Blitz Chess Chats #1 | A/Prof Joel Rhee | Medical Care of Older People Living in Aged Care Homes
#blitzchesschat #interview #jaenischgambit
Welcome to the first video of this new series, Blitz Chess Chats! Here, I speak to medical academics and researchers about their field of expertise and program of research… and we start the interview under the pressure test of a game of 5-minute blitz! Come for the chess and stay for the interview! ♟️🤪👍
I spoke to Associate Professor Joel Rhee, a Specialist General Practitioner (a “Family Physician” in North America and some other countries), and the Head of the Discipline of General Practice, in the School of Clinical Medicine at the University of New South Wales. A/Prof Rhee’s specific interest is in older person care, and we spoke of the delivery of primary medical care to people living in aged care homes.
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Contents
5-min blitz: Ruy López Opening: Jaenisch Gambit
Full transcript of the interview
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The game
Joel had the white pieces and played the Ruy López Opening, to which I responded with my favourite, the Jaenisch Gambit (1. e4 e5 2. Nf3 Nc6 3. Bb5 f5)! In the very first game I played against Joel many years ago, he also played the Ruy López and crushed me back then! Against the Jaenisch, Joel responded with one of the best approaches for White, which is (4. d3), supporting his e4-pawn. We exchanged (4… fxe4 5. dxe4), and although White is definitely just better, we both have tactical opportunities. White gains a semi-open d-file controlled by their queen, while Black has the semi-open f-file, which forms the setting of a future attack on White’s weak f-pawn.
On turn 7, my kingside castling (7… O-O) was a blunder, but luckily, Joel didn’t see it. He potentially had (8. Bxf6), capturing the knight and removing the defender of the d5 square. A subsequent (9. Qd5+) is an absolute fork of the king and my undefended c5-bishop, winning the bishop. This is another great example of an open d-file giving the potential for a quick win tactic in the opening (which was the theme of my most recent “whimsical” quick wins article).
On turn 11, Joel had the correct intuition that he needed to make some exchanges. However, he started with the natural trading of the Ruy López bishop for my knight (11. Bxc6?), which in this position was a mistake that returned the evaluation to equal. Interestingly, after (12. Nxf6+), the engine preferred recapturing with the g-pawn (12… gxf6), opening the g-file and exposing my king. In the game, I thought that this move was probably “engine correct”, but that it would be a strategic mistake to create a permanent weakness in my king’s defences, especially in blitz. So, I opted instead to trade away my rook for White’s bishop (12… Rxf6!? 13. Bxf6 Qxf6). Why? For the relative loss of material, I gained activity and a massive attack on White’s f2 square after (14… Rf8)! Joel identified the big attack in the game but simply knowing that it is coming doesn’t mean that it can be so easily avoided!
Joel responded with (15. g4?), a move he acknowledged was risky in game. This was a mistake, though the correct move wasn’t the easiest to find (15. Kh1). Joel was possibly hoping that I would sacrifice my bishop, and I was tempted! However, that felt unwise as I didn’t have enough attackers then compared to defenders. Instead, I found the correct backward bishop move (15… Bg6).
With the big attack down the f-file, White’s good choices became extremely limited, and on turn 17, they had only two options that maintained equality. They needed to add a second defender to their e4-pawn: either Rae1 or Nd2, neither of which were especially obvious moves. Running out of time, Joel instead played the blunderous (17. Qe2??), and Stockfish now finds that a forced checkmate is available! At this point, Joel had only seconds left on the clock while I still had a comfortable amount of time left. On analysis, I had several tactics that would have resulted in more optimal moves to force a checkmate win. In game, I opted to play very quickly to counterattack Joel’s queen, forcing him to spend time thinking and ultimately, he flagged (ran out of time) on turn 21 as he played (21. Qg3??). I still feel like I had a moral victory as the natural (21… Qxg3#) response would have been checkmate. Good game!
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Interview synopsis
Note: click on the links to go directly to the video at the timestamp.
The interview with A/Prof Joel Rhee started [9:10] with an overview of multimorbidity, one of the major challenges in the medical care of older people living in residential aged care homes. This led to a discussion [11:18] of the critical role of family doctors, and expert generalism, in managing care complexity.
