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You have a patient with dementia severe enough that she cannot recognize relatives.  She falls and breaks her hip.  Should she have an operation, and risk the pain, potential complications, and attendant delirium associated with the operation?  Should she be treated non-operatively, with aggressive symptom management?  A huge part of this decision rests on (1) her previously stated wishes, values, and goals (prior to the onset of dementia); and (2) the outcomes of surgery for patients with dementia.

In today’s podcast we talk with surgeon Samir Shah and Health Services Researcher Joel Weissman about a pair of JAGS articles they published on the outcomes of high risk surgery and advance care planning among persons with dementia.  Toward the end we get to hear from Samir about how he would approach decision making for a patient such as the above patient, and from Joel Weissman about what’s to be done about the pressure and incentives our health system exerts to operate, operate, operate.  


Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: Today, we are delighted to welcome Joel Weissman, who is a health services researcher and deputy director and chief science officer for surgery at the Center for Surgery and Public Health at Harvard Medical School. Did I get that right?

Joel: Oh yeah.

Alex: Oh, good.

Joel: The Brigham and Women’s Hospital likes me to say that too.

Alex: And the Brigham and Women’s Hospital. And when I was a general medicine fellow at Beth Israel Deaconess after finishing residency at the Brigham, I took a class in health services research and Joel Weissman was my teacher. So thank you so much for coming to the GeriPal podcast, Joel.

Joel: Glad to see that things worked out.

Alex: And we’re also delighted to welcome Samir Shah, who is a vascular surgeon at the University of Florida. Welcome to the GeriPal podcast, Samir.

Samir: Thanks, Alex and Eric.

Eric: So we’re going to be talking about dementia and considerations around surgery for individuals with dementia. Before we go into this topic, who has a song request for Alex?

Joel: Yes. It was Remember Me. Was that the title?

Alex: I think it’s I Will Remember You.

Joel: Yeah, right, I Will Remember You, right.

Alex: By …

Joel: Sarah McLachlan.

Alex: … Sarah McLachlan. Although I’m going to do the Ed Helms version from The Office … which is pretty similar.

Alex: Why this song, Joel?

Joel: Well, I just thought it sort of engaged me on two levels. One is it’s about remembering somebody who’s passed away. You could interpret that. And since we’re really talking about dementia and memory problems, it sort of had that term in there also. And it’s a beautiful song. It’s just it’s very moving, very beautiful song. It’s not a light song, but I thought it would be a nice addition to the podcast.

Alex: Great choice. Here we go. (singing)

Eric: More of that song at the end of the podcast. What was The Office episode with this one, Alex?

Alex: I actually couldn’t remember. And they don’t post the full Office episode on YouTube. They just show a picture of the guy, Ed Helms. I think he was on Saturday Night Live before that. With a guitar. But a great song.

Joel: I see.

Eric: So, let’s dive into the topic. Maybe I can turn to both of you about how you got interested in thinking about decision-making and surgical care for those with dementia. Joel, do you want to start off?

Joel: Sure. Well, for me it was a personal story. My mother-in-law, Ruth Leman, was a professor emeritus at American University. Really, a smart and caring woman. And she developed dementia in her later years and she had pretty advanced dementia. And at some point, she was living in assisted living and fell and broke her hip. And she was rushed to the hospital. They didn’t send any paperwork with her and they were ready to wheel her into the operating room, but they didn’t have operating hours available, and so they delayed. And then, the family, her kids got together, my wife and her brother and sister got together and said, wait a minute, mom did not want this, right? She has advance dementia. She wasn’t communicating, she couldn’t remember anybody’s name, nothing. And she said, we didn’t want this. And they agreed on that and they talked to the people at the hospital, the surgeons and the nurses. And the nurses says you’re making the right decision.

Joel: And they kept her comfortable. She went to an inpatient hospice and they kept her comfortable for a couple of weeks and she passed away. And it was the right thing to do. And there’s been some recent research specifically about in fractures for patients that are very frail or have dementia and it’s sort of the same thing. You might be able to extend your life a little bit, but at what cost? So, that was maybe 20 years ago at this point and it really got me down the road thinking about advance care planning, end-of-life care, and similar consequences.

