Lauren Taylor: Ethics and Public Health (Health & Veritas Ep. 29)

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 the latest episode, they talk with NYU’s Lauren Taylor about the “dirty hands problem” and other ethical dilemmas inherent in efforts to improve health.

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
Harlan M. Krumholz
Harold H. Hines, Jr. Professor of Medicine and Director of the Yale Center for Outcomes Research and Evaluation
Lauren Taylor
Assistant Professor, Department of Population Health, NYU Langone School of Medicine

April 14, 2022

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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. We’re trying to get closer to the truth about health and healthcare.

This week, we will be speaking with Professor Lauren Taylor of New York University, but first, we like to check in on current health news. And Harlan, there’s an original investigation in JAMA Network Open today that reports that there is a decline in life expectancy in the U.S. during the first year of the pandemic, so 2020, on a scale not seen in 21 peer countries, substantially widening the preexisting gap in life expectancy between the U.S. and these peer countries. 1.9 years in total, and this is disproportionately falls on Hispanic and non-Hispanic black populations. For Hispanic populations, the loss of years of life expectancy was 3.7 years. It’s just a mammoth number for a single year.

We did worse than some of the hardest-hit regions in Europe. Our white population did worse than Belgium and Italy. So this is not just about race but our overall poor outcomes compared to peer nations, many of which we don’t even consider to be in our league, quite frankly. Our nation continues to have to reckon with life and public health and issues between the two, but I continue to fear that we are not ready to have this conversation and have allowed these issues both about life expectancy, outcomes, individual and public health, we’re allowing this to get ever more politicized. I know you are also working on outcomes-related COVID papers as well as geography. Do you have thoughts on this particular paper?

Harlan Krumholz: First, I think it’s hard to make these calculations about life expectancy in real time. These are projections. It’s not like you follow people from birth. You’re making calculations based on mortality rates and information that you’re gathering about the population. And of course, in a place like the United States, things are changing. I mean, we didn’t get a lot of immigration over the last two years. There was a lot of deaths, trying to figure out what you attribute them to and how you do this.

But look, this is very consistent with the message that we’ve seen from a lot of different directions, and I think it’s reasonable to have confidence that we did poorly relative to other places with regard to outcomes related to the pandemic. I mean, we did really poorly. And in a way, I think it was a choice in this country. It was a choice to say, we’re going to let states define policies. I mean, if we had done as well as the very best places in the country, I think we would’ve rivaled some of the best places in the world, but this is a big, diverse country that’s essentially in the midst of a struggle, a struggle of ideas, a struggle of seeing the world in different ways. And as a result, there were lots of lives lost in this country that probably could have been, you know.... Those were preventable deaths.

Howard Forman: Yeah. I agree with you. And look, it ties in with our guest today, who has spent a lot of time looking at how the richest nation in the world is not able to deliver on that promise of wealth and income superiority, so to speak.

Harlan Krumholz: Yeah. Yeah. Impressive paper, though. If anybody wants to take a look at it, it’s an impressive paper.

Howard Forman: I’m excited to introduce Professor Lauren Taylor. Lauren Taylor is an assistant professor in the Department of Population Health at NYU Grossman School of Medicine, where she studies governance and management of health improvement efforts within the U.S. and abroad. I first came to know her when she was one of our first elite BS/MPH students at Yale. And then she worked with Betsy Bradley, the current president of Vassar and our friend and former Health & Veritas podcast guest, as a co-author of The American Health Care Paradox, a groundbreaking book about the social determinants of health that is now required reading at many medical schools. After leaving Yale, she earned her master’s of divinity at Harvard’s Divinity School and her PhD in health policy and management from Harvard Business School.

And before I ask a first question, I just want to point out how unusual this background is, but how much you have integrated so much of what you’ve done, both in the classroom as well as content creation, to get you to where you are in your career right now. And I just wonder if you want to say just a brief words about the timing of the divinity degree in context with getting a PhD in health policy and management.

