Nita Ahuja: Epigenetics and Cancer

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University, and we’re trying to get closer to the truth about health and healthcare. This week, we’re really excited to have Dr. Nita Ahuja on today. But first, we like to check in on current hot topics in health and healthcare. And one of those topics, if you can believe it, is phenylephrine. A topic that other people may not know much about, but you tweeted about it and literally on the same day, my father said to me, “I want to know what Harlan thinks about phenylephrine.” I kid you not. That’s exactly what he said, and I said, “It’s a good thing because I think he’s willing to talk about it on the podcast.” So tell us—

Harlan Krumholz: Well, I am.

Howard Forman: ...your thoughts on this.

Harlan Krumholz: I am willing to talk about it. But also, the listeners should know that this is something that’s interested you for maybe a couple of decades, so you probably know a lot more. But anyway, let’s just frame this for everyone. So an advisory panel to the Food and Drug Administration got together and was pondering this issue about a very common cold medication, an over-the-counter cold medication, and they unanimously voted that this common decongestant ingredient, phenylephrine, is ineffective. Ineffective.

You sometimes get these unanimous votes, but this was like, I think, “Slam dunk. Sorry, folks. This drug that a lot of people have been buying over the counter to help them with cold symptoms probably doesn’t work...,” and the FDA will likely—now, this was advisory but the FDA often follows the advice of an advisory committee like this and would, I don’t know, result in the FDA—if they follow through on this—pulling, I don’t know what, hundreds of products from the store shelves throughout the nation. So just to be clear, phenylephrine is found in a wide range of cold and flu medications, including Sudafed PE; Benadryl Allergy, D-Plus, Sinus; and Vicks DayQuil Cold and Flu Relief. I mean, you almost can’t find a cold medication that didn’t have this stuff in it and claim that’s the decongestant that will help you.

Howard Forman: It’s in everything. Almost every cold medicine that says the word decongestion on it includes phenylephrine. Like they have different things in it for different symptoms, but the one for decongestion is almost always phenylephrine.

Harlan Krumholz: And just to be clear, Howie, this phenylephrine, lots of people have heard about pseudoephedrine, right? And I think people get this all confused in their heads too. Is phenylephrine the thing that raises your blood pressure and you can make meth from? No, that’s not it. It’s pseudoephedrine. And when it started to get hard to buy, when you go into the drugstore and you’ve got to ask someone to unlock a thing and show your ID and go through all this rigamarole to buy a product with pseudoephedrine, that’s because that drug can be used to make meth. So basically, the companies went to something that people could just slip into their basket without having to go through all of that, and they pulled in this phenylephrine. But the problem was, it had never really been shown to be effective and so... I think it goes back to 1976 where—

Howard Forman: ’76. Yep.

Harlan Krumholz: ...this stuff was coming out.

Howard Forman: Yeah, no. So a couple of quick things that I think are funny for our listeners is pseudoephedrine, pseudoephedrine is the chemical name, is what was the reason for why we called it “Sudafed.” But soon as this happened, what you described related to meth, the Sudafed brand name decided, “Well, we have to have a Sudafed product that’s not behind the counter, so we’ll just put phenylephrine in.” So Sudafed’s a brand name. You can buy Sudafed-branded phenylephrine or you could buy Sudafed-branded pseudoephedrine. And so, it’s not that surprising that people don’t even realize that what they used to use as pseudoephedrine has now become phenylephrine without even noticing it.

Harlan Krumholz: Basically, they sound alike. I don’t think people notice. But there’s lots of questions about a lot of other drugs now too, Howie, and I know that you’re a big fan of pseudoephedrine. I mean, in other words, you believe it works. I mean, even as it can cause elevated blood pressure and could cause the side effects, but I mean, you believe it works anyway. But I’m of the mind that... I don’t know. My wife is a big fan of Mucinex, and I keep telling her it’s like, “These drugs have not been subjected to the same level of rigor as your typical prescription-based drugs.” And in knowing whether they work, who do they work, and when do they work best, what’s the effect size in them, and how do people experience them, it’s just something that’s beyond the evidence that we’ve really got.