Eric: Yeah. I think there was a JAMA Surgery article looking at, I think it was JAMA Surgery, individuals who … It was out of Europe, I think the Netherlands, people who got surgery for hip fracture, individuals with advanced dementia who got surgery and those who didn’t showing that those who got it lived longer, but quality of life was really no different between the two groups.

Joel: And they didn’t live that much longer. I mean weeks or months.

Eric: Mm-hmm.

Eric: How about you, Samir?

Samir: For me, it really came out of an interest in improving the care of patients who undergo surgery. So when I was a resident at Cleveland Clinic, I got to see really cutting-edge technology, some of the best surgeons in the country, and perhaps in the world, operating on patients. And I came to the now I think naive conclusion that fixing and avoiding complications was the secret. And then when I went to fellowship for vascular surgery, I had the opportunity to really observe a lot of patients who had the same high quality, high technical quality care and didn’t have complications, but still didn’t look like successes to me. These are people who had prolonged periods of impaired mobility, who lost their ability to live independently. And I came to the conclusion that the way that I was interested in improving care was trying to improve decision-making, to make sure that physicians and patients and their families really understood what they were getting into and try to make the decisions lined up with their actual goals.

Eric: So, let’s talk about that. So, decision-making and surgical procedures. Now, historically, there was a lot of discussion about the perioperative risks, especially in older adults. And I learned, so you have this wonderful paper that just came out in JAGS, Journal of the American Geriatrics Society, titled Patients Living with Dementia Have Worse Outcomes When Undergoing High-Risk Procedures. And the very first line of that, we’ll have links to this on our show notes, is surgical procedures are common with over half of all surgeries in the US occurring in patients 65 years and older. So the majority of people undergoing surgery are older adults. Is that right?

Samir: That’s right. I mean, there are over 2 million people in the United States alone who are 65 or older and undergo an inpatient procedure or surgery every single year. And we know that a third of Medicare beneficiaries undergo surgery in the last year of life with 18% of those occurring in the last month of life. So this is a very common occurrence.

Eric: Wow, 18 like one out of five.

Samir: That’s right.

Eric: And do we have any data around how many of these people have cognitive issues, Alzheimer’s disease or related dementias?

Samir: I don’t know of any data like that. Joel may know. But we know that 30% of all decedents who are Medicare beneficiaries either die from dementia or have an existing diagnosis of dementia, which is something we talk about quite often, Joel and I.

Joel: Yeah. Not to correct my colleague, I think it was closer to 50%, Samir, is what we found recently. Fifty percent have a diagnosis in their record of decedents have dementia.

Eric: And what do we know about the outcomes of individuals getting these procedures, especially those with cognitive issues and dementia.

Joel: I can say they … We know they’re worse, but what’s interesting is Samir and I have a research project now where we’re doing some case studies around the country and talking to a lot of surgeons and surgeons just know generally that patients with dementia do worse after surgery and they worry about the development of delirium and so on. But they don’t really have a lot of condition-specific or procedure-specific information at all. And they don’t really have good data on it. And also, when they think of doing worse, they think of these 30-day outcomes like mortality and complications. But as Samir was mentioning, there’s ability to live independently, loss of function. We think there are some cases, certain kinds of illnesses or conditions or operations, where people have the surgery and never get out of bed again.

Eric: Yeah. What did you find in the JAGS paper, Samir?

Samir: We found … So, in the paper that you’re talking about, we looked at Mass General and Brigham and Women’s hospitals and all of their affiliates. And we looked at the electronic health records at both of those hospital systems, the MGB network, folks who had fee-for-service Medicare coverage from October 2015 to about September 2017, 6,800 patients. And we were specifically interested in looking at patients who had high-risk inpatient procedures. So we followed Gretchen Schwarze’s definition, which was 1% or higher inpatient mortality was considered high-risk.

Eric: What are some examples of that?

