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NCIRE-The Veterans Health Research Institute is the leading private nonprofit institute devoted to Veterans health research in the United States. Our mission is to advance Veterans health through research.

We support the work of some of the nation's foremost physicians and scientists at the San Francisco Veterans Affairs Medical Center, the premier biomedical research facility in the VA system. All have faculty appointments at the University of California, San Francisco, which has its own proud traditions of research and patient care. We also partner with the U.S. Department of Defense to support health research on behalf of our men and women in the Armed Forces.

Those who have served in uniform have given their best for their country. In return, we believe that they deserve nothing less than the best health care research we can provide.

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Alexander K. Smith, MD, MS, MPH

Staff Physician, Geriatrics Service, SFVAMC
Associate Professor of Medicine, UCSF

Email: alexander.smith2@va.gov

Improving the Care of Frail Elders from Diverse Communities

Dr. Smith is a general internist dually trained in palliative medicine and health services research, and his primary objective is to become a leading independent investigator at the intersection of geriatrics and palliative care.  Dr. Smith’s primary research focus is on improving the care of frail elders from diverse communities. 

Dr. Smith attended medical school in the UCB/UCSF Joint Medical program.  After training in primary care internal medicine at the Brigham and Women's Hospital (BWH), he completed a one-year fellowship in Palliative Medicine at the BWH, followed by a two-year General Medicine research fellowship at Beth Israel Deaconess Medical Center, including an MPH from the Harvard School of Public Health.

As a fellow, Dr. Smith found himself thinking about the paradox that the overwhelming need for palliative care services occurs in the elderly.  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.

The opportunity to obtain a faculty position in the UCSF Geriatrics Division proved a perfect fit for Dr. Smith’s interests.  In his first two years on faculty Dr. Smith joined UCSF's CTSI/K-Scholars Program and the Center for Aging in Diverse Communities. He has received excellent mentorship from Ken Covinsky, Bernie Lo, Seth Landefeld, Louise Walter, and Eliseo Pérez-Stable.  Dr. Smith co-founded a blog at the start of his second year to provide an open forum for the exchange of ideas between the geriatrics and palliative care communities and to have a "voice" on a national stage (www.GeriPal.org).  Dr. Smith has been fortunate to receive funding for his research, including a Diversity Supplement Award from the NIA, a foundation award from the National Palliative Care Research Center, a career development award from the GreenwallFaculty Scholars program in Bioethics, and a KL2 award administered through the CTSI.  

Dr. Smith’s research program to date has focused on three major areas at the intersection of geriatrics and palliative medicine - end-of-life life experiences of diverse elders, prognosis and prognosis communication in the elderly, and quality of life in late life disability.   First, during Dr. Smith’s fellowship in Palliative Medicine, he was troubled by differences in care between seriously ill minority and non-minority patients. Dr. Smith therefore conducted a number of studies examining racial and ethnic disparities in advance care planning and end-of-life care, focusing on factors that might explain observed differences.  Second, he conducted a study in San Francisco's On Lokpopulation finding that 2/3 of 60 disabled elders from diverse communities would like their doctor to talk with them if they knew they had a prognosis of 5 years or less. This led to a publication in the New England Journal of Medicine where he recommended that clinicians routinely offer to discuss prognosis with very elderly patients.  Dr. Smith followed this by mentoring a UCSF medical student to a first-author publication in JAMA, a systematic review of prognostic indices for older adults.  Dr. Smith translated these findings from the systematic review into a set of online calculators clinicians can use to estimate life expectancy for older adults (www.eprognosis.org).  This work received considerable media attention, including multiple stories in the New York Times, a story in USA Today, and an invited presentation to the National Academy of Sciences Committee on Science, Technology, and Law in Washington DC.  The website ePrognosis received half a millionpageviews in the first week.

To see Dr. Smith on Pub Med, click here.