Joel then described [15:26] his program of research with an aim to improve medical care in aged care homes, including [18:32] findings that substantial doctor time is lost to administrative tasks, and [26:50], evidence from a large data linkage study that demonstrated that residents of aged care homes experienced a dramatic loss of access to skin cancer treatment on admission.
Finally, we discussed [32:27] Joel’s insights from his career as an academic family physician undertaking research and providing care to people living in aged care homes. He described the features of a good death, choice, control and dignity. He also noted the critical importance of ensuring that new technological advances in the care of older people are concordant with their values and preferences.
It's a matter of aligning. Obviously, with the advancements in medical technologies and science, and AI and everything, a lot of things are possible. And so, the main challenge will be making sure that the availability of these very high-tech treatments is aligned with the values and the preferences of our older adults. I think that's going to be the key.
— A/Prof Joel Rhee, 9 May 2025
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Post-game interview transcript
Dr Michael Tam
So, tell me a little bit more about the nature of looking after older people, so aged care. So, you're a specialist general practitioner, or in North America, a family physician. What's your perspective on the role of family doctors and on looking after older people.
A/Prof Joel Rhee
Yeah, so I think… In looking after other people, it becomes an issue of not only looking after acute health concerns. But a lot of the work involves managing lots of… we call it multimorbidity, lots of medical conditions. And these are often medical conditions that are even unrelated to each other. Because you can think of conditions such as heart disease, which is often linked to things like blood pressure or high cholesterol and sometimes diabetes or you know, that kind of thing could all be interlinked. But, in many situations with older people, you do develop diseases which are not even particularly interlinked. It becomes challenging to manage these conditions. And patients often talk about or joke, and I think they're semi-serious when they do joke about it, which is that being a patient feels like a job.
Dr Michael Tam
Yes, yes, yeah. Yes, and so “multimorbidity” being someone living with multiple conditions at the same time. And as you mentioned, as people get older, but that's actually even the case for younger people as well, that the combination of multiple conditions substantially increases the complexity of care.
A/Prof Joel Rhee
Exactly. It's a recognition also of the fact that these conditions themselves have a significant burden on people and their ability to manage their day-to-day life; their ability to manage their, you know, could be jobs, but often older people they retired, but in terms of managing their family life, their personal life, etc. It significantly affects that.
But it's also the treatment itself. The fact that many of these chronic conditions means that you've got to see health providers like doctors and allied health staff or nurses on a regular basis. So many tasks that need to be done… maybe you need regular blood tests or regular x-rays or ultrasounds or whatever, to monitor, and various non-GP specialists that you need to see.
All of that adds to that burden, and I think one of the challenges I think of working with people who are older is how do you make sure that the burden of the conditions themselves is… well addressed by treatments. And making sure that treatment burden doesn't outweigh the potential benefits in terms of the effect on the actual condition.
Dr Michael Tam
Yes, yes. I suppose a naive way of thinking about health treatments is a very linear sort of way. So, someone has condition A OR problem B and well, this would be a treatment or a person you could see. So, you refer the person to this provider and then another condition you refer to another provider. In each narrow slice that can seem to make a lot of sense. But when you live with, let’s say 5 or 6 different conditions, each of those conditions may potentially be managed by one or two healthcare providers, suddenly, if you follow that sort of mode of think, you could be seeing like 15-20 people, which is completely unrealistic.
A/Prof Joel Rhee
Exactly.
Dr Michael Tam
And to me, now I'm of course a family doctor myself, that one of the great roles of medical generalism is to prioritise the care. So, “where can things be simplified?”, “where things can be consolidated?”. Where every additional burden of care must have some sort of palpable benefit, rather than necessarily just a theoretical benefit.
A/Prof Joel Rhee
Exactly. Yeah, that's right. And often it means that family doctors and other generalists can utilise their skills in looking after lots of different conditions, and in managing lots of chronic conditions.
I think one of the interesting things about it is that non-GP specialists are often very good at managing specific conditions, there's no doubt about that. They're very well read up in terms of latest techniques, latest research evidence, that kind of thing. And they know exactly what the best way to manage your condition is. But often the family doctors or GPs and other generalists are actually doing a good job as well. It might not be perfect; might not be the standard of someone who's dedicated decades of study into a particular area. But often they can do a very good job, and to someone who's got lots of medical conditions, sometimes getting your family doctor to look after those many conditions is much more preferable compared to seeing ten different doctors you know for different conditions.
Dr Michael Tam
Now can you tell me a little bit about some of the research work that you've done. Or is there something that you're working on at the moment?
A/Prof Joel Rhee
There's a programme of research that department is doing, around improving the way that we look after people living in aged care homes. So, these are called different things in different countries. But in Australia we call them “residential aged care homes”… People who qualify to live in one of these aged care homes, depend on the level of disability or level of function. Most people who live there are very frail, may have dementia, and those conditions. They require a lot of assistance basically to live there.
Dr Michael Tam
So, in other in other parts of the world, or in the vernacular, these might be “nursing homes” or “retirement villages”.
A/Prof Joel Rhee
That's right. And so, these patients do require a lot of support in terms of career support. So, personal care when it comes down to activities of daily living and that kind of thing. They also require a lot of support from nursing perspective, for example managing medications, and you know… They might have wounds that require good care nursing care and things like that.
But they also require good quality medical care as well. And in Australia, GPs or family doctors are the ones who provide that day to day or continuing medical care for these patients. It’s a significant challenge for GPs because the resources that's available for doctors for people living in aged care homes is very limited. And that's a product often of the fact that many people living in aged care homes have poor mobility. Some could actually be bedbound and can't travel outside, and the reality is most healthcare services in Australia, and I suspect around the world, are mainly geared towards people who could walk into their facility.
So, you know, even getting things like scans and ultrasounds can be a challenge. Getting healthcare services other than GP, so non-GP specialists to see patients in nursing homes can be a huge challenge as well.
So, it's a massive challenge for our healthcare system. Our research is looking into ways to improve the way we look after patients in that setting.
Dr Michael Tam
OK, OK. And can you tell me… how the study will do that. So how will you investigate this? It sounds like it's very important trying to provide better care to older people.
A/Prof Joel Rhee
Yeah. So, there's a range of different studies that we're doing. So, for example, we conducted a number of interviews with people who live in aged care homes as well as their families and informal carers to explore their experience of receiving medical care in that setting and they've told us a lot of really important ideas. And one of those, for example, is the fact that many people don't seem to have a strong relationship with their own GP. And the reason for that is because… often the discussion of healthcare for residents appeared to be mainly between the GP and the nursing and the care home staff. And often it doesn't seem to involve the residents or the family carers as much. That's quite unfortunate that that's the case.
And as a family doctor who actually looks after people living in aged care homes, I can see where that's coming from, because there's so much administrative tasks that doctors have to do in aged care homes. So, things like filling in medication charts and doing those routine everyday things; most of your time is spent in discussing and talking to your care staff and nursing staff and not enough time is spent in talking to the residents or their family and carers.
So that's an important lesson. One of our medical students from last year who's doing a yearlong research project; actually, what she did was she went around different GPs visiting aged care homes and she went around with a stopwatch, and she documented exactly what GPs are doing in aged care homes.
And that was really sobering. So, the results came out. And the reality of that was that the majority of their time seemed to be spent on doing administrative tasks. And shockingly also even things like logging into computer that took up quite a significant proportion of time, and finding staff to talk to just wandering around the nursing home looking for the nurses or the carers to talk to. All of that took up so much of that time that there was insufficient time that they could actually spend in talking and examining and helping the residents themselves.
Dr Michael Tam
Yes, it's interesting because you know time is… of all the resources is non-elastic. You know, you can't just make more time. There's only so much. But it is something that from a health services perspective is relatively difficult to measure. So, if you look at inputs like financial costs, we've got very, very good systems to monitor that. In terms of staffing, you know you can look at payroll, there's a whole number of ways you can do. In terms of goods and items, you can look at inventory and how much expenditure goes into particular items.
But this issue of time; I think we see it in the community as well and in in some other countries, I think the US in particular, this phenomenon that increasing amounts of the fraction of clinician time being spent on administrative process tasks but not direct patient-related care. Of course, processes are important too, but not direct patient-related care does seem to be a growing experienced phenomenon by clinicians.