Samir: All the things that would come to mind. So, most open heart surgery, a lot of neurosurgery, but surprisingly, even a lot of orthopedic surgery and percutaneous procedures, believe it or not, are also incorporated into this. Not to get too much into the weeds, but we actually ended up creating this list from scratch. So we looked at Medicare data, we called out everything that had this 1% cutoff or higher. The problem, though, is that you have to separate out things that just happen to occur in patients who are very sick. So for example, tracheostomies frequently occur in patients who are quite ill, but it’s not the trach itself that tends to lead to the mortality, it’s their generalized illness. So we had myself and other board certified surgeons from different specialties go through this very large list and then come up with whether or not we thought it was really causally related to mortality generally. And then we had disagreements and we used a consensus building process to come up with a final list.

Samir: So we applied that list to this work, and we found that about 8% of that 6,800 patient population we were looking at had dementia. And when we looked at the outcomes, we found all of the things that we had hypothesized, namely that patients with dementia had a higher 90-day mortality. They were more likely to have a major inpatient surgical complication. They stayed in the hospital for longer. And importantly, they were less likely to be discharged home if they came from home. And whether or not they came from home, they were more likely to be discharged to a higher level of care. Meaning, if they came from home to go to a SNF or an LTACH, if they came from a SNF to go to an LTACH.

Joel: And by the way, I should mention that some of the work that’s been done in the past on patients with dementia in the hospital, it’s been based on Emily Finlayson’s work looking at surgery, but really looking only at nursing home patients. And we found out in our work that something like 70 or 80% of patients with dementia who have surgery come from the community, who are coming from home. So, where they end up after, what happens to them and where they end up is actually a big deal.

Samir: And this idea that patients with dementia undergoing high-risk surgery are coming or institutionalized is just incorrect. We had a previous paper published in the Journal of Vascular Surgery where we looked at 211,000 patients undergoing vascular surgeries. They’re all Medicare beneficiaries. And we found that the overwhelming majority of them came from home.

Eric: So what do we do with the information? So people with this information, like people with dementia are higher risk with these procedures from both postoperative complications and also longer term outcomes, like 90-day mortality, where they get discharged to. Does this argue that we shouldn’t be doing those surgeries? Does this mean that we should be doing something else differently before those surgeries?

Samir: I think it may mean both of those things. There’s not been literature that I’m aware of that demonstrates how much of this is sort of goal concordant care or not. But the sense that I get as a clinician is that, a lot of times, we’ve gone down this very long road only to come to the end and have the patient of their family say, well, gosh, I wish that we had known more about these different adverse outcomes that could have occurred or what we were really aiming at, because if we had, we would’ve made different decisions. So that’s an example of where in some of these patients, we probably ought not to be offering them an operation. In other cases, I know that there’s opportunities for interventions like rehabilitation. So there may be an opportunity to improve outcomes without just saying, no, you shouldn’t get a surgery because you’re at high risk for complications.

Joel: And so I would say as a non-clinician, I mean, it’s hard for me to weigh in with a lot of evidence on this, but surgical decision-making is more than just yes or no, right? A lot of times it’s when, when to start, or it can be different types of procedures that somebody may want to undergo. So some of it is, in fact, life and death, some of it is emergency, some of it is elective. And so you have to think about those things separately. And I think we tend a little bit, Samir and I, to focus on really the life and death decisions.

Joel: And the question becomes how bad is too bad, right? What kind of … If I were to tell you that if I were to tell a surgeon that their mortality rate is 20%, they would be horrified. They’re talking about, well, anything over 1% is considered high risk. They would be horrified. And yet, some patients say, well, that gives me 80% chance of survival. So, you really have to leave this up to the patients and their families to understand what the context is and what is meaningful to them.

Alex: Couple points there. Just riffing off of what Joel said, there’s this famous scene in, what is it, Dumb and Dumber?

Joel: Yes. Yes, it is.

Alex: But I’m talking about-

Joel: Talk about it. In fact, I probably mentioned it in the class.

Alex: You probably did, yes. You can find the scene on YouTube. I use it in teaching in palliative care, where the main character says, “Do I have a chance,” to this girl that he’s really, this woman he’s really interested in. And she says, “It’s really low.” And he says, “Just give me a number.” And she says, it’s like … He says, “Is it like one in 10,000?” She says, “No, it’s more like one in a million.” And he goes, Jim Carrey goes, “So you’re saying there’s a chance,” right? So for some people, that really small chance may be worth it to them, and maybe that small glimmer of hope.