And most of these have been studied in very rudimentary ways, often a long time ago, and maybe in labs that, to be honest, could have been biased. I mean, this thing with phenylephrine in 1976, there’s at least some reports that the places where it was found to be effective was a single lab that wasn’t concordant with a lot of other places. The Atlantic article that came out this week was commenting on this. And so maybe it’s time for us to take a step back and think about the evidence base. Because billions of dollars are spent on these drugs, people are expecting to do something good and we honestly don’t have the kind of evidence that we need to know whether they’re truly effective.

Howard Forman: Yeah. And it goes to what... in my class, we talked about yesterday that a lot of healthcare is not fully informed. Your career has been committed to answering the questions, the hard questions, and we still need thousands of Harlan Krumholzes to answer these questions.

Harlan Krumholz: No, come on. But one thing I did when I was on the Board of Governors of the Patient-Centered Outcomes Research Institute, especially in the beginning, I tried to turn the organization towards doing a large number of randomized trials on products that were specifically designed or sold as helping people feel better. So I said, “Pain, cold symptoms, flu symptoms, insomnia.” I mean, there’s a whole range of drugs. Even we need more and better evidence around depression because there’s still questions about the SSRIs and a whole range of things.

Tamiflu, the country stockpiled $10 billion of Tamiflu for a flu pandemic. There were questions about the quality of those studies. And I felt the reason you could do a lot of trials quickly is because the endpoint was a patient-reported endpoint: “Do I feel better?” And these are, for people listening, it’s not an event. You’re not waiting for a heart attack to occur. You’re actually... everybody can contribute information that goes into the endpoint, and it’s a continuous endpoint. It can go from 0 to 100 and that statistically enables you to have better power in the study, able to do the study with smaller numbers of people.

And then, what I really wanted to do was, “Let’s do it in younger people and older people. Let’s do it in men and women. Let’s do it in people with a lot of comorbidity and people who do not. So we can really fill out the knowledge risk.” I couldn’t get them to move in this direction, but I’m still hopeful one day maybe they will. Certainly, NIH should be doing this too.

Howard Forman: Let’s hope. It’s not that expensive to do these things, by the way.

Harlan Krumholz: Yeah. So yep, people should stay tuned. We’ll see what happens. We’ll see if they pull all that stuff off the shelf. But hey, let’s get to our guest. We have a wonderful guest today.

Howard Forman: Dr. Nita Ahuja is Yale New Haven Hospital’s chief of surgery, the chair of the Department of Surgery, and the William H. Carmalt Professor of Surgery at the Yale School of Medicine. Dr. Ahuja runs the Yale Cancer Center as associate director and specializes in treating soft tissue sarcomas and cancers of the connective tissue. She is renowned for her peritoneal cancer treatment as well as using world-class technologies such as heated intraperitoneal chemotherapy to treat her patients.

Dr. Ahuja has a relentless focus on patient care and patient service. Her research is internationally acclaimed, and much of her most influential work has focused on epigenetic cancer therapy research and translational epigenetics. In addition to her research, she’s an exceptional leader of one of the largest surgery departments in the country. She’s an elected member of the National Academy of Medicine. She graduated with a bachelor’s degree in biology and mathematics from the University of Maryland.

She obtained her MD from Duke and completed her residency and fellowship at Johns Hopkins and subsequently received her MBA from the Carey School of Business at Johns Hopkins University. So first of all, I want to just welcome you to the podcast and I want to go in and ask you probably the most complicated question first which is, what is epigenetics? Because your contributions are legion but I will be honest with you, I knew very little about it until I started getting ready for today’s segment.

Nita Ahuja: Well, first of all, I’m really glad to be here with both of you on this podcast. It’s an impressive repertoire of people you’ve had. Epigenetics, the way I think about it, the word means, if you break it down, “in addition to genetics.” So genetics, we all know, it’s our alphabet soup. That is our DNA. It’s four letters, it’s A-T-C-G. So that’s genetics.

And typically when genes go bad or mutate, the letters change and those are permanent effects. You can’t reverse them. But genes can make stuff, they make protein. And so there are ways of regulating that beyond genetics, and that’s what epigenetics is. The way of thinking of what is the difference between hardware, which is our genetics, and what is software, which is epigenetics. And epigenetics then allows us to turn our genes on and off depending on things like environmental exposures, our diet, things like stress, and it has... The effects of those epigenetic changes are equivalent to genetics. But here’s the zinger, those effects in the laboratory can be reversed, whereas we can’t change our code. Once changed, the DNA code, you can’t change it again. So the software can be manipulated, the hardware not so.

