Dr. Vineet Arora: Reinventing Medical Education (Health & Veritas Ep. 56)

On the Health & Veritas podcast, Yale physician-professors Howard Forman and Harlan Krumholz talk about the latest news and ideas in healthcare and seek out the truth amid the noise. In this episode, Harlan provides updates on R.S.V., flu, and COVID-19; Howie considers the growing use of hallucinogens for treatment of severe depression. And they are joined by Dr. Vineet Arora, dean of medical education at the University of Chicago, to discuss the future of medical Twitter and how medical education is changing in the wake of the pandemic.

Dr. Vineet Arora

University of Chicago

Vineet Arora
Herbert T. Abelson Professor of Medicine & Dean for Medical Education, University of Chicago
Harlan M. Krumholz
Harold H. Hines, Jr. Professor of Medicine and Director of the Yale Center for Outcomes Research and Evaluation
Howard P. Forman
Professor of Radiology and Biomedical Imaging, Economics, Public Health, and Management; Co-founder, Pozen-Commonwealth Fund Fellowship in Health Equity Leadership, MD/MBA Program, and MBA for Executives Program

November 17, 2022

Listen now:

Links

“A ‘Tripledemic’? Flu, R.S.V. and Covid May Collide This Winter, Experts Say”

“Twitter has spent years trying to combat health misinformation. Will Musk’s takeover make that harder?”

“A fake tweet sparked panic at Eli Lilly and may have cost Twitter millions”

“The ‘bot holiday’ and why clinicians can’t tackle disinformation alone”

“What is #MedMastodon & why might we need it?”

“Some Twitter users flying the coop hope Mastodon will be a safe landing”

University of Chicago: Pritzker EVOLVES

“Colorado Legalizes Magic Mushrooms”

“Single-Dose Psilocybin for a Treatment-Resistant Episode of Major Depression”

Learn more about the MBA for Executives program at Yale SOM.

Email Howie and Harlan comments or questions.

Subscribe to Health & Veritas in Apple Podcasts, Spotify, Google Podcasts, or your favorite podcast player.

TRANSCRIPT

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

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University, and we’re trying to get closer to the truth about health and healthcare. This week, we will be speaking with Dr. Vineet Arora, but first, what’s got your attention this week, Harlan?

Harlan Krumholz: Hey, Howie. I thought, first of all, I might just do some quick updates about what’s going on in infectious disease. Since the beginning of the pandemic, we’ve been laser-focused now on the way in which viruses run through our society. Right now, we’ve got three that are occupying our attention. That’s not even counting monkeypox, but the RSV [respiratory syncytial virus] cases continue to go up. We’re doing a lot of testing, and I think that there’s some good news, which is positivity rates seem to be coming down. If we look back in previous seasons, RSV season usually lasts about five months, and so it’s been very interesting to see what’s going to happen here. We’re getting a lot of reports from children’s hospitals and the places that there seem to be maybe more severe cases than there have been in typical seasons, which are leading to people ending up being hospitalized.

Again, it represents a very small number of people of all those who are infected, but it’s always catastrophic when a child needs that kind of attention. And so, we’re going to have to see what happens on Thanksgiving. I think a bigger story, to me, is what’s going to happen with flu. So, if you look at the flu cases, flu’s starting a bit earlier and the curve is steeper than what we’ve seen in many of the other flu seasons. So, it means it’s starting earlier, and it’s going up more rapidly than what we’ve seen. Of course, there’s, as always, regional variation, and it seems, for example, that the states that are getting hit hardest right now are in the South and in the mid-Atlantic. But we’re going to have to keep an eye on this. In a way, because we’ve been masking over these past few seasons and we almost had a nonexistent flu season in the past couple years, people might be more primed to be affected by flu.

It shouldn’t surprise us that this could be a difficult flu season. That’s just what we need on top of everything else, but that might be what it’s going to be, so we’ve got to keep our eye on that. We’re just at the beginning. And then, COVID, we’re at a moment where, I don’t know, there are more than 300 subvariants that are running around the world. There’s not one that’s dominating globally, and that’s a new thing, because we were always like, “Well, here they are,” and then one outcompetes the rest of them and ends up becoming dominant. But right now, we’re seeing just a lot of different variants. The hotspots right now seem to be in Southeast Asia, in the Pacific region, Western Pacific region, but we’re going to have to keep an eye on this.

