How Can We Improve Surgery for Older Adults? Aaron Baggs, Emily Finlayson, Ali Torbati

Eric 00:00

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex

This is Alex Smith.

Eric

And Alex, today we’re going to be talking about the intersection between geriatrics and surgery and geriatric surgical verification programs. Who do we have with us to talk about this?

Alex

We’ve got a Full house. We have Aaron Baggs who brought this idea to us. Thank you, Aaron, for bringing this idea. He’s a general surgeon who specializes in bariatric surgery at Kaiser Permanente East Bay. Aaron, welcome to the GeriPal Podcast.

Aaron

Excellent. Thank you.

Alex

And I should say Aaron works with my wife, Cindy, who’s an anesthesiologist over there. And then we have Ali Torbati, who’s a geriatrician who works with the geriatric preoperative team and does clinical work in SNFs. and works with Aaron and Kaiser, and the views of both Ali and Aaron expressed in this podcast are their own and don’t represent that of Kaiser. Ali, welcome to the GeriPal Podcast.

Ali 01:10

Thank you so much for having us.

Alex 01:12

And we’re delighted to welcome Emily Finlayson, who’s a colorectal surgeon and researcher at UCSF. I think you were on before, but it’s been a while. Is that right?

Emily

No, no, this is my first time.

Eric

I was shocked… I actually had to go to the GeriPal AI. You know, we have that little AI search button on GeriPal, and I check, and this is Emily’s first time on the podcast.

Emily 01:36

Happy to be here.

Alex 01:43

And we also have Rachel Borthwell, who is a surgery resident in UCSF East Bay, who’s kind of joining us as a guest host. Rachel, welcome to GeriPal.

Rachel 01:54

Happy to be here.

Eric 01:56

So we did have a geriatric pre-op podcast with Vicki Tang several years ago. We’ll have a link to that in our show notes, but we’re going to dive into this topic. But before we do, who has a song request for Alex?

Ali 02:09

I do have a song request.

Eric 02:10

What’s the song?

Ali 02:12

I would like to request Turning Table by Adele, please.

Eric 02:16

Why did you pick this song?

Ali 02:18

So I, during my career, I took a lot, take care of a lot of patients before, after surgery. And there was always an element of surprise for them that, man, this is way harder than I thought, or this is not really what I expected. And it always gave me this feeling that, are we in a relationship that’s not working? And I feel that everyone needs some level of empowerment and maybe stopping these turning tables. And that’s why it reminds me of the relationship that sometimes we have with our patients.

Eric 02:50

Wonderful.

Alex 02:51

Great explanation. All right.

Eric 02:53

How hard is Adele, Alex?

Alex 02:55

Adele is…yeah, this won’t sound like Adele. And if you’re listening on audio only, then you get my wife Cindy on piano. And if you’re watching on YouTube, then you got me kind of with a Neil Young-ified version on guitar. Here we go.

Alex 03:16

(singing)

Eric 04:19

Wonderful. Thank you, Alex.

Alex 04:21

That was a lot of fun, Ollie. Thank you for that one. Enjoyed that.

Ali 04:24

Thank you.

Eric 04:25

All right. Aaron, I’m going to turn to you first. What got a surgeon interested in the intersection between surgery and geriatrics? What motivated you to start thinking about this?

Aaron 04:38

So there’s always, you know, family history. And I think from Doing surgery, we’re basically trained as a problem-focused specialty, identify the problem, fix the problem, move on. And after seeing a couple of family members go through the hospital, some time in the ICU, and different specialties addressing individual problems, the cardiologist looks at potentially doing a cath, renal just looks at renal function, pulmonary is just looking at adjusting the vent. Surgery’s just considering, you know, fixing, you know, the bowel obstruction.

Really, you know, our training is not really designed to really look at the whole patient. And it’s frustrating. And after, you know, many years of that, you know, I heard about the Geriatric Surgery Verification Program back in 2017, ’18, ’19 when it was just getting started. And, you know, I thought it sounded like a good idea as far as trying to figure out a better way. to work with patients and look at problems and how to, you know, address the patient-focused issues rather than just, you know, the individual organ system.

Eric 05:46

Yeah. Rachel, would you agree as a, you know, in training as a surgeon, how do you feel about that?

Rachel 05:53

Yeah. I mean, I think I would definitely agree that, especially within the first couple years of residency, we’re very much focused on going in and if there’s an opportunity to offer surgery to patients, We don’t really have those conversations about what their goals may be and why, you know, we talk about the risks and benefits of surgery, but I think we skip over a lot of important things, many that Dr. Baggs mentioned.

Aaron 06:21

And I will say that the residents are actually much more receptive to changing their focus than, you know, some of the other surgeons like myself who’ve been doing this for decades. And, you know, it’s worked for this long, just keep doing it. But I think, you know, our patient population is aging and, and I think Ali will talk about this some. You know, geriatricians are particularly good at taking care of patients in their, you know, last decade or so of life, palliative care in their last year or so of life.

Surgeons don’t, we don’t think of ourselves as taking care of patients in their last decade of life, but we are. There’s just a lot of patients who come in, you know, who are over 80. Yeah. with a bunch of medical problems. And I think we really need to change some of our focus on, you know, how we take care of them. It’s not the same operation in a 60-year-old as it is in an 80-year-old.

Eric 07:11

And then Emily, from your perspective, I’m going to take a step back. Can you tell me a little bit about the history of the Geriatric Surgical Verification Program? Why did somebody decide, you know what, we need a separate certification program Just for geriatrics and surgery?

Emily 07:28

Yeah, that’s a really great question. I mean, historically, the verification programs have really been sort of, sort of specialty-focused, so trauma or vascular or cancer. And I think there was a growing body of literature in the sort of ’80s and ’90s around, is surgery safe in older patients? And there was this big enthusiasm, we should do more surgery, and things were kind of going back and forth. So, I think there was really an appetite for figuring out how to take care of older patients more successfully, and then build some kind of program that could be layered at every hospital.

So not just trauma centers and getting verified in trauma, but large academic centers, VAs, integrated health systems, rural health systems. Could we create something that they could implement to improve care in every setting? So it’s a little different than those sort of you know, set the, the, the programs that are designed for sort of major referral centers. So it really took a different tack. And you can really see that in the evolution. I think it was very ambitious at first.

I mean, you know, stakeholders, the usual sort of way of building out a program and figuring out what’s feasible, what’s valid, and creating sort of a bigger, um, verification program. Uh, but, but really over time it became clear that, that those standards, although people were very excited about ’em, they could see the value in them, that we needed to create something that was more accessible for all different health systems.

And that’s sort of how we got to the age-friendly program that can align with age-friendly programs in nonsurgical areas. So it really, the goal was to be accessible. It took us several iterations to get there, but I think we really have a package now that aligns, that is approachable and accessible for all different health systems. It also aligns with CMS payments. So there’s sort of kind of a win-win, kind of a wordy answer to your question.

Eric 09:17

And from a surgeon’s perspective, like what is different from the older adult? Like when you’re thinking about the older adult, like is this just good care that everybody should have or is there something particular?

Emily 09:29

Well, there’s really the same themes that, that, that medicine has around taking care of older patients, sort of preserving mentation, preserving function, aligning goals when people have less of a runway for the rest of their life. And really sort of weaving in, you know, what’s important to patients. I think what’s, you know, salient for a 35-year-old cancer patient in terms of length of life and, you know, what they can accomplish versus someone who’s 85 and has a cancer, what the goals are. And we know from Terry Fried’s work, that’s function, function, function.

Eric 09:59

Yeah. And then when we think about surgeries, I don’t know, we were talking about this, is that talking about the goals of surgery versus like, when I think about like goals of care, like we’re often thinking about like advanced directive. How do, like, how, how do you think about like goals of surgery and how that fits into the, the bigger picture? And how did that fit into the GSV?

Emily 10:20

Yeah, it really, I think that the GSV helps usher in sort of a paradigm shift about how we talk to patients about what they’re going to accomplish from surgery. So, I think we, people have started to back up a little bit more and think about what’s on offer with the surgery, what can we accomplish? And then really integrating that with the very individual goals of the patient.

I think, you know, historically what’s tracked by registries, what’s tracked by your hospital is 30-day mortality, readmissions, things that, you know, approach the bottom line for the hospital, but also are very salient for the surgeon, ’cause there’s nothing worse for the surgeon than a death, an early death. And the decline in function or cognition or independence, that happens outside of your purview. And I think the GSV really brought that onto the table and people are starting to think about that and weave that into their conversations.

So, I think that was a very big service for the GSV to, to, to really sort of bring that to the fore. But it still remains a challenge because we don’t, it’s very onerous and expensive to track those kind of outcomes. Yeah. And surveys and 90-day results and people are just, you know, doing the bare minimum trying to get the 30-day in-hospital mortality rates. So, still more work to do, but it’s now sort of in the, in the frontal cortex.

Eric 11:32

Okay, let’s talk about how this actually looks like boots on the ground implementing a GSV program. Ali, I’m going to first turn to you. As a geriatrician, how did you get interested in this intersection between geriatrics and surgery?

Ali 11:47

I think I was always interested in working with surgeons and co-management with trauma, ortho. A lot of work that Dr. Mendelson did with AGS was very I was very interested in this work, and I always knew that we need a better upgraded 2.0 pre-op specifically for geriatric patients. The Sinai Abbreviation Geriatric Evaluation article was very attractive years ago to me to start looking at doing Mini-Cog, doing deep risk versus benefit informed consent with our patients.

So that was one aspect, but I think the bigger aspect that I had was I’m a very big fan of implementing geriatric model of care. And I truly believe the biggest innovation in the 21st century in medicine and healthcare delivery is moving from a disease-oriented approach to a patient-centric approach. And geriatricians the last decade and palliative toward the end of their life have been leading this cultural change.

Eric 12:58

Yeah.

Ali 12:59

And I found out partnering with surgeon and anesthesiologist has been amazing. And historically we have not been thriving geriatrician when it comes to implementation, but when we partner with surgeon and anesthesiologist, We can start doing so many things together and we’re having fun.

Eric 13:20

So tell me, how did, at your hospital, how did the decision was made? You know what, we should do this GSP program.

Ali 13:29

I see. I think my conversation with Aaron started in a backyard of a nursing home in Berkeley. And we sat down and we talked about some of the pilot that ACS is doing. with one of our service area in Fresno. And we talk about the need for this higher level of high-quality informed consent, high-quality risk assessment, and high-quality care planning before that. If you are 80 years old and you’re going to fix your rotator cuff and you’re going to be non-weight-bearing for 8 weeks while you’re using a walker, 8 weeks of non-weight-bearing means 8 weeks on a wheelchair. Yeah. Yeah.

Eric 14:10

8 weeks of muscle loss. 8 weeks of—

Ali 14:12

Yes, everything. All this decline. Do you have a plan? How do you want to deal with it? So these are all questions that we feel that need to happen before surgery.

Eric 14:20

Aaron, what were you doing in the backyard of a nursing home?

Aaron 14:23

I heard about this, this really awesome geriatrician that I should go talk to about introducing geriatric surgery verification. And, you know, Emily mentioned the start of the program. I mean, it started with like 200 standards and Subendra Banerjee, one of my mentors in Fresno, managed to whittle it down to 30. But it’s a lot. It takes a lot of people to implement. And without the help of, you know, Ali and the other geriatricians, I mean, I can think it’s a good program, but I can’t figure it out without their framing.

Eric 15:01

Yeah. And when did you start the task of doing the GSP program, and when did you actually get certified? What does that timeline look for you briefly?

Aaron 15:09

It’s years. So, I mean, I was hearing about it in 2017, ’18, ’19. We started in 2019, then there was a bit of an event in 2020, but we kept going, which I think was the right idea.

Eric 15:22

Yeah.

Aaron 15:23

And it was ’23 before we were actually verified.

Eric 15:27

And for our audience, what does it look like Before, a little bit. I think we all mostly know what before, but how does it look different once, what does the care look like as far as how is it different for folks undergoing surgery now, older adults?

Aaron 15:43

At our facility, we leveraged our perioperative medicine department to include some geriatric training. So, they’re better at assessing, you know, not just is this patient going to survive general anesthesia, but what are their ADLs, IADLs? What do they have available for support? You know, their level of cognitive function, they get a tug test. So there’s just overall better evaluation for vulnerabilities.

Eric 16:09

Do you assess for like frailty too?

Aaron 16:11

Yes. All of those things.

Eric 16:13

All of those things.

Aaron 16:14

You know, and again, we thank Emily for all of her work and guidance as far as, you know, the standards. But our surgeons are also having more of a discussion. You know, what do you expect from this operation? We get a quote. What matters most to you? I mean, that’s a big change. I mean, before, and, you know, I don’t know, Rachel may tell you things have changed in the 30 years since I trained, but I mean, it’s just like, you’re going to have this operation, you could bleed, you could get an infection, you could die, and just sign here. And it is so much more that the residents are doing now than I did back in the ’90s.

Ali 16:48

And one thing I want to add that to my fellow geriatrician, A lot of cultural change started from the OR. We learned how to do handwashing from our operation rooms. There’s a lot of potential to change the culture of a healthcare system through the operation room because not only the surgeon, the anesthesiologists are amazing partners.

Eric 17:12

Yeah.

Ali 17:12

And man, they’re good at implementing. And they take a good idea, they take it to the next level. And they have been an amazing partner for us. And I think there’s a lot of opportunity if you’re in the system and you wanna implement a geriatric idea and culture, knock at your surgeon’s door, knock at your anesthesiologist’s door and say, hey, what do you think about this? And share your ideas and get them input and get them some logistic implementation idea.

Eric 17:39

All right, Rachel, I got a question for you. As a resident, you probably rotated through places with the GSV and without. What’s the cult— is there a culture shock? Like, is there when you’re first doing this?

Rachel 17:51

You know, I think what I noticed when I rotated over at Kaiser where they had the senior surgical care program, um, there was a structure that I think I was lacking in other places that I had rotated through. And so I really appreciated, um, sort of how it was embedded into Epic. It was fairly easy to use. Um, and it also allowed me to kind of pause and have longer conversations with my patients, asking them about what matters, using sort of the ACS NISQIP score to factor in, um, to decision-making.

Eric 18:28

What, what’s that?

Rachel 18:30

Um, so it is a, uh, a calculator that you can use and you’re able to actually put in what the patient’s operation is and then all of their sociodemographics or comorbidities. And it gives you their risk of postoperative complications. And that’s actually embedded within Epic through the…

Aaron 18:49

Just as an aside, one of the things that, that is now available is not just the usual, you know, 30-day mortality, prolonged length of stay, pancreatic leak, but also some of the geriatric, you know, functional changes, decline in mobility, prolonged, you know, non-hospital discharge. just, just a lot better look at, you know, what their outcomes are going to be as far as function.

Eric 19:11

Well, let me ask you that, Emily, because you were talking about some of the difficulties in data acquisition. EHRs are notoriously terrible for assessing and documenting functional status. Is that still the case?

