

The most interesting aspect of the new book is the chapter format. The editors put together what can be best described as a detailed FAQs (Frequently Asked Questions) on palliative medicine. There are 81 questions that are addressed in depth in the corresponding chapters.  Some of my favorite questions from the book include:

Symptom Management Section:
How should patient-controlled analgesia be used in patients with serious illness and those experiencing post-op pain?Which opioids are safest and most effective in renal failure? How should methadone be started and titrated in opioid-naïve and opioid-tolerant patients? When should corticosteroids be used to manage pain? When should radiopharmaceutica…

Please don't go. We'll eat you up. We love you so.

Above is Christopher Nieman's beautiful illustration of Maurice Sendak's heartwarming and deeply moving NPR interview with Fresh Air's Terry Gross.  It's hard not to be inspired listening to Sendak talking about the beauty he sees in the world:
SENDAK: Yes. I'm not unhappy about becoming old. I'm not unhappy about what must be. It makes me cry only when I see my friends go before me and life is emptied. I don't believe in an afterlife, but I still fully expect to see my brother again. And it's like a dream life. But, you know, there's something I'm finding out as I'm aging that I am in love with the world. And I look right now, as we speak together, out my window in my studio and I see my trees and my beautiful, beautiful maples that are hundreds of years old, they're beautiful. And you see I can see how beautiful they are. I can take time to see how beautiful they are. It is a blessing to get old. It is a blessing to find the time to do…

Successful Aging Does Not Equal Aging without Disability

What does successful aging look like? In one of the more influential papers on the subject published in 1987, Rowe and Kahn describe successful aging as involving freedom from disease and disability.  This definition has been adapted over time but is still being used today.  Take a recent study published in CMAJ defining "successful aging" at 60 years of age or older as satisfying each of following criteria:
no history of cancer, coronary artery disease, stroke or diabetes; good cognitive, physical, respiratory and cardiovascular functioningthe absence of disabilityand good mental health. These definitions are subject to criticism from multiple aspects. First, by definition almost all older adults will at some point “fail” in aging successfully given the high incidence of cognitive and functional limitations affecting the elderly, as well as the high incidence of multimorbidity. Secondly, these definitions fail to include perceptions of older adults about what they believe…

The Official Launch of PREPARE: an Easy-to-Use, Online Advance Care Planning Tool

HOW can people prepare to have the conversation about what matters most in life and HOW can they prepare for medical decision making? A new, interactive, easy-to-use, advance care planning website called PREPARE can help (www.prepareforyourcare.org).  PREPARE shows people, through videos and a step-by-step process, HOW to have the conversation and make informed medical decisions.  


I have been profoundly struck by examples in my own family and from my geriatrics and palliative care patients, that most people lack a framework to face complex medical decisions when they arise. We, the healthcare establishment, admonish people to do advance care planning, by which we often mean to fill out advance directive forms focused on hypothetical scenarios and preferences for life-sustaining treatments such as CPR. Because no one can predict all unforeseen medical and personal circumstances, this approach to advance care planning does not always help when faced with a medical crisis.

What we oft…