Alex: But moving on from Jim Carrey and Dumb and Dumber, Samir, I wanted to ask you, someone once taught me, it’s possible it’s Joel, I’m not sure, someone once said that research is the meticulous documentation of the blatantly obvious. And you did say at the beginning of when you’re first talking about the results here that we found what we would expect to find, patients with dementia did worse. I mean, isn’t that … That’s like exactly what you found, right? Patients with dementia do worse at everything. Is there something in your study that suggests that even compared to similarly sick people, they did worse?

Samir: I mean, in this paper, we compared patients who had dementia against patients who did not have dementia. So we tried to take that into account. We didn’t have a grading of dementia, which is a limitation, but we found that taking that into account, if you have two relatively comparable patients undergoing similar risk procedures, that patient with dementia has worse outcomes.

Joel: Can you talk a little bit about it? Because I know you’ve mentioned this to me. That it’s important … Yeah, we know they do worse, but it’s important to put a number on that, right? And also to make it specific to different procedures.

Samir: Absolutely. I was just about to say that. I mean, there is a lot of value for patients and also for practitioners to be able to give some sense of the magnitude of how much worse people do. I think it’s helpful to be able to say, look, if you have dementia and you undergo this procedure, you’re twice as likely as somebody else who doesn’t have dementia to end up in a nursing home for a prolonged period of time. I think that’s something that patients and their families can more intuitively make sense of than me just saying, I think you’re going to have a harder time getting through the surgery.

Alex: And before we get to … I know where Eric wants to go next. But before we get there, one more question about this study. Do you think surgeons have an intuitive sense of what a high-risk procedure is and does that align with what you studied in your JAGS paper?

Samir: That is a tricky question to answer. I feel I’m going to get some heated responses if there are any surgeons listening to this. I think that-

Alex: We like heated responses, by the way, so please continue.

Samir: Yeah. Please send all of those to Alex and Eric. I think surgeons think that they have an intrinsic sense of high-risk and they have a good sense of frailty, but I’m not sure that that’s borne out by our list of procedures. I’ve had the privilege of working at a lot of high class institutions with very skilled and renowned surgeons and I will say that different people have strikingly different tolerance for and conception of risk. So I would say that, in general, I would not rely on the people practicing surgery to be able to confidently classify something as high-risk versus not.

Joel: And to put a finer point on that, I’d also say, I mean, the American College of Surgeons has risk scores, right, that you can tell the patient. But believe it or not, you don’t know what the added risk is to having dementia on top of that risk score. It’s just one of the many cases of a risk score that doesn’t take significant factors into account.

Alex: So NSQIP is this tool, online tool, right, to estimate risk for various surgeries. But what you’re saying is if … And I think it’s pretty commonly used by surgeons. It doesn’t have a dementia or no dementia indicator.

Joel: I think that’s in the process of being changed or if it has changed, it’s changed very recently. But I remember, when we were writing this most recent grant proposal a couple years ago, they didn’t even collect dementia as a variable. So, yeah. But it is changing, thanks to the work of folks like Zara Cooper and others.

Samir: Yeah.

Alex: Great.

Eric: So hip fracture was common in this study, right, that you looked at.

Joel: That’s right.

Eric: Would most surgeons claim that’s a high-risk procedure?

Joel: I don’t know. As a non-orthopedist, I’m not sure. I don’t think they would, but I’m not sure.

Eric: Yeah. I’m just thinking back to my own training. So the interesting thing is it’s probably not perioperative high-risk, right? But the 90 and six-month mortality is exceptionally high in individuals with advanced dementia, where it’s basically a hospice diagnosis when somebody has a hip fracture with advanced dementia. And I wondered like, Joel, for you, when you had those conversations with your own family about it, how much was the focus on periprocedural complications versus probably the outcomes that matter most? What does it mean for functional status, symptom management, location of care?

Joel: I’ll come into that in a second. But I also … Again, I’m also getting on thin ice by thinking like a surgeon, but I’ve heard this before because I talked to a lot of them, is that the perioperative risk may not be exceptionally high, but in the case of hip fracture, they know that if you don’t operate on person, then they’re likely to die. And plus, they see it as somewhat palliative because it does, if successful, deal with the pain, otherwise the patient needs a lot of pain medications. And I think this paper you talked about, Eric, talked about the quality of life and pain control is not all that different.

