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.

What’s the ideal blood pressure target for older adults with hypertension? Should we aim for a systolic BP of 120 mmHg in all older adults, as suggested by the SPRINT trial? Or should we be more flexible—especially for those who are frail or among the oldest old?

This week on the GeriPal Podcast, we explore the nuances of managing blood pressure in older adults with our guests Dr. Mark Supiano, Dr. Mitra Jamshidian, and Dr. Simon Ascher.

Now, some of our astute GeriPal listeners may say, “wait, didn't you already talk about this with Mark Supiano in a 2017 podcast titled How Low Should We Go with Blood Pressure in Older Adults?” Yes, we sure did, but we decided to revisit this topic as Mitra Jamshidian and Simon Ascher published a new JAGS research study focused on developing a framework to individualize the net benefit of intensive blood pressure control based on the results of the SPRINT trial. Their key finding: most community-dwelling older adults in the SPRINT trial experienced greater benefits than harms from more aggressive blood pressure targets—even those who were older, frail, or on multiple medications.

Join us for an in-depth discussion on balancing risks, benefits, and patient preferences in hypertension management for older adults. Plus, we might just sneak in a little Frank Sinatra for good measure.

In this week’s episode, we dig into two deceptively simple questions: When does someone become a cancer survivor, and should palliative care be in the business of caring for them? Spoiler: It’s more complicated than it seems.

We’ve invited two palliative care doctors to talk about survivorship with us: Laura Petrillo, a physician-researcher at Mass General Hospital and Harvard Medical School, and Laura Shoemaker, an outpatient palliative care doctor at the Cleveland Clinic. This episode is a must-listen for those navigating the evolving landscape of cancer care, and asking not just how we treat cancer, but how we support people who are living with it.

If you want some further reading on survivorship, check out some of these articles:

• A NEJM article titled “Time to Study Metastatic-Cancer Survivorship”

• A ASCO publication that includes a section on survivorship - Patient-Centered Palliative Care for Patients With Advanced Lung Cancer

• A webinar on survivorship - Blending Survivorship and Palliative Care (NCI)
  
  

June Lunney famously characterized the end of life functional course of people with dementia as a slow dwindle over time. Tom Gill later found that people with dementia do indeed have persistent severe disability throughout the last year of their lives.

But from our clinical work, many of us are familiar with people with dementia who experience sudden shocks to their health, think hip fracture, think hospitalization for pneumonia. Those disruptive events or shocks often portend a major decline in function from which people with dementia never fully recover. And they’re often a sign of (or cause of?) worsening prognosis.

Today we talk about disruptive events, or health and wealth shocks. We start with Lauren Hunt, who described the incidence and outcomes of hip fracture and hospitalization for pneumonia in a pair of publications in JAGS, comparing people with dementia who experience these events to people without dementia. We then turn to social events, starting with Rebecca Rodin, who studied the effect of widowhood on mortality and function for people with dementia, cancer, and organ failure, published in JAMA Network Open. Finally, we turn to Tsai-Chin Cho, who studied the impact of a wealth shock (loss of 75%+ of wealth in a short time period) on cognitive decline in 4 countries. Tsai-Chin’s article, published in Lancet Healthy Longevity, found a tantalizing hint that countries with stronger safety nets had lower incidence of wealth shocks, and less of a deleterious impact of the wealth shock on cognitive function.

Wait, so one key message is that social health is linked to physical and cognitive health?!? And the government can do something about that?!? Yes indeed, we like to hammer that home regularly, dear listeners.

And I enjoyed singing Leonard Cohent’s Who By Fire, about the many ways people might die…you know…typical uplifting GeriPal song lyrics!

-Alex Smith

Additional links mentioned by Tsai-Chin Cho:

-Wealth shocks and mortality in the US

-Change in marital status as a risk for wealth shock