Lauren Taylor: Sure. Thanks, Howie. It’s fun to be here. So I was working for Betsy Bradley and working at Yale at what was then the Global Health Leadership Institute, doing a lot of international travel, thinking about monitoring an evaluation of big global health projects. And what led me to divinity school was really something that I think a lot of young people face, maybe people of all ages, but I started to have questions about kind of like, what is my purpose here? Am I doing something uniquely well or that I am uniquely suited to do? And how do I think about kind of professional integrity and what it means to live an honest professional life. And global health is full of, lots of mixed incentives, just like U.S. healthcare is. And I think I was just really looking to take some time to step back and ask some hard questions of myself.

And really, when I went to divinity school, I thought that I was going to step back from research and policy altogether and wind up doing hospital chaplaincy. That was the plan. And it was only when I went and I spent a couple years training as a hospital chaplain that a really generous chaplaincy mentor sat me down and said, “Lauren, we could make you good at this.” And I said, “Oh boy. Well, that clearly means I’m not good at it now.”

And she said, “Well, you know that chaplaincy is all about being at the bedside and simply being present and accompanying people, but you have an instinct to fix things. And you know intellectually that that’s not the right instinct to bring to the bedside, but you can’t help yourself. And so we can train you out of that. It’s just going to take years and repetition. But before you commit to that, I want you to really ask yourself, is this the best use of your gifts?” which of course was a devastating conversation to have at the time. I thought, “Oh, what have I done? I screwed up. I spent this time at divinity school, and now I’m not going to be a chaplain.”

But that’s then ultimately what set me back on the path to do my PhD and to say, yeah, she was right. I do have an instinct to fix things. I’m not an irrepressible fixer. Next to Harvard MBAs, I look very low-key, but I had more of an instinct to fix things than the average chaplain. And so navigating that instinct to fix things with an instinct to kind of be reflective and thoughtful and not leap to action is what I try and do in my academic work now.

Harlan Krumholz: Oh my God, that’s one of the best answers I’ve ever heard on Health & Veritas. Gosh, that’s just so powerful. There’s so much I want to talk to you about. You really combine this sense of fixing it, but I do think that your divinity background has given you an ability to take an ethical perspective on the work in global health. And I want to get to that in a minute.

But just for our listeners, because many people might not be as familiar with your book, the book you did with Betsy, and it remains a groundbreaking book, I just wonder if you want to give them a sense of what the main message was, because it’s really powerful. It’s different than what people have heard. I still feel we haven’t fully internalized the message or acted on it in the ways that maybe we should. But can you just share with the group a little bit? What was the premise of the book, and what did you find in the work you did?

Lauren Taylor: Sure. So the book was The American Health Care Paradox. It’s now going on 10 years old. So it came out in 2013. And the premise of the book was to say, look, we’ve spent a lot of time, energy, and kind of political will trying to reform healthcare from the inside and to try and fix drug pricing and tort reform and other healthcare fixes, but maybe it is high time we look outside the healthcare system for some levers of influence. And specifically, we were saying social service spending was a place and social programming really was a place where we could potentially move the needle meaningfully on health outcomes, because in many cases, those social programs or kind of social determinants of health—the nutritional status, access to transportation, the quality of housing—are hugely impactful for people’s health and often more impactful, we think, than the quality of the medical care they receive.

So that was the gist, and it started with an empirical look in Chapter 1, and then from there, and what we really did with the time we had writing the book was to do some new research, historical and kind of ethnographic around the United States, to say, what would it look like to try and bring healthcare and social services closer together? Why is it historically been so difficult to move these behemoth bureaucracies into even conversation with each other, to say nothing about coordination? And so really, we were, I think, on the beginning edge of the conversation about increasing attention and funding for social determinants of health back in 2013.

Harlan Krumholz: A very powerful book. It sort of takes a stab at why, year after year, despite all the talk about reform, we really actually end up spending more and getting less out of healthcare, at least not getting the return on investment. And you guys went after it and said, well, maybe if you look at the systems that are really getting more returns, they’re having a more balanced investment in a wide range of areas, not just in healthcare.