Again, in the U.S., the cases are coming and going. There’s some regional differences, but we’re not seeing marked evidence of the kind of spread and spike that we thought we might see at this time. We’ll see what happens in the winter. I attribute this to there are a lot of people who have either been infected, a fair number of people who’ve been fully vaccinated. The country probably is in a position now where it’s able to defend a little bit better from this infection, but we also know that this protection wanes over time. So, as the variants evolve and our protection wanes, I’m just singing the same song, which is we’re just going to have to stay ever vigilant about this. The wastewater monitoring across the U.S. shows relatively flat right now, so I think it’s saying that we’re keeping this at bay.

Howard Forman: I just want to respond to that. The one thing I’ll say anecdotally, because I’m in the ER just enough to be able to know what’s going on in the ER with the respiratory illnesses, it is not at a level that surprises me at all. In fact, I see almost no cases of COVID lung or bad pneumonia associated with influenza or even, quite frankly, RSV cases that are surprisingly so. From an acuity point of view, the numbers may be very high, but from an acuity standpoint, it’s not that different than previous outbreaks that we’ve seen. When it comes to COVID, it’s substantially lower. The acquired immunity that we have either through vaccination or prior infection is preventing really bad pulmonary cases. That doesn’t mean it’s preventing other systemic problems.

Harlan Krumholz: Or long COVID, but yeah, I think for the moment, we’re still representing a bit of hiatus.

Howard Forman: Dr. Vineet Arora is the Herbert T. Abelson Professor of Medicine and Dean for Medical Education at the University of Chicago Pritzker School of Medicine. She specializes in improving the quality of medical education, focusing her work on a learning environment for medical trainees. She’s a scholarly expert on patient handoffs and hospital medicine, which she continues to practice. She uses social media exceptionally well, both for her academic teaching prowess as well as for the broader goal of improving the public’s health. Dr. Arora has won awards from the Society of Hospital Medicine, the Society of General Internal Medicine, and more. She has been recognized as a master educator at the University of Chicago and is an elected member of the National Academy of Medicine. She received a B.A. from Hopkins, an M.D. from Washington University in St. Louis, completed her internal medicine residency and fellowship at the University of Chicago, and earned a master’s degree from the Harris School of Public Policy at the University of Chicago.

So, first of all, Dean Arora, welcome to the Health & Veritas podcast. You are a multitalented physician, scholar, educator, and so I struggled for where we would start. But your academic work around advocacy and misinformation have stood out, particularly during the pandemic. In May of this year, you followed that up with a perspective piece with colleagues in The New England Journal of Medicine, urging that we do more to prepare healthcare professionals to push back at healthcare misinformation as well as other measures to support them in that effort. So, with the recent takeover of Twitter by Elon Musk, are you more or are you less concerned? What can we do? What recommendations can you give our listeners?

Vineet Arora: Thank you so much for having me here. It’s lovely to be here with you, Howie and Harlan, and it feels like being with old friends. So, let’s go to Twitter. Let’s dive right in. So, Elon Musk, or sometimes “Elephant Tusk,” as I’ve seen him being called on Twitter to keep anonymity, I would say, certainly, I’m very concerned about the future of Twitter. I use social media and a lot of different platforms, but Twitter was my gateway drug, as I like to say, and that was how I got involved. I had a Twitter account before I had LinkedIn, before even I had Facebook, which was unique for my generation. That was really the platform that drew me in. I’ve been on it for a long time. I was one of the earliest people on the #medicaleducation hashtag and still remember those early days on Twitter.

I am very sad. I was just recently at the Association of American Medical Colleges meetings with other deans from medical schools and leaders in medical education. Top of mind was what are we going to do? Because we’ve built a community. Everyone expressed their sadness, and I think they express their sadness because the value of social media is in the community. The recent initiatives by Elon Musk have really decimated the community. We’re losing followers, and then the announcements are being made about the verification process being up for sale. And then, most recently, with the parody accounts, even in Elon Musk’s name, highlighting the vulnerabilities of that platform, even Eli Lilly with free insulin. Most people don’t have the time or the savviness to be like, “Let me go dissect what’s true and what’s false,” and so, literally, having an announcement like that, we know that false information spreads like wildfire.