Emily 19:27

Yeah. I mean, we’ve made all sorts of tabs for frailty, but it just, it’s really hard to get it populated. Um, I think with the, you know, more integration of AI, there’s probably gonna be more sort of just automatic frailty measures that are gonna be generated from that and put in, populated into your note. But the question is, you know, user, is the user using it? Is the surgeon conveying that information with the patient? Are they helping interpret the data? How are they using that in the conversation?

Eric 19:54

And how should they, let’s say, let’s say somebody’s frailty level is high and they, they were delirious during the last hospitalization, you’re worried about their risk for delirium in the pre-op setting. Do you just take note of that or should there be action on that?

Emily 20:09

So even in the Age Friendly, the thing that makes the Age Friendly challenging for some people is it’s not just assessment of geriatric vulnerabilities.

Eric 20:17

Yeah.

Emily 20:17

Uh, but it’s really targeted optimization for elective operations. Um, and that’s something that can be super challenging, right? Because you have this, you know, defined window between when you see the patient and when the surgery is. And getting all of those, if you’re trying to optimize sort of, you know, delirium risk and function and nutrition and lining up the family support and all those vulnerabilities that you want to bolster, you know, integrated health systems like Kaiser are definitely better situated to deliver all of these services.

But fee-for-service, it tends to be very challenging and getting in to see those providers is super challenging. So there is a role for prehab, and even if it’s not just And prehab for older adults is not just like protein shakes and leg lifts, right? It’s, you know, it’s, it’s exercise and nutrition, but it’s also, you know, anxiety reduction and family support and setting up the house and advanced directives and goals of care work and, you know, all that kind of stuff. So that’s something where people are still working really hard to try to, you know, access that, those services.

I think everyone, like frailty’s kind of sexy to talk about frailty. I really strongly believe that we should just break out all those geriatric vulnerabilities because that’s where we’re going to have an opportunity to figure out, well, this person has a frailty score that’s high, but it has mostly to do with this X, Y, and Z. So how can we target those vulnerabilities and try to bolster those?

Eric 21:36

Like cognition, polypharmacy.

Emily 21:39

Yeah. Social support. Yeah. All that stuff.

Eric 21:42

Ali, are you involved in that? You do pre-op, pre-prehab?

Ali 21:46

Um, so in our system, um, We did a lot of the work moved to the pre-op clinic. So we have a robust pre-op clinic, mainly run by our internal medicine, hospitalists, and anesthesiologists. So we realized we didn’t have enough geriatricians in our system. We are a tertiary center, very busy, many OR per day. So we kind of implement some structure for our POM doctors to do this evaluation.

And whenever they find out there is a high-risk patient, there’s some geriatric syndrome that needs to be addressed, or there is some gap on, on the understanding of risk versus benefit, they will be discussed during our weekly board meeting. So I attend the weekly board meeting and we come up with a wide range of intervention from stopping a statin on a patient with pancreatic cancer to all the way reapproaching the surgeon that You may benefit to have a second discussion about the risk versus benefit. And we do a lot of Dr. Schwartz, Steve, why do you want to have surgery during the board meeting?

Eric 22:51

So is this like tumor board? Is there a bunch of different disciplines? Like who’s involved in these discussions?

Ali 22:57

So we have a surgeon. We usually invite the surgeon who will do the procedure. We usually invite the primary care doctor. I’m the geriatrician. There is a palliative doctor. There is an occupational therapist who actually calls the patient before the meeting. There is a dietitian who actually calls also. Um, recently we added a chaplain to our board meeting.

Eric 23:19

Wow.

Ali 23:20

And, uh, we have a palliative attending also attending. Uh, Aaron, who am I missing? Oh, uh, nursing champion, a case manager. Uh, who else? Like

Aaron 23:30

anesthesia, perioperative medicine, preoperative medicine.

Ali 23:34

Yes.

Eric 23:34

And you’re just going case after case, like talking about all the high-risk patients.

Ali 23:39

So we get an email on Friday with the patient we’re going to discuss on Tuesday with the Nescope score and some of the challenges, some of the positive findings. Oh, this tag was too long, or this patient MOCA mini-COG was positive, or patient is not sure if you want to have surgery or not. Things like that with some brief kind of information from the patient on Friday. And our amazing team, Cecilia and John, work on getting all these things ready by Tuesday. And sometimes we have some patients last minute added to the board too, but we talk about them about 1 hour. And on average, we have 5 to 6 patients per board review.

And we come up with recommendations for multiple people, for the primary care doctor, for the surgeon, for the surgical team. And we have the chief of anesthesiology in the meeting. So she sometimes reach out to the doctor who gonna do the procedure and say, hey, be careful with that, or be mindful about this, or maybe we should do this. Or, and then a lot of written recommendation. And again, this is more an advisory and recommendation board, but we also reach out directly to some of these providers, say, since we talk about this patient and we think that way, or please be mindful about the other approach.

And, we really, and the other aspect, which is very important is we feel this board meeting look like a learning class for us. Um, I learned so much from our chaplain about faith and belief and how important it is to pay attention to, to the patient values and learn so much about pre-op evaluation. And they learned so much from other people too. Yeah. Um, and it has been truly a, a learning class, but also a, a lab, an experimental place. We try different way. We, we, we do different approach until we find what works the best and we implement that best practice.

