As Betty Ferrell says on our podcast today, nurses play an essential role in care of people with serious illness. Who spends the most time with the patient in the infusion center? Doing home care? Hospice visits? In the ICU at the bedside? Nurses.

ELNEC (End-of-Life Nursing Education Consortium) celebrates it’s 25th anniversary in 2025. We talk today with Betty Ferrell, who has been a nurse for 47 years, and is the founder and PI of ELNEC.

As I argue on the podcast, ELNEC has likely done more to lift the primary palliative care skills of clinicians than any other initiative. Full stop. Some numbers to back it up:

1. ELNEC has trained more than 48,000 providers in a train the trainer model

2. Over 1.5 million clinicians have been educated in ELNEC

3. ELNEC curricula are integrated int 1180 undergraduate and 394 graduate Schools of Nursing

4. ELNEC has been taught in over 100 countries

Today we talk about the origin story of ELNEC, the special role of nurses in palliative care, empowering as well as educating nurses, interprofessional ELNEC training, and opportunities and challenges ELNEC faces over the next 25 years.

Enjoy!

-@AlexSmithMD

Eric asks the question that is on many of our minds - is the future of AI more Skynet from Terminator, in which AI takes over the world and drives humanity to the brink of extinction, or Wall-E, in which a benevolent and empathetic AI restores our humanity?

Our guest today is Bob Wachter, Chair of Medicine at UCSF and author of the Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. Bob recently wrote an essay in JAMA on AI and delivered a UCSF Grand Rounds on the same topic. We discuss, among other things:

• Findings that in several studies AI was rated by patients as more empathetic than human clinicians (not less, that isn’t a typo). Turns my concern about lack of empathy from AI on its head - the AI may be more empathetic than clinicians, not less.

• Skepticism on the ability of predictive models to transform healthcare

• Consolidation of EHR’s into the hands of a very few companies, and potential for the drug and device industry to influence care delivery by tweaking AI in ways that are not transparent and already a sort of magical black box.

• AI may de-skill clinicians in the same way that autopilot deskilled pilots, who no longer new how to fly the plane without autopilot

• A live demonstration of AI breaking a cancer diagnosis to a young adult with kids (VITAL Talk watch out)

• Use cases in healthcare: Bob predicts everyone will use digital scribes to chart within two years

• Concerns about bias and other anticipated and unanticipated issues

And a real treat- Bob plays the song for this one! Terrific rendition of Tomorrow from the musical Annie on piano (a strong hint there about Bob’s answer to Eric’s first question). Enjoy!

-@AlexSmithMD

Ambivalence is a tough concept when it comes to decision-making. On the one hand, when people have ambivalence but haven't explored why they are ambivalent, they are prone to bad, value-incongruent decisions. On the other hand, acknowledging and exploring ambivalence may lead to better, more ethical, and less biased decisions.

On today's podcast, Joshua Briscoe, Bryanna Moore, Jennifer Blumenthal-Barby, and Olubukunola Dwyer discuss the challenges of ambivalence and ways to address them. This podcast was initially sparked by Josh’s “Note From a Family Meeting” Substack post titled “Ambivalence in Clinical Decision-Making,” which discussed Bryanna’s and Jenny’s 2022 article titled “Two Minds, One Patient: Clearing up Confusion About Ambivalence."

Bryanna’s and Jenny’s article is particularly unique as it discusses these “ambivalent-related phenomena” and that these different kinds of “ambivalence” may call for different approaches with patients, surrogates (and health care providers):

In addition to defining these “ambivalent related phenomena” we ask our guests to cover some of these topics:

• Is ambivalence good, bad, or just a normal part of decision-making?

• Does being ambivalent mean you don’t care about the decision?

• What should we be more worried about in decision-making, ambivalence or the lack thereof?

• The concern about resolving ambivalence too quickly, as it might rush past important work that needs to be done to make a good decision.

• What about ambivalence on the part of the provider? How should we think about that?

• How do you resolve ambivalence?

Lastly, the one takeaway point from this podcast is that the next time I see ambiguity (or have it myself), I should ask the following question: “I see you are struggling with this decision. Tell me how you are feeling about it.”