The way I read—first, I think it’s just as relevant today as it was then, unfortunately. It’s just as relevant. We haven’t made much progress, but it still remains a light in the darkness around where we might go. But I also interpreted around health equity because I think that when I look at our march towards eliminating disparities, healthy people, the United States government call for what our aspiration’s going to be in the next year. 1990, “we have healthy people, 2000.” In 2000, “we have healthy people, 2010.” The government keeps saying what its aspiration is for 10 years coming. Even the 2020 going to ’23, they say, “Eliminate disparities. We’re making no progress.”

And in part, it seems to me that investments within healthcare itself exclusively are going to fail to address issues of health equity within our state. We have work to do within the healthcare systems. There certainly are issues to address, but that can’t be the whole picture. And so I just thought your work... I wonder what you think about that, but I thought your work has as much relevance to solving issues of health equity as they do towards just reforming healthcare efficiency and productivity and return in general. What do you think about that?

Lauren Taylor: Yeah. I think that’s a generous read, Harlan. I think if we were to do the book over again now, 10 years on, in fact, we might have framed it much more around health equity. And I think we faced a real strategic question in doing the book back in 2012, 2013, and that was, look, we’re going to talk about social services. We’re going to talk about social determinants of health. The kind of image that first comes to mind for people when you think about social programs is the welfare state, the welfare queen, poor people, and often people of color. And Betsy and I, at the time, said we really want to push back on that and try and make an argument that social determinants of health are relevant for everyone.

Harlan Krumholz: Yeah, definitely. Sure.

Lauren Taylor: And so we went with that tack, and we did not, I would say, double down as much on either race or class or health equity, as in saying, look, we’ve got disparities, and this is a particularly prudent and important strategy for kind of bringing the bottom up. And I think if we were to do it again, or if I were given the chance to do it again, I would frame that differently now. I would be much more intentional and explicit about saying, look, of course, social determinants of health as a concept are relevant for everyone. Fine. Take that at face value. But as a policy matter, the place where we’re really going to see a lot of movement from additional investment in social services and social programs is not among those of us who have corporate jobs and corporate commercial insurance, et cetera. It’s among the folks who rely on those programs. And so frankly, if I were to do it again, that would be something I do differently.

Howard Forman: You wrote a paper almost four years ago now that you entitled “How Do We Fund Flourishing?” But the paper addresses the issue, which we see every day right now, that a lot of novel payment schemes by states and even the federal government look to repurpose healthcare dollars to be used to address issues of social determinants of health. And you write this paper talking about the unintended consequences that might fall from that, that while the premise might sound good, it may not be the best strategy or tactic. Do you want to just speak to that a little bit and explain?

Lauren Taylor: Yeah. So this is something that I think I’ve evolved on in the 10 or so years that I’ve been thinking about it. And I would say initially, meaning when we were working on the book, I think I was where many people frankly are now, which is saying, look, we have real social needs. People lack basic goods that are highly influential for their health. We need to remedy them. So what’s the kind of easiest way to do that? And I worked in health policy and health services research. So I said, “Let’s run some additional monies through the healthcare system.”

And I think, as you’re saying, this is still a really prominent strategy and one that a lot of people are really enthusiastic about. So you think about, you had Mandy Cohen on the pod, North Carolina’s Medicaid waiver, totally groundbreaking, in part for its willingness to set prices for social services and use Medicaid dollars to pay for those things.

And I’m not saying that I think that is the wrong way to go, but I think for my own clarity, I try and keep in mind, “Okay, what’s first best and what’s second best?” In an ideal state, first best, I think we want to run these monies through social services. I don’t think we want to use healthcare as a flow-through (a) because it’s going to make everything more expensive, (b) because it’s just bureaucratic. Now, you’ve got to try to send the money from Medicaid to a healthcare system and then wrestle that money out of a healthcare system through some contracting process to a community-based organization. And I think it maybe gives undue influence to healthcare people to decide what is valuable, when that should be a democratic process, or at least a process made by policymakers who are really educated and thoughtful about social policy.

