400th Episode Celebration: Ask Us Anything, Hot Ones-style

Eric 00:16

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:19

This is Alex Smith.

Anne and Lynn 00:25

And this is the 400th episode! Whoa!

Alex 00:25

400. Can you believe it?

Eric 00:26

10 years.

Alex 00:27

10 years. That’s right.

Eric 00:28

2016 to 2026.

Alex 00:30

Yeah. Yeah. You and Ken said, hey, let’s record a podcast about bed alarms. Bring your guitar.

Anne 00:36

And what did you say, Alex?

Alex 00:37

I said, sure, I’ll sing Free Fallin’.

Anne 00:40

I’m pretty sure you said, what’s a podcast? [laughter]

Alex 00:42

Yeah, that’s true. I hadn’t actually listened to a podcast before I recorded a podcast.

Eric 00:46

Alex, who’s in the room with us?

Alex 00:47

Oh, yes. We should introduce our guest hosts. Returning from the 300th episode, and frequent guest hosts, we have Anne Kelly, who’s a social worker in palliative care.

Anne 00:56

Hello.

Alex 00:57

And we have Lynn Flint, who is the director of the GeriPal Fellowship at UCSF. And returning as guest host. Thank you, Lynn.

Lynn 01:07

And outpatient palliative care doctor.

Alex 01:09

There you go. Great.

Eric 01:10

Anne and Lynn, what are we doing today?

Anne 01:12

Well, for those of you who’ve been listening for a while, and you probably helped us celebrate the 300th episode, so this is gonna be a little deja vu for you, but we are gonna do. We’re bringing back what works. Well, we’re gonna do an Ask Me Anything, and we’re gonna do it Hot Ones style.

Eric 01:31

Oh, again, what’s Hot Ones? Remind me.

Lynn 01:35

Well, you’ll see in front of us here, if you’re watching on YouTube, we’ve got some delicious wings with really hot sauce arranged in order on our plate. So as we go through today, we’re gonna take a few pauses and gradually increase the spice level.

Eric 01:51

Oh, Extreme Regret is one of the names.

Alex 01:54

Extreme Regret.

Eric 01:55

Extreme Regret.

Anne 01:57

I think that’s a familiar feeling for some of us. I also will say you, some of your listeners, kindly wrote in and contributed some questions.

Alex 02:07

Thank you, listeners.

Anne 02:08

And so what we’re going to be doing is, as we’re eating these deliciously hot wings, we’re going to be going through asking you both some questions, asking you to think hard.

Alex 02:18

Should we start with.

Eric 02:19

Well, before we start, do we have a song request?

Alex 02:21

Oh, right, the song.

Eric 02:24

And Lynn, do you have a song request?

Lynn 02:25

Of course we have a song request.

Eric 02:27

Let me guess. Taylor Swift?

Lynn 02:29

Yeah, that’s right.

Alex 02:31

What song, what song, and why?

Lynn 02:33

So the song is 22. And it’s a fun, carefree song. And one of the questions actually made me think of it.

Alex 02:41

Oh, okay. So when we get to that question, then we’ll understand the rationale.

Lynn 02:46

I think so.

Alex 02:47

Okay. Interesting. I’m curious what that question’s about. Okay, here we go. He’s a little bit.

Alex 02:57

(singing)

Lynn 03:59

That was an outstanding version.

Anne 04:02

Also, I feel like most of us are still pretty close to 22. Yeah.

Eric 04:05

Yeah.

Lynn 04:09

There’s so many reasons I requested the song because I think it’s, you know, you’re forever 22.

Anne 04:14

All right, well, we are going to dig in here and I’m going to ask all of you to start with your first wing. Number one here. And as we take a bite, Lynn’s going to start us off with some questions.

Lynn 04:31

So we got lots of great questions from the listeners, but Anne and I also took the liberty of peppering in a few of our own.

Anne 04:39

Good one, Lynn.

Alex 04:41

Good one.

Eric 04:41

Is this one supposed to be the most mild?

Lynn 04:44

Oh, no. I thought either.

Alex 04:45

Oh, my God. We weren’t exactly sure what order, but that’s pretty spicy for a starter.

Lynn 04:51

Makes you afraid of what’s to come and stuff. Anyway, here’s your first question. Thinking about this coffee or tea and who makes it best?

Alex 05:02

Definitely coffee.

Eric 05:03

Don’t drink Alex’s coffee. Do not drink Alex’s coffee. [laughter]

Alex 05:06

My coffee’s the best. Here, I’ve got one right here.

Eric 05:10

Don’t drink it.

Alex 05:10

It’s 3/4 soy milk, a splash of vanilla creamer, and then the remainder of the cup is filled with…

Anne 05:17

For the listeners out there. More than once I’ve had to explain to Alex that I should not be able to see through the coffee when he makes a pot of coffee. [laughter]

Alex 05:24

It is also permissible if you have, like leftover Grounds in. And later in the day, you want some more coffee to add some water to the machine, pour it over the leftover grounds, and drink that coffee.

Eric 05:35

I’m going to do a hard pass on this question because I got to move Alex beyond the coffee.

Anne 05:42

Okay, next question. Do either of you have any jokes that you sometimes use with your patients?

Eric 05:48

Anna’s saying this and looking at me because…my joke is always when we’re talking about bowel movements, your number two is our number one. And then Anne rolls her eyes like clockwork. Like clockwork.

Alex 06:01

Like clockwork.

Anne 06:02

Do you have any jokes, Alex?

Alex 06:04

I don’t think so.

Lynn 06:10

Okay, let’s launch into the next question.

Anne 06:13

Grab a second wing, everybody.

Lynn 06:14

Oh, okay.

Alex 06:16

Oh, we’re on the second wing.

Lynn 06:17

Yeah, we’re on the second wing.

Alex 06:18

Oh, wow. We’re moving along.

Lynn 06:20

So this is from Paul Zimmerman, who’s a palliative care physician and fellowship director at UNC.

Alex 06:26

All right. Hi, Paul.

Lynn 06:27

And Paul’s question is the one that made me sort of confirm that I wanted to ask for 20 as my song. Paul says, I’ve listened to many of your podcasts and have met both of you on a few GeriPal pub crawls.

Alex 06:40

Great. Thank you for coming out, Paul.

Lynn 06:41

You both seem like genuinely happy people who bring a lot of joy and energy to your work. What advice would you give to others who want to help cultivate more fun and camaraderie in the field and in the workplace?

Alex 06:55

Ooh.

Eric 06:56

First of all, this one is not spicy at all, by the way.

Alex 06:59

This is like a Trader Joe’s spicy honey sauce.

Eric 07:02

It is just honey. That is the. That is. Why didn’t we start off with one?

Alex 07:06

Was Fly by Jing. Sichuan chili crisp. Mm. That one was spicy. Yeah. Okay, so what can we do to build community? Well, I think the beauty of social media is it’s democratizing. Anybody can start a podcast, and we’ve. We love it when people start podcasts. Or we used to help people get into social media before as. What would Bob Wachter call it? Like a cesspool.

Eric 07:28

Yeah.

Alex 07:29

Owned by oligarchs who. Yeah. Using it for their own agendas. So anybody can use it. And there are many people who have started it even recently, like Stephanie Rogers, who we recently on, who has an amazing Instagram account that everybody should check out. Something. Do you remember what it was? Something with Stephanie, like, yeah, yeah.

Better aging with Stephanie. Something like that. Anyway. Yes. There are very. There aren’t a whole lot of podcasts, I would say, aimed at the clinician audience, which is our primary target. Like clinicians, researchers, multidisciplinary folks who are engaged in improving care for people with serious illness or older adults. And so there’s. That’s also opportunity, so there’s room for others.

Lynn 08:09

But do you.

Alex 08:10

Do you. Whatever you do, build community, right? Maybe you’re a comedian. I think there’s a comedian at UNC who we want to have on at some point. You know, maybe you do improv. Maybe you’re a storyteller. You know, figure out your own way to bring people together. Cause I do think that one of the reasons we’re in this field and we stay in the field is that sense of shared purpose and community.

Eric 08:33

Yeah. And doing both geriatrics and palliative care is fun. Like, this is actually fun work, which is always weird when you’re talking to people at parties. What do you do? If I mentioned geriatrics or palliative care, it usually ends the conversation. But like this. This morning, I was in with a patient, and we were just talking about his life. We were laughing. We were joking together. I did not use your number two as my number one joke.

Cause I already used it last week on him. But I guess I really. I don’t know. When you’re working with a good team, you’re seeing these patients. It’s not all sadness. There’s a tremendous amount of joy. And I think bringing the joy back into medicine is a lot of what we do in geriatrics and palliative care.

Lynn 09:13

Great.

Anne 09:15

Well, our next question is also from someone at unc, Meredith Gilliam, a physician. And she’s asking, has any interview caused you to change something about your own clinical practice?

Eric 09:28

Ooh. What do you think, Alex?

Alex 09:30

Sure. Lots of interviews have caused me to change things about. Like, for example, we did podcasts on loneliness and social isolation. And then I resolved to ask every patient the next time I was on service, do you feel lonely? Which, of course, is not in the UCLA loneliness scale, which is like the official scale, but it’s the question I can remember. And a similar experience when we had the podcast with Jackie Cruiser and others about that paper. You know, maybe don’t say, if you needed intubation, what should we do?

Eric 10:03

Why not?

Alex 10:04

Yeah. Or if you needed, you know, tube feeding, what should we do?

Eric 10:08

I need to know why.

Alex 10:09

Yeah. So, right. So briefly, why not? Eric, I’m Asking you the reason is, of course there are. If you say needed, then it sounds like it’s absolutely essential. Right. But there are many alternatives. So the better question is if your loved one was short of breath or if you were short of breath. You know, let’s talk about ways in which we could treat that. And there are a variety of different ways.

Eric 10:32

Yeah. And I also like the one. And I still have to remember this is because I think we talked about want too, in that and how want can be fantastical. Like, I want to win the lottery, but I don’t necessarily expect to win the lottery. So want, like, do you want to be intubated? It’s a dumb question. So rethinking both need and want and maybe using different terms, that’s one thing.

I think the other podcast that we’ve done on Buprenorphine. Yeah, definitely use a lot more buprenorphine now. Way more buprenorphine as a way to both help manage symptoms, pain, encourage all of our listeners. If you haven’t read or listened to the buprenorphine podcast, check those out because that’s one thing that’s definitely changed with my practice.

Alex 11:15

Also thinking about, I used to use gabapentin for everything. Maybe you don’t use it for everything.

Eric 11:23

That’s actually one of our top podcasts, the gabapentinoids podcast. We’ve had a couple of them, but really decreasing the use of that and deprescribing them.

Alex 11:33

Yeah, I also like. Well there, so I could go on.

Anne 11:35

I know I’m not going to let you because we have a lot of good questions to go through. And you guys, let’s get some heat in.

Eric 11:42

Okay, I like that last one.

Alex 11:45

We spend the whole hour on that one.

Anne 11:46

Moving on, get to that.

Alex 11:47

We’re going to try the mango. This is from Hawaii. This is from Ma, made with Maui chilies.

Anne 11:53

So while you’re eating that, our next question, what medical term do you still have trouble spelling?

Alex 12:00

All of them?

Eric 12:03

Maui. By the way, the Maui is not spicy at all.

Alex 12:07

Not spicy.

Eric 12:08

I’m liking.

Alex 12:09

Yeah, this is spicy. In Hawaii, relatively stick. In Hawaii, no food is spicy. This is spicy.

Lynn 12:15

But, you know, it’s not spicy.

Alex 12:17

Not spicy.

Eric 12:18

I’m actually going to mix it a little bit with the first one because I need a little bit of heat just so I don’t get it a lot. Wait, what was the question again?

Lynn 12:26

What word is hard for you to spell?

Alex 12:28

Well, I remember I. When I. When my kids were young and I dropped them off at daycare and Then you had to write down what foods they had. And then, like, my wife would pick up the kid at the end of the day, and she’d say, alex, how do you spell banana? How many N’s are in banana? I’m a terrible speller. Dear, dear listeners. So I’m sure that every word I misspell. And there’s no autocorrect in the electronic health record we use, right?

Eric 12:53

Yeah.

Anne 12:54

There’s a spell check for.

Alex 12:55

Oh, there is.

Lynn 12:56

Yeah, there is.

Anne 12:58

We’ll talk about that after the taping. Here, Alex.

Eric 13:01

Drug regimen. Regimen is a hard one for me. Regimen. Regimen.

Lynn 13:07

These are not medical terms.

Eric 13:08

All right, Medical term. Medical term. Ish. My oldest story is that we did a New England Journal family meeting podcast video, and was in that. And we’re submitting our paper to the New England Journal, and we talked about a mnemonic, and the editorial response back to us was, no. Yeah, it was. Well, I spelled it pneumonic with a pn and they reminded me pneumonic for this. This is not like a pneumonic.

Alex 13:38

Like, you’re too used to using doctor terms like pneumonia.

Eric 13:41

Yeah, like pneumonia. This is mnic. Yeah.

Alex 13:44

Yeah. Different. Yeah.

Lynn 13:46

Okay, so first of all, that question makes me think of the first question because it reminds me of our geriatrics spelling bee. Just putting that out there. Spelling bee. I lost on the generic for kepra, which I can’t pronounce either. I can’t spell it or pronounce it. Anyways. Okay. Our next question comes from Meredith Heller. Okay. And she asks, since you conceived of this podcast, is your audience who you imagined it would be? Any surprises and you started to allude to this earlier? Alex, the audience.

Alex 14:19

Yeah, I think that the surprises are. I’m just mostly surprised and grateful at how big it’s become, because I just love it when people come up to us and say, I listen to your podcast, and it’s, you know, clinicians from all different, you know, walks of life. You know, nurses, nurse practitioners, social workers. So multidisciplinary people, researchers. It’s just great.

Eric 14:44

Yeah.

Alex 14:45

I’m just continually surprised.

Eric 14:46

I think it’s kind of cool that Alex and I are actually going to Brazil in a week to do a live podcast in Sao Paulo. How’s your Portuguese, Alex? You getting ready for that?

Alex 14:55

Not to do bam? Yeah, same.

Eric 14:57

Alex is learning Portuguese.

Alex 14:59

No, no.

Eric 15:01

I tried it for a week, and I failed. But just the fact that we have a greater international presence, I think is really cool. Thanks to a Big shout out to all the Brazilian guys. That’s our number three market for J. Pal.

Alex 15:13

So it’s U.S. canada, then Brazil or U.S. australia. Than Brazil.

Eric 15:17

Oh, God, I forgot who number two is. I got. I gotta look at number two. I think Brazil is number three. Yeah. I’m just surprised that the reach. And then I love going to HPM and doing our bar crawl just because we get to see everybody who listens to it.

Anne 15:32

GeriPal. Big in Brazil.

Eric 15:34

Big in Brazil.

Anne 15:35

Okay, this next question comes from a friend of the podcast, Nancy Lundeberg.

Alex 15:41

Nancy. Hello, Nancy.

Eric 15:42

Hello, Nancy.

Anne 15:43

And she’s asking, looking back at the podcast, is there anything you would do differently? Grab a wing while you think about that, by the way.

Eric 15:49

Oh, we gotta switch to the next wing.

Alex 15:51

I’ll start answering. Or you. You. I’ll start answering while Eric’s chewing there. Um, anything you’d do differently? I think we would have. Okay, so yes, I would have done some things differently. There are some earlier episodes. When you listen to those episodes, maybe skip over the song because I would just wing it. I would, like, practice it for, like, five minutes before, and it was, like, pretty bad sometimes. And that that worth served a purpose.

Right. Because then we all laughed about it when I’d flub a chord or, you know, lost my place. And then that break everybody out of their academic mood. But now, as many of you know, when you listen, only then you get a higher quality recording that I record in advance. And I do try to put more time into preparing the song. So apologies for those listeners who joined us early, but hopefully that has changed. I would have done that earlier had I known I had no regrets.

Eric 16:49

I think we learn as we grow. And I think the one thing is, I don’t know, I feel like winging it sometimes. I mean, this is. We try to keep it casual on this podcast. Sometimes we say stupid stuff, sometimes we don’t. Oftentimes I do say stupid stuff. But that’s okay. Like, this is like, we always tell our guests when they join our podcast, think of ourselves. You’re not on it’s not Grand Rounds. This is not like a podcast. We’re sitting at a dinner table.

Alex 17:17

That’s right.

Eric 17:17

And we’re having a conversation. And like, why? Why would you regret anything?

Alex 17:22

Yeah.

Eric 17:22

Having that conversation.

Lynn 17:25

All right, thank you. Okay, moving on. We have Mike. We. A few people asked sort of overlapping questions. So we are up to this one where we have Michael Reynolds in Davis, California, and Audrey Tan. They’re both wondering, what do you think palliative care will look like in 10 years time.

Alex 17:42

Oh, you go first. I’m still eating this last one. Yeah, this is Sriracha, by the way.

Eric 17:47

I think one recent episode that we did on community based palliative care was enlightening to me is the growth of for profit palliative care systems. I think we’re probably going to see, you know, in the next five years that enter into geriatrics. We’re seeing it in some places a little bit of growth around pace and for profit, but I think we’re really seeing it first in hospice and now we’re seeing in palliative care. So it’s moving farther and farther upstream.

So I think in five years, I think a lot of us are going to be dealing with some of these issues of how do we work within for profit systems. And honestly, if you’re working for academic, nonprofit, a lot of that starts looking like for profit where you have these large academic centers buying up all of these small ones. And how do we in pall health care work within those systems, advocate for our patients when there are potentially motivations that are more around focused on bottom line than it is on best care possible that we can deliver to patients?

Alex 18:48

Yeah, my answer is going to be about AI, But I also have to ask, are there other questions about AI? So maybe.

Eric 18:55

Yeah, I should.

Lynn 18:55

Yeah, we’ll get to AI.

Alex 18:56

We’ll get to AI.

Lynn 18:57

Yeah.

Alex 18:57

Does that mean I shouldn’t say talk about AI now?

Lynn 19:01

We’ll talk about AI in a minute.

Alex 19:02

Okay, I’ll give a different answer. All right. What else about palliative care is going to change in 10 years? Well, okay, I’ll be optimistic. I think that we’ve been building the scientific research base for some time and we are at a critical point where we’re just, you know, the NIH is now funding a tremendous amount of palliative care research, including the Ascent Group, which is a research infrastructure funded by the National Institutes of Health. And it supports early career investigators and mid career investigators primarily.

But it also provides an infrastructure for palliative care research nationally. And I am hopeful and optimistic that that will lead to major advances across the whole continuum of palliative care, from communication to health services type research, to care in the hospital, care at the bedside, you know, in the nursing home, care outside of the hospital, in the clinic and at inpatient’s homes, and improving the hospice Medicare benefit, for example. That’s my optimism speaking. I hope that’s true.

Lynn 20:11

All right, thank you. And then the next future question relates a little bit to what Eric was talking about from Dana Lustbader. Dr. Dana Lutzbader says given palliative care is rapidly expanding into home based care, this is palliative care, often with a focus of reducing hospital admissions. How should the field think about its identity in this changing context?

Eric 20:34

That’s a great question. I think always keeping your mission to your heart and really think about what are we trying to achieve here. So I think delivering the best care possible to patients is our kind of North Star. And in order to do that, I’m going to just do a shout out to what our title is for this podcast, GeriPal. Because if you are delivering that type of care in the community, you can’t really be doing it without really some competency.

In geriatrics, palliative care is if we’re moving into outpatient farther upstream, dealing with folks with cognitive impairment, dementia, frailty, you gotta know what those things are and how to manage it. Oftentimes more so than what we do in our training as palliative care providers and fellowship. So I think we have to integrate more geriatrics into palliative care, similar to how we’re doing in geriatrics, where like every geri fellow is doing some palliative care rotations. Why aren’t we doing the same in palliative care where they’re doing mandatory geriatric rotations, especially in a community.

Alex 21:37

I like Eric’s answer and I’m going to add to add because you said North Star and I’m remembering that triggered me to remember, oh, we did a podcast where I also said North Star and that was talking about health equity and guiding North Star in the type of research we do and the care that we provide and that we should always be asking ourselves, how will this affect various groups, particularly groups who have been historically disadvantaged, for example, and how can we improve this so that it boosts up those groups and or is applied equally to boost up all groups rather than a particular group of historically privileged peoples.

Eric 22:18

Which also reminds me of one of our last podcasts on rural palliative care. Yeah, same thing with rural geriatrics. It is a population of folks that have high mortality, high morbidity, very little healthcare access. And what are we doing to improve the care for those folks?

Anne 22:34

Okay, I’m going to invite you to start working on another wing. I also. Yeah. And I want to say, Alex, the last time we did this, compared to today, like this time last year, our sinuses were really starting to get like, erect. We started crying. I feel like you’ve shown up here with these hot sauces. Maybe a little bit gun shy, self preserving today.

Eric 22:58

The first one was the only hot one so far.

Anne 23:03

The pendulum has really swung a different,

Eric 23:06

by the way, Mojo. I am actually dipping my my into the first one because I knew I

Alex 23:13

need the spice with the last three. They escalate quite rapidly.

Anne 23:16

We’re not really doing hot ones. We’re doing ask me anything over chicken nuggets right now is what it feels like.

Lynn 23:21

I love chicken nuggets.

Alex 23:23

I just want to say I’m not unhappy in the right place.

Anne 23:26

Okay.

Alex 23:26

And I’m already sweating.

Eric 23:28

I have not even got into the milk yet.

Anne 23:30

So as you go ahead and eat that very mild chicken wing that is next on your plate, Sabrina Freitas asks, what do you think the future of geriatrics looks like and what advice do you have for a soon to be medical student interested in geriatrics?

Eric 23:48

My advice would be go into geriatrics. The population is definitely growing for the field. There’s a tremendous amount of need and there’s so much that we can do to improve the lives of these patients. And the skills that you will learn in a geriatric fellowship will really last a lifetime as a healthcare provider. So I do mostly palliative care now, clinically, currently, and I bring in those geriatric seals every single day into my palliative care practice. And I am so happy I did a geriatrics fellowship. I am actually, I’m one of those optimistic about our field. It was a little rough year from a fellowship standpoint this last year. I’m hoping.

Alex 24:27

What do you mean?

Eric 24:29

A decline in the number of applicants nationwide? Yeah, I actually think it’s a blip. I don’t know. I just feel optimistic. I like talking to med students. I think that there is this focus on geriatrics. Yes, we have to do a lot as far as increasing the pay disparity between geriatrics and other fields. But geriatrics, if you talk to a geriatrician, they love the field. They’re satisfied with the work that they do. And then a lot of that is just because we get to work with great patients and actually really have a meaningful impact on their lives.

Alex 25:03

Yeah, yeah. I think that this question, what it’s hinting at here is that article by. It was Jerry Gerwitz.

Lynn 25:10

Right.

Alex 25:10

We had on the podcast in JAMA about geriatrics and concerns about the direction in which it was heading, which I think are great concerns to raise and discuss in our field. And I am glad that he started that conversation or continued it. And there’s certainly. We had disagreements about the data and what they mean and what the future of the field looks like on our podcast. I’m sure many of you had these similar discussions at your institutions within geriatrics. And I guess I would say that I am very optimistic about the future of geriatrics in general just because of the aging of our society and that people who are in Congress, in places of power, presidents, are also aging.

And I think we show our value to those people and that that will come back to us eventually. But we really do need a groundswell of support in order to. Because, you know, I think the reimbursement issue is really big here. And I worry that we had a terrific podcast about billing in geriatrics and palliative care, separate podcasts. And I think people really need to leverage those opportunities because, of course, when people are graduating from medical school with huge debts and they’re continuous through residency, they may end up choosing a different field.

Eric 26:36

And I would also say this is not limited to geriatrics. Like, if we really want to promote better care for older adults, we gotta pay primary care more. Yeah, we gotta pay those cognitive specialties. Nephrology, another great one where, you know, they’re delivering amazing care, but they don’t get paid as much. So you’re seeing decreasing number of people applying to nephrology. Man, if I had one wish it was actually would be to improve how we deliver primary care and actually pay. Pay reciprocally for.

For that type of care too. And I just wanted to go back to my optimistic place is when I was a med student, nobody taught us what an IADL or ADL is. Now it’s like infused into the curriculum. We just did a podcast on age friendly healthcare, which is being infused into hospitals. Nurses are being taught delirium. There is so much geriatrics that is happening in healthcare systems now that wasn’t there 20 years ago. And I think that part for me is also very optimistic that oncologists are being trained on how to do this. And that says a lot to, like, those geriatricians who’ve infused that into all of these different specialties disciplines. And that’s cool.

Lynn 27:50

Cool. Thank you. I think we should have GeriPal fellowships.

Alex 27:54

We do think. Yeah, you direct one.

Eric 27:57

Wait, are we going. Are we moving on in our.

Lynn 28:00

That was a transition statement.

Alex 28:01

Okay.

Lynn 28:02

Okay. Are we moving on in our wings?

Anne 28:05

Sure.

Alex 28:05

We only have three left. And this is where it gets tough.

Anne 28:08

Okay, let’s do one more.

Alex 28:09

All Right.

Lynn 28:09

We’ll do one more question, and then we’ll move on. Okay. So from Eric. Eric has moved on.

Eric 28:13

I needed some eat.

Lynn 28:16

Margo.

Eric 28:17

Let’s get his spice here.

Lynn 28:18

The next question is Margo Smith.

Alex 28:21

Here you go. That’s my mom. Hi, Mom.

Lynn 28:23

Oh, it’s your mom.

Alex 28:24

It is, yeah.

Lynn 28:25

Oh, wait, this is really funny, because listen to her question.

Alex 28:32

Eric’s getting the spice now.

Eric 28:33

Oh, that took. That took, like, 30 seconds for that spice.

Lynn 28:36

Okay, your mom asked, should doctors be required to reveal that they are using AI in their diagnosis and treatment plan? And how do we know what is evidence from hallucination?

Alex 28:50

Oh, that’s great. Good question, Mom. You’re.

Lynn 28:53

You must be, like, really connected because you really wanted to talk about. Right.

Alex 28:57

I wanted to talk about AI earlier.

Lynn 28:58

Yeah.

Alex 28:58

Okay. I’ve soured on AI I used to be more enthusiastic. I mostly talk with AI Because I kind of like the voice interaction, and I’m a slow typer, and I have giant thumbs, so I can’t really do it fast on my phone. But I enjoyed having conversations with AI it was mostly correct, kind of like a friend, you know? And yet recently, I’ve been more disillusioned, particularly as an editor at jags is, like, the number of submissions that are likely AI or clearly AI has just gone through the roof, particularly as, like, we’re getting a number of reviews or, you know, trainees are using AI to write their papers, their reviews, their grants.

It makes me worried because, of course, there’s a connection between how we write and how we think. And it is a painful and important and exciting process to learn how to write well, to make an argument clearly. And if we lose that, if we de skill people’s ability to write, we are also de skilling their ability to think clearly. So I worry about that. And I do see AI used increasingly in clinical practice. I think people. We had a podcast with our chair of medicine, Bob Wachter, about his recent book, which was very optimistic about the future of AI I’m beginning to sour on it in my world, and I worry that in the clinical world, I mean, we asked him about this.

We said, is there any world in which instead of calling this book a giant leap, you call it a giant letdown? He said, no, he didn’t really feel that way. I’m starting to feel a little bit that way. And I worry it’s going to be like the similar story that we had with the social media, with electronic health records. We’ve been burned before. Maybe I’m extra sensitive to it, but I feel like I’m on the leading edge of being burned again.

Eric 30:49

Is that a song? Trying to remember what song with that.

Alex 30:51

Oh, sing it.

Eric 30:52

I’m trying to remember the lyrics.

Lynn 30:55

It’s all right.

Alex 30:56

We’re spontaneous. We just. What’d you say?

Anne 30:59

Just wing it.

Eric 31:01

There we go. Finally, the pun comes.

Anne 31:05

Just gonna keep reusing that one.

Eric 31:07

This one has spice. It kicks in after 30 seconds.

Anne 31:10

After there’s a sleeper wave. Yeah.

Eric 31:12

I would say this is that. I used AI this morning. It was around PTSD and nightmares. I remember randomized control study on prazosin and nightmares, But I didn’t know what was published in the last, like, six years. So I actually did open evidence just to see if there’s anything else around nightmares and PTSD symptoms. Do I think we have to let our patients know that we did that? No, I don’t think we need to know that. If we use ambient AI, I think they should know that.

I think if we’re giving, you know, some billionaire oligarch patients information through an AI agent, we should probably actually let patients know that and give them the option not to send their patient information out there. But I think that’s gonna become harder and harder because these are gonna be built into EMRs. Yeah. So I’m both optimistic and I. I also agree with Alex. Like, we. We’ve been here before. We’ve been burnt multiple times. Alex is really struggling with the spice.

Anne 32:08

Alex’s eyes just said.

Alex 32:09

Oh, God.

Lynn 32:10

Yeah.

Speaker 4 32:11

Whoa.

Alex 32:13

This one is, like, incredibly hot. Okay.

Eric 32:17

Yeah, yeah.

Lynn 32:17

Okay.

Alex 32:18

Trust the threshold.

Eric 32:18

I also never fully trust what the AI agent is. Is telling me, because it’s hard to

Alex 32:25

know if it’s a hallucination or even, like, where is the data coming from?

Eric 32:27

I think stuff that’s really well done or that we have a lot of research in it does a pretty good job. Stuff that’s more marginal as far as the research, I think it still struggles with. And it pulls up a lot of bad journals when it’s pulling up information.

Alex 32:44

Right. I don’t want to pick on an AI, but we did try to enter some information about, like, dude, what’s the prognosis for this particular patient with these characteristics? And it kind of made something up. It, like, filled in a bunch of factors that are in a model, but it didn’t actually know what they were because we didn’t tell it what they were. And so it somehow made them up and came up with a number. So there are some concerns about people’s use of AI, And I Agree. I don’t think you can disclose it now because it’s ubiquitous. It’s everywhere. It’s not possible, it’s not realistic.

Eric 33:16

Are you an AI agent?

Alex 33:17

I might be, yeah.

Lynn 33:19

Before we go into make this like a podcast about AI, okay, I do want to say there’s a big article in the newspaper this weekend that is like a call to action to essentially stop using AI for writing because our brains are probably eroding that.

Alex 33:35

Yeah, people should read that. Also read Ezra Klein’s article about how he’s concerned people are uploading themselves to AI. Remember when we contributed to social media, all that content we gave away for free. Now people are like giving stuff away to all these AI companies for themselves. Even deeper aspects of this podcast, their conversations. Right.

Lynn 33:55

Check out Alex’s TikTok account.

Anne 34:03

He gives so much of himself.

Lynn 34:04

He really up his nose.

Anne 34:07

So personal.

Lynn 34:08

So next I’m going to move us on. We could talk about that all day. So Elizabeth Cobbs says, are there ways you noticed ageism in your day to day? What are some of the things that you do to help combat ageism?

Alex 34:22

Oof.

Eric 34:23

Oh, this is a good one. That’s a good one. Alex, you have any thoughts on this one? I’m trying to think.

Alex 34:28

Well, I think the major ways in which I see ageism are through treatment of disabled older adults, people who have late life disability, not giving that space, not moving aside for them, taking up handicap seats. In sort of my day to day reality, man, I could just have to say that I came back from this conference, this bioethics conference in Austin hosted by the Greenwald foundation, and we were having a discussion there about, you know, allocation of scarce resources.

And I think there is a healthy debate that we’ve had on this podcast and talked about, you know, should we be prioritizing scarce resources to younger people over older people. And that is a debate and discussion that I have two minds about. I’ll just go into it briefly because I know we have many questions to come, but on the one hand, I feel like the fair innings argument that those who are younger have a longer Runway ahead of them and they should be allowed the opportunity to experience all of life’s innings as opposed to those who are in the ninth inning.

That makes intuitive sense to me. The problem I have is that that’s like in a vacuum and that in our current society, there’s so much ageism that informs our choices that might reinforce those stereotypes. In fact, it might even inform the stereotype to begin with. Right. And so I worry about ageism as a result of allocation decisions.

Eric 35:58

Yeah. I was just thinking back to when the dialysis was initially created. There was set up in the God committee up in Seattle where they decided who got and who didn’t get these. This scarce resource of dialysis and social worth was one of those factors that. That was part of that decision. Which sounds eerily familiar in a way to this, like, who gets to decide who is socially worthwhile to get this treatment versus those who aren’t, which is not too far off from this innings idea.

So we gotta be really, really careful. I think the other thing that I noticed, I mainly work in the hospital, so, you know, just the daily practice of ageism. Like, we have people who we see who people think may not have capacity to make decisions. I think that’s partly. They would question that if they were a lot younger, but if they’re older, they don’t question it. And sometimes all they need is like a pocket talker so they can hear better.

Alex 36:56

Right.

Eric 36:57

So really think, like when we’re seeing patients is how much is ageism playing into our diagnostic reasoning, even around things like capacity?

Anne 37:09

Okay, the next question is from Bobby Fleck, who’s a palliative care chaplain in Chattanooga, Tennessee. How does your own faith or spirituality influence your work, both in terms of caring for patients and families and in terms of your own personal coping?

Eric 37:27

I’ll start off. One of my first articles I ever wrote was, like, how to Approach a Miracle, which was. I think it was jpsm, the article was in. And what I learned in writing that article and talking to smart people, Dancel, Maisie and others is that man, even if I don’t consider myself religious. I also take a little bit of concern with the term spiritual because I do think it brings in a religious undertone that our patients are often are.

And patients tend to be very different than healthcare providers in their views and their religiosity. And we do our disservice to our patients if we’re not exploring their spirituality, their how religion impacts their decision making, how that impacts their coping. So I think that’s an incredibly important question to explore with patients. So I try to do that despite, like, I consider myself an. An atheist. But I realize spirituality and religion is critical for the work that I do.

Alex 38:29

Yeah. So I was raised Unitarian Universalist, which is, you know, what’s the joke about? Speaking of jokes, that was the first question. The Unitarian Universalist. How do you scare the universe? Unitarian Universalists of your neighborhood? You burn a question mark into their yard because they’re always questioning. And there’s no, you know, set of you must believe this, you know, rules. And yet there are several principles that Unitarian, you use, as we call ourselves, like, to believe.

And that includes things like there’s an interconnectedness between all beings. And when I was in medical school, my dad got sick with cancer. I probably told this story on the podcast before. And as he became sicker, he had glioblastoma multiforme. He became more spiritual. And it really was a remarkable transformation, you know, thinking. Finding a way to think of this disease in some small way as a gift that allowed for, as Susan Block has said, like peace, growth, and transformation at the end of life.

So my first research studies were on people who were nearing the end of life and their relationship with spirituality and how their experience was informed by their spirituality and how their experience informed their spiritual beliefs. So I absolutely think it’s incredibly important in everything we do because the most fundamental questions that people are asking are spiritual, right? Like, why is this happening to me? What did I do? And how can I get right with God? And what does this mean in terms of my relationships with others, my relationship with whatever higher power? So that’s my take.

Lynn 40:16

Great.

Anne 40:17

I’m going to invite you to get on to your next.

Alex 40:20

I’m terrified chicken nugget.

Eric 40:22

Because that last one is hard. It’s not as bad as the last one.

Alex 40:25

Oh, it’s not. Okay. It might be slightly out of order.

Anne 40:28

Dear listener, this next question is, however, a hot take from someone named Sean Morrison. Is that name familiar to anyone in the studio?

Alex 40:38

Hi, Sean.

Anne 40:38

Oh, and Sean’s asking, hey, why are we still advocating for advanced care planning? It’s less effective than gabapentin.

Alex 40:49

Sean says he’s trying to blow up our podcast. It’s less effective than gabapentin.

Lynn 40:57

We’ve silenced them.

Anne 40:59

This is the perfect humor for the Jerry Bell podcast.

Eric 41:02

I would say. I would say a couple things. First is I agree with Sean fully that gabapentin generally doesn’t work. Oh, number needed treat is like seven. So even in the best case scenario in these studies, for the very few conditions, it was actually tested in rigorous studies. Six of seven people are not going to show a significant benefit from gabapentin.

Lynn 41:24

This is not a question about gabapentin.

Eric 41:25

God, can I just keep it on gabapentin?

Lynn 41:28

No.

Eric 41:29

Dang it. Advanced care planning. I would say this is that.

Alex 41:34

I don’t know.

Eric 41:34

There are some questions like, I don’t need a super rigorous answer to, like, should somebody Do a durable power attorney form to assign somebody a healthcare agent just in case that they lose their ability. I don’t think everybody needs to do that. But man, in clinical practice it is often so very helpful. And it’s actually very helpful if as their illness progresses that they actually have some type of discussion with their patients. So I think things like prepare for your care. It just makes like clinical sense. And I get that we have a lot of like history, like we’ve been burnt by things that make clinical sense that don’t actually work.

But the, the harms are actually very, very small. Like you, you talk about your health with somebody. What’s important, what, what’s meaningful if done in a right way, there’s costs associated with it. Like it takes some time, but outside of that, like, why not? And I think it is often an arbitrage distinction to go from what’s advanced care planning to like, what is serious illness communication? Like the things that we do every single day, like on our geriatrics and palliative care services, like talking about people, what’s important to them when they get them in the hospital. We’re always talking about some future event, right?

Like if you were to have a cardiac arrest in somebody who has like widely metastatic cancer is being admitted for hypotension, like we’re still talking about stuff in the future. So it’s always advanced care planning. It’s just how far in advance does the value proposition for advanced care planning start to erode? And I think it’s really never for picking a healthcare surrogate. And I think for, you know, doing an advanced directive, like the living will component, I do think it probably should focus more on those with serious illness.

Alex 43:27

I’ll just add briefly that I think that we are still emphasizing advanced care planning in part because advanced directives are fairly easy to measure. And for researchers, we tend to follow things that are measured. And this is like a structural issue that’s leading to this emphasis in our work in not just research, but also potentially in quality reporting, which I know, Sean Morrison, you’re deeply concerned about. And that what does that mean? Like, how do we address that?

I think we have to address the fundamental structural issue and start measuring things that matter more. Like my mentor, Ken Covinsky, who everybody knows, has been on the podcast many times, his major focus has been hospital acquired disability and disability, late life disability in general. And he’s been advocating for years that we should routinely measure disability, put it in the medical chart. And I think there’s an analogous there’s analogy here about instead of measuring something that we think of questionable importance, is there an advanced, signed, advanced directive?

We should start focusing on capturing measures that matter routinely in clinical practice. You know, quality of. We can debate what that is. Quality communication. Do you feel heard and understood? You know, after the death occurred, did you feel prepared for what happened? Right. Those sorts of measures are really important, and they’re not routinely captured. And if they were, I would hope that our field would start to move towards growth in that area, because that’s fundamentally what we care about the most. Right.

Eric 44:56

Yeah.

Alex 44:56

The communication.

Eric 44:57

I was trying to think about measuring these hot sauces because I do think that they’re out of order. With that said, the last one was Carolina Reaper.

Alex 45:04

Right. You’d think it’d be hotter. The one before that, that was super hot. That was. Oh, Elijah’s extreme ex father and son Reaper sauce.

Eric 45:14

Yeah.

Alex 45:14

Okay.

Lynn 45:14

Okay. That’s a good. We’re gonna move on.

Alex 45:16

Okay. Cause I’m worried about the last move on.

Lynn 45:20

Okay.

Alex 45:21

We don’t have to have the last wing yet, though, right?

Lynn 45:23

Not yet. Not yet. So we have a question from Ellen Rand. Since the COVID pandemic forced us all to think differently about treatments like ventilators, do you have any lasting changes to your practice when it comes to guiding providers and families around these interventions?

Eric 45:41

Ooh, from. From the COVID pandemic. Like, lasting. From the COVID pandemic.

Alex 45:47

I’m not sure I understand the question.

Lynn 45:48

What it made me think of is, is the sort of conversations around resource allocation that we were forced to have in that time as we were planning and sort of anticipating what was going to happen.

Eric 45:58

Okay, I got an answer. Lasting changes, I would say this is that I think we’ve all had to learn how to do these conversations via Zoom, via telephone, a lot more often than we did before. And specifically in the outpatient setting, like Lynn, how often are you using Zoom for your outpatient clinics?

Lynn 46:17

All the time.

Eric 46:18

All the time. So I think one last thing. Thing is really learning how to use different technology to have these goals of care conversations with family members, which is something that we do here. We have, you know, iPads in the icu. We’re bringing in family members from long distance over Zoom and va, Video Connect and other other things to bring people together. I think that was a specifically positive aspect of the COVID pandemic.

Alex 46:47

Yeah, I know we have a lot of questions, and I think I said my piece about resource allocation earlier.

Lynn 46:52

Okay.

Anne 46:52

All right, next question. Joanne Lynn is worried that increasing numbers of older adults will resort to hastening their own deaths through measures like voluntary stopping of eating and drinking or participating in medical aid and dying because supportive services are unavailable to them. Is that something you worry about? And what are some of the strategies that GeriPal listeners could use to help avoid this outcome?

Eric 47:17

Man, that’s usually our the comments I get the most are podcasts we’ve done on medically aid and dying, volunteer cessation of eating and drinking. I know it brings up a lot of passion from both sides who some people who think, let’s say, medically aid and dying is not appropriate and those that do. I try to keep an open mind where I kind of fall on the debate, knowing that there is so much passion on each side that I don’t see myself as an expert in this.

I specifically don’t do, let’s say, medical aid by myself. But I can see scenarios where I think it’s really appropriate. And I do worry about like utilization, like hospice utilization. With that said, I think hospice utilization is actually fairly high in people in California who use medically aid and dying, which at least for me, kind of calms my thoughts. I think our most probably commented podcast was what was happening in Canada with medically aid and dying and some of the arguments around slippery slope. Like is this not just restricted to seriously ill patients, younger patients who may not be dying of a terminal illness? And I can see where the guardrails are slowly being kind of loosened. We’re not seeing that in the US really, but it is a concern.

Alex 48:38

I don’t know.

Eric 48:39

What do you think, Alex?

Alex 48:39

Yeah, I agree and I know we want to move on. This is a tough one. We could do a whole podcast about this one. I think just to add to what Eric said, I think in California we started we legalized medical aid and dying in 2016, the same year we started this podcast. And I wrote an article with Laura Petrillo about my concerns about enacting medical aid and dying in California at incredibly diverse state, you know, the most diverse state to legalize medical aid and dying, I believe still.

And I worry about legalizing something for very few people who tend to be white, wealthy upper class and privilege. Why are we creating this law for these people? That said, I have to say that I haven’t heard much in the way of pushback from minoritized communities about legalization in California. I think it has gone fairly well in California and that is encouraging. And we have to be like vigilant to keep these guardrails up. Keep thinking our Way through this as new categories are considered, some of the guardrails are questioned, et cetera. Eric?

Eric 49:49

Yeah, and one of the guardrails that we talked about was, we did a podcast with Thaddeus Pope on, you know, using voluntary cessation of eating and drinking as a pathway to medically and dying for people who do not have a terminal illness at baseline. And I think that was a really. I will have a link to that in the show notes. But again, people trying to loosen the guardrails to get more people eligible, which I kind of disagree with.

Lynn 50:17

I also want to say, I think Joanne Lynn is also talking about the fact that we have diminishing resources for support to older adults in our communities. And she’s worried that people are gonna now be looking to these interventions to shorten their life because they don’t get the support to get along.

Eric 50:33

I would say this is too. We don’t have diminishing money going into this. We are just reallocating those resources to very expensive drugs, hospitalizations, procedures. I mean, the fact that we are happy to give multiple MRIs, PET scans, you know, 50,000 or $35,000 aducanumab drugs, Willy nilly, but not wanting to actually help people in their homes, not paying for hearing aids like that is a, that’s a decision. The resources are there. We just allocate them towards generally for profit companies that have specific interests.

Lynn 51:13

Okay, I’m going to move us into the next questions. Thanks, Eric. So the next one comes from Anne Pomper. And I’m going to ask for each of you to give your top tip here. How do you recommend patients and families communicate with providers to guide conversations toward what matters most?

Eric 51:30

Oh, how do you initiate this with your provider? I’m going to do a shout out again, I said prepare for your career. I think that’s a great place to start for patients and families to use to think about goals of care because it also has a section on how to talk to your provider about what’s important to you. So giving people those words, I also just think bringing it up with them is not being shy to bring it up because I think providers are often shy to talk about things like prognosis goals of care. And if a patient or a family member brings it up, I think they’re more likely to. So just having the courage just to. To talk to your provider. Alex is starting on the Ghost Pepper.

Lynn 52:11

Okay. And Eric, you gave two tips, so you gave one for you and one for Alex. All right, so we’re moving on to well, yeah, this is our final audience contributed question and our final hot sauce is so hot. Oh, man.

Alex 52:26

It’s not the extreme regret.

Eric 52:28

This is ghost pepper.

Alex 52:29

Oh, it’s ghost pepper.

Lynn 52:29

Ghost pepper.

Alex 52:30

One of these is called extreme.

Eric 52:32

That was the last one which was not that extreme. I’ve had much more regret in my life.

Lynn 52:37

Okay, that’s for another podcast. Okay. Allison Silvers, chief healthcare transformation at CAPSI center to Advanced Palliative Care, asks, why hasn’t palliative care in the emergency room, in the emergency department taken off? And you gotta answer it now.

Eric 52:58

Ghost pepper. Ghost pepper.

Lynn 53:00

Too much hot sauce.

Alex 53:01

Oh, my gosh, that was fun.

Anne 53:02

Visiting the ED in.

Alex 53:03

Yeah. One of my first research studies when I was in research fellowship was about palliative care in the emergency department. You know, am I doing the right thing? Which is a quote from emergency medicine providers who felt like, conflicted. Like, I feel like maybe I’m not doing the right thing here. And yet this is what I’ve been trained to do, you know, the other quotes were like, ABCs, ABCs, ABCs. And when somebody comes in with a DNR or his own hospice and they come to the emergency department, why? What are they doing here? This isn’t what I was trained to do. Why are they in the emergency department?

This is so hot. Everybody’s suffering here. There’s a lot of milk being poured. So why isn’t it taken off? I think that there are factors that are both structural and cultural, and I think that they’re shifting. So I think that the shift is that many people in emergency medicine are recognizing the importance of palliative care and taking a palliative approach. And I could, you know, I only. Sorry. Sweating here. Anecdotal evidence. We see a lot of emergency providers come to the annual assembly. We had many of our palliative care fellows, our emergency medicine trained. We have.

Lynn 54:15

We need one of them in here, like right now.

Alex 54:16

I know, I’m trying to finish. And so I think there is a culture shift within emergency medicine, you know, and I’ve talked to many researchers who are at that Jerry Pali emergency medicine interface. But the structural issues are what’s limiting. And the major structural issue is time. Like, you don’t have a lot of time in the emergency medicine. So many of the things we do are so time intensive, you know, like these high quality serious illness conversations.

Everybody’s dying in here. Who’s like, blowing their noses, oh, wow, it’s spicy, right? That takes time. Like, you don’t have time to have a. That the Full conversation. And I. I think we’re. People are starting to develop tools that could be used in the emergency department to have. Start the conversation there, get it going or have, you know, when you have to have a time efficient conversation. But it’s hard, I have to tell you.

Lynn 55:12

Okay.

Eric 55:12

I am not sure why I went back for a second, but I was trying to finish that last one. It hurts. I would agree with Alex, too. You know, if you don’t change the actual system, like, if you just do training of healthcare providers. We just did a. We did a podcast last year on palliative care and the ed and if it’s just education, that’s just not gonna work. Like, we actually have to change how we care for people. The structures of care for people, kind of similar to Jerry. Eds, I think, you know, bringing in and infusing geriatrics, infusing palliative care, and everything that’s happening in the ed, Even if you’re not bringing a specialty palliative care. Whew, you’re doing good. Primary palliative care. Next question.

Anne 55:52

Okay, well, now I’m really glad that Alex didn’t make us do that 10 times, because this last one was tough.

Alex 55:58

Oh, so hot.

Anne 55:59

Okay, you guys, you reached the finale for a very special lightning round. Okay, we’ve gotten to the end. Clucky you. I’ve been saving that one.

Eric 56:13

Is that a chicken?

Anne 56:14

That is saving that one. You’re welcome, everybody. Okay. Okay, these next three questions are. Lightning round. Okay, we’re celebrating the 400th episode. Looking forward to 500. Right. So in the next 100 episodes, if you could have any celebrity as a podcast guest, who would it be?

Alex 56:33

Vivek Murthy. Vivek. We’re trying to get a model of the United States. Come on the podcast.

Lynn 56:39

Come on the podcast. You were my resident.

Alex 56:42

Anybody who’s a listener out there who knows Vivek or runs into him, please tell him we would love to have him on the GeriPal podcast.

Anne 56:49

Well, I’m going Brad Pitt or Dolly Parton. [laughter]

Eric 56:54

Dolly Parton.

Lynn 56:55

Okay. All right. Alex, is there a song that you hope you never have to play? Potential guests, listen closely.

Alex 57:10

I don’t know. I don’t think there is a song. I mean, there are songs that are really hard to play. Like, if you requested classical music, that would be hard.

Eric 57:18

Would you play Milkshake again?

Alex 57:19

No, no. Eric did request that.

Eric 57:22

Yeah. One of our hundredth podcast listeners who are going to come up on the show. I’d love to hear Alex do Some tool.

Alex 57:29

I don’t know what that is.

Eric 57:30

Yeah, just remember Tool Charlie.

Lynn 57:33

Xcx.

Alex 57:34

I don’t know what that is either.

Lynn 57:35

Silence the room. Okay.

Anne 57:38

And lastly, if you had to add something new and fun to the podcast experience in the next 100 episodes, what would it be?

Eric 57:47

I don’t know. The last episode we did with Stephanie Rogers, she came in, play the fiddle on one side of me. Alex was playing on the other side.

Alex 57:55

Erica.

Eric 57:56

I was just in the middle.

Alex 57:57

Check out the Instagram of this Erica Kazoo.

Eric 58:01

Check out my son’s comment on the Instagram.

Alex 58:04

Guy in the middle is pretty useless. Ngl. Not gonna lie.

Eric 58:09

Cowbell. I think I can learn how to do a triangle maybe. Or a cowbell.

Alex 58:12

There you go, Alex. We’re open to any suggestions from you, dear listeners. Yes, Lynn.

Lynn 58:18

Dunk tank.

Alex 58:19

Dunk tank. Lynn wanted to do a dunk tank for this episode.

Eric 58:23

That’s a 500th episode.

Alex 58:24

We’ll do a dunk tank.

Anne 58:25

I also think it could be interesting. What if you guys had a live streaming event?

Eric 58:29

Yeah, we kind of. Brazil. We’re doing that. Well, it’s not live.

Anne 58:33

People could watch you live on YouTube. Think about it.

Alex 58:39

Oh, the two of you who are watching us? Yeah, I know everybody else is working because it’s the middle of.

Anne 58:47

We’ll really advertise it in Brazil. Okay, you guys, you’ve reached the end of your Ask me anything. Well done.

Eric 58:54

Thank you, everybody. Maybe we do a little bit more Taylor Swift.

Alex 58:57

Okay. A little bit more.

Alex 59:05

(singing)

Eric 59:27

Lynn and Anne, thanks for leading us through this 400th podcast.

Lynn and Anne 59:31

Thank you.

Eric 59:33

And thank you to our listeners for your continued support.

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