Howard Forman: And so, just one follow-up point, this potentially leads to treatments for cancers and other diseases, correct? That’s my understanding from looking at some of your work.

Nita Ahuja: Absolutely. I mean, when I started in this field, I was in training. I was a postdoc in the ’90s, and I heard about this field and I, like you, had never heard about this. But the aha moment was, I’m like, “Oh, this is reversible. How cool is that?” And even in the 20th century, back in the ’90s, we could do this in the laboratory. We could turn genes on which had been turned off because of these epigenetic changes. So the light bulb went off, and a dream came like, “Can we start to treat cancers in the future with this?” and that was a lot of my journey in Baltimore to start to do this and work with other teams on that.

Harlan Krumholz: We’re so lucky to have you at Yale. It’s just remarkable the breadth of your experience and expertise but... by the way, just on the code, right? With CRISPR today, though, we can actually change the code, right? I mean, people will be going in and snipping out—

Nita Ahuja: Yes, yes. We can. Yes, we can.

Harlan Krumholz: Our code and switching it out, right?

Nita Ahuja: Absolutely.

Harlan Krumholz: But we’ll see, not yet actualized. One thing I wanted to ask you is, I know you’re one of the world’s experts in what people are calling liquid biopsies. And for people listening, this is... we think about biopsies of tissues where we go in and take a piece of tissue and try to characterize it. But these liquid biopsies are basically blood tests which can give us profiles or signatures that can suggest the presence of diseases like cancer. There’s been a lot of controversy about this. Grail, a company that got a lot of attention, is struggling. There’s a lot of startups in the world who are trying to make progress in this area. Will it be possible, do you think, one day, for us just to go in for a preventive visit, have them draw blood from us, and tell us that in two years or three years with more traditional methods we would’ve been able to detect this cancer, we can now detect it far in advance? Are you optimistic about this now, given some of the challenges with it?

Nita Ahuja: Fundamentally, yes. I think the thing with science is the more you learn, the more you know you don’t know. And liquid biopsies, in my sense, are in that because although DNA is shed.... Many years ago, we didn’t know that things were shed even by tiny tumors, and now we know actually that cancers are shedding stuff in our blood, in our sputum, in our urine. The problem is, of course, we don’t know where it’s coming from, oftentimes. We don’t know that when a cancer changes from a non-cancerous but ultimately abnormal to cancer in many diseases.

So I think those things will fundamentally happen. I have a lot of faith in human knowledge. I think, realistically, we often think the timeline is perhaps faster than we think it is. But think about things we can diagnose on CAT scans in the last 20 years, we can see one-millimeter things. Whereas I remember being early on as an intern and although we had CAT scans, our cuts were centimeters apart, and the precision of a CAT scan... so technology improves. That is where, this is, in some ways the 20th and 21st century, seeing how fast technology’s improving. I think where we struggle is that there’s ambiguity and when that ambiguity and confusion happens, people want to go quickly to easy answers. And we just need to be comfortable that we’ll learn, and we’ll often move ahead, but sometimes we go backwards a little bit and I think the Grail and the venture capital are probably resettling, and we’ll get there. My work has been more, slower. Just because I’m more academic, it has been slower.

Harlan Krumholz: Well, you’re rigorous, and we appreciate that. One thing though that I’ve heard is maybe these will find their best utility in cancer recurrences. So if they’re focused in on people who’ve had cancer, now we’re trying to monitor and surveil whether or not there’s any recurrence and whether we have to go in. Do you think that might be the place where these, at least, find their first application?

Nita Ahuja: That’s obviously the easier space because you don’t have to diagnose the cancer, you just have to... now you know where the cancer is coming from. So if you see some abnormality in the liquid biopsy, and there are many different marks you can check, you’re really just saying, “Okay. The cancer is coming back.” And there’s some nice signals that these liquid biopsies pick it up a little faster than, say, a CAT scan or the other fancy scans.

Now, there’s a bigger question. Yes, I think it’s easier to do it in the surveillance stage, which is what you’re saying. You know you have a cancer, I’m going to follow you along, and now, I can pick up a recurrence. The cynic in me then says, “So what if? What if you pick up a cancer two weeks or two months earlier? Does it fundamentally make a difference?” So yes, we can show a utility for it, but will this make a difference in our patient’s life? And that’s, perhaps, being a clinician scientist, I think I always wear my hat as a clinician first, as a doctor first, and think about, “What does my patient want?” My patient only wants to live longer. And to me, that question then becomes... and that, we don’t know like we’re picking up—

Harlan Krumholz: Oh my god. I’m going to call you an honorary outcomes researcher because that’s the whole point which is at the end of the day—

Nita Ahuja: I’m so honored. Oh my god. Dr. Krumholz, calling me that—

Harlan Krumholz: At the end of the day, have we made a difference in people’s lives? Oh, my gosh. I’m so happy.

Howard Forman: That’s where it’s at. But let me just say this, there are, as Harlan said, you’re a quadruple threat. And it is extremely unusual to find somebody who is a rock star in the clinical realm and in the research realm and in the educational realm and still be able to want to lead and to lead successfully. You went ahead and got an MBA just a few years before you came to Yale. What prompted you to do that, and can you tell us your thoughts on leadership in medicine?

Nita Ahuja: So perhaps a little anecdote in why I did my MBA, I would tell you if I’m going to give the nice answer of “well, it was all planned because learning those skills is so critical.” As in life, I think you are in the right space at the right time, and I had just started taking more administrative roles. I was learning. I was a rookie learner. But bringing my scientific mind to administration, I was learning the ropes, and I have a younger sister who’s a surgeon, and her boss wanted her to do an MBA. And she came up to me and said, “You know, Hopkins has a new program. Why don’t you come and do this? It’d be a great experience for us to do this together, and I think they’re interested in more physician leadership.” So being sort of facetious, that was perhaps the thing.

But of course, there was a decision in the back of my mind that, a desire that physicians should lead. And to do that, we need to understand what are our peers, who our administrators have trained, and getting that training is important. Because clearly, I had to pay tuition. It wasn’t cheap. So there was a... and that story was meant to be slightly facetious, but it is that it is important for more physician leaders to be there in medicine.

The sense of what we see in healthcare, and you know this or both of you know this, it’s complex. So who knows this better? We know they’re day and night and that decision to make an MBA is one I’ve never regretted. I worked with very smart people who were not in medicine and understood factors, things that I know Harlan and you know really well. But perhaps, me being the lab scientist didn’t appreciate that how much of our societal factors can impact healthcare delivery, and I think that was a light bulb. And since then, it’s something I’ve really gone after, and perhaps the decision to come here to Yale six years and take on an administrative role is to talk about more physician leaders who can really balance and think about how do you do good clinical care while managing a very complicated healthcare environment, I think, requires training, just like we train to do epigenetics or be a surgeon.

Harlan Krumholz: I’ve got a couple things I want to tap in you. So you’re a fabulous leader. I hope one day we won’t have to say you’re a leading woman surgeon, that we won’t even have to say that word anymore because it’ll just be, “You’re a surgeon.” But today, still, there’s a lot of focus on women in surgery because it still represents something new and things are changing. I mean, what it looks like to be a surgeon is very different today and refreshingly and importantly different than it was.

And then, we see studies coming out. I want to talk about one group of studies first and then another. But the first set of studies I want to talk to you about are the two studies that came out just recently that indicated that female surgeons, women surgeons, are less likely to experience complications and get better outcomes than men. And by the way, this isn’t the first couple studies that have shown this. And one of them was a study that was broad-based, in large that was in Canada with over a million patients. Another one was more focused in Sweden, which was focusing really on cholecystectomy outcomes. And so, it was sort of more narrowly.

The Swedish study showed really large differences, and they had a lot of data to adjust for differences in case makes where the patient is different, and all those sorts of things. The Ontario one found smaller differences. But of course, it was also looking across a broader range of surgeries. In my heart, I might imagine that this is true, that there are differences between men and women in their approach to medicine and surgery. And I just wonder what your reflection is on this because these differences are large enough to be important, and are they telling us something that’s going on? Do you believe them and how are you thinking about them?