So I would just say first best, my preference, and this is what I lay out in the paper you’re referring to, is can we galvanize the political will to do this kind of right and do it through social services? Now, we’re a long way from a first-best world, right? We live in a deeply, politically vexing scenario. And I think for better and for worse, as much as we talk about trying to bring down healthcare costs, there’s just always more room in a healthcare budget, and hiding a little bit of money for social determinants of health in a Medicaid budget or even in a health system budget kind of doesn’t generate much attention.

And so there’s a really politically expedient argument for saying, look, there’s moral urgency to meeting people’s needs—transportation, housing, food, safety. And so however we can get that done, we should get it done, and maybe that’s through healthcare. And I think that’s where I am, in kind of sitting uncomfortably with the reality that the world is as it is, and funding things right now through healthcare may be the best we can do. It’s not my first-best preference, but it’s something I’m willing to live with.

Harlan Krumholz: Lauren, I want to talk to you about some of the moral issues that arise in doing global health, and there are two that come to mind. This week in The New England Journal of Medicine, Lisa Rosenbaum, a friend and cardiologist, has written a piece. She’s a national writer for The New England Journal of Medicine. She writes always a lot of thoughtful pieces. She wrote “Unclouded Judgment—Global Health and the Moral Clarity of Paul Farmer.” And she talks about how Farmer sort of rejected the constraints imposed upon him by other organizations and often aspired to do other things.

But in doing so, she talks about how Farmer was often making choices. And for example, somebody that he ran across in Haiti who needed valve disease and, well, they were able to garner twenty, thirty thousand dollars to medevac the person ultimately to Mass General and get surgery. And talking about the trade-offs of what that money could have done on the ground in Haiti, in terms of, for many people, or there was a story about where he walked for two hours to see two people, and the person walking with him was sort of questioning, “Well, you could have seen 20 people or 30 people, if you hadn’t traveled so far.” And he’s saying, “Well, every life’s worth is much as every other life, but there’re constantly all these trade-offs.”

So there’s a issue of how the money is distributed. I mean, we live in a society of abundance where we waste dollars all the time in healthcare, but when we do global health, we’re often in environments where it’s just so darn resource-poor that every dollar spent is—you can actually see what the effect of where it wouldn’t go, right? Because it’s not that there’s abundance. There’s that ethical dilemma. And then the other ethical dilemma is working with people, teams, governments that may not share the kind of values that you have. And trying to figure out, am I strengthening values that seem antithetical to what I believe in, in the interest of trying to save individuals, or am I actually doing the right thing by working with them?

To me, those are two really critical things that kept plaguing me as I was working in the global health area. I wonder if you, with your experience and background, have you reflected on those two? And I just wonder if you have any comments on either or both of those issues.

Lauren Taylor: Absolutely. Two great, deep hard issues, the kind that you just live with. You don’t solve, or at least, I have no intention of solving, but rather living with. The first is really... And Paul—my goodness, I still can’t believe that we need to talk about him in the past tense—was such a giant in the field. And I agree with you that he was intentional about pushing back on a cost-effectiveness paradigm as the only relevant one for decision-making.

And I actually had a chance to talk to him on stage. Gosh, now going back to my divinity school days, it was probably 2014 or 2015. And we had him at Harvard Divinity School because he had just written a fabulous book with Father Gustavo Gutiérrez, and it was called In the Company of the Poor. And the book was kind of not one of his best known. He’s got Pathologies of Power, and he’s got kind of the canonical Farmer, but this was a small book that he wrote with this Jesuit priest, where they discussed at great length the way in which liberation theology had inflected and animated Paul’s life and work in Partners In Health.