Joel: That, by the way, surgery is also very painful. When we had that discussion with my mother-in-law, we weren’t sophisticated enough to think about all the outcomes of the, negative outcomes of the surgery itself. But we did think about the fact that there are many procedures that require a lot of aftercare and rehabilitation. And if you’re unable to follow directions and if you’re, I’m not sure of the word, but if you’re distracted and unstable emotionally, that you can’t accomplish those long-term rehabilitative goals. So we just knew that it was just not a good outcome for my mother-in-law.

Samir: And Joel, I think what you’re saying highlights a really important point, which is that surgeons frequently talk about mortality and complications and much of the literature, including the paper that we’ve published, focuses on that to some extent because it’s easy to grasp, it’s easy to measure, but in so many different cases, it’s not just whether you survive or not. You want to survive and have the type of life that you envision for yourself. You want to be able to continue living independently or walking around or playing with your grandchildren or whatever it is for you in particular. But those are precisely the sorts of things that are not routinely measured, assessed, or incorporated in any systematic way into surgical decision-making.

Eric: How does advance care planning before all of this fit in too? Does it happen?

Joel: Well, so first of all, advance care planning is an underutilized option. It’s been somewhat … People have sort of thought about the value of it quite a bit. I look at advance care planning the way I look at cultural competency or patient safety or coordination of care. And where I’m going with this is even if … Or patient-centered medical home, patient-centered care, right? All these sorts of things, it’s often difficult to show evidence of a huge impact, but it should be done, right?

Eric: Yeah.

Joel: It’s hard for me to believe that people think that we should not have discussions with patients about what their preferences and values are, about what happens to them when they get seriously ill. So that’s the problem I have with the critics of advance care planning. The reality is in work that Samir and I have done, we’ve actually showed that having advance care planning does in fact change the kind of end-of-life outcomes that you have. And Samir, I think, should talk about the paper that in terms of the timing of it. So, it’s got a long way to go, but it’s a work in progress and we need to do it better, but I absolutely think it should be done.

Samir: As some of your audience may know, there are new billing codes introduced January 1st, 2016 to start reimbursing for having advance care planning discussions. And that really created an opportunity to study this. So, we looked at Medicare beneficiaries from 2000- mid to late 2016 to 2017, ended up looking at somewhere around, I think, 289,000 fee-for-service Medicare beneficiaries with dementia and we found undergoing inpatient surgery. So this is an intrinsically higher risk population, a population in many ways that is ideally suited for advance care planning. And for each of those, we had a six-month study window before surgical admission and after surgical admission. Within that 12-ish month window, we found that only seven and a half percent of patients had billed advance care planning. So, an extraordinarily low number.

Samir: Now, I can already hear the grumbling, which is that this must occur a lot of times, but it’s not billed for. I freely concede that point, but there’s no way that it’s occurring 75% of the time and only being billed one-tenth of that, those occurrences. It’s not done very often. Another interesting thing we found is that most of the time, of those seven and a half percent, most of the time, it occurred after surgery. And in our multivariable analysis, one of the things we found that was associated with having ACP conversations was either having a major complication or dying. So, our takeaway points from that study were that it happens very infrequently and that it tends to occur reactively after the fact and in patients who are critically ill. So, the timing is not ideal. You would think that ACP conversation before surgery would have more of an impact because that’s when you have an opportunity to forego surgery altogether.

Eric: So it’s kind of not very advance care planning.

Samir: That’s right.

Eric: It happens more in the moment decision-making when they’re doing this rather than preparing for a potential negative outcome. And in individuals with dementia, what I’m also hearing is those negative outcomes are much more likely than those without dementia.

Joel: Right. And by the way, I think your listeners would probably remember that the history of the billing codes in Medicare, that this came up during the debate over Obamacare. And that was when Sarah Palin said that we’re going to basically throw model off the train and she talked about death panels. And that was about a provision to compensate physicians for having these very long and intense conversations. That provision was taken out of Obamacare back in 2007, 2008. But then as Samir mentioned, 2016, without much fanfare or debate, but listening to physicians who thought that they should be compensated for this, CMS, the Center for Medicare and Medicaid Services, said, you know what, we’re going to do it anyway. And they’re committed to this, but there are some other issues about why it’s not necessarily being billed, but that would be a topic for another podcast.

