Faculty Profiles

Alexander Smith, MD, MPH
MED-GERIATRICS
Associate Professor

(Database place holder)
415-221-4810x4684
aksmith@ucsf.edu

Overview:
Alex Smith is a clinician-researcher who is at the forefront of efforts to integrate Geriatrics and Palliative Care. Dr. Smith received his medical school training in the UC Berkeley/UCSF Joint Medical Program. He completed a primary care internal medicine residency at Brigham and Women's Hospital (BWH) followed by two fellowships, a one-year clinical fellowship in Palliative Medicine at BWH and Dana Farber Cancer Institute, followed by a two-year General Internal Medicine Fellowship at Beth Israel Deaconess Medical Center, including an MPH from the Harvard School of Public Health. Dr. Smith returned to UCSF in July 2008 as faculty in the Division of Geriatrics.


Dr. Smith's research program focuses on improving palliative care for vulnerable and dependent elders. He has strong interests in bioethics and improving patient-physician communication. He is currently funded by a Paul Beeson National Institute on Aging K23 career development award. Dr. Smith works clinically on the Hospice and Palliative Care Service at the SF VAMC. Dr. Smith and Dr. Eric Widera co-founded GeriPal, a Geriatrics and Palliative Care Blog, the leading source for news and commentary related to Geriatrics and Palliative Care on the web. GeriPal received nearly 2.5 million page views between 2009 and 2015. Also working with Dr. Widera and Drs. Sei Lee and Mara Schonberg, Dr. Smith launched ePrognosis, an online set of prognostic calculators for the elderly. ePrognosis had over half a million page views in the first week, and over 1 million between 2012 and 2015.


Research:
Dr. Smith is a general internist dually trained in palliative medicine and health services research, focused on integrating geriatrics and palliative care.


Dr. Smith's research is motivated by a recognition that the overwhelming need for palliative care services occurs in the elderly. Unfortunately, however, older persons are severely underrepresented both in the receipt of palliative care services and in palliative care research. This gap in our understanding exists for a reason: the challenges of studying palliative care needs in frail elders with multiple diagnoses, and frequently with functional and cognitive impairment, are much more complicated than studying these needs in younger patients with cancer. Dr. Smith embraces the challenge of research in this complex area.


While Dr. Smith is broadly interested in issues at the intersection of geriatrics and palliative care, his research has largely been organized around three primary areas: end-of-life experiences, patient-doctor communication, and cultural attitudes toward care. In a series of studies examining a nationally representative group of older adults who died, Dr. Smith demonstrated that: (1) pain due to arthritis is under-recognized in the last years of life; (2) lengths of stay in nursing homes for patients who die are shorter than generally appreciated (median 5 months, average 14 months); and (3) emergency departments and skilled nursing facilities are common sites of care in the last months of life and should be a focus of efforts to improve the quality of palliative care. Dr. Smith has a strong interest in understanding how cultural factors influence the perspectives and experiences of patients with serious illness or disability and their families. For example, in a recent study, Dr. Smith found that two-thirds of Chinese American, African American, Latino, and white elders with disability would want to be told their prognosis if they had less than 5 years left to live. He therefore argues that clinicians should offer to discuss prognosis with their very elderly patients, both because it allows for more informed medical decision making and because many patients want to know so they can prepare for the future.


Clinical:
Dr. Smith's primary clinical work is on the Hospice and Palliative Care service at the SF VAMC. In this capacity, he consults on the management of patients with palliative care needs in the hospital and cares for patients who reside in the hospice facility located within the Community Living Center.

Awards and Honors

2013   Research Mentor of the Year, Medical Students in Aging Research, 2013
2012   Paul Beeson Career Development Award In Geriatrics, American Federation for Aging Research/NIA, 2012-2017
2012   Best Paper of the Year Award, Society of General Internal Medicine, 2012
2012   Top Reviewer, Annals of Internal Medicine, 2012
2010   Greenwall Faculty Scholar in Bioethics, Greenwall Foundation, 2010-2014
2004   Outstanding Resident Mentor Award, Brigham and Women's Hospital, 2004-2005
1996   Phi Beta Kappa, University of Michigan, 1996

Recent Articles (46)

Subjective, Objective, and Observed Long-term Survival: A Longitudinal Cohort Study. JAMA Intern Med. 2015 Dec 1; 175(12):1986-8.

Increase in Disability Prevalence Before Hip Fracture. J Am Geriatr Soc. 2015 Oct; 63(10):2029-35.

Pain in Community-Dwelling Older Adults with Dementia: Results from the National Health and Aging Trends Study. J Am Geriatr Soc. 2015 Aug; 63(8):1503-11.

Tools to Promote Shared Decision Making in Serious Illness: A Systematic Review. JAMA Intern Med. 2015 Jul 1; 175(7):1213-21.

Hearing loss in palliative care. J Palliat Med. 2015 Jun; 18(6):559-62.

Discrimination in Healthcare Settings is Associated with Disability in Older Adults: Health and Retirement Study, 2008-2012. J Gen Intern Med. 2015 Oct; 30(10):1413-20.

Pain behind bars: the epidemiology of pain in older jail inmates in a county jail. J Palliat Med. 2014 Dec; 17(12):1336-43.

Usefulness and effect of online prognostic calculators. J Am Geriatr Soc. 2014 Dec; 62(12):2444-5.

Leveraging the health and retirement study to advance palliative care research. J Palliat Med. 2014 May; 17(5):506-11.

Elder self-neglect--how can a physician help? N Engl J Med. 2013 Dec 26; 369(26):2476-9.

Disability during the last two years of life. JAMA Intern Med. 2013 Sep 9; 173(16):1506-13.

Opening it up for more questions: racial disparities in hospice use. J Pain Symptom Manage. 2013 Nov; 46(5):617.

When previously expressed wishes conflict with best interests. JAMA Intern Med. 2013 Jul 8; 173(13):1241-5.

Uncertainty--the other side of prognosis. N Engl J Med. 2013 Jun 27; 368(26):2448-50.

The diverse landscape of palliative care clinics. J Palliat Med. 2013 Jun; 16(6):661-8.

Palliative care: an approach for all internists: comment on "Early palliative care in advanced lung cancer: a qualitative study". JAMA Intern Med. 2013 Feb 25; 173(4):291-2.

Advance care planning and the quality of end-of-life care in older adults. J Am Geriatr Soc. 2013 Feb; 61(2):209-14.

Every patient is an individual: clinicians balance individual factors when discussing prognosis with diverse frail elderly adults. J Am Geriatr Soc. 2013 Feb; 61(2):264-9.

Perceptions of successful aging among diverse elders with late-life disability. Gerontologist. 2013 Dec; 53(6):939-49.

Use of the Medicare posthospitalization skilled nursing benefit in the last 6 months of life. Arch Intern Med. 2012 Nov 12; 172(20):1573-9.

The problem with actually tattooing DNR across your chest. J Gen Intern Med. 2012 Oct; 27(10):1238-9.

Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Aff (Millwood). 2012 Jun; 31(6):1277-85.

Quality of life in late-life disability: "I don't feel bitter because I am in a wheelchair". J Am Geriatr Soc. 2012 Mar; 60(3):569-76.

Prognostic indices for older adults: a systematic review. JAMA. 2012 Jan 11; 307(2):182-92.

Discussing overall prognosis with the very elderly. N Engl J Med. 2011 Dec 8; 365(23):2149-51.

"Knowing is better": preferences of diverse older adults for discussing prognosis. J Gen Intern Med. 2012 May; 27(5):568-75.

"Her husband doesn't speak much English": conducting a family meeting with an interpreter. J Palliat Med. 2012 Apr; 15(4):494-8.

Conducting high-value secondary dataset analysis: an introductory guide and resources. J Gen Intern Med. 2011 Aug; 26(8):920-9.

The epidemiology of pain during the last 2 years of life. Ann Intern Med. 2010 Nov 2; 153(9):563-9.

African Americans and end-of-life care #204. J Palliat Med. 2010 Nov; 13(11):1382-3.

Length of stay for older adults residing in nursing homes at the end of life. J Am Geriatr Soc. 2010 Sep; 58(9):1701-6.

Update in palliative medicine. Am J Hosp Palliat Care. 2010 Sep; 27(6):420-7.

Emergency department experiences of acutely symptomatic patients with terminal illness and their family caregivers. J Pain Symptom Manage. 2010 Jun; 39(6):972-81.

Outpatient palliative care practices. Arch Intern Med. 2010 Apr 12; 170(7):654-5.

The death of Ivan Ilyich and pain relief at the end of life. Lancet. 2009 Sep 12; 374(9693):872-3.

Crying: experiences and attitudes of third-year medical students and interns. Teach Learn Med. 2009 Jul; 21(3):180-7.

Palliative care for Latino patients and their families: whenever we prayed, she wept. JAMA. 2009 Mar 11; 301(10):1047-57, E1.

Racial and ethnic differences in end-of-life care in fee-for-service Medicare beneficiaries with advanced cancer. J Am Geriatr Soc. 2009 Jan; 57(1):153-8.

Am I doing the right thing? Provider perspectives on improving palliative care in the emergency department. Ann Emerg Med. 2009 Jul; 54(1):86-93, 93.e1.

Racial and ethnic differences in advance care planning among patients with cancer: impact of terminal illness acknowledgment, religiousness, and treatment preferences. J Clin Oncol. 2008 Sep 1; 26(25):4131-7.

Racial/ethnic disparities in liver transplant surgery and hospice use: parallels, differences, and unanswered questions. Am J Hosp Palliat Care. 2008 Aug-Sep; 25(4):285-91.

Differences in the quality of the patient-physician relationship among terminally ill African-American and white patients: impact on advance care planning and treatment preferences. J Gen Intern Med. 2007 Nov; 22(11):1579-82.

On being fired: experiences of patient-initiated termination of the patient-physician relationship in palliative medicine. J Palliat Med. 2007 Aug; 10(4):938-47.

Resident approaches to advance care planning on the day of hospital admission. Arch Intern Med. 2006 Aug 14-28; 166(15):1597-602.

CT and MRI of retroperitoneal edema associated with large uterine leiomyomas. J Comput Assist Tomogr. 2002 May-Jun; 26(3):459-61.

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