July 22, 2025 • 29 mins
Join Dr. Jerry Gurwitz, from UMass Chan Medical School and UMass Memorial Medical Center, and Drs. Namrata Singh from University of Washington, Melissa Loh from the University of Rochester, and Rasheeda Hall from Duke University, as they highlight opportunities for rheumatology, oncology, and nephrology specialists to implement MCC Care.
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Episode Transcript
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SPEAKER_01 (00:00):
Welcome, my name is Jerry Gerwitz and I am a
geriatrician at UMass ChanMedical School in Worcester,
Massachusetts.
And I am extremely pleased to bemoderating this podcast as part
of our AGS Aging LearningCollaborative Curriculum.
The AGS Aging LearningCollaborative Curriculum is a
(00:22):
comprehensive curriculumspecifically designed for early
stage investigators interestedin incorporating the science of
multiple chronic conditions orMCCs into their research.
The curriculum is a jointendeavor of the American
Geriatric Society and the AgingInitiative and is funded by the
(00:43):
National Institute on Aging.
And as an aside, if you areapplying for an NIH career
award, this curriculum is a mustto incorporate into the training
section of your application.
I am truly excited to bespeaking with three authors of
new topic additions to ourBasics of MCCs module.
(01:08):
The three topics are multiplechronic conditions in geriatric
nephrology, multiple chronicconditions in rheumatic
diseases, and multiple chronicconditions in geriatric
oncology.
So welcome, Dr.
Rashida Hall, Dr.
Nimrata Singh, and Dr.
Melissa Lowe.
Thank you, thank you very muchfor speaking with me today.
(01:32):
I'd like to begin by asking eachof you to say a few words about
yourself, a bit about how youchose your specialty, and also
about your personal epiphany, ifthere was one, that led you to
recognize the importance ofmultiple chronic conditions in
(01:53):
caring for your patients, inyour research, and in your
teaching.
So let me begin by askingRashida.
SPEAKER_00 (02:01):
Thank you, Jerry, for inviting us to be a part of
the series.
So myself, my name is RashidaHall, and I am an associate
professor in the Division ofNephrology at Duke University
School of Medicine.
And my clinical research nichehas been in geriatric nephrology
since my fellowship training.
And I point it out because Ibelieve that's when the epiphany
(02:23):
actually started when I was anephrology fellow.
There are definitely severaloccurrences of patients who I
encountered where their kidneyfunction recovery was really
poor.
And often it was related to theother chronic conditions they
were experiencing or theirfailure of those conditions,
(02:43):
like if they were in anintensive care unit.
So it's really clear to me thatfor many patients with kidney
disease, having other chronicconditions actually played a
huge role in what would happenwith their kidneys.
And in fact, as part of aninitial training is remembering
and being cognizant thatdiabetes and hypertension, as
common as they are, are chronicconditions that do contribute to
(03:07):
the onset and the worsening ofkidney disease.
And now as an attending at theDurham VA, I lead a geriatric
nephrology clinic.
Now I get to embrace thecomplexity.
When patients have multiplechronic conditions, I consider
that part of thinking throughthe care plan.
So like when it's a conversationabout their kidney failure
(03:31):
options, dialysis, transplant,or conservative kidney
management, the other conditionsare relevant to the
conversation.
because perhaps someone's lifeexpectancy or their preferences
would differ based on thepresence of those conditions.
And not only that, when it comesto having chronic kidney disease
(03:52):
and maintaining stable kidneyfunction, it's important that
patients are able to managetheir condition on their own.
Sometimes having other chronicconditions can make it harder to
do the self-management, whetherit's like dementia.
So maybe now we have to engagesomeone else to help them
maintain medication adherence,or maybe there are certain
(04:16):
medications for other conditionslike heart failure or arthritis
that then make managing theirkidney disease a little bit
harder.
So those are my thoughts aroundthe importance of chronic
conditions clinically, As aresearcher, I spend my research
focus on doing research thatwill lead to better outcomes for
(04:37):
older adults with kidneydisease.
It's hard to disentanglemultiple chronic conditions from
end-stage kidney disease when itcomes to whatever events that
may occur and how likely it isfrom these conditions or kidney
disease.
But still, I think it's reallyrelevant because we know there's
enough data out there that wouldsuggest that having, you know,
(05:00):
this accumulation of chronicconditions does make some
patients more vulnerable.
And so ways that we can identifythose patients in a way that
might kind of give them adifferent kind of care pathway
from someone else who only haskidney disease does help with
improving outcomes for patients.
SPEAKER_01 (05:19):
Thank you, Rashida.
Nimrata, can you say a few wordsabout yourself and how you got
to where you are?
SPEAKER_02 (05:25):
Yes, definitely.
But first of all, I want to say,just like Rashida said, thank
you so much for including me inthis effort.
Really appreciate it.
I am Namrata Singh.
I'm an adult rheumatologist atthe University of Washington.
First of all, what led me tobecoming a rheumatologist, I
would say, is really got drawnto the management of complex
(05:48):
patients, diagnostic reasoningit entails, and really the
long-term relationship we buildwith our patients as they
navigate chronic illnesses.
And then over time, you know, itdidn't take too long to realize
that it was impossible to ignorethat most of my patients are not
just managing rheumatoidarthritis or lupus, etc.
(06:09):
They are really living withother things like they also are
navigating heart disease,perhaps depression.
Some of my patients are dealingwith cancer at the same time.
Turning point, I would say theepiphany really came when I
realized that so-called goldstandard guidelines of which
I've been part of, like forrheumatoid arthritis, for
(06:29):
example, they really oftenoverlook the realities of older
adults, especially with aging,polypharmacy, and focusing on a
single disease isn't just enoughis really what led me to be
gravitating towards multiplechronic conditions and the whole
field around it.
And keeping in mind that we needto treat the whole person and
(06:51):
not just one individual.
of their medical problem list.
And then this really also guideshow I do my research.
So for example, my researchfocuses on the treatment
outcomes specifically related tocancer and cardiovascular
disease risk in adults withautoimmune rheumatic diseases.