And I asked him, I said, “So, Paul...” I kind of put it straight to him, and I said, “So what do you think about all this cost-effectiveness stuff?” And I think I overstated the question and I said, “Isn’t it all bollocks or something?” And true to form, he was so thoughtful and nuanced, and he said, “Look, I don’t want to throw it out. It’s not as if there’s no value because in a very real sense, there are scarce resources in the world, but I just want to push back on the idea that it’s the only relevant paradigm.”

And I think... I don’t remember him saying this, but when I think about his life, I think he was totally willing to be respectful of cost-effectiveness kind of metrics and rationing schemes, if you will, when he was sitting in his kind of executive chair, running Partners In Health and kind organizing the stuff, system, space, et cetera. But I think when he was in the field, being that human clinician, he was just not willing to use that frame anymore, and he was much more interested in accompaniment as kind of a moral guide and a moral, yeah, just framework. And so that meant—

Harlan Krumholz: Yeah. I sort of thought it’s like he brought his doctor eyes to population and global health in that way. I mean, I think most doctors act that way. They can engage in conversations in rooms with others, but when they’re sitting across from their own patients ... and he made everyone his patient in a sense, and he fought for them in that way. But anyway, that’s a poignant story.

Let me just ask about the other one. I just wonder when you are aligned with governments or values that conflict with yours, how do you manage that?

Lauren Taylor: Yeah. This is one of... In philosophy, it’s known as the problem of dirty hands, and it’s the question of how willing are you, as a moral agent, to sully yourself or dirty your hands by associating or collaborating with entities whose views you don’t agree with. And I think the most relevant work here is a study that I did in Ghana, where there was a group of completely biomedical, by-the-book, as you and I would understand them, psychiatrists working at the University of Ghana Medical School. There’s a hugely underresourced mental health system. So you’ve got something like 12 psychiatrists for a population of 25 million people. What fills the gap? A robust informal sector of what are known as prayer camps, and these prayer camps have varying levels of kind of quality, if you could even call it that, but some have documented histories of human rights abuses.

And so a key question for the kind of psychiatrists of Ghana is, to what extent are we willing to go out and collaborate with these prayer camps to gain access to patients who see them as totally legitimate sources of care? And so this brings this question of how dirty are you willing to get your hands right to the fore? And my experience watching this unfold in Ghana is that the physicians who I very much respect said, “Look, we owe those patients the best possible care we can get them. If that means we have to kind of sully our names or cloud our own consciences by virtue of getting into some kind of arrangement with these prayer camps, we are willing to do it in some sense, because the ends justify the means.”

Now, I think that that calculus can change for me when it’s not a relatively anonymous group of physicians, but it’s instead MSF, right, Médecins Sans Frontières, or it’s the American Red Cross, because I do think there can be huge signaling value when a real public name brand is willing to affiliate. And seemingly, the concern is that you’re not only affiliating but endorsing the practices of the government or the tribe or the whatever it is.

And so there are cases where I think it comes down to a cost benefit. How many people do you think you’re going to be willing to help? And what would be the negative consequences of allowing your brand and name to seem to give a sort of valance or kind of check mark to the bad actors?

I mean, this just came out. Did you see the NBER [National Bureau of Economic Research] paper, where it was a bunch of economists here in the U.S., and they had used a Donald Trump advertisement to try and drum up vaccine enrollments? And it was hugely effective because, guess what, there’s a lot of people out there who think Donald Trump is an authority on all sorts of things. And I think the public health community generally squirms and says, “Ooh, I don’t want to be seen endorsing anything. Donald Trump says there’s many problematic things.” But in a pandemic and a public health emergency, I think I’m on the side of that one of, you take the clip you want to take. If he happens to be saying something good? Back it, put it out there, get shots in arms.

Harlan Krumholz: Yeah. Yeah.

Howard Forman: I’m just going to ask one quick question, because I know we’re short on time, but there is a paper you just published in Stanford Social Innovation Review, I think is what it was called. Very related to what we’re talking about, but much more relevant to the current moment, which is on the dirty money dilemma. And specifically for me, I talk to people often about, right now, what if a Russian oligarch wanted to give Yale money? What if somebody whose name was impugned for whatