GeriPal Doctors with Millions of Listeners Explain Why We Are Aging Wrong

Episode Transcript:

hello and good afternoon everybody and I guess good morning for those of us who are on the west coast today uh welcome to the care plan today I am joined with my wonderful co-host dr david casserette and we're doing a little bit of flipping the script on jerry pal's legendary hosts doctors alex smith and eric madera um they have interviewed hundreds of experts and usually are the ones asking the questions but today it's our turn how are you guys doing today Wonderful. Great. Thank you. So exciting. Yes, it's so exciting to have you on. I have been waiting for this one. I like to start my podcast with a little bit of a rapid fire. So I'm going to go ahead and jump right in. So if you could feature actually real quick, if you could both answer this question, that would be super fabulous. But if you could each feature any historical figure on Jerry Powell, who would it be and what would you ask them? Yeah, mine is easy. I always think about the founder of Hospice and Palliative Medicine is someone called Dame Cicely Saunders, who really led the movement first in the UK. And if you talk to the founders of Hospice and Palliative Care, she was so instrumental. She was a nurse, a social worker, and a physician. And what I loved about it, we did a podcast on the beginnings of palliative care, is that she would bring in the people who would visit her with a glass of sherry in her office. So I'd buy a nice bottle of sherry. We would share it with Dame Cicely Saunders. And I just love to hear how palliative care and hospice grew up back in the UK when she was still alive. I love that answer. That was awesome. Alex? My answer is Sir William Osler, who was like one of the founders of modern medicine. And back in the time, if you look at the textbooks, William Osler's textbook of medicine, About a third of it was dedicated to prognosis, a third to treatment, and a third to diagnosis. And that's changed over time. If you look at modern textbooks, it's almost all diagnosis and treatment because our ability to diagnose and treat has expanded tremendously. Back in the time of William Osler, One of the main things, we didn't have a lot of diagnostic tests or treatments, but one of the main things and services that physicians could provide to patients and their families was to tell them what to expect. You know, you have this pneumonia. Here's what might be ahead for you. And Nicholas Christakis has said, documented the loss of our focus on prognostication over time. And one of the main things that Eric and I are invested in is helping clinicians have the tools to estimate prognosis for older adults and people with serious illness so they can help them plan for the future and make clinical decisions. One of the other things in addition to our podcast that I'll plug is e-prognosis. Check it out, listeners. Online tools for estimating prognosis. Bringing the crystal ball back in medicine. And you can tell we're very bad at rapid fire. I'm excited to see how the rest of the podcast is going to go. Long-winded and tangential. I love it. But you talk fast. It works. Go ahead, David. Your question. Yeah, I'm gonna skip around a little bit. You know, everybody on your podcast on Jerry Powell knows, all your listeners know of your work on the podcast, but what about your day job? What you really get paid to do would surprise them. If you put a bunch of Jerry Powell listeners in a room and told them about your day, what would be most surprising to them? I don't. Yeah. I mean, the thing is, on the podcast, I take a song request from the listeners and it's a weekly podcast. So every week I have to learn a new song and play a bit of it on my guitar and sing it. and it's usually related to the topic at hand and sometimes it's quite humorous, sometimes it's quite serious. I love learning about all this music that I would otherwise not have been exposed to or learned. It's a great way of integrating that artistic side. But podcast listeners might think that I'm a musician. I don't know that that's mostly what I do. I actually do mostly do research and mostly do mentoring. So I spend most of my days, if you look at my calendar, like over half of the meetings that I have are with my mentees, helping them get their research careers off the ground. Oh, that's amazing. I love that. And for me, I would say, so we do a podcast on geriatrics and palliative care. And I once saw a piece of feedback, I think it's a review, that said there was too much laughing about a serious subject. And I thought, man, like, how surprised would this person be is that there is a lot of fun, excitement, and joy in geriatrics, hospice, and palliative care, even at the very end of life. Like, I'm laughing with patients. They're enjoying their life. Not always, sometimes. And I think that is the surprising thing for my job is that there is still a lot of humor, a lot of joy, even at the very end of life. I love that. I guess I'll know where I'll be going, which hospital I'll be going to. Next one for you guys is, I guess, what's your prediction? Will flying cars exist before we fix health care? Flying cars are an easy engineering solution. I mean, there's a way to get to a flying car. Health care, though, health care is a complex idea, mostly. So you're not going to ever fix health care because it's complex. We can continue to try to improve. make it better, but I don't think you're ever going to fix it because it's also so individualized. What good healthcare looks like for one person may be a little bit different than another. We're doing a podcast this week on the good death. How do you even define things like a good death? Because it's so individualized. So it's nothing you can truly fix. That's my take. Yeah. There's a saying, the future is here already. It's just unevenly distributed. And I was reading an article in New York Times by a friend, Farrah Stockman, who's on the editorial board, and she was on our podcast a couple months ago. And she was writing an article about this Detroit show of innovative technology that she went to. And she writes, there was a flying car. And I happened to read that yesterday as I also read your questions, which just goes to show that it's already here. Like we have the flying cars. And as Eric said, like the healthcare thing is going to be a forever issue. I don't know if that's the answer I was hoping to hear, but you said it with a smile on your face. I'm going to keep smiling and chugging along. Yeah. So you guys have been working on GeriPal for over a decade now. It's pretty awesome. But if you could travel back in time to two thousand twelve and tell your younger selves one thing about where geriatrics and palliative care would be in the year twenty twenty five, what would blow their minds the most? That, unfortunately, we're still struggling with a lot of the same things in both geriatrics, hospitals, and palliative care. And I think that there are some things that are maybe improving, but We're also seeing a lot of big challenges, just the sheer amount of money and private equity entering into these spaces, too, gives me huge pause for the future. I think that would be the two thousand twelve. Eric would be very surprised just about the sheer amount of money people are pouring into something as. You know what used to be very care oriented, like hospice care or even long term care, it's just. Then that would be my also what I'd be shocked about, but also what I'm very worried about in the future of the field. And for me, he went pessimism. I'll go optimism. We started Jerry Pal first as a blog back in like two thousand nine whenever a lot of people were blogging. People have blogs. Then people like sort of stop blogging over time. Then we started doing podcasts because that's what people are doing. What we started Jerry Palp as a blog and now podcast because there was tension between the fields of geriatrics and palliative care. And there was some, you know, and there's stuff like for complex reasons. And I think people would be. Relieved, excited, happy to hear, thrilled even that there's been so much integration of geriatrics and palliative care. There are fellowships in geriatrics and palliative care. Lynn Flint, who's in the office through that wall, is director of our GeriPAL fellowship. There are divisions that are named geriatrics and GeriPAL divisions, right? Who do you want to do that I lead? There you go. There you go. So I think people would be excited to see that the way the fields of geriatrics and palliative care have learned that they have more to gain from working with each other than they do working at odds. I love that. Dr. Kasser, do you have any thoughts on that? Just a follow-up question. I was there. I have been here in this field. Why do you think the animosity between geriatrics and palliative care Yeah, I think both are relatively small fields. And for geriatrics in particular, there was a very big growth in geriatrics and they kind of has leveled off over the last two decades. And I think that there was concern that, you know, that the palliative care is a much newer field, too. And even fellowships in hospice-impelled medicine, that's like a two thousand eight, two thousand nine new thing. ACGME accredited fellowships in hospice-impelled medicine. So I think that there was worry that what's it going to do to the field of geriatrics? Are people going to move over to hospice? Palliative care and I don't think we actually saw that the levels of geriatrics has kind of stayed the same for fellowships We've seen a growth in palliative medicine and if anything the really great thing about geriatrics too is we've see and we currently are seeing a growth in other specialties surgery Oncology doing like Jerry oncology Jerry surgery having geriatric emergency rooms like people recognizing that this older population actually deserves not the same type of health care, every everything else that we're giving everybody else, but maybe some type of more specialized care or more nuanced care. I love it. Just so you know, that's probably going to be the thumbnail for this, because that was so well, so perfectly executed. But now I feel like it's time to get a little controversial. So I know everyone in our audience has aging parents or is thinking about their own aging to some extent. What do you think is like the biggest lie that you've seen your patients tell themselves about getting older that you wish you could just like shake people out of? I think I worry about this idea that more is better. Like the more specialists you see, the better care you're getting. that with each additional medication that you take or vitamin, that it must be better, right? And I think that people don't appreciate the extent to which polypharmacy, medication side effects, adverse reactions to medications, medication interactions, can do more harm than they do good at some point. And that when they go to see that next specialist, that specialist almost always feels obligated to do something. And for them, that means prescribing something or ordering a new test. And that sometimes the best treatment is taking away a medication rather than adding a new one. What happened to less is more? That's perfect. Less is more. Mine would be that this myth that aging sucks. Aging is terrible. No one wants to age like we are lucky if we age. We are lucky if we get older. Some people aren't lucky. And I think like I always remember a study Alex did a long time ago looking at people who were older, who had severe disability, asked them about their quality of life and they rated their quality of life as good. But if you asked a bunch of like, thirty year olds, how would you rate their quality of life? They probably would have rated the same thing. So I would say the myth that we have to get over is that aging is a bad thing. And I would say we are lucky if we age. Absolutely. We're really bad at predicting our accommodation to future events. There's a guy I surf with who said, look, if I ever can't run an eight-minute mile, just put me down. And I wanted to tell him, all right, I'm going to come back in five years. Because not being able to run an eight-minute mile is not really grounds for Aiden dying. Yeah, I don't think we quite get how adaptable we are as a human species is that we learn to adapt and turns out our quality of life is not that bad when we do. I always say, I mean, if you're, if you're don't get old, then you die young and who wants to die young? You know, like that's not, that's not, that's not the point of it. And I do feel like as like a society as a whole, like this whole concept of like youth and like being young forever is like something that we've been obsessed with. And I feel like, like the new generations are starting to move slightly away from that. So it's giving me, it's giving me some hope and I'm hoping. Oh, that's interesting. That's refreshing to hear Nirvana. Yeah. I mean, I don't know. Like, I feel like the, like, uh, not that I don't want to. let me not get on this soapbox, but just real quick is that there's, there's so much in like beauty standards for women, especially, you know, like the younger you look, the more like attractive and desirable you are. And so a lot of cosmetic like procedures have been going on, but I do feel like with Gen Z, we are starting to move slightly away from that and kind of embrace like the more natural and like the, I guess what they like to call the clean girl aesthetic of just like, being the way that you are and like treating your body in a healthy way and just kind of hoping for the best. So yeah, my fingers are crossed. I'm going to cross my fingers with you for that. The clean girl aesthetic. I love that. Taught you something that you didn't know today. I didn't think that was going to happen. I love it. All right, cool. Let me shift gears a little bit and ask you guys about AI and tech. As you look at the palliative care geriatrics fields, combine them, pick whichever one you want, what's your overall sense of how tech and AI in particular are coming in? Are you optimistic, excited? Are you kind of worried? Are you just kind of over all the discussion about new tech companies and AI ready to move on? Yes. Yes. All of the above, if this is a test question. I mean, I would say it has the potential to be incredibly disruptive. potentially very devastating. I'm really eager to see where things are going. Every month, we're seeing more integration of AI. AI scribes. The AI is listening as you're talking to the patient. It's taking notes. It's doing everything for you. Maybe you can focus on other things. With that said, our system is generally not one that allows healthcare providers, physicians, social workers to have more time to do things. So you're probably just going to focus more on efficiency and seeing more patients as these AI tools kind of take over. And I think that's one concern from these AI tools is that I think the hope is it will give us more time to be doctors and social workers instead of computer typists. The flip side is the healthcare system will probably make us to be more efficient and spend less time with patients because the AI is doing these other things. And that's my biggest concern. So I have great trepidation, but also optimism that we're going to find a balance, but I don't know what that balance will look like. We had Bob Wachter on our podcast, and he talked about AI in the future of medicine. And we thought that palliative care, geriatrics, we have tough conversations with patients. We talk about the hardest stuff, end of life, dying, prognosis. grief. And we thought there's no way that an AI, we're going to be the last field of medicine that AI replaces because everybody should be asking, you know, well, can't AI do what I do? And we thought there's no way, right? So then Bob pulls out his phone. He has access to the latest model of ChatGPT and he asks it. He says, let's do this live on your podcast. And I think this is a chapter in his book that's coming out this fall about AI. And he says to the AI, I'm a doctor. I'm about to see a young woman who has newly diagnosed metastatic cancer. She has several kids. And I want to break this news to her sensitively, thoughtfully. I want to be attentive to strong emotions. Can you please give me some language of how I might approach this? And then the AI proceeded to give a terrific model example about how they would approach this conversation. And we were blown away on the podcast. Well, I was blown away. I should say Eric felt like it was a little too uncanny valley. Yeah. Have you heard of Uncanny Valley? I don't think so. That one might have gone over my head right there. Yeah, it's this idea. We actually did a podcast on Uncanny Valley, too, where this this idea where you can have something that looks cartoonish and it doesn't feel bad at all. You can have something that's like perfectly realistic and it looks good. But there is a zone where it's like you can tell there's something off. And it creates this emotional reaction inside us. There's this movie called The Polar Express where everybody talks about how the graphics in that was the uncanny valley. It was almost there, but not there enough. It was cartoonish, but not cartoonish enough. This uncanny valley. And I think the concern is when we have these, we're taught how to communicate with people. using how to address emotions and empathy and all of that. As humans, we're really good at picking up inauthentic communication. And I see that in AI. It is inauthentic. Maybe I'll get to a point where it feels much more authentic. But I had actually had an empathic communication with my internet provider once with an AI bot. And it made me so... I'm not saying which one, but it rhymes with rom-grast. It made me so mad. And I worry we're going to be integrating that in healthcare and it's just going to be making people very mad. But don't you think people are developing, if not calluses, then at least a little bit of a tolerance to that? I've been working with Catherine Pollack here at Duke on something we're calling Goal Coach, which is an AI-powered... Goals of Care tool that just got a fundable, hopefully fundable score from NIH and SBIR. But that's something we're doing with Careyaya. And the feedback we've gotten has been, yeah, I mean, I kind of know it's not an oncologist I'm talking to, but that's kind of good because I wouldn't tell my oncologist half the things I'm telling this app. um but I kind of think that I can identify it as not quite real you know I think that's where the uncanny valley takes place of it like if you watch a cartoon it's not distressing at all you know it's a cartoon but if you're trying to get mimic so close like a human on the other line I think that's where we get in danger like if that comcat or rom rast uh app um with the ai said I am an ai agent bot And it doesn't try to perfectly mimic human. I think you're in a much better spot than if you try to mimic human, then you get into this uncanny valley where it can actually make people angry. And I'll go the other direction and say, I'm optimistic about the incorporation of AI, improving conversations, improving the quality of information patients get, offering more opportunities to care for people with serious illness because we don't have enough palliative care providers to meet the needs of all people with serious illness. And so, or people who are living alone, lonely, right? And don't have companions, right? We don't have that. We don't have the workforce for that. And so I'm optimistic about the UC. A lot of doctors we talked to don't like to hear this. Like when I say this at conferences, like people, they look like they're ready to boo, right? They want to hear that we are irreplaceable. Our functions, there's no way they can do what we do, right? But I kind of think maybe they can do a lot of what we do. That's the thing. We could assign Jerry Powell over to chat GPT for an episode. Yeah. Actually, one of my kids suggested that or somebody suggested that recently that we should have an episode where our guests are ChatGPT, Anthropic and Llama. Right. Those are the names of our three guests. And we have a podcast with those three guests. I would join just I would say yeah that hundred percent I'm there sign me up send me the dates and the time I'm absolutely there but no I completely agree with that notion I think that like using ai to enhance human connection versus replace that's really that's really like the the essence or I guess the goal when it comes to at least in my opinion um bringing ai into the space because there's only there's only so many people that can do certain things. And there's only so much access to other people, like rural areas, specifically in America, where there's the closest geriatric or palliative or neurologist that you're going to find is a three and a half hour drive away. What kind of other options do you have? So I think in those instances, it can definitely be a beautiful thing. But when it starts to replace that human connection, then that's when it gets a little bit iffy, I would say. So yeah, that's my two cents. But I do have a question for, I guess, the forty something professional that's listening to us right now. That's generally tends to be sandwiched between their kids and their aging parents and part of that iconic sandwich generation. What would be one conversation that you would suggest that they should start having with their parents this month that they've probably been avoiding? Yes, sure. I'll go advanced care planning. Advanced care planning has taken kind of a beating in the palliative care community, and maybe this is just like... I don't know the extent to which this is known outside of the palliative care community, but there have been those within palliative care who have said... that advanced care planning, which is a process of planning for future care, including in states in which you might have serious illness, lack the ability to make your own decisions. So you'd be looking to somebody else to make decisions. Who would you assign? How would you prepare that person to make those decisions? that all of that care planning, and it has been critiqued that there's been too much focus on that, and that we can't possibly anticipate all future scenarios and prepare somebody for that, and that we should instead focus on improving communication we're having with people who are experiencing serious illness already, because there's such a lack of that. That said, I feel like there is value in assigning somebody to be your surrogate decision maker, to be your healthcare proxy. and giving them a general sense of what's important to you so that that person feels like they are better prepared to make those decisions. They can't prepare for every possible scenario, but it's likely reassuring to the person who knows that they might get seriously at some point and to assign somebody else to make those decisions and to the surrogate decision maker that they have some information to work with. That's a great answer. Eric? I'm going to go less technical, which is, you know, we care for a lot of people who are approaching the very end of life. And, you know, family members often ask, like, what do we talk about? What do we say? Ira Biok wrote this great book called The Four Things, The Four Things to Say. You know, I love you. Thank you. I forgive you. Please forgive me. And we talk about that, people approaching the end of life. But why wait? why not talk about those things right now talk about those things that matter both like Alex said like you know what do you want your future to look like what happens if things don't go that well even talking about things like like how do you want to be what do you want your body to happen after you die I think those are really important questions to talk about and to figure out and it's also important just to have those real conversations I love you Thank you. I forgive you. Please forgive me. Aw. I'm going to get emotional. That was good. I was not expecting to feel some type of way after you guys said that. But that's, yeah, I mean. my parents are still in their fifties and knock on wood in great shape, but being in the space and kind of working with older adults as someone who's in their twenties, it does really open your eyes up a lot as to what life is going to look like. And I am really grateful, I guess, to people like you and just like knowing that there are resources out there to help you through those last stages as well. So thank you. I love that. Thank you, Nirvana. Of course. So next question is a little bit more practical, but Jerry Pal spans pretty much every topic under the sun. Everything from like you and I talked about cannabis a while ago, and you mentioned AI, and I remember years ago you did something on thickened liquids and how they taste, like everything. So I mean, looking at that span of every aspect of geriatrics and palliative care that you've covered, and thinking about some of the problems that people have identified some of the challenges you've talked about, is there one thing either in geriatrics or palliative care both, that if you could wave a magic wand you can you would fix like one one thing you get one one fix in the next twenty minutes, what would you would you try to fix? I love this. We often end with a magic wand question. I don't think how hard it is for the person on the other side to answer. Do you go big? Do you go small? Do you got one, Alex? I would increase the workforce of geriatrics and palliative care providers. And I don't know how that happens, whether it's by increasing reimbursement so that more people might be listening. Yeah, go into it. But I got a magic wand. Yeah, just like David said. I'm going to make it happen because if we had more geriatric providers and more palliative care providers, we would be better able to meet the needs of our aging population and people who are living with serious illness. While Eric thinks of his name in front of you, But I have a quick follow up for you, Alex. So we do. Kariaya does have forty thousand undergraduate pre-med nursing and pre-PA students who are on our platform right now, many of who are listening to this podcast and will be listening to this podcast. So I guess any words of advice or anything you'd like to share as someone in this field to kind of help encourage others to kind of make the same decision as well. Geriakos. And palliative care are great fields to go into. Think about what's really important to you in the career that you want to have. I'm sure that other fields are fulfilling. Geriatrics and palliative care is incredibly rewarding work because you're helping provide whole person care. This is why most people go into health care in the first place, right? Not to take care of a specific organ, but to take care of people, whole people. You get to refocus on that and what matters most if you go into geriatrics and palliative care. I love it. I guess my math, go ahead, Dave, you got to follow up. I was just going to add the other reason to go into geriatrics and palliative care is the people really are cool and fun. And you just can't have as much fun with a cardiothoracic surgeon as you can with us. That's empirically demonstrated, validated, statistically true. And the work is incredibly fun. If you look at job satisfaction, geriatrics has the highest job satisfaction out there of all the physicians. And I'm sure it's true for the nurses in the field and everybody else. So it's a great field to go into for all of those reasons. Oh, I love that. What's your magic wand now? So my magic, I'm going to go back to Alex. So for everybody that's listening here, I think you are going to develop a crystal ball. The way you think about patients, you're going to be implicitly thinking about prognosis. And I think the key is to make that bring back prognosis into everything that we do in health care because it's so important. It's not just important determining benefits like hospice, but when we think about interventions from cancer screening to how we manage diabetes, all of that prognosis matters so deeply when we think about what's the best way to manage this patient. and to start preparing people for kind of finances. When we make diagnoses like Alzheimer's, these people want to know. I had Bell's palsy like ten years ago. The most important question I had was, is it going to get better and how soon is it going to get better? Like I wanted to know those things. So like Alex said, health care is not just about diagnosis and treatment, but we got to bring in that third pillar, which is prognosis. I love it. I love it. I love it. I love it. Your answers are just so thoughtful. And it takes a second for me to take them and be like, oh, my God. Wow, that's awesome. I love it. This one is a little bit less of a diplomatic question. I'm excited to hear both of your takes on this. But do you guys think that nursing homes are ever not going to suck? yes and no um I think it's really dependent um is if I ask my question do I want to live in a nursing home even the the best nursing home you can design with the best staffing right now I'd say no like my home is really important to me and everything that we do in medicine has trade-offs everything we do in healthcare has trade-offs Would I rather be at home and spend a credible amount on caregivers to do that if I was really sick? Or would I be okay with potentially going into some type of institutional care like a nursing home where I may be able to help my family more kind of financially by not dwindling our finances? That's a trade-off. have to make and you know fundamentally a nursing home is institutional care it's about increasing efficiencies you're managing you know multiple people at once and that that's the trade-off that that we're gonna make I think that there's some really amazing nursing homes out there and fundamentally it's never gonna be like your home in both good and bad ways yeah Yeah, there are terrific nursing homes out there already. And they're unevenly distributed, right? There are people who have access and the resources to afford living in some terrific nursing homes. And there are some other nursing homes that are doing a poor job, lack resources, lack staff. And that problem is only exacerbated by private equity, buying up nursing homes, cutting staff in order to increase profits. That is a major, major problem that's going on now. That said, and cuts to Medicaid are not going to help us because cuts to Medicaid, which is the major source of funding for long term care in this country, are going to hurt older vulnerable people who reside in nursing homes who, oh, by the way, don't typically have the ability to vote. And so what happens to them is determined by other people. And that's a real issue. So I have some optimism about this because I think there'll be pushback against this. I think there already is some pushback against this, particularly when people sort of like got to peek under the lid about what's happening in nursing homes during COVID. and uh so I have a little bit of optimism and uh and yet there's there's just so many forces that are uh making me more pessimistic about this particular area yeah and I would say that uh you know assisted living facilities are basically the nursing homes for the rich It's, you know, private pay. You're not relying on things like Medicaid and you can do really nice assisted living facilities where, you know, nursing homes are like Alex said, that there's great inequality in the type of care that we give. Hmm. I mean, yeah, absolutely. One hundred percent. I mean, say it louder for the people in the back. I think there's some audience questions about Medicaid and Medicare and things like that as well. So I'll definitely get into that. We were talking about this a couple of days ago when I sent over the questions. Y'all were like, we're not even going to get through twenty percent of these. And you are so correct because Maybe less than a quarter of these questions. But I'm going to ask one more just because I've been really excited to ask this question. And then I'm going to turn it over to the audience. And then I'm going to try and convince you guys to come back on the podcast at some point in the future. Anytime. Awesome. Great. Great. With a guitar. Because what do you mean you didn't bring your guitar? I'm going to make a song request and send it to you. But this is going to be kind of fun to like wrap up my questions. We're going to go back into the rapid fire, but a little bit of a different rapid fire. So I'm going to throw out some scenarios at you guys and give me your instant reaction. And your reaction should be the closer you are to your screen, the more excited you are about this topic. And the further away from your screen that you are, you're like, Please get that away from me as soon as possible. So let's see. First one is virtual reality therapy for dementia patients. Can I go both ways? I'm not sure which way I want to go on this one. I'll go back. The other one's forward. Just balance. Yeah, you're just teeter-totter. Alex does not like it. All right, that's fine. That's fine. We got AI-powered medication management. Ooh. We like this one. All right. Okay. Okay. Love it. Love it. Next one is intergenerational housing becoming more mainstream. They are in the screen. They couldn't get that. And last one, I think I might know the answer to this, but I'm still excited to see Medicare for all actually happening. They entered North Carolina. They left the West Coast and are on the East Coast now. That was awesome. Thank you. I had such a good time. I do want to give our audience a fair chance as well. So let me go ahead and see what these questions are. We have one that's asking, how are rising rates of health insurance denials impacting patients and families? Can you also talk about the moral injury they create for physicians? And do you think that's responsible for the rising rates of burnout? That's a lot to unpack right there. Yeah. I mean, I think this is a really complex topic that I think if you just, you know, touch on it, you can make great sounding points like, you know, insurance companies are denying care. I do... you know, just to play devil's advocate is I do think that there is a balance. There is a lot of like Alex was talking about before. There is a lot of tests and stuff done that probably shouldn't be done. You don't need the MRI for that person who just has acute back pain and they're like forty five and they have no risk factors. So I do think that there there is a balance. I think, you know, we are stuck in this health care system, the United States, which is a fragmented health care system that's focused on for-profit um doing doing doing but not really caring caring caring I think there are much better systems out there single-payer systems like in the uk and elsewhere where it's more about caring and providing the right care at the right time I hope for a future where we can be in that place and that's where my moral injury comes in is that I do think single payer systems are the better approach to managing population health. And I wish we had more of that. Alex, anything to add or echo? No, that was extremely well said. Awesome. Love it. That's great. Grab an audience question that just struck me as being interesting. Please. One listener wanted to know, what are the most underrated skills in end of life care? You talked about some skills, but are there some that you found to be really helpful that people don't appreciate? You know, I was fortunate to do palliative care fellowship underneath Susan Blocks and the late, great Andy Billings. And I remember Andy Billings saying that the reason palliative care is so interesting is not the symptom management focus. Like, there is a limited amount to what you can know for symptom management. The reason palliative care is interesting is the endless complexity of people's psychological and social situations and the communication with them about the ways in which they're experiencing serious illness in relation to other people, and the ways that they interpret that in terms of the meaning and purpose in their own lives. That's what's most interesting. To me, that rings absolutely true, and that's why I love these fields. For me, it's curiosity. It's one thing to ask a question like, what are you hoping for what's important to you what are you worried about but if you have curiosity and how they answer that question you're not really moving anything forward um so I do think curiosity is important like if they say I want to live forever huh that's interesting tell me more uh ask those follow-up questions uh be curious and I think that is a key to both geriatrics and palliative care I love it. That's wonderful. We actually have another position in the comments asking this question. The last six months of life are when we spend the most on care and it's the least effective. How can we begin that education early enough? People die in debt or lose their legacy trying to treat a dying body. Yeah, there's a lot that can be said about the limitations of studies that look only at people towards the end of their lives and whether that sort of stat about, you know, huge amounts of Medicare spending going towards people in the last six months is accurate. I do think that the underlying, I want to ally with the underlying notion that in the U.S. healthcare system, there's almost like a conveyor belt or escalator of care that is driving in one direction, and that is towards more intensive, more expensive, life-prolonging care. And that's sort of the default. Oh, whoa, there's