And it further shapes how Imentor in my teaching.
(07:14):
So for example, more and moreI've found myself telling my
mentees that let's maybe ask thepatient, not just what is the
right medication, but maybeperhaps what matters most to
you.
And keep in mind, how do all theconditions that they have
intersect?
And maybe what might be drug Aas a right choice for somebody
(07:36):
with isolated rheumatoidarthritis, perhaps is our drug
number 10 of choice when we aremanaging somebody with
rheumatoid arthritis, cancer,heart disease, et cetera.
So I think overall, gravitatingtowards multiple chronic
conditions research hasdefinitely guided my practice
and how I teach.
SPEAKER_01 (07:55):
Thanks, Namrata, and that's really fascinating.
Melissa?
SPEAKER_03 (07:59):
Well, like Rashida and Namrata, thank you for
having me here.
I'm Melissa Lo.
I am an associate professor andgeriatric oncologist at the
University of Rochester.
I'm trained in both hematology,oncology, and geriatrics, and my
research focuses focuses onoptimizing care of older adults
with blood cancers by doingclinical trials, not therapeutic
(08:22):
trials, but clinical trialsfocusing on behavior and
supportive care trials, such asexercise study or programs that
help elicit patient preferences.
So how that interest came aboutwas I have a longstanding
interest in cancer, bothclinically and research, since
medical school.
And talking to patients withcancer always gives me a great
(08:43):
sense of satisfaction because Ifelt that I'm able to actually
make a difference in makingtheir life a little less lousy.
But the epiphany was that as Itook care of these patients,
like many others, I realizedthat most of them are older.
What I also realized that manyof them have multiple chronic
conditions and their care areoften more complex and really
not straightforward.
(09:03):
And honestly, emotionally, itwas very difficult for me to
take care of them, probablybecause I was not comfortable.
And because I know I was notcomfortable, I really felt the
need to learn geriatrics so Ihave a better understanding of
how best to care for them,cancer and multiple chronic
conditions.
And then as I got deeper, I wasjust really interested in
geriatric oncology because thatmade me a better doctor.
(09:25):
Again, the more I learned, themore I realized there's no clear
answer.
And one of the main reasons isthat we don't really study this
population enough.
So in cancer, our treatmentdecision is often guided by
randomized clinical trials.
And we love randomized clinicaltrials.
It's all worth a place incancer.
But for many reasons, all olderadults are not represented in
(09:46):
randomized clinical trials ofcancer.
So in other words, in clinicalpractice, it's a little bit of
a, it's not a little bit, it'sactually a lot of guesswork in
terms of recommendations.
So whether or not the treatmentwork, but more importantly, like
we actually don't know how muchharm we're going to cause.
So with that gap, I really feellike the need to research and
study older adults with cancer,the gap was really in blood
(10:09):
cancer that I found more so thansolid tumor.
And that sort of led to myinterest in geriatric oncology,
specifically in hematology.
SPEAKER_01 (10:17):
Really interesting.
Let me switch gears a littlebit.
Are there any key principlesthat you have found over the
course of your careers that youthink should be emphasized to
trainees or that serve asunderpinnings of your research
ideas related to multiplechronic conditions in older
(10:39):
adults?
Let me start with Nimrata.
SPEAKER_02 (10:42):
Yes, that's a wonderful question.
(11:12):
So for example, you know,managing rheumatoid arthritis in
someone with diabetes, coronarydisease or depression doesn't
just mean that we give them onepill today, they come four
months later, we give themanother pill and just keep
adding pills if they're notfeeling better.
It's about what matters most tothem.
And understanding if maybe thefact that they're not responding
(11:34):
is, do they have the financialmeans to take them or, you know,
support at home.
So really caring about theperson per se, rather than just
saying, oh, I'm going to takethis pill.
X amount of joints are swollentoday.
We need to keep adding drugs isone principle, I would say.
And tied towards that is theother one is about minimizing
harm through thoughtfulprescribing.
(11:54):
I've been at the AmericanGeriatric Society meetings, et
cetera.
I've learned that polypharmacysometimes is inevitable in our
patients, but at leastthoughtful prescribing should
not be a difficult decision tomake in the clinic.
So I try to emphasizedeprescribing when possible,
looking out for drug-druginteractions, and especially
(12:16):
shared decision-making when itcomes to immunosuppressing some
of our complex patients.
And at the same time, maybe thethird principle you can say is a
cumulative risk awareness.
So It's not that sometimes wethink one and one will make two.
Multiple chronic conditions arenot just additive.
They're multiplicative in someways.
(12:37):
And similarly, that's why thisis driving the research I do.
And just as Melissa wasoutlining, the care for patients
with multiple chronicconditions, be they be older
adults or in general, justmultiple chronic conditions,
they are just so paucity of datain terms of What trial data can
I extrapolate to a patient rightin front of me in the clinic?
(12:59):
They never fit a mold that thetreatment guidelines present to
us.
And so keeping in mind thatpatients sometimes with multiple
chronic conditions are not theperson that a guidelines X
recommendation, Y recommendationmight fit.
And then last but not least, tokeep in mind that I think about
is dynamic and longitudinalcare.
(13:20):
Just like, you know, perhapstrue also for Rashida and
Melissa, my patients usuallytend to live, you know, with
their disease.
It's not like maybe infection orflu-like illness that will get
better over time and that'll bethe end of it.
So managing multiple chronicconditions requires ongoing
reassessment.
For example, what might work forsomebody at 60 may be very
(13:41):
burdensome or harmful even bythe age of 80 years old.
So keeping in mind and valuingbeing flexible and reassessing a
person's Thank you.
Melissa, some key principlesthat you think about that our
(14:08):
listeners
SPEAKER_01 (14:18):
should know.
SPEAKER_03 (14:20):
Thank you for that question.
I agree with everything thatNamrata said.
I think the principles inoncology are and should be very
similar to geriatrics.
And honestly, across thedifferent specialties, I don't
see it being different betweenan older adult with cancer and
an older adult with chronickidney disease and an older
adult with rheumatoid arthritis,for example, or without any
(14:41):
chronic illnesses or multiplechronic conditions.
Having said that, I would justemphasize on three principles,
just making it more concrete.
So in the world of geriatriconcology, we have been pushing
to do what we call acomprehensive geriatric
assessment, basically anevaluation of the overall health
of an older adult, which givesyou a better understanding of
(15:04):
one with multiple chroniccondition.
So in cancer, precision medicineis such a hot topic where we're
always pushing to try andunderstand the cancer more.
But we're not so good at tryingto understand the health of an
older adult, which is ironic.
Through geriatric assessment,that is what we think the best
way of understanding the healthof an older adult and then
(15:26):
combining them with the cancerin terms of better understanding
of the tumor biology together, Ithink will help drive care a
little bit better.
But it's also beyond that.
There's also the next principle,which is really understanding
what matters to patients andtrying to elicit the values and
preferences right from thebeginning, and then
(15:48):
longitudinally, as well as theircaregivers, because in older
adults with cancer, roughly 70%of them have caregivers present
with them.
So understanding the dynamicsput in patients and caregivers,
as well as the social context,and then try to elicit
preferences in the context ofthat really will help drive
personalized medicine for anolder adult with cancer.
(16:11):
And then finally, now,understanding what their health
is through geriatric assessment,what their values and
preferences are, really try tooptimize care through first
recommending the right treatmentfor the cancer, but also the
right supportive care andbehavior interventions.
Again, make life a little lesslousier as they go through
(16:32):
cancer treatment becauseoftentimes we're causing a lot
of side effects and we know alot of the non-drug
interventions can help improve alot of this experience, like
fatigue or decrease in physicalfunction.
Again, just to come back to thethree principles, doing a
thorough evaluation, dogeriatric assessment, try to
elicit their values andpreferences, and then with that,
(16:54):
try to optimize care throughsupportive care and behavioral
program in the context of theircancer care.
SPEAKER_01 (17:01):
That's great, Melissa.
Thank you.
Rashida, same question, keyprinciples relevant to your
specialty, as well as the careof older adults in general.
SPEAKER_00 (17:12):
Absolutely.
And my goodness, Nirana andMelissa really, really hit
everything I was thinking aboutas well.
So I'll co-sign a few things.
One of the first things Ithought about was how critical
it is to have a patient-centeredfocus to care planning.
(17:33):
And then, Radha, you mentionedthat.
And the key example really comesthrough in talking to trainees
about shared decision-makingwith respect to kidney failure,
treatment options, and leaningin that direction more so than
telling someone, hey, it's timeto start dialysis.
Instead, really, this is likethe perfect arena to take stock
(17:56):
of the entire patient and have ashared decision-making
conversation so that theirchoice, what happens next, is
really aligned with theirpreferences.
Another thing I heard come upwas the lack of evidence, but
then more so is that becausethere's no evidence, then there
are limited guidelines.
(18:17):
And so one of the principlesrelated to multiple chronic
conditions is to be able to walkthat fine line when the patient
in front of you maybe doesn'tfit what the guideline is
saying.
And that happens quite often forolder adults with kidney
disease, in particular, whetherit's around surgical decisions
(18:40):
or maybe even chemotherapy.
even more preventative serviceslike cancer, breast cancer, or
colon cancer screenings, likemany of the things that seem
very straightforward for anolder adult with very few
chronic conditions or just oneis not as clear cut because now
(19:01):
if you have multiple chronicconditions, including kidney
disease or dialysis, now we'rethinking about life expectancy,
patient preferences, and reallytrying to find ways what works
best for this patient.
And oftentimes we really shouldget their opinion on that.
And so that's one other area Ilike to emphasize with trainees.
(19:23):
I think from the conversation,listening to Narada and Melissa,
one thought that came to mind isthinking about the healthcare
system in general and how ourpatients fit into it, especially
when it's an older adult who isreceiving hemodialysis.
They have a medical record intheir hemodialysis clinic, but
(19:46):
they also may have a medicalrecord at their primary care
clinic and how many otherdoctors they have, right?
And if they're not allconnected, the fragmented care
is often a real challenge formanaging these patients and
really puts them at risk formedication mistakes, as well as
delays in care.
(20:07):
And so I think is very relatedto multiple chronic conditions
because it's not just thesepatients.
And so the awareness aroundbeing more vigilant and trying
to find different ways to, to,work the system when needed to
make sure that the care ispropagated appropriately.
And I think even an addedcomponent would be the person
(20:30):
who's discharged to a skillednursing facility and how the
medication reconciliation maychange in those settings also.
Because especially forindividuals with kidney disease
and of older age, we really areat risk of many mistakes from
medication dosing andmedication-related problems that
(20:50):
could be avoided.
SPEAKER_01 (20:52):
Thank you.
All of you think in a veryprogressive way about this topic
of multiple chronic conditions.
I guess I want to ask you now,what are the opportunities for
getting your colleagues to havethe same sort of mindset that
all of you have?
What are the opportunities andalso what are the challenges?
(21:13):
And I guess I'd like to ask allthree of you to respond and say
something about that.
So nobody in particular.
Any of you have thoughts aboutthat?
SPEAKER_03 (21:23):
I think there are many, many challenges.
Some of them are easier.
Some of them are very difficult.
So I'll start.
I think the initial challengewas that there was not a lot of
evidence that doing geriatricassessment, for example, for
older adults with chronicconditions and cancer actually
(21:45):
improve outcome.
As I say, in the world ofcancer, no randomized trial, no
evidence, you can't reallyimplement it.
That was the big push from thecommunity to create and develop
randomized trial to prove thatit works.
And we finally had that, Ithink, in the past five years.
And since then, the major cancerorganizations have put out
(22:07):
guidelines.
So the evidence is there.
Now, does it help?
Maybe, maybe not, because reallythe time and the reimbursement
are still the biggest problem.
And oncologists only have 10, 15minutes per patient.
How is it possible for them todo it?
Having said that, there are manypeople who have proven that you
(22:30):
can do it outside of the clinicvisit.
It's part of lacking awareness.
And also there are just somepeople who don't believe in it
and just wouldn't do it.
So it's just continual effortsat multiple levels, including
patient advocates and patientsthemselves to push for this to
happen.
So partnering with patients iswhat I think the community is
(22:53):
trying to do more as well asinfluencing reimbursement and
also policy levels.
I think ultimately to changebehavior, you have to reimburse
people for their time.
Otherwise, people just wouldn'tdo it.
So recently there isreimbursement for eliciting, for
example, patient preferences,right?
(23:13):
Is there a way to try and dothat through geriatric
assessment?
That I think will probablychange practice to a larger
extent.
because now you get the pressurefrom the healthcare systems,
which is often what's needed tomove things forward in the
larger extent.
So that's my two cents.
SPEAKER_02 (23:32):
I would say for the challenges, again, just want to
emphasize already what Melissasaid, and actually Rashida
started covering also, is thefragmentation, right, of the
healthcare system is what youwere alluding to earlier,
Rashida.
And we have the subspecialtiesare siloed, right?
So a person with multiplechronic condition, for example,
(23:52):
might get ex-opinion from thecardiologist.
Pulmonologists will say, this isnot related to your, you know,
this drug.
Let's put you on another drugfor your respiratory issue.
And then they come to thearthritis doctors and now they
are like, oh, my ankles areswollen.
I wonder why.
And, you know, maybe I needsomething for my arthritis.
So I think really fragmentationof care, the subspecialties not
(24:15):
talking to each other.
And again, why?
Probably because doing all thatbehind the scene communication
is never rewarded and nevertaken into account.
an RVU-based system, right?
Like XRVUs is what you need andthis is your target.
You have to meet this.
And some of the care slides downthe hill, unfortunately.
So again, these are Maybe loftysteps are needed to overcome
(24:38):
these challenges, really,because these have been embedded
in the healthcare system for along time.
But hopefully, moving the needleone day at a time will make a
difference.
But first of all, evenrecognizing that this is what
the barriers are might be a goodstart, I might say.
These are all the system level,but then also cognitively, the
(24:58):
cognitive challenges, right?
Like for me to even get a buy-infrom some of my colleagues in
rheumatology, let alone thementees or fellows or trainees
is like, why should I care abouttheir frailty status?
Why should I care about theirfunctional status?
I am going to just focus on howmany tender joints they have,
how many swollen joints theyhave and move on because I only
(25:20):
have 10 minutes per patient, asyou were saying, or 20 minutes
per patient.
So sometimes just understandingthe question to us as
rheumatologists is not how tocontrol their RA, but maybe how
to support this person livingwith RA, depression, cancer, and
I'm sure the list will keepgoing on.
So those were like cognitivechallenges, system-wide
(25:40):
challenges.
And I do want to say somethingabout maybe also on the brighter
side of things of theopportunities in front of us.
And I think for me as arheumatologist, one big
opportunity I see is most of mydiseases are multisystem So
it's, we've always had adialogue somehow, either via
text or via epic chat or someother way to my cardiologist,
(26:03):
geriatric colleague, you know,primary care doctors, because
our diseases span systems andnot just limited to the joints.
This is a great opportunity forme as a rheumatologist to maybe
spread the MCC principles on awider level and not just even
within rheumatology.
So there's some momentum alreadyI see at our American College of
(26:25):
Rheumatology meeting, forexample.
A few of us are trying again andagain to increase attention to
our aging population and evennow value-based cares being
offered in terms of attentiongiven to that, I think should
help and be great opportunitiesfor for us to continue to avail
in the future.
I'm
SPEAKER_00 (26:46):
going to chime in.
You guys are so brilliant intoso many ideas rolling that gets
my mind turning too.
I'll speak more aboutopportunities, but briefly, I
think the challenges really doresonate for the silver
nephrology too.
It's like everything you guysmentioned reminded me of the
outcomes from a qualitativepaper I did around what are the
(27:09):
factors that would impact theprescribing medications in a
dialysis clinic.
And so the clinicians whoparticipated were like, we don't
have time to talk about allthese medications.
We have competing prioritieswith focusing on just their
dialysis.
You know, we're not being paidto do all these other things
(27:29):
just to do the dialysisprescription, right?
But then not only that, like, Idon't even know how to be
prescribed.
How would I titrate downgabapentin, right?
All the self-efficacy competingpriorities the incentives
because oftentimes there's someregulatory issues behind the
scenes or different things thatneed to be accomplished that
(27:50):
create higher priority thanthis.
But then that leads to perhapsan opportunity because I think
there's room for new qualitymeasures in general.
And I have the honor of being onAmerican Society of Nephrology's
Quality Committee.
We were just talking yesterday,we were reviewing the Medicare
Advantage star ratings andlooking at different ways that
(28:13):
they are evaluating care.
Like for example, there's ametric on medication adherence
for high blood pressure thatthere should be a certain
proportion of people on MedicareAdvantage who receive a RAS
antagonist, like an ACEinhibitor or ARB.
Interestingly, that metricexcludes people on dialysis.
(28:36):
And we're digging into, we'renot sure why, maybe because they
have other chronic conditions,maybe because they're frail.
But, you know, it seems to methat there's an opportunity for
specific quality measures to becreated that fit this The
multiple chronic conditionpatient who, while we may not
have guidelines, I do think thatwhat we're talking about here
(28:59):
today with these frameworksreally could be boiled into
specific metrics that could beaccessible one day.
So that's my new idea, new shinyidea.
But otherwise, more low-hangingfruit would be sharing this
curriculum because I'm realizingthat, you know, while we say
it's so great for early stageinvestigators, that also many
(29:22):
senior nephrologists could alsobenefit from it, as well as our
advanced practice providers,anyone who works with patients
with kidney disease.
I think it would be eye-openingfor them, too.
SPEAKER_01 (29:33):
Well, I agree.
And I just want to thank all ofyou for a fantastic discussion.
All of you are great, great rolemodels.
And I look forward to hearingabout your successes over the
rest of your careers.
And thank you so much fortalking with me today.
SPEAKER_02 (29:51):
Thank you for having us.
So much.
Thank you for this opportunity.
Thank you.
Welcome, my name is Jerry Gerwitz and I am a
geriatrician at UMass ChanMedical School in Worcester,
Massachusetts.
And I am extremely pleased to bemoderating this podcast as part
of our AGS Aging LearningCollaborative Curriculum.
The AGS Aging LearningCollaborative Curriculum is a
(00:22):
comprehensive curriculumspecifically designed for early
stage investigators interestedin incorporating the science of
multiple chronic conditions orMCCs into their research.
The curriculum is a jointendeavor of the American
Geriatric Society and the AgingInitiative and is funded by the
(00:43):
National Institute on Aging.
And as an aside, if you areapplying for an NIH career
award, this curriculum is a mustto incorporate into the training
section of your application.
I am truly excited to bespeaking with three authors of
new topic additions to ourBasics of MCCs module.
(01:08):
The three topics are multiplechronic conditions in geriatric
nephrology, multiple chronicconditions in rheumatic
diseases, and multiple chronicconditions in geriatric
oncology.
So welcome, Dr.
Rashida Hall, Dr.
Nimrata Singh, and Dr.
Melissa Lowe.
Thank you, thank you very muchfor speaking with me today.
(01:32):
I'd like to begin by asking eachof you to say a few words about
yourself, a bit about how youchose your specialty, and also
about your personal epiphany, ifthere was one, that led you to
recognize the importance ofmultiple chronic conditions in
(01:53):
caring for your patients, inyour research, and in your
teaching.
So let me begin by askingRashida.
SPEAKER_00 (02:01):
Thank you, Jerry, for inviting us to be a part of
the series.
So myself, my name is RashidaHall, and I am an associate
professor in the Division ofNephrology at Duke University
School of Medicine.
And my clinical research nichehas been in geriatric nephrology
since my fellowship training.
And I point it out because Ibelieve that's when the epiphany
(02:23):
actually started when I was anephrology fellow.
There are definitely severaloccurrences of patients who I
encountered where their kidneyfunction recovery was really
poor.
And often it was related to theother chronic conditions they
were experiencing or theirfailure of those conditions,
(02:43):
like if they were in anintensive care unit.
So it's really clear to me thatfor many patients with kidney
disease, having other chronicconditions actually played a
huge role in what would happenwith their kidneys.
And in fact, as part of aninitial training is remembering
and being cognizant thatdiabetes and hypertension, as
common as they are, are chronicconditions that do contribute to
(03:07):
the onset and the worsening ofkidney disease.
And now as an attending at theDurham VA, I lead a geriatric
nephrology clinic.
Now I get to embrace thecomplexity.
When patients have multiplechronic conditions, I consider
that part of thinking throughthe care plan.
So like when it's a conversationabout their kidney failure
(03:31):
options, dialysis, transplant,or conservative kidney
management, the other conditionsare relevant to the
conversation.
because perhaps someone's lifeexpectancy or their preferences
would differ based on thepresence of those conditions.
And not only that, when it comesto having chronic kidney disease
(03:52):
and maintaining stable kidneyfunction, it's important that
patients are able to managetheir condition on their own.
Sometimes having other chronicconditions can make it harder to
do the self-management, whetherit's like dementia.
So maybe now we have to engagesomeone else to help them
maintain medication adherence,or maybe there are certain
(04:16):
medications for other conditionslike heart failure or arthritis
that then make managing theirkidney disease a little bit
harder.
So those are my thoughts aroundthe importance of chronic
conditions clinically, As aresearcher, I spend my research
focus on doing research thatwill lead to better outcomes for
(04:37):
older adults with kidneydisease.
It's hard to disentanglemultiple chronic conditions from
end-stage kidney disease when itcomes to whatever events that
may occur and how likely it isfrom these conditions or kidney
disease.
But still, I think it's reallyrelevant because we know there's
enough data out there that wouldsuggest that having, you know,
(05:00):
this accumulation of chronicconditions does make some
patients more vulnerable.
And so ways that we can identifythose patients in a way that
might kind of give them adifferent kind of care pathway
from someone else who only haskidney disease does help with
improving outcomes for patients.
SPEAKER_01 (05:19):
Thank you, Rashida.
Nimrata, can you say a few wordsabout yourself and how you got
to where you are?
SPEAKER_02 (05:25):
Yes, definitely.
But first of all, I want to say,just like Rashida said, thank
you so much for including me inthis effort.
Really appreciate it.
I am Namrata Singh.
I'm an adult rheumatologist atthe University of Washington.
First of all, what led me tobecoming a rheumatologist, I
would say, is really got drawnto the management of complex
(05:48):
patients, diagnostic reasoningit entails, and really the
long-term relationship we buildwith our patients as they
navigate chronic illnesses.
And then over time, you know, itdidn't take too long to realize
that it was impossible to ignorethat most of my patients are not
just managing rheumatoidarthritis or lupus, etc.
(06:09):
They are really living withother things like they also are
navigating heart disease,perhaps depression.
Some of my patients are dealingwith cancer at the same time.
Turning point, I would say theepiphany really came when I
realized that so-called goldstandard guidelines of which
I've been part of, like forrheumatoid arthritis, for
(06:29):
example, they really oftenoverlook the realities of older
adults, especially with aging,polypharmacy, and focusing on a
single disease isn't just enoughis really what led me to be
gravitating towards multiplechronic conditions and the whole
field around it.
And keeping in mind that we needto treat the whole person and
(06:51):
not just one individual.
of their medical problem list.
And then this really also guideshow I do my research.
So for example, my researchfocuses on the treatment
outcomes specifically related tocancer and cardiovascular
disease risk in adults withautoimmune rheumatic diseases.
And it further shapes how Imentor in my teaching.
(07:14):
So for example, more and moreI've found myself telling my
mentees that let's maybe ask thepatient, not just what is the
right medication, but maybeperhaps what matters most to
you.
And keep in mind, how do all theconditions that they have
intersect?
And maybe what might be drug Aas a right choice for somebody
(07:36):
with isolated rheumatoidarthritis, perhaps is our drug
number 10 of choice when we aremanaging somebody with
rheumatoid arthritis, cancer,heart disease, et cetera.
So I think overall, gravitatingtowards multiple chronic
conditions research hasdefinitely guided my practice
and how I teach.
SPEAKER_01 (07:55):
Thanks, Namrata, and that's really fascinating.
Melissa?
SPEAKER_03 (07:59):
Well, like Rashida and Namrata, thank you for
having me here.
I'm Melissa Lo.
I am an associate professor andgeriatric oncologist at the
University of Rochester.
I'm trained in both hematology,oncology, and geriatrics, and my
research focuses focuses onoptimizing care of older adults
with blood cancers by doingclinical trials, not therapeutic
(08:22):
trials, but clinical trialsfocusing on behavior and
supportive care trials, such asexercise study or programs that
help elicit patient preferences.
So how that interest came aboutwas I have a longstanding
interest in cancer, bothclinically and research, since
medical school.
And talking to patients withcancer always gives me a great
(08:43):
sense of satisfaction because Ifelt that I'm able to actually
make a difference in makingtheir life a little less lousy.
But the epiphany was that as Itook care of these patients,
like many others, I realizedthat most of them are older.
What I also realized that manyof them have multiple chronic
conditions and their care areoften more complex and really
not straightforward.
(09:03):
And honestly, emotionally, itwas very difficult for me to
take care of them, probablybecause I was not comfortable.
And because I know I was notcomfortable, I really felt the
need to learn geriatrics so Ihave a better understanding of
how best to care for them,cancer and multiple chronic
conditions.
And then as I got deeper, I wasjust really interested in
geriatric oncology because thatmade me a better doctor.
(09:25):
Again, the more I learned, themore I realized there's no clear
answer.
And one of the main reasons isthat we don't really study this
population enough.
So in cancer, our treatmentdecision is often guided by
randomized clinical trials.
And we love randomized clinicaltrials.
It's all worth a place incancer.
But for many reasons, all olderadults are not represented in
(09:46):
randomized clinical trials ofcancer.
So in other words, in clinicalpractice, it's a little bit of
a, it's not a little bit, it'sactually a lot of guesswork in
terms of recommendations.
So whether or not the treatmentwork, but more importantly, like
we actually don't know how muchharm we're going to cause.
So with that gap, I really feellike the need to research and
study older adults with cancer,the gap was really in blood
(10:09):
cancer that I found more so thansolid tumor.
And that sort of led to myinterest in geriatric oncology,
specifically in hematology.
SPEAKER_01 (10:17):
Really interesting.
Let me switch gears a littlebit.
Are there any key principlesthat you have found over the
course of your careers that youthink should be emphasized to
trainees or that serve asunderpinnings of your research
ideas related to multiplechronic conditions in older
(10:39):
adults?
Let me start with Nimrata.
SPEAKER_02 (10:42):
Yes, that's a wonderful question.
(11:12):
So for example, you know,managing rheumatoid arthritis in
someone with diabetes, coronarydisease or depression doesn't
just mean that we give them onepill today, they come four
months later, we give themanother pill and just keep
adding pills if they're notfeeling better.
It's about what matters most tothem.
And understanding if maybe thefact that they're not responding
(11:34):
is, do they have the financialmeans to take them or, you know,
support at home.
So really caring about theperson per se, rather than just
saying, oh, I'm going to takethis pill.
X amount of joints are swollentoday.
We need to keep adding drugs isone principle, I would say.
And tied towards that is theother one is about minimizing
harm through thoughtfulprescribing.
(11:54):
I've been at the AmericanGeriatric Society meetings, et
cetera.
I've learned that polypharmacysometimes is inevitable in our
patients, but at leastthoughtful prescribing should
not be a difficult decision tomake in the clinic.
So I try to emphasizedeprescribing when possible,
looking out for drug-druginteractions, and especially
(12:16):
shared decision-making when itcomes to immunosuppressing some
of our complex patients.
And at the same time, maybe thethird principle you can say is a
cumulative risk awareness.
So It's not that sometimes wethink one and one will make two.
Multiple chronic conditions arenot just additive.
They're multiplicative in someways.
(12:37):
And similarly, that's why thisis driving the research I do.
And just as Melissa wasoutlining, the care for patients
with multiple chronicconditions, be they be older
adults or in general, justmultiple chronic conditions,
they are just so paucity of datain terms of What trial data can
I extrapolate to a patient rightin front of me in the clinic?
(12:59):
They never fit a mold that thetreatment guidelines present to
us.
And so keeping in mind thatpatients sometimes with multiple
chronic conditions are not theperson that a guidelines X
recommendation, Y recommendationmight fit.
And then last but not least, tokeep in mind that I think about
is dynamic and longitudinalcare.
(13:20):
Just like, you know, perhapstrue also for Rashida and
Melissa, my patients usuallytend to live, you know, with
their disease.
It's not like maybe infection orflu-like illness that will get
better over time and that'll bethe end of it.
So managing multiple chronicconditions requires ongoing
reassessment.
For example, what might work forsomebody at 60 may be very
(13:41):
burdensome or harmful even bythe age of 80 years old.
So keeping in mind and valuingbeing flexible and reassessing a
person's Thank you.
Melissa, some key principlesthat you think about that our
(14:08):
listeners
SPEAKER_01 (14:18):
should know.
SPEAKER_03 (14:20):
Thank you for that question.
I agree with everything thatNamrata said.
I think the principles inoncology are and should be very
similar to geriatrics.
And honestly, across thedifferent specialties, I don't
see it being different betweenan older adult with cancer and
an older adult with chronickidney disease and an older
adult with rheumatoid arthritis,for example, or without any
(14:41):
chronic illnesses or multiplechronic conditions.
Having said that, I would justemphasize on three principles,
just making it more concrete.
So in the world of geriatriconcology, we have been pushing
to do what we call acomprehensive geriatric
assessment, basically anevaluation of the overall health
of an older adult, which givesyou a better understanding of
(15:04):
one with multiple chroniccondition.
So in cancer, precision medicineis such a hot topic where we're
always pushing to try andunderstand the cancer more.
But we're not so good at tryingto understand the health of an
older adult, which is ironic.
Through geriatric assessment,that is what we think the best
way of understanding the healthof an older adult and then
(15:26):
combining them with the cancerin terms of better understanding
of the tumor biology together, Ithink will help drive care a
little bit better.
But it's also beyond that.
There's also the next principle,which is really understanding
what matters to patients andtrying to elicit the values and
preferences right from thebeginning, and then
(15:48):
longitudinally, as well as theircaregivers, because in older
adults with cancer, roughly 70%of them have caregivers present
with them.
So understanding the dynamicsput in patients and caregivers,
as well as the social context,and then try to elicit
preferences in the context ofthat really will help drive
personalized medicine for anolder adult with cancer.
(16:11):
And then finally, now,understanding what their health
is through geriatric assessment,what their values and
preferences are, really try tooptimize care through first
recommending the right treatmentfor the cancer, but also the
right supportive care andbehavior interventions.
Again, make life a little lesslousier as they go through
(16:32):
cancer treatment becauseoftentimes we're causing a lot
of side effects and we know alot of the non-drug
interventions can help improve alot of this experience, like
fatigue or decrease in physicalfunction.
Again, just to come back to thethree principles, doing a
thorough evaluation, dogeriatric assessment, try to
elicit their values andpreferences, and then with that,
(16:54):
try to optimize care throughsupportive care and behavioral
program in the context of theircancer care.
SPEAKER_01 (17:01):
That's great, Melissa.
Thank you.
Rashida, same question, keyprinciples relevant to your
specialty, as well as the careof older adults in general.
SPEAKER_00 (17:12):
Absolutely.
And my goodness, Nirana andMelissa really, really hit
everything I was thinking aboutas well.
So I'll co-sign a few things.
One of the first things Ithought about was how critical
it is to have a patient-centeredfocus to care planning.
(17:33):
And then, Radha, you mentionedthat.
And the key example really comesthrough in talking to trainees
about shared decision-makingwith respect to kidney failure,
treatment options, and leaningin that direction more so than
telling someone, hey, it's timeto start dialysis.
Instead, really, this is likethe perfect arena to take stock
(17:56):
of the entire patient and have ashared decision-making
conversation so that theirchoice, what happens next, is
really aligned with theirpreferences.
Another thing I heard come upwas the lack of evidence, but
then more so is that becausethere's no evidence, then there
are limited guidelines.
(18:17):
And so one of the principlesrelated to multiple chronic
conditions is to be able to walkthat fine line when the patient
in front of you maybe doesn'tfit what the guideline is
saying.
And that happens quite often forolder adults with kidney
disease, in particular, whetherit's around surgical decisions
(18:40):
or maybe even chemotherapy.
even more preventative serviceslike cancer, breast cancer, or
colon cancer screenings, likemany of the things that seem
very straightforward for anolder adult with very few
chronic conditions or just oneis not as clear cut because now
(19:01):
if you have multiple chronicconditions, including kidney
disease or dialysis, now we'rethinking about life expectancy,
patient preferences, and reallytrying to find ways what works
best for this patient.
And oftentimes we really shouldget their opinion on that.
And so that's one other area Ilike to emphasize with trainees.
(19:23):
I think from the conversation,listening to Narada and Melissa,
one thought that came to mind isthinking about the healthcare
system in general and how ourpatients fit into it, especially
when it's an older adult who isreceiving hemodialysis.
They have a medical record intheir hemodialysis clinic, but
(19:46):
they also may have a medicalrecord at their primary care
clinic and how many otherdoctors they have, right?
And if they're not allconnected, the fragmented care
is often a real challenge formanaging these patients and
really puts them at risk formedication mistakes, as well as
delays in care.
(20:07):
And so I think is very relatedto multiple chronic conditions
because it's not just thesepatients.
And so the awareness aroundbeing more vigilant and trying
to find different ways to, to,work the system when needed to
make sure that the care ispropagated appropriately.
And I think even an addedcomponent would be the person
(20:30):
who's discharged to a skillednursing facility and how the
medication reconciliation maychange in those settings also.
Because especially forindividuals with kidney disease
and of older age, we really areat risk of many mistakes from
medication dosing andmedication-related problems that
(20:50):
could be avoided.
SPEAKER_01 (20:52):
Thank you.
All of you think in a veryprogressive way about this topic
of multiple chronic conditions.
I guess I want to ask you now,what are the opportunities for
getting your colleagues to havethe same sort of mindset that
all of you have?
What are the opportunities andalso what are the challenges?
(21:13):
And I guess I'd like to ask allthree of you to respond and say
something about that.
So nobody in particular.
Any of you have thoughts aboutthat?
SPEAKER_03 (21:23):
I think there are many, many challenges.
Some of them are easier.
Some of them are very difficult.
So I'll start.
I think the initial challengewas that there was not a lot of
evidence that doing geriatricassessment, for example, for
older adults with chronicconditions and cancer actually
(21:45):
improve outcome.
As I say, in the world ofcancer, no randomized trial, no
evidence, you can't reallyimplement it.
That was the big push from thecommunity to create and develop
randomized trial to prove thatit works.
And we finally had that, Ithink, in the past five years.
And since then, the major cancerorganizations have put out
(22:07):
guidelines.
So the evidence is there.
Now, does it help?
Maybe, maybe not, because reallythe time and the reimbursement
are still the biggest problem.
And oncologists only have 10, 15minutes per patient.
How is it possible for them todo it?
Having said that, there are manypeople who have proven that you
(22:30):
can do it outside of the clinicvisit.
It's part of lacking awareness.
And also there are just somepeople who don't believe in it
and just wouldn't do it.
So it's just continual effortsat multiple levels, including
patient advocates and patientsthemselves to push for this to
happen.