Eric: So Samir, you’re a surgeon, right?

Samir: That’s right.

Eric: Let’s say tomorrow, a patient comes into your clinic. They have dementia, they’re in there with their family. How do you handle these situations and what does that clinic setting look like when you’re discussing possible surgery? And do you do it any different for those with or without dementia?

Samir: For patients who I consider to be higher risk, and I think that would include all folks who have dementia, I try very, very hard to incorporate family members or other decision-makers into the decision. And I try to provide as much objective data as I can on mortality risk and complication risk, but I also try to paint a clear picture of what life may look like afterwards, what the best case scenario is, the worst case scenario, and the most likely case scenario. And I try to tease out what they’re trying to do. Is it that they want to live as long as possible, irrespective of the risks that they may have to go through? Or is it that they’re trying to maximize some particular feature of their life, mobility, for example, as long as they can, but they don’t want to do anything that may imperil that?

Eric: Yeah.

Samir: And I’m fortunate in that … If my bosses are listening, Dr. Huber and Dr. Upchurch, they have created a job for me where I basically can take as much time as I need to talk with patients. It’s all okay and it synergizes well with my research efforts. But I worry about surgeons who may not have those luxuries. That’s a difficult, so much more effort to talk to patients and their families about not doing surgery and the concerns around surgery compared to just saying, sure, I’ll sign you up for the aneurysm repair. It’s going to be high-risk, but I think we can get you through it.

Eric: So the path of least resistance is actually to do the invasive procedure.

Samir: Unequivocally, unequivocally. It’s the path of least resistance from all kinds of different perspectives. I mean, financially, the bulk of the American healthcare system is a fee-for-service system. I don’t think there are any surgeons who come to work and say, hey, I’m going to do some work that’s GOLD-discordant today just to generate more revenue for myself or my institution, but the whole system is geared towards doing more stuff and not really caring about value or quality. The other problem that Gretchen Schwarze is investigating that’s very difficult to pick apart is this idea that she calls clinical momentum. That by the time a patient arrives in a surgeon’s office, there’s a train that has left many, many days ago and that is moving at great speed towards the conclusion of surgery. And for me, as a surgeon, to interface with that patient or their family and say, “I’m not sure that you’re headed to the right destination. Maybe we ought not to do that,” is so, so difficult, especially since that’s oftentimes the first time I’m meeting that person.

Eric: And you mentioned Gretchen Schwarze. We actually had a podcast on, we talked about scenario planning, best case/worst case. I love that because it’s around telling a story of what, what the outcomes are actually going to look like instead of just data and percentages. What does the best case story look like? What does the worst case story look like? And the worst case is often not just dying in the OR because, usually, it doesn’t happen. It’s complications, prolonged ICU stays, and eventually dying in the ICU for a lot of patients. When you’re talking with patients, do you get a sense it’s the stories that are more impactful or is it like the data around outcomes?

Samir: Now, I really try to convey a visceral sense of what a bad outcome looks like instead of data. I think people, most people, unless they come from some kind of quantitative background, if they’re a health services researcher, an engineer or something, sometimes numbers really speak to those patients, but most patients don’t fit into those kinds of categories. And if I tell them, you have a 10% risk of prolonged pulmonary failure and you’ll require a trach, that doesn’t make any sense to them. But if I tell them you won’t be able to walk or move or talk for a prolonged period of time, you’re going to be in ICU for a long period of time, you’re at risk for bed sores and blood clots in your legs, almost certainly, you’re going to end up going to a rehabilitation center or a nursing home. You may end up there indefinitely. You’re not going to end up going back home after the surgery. You’ll have a feeding tube. Those kinds of things I think resonate more with people. So it’s the stories rather than the data, for better or for worse.

Alex: And, Joel, how do we get out of this, from a policy perspective? Where surgeons are motivated to do more, where the path of least resistance is to operate, where maybe some of these conversations are happening and not being billed, but whatever proportion it is, it’s definitely low, even if it’s somewhat higher than what you found in your study. What’s the way forward here?