Alex 25:42

I love this. This is great. What, what do you call it? Geriatric surgery board?

Ali 25:47

We call it senior surgical board meeting, weekly senior surgical board meeting.

Alex 25:52

And, and have you heard of other places that are doing this?

Emily 25:55

Yeah, that’s one of the original GSV standards. That’s one of the standards is that you do this kind of review for elective cases. Yeah.

Alex 26:03

Oh, I love this. This is great.

Ali 26:06

One thing I really like about GSV is truly people who created are not only scientists and knowledgeable about geriatrics. They’re people that they did healthcare implementation. Like they, and I don’t know, I’m just guessing they have been leaders in healthcare. So they know how to implement change in healthcare. So GSV has been a very good structure about how to implement.

I do have my own feedback sometimes for some of these standards and some of the things, especially regarding the geriatricians not being mandatory to be part of the board. But overall, I think this is a very good structure, really well designed to implement. This is an area that we always had challenge about implementing high-scale geriatric models.

Alex 26:55

And currently, did you just say there’s no requirement that a geriatrician be on the board?

Ali 27:01

That’s correct. The term used in, correct me, Emily, if I’m wrong, Standard 2.3.5.8 is healthcare provider with geriatric expertise. I’m wondering if we would say this is an oncology board and you don’t have to have an oncologist on the board. how that would be working, but we are very humble people. We would show up no matter what. But I think we discussed that during AGS actually, that why having a geriatrician is not mandatory, at least for level 1 certification.

Eric 27:34

Emily, what’s the history behind that?

Emily 27:36

I mean, there’s just a, you know, a national geriatrician shortage. So most, we’ve tried to make this accessible to all hospitals. So, you know, a geriatric CNS or nurse practitioner, I mean, we have to be a little bit more Liberal in our requirements for the input of someone with that focus. In a perfect world, we would have, you know, a geriatrician on every board in every hospital in the United States. That would be lovely.

Ali 28:02

But we are looking to implement the biggest overhaul of the recent modern healthcare delivery in our systems and not asking or not mandating the expert to be involved. And trying to be mindful that that’s how we solve the empty spot in geriatric fellowship positions. You have to think about what’s the chain of it. If we make it optional for the systems to, you can use an NP rather than a geriatrician, then our program director will have a hard time finding residents to fill their spots.

Eric 28:39

Yeah, a little bit of a chicken and an egg there.

Emily 28:41

Totally.

Eric 28:42

Let me ask you this. What’s the, is there a role for palliative care specialists and is it similar?

Emily 28:47

Same, same, same, you know, not enough. Uh, cuz we wanted to make this a very accessible program. So, um, you know, we really tried hard to integrate as many palliative care principles as possible.

Eric 29:00

Yeah.

Emily 29:00

Uh, in the absence of having, you know, a board-certified palliative care physician. And I’m really excited about this sort of explosion of surgical trainees getting, uh, double-boarded in palliative care. So I think we’ll have a A solution, a built-in solution too.

Eric 29:15

So, yeah. Okay. So we talked about outpatient. Is there any difference what happens in the OR with GSV?

Emily 29:23

You know, when we were designing the program, we had, you know, all the stakeholders at the table, including anesthesia. There’s not a lot of consensus around like the best drugs to give or this or that. There’s, you know, things around pain control after surgery. So a lot of the, yeah. Uh, standards are around sort of postoperative bundles and not so much about the intraoperative management.

So the really the focus is getting the right patient into the OR, making sure the goals are aligned, optimizing patient before surgery, and then what bundles can you bring in after surgery so that people can not get delirious, maintain their function, have adequate nutrition, you know, get PT, like those kind of bundles to really make sure that patients recover well after surgery.

Eric 30:03

And Erin, what does that look like from your implementation?

Aaron 30:06

Sure. Well, and, and part of, you know, around what Emily was just saying is, you know, the, I think the, the time in the OR is fairly generic. Avoid too many narcotics.

Eric 30:17

Yeah.

Aaron 30:17

But I think the, and, you know, use multimodal, try to, you know, the rest of it, use a block if you can. But I think the biggest, you know, benefit as far as the Geriatric Surgery Verification Program is like, have a better discussion ahead of time about what the operation’s impact is going to be. Yeah. Really, You know, the patient and the family really should be invested in that operation and really be invested in whatever the potential outcomes are.

Eric 30:41

Yeah.

Aaron 30:41

So they’re going into it not to cure the cancer, but they’re going into it to live longer. They’re going into it to avoid disability. They’re going into it to be functional. They’re going into it just for a biopsy to make a tissue diagnosis. And they are aware that if things don’t go well, this is what it’s gonna look like. They’re gonna be in, uh, you know, in the ICU for a while and they may not go home. Um, to me, that’s, that’s a big chunk of the value. Um, the pre and the post.

Eric 31:07

Yeah.

Aaron 31:07

And making sure that when you are in the OR, you’re getting the operation that the patient really understands. Maybe that’s, yeah, not a total joint replacement. Maybe it’s just a pinning so that you’re, you know, have a better understanding of what your outcomes are gonna be.