It spreads like wildfire in the resident workroom, it spreads like wildfire on Twitter, and unless we’ve got the staff, the human element to adjudicate those things, which I know a lot of staff have been let go at Twitter, we’re going to see that platform fall apart. Some people are speculating it’s just a matter of weeks. And so, I’m still there and I’m watching, but I’ve diversified my own personal use. I’ve started Mastodon; I’ve been on LinkedIn. LinkedIn is a platform I started using much more during the pandemic when I was associate chief medical officer in charge of engagement. I noticed a lot of our nurses were on LinkedIn, and people were posting their pride for the organization. And so, that’s been an interesting journey to follow as well. So, I think that social media’s not dying, but a platform may be dying, and we need to think about how to safeguard future platforms from this.

Howard Forman: Do you want to just briefly follow up and tell our listeners about the Eli Lilly insulin issue? Because for the three of us, we know about it from Twitter, but many people aren’t even on Twitter.

Vineet Arora: Yeah, yeah. You’ll correct me if I’m wrong, please jump in, but I think that with the new verification up for sale and Twitter Blue, it’s easy to make a parody account. Now you have to say you’re a parody account. Before, a lot of parody accounts popped up, including Elon Musk’s parody account, that just said, “Oh, I’m Elon Musk.” Used the same picture, same with Eli Lilly. And then, one of the first tweets from this supposed parody account that looked identical to the real account was, “We’re going to give insulin for free,” and it got retweeted, sent around the world. I think initially when I saw it, I’ll be honest, when I saw it for a moment, I was like, “What,” because your brain is just processing the information quickly and you’re like, “What is this?” You had to pause, and take a look, and then explode the replies to understand what was really happening.

That’s an example of health misinformation that affects millions of people who are on insulin, but it also was right in the week, maybe even the days right before the midterm election. We know that misinformation and disinformation isn’t just a problem in healthcare. It’s a problem for governments. It’s a problem that’s really underlying democracies and countries. We had a piece in STAT when the New England Journal article came out that you mentioned. We had a piece in STAT, a companion piece, that talked about the bot holiday, which was when Ukraine was invaded by Russia. What a lot of us noticed, we were on Twitter promoting vaccination, was that the bots who were initially accounts that were attacking us for promoting vaccination went quiet.

It was like the eye of Sauron, for any Lord of the Rings fans out there. It was diverted away to Ukraine. And then, all of a sudden, people have actually done studies to show that the same accounts that really promote Russia and agree with Russia also disagree with vaccination. 80% overlap. And so, clearly, there is this manufactured war out there on social media. That’s why it’s important that healthcare workers are aware and engage.

Harlan Krumholz: I wonder, just as a quick follow-up to the other thing you said, you said you’re considering using Mastodon. Do you want to just comment about that? What do you think if people flee Twitter? Is there an option to be able to reconstitute the community?

Vineet Arora: Yeah. Yeah, so as an early adopter of Twitter, I will say that I had been telling people that I was moving away from Twitter, even though I love Twitter and I’ve given talks about Twitter, I actually started telling people earlier this year, “Move over to LinkedIn. I’m moving over to LinkedIn,” and started doing more on LinkedIn because the vitriol on Twitter was so extreme. I found it to be like we’re all burned out and who wants to try to promote vaccination, or public health measures, or even just talk about diversity, equity, and inclusion, things that we value in medical education, and then be quote-tweeted and have right-wing folks that are after you for valuing certain things. And so, I felt that civil discourse had died on Twitter. So, I had been moderating my use, and when the opportunity I learned to join Mastodon came up, I was like, “Oh, gosh. I don’t know if I can learn another platform.”

There’s a guy I follow on Twitter named Nick Mark, who is Dr. Nick, and he had posted that he created a med Mastodon server. I heard that Mastodon was this federated universe of planets, if you will, and you have to choose what planet you’re going to be on. I thought, “Okay. Maybe I’m not ready to join the big Mastodon, but I can follow my friends over to the med Mastodon and learn.” I went over there and I just announced, “I’m going over,” and I actually was really surprised. I saw a lot of people I know, I saw a lot of people who followed me, and then at the conference that I was at, a lot of people were like, “Where are you going? Did you join Mastodon?” It’s getting a lot of buzz, a lot of pickup.