Nita Ahuja: Interesting. Those two papers got a lot of press from many people. I think certainly I’m not going to argue with you on the validity of the papers. I’ll leave it to the experts. I think it’s too soon to tell. In some ways, my sense is there’s a selection bias that the women who are coming into surgery understand that they are the first, and many are the first. There’s often a sense to pick people who will stay in the field. Many of us came into the field when there were no or very few women. It’s changing rapidly. This year, my intern class is 60% women. Amazing.

Harlan Krumholz: Oh my goodness. Wow. That’s incredible.

Nita Ahuja: So I think it’s a little too early to tell in that, are women inherently better surgeons? I mean, I can make up all types of answers and I think we both could, all three of us could, that perhaps we may have more fine motor movement. I do think there’s lots of studies in other fields saying women are better listeners. So maybe we pay more attention to complications and in surgery there’s, of course, your technical skills but what makes... that makes a good surgeon. What makes a great surgeon is someone who prevents or addresses complications. So maybe these women surgeons are listening to their patients more and being better doctors, but that’s a hypothesis. I have no data to prove this but that’s some of my gut. I think some of it is just selection bias.

There’s a flip side to this which we need to remember, and I got to say it for my women surgeons. There’s also been studies that when bad outcomes happen to women, they’re penalized much more than the male surgeons. The male surgeons don’t see any impact, but the woman surgeon sees a huge impact. So that selection, it makes you a bit more conscientious, more paying attention to details. So perhaps, this is broader than just that we are better listeners. Perhaps we have to be, because the consequences to those people’s careers may be disproportionate.

Howard Forman: Radiology is notoriously heavily weighted towards men more than women. There are a lot of fields that are like that, and surgery was one of them. You just mentioned that your incoming class here at Yale is, I think, 60%. Are there any lessons that you’ve learned that got you to that point? Are there things that have worked for you to be able to recruit a more gender parity class?

Nita Ahuja: We’ve changed this. When I first arrived here, we were lagging in our faculty composition behind the nation. And then, our residency classes were probably like the nation. We’ve made some efforts in being, representing inclusion. So when they see that, then—you know this—it changes. So my vice chair of research is a wonderful surgeon by the name of Paris Butler. We brought him from UPenn, and he has really talked about what a great school Yale is, what a great health system Yale New Haven Health is, and people resonate. This generation, the Gen Z, really lives by its values. So that changed it pretty dramatically. I hope we’ll keep it up.

But I think, to me, the piece of representation is that our people, our patients, are diverse and they need women, they need men, they need different gender, races, etc. So the more we do that, healthcare is needed by everybody, and we need to represent our societal needs, and we try to do that. I think the other piece surgery has done, especially general surgery, which is my field versus say some of the fields like orthopedics where there’s still... my colleague here, Lisa Latonza, is trying to ensure that, is our leaders have also changed and have advocated nationally to bring more women into leadership. So that has made a big difference not only here at Yale but around the country.

Harlan Krumholz: I just want to lead into maybe a final question. This one’s a tough one. I’m sure you saw that the British Journal of Surgery recently published an academic article that was titled “Sexual Harassment, Sexual Assault, and Rape by Colleagues in the Surgical Workforce and How Women and Men Are Living Different Realities.” This is an observational study in the national health service population in the UK but it almost, undoubtedly, is a generalizable finding across countries. You’re a remarkable leader in surgery. When you read something like that... I mean, how do we create a different field for the future? I mean, how do we create a better future and a safer place for people to be able to become great doctors and surgeons without this fear of this kind of environment?

Nita Ahuja: Yeah. I mean, although I didn’t read the study, this is not the first one or I think I saw snippets of it, but it’s sad, right? And this is where, I think, leadership matters. We have to pick leaders who understand that their job is to clearly lead by a North Star and hold their teams accountable. It embarrasses me, but I think sometimes healthcare has allowed certain people who may be brilliant in other aspects but have not paid attention to making sure that people feel respected, safe, and... either because they’re a brilliant surgeon, brilliant researcher, you can name this, right? So that is upon us, and as I stepped up to leadership, I have to make sure that I’m leading by those values. But as importantly, that when we pick our leaders, we’re of course looking at our... academia loves that CV, right? We have these massive curriculum vitae with pages and pages of our accomplishments, but that is not leading. That’s about you as a person.

So changing from how I advertise myself but selecting someone who leads others with those values about making sure that we are paying attention to harassment and inclusion and making sure all voices are represented is something that I would say I’m still trying to understand. How do I select people with those criteria in mind? So I study a lot of business literature to understand how corporations have done that. I think there’s some signals there that we, in academia and higher education, can take that from and not just use the CV. The CV in my mind is, “Okay. It’s good. Now, let’s see what do you do in managing those critical conversations when the rubber hits the road.”

And the last piece is you have to create a culture of safety. I can tell you when I was a resident or even a junior faculty, I was afraid to speak up and you’re the only female. To speak up takes a lot of guts. But our current generation absolutely speaks up for it and as leader, I think it’s absolutely our job, our duty to make sure we create those psychological safety beyond the processes that, of course, the rules that, “You shall not do this.” But then, you have to make sure that it can actually happen. Otherwise, things happen in the shadows, and you got to look in the shadows intentionally and make sure we stop this once and for all.

Howard Forman: Well, we just greatly appreciate everything you’ve done for Yale, for surgery, and the advancement of, really, patient care throughout the country, so thank you very much.

Harlan Krumholz: Yeah. We’re so fortunate to have you here and so appreciate that you came on the program. Thank you so much.

Nita Ahuja: Thank you for inviting me. It’s terrific to spend some time with you.

Harlan Krumholz: Hey, that was just a terrific interview, Howie. We’re so lucky to have her here. So happy that she came on the program. But let’s get to your segment, what’s on your mind this week?

Howard Forman: Yeah. So two separate articles in lay press caught my attention earlier this week, and they’re related. One, Greenwood Leflore Hospital, a rural hospital in the Mississippi Delta, is on the verge of closing, having already curtailed many services. And then separately, the Dana-Farber Cancer Institute in Boston is potentially and likely changing hands, shifting from an existing relationship with the Brigham and Women’s Hospital to a freestanding center affiliated with the Beth Israel Deaconess [Medical Center]. And what these stories have in common is that medicine is a big business, and it’s only a sustainable business model if government vastly subsidizes the care of those less fortunate or you decide only to care for the more well-to-do. And that troubles me a lot, and I know it troubles you.

Harlan Krumholz: Yeah. So are you saying that this Mississippi Hospital, I know that its primary clientele are poor Black individuals living in Mississippi and that’s just not... there’s no business model that works given that Mississippi restricts Medicaid, it’s not a—

Howard Forman: That’s right. Mississippi didn’t expand Medicaid. It’s poor. You add these things together, and you say to yourself, “Poor people who are disproportionately Black in the Mississippi Delta are never going to have the fair shake that other people in this country have.”

Harlan Krumholz: And then if you look at these large cancer centers, and it’s not just in Boston. I mean, people are building new cancer centers throughout the country, even as the overall trend is to move patients out of the hospital and being able to treat them as outpatients, but because of the financial incentives that are coming out with the new cancer therapies who need to be infused within the hospitals, all of a sudden these new hospitals are popping up. I mean, is that your point, that this is a real response?

Howard Forman: Oh my god. Look, the Dana-Farber Cancer Institute made $300 million in 2021. I don’t have the 2022 figures but I’m imagining it’s in that same range. This is at the same time that Mass General Hospital and the Brigham are losing hundreds of millions of dollars. Yale New Haven Hospital is losing hundreds of millions of dollars. Like general healthcare in a hospital in an urban setting with a poor community is almost unsustainable now, but cancer care is profitable.

Harlan Krumholz: I want to just ask you another thing which is this segmentation of this. I mean, the Brigham had been negotiating with Dana-Farber. They’ve had a long-term relationship. Brigham and Women’s Hospital is a very famous hospital in the country. They’re a prominent institution. They’d had a very synergistic relationship with Dana-Farber Cancer Hospital, and they’ve been arguing that we really shouldn’t be splitting out a cancer hospital. You need actual, to be integrated in with all the other services. Dana-Farber, I know that they’re going to be working with Beth Israel Deaconess, but it’s going to be more of a standalone. I’ve seen this in orthopedics, I’ve seen this in cardiovascular. I mean, it’s like a culling out of the high-profit centers.

Howard Forman: Exactly.

Harlan Krumholz: And saying, “Let’s not be part of the whole anymore—”

Howard Forman: Exactly.

Harlan Krumholz: “Let’s actually optimize the profits that can be...” and we don’t have to say “profits,” some of it is nonprofit hospitals, but the margins that can be generated by when you just say, “Let us just do our stuff,” because the way that medicine is organized, this particular area make some big, big margin profit. It depends.

Howard Forman: That’s right. And if you—

Harlan Krumholz: That—

Howard Forman: Yeah. If you start carving out the joint replacements, the cancer therapy, the cardiovascular interventions, if you carve that all out, what you’re left is all money-losing propositions.

Harlan Krumholz: And doesn’t this relate also to the things you’ve been talking about around private equity? I mean, these all become opportunities for business to come in and say, “Let’s just take this little narrow piece because it’s a margin,” and medicine was always built on this transfer of profits in one area to areas that were unprofitable. Even the emergency department, pediatrics, a whole range of other areas that are essential but don’t have that same sort of—

Howard Forman: That’s right. We counted on people to just do what was right and maybe that’s not going to be enough.

Harlan Krumholz: And where do you see this ending up? I mean, what’s going to happen?

Howard Forman: I think this gets... Unless somebody starts to really use very draconian measures and the State of Massachusetts, for instance, could do things in Massachusetts but it’s unlikely to happen elsewhere. Unless you do really drastic measures, it gets worse before it gets better. And the only way it gets better, quite honestly, is if we start to put everybody on an equal playing field and that requires some type of large-scale expansion of either Medicaid or Medicare and having everybody being treated equally. But until then, people are going to naturally go after the most profitable patients, and that’s not good for the vast majority of patients.

Harlan Krumholz: So some people will say, “This is where we need Medicare For All or Medicaid For All, and we need to expand our thing.” But then, the critics will look to the National Health Service and say, “They’re falling apart.” I mean, they’ve got a single budget. They’re trying to manage the healthcare system. Docs are striking, bolting from the system, patients are complaining, nobody’s happy. How are we going to solve this?

Howard Forman: Well, look, the National Health Service of England operates on practically half the budget that we do, on a per capita basis. So you could split the difference and we could still be saving money. I mean, the issue really is do we believe that healthcare is something that everybody should have access to or not? And right now, we absolutely don’t believe that.

Harlan Krumholz: Yeah. I think that’s the final thing for me about this which is net net. I mean, it’s just adding to the inequalities, the inequities, the disparities within our society. And because there is this piece of this as to if you’ve got resources, you’re going to be able to get to these highfalutin places. You’ve got good insurance. If you don’t, they’re not looking for you to come there and so... right? I mean, this is the—

Howard Forman: It’s a problem, it’s unsustainable, and we need to... we will keep coming back to this on the podcast, hopefully with some different examples and maybe some solutions in areas where it works. But it is very disappointing this week because that hospital in Mississippi is almost certainly going to close either within the next week or at least within the next few months.

Harlan Krumholz: And we may have a dysfunctional government, but we can’t give up on the idea that we need to actually improve healthcare. The healthcare reform needs to be reinvigorated because there’s just so many areas that need to be fixed.

You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can find us on any of the social media platforms you use.

Harlan Krumholz: You’re changing the outro.

Howard Forman: I know, I know. But we’re also on Twitter or X.

Harlan Krumholz: Yeah. We are but I don’t know if they start charging, and I’m getting increasingly concerned about it. But yeah, if you do go to X, I’m @H-M-K-Y-A-L-E, that’s @HMKYale.

Howard Forman: And I’m @TheHowie, that’s @T-H-E-H-O-W-I-E. You can also email us, and we would love you to email us at health.veritas@yale.edu. Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs or check out our website at som.yale.edu/emba.

Harlan Krumholz: If you email us, tell us about what we should do for our social media strategy. Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and to our producer, Miranda Shafer. Amazing week in, week out. Thank you so much. Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Talk to you soon.