Eric 31:21

And

Emily 31:22

then, and to get back to Eric’s question, yeah, this is super hard in the acute setting. So you’re called down to the emergency room. Rachel, I’m sure this is very salient for you ’cause you’re the first line. You go down there. And, you know, you’re a surgeon, you wanna fix it. There’s a bowel obstruction or a perforation and there’s carcinomatosis, and what’s the best thing to do for the patient? Uh, and to be able to have that conversation in that really compressed amount of time that surgery might be, you know, helpful or not.

Rachel 31:46

Mm-hmm.

Emily 31:47

Um, I think it’s particularly salient in cancer patients where the cancer culture says fight, fight, fight. And if you choose not to do something, you’re sort of falling down as this cancer warrior. So those, like, those conversations are so fraught and so compressed. You have very little time. To go in and sort of establish a relationship and to really elicit those goals and dreams and aspirations of the patient.

And this is why I’m so excited that your generation is really sort of grabbing onto these principles and really bringing them and integrating them, um, early on. And, um, it’s on us, uh, to make sure that we, you know, carve out time in your training that you’re able to sort of think about that and develop those skills.

Eric 32:25

I can imagine, Rachel. that you have a lot on your plate when you’re going down and seeing the patients. And I could imagine that, you know, people telling you to do more stuff, click more buttons, it gives structure, like you said, but it could also be frustrating. Like, why am I doing this? Is there a component of that at all as a trainee?

Rachel 32:49

I mean, I think, I think definitely within the first couple years of training where you’re just trying to get your bearings and get good at patient care, There is that initial like, wow, this is just a lot of extra things that I have to do. But I would say definitely as a 3rd-year resident where I felt more confident in my ability to go down and have conversations with patients, that’s where I felt like having, you know, the senior surgical care, um, available to me was really helpful and it gave me pause and allowed me to kind of slow down and have tougher conversations.

Eric 33:24

I guess, Emily, my question then is, because goals of care conversations are really hard, is this tagged in with education, like teaching surgeons how to have these conversations in a different way?

Emily 33:37

Yeah, I think someone earlier sort of evoked Gretchen Schwarzy. She’s made a really beautiful curriculum that, you know, we’ve brought periodically to our trainees to make a structure around sort of the worst case, best case, worst case paradigm for discussing risk and being able to fully explain sort of that granular level of recovery as opposed to sort of the, you know, fix-it list. There are curriculum available to teach these kind of things.

Alex 34:02

Yeah.

Emily 34:03

And also just modeling by your attendings is very important as well.

Alex 34:09

We had Gretchen on to talk about best case, worst case at one point, and then we had her on for a separate podcast to talk about her new vision for surgical communication. And the limited number of outcomes that surgery can produce and how surgeons can focus on that when they’re talking with their patients. Uh, Rachel, oh wait, Eric, are we talking, we’re still talking about, we did outpatient, inpatient. We’re going to continue there.

Eric 34:32

Uh, no, I’m ready to talk about what happens after surgery, but if you’ve got another question.

Alex 34:36

Okay. I’m going to go after and then, because I have a question for Rachel about, um, like, okay, Rachel, like you’ve tried to get this going, right, at some places and met with some pushback. Could you talk in general terms about what that pushback is? Maybe we could have a quick discussion about that.

Rachel 34:54

Um, you know, I think I’ve, I started really in the quality improvement stages when I, when I started my professional development time. And I think the major roadblocks along the way is just getting the buy-in from other people. Um, I managed to find a mentor, uh, an attending that is very much interested in this work. But I think as I’ve gone to like nursing specifically within my clinic, I’ve gotten pushback about, you know, their time and their lack of time to be able to commit to helping me with some of these projects.

Eric 35:30

Aaron and Ali, how did you get over that?

Alex 35:32

Yeah,

Aaron 35:33

sure. So, and, and Rachel’s absolutely correct. There, there are a lot of different competing priorities. And again, this, this is part of, this goes back to the standards, right? You just have to have involvement of nursing. So that means it goes to the chief nurse executive. They have to make time to develop nurse champions on every floor that takes care of surgical patients.

And those nurses are resources for every nurse on that floor. Without that structure, it’s, it’s like Rachel and I trying to, you know, yell at people to do stuff. It doesn’t work. You’ve gotta, you’ve gotta have the whole structure in place. Yeah. And the support throughout the administration, top down.

Alex 36:09

Yeah. I think there’s also, didn’t I, I recall hearing that surgeons have incredible, they feel incredible ownership over their patients. And is there a concern from some surgeons that this represents, you know, bringing a patient to a board meeting with all these other specialists, that’s loss of control of my fiefdom. Like, these are my, I have responsibility for this. I’m doing this really invasive, serious thing. And so for good reason, they have ownership. And could this represent a threat to that?

Aaron 36:39

It can. And I, but I will say, you know, it’s obviously we’ve been doing this for quite a few years, but I mean, now I can have a discussion with my HPB surgeons about his patient’s risk of delirium, right? 5 years ago, we wouldn’t have that discussion. We talked about leak rates and SSIs. And, you know, they’d publish a paper about, you know, 2-year mortality. But now, you know, we can have a discussion about an individual patient and their risk of delirium. I think that is something of a paradigm change.

Ali 37:07

I would just want to add something to, Alex, your concern. This is more a fear and concern than reality. I had the same concern when we started this work, but the day that I saw this tall spine surgeon sitting in the board meeting and explaining how he’s going to make his patients’ life better, or how are we going to make things better for the patient from a patient-centric perspective? I think we underestimate the involvement and the level of partnership that our surgeons are ready to provide patient-centric care.

A lot of it is concerned, and I totally understand, there’s some concern that some models of reimbursement are not really invested on less or slowing down sometimes evaluation before surgery. Me and Aaron, we are lucky that we are working in a system that we are invested in our patient happiness and in our patient health. And we want our patient to thrive. And that’s how we make our money in our system. And I know CMS is working on some model of reimbursement that will basically push the money in a direction that is better for our patient’s health, is better for our society. But I think more than that, we underestimate how good of a partner surgeons are.

Eric 38:23

Wonderful, lovely words. I do want to get to, because we’re running out of time, what actually is happening after surgery. Emily, can you just briefly discuss kind of what does GSV say should be happening in the post-op setting?

Emily 38:38

You mean the post-hospitalization setting?

Eric 38:40

No, post-op in the hospital and maybe even after hospitalization.

Emily 38:45

Yeah, yeah. So it’s interesting because we had, you know, someone mentioned earlier 200 standards and it was pretty unwieldy and we just basically locked all the GSV founding members in a room and said, like, we’re not leaving until we get this down to a bite-sized…

Alex 38:59

It’s like a Pope encyclical.

Emily 39:01

Right, exactly. The smoke was coming. But really, it was all hanging around some different themes. It’s, you know, what matters, goals of care, it’s nutrition, hydration, it’s function, and it’s cognition. And so really in the post, like, those run through all the episodes of care, but really That’s where sort of the nursing bundles come in. And like, if it wasn’t focused on one of those things, it wasn’t, you know, people really fixated on like, we need some pet, you know, pets in the hospital post-op for mental health, you know, like things. But people were like hanging onto these really emotionally…

Eric 39:32

Yeah. That’s nice.

Emily 39:32

Very attached. But what, what’s really the basics? So it’s really everything hanging around that. And it’s really effective nursing bundles. Um, and I also just wanna call out, you know, there’s a lot of discussion around, you know, making sure you have buy-in. The surgeons have, you know, having the, the spine surgeon buy-in of the surgeons, the nurses, buy-in, but you also need to have the, the buy-in of the health system, right? Mm-hmm. Because it’s another program that someone’s approaching them and saying, you know, we want you to support this program. You’re gonna give the resources you have, you know, there’s like a, a nominal fee to join the program.

Sometimes that’s too much of a speed bump for a health system to, to think is worthwhile. Um, and you have to, you know, gather data. And so you have to have the buy-in of the health system. And that’s where Kaiser was just so amazing as an early adopter. Um, to really just dive in and be like, we will be a partner in creating these standards. And if you don’t have that leadership buy-in, no matter how, um, energetic and dedicated the geriatrician is, or the, or the surgeon or the resident, unless you have that structural buy-in, it’s really gonna, you’re gonna have a hard time sustaining it.

Eric 40:36

And there’s a wonderful website to go to, the GSV, uh, website, which we’ll have a link to in our show notes. Um, The one thing that confuses me, and I think you’ve alluded to it several times, 2 different standards. One is a GSV standard, and there’s another document, GSV Age-Friendly Standards. What’s the difference between those 2? Can you just clarify that for me?

Emily 41:01

Yeah. So the, the other ones are sort of the, the initial ones are sort of a nod to the OG standards, sort of the, this is the aspirational standards. This is what Kaiser’s really worked on and has really been able to hit the mark. You know, we, those are the first ones that we rolled out or in an iteration of the first ones we rolled out. And those for a lot of hospitals were just not achievable. So, people not passing their certification or people just not signing up because they thought it was too much.

They didn’t, weren’t be, they weren’t going to be able to achieve it. So, a second iteration is in order to reach more hospitals and also to align with Both age-friendly standards for non-surgical specialties, so people getting age-friendly certification for non-surgical care aligning with that, and also aligning with sort of newer CMS reimbursement standards. So really, those are the age-friendly is really designed to be something that’s accessible, aligned with other programs, and aligned with reimbursement.

So this is sort of a I’d like to think of a starter or even like a lifelong. Um, approach to it. Um, but you have systems like Kaiser that really partnered and built the program with us, and they’re always gonna, I would imagine, go for, go for the brass ring, right? ‘Cause they’re, they can do it. They’ve shown they can do it. They see it makes a difference. They have their, their physicians and nurses are totally bought in. So there’s no reason to downgrade at that point because you’re like, you’re hitting all your marks. Um, so it’s really a way that the, the Age Friendly is really a way to, to lower the bar, not lower the, Just make the entry a little bit less activation energy.