Harlan Krumholz: What’s the advantage of it? How do they manage the filtering and so forth?

Vineet Arora: So, there’s one thing that’s really unique about Mastodon that I like, which is that you cannot quote-tweet somebody. I’ve started to realize that it’s a way to quell a little bit of the violence out there, because you can reply to somebody and engage in the discourse, but you can’t basically say, “I’m going to amplify this person and just trash them to all of my followers.” The other advantage of Mastodon is it’s still early, so it reminds me of early Twitter. It’s got an interesting vibe, techy, a little geeky, which is what I like. People are learning. They’re learning together how to use it. They’re like, “How does this work?” Nick releases emojis and icons. We’re like, “Oh, that’s interesting.” There’s a way to link your Twitter account to your Mastodon account, so that for folks like me, early Twitter in 2009, I had a lot more time than I have now.

I don’t have a lot of time right now. So, for me, it has to fit into my workday. When I was at the conference, when I would post to Twitter, it would auto-post to Mastodon. I was getting more robust interest and replies on Mastodon than on Twitter, better answers and questions. I realized that my community, people who want to engage were moving over to Mastodon. They were like, “Please reply on Mastodon,” and I moved over and I would reply to them. And so, with all social media, you get what you put in. I think that we’re growing as Mastodon grows, and we’re going to learn from that. The interesting thing about it is it’s not owned by—it has one owner, but these universes, it’s like being in a Facebook group with a moderator. The moderator has a lot of influence, and so, trust in the moderator.

This guy, Nick, he created this medical education, like shorthand ICU pearls, during the pandemic that got a lot of traction. That’s one of the reasons I started following him, being a trusted person to be like, “Okay, if you’re redeployed to the ICU, here’s this ICU pearl that you can follow along.” I felt he has a good heart, his mission’s in the right place, and that was what drew me to being like, “Okay, I have a trusted person who I think would do a good job moderating all of this on Mastodon.” But I don’t know where we’re going to end up. So, I don’t know. Have you guys switched to Mastodon?

Harlan Krumholz: No, but after hearing you, I think it might be worth some exploring.

Howard Forman: I have an account there. Yeah, I have an account.

Vineet Arora: I know, I follow you!

Howard Forman: Yeah, it’s a much more limited thing, because as you said, it’s federated, and I just joined on the social one. You have to figure out where to survive. I may think about switching to your server.

Vineet Arora: Yeah, it’s growing exponentially, but it’s clunky. I posted on Mastodon, “This is so clunky. What do we do?” And you know what the answer I got was? “The clunkiness is us.” “We embrace the clunkiness.” So, there is a little bit of a culture of Mastodon right now. That’s something that we have to respect. There are people that are there, and there’s a Twitter migration. What will that do to the culture of Mastodon is an important question for those who really like Mastodon.

Harlan Krumholz: That’s nice. You guys are ahead of me. I’m going to have to try to catch up and check this out. I wanted to just pivot to one other quick area. The world of medicine is changing so rapidly, and yet, a lot of the teaching and approach to education is still anchored in the past. In a way, we’re teaching medicine from the past and not looking forward to the future, a future that’s going to have a lot of televisits, that social media is a big part of, that people are going to be having mobile devices. There’s going to be a lot of DIY stuff out there. There’s an ecosystem of medicine in the future that’s going to be vastly different than the one that we grew up in, and yet, even when...I wrote this piece and said, “I think the stethoscope is not providing important information.” I said, “Stethoscope is dead.”

It’s nice to show, but if you do study, after study, after study about skills people have with auscultation, it reveals that doctors are no longer able to discern heart sounds in ways that have diagnostic accuracy. Whether they could 40, 50 years ago, I don’t know, but I know now, it’s not good. I know we’ve got sensor technology that could just solve this problem, merely pattern recognition. The blowback was like, “How can you possibly say that we’ve got to be doing this? We’ve got to be putting this stethoscope on,” without even just recognizing, “No, maybe we need to move on from what’s not working [to] what is working.” And so, how are you thinking about this as you’re educating people, engaging in curricula, and trying to create objectives about what people need to know? It’s a challenge, right?