I would have thought that this also potentially provides a significant opportunity because one could imagine that these process related things, administrative things which are often protocolised, might be something that could be improved quite a lot with new technologies, particularly AI-type processes. And what are your thoughts on that?
A/Prof Joel Rhee
Yeah, definitely. I think there's obviously examples of AI scribes. So, they're not widespread in aged care home settings, but definitely in mainstream general practice in Australia, and I suspect in other countries. Where AI can actually be listening in, obviously with patient consent, but listening in on consultations, and you can generate a summary or notes even, for the clinician. That would save a bunch of time even doing that. It could assist in things like even generating referral letters and other documentation. Obviously, that will require the clinician to review and make sure it's all correct, that kind of thing but still, it could save a lot of time. I think AI is definitely going to be one of those potential time saving devices.
The other interesting recommendation that came from that study that I was talking about with the medical student is she actually… it was quite fortuitous that it happened. In majority of cases in aged care homes, the family doctors will go around and see patients in their own room. That’s how things are done. But in one doctor's case, when she was doing the observation, that doctor had an access to a dedicated consultation room. And so, that doctor's model was that the nursing staff and the carer staff would bring in patients and they'll actually see them in a private space…
Dr Michael Tam
So, you mean a private space in the aged care home?
A/Prof Joel Rhee
That's right. And what was really interesting about it was when that doctor was doing that, the amount of time they spent on things like finding the staff or administrative tasks and other thing dramatically reduced. So, the doctor was actually spending a lot more of that time together with the resident. That was really interesting and one of the recommendations we were trying to make is: you know, if aged care homes could provide a consultation room for the family doctor or other clinicians, that could actually be something that could dramatically change or improve the way we look after people.
Dr Michael Tam
Yeah, that's fascinating.
Probably around 15 years ago I used to look after around 35 residents in an aged care home, and that facility is now closed down. But we exactly had that. There was a clinic room as part of the facility. And generally, I would see the residents I cared for in the clinic room. Certainly, for some of the some of the residents, they could bring themselves to the room. Others would need to be directed by care staff. And only a minority would I see the person in their own room. Usually, these would be people who were basically room-bound. So, either due to physical disability, or maybe they were blind, or having quite severe dementia. But the majority of people would be in the clinic room.
I've never really entirely thought about it… and I haven't done a huge amount of aged care work. But I've never really thought about that that wasn't actually a very routine thing in the aged care facilities.
A/Prof Joel Rhee
It's, I think depends on each facility whether they have a consultation room. I've certainly been in aged care homes where they had a consultation room, but it wasn't equipped well. And often it's used more as an office rather than set up as a consultation space. Things like having an examination bed; often they don't have that available. Some nursing homes would, but others don't.
And in fact, one of the other studies that another student did was he analysed lots of data. And what we found was that when older adults are going to aged care homes, their skin cancer treatment drops off dramatically. And it’s not as if they're getting any younger. They're not. But when you look at the time period before going into the aged care home, and when you look at how many times are they getting their skin cancer treated, and when you compare that with once they get into the aged care home, then there's a dramatic drop off.
Some people will say, well, that's reflective of the fact that, you know, maybe that person's health has deteriorated, and that’s why they're in the aged care home in the first place. But I think it's a bit more than that. Once again, I suspect that the reason for some of that would be because in aged care homes there's not enough space where doctors can actually examine the skin well, let alone actually treat skin cancer. Because for that, you need an examination couch. You need good lighting.
Like, I remember trying to cut out skin cancers from people in their rooms, and I suffered badly because of… my back. You're hunched over trying to do this in bad lighting.
Dr Michael Tam
It was a bit heroic.
A/Prof Joel Rhee
And it's. Yeah, that's right. My back was not good…! Yeah, so I never tried to do that again. I imagine that you just need better conditions basically to do the procedure. So once again, that's another example of our research highlighting some of the ways in which we could provide better care.
Dr Michael Tam
Yeah, and I suppose the concern is… The very notion of someone moving towards supported living is that we provide the care for the older person, but is there a risk that this is just a representation of many other types, many other fields of care, where we've actually created… oh what's the right way to describe it?
It's not discriminatory… but in fact that that people have lost access to care in a situation where they should have increased access to care.
A/Prof Joel Rhee
That's right. Yeah. And that's a really good point. So, another issue which I've flagged is the difficulty of people living in aged care homes accessing non-GP specialist services. So, one of the issues obviously is that a lot of the non-GP specialist care in Australia, as you know, is delivered in by private specialists. Obviously, the public hospitals and their outpatient clinic does a heroic job, but it's heroic because there's not enough of them around. So, a lot of that work is actually done by private specialists. And the reality is, and it's fully understandable, it's not a criticism of what they're doing, is that it's very difficult for private specialists to set up their clinic in such a way so it's accessible to people who might have reduced mobility… for instance, bedbound patients. It's next to impossible for them to go to radiology even and get a scan.
So, it's a significant barrier. It's not their fault. It's not that non-GP specialist or radiology provider’s fault, but it basically makes access for those patients really difficult.
Dr Michael Tam
Well, these are system issues. Australia, I suppose has a socialised insurance scheme through Medicare, but nonetheless the majority of providers are still in the private sector. So, we use market mechanisms, and we can get market failures.
A/Prof Joel Rhee
Just right. Exactly. And obviously here the market failure would be because 98% or 99% of their clientele or patient base would be people who are mobile, or who could at least get a wheelchair, that they've set up that way obviously.
So, a lot of the market failure would be addressed by public clinics and public system, but obviously they're really struggling as we all know. So that's the other issue.
Dr Michael Tam
Now I'm going to ask you: you've had such a long career working as a family physician, so, a specialist general practitioner with a specific interest in older person care. What major insights and have you got in terms of what's important, and how could things be better moving into the future?
A/Prof Joel Rhee
Yeah, I think it's a matter of aligning… Obviously, with the advancements in medical technologies and science, and AI and everything, a lot of things are possible. And so, I think the main challenge will be making sure that the availability of these very high-tech treatments is aligned with the values and the preferences of our older adults. I think that's going to be the key.
And I suppose we're getting into talking about advanced care planning in a sense. Which is around basically making sure that individuals can have a say or express their preferences for how they want to be treated in the future, if they are no longer able to voice, you know, make the decision. So, I think that's an important element which is going to become more and more important.
Because… maybe in the future things will change, but so far, everybody dies. There’s 100% mortality, and when we ask people how do they want to die, I think most people say well, they want to die in a place of their choosing. We commonly talk about people wanting to die at home, but that's not quite true, isn't it? Some people would say I want to die at home. Others say that, actually dying at home might make things very stressful for their families. And other people might actually be in an unfortunate situation where home is not the nicest environment.
So, it does differ person to person, but they want to be in a setting of their choice, and also obviously most people want to die with dignity. They don't want to be in pain. They want to make sure that they have dignity. They have choice. That if they have any symptoms like pain or shortness of breath or other things, that that's well controlled. And surrounded by people that they love, and who loves them back. So that the sort of seems to be the characteristics of where people want to die.
Dr Michael Tam
Yeah. And I think that it's a really important view actually of healthcare and medicine. Because… I was going to ask you a question about humanoid robots! You know, with Tesla, and I think the South Koreans and Japanese are quite advanced in trying to make humanoid robots. But we can get sometimes distracted with the flash-bang of technology, but it has to match with people's values. And, what’s the purpose? Trying to live a good life. Maybe have a good death. That's the purpose and needs to be merged with that. There's no point having… you know, a Tesla-bot that's a bully!
I think making sure that we're empowering people so that they're able to enact their autonomy in their decisions is important.
Dr Michael Tam
Thank you very much for speaking with me and being the first guinea pig for this series!
A/Prof Joel Rhee
No, thanks very much. And yeah, we should rematch. So, I don't get… eh, it was an unfortunate loss.
Dr Michael Tam
I'll stop while I’m ahead; that was a good win!
A/Prof Joel Rhee
Thanks very much.
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For inspiration on great opening attacks to play in blitz chess, check out my new book, “Become a Chess Assassin! Learn to play the best chess opening attacks”.