Eric 42:40

Is there any data to convince upper executive leadership around cost? Like, this is going to save you some…

Emily 42:49

Yeah, some of the early… you know, it’s always different in an integrated health system and a fee-for-service. So, the challenge is traditionally more in the fee-for-service because adding more costs more. But some of the early adopters, one of the Hopkins affiliate hospitals, they published their results. They were doing the original standards. They saw, you know, improvements in outcome. Um, so there’s data out there to show that this is gonna make a difference.

Eric 43:12

Yeah. Rachel, do you have any questions? I wanna open up to you. I have one last question from my standpoint.

Rachel 43:19

I’m just thinking, no, I mean, I think you guys really answered all the questions that I had.

Eric 43:26

So I gotta, uh, go ahead.

Rachel 43:28

I guess one thing that I’m wondering is like, Has anybody been able to do this in a county setting or more of a resource-poor setting?

Emily 43:37

Yeah, there, there have been some. I, it’s, I think it’s ironic that people always say like, oh, the academic centers can do it. That’s generally has not been the case. So I don’t think we should make assumptions about different resource hospitals. I think it really, it has more to do with sort of the buy-in of the leadership and also just the passion and the drive of the of the champions on the ground. So yeah, it’s something that some safety net hospitals have been able to achieve. It’s, you know, it’s, and I think with the age-friendly standards, it’s going to be even more approachable.

Aaron 44:07

Awesome. And I think that’s, you know, one of the benefits of the age-friendly standards, um, because there are so many other initiatives for age-friendly patient care, whether that’s, you know, in the emergency department, whether that’s for the hospital and non-surgical patients, I think the age-friendly standards, um, as a way to help bring our surgical patients aligned in there for more hospitals. I mean, and that’s the goal, right?

Ali 44:30

Yeah.

Aaron 44:30

You know, it’s nice to have 30 standards. I wouldn’t consider it a downgrade to go to the age-friendly standards. But I mean, we all want to see these patients get better goal-aligned care.

Eric 44:41

All right. My last question to all of you is, let’s say you’re trying to convince our listeners that if they’re going to focus on one aspect of age-friendly care in the hospital setting, This is the right one, GSV. Would you be willing to tell me, like, what’s your one thing? Lightning round. Ali, what’s yours? Convince our listeners.

Ali 45:06

I think, again, I really like the wisdom behind the structures and the people who were in the room that Emily said. They’re people that they had hands-on implementation and hands-on the reality. And I really like the structure and the wisdom behind a lot of these including reaching out to the community, for example. Yeah. The importance of QI and all these things that each one of them led to so much progress in our healthcare system.

But I, at the end, I think the best part of this work is, I don’t want to say goals of care. This is more palliative. We say what matters most in geriatrics or patient priority in geriatrics. The deep informed consent that we do for our members. is so valuable to me. Like we sit down with them, we really give them a good trajectory, the reality, what they’re going to face. And that’s the trust that we build is amazing.

Eric 46:01

That’s amazing.

Ali 46:01

And I think that’s the biggest part and biggest value of works like this.

Eric 46:05

Aaron, what’s yours?

Aaron 46:06

So Ali took mine, which is the what matters most, but, but I will say, you know, the other big value is, you know, Emily talked about how bad it is when you do an operation and the patient dies. But I mean, I think it’s also bad if you do an operation and the patient dies and like they didn’t really understand that that was a potential outcome.

Eric 46:25

Yeah.

Aaron 46:25

Right. And the family didn’t really understand that was, you know, maybe a likely outcome.

Eric 46:29

Yeah.

Aaron 46:30

I mean, if, if the patient goes into surgery and has a bad outcome, but everybody knows it’s a possibility and it happens, I feel much better about myself and our intervention than if, you know, they didn’t know.

Eric 46:42

Yeah. Wonderful. Emily?

Emily 46:45

Yeah, I mean, my argument would be, you know, if you look at cardiovascular surgery, you look at cancer surgery, this is predominantly the diseases of older adults. There’s millions, you know, millions and millions of older adults getting surgery every year. We need to do it better. It’s better for them holistically. It’s better for the surgeon in terms of their trauma of having a bad outcome, and it’s good for the hospital’s bottom line. So wonderful. Right person, right operation. Um, and do the best you can to support them through it. So, you know, high-risk, high-reward surgery, you gotta make sure that it’s, uh, you know,

Eric 47:14

Rachel, do you got one from a trainee perspective? Why should we do this? Like convince our listeners.

Rachel 47:21

Yeah. I mean, I think as a trainee, we’re always trying to think about how to do what’s best for our patients. And I’m constantly caring for different older adults and trying to think about how to optimize their care while they’re in the hospital and then get them to a safe dispo. Um, and so I think all of these components factor into how to do that best.

Eric 47:44

Wonderful. And like, like these are the people, the future people are going to be caring for older adults. It seems like this is a great opportunity from an educational perspective too.

Alex 47:54

Absolutely.

Eric 47:54

Yeah. As we turn the tables, Alex.

Alex 47:57

There you go. There’s the link.

Alex 48:06

(singing)

Eric 49:09

Ali, Emily, Rachel, Aaron, thanks for being on this GeriPal Podcast.

Emily 49:13

Thanks for having us.

Aaron 49:14

Thank you.

Rachel 49:15

Thanks for having me.

Eric 49:16

And thank you to all of our listeners for your continued support.

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