Vineet Arora: Yeah.

Harlan Krumholz: The world’s rapidly evolving.

Vineet Arora: Yeah. No, that’s such a great question and thanks for this amazing question that comes at a time that I’m thinking about this a lot. And so, I actually moved over from health system leadership to educational leadership to take this role. It struck me, I was knee-deep in pandemic operations and how much innovation we stood up, and then I came over to the medical school and I was like, “Wow. We have a traditional curriculum and it’s still a one-to-many lecture.” We know a lot about learning. We know a lot about active learning and immersive learning, simulation, technology, and education even is advancing. But I do think that we are very slow adopters in medical education. Why is that? One reason is funding. There’s just not the NIH of medical education to accelerate innovations. And then, I think we all know in academic health centers that tripartite mission. Education happens to be the afterthought sometimes, and it really needs to be upfront and center.

And then, I do think that we sometimes get stuck into this rinse-and-repeat cycle and change is very hard, even the way we change the emotions of change. Trainees hate change. So sometimes, that keeps us anchored in an old reality. But I am really struck by the way the pace of digital health, AI, even the practice of medicine when I go attend is changing, but we’re still stuck teaching old methods. In fact, sometimes we hear people say, “I know you learned this second year or first year this way, but here’s how you really should present,” and I’m like, “Why are we saying that?” So, how can we reconcile this? One of the things that we have done is to launch curriculum renewal here. So, within the first 90 days, I’ve looked at a lot of leadership books, I used the social capital and timing I had, we have not changed our curriculum since 2009, but we have an amazing team here ready to change.

I looked at a lot of change management principles, leveraged a lot of public policy, organizational policy theory that I had learned, and thought, “Well, if we’re going to change, it’s got to be now and I can be the turnaround person to do it with, at least bring the vision, while I’ve got this amazing team who’s going to build the architecture.” And so, within the first 90 days, we launched a curriculum change here called Evolves, a renewal process, “Ensuring a Vision of Leading with our Values.” The reason that name was so important is because we don’t want to throw the baby out with the bathwater. The mission and vision, we feel, is very important here. We’re here on the South Side of Chicago.

We are the only Top 20 research medical school that’s also on the Top 10 most diverse ranked list, with 36% of our students coming in underrepresented in medicine. A third are coming in identifying as LGBTQ+. We have doubled the number of students from low-income households. So, we have really tried to live and breathe diversity, equity, and inclusion. A lot of this work predates my arrival. I’m inheriting this work from amazing leaders, but we want to be important cultural stewards of that. We don’t want that to get lost. And also, why do people come here? They come here for this health equity, social justice mission, learning about healthcare system science and being immersed here in the University of Chicago and also to serve our patients and our community. So, I’m very data-driven, so we started with crowdsourcing. We sent out a survey to everybody in Phase One, said, “Tell us your ideas, but also tell us what you want to preserve.”

We had alumni, residents, faculty, all sorts of people engaged, students. It allowed people to feel that the change was coming and they could contribute to the change. They told us a lot of this, they told us what they value. They also told us what they need changed. We have a very traditional 2 + 2 curriculum and it’s very lecture-heavy in the preclinical. And so, they really valued also this focus on research. We have amazing students. They’re always presenting at conferences and 90-plus percent of them publish in peer-reviewed abstract or publication format, which is not even a requirement, but it’s like well above national average. So, they told us what they wanted preserved, but they also told us what they wanted changed, and we had to listen to that. That meant some critical conversations. We’re in the Biological Sciences Division, where we are co-sharing our building with basic scientists, and we need to bring everyone to the table to say, “How can we compress the curriculum but also use better techniques?”

We are a school, not unlike others, that when the pandemic came, flipping a lecture to a Zoom with just boxes of 100 people and having that go on from 9:00 to 5:00, that’s what I did at Wash U and my curriculum, it’s got a new curriculum now, it does not fly. It actually compounded the mental health crisis that we are seeing in our young people. I saw this with my daughter. So, we have to get to building community but active learning and deploying better engagement. The other thing that I will tell you is when I was in the hospital, we’ve always viewed students and residents as learners. “Oh, what can they do?” It’s always a deficiency model. “Oh, you can’t do this yet. Make sure you dwell here and learn more.” But how do you learn? Maybe you learn in a classroom and then you’re going to go practice on a patient.