questions here. I just realized there's a whole feature that I did not know about. And we're discovering it along with it. And anyway, the point is that when that's the default, that we need to have forces that counterbalance. that default because the the default like you know there's a people have written about this we shouldn't be saying that you need to have a ventilator you need chemotherapy what would we do if you needed uh nutrition can we the only way we could do it is give it to you in the vein or through a feeding tube There are alternatives to all of those things, right? And the different way of just phrasing it to our patients is, how should we treat you if you're short of breath? That's not the same as what would we do if you needed a ventilator? How should we treat you if you were nearing the end of your life and you weren't as interested in eating? Very different from the only way we could get nutrition into you is through the vein or through a feeding tube. So we need to develop the language and skills to communicate with people about the alternatives to the default escalator of escalating care. And doing what you're doing, actually talking about it, having these podcasts, having these live sessions where you're bringing up these really important topics. I think that's going to be critical. Thank you, I appreciate it. And just really quick, do you think that like, I guess this is something that should be taught in med school or you think this is just something you learn as you become more of a seasoned physician? I think it should happen even before med school or nursing school or social work school. It should be integrated. I think we should be doing more talking about death with children. It's a part of our lives. It's one of the most important part of our lives. It's important even when we think about prognosis, as we think about how do we integrate prognosis more into it, death is a part of that. I think some fields, as we think about if you ever meet with a financial advisor, you're going to be thinking about death. It may not be explicit, but I think it's really important to make it explicit. It actually is more important as we think about financial planning. But I think even at dinner the other day, we were with some friends and we were talking about how Like, what is everybody's your burial or cremation or what do they want when they die? Like even after death. I think those are important topics. So yeah, I well before. Yeah. You don't have to go to med school to talk about this stuff. Thank you. Yes. Oh my gosh. That's yeah. I said the other one was going to be a thumbnail. This one's a really quick last one. If you guys could just answer in a couple of words. We have someone asking, does the average older adult patient know of or use ChatGPT or an analog. My dad just learned about it and I was amazed that because none of his friends use it and they're all retired, they might not hear about it or feel the desire to use it. Of course, the application of it for answering health-related questions might not be advisable from a physician's perspective, but digital literacy and access to information and resources can bridge a lot of gaps sometimes. quarter year do you guys think that more people do or don't know about this stuff and I guess like what is a physician's role in digital literacy yeah a year ago I would say no now it's hard not to like if you google something the very first response is going to be an a right ai response they may not know it but they're already interacting with their eyes yeah you're talking to comcast you're going to be working with ai so it it's it's being integrated at such a fast pace I don't know what a year from now will even look like, but I can tell you that people are using it even if they don't know that they're using it. Yeah, there you go. There you go. That's interesting. But I guess just really quick wrap up. Do you think that like whose responsibility is it to teach older adults digital literacy? I think that the companies should realize that there is a vast market and ways to help older people and talking about the aging baby baby boomer uh demographic like this is a massive number of people who they can market to if they can teach them the skills of and make tools that are friendly and accessible for older adults I would say this too, is that while there's great promise, the ability to scam both younger and older adults is going to skyrocket in the next couple of months to years. Even creating safe words, like if your child asks you for money, have a safe word that you've never talked with Alexa about or Siri about, to know that this is the right person and it just doesn't sound and look like them, which could now be completely mimicked by AI so having like a safe word whatever that word is so if anybody asks for money you know what it is and I'll say I have a rule with my mom who is AD that anytime she's going to make a major financial decision she runs it by me first oh okay that's that's good we talk it over independence because it's like let's just consult with one another well I could go on for about two more hours if it was up to me, but I know that y'all have to go. But thank you so, so much for staying on a little bit longer than expected and answering our audience questions. I had an absolute blast. Thank you, David. Thank you, David. Thank you so much. Thank you. Bye.