So partnering with patients iswhat I think the community is
(22:53):
trying to do more as well asinfluencing reimbursement and
also policy levels.
I think ultimately to changebehavior, you have to reimburse
people for their time.
Otherwise, people just wouldn'tdo it.
So recently there isreimbursement for eliciting, for
example, patient preferences,right?
(23:13):
Is there a way to try and dothat through geriatric
assessment?
That I think will probablychange practice to a larger
extent.
because now you get the pressurefrom the healthcare systems,
which is often what's needed tomove things forward in the
larger extent.
So that's my two cents.
SPEAKER_02 (23:32):
I would say for the challenges, again, just want to
emphasize already what Melissasaid, and actually Rashida
started covering also, is thefragmentation, right, of the
healthcare system is what youwere alluding to earlier,
Rashida.
And we have the subspecialtiesare siloed, right?
So a person with multiplechronic condition, for example,
(23:52):
might get ex-opinion from thecardiologist.
Pulmonologists will say, this isnot related to your, you know,
this drug.
Let's put you on another drugfor your respiratory issue.
And then they come to thearthritis doctors and now they
are like, oh, my ankles areswollen.
I wonder why.
And, you know, maybe I needsomething for my arthritis.
So I think really fragmentationof care, the subspecialties not
(24:15):
talking to each other.
And again, why?
Probably because doing all thatbehind the scene communication
is never rewarded and nevertaken into account.
an RVU-based system, right?
Like XRVUs is what you need andthis is your target.
You have to meet this.
And some of the care slides downthe hill, unfortunately.
So again, these are Maybe loftysteps are needed to overcome
(24:38):
these challenges, really,because these have been embedded
in the healthcare system for along time.
But hopefully, moving the needleone day at a time will make a
difference.
But first of all, evenrecognizing that this is what
the barriers are might be a goodstart, I might say.
These are all the system level,but then also cognitively, the
(24:58):
cognitive challenges, right?
Like for me to even get a buy-infrom some of my colleagues in
rheumatology, let alone thementees or fellows or trainees
is like, why should I care abouttheir frailty status?
Why should I care about theirfunctional status?
I am going to just focus on howmany tender joints they have,
how many swollen joints theyhave and move on because I only
(25:20):
have 10 minutes per patient, asyou were saying, or 20 minutes
per patient.
So sometimes just understandingthe question to us as
rheumatologists is not how tocontrol their RA, but maybe how
to support this person livingwith RA, depression, cancer, and
I'm sure the list will keepgoing on.
So those were like cognitivechallenges, system-wide
(25:40):
challenges.
And I do want to say somethingabout maybe also on the brighter
side of things of theopportunities in front of us.
And I think for me as arheumatologist, one big
opportunity I see is most of mydiseases are multisystem So
it's, we've always had adialogue somehow, either via
text or via epic chat or someother way to my cardiologist,
(26:03):
geriatric colleague, you know,primary care doctors, because
our diseases span systems andnot just limited to the joints.
This is a great opportunity forme as a rheumatologist to maybe
spread the MCC principles on awider level and not just even
within rheumatology.
So there's some momentum alreadyI see at our American College of
(26:25):
Rheumatology meeting, forexample.
A few of us are trying again andagain to increase attention to
our aging population and evennow value-based cares being
offered in terms of attentiongiven to that, I think should
help and be great opportunitiesfor for us to continue to avail
in the future.
I'm
SPEAKER_00 (26:46):
going to chime in.
You guys are so brilliant intoso many ideas rolling that gets
my mind turning too.
I'll speak more aboutopportunities, but briefly, I
think the challenges really doresonate for the silver
nephrology too.
It's like everything you guysmentioned reminded me of the
outcomes from a qualitativepaper I did around what are the
(27:09):
factors that would impact theprescribing medications in a
dialysis clinic.
And so the clinicians whoparticipated were like, we don't
have time to talk about allthese medications.
We have competing prioritieswith focusing on just their
dialysis.
You know, we're not being paidto do all these other things
(27:29):
just to do the dialysisprescription, right?
But then not only that, like, Idon't even know how to be
prescribed.
How would I titrate downgabapentin, right?
All the self-efficacy competingpriorities the incentives
because oftentimes there's someregulatory issues behind the
scenes or different things thatneed to be accomplished that
(27:50):
create higher priority thanthis.
But then that leads to perhapsan opportunity because I think
there's room for new qualitymeasures in general.
And I have the honor of being onAmerican Society of Nephrology's
Quality Committee.
We were just talking yesterday,we were reviewing the Medicare
Advantage star ratings andlooking at different ways that
(28:13):
they are evaluating care.
Like for example, there's ametric on medication adherence
for high blood pressure thatthere should be a certain
proportion of people on MedicareAdvantage who receive a RAS
antagonist, like an ACEinhibitor or ARB.
Interestingly, that metricexcludes people on dialysis.
(28:36):
And we're digging into, we'renot sure why, maybe because they
have other chronic conditions,maybe because they're frail.
But, you know, it seems to methat there's an opportunity for
specific quality measures to becreated that fit this The
multiple chronic conditionpatient who, while we may not
have guidelines, I do think thatwhat we're talking about here
(28:59):
today with these frameworksreally could be boiled into
specific metrics that could beaccessible one day.
So that's my new idea, new shinyidea.
But otherwise, more low-hangingfruit would be sharing this
curriculum because I'm realizingthat, you know, while we say
it's so great for early stageinvestigators, that also many
(29:22):
senior nephrologists could alsobenefit from it, as well as our
advanced practice providers,anyone who works with patients
with kidney disease.
I think it would be eye-openingfor them, too.
SPEAKER_01 (29:33):
Well, I agree.
And I just want to thank all ofyou for a fantastic discussion.
All of you are great, great rolemodels.
And I look forward to hearingabout your successes over the
rest of your careers.
And thank you so much fortalking with me today.
SPEAKER_02 (29:51):
Thank you for having us.
So much.
Thank you for this opportunity.
Thank you.
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