In the pandemic, something really interesting happened, which is the hospital opened its doors. I remember getting a call from the HICS [Hospital Incident Command System] team being like, “Can you mobilize volunteers to help us with this, that, or the other thing?” So, we opened the doors. The students answered in droves. They were standing up telehealth, doing hotlines, building platforms, doing literature searches to support the COVID unit. You got it. Basically, it showed us that our students and residents are more than just learners. They have value-added roles they can play and learn from. And so, that’s what we’re doing right now, is how to really convert some of the things people were doing on a volunteer basis to say, “This is a learning experience and a value-added experience,” and how to connect the dots so that you experience the health system and can actually contribute in an earlier way. Many of our students worked at Epic, or took years off, et cetera. How do we deploy that and say, “You are actually part of our team, and here’s how you’re going to help.” So, that’s a short summary of our curriculum effort.

Harlan Krumholz: This is what we came to hear. I wanted to bring one last thing up before our time is over. You introduced me to CO2 monitors. Harlan and I talked offline about that. But more importantly, there’s an article in The New York Times this week that says, “As the pandemic drags on, some people can’t let go,” or something like that. It’s true. There are people who are absolutely still living in fear and then there are other people who have just ignored the pandemic. You’re smack dab in the middle, using an evidence basis to make decisions about your life, about your career, about your children’s lives, your husband, your family, and so on. Can you just give us a quick sense of how you think about the things you do in order to maintain what is, in my opinion, as close to normal as you can get, while also being very protective of yourself and others against COVID?

Vineet Arora: Yeah. No, that’s an interesting question. I’ve definitely evolved my thinking, but I also have to think about people I protect. And so, when I get close to traveling to see my family, who are at risk, or visiting other at-risk relatives, I am much more aggressive about things like masking and testing. But at the same time, there are things that I want to live my life. I want to go to the conference and go to dinner with colleagues and friends. So, I take calculated risks. A friend of mine who’s a pediatrician, who’s a big fan of Frozen, so she quotes Olaf from Frozen, which is, “Some people aren’t worth melting for.” And so, the people on the plane when I’m traveling, I’m like, “Yeah, I don’t have anything against anyone, but I know statistically speaking, there is probably a higher risk here, so I’m going to mask up on the plane and in transit.”

I’m going to also teach my kids, within reason, to try to help do that. I also had a baby during the pandemic who was unvaccinated for a large portion of the pandemic, and when we got COVID, because we did, it’s hard when everyone dropped masking, it came to us through the school and affected my son. It was hard. He was sick. He was more sick than you would just say is mild and he also had to be home for 10 days, because at the time, CDC said, “If you’re unvaccinated and can’t mask, you need to stay home for 10 days.” So, we could not have him in childcare for 10 days and that led to me missing, as a first year dean in medical education, a lot of graduation events and our reunion. And so, I was like, “This is a big compromise.”

So I live and breathe it. We make decisions to support our students who are largely low-risk, being able to gather and be social and make personal decisions, but we also want to be honest with the fact that there are going to be people who want to be protected at times. We have doctors on our staff who are immunocompromised and staff who are immunocompromised, so we need to respect that as well. I wish there was better civil discourse about this and more empathy for each other, because I see it both ways. Unfortunately, I don’t see that a lot right now, so that really is painful.

Howard Forman: Well, I appreciate your thoughtfulness about this.

Harlan Krumholz: Anyway, thank you so much. This is just terrific. Howie, she’s got so much charisma. She’s such a great communicator. I’m so glad that we were able to have her.

Howard Forman: We’ve got to have her back, and thankfully, hopefully, we can have that opportunity.

Vineet Arora: Yeah, thank you guys so much, and look forward to seeing you in person someday.

Harlan Krumholz: So, that was a great interview with Vineet, Howie. So, let’s pivot to the next segment. What’s on your mind this week?

Howard Forman: Yeah. So, one election outcome that I was not following last week, when last we spoke, was the magic mushroom vote, or Proposition 122, in Colorado.

Harlan Krumholz: I didn’t know about this.