Joel: And I don’t think there’s a … There’s no simple answer to this. I was thinking, it’s not so much the path of least resistance as the path of propulsion, right? I mean, it’s pushing patients in this direction. I think part of the problem is fee-for-service and surgeons being evaluated and compensated on the basis of what’s called relative value units or their productivity, right? As opposed to … I think I haven’t seen the research, but I’ll bet if you looked at places like Kaiser, which has a per member per month fee and their surgeons are all salaried and regardless of the RVUs that maybe they’re providing, or at least that doesn’t weigh in quite as heavily on that, that when you talk about value in the healthcare system, that you can balance this out. So I think we need to get away from the fee-for-service RVU system and put surgeons in the place where they can think about what’s best for the patient and what’s best for society in the healthcare system.

Alex: Mm-hmm. Maybe if we had a greater amount of reimbursement, not just for advance care planning, which should occur in advance, but for serious illness communication conversations, regardless of the outcome, whether they have the surgery or not, people should be compensated for that difficult, complex procedure that they’re engaging in, which has a parallel in a difficult, complex surgery. It’s a skill that requires teaching and practice and feedback in order to learn and do well. So maybe we need some greater incentive to have those procedures, those conversations, as well as quality metrics to make sure people are doing them well.

Joel: Yeah. And you two guys are both palliative care docs, right?

Alex: Mm-hmm.

Joel: And I learned only recently, I hadn’t been aware of this, but most of that happens after a patient’s been hospitalized. And that these serious illness conversations ought to involve more palliative care consultations, I think. When the patient is going down that road and having more complications, just from their illness, they need to start thinking about these things. And I think that we do need more of that information and you’re right. So I think Medicare is still sticking with this idea of being able to bill for advance care planning, which can include a serious illness conversation. And hopefully, they’re going to improve the program and make it more worthwhile because it’s not only important for the patients and the doctors, but also researchers, just to be able to know what’s going on.

Alex: Mm-hmm. Last question from me. We put a lot on the surgeon here. Are there other members of the team we should be involved? Is there a role for the primary care doctor, for the anesthesiologist, for the consulting team, for …

Eric: Integrative geriatrics.

Alex: … pre-operative assessment? Yep, for geriatrics? We’re available, palliative care.

Samir: Yeah. I think it’d be hard to find someone who would say no to that. As you mentioned, the surgeon is sometimes the last person in a long sequence of people and events that results in surgery and involving all the other members of the care team, the nephrologists, cardiologists, primary care doctors, geriatricians, is crucial to making better decisions.

Joel: And so, I would say those sorts of services, they cost money and they’re not necessarily well reimbursed. And yet, if you can imagine a system where value is more important, where goal-concordance is more important, then it does have value. And that we need to incorporate that into how we care for our patients.

Eric: Last question from me. You had a magic wand, you can make one change around this topic, policy, individual provider, patient, family, anything, Samir, what are you going to use that magic wand on?

Samir: I would use it to have data around non-technical outcomes, to be able to say to a patient, if you undergo this surgery, this is how I predict your future will look like, in terms of mobility, pain, independent living, and so on and so forth. That would be sort of the magic wish for me.

Eric: So not just 30-day mortality?

Samir: No. The full thing. I would love to be able to paint an accurate picture for patients about what life will look like after surgery.

Eric: Joel? It’s got a little bit-

Joel: I absolutely agree with that. We’re all about data. Those are patient-centered outcomes, patient relevant or patient important outcomes. And I would just make sure that the idea of having these discussions with your loved ones, your partners, or whatever, throughout your life are what’s actually important. And that it’s not only having discussions with your doctors, but having discussions with everybody else so they know what you want.

Eric: And it sounds like that helped for you too. You were able to come together as a family and say, she wouldn’t have wanted this.

Joel: Exactly.

Eric: Well, I want to thank both of you. But before we leave, Alex, I think you got a little bit more of Sarah McLachlan going on here.

Eric: (singing)

Eric: Samir, Joel, very, very big thank you for joining us on this podcast today.

Samir: Thanks for having me.

Joel: Thanks for having us, yep.

Eric: As always, thank you Archstone Foundation for your continued support and to all of our listeners.

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