Howard Forman: Yeah, I know. So, it passed by a 5% margin. It decriminalizes the possession and use of hallucinogens by people over the age of 21. It begins to create a regulated environment.

Harlan Krumholz: Just to say, hallucinogens, so these are hallucinogens?

Howard Forman: Yeah. Yeah. So, this is like psilocybin, like LSD, but psilocybin is the big one that I’m going to talk about. These are drugs that induce hallucinations and people have used recreationally, but now they have clinical use. Oregon passed a similar bill about two years ago, and they’re going to first start really putting it into place this coming January. So, there’s no state that really has an apparatus about this yet. This comes on the heel of a recently published study in The New England Journal of Medicine, it was about two or three weeks ago, that demonstrated a significant positive effect of a single dose of psilocybin, which is a hallucinogen, for the treatment-resistant depression. So, this is debilitating. It’s also an all-too-common illness, depression that does not respond to treatment. Therapeutic breakthroughs are few and far between otherwise, despite the fact that billions of dollars are being spent on this, on several classes of drugs.

So, at first, I was just fascinated by the study, because hallucinogens have been purported to be effective for depression, for alcohol use disorder, and for anxiety for several years. But well-done trials have been sparse until recently. This one that we’re talking about today is a Phase 2 trial, and it’s pretty compelling. But the accompanying editorial in The New England Journal of Medicine is what drew my attention, almost conceding that the treatment likely works, at least in the shorter term. The author of the editorial raises serious questions about how this could be implemented in alignment with the trial. So, get this. Sessions are six to eight hours in duration. They’re conducted in a non-clinical calming living room–like environment with participants listening to a specially designed music playlist and isolated by eye shades and earphones. At least two personnel are actively working with the patient during this time and therapist training is considered intensive.

Is this what the regulated environment in Oregon or Colorado is going to look like? This is a risky drug. Side effects were not insubstantial, by the way. They include nausea, vomiting, severe headache, but also suicidal ideation, self-harm, major depression exacerbation. There are going to be more trials to go before this treatment could really be mainstream clinically, but what we’ve learned from this trial is still valuable, and we’re going to see synthetic drugs that might be safer for the future. I, personally, am all for decriminalizing drug possession, drug use, and drug sales to people over the age of 21. In general, that’s how I hold, but I am really worried that this therapy will be commercialized faster than the evidence might support. The trial I mentioned, by the way, is sponsored by just such a for-profit entity. I’m hoping that the regulatory process in Colorado will follow the methodical process being enacted in Oregon and go really slow. This may well work, but these drugs can be very potent. We should continue to collect the best evidence and we should use it to guide the right therapy for each individual.

Harlan Krumholz: Yeah, you’re making a really good point, Howie. I was talking to Gerry Sanacora, who’s one of our great psychiatrists and researchers here at Yale, about this trial. Let’s just be clear for people listening, it is a Phase 2 double-blind trial, an early one. Only 79 people. There really was no control. They tested a 25-milligram group, a 10-milligram group, and a 1-milligram group. So, they took everyone through all of this and they really were trying to see whether or not there was a difference in the dosing. What they saw was that the 25-milligram but not the 10-milligram reduced depression scores more than the 1-milligram dose.

So, again, this wasn’t a large-scale trial, and as Howie has described, you could wonder whether or not some of the effect, in the context of all of this, was because of the attention that they were getting and the context that was provided. Anyway, you’re right on, Howie. Solid here, because it comes out and gets promoted as a positive trial, but you’ve got to really look at how it was executed. It’s simply not scalable in this way, and it’s not even clear to us, very small, that this thing is going to be what it means. And meanwhile, they’re passing laws to say people can try them recreationally. We got to be very careful with this.

Howard Forman: Yeah. You could easily imagine this being used recreationally very soon if Colorado and Oregon aren’t careful about how they roll this out.

Harlan Krumholz: Yeah, absolutely. 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 Twitter.

Harlan Krumholz: @hmkyale. That’s hmkyale.

Howard Forman: And I’m @thehowie. That’s at T-H-E-H-O-W-I-E. You can also 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 you can check out our website at som.yale.edu/emda.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Jenny Tan, and to our producer, Miranda Shafer. They are amazing. Talk to you soon, Howie.

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

Department: Faculty Viewpoints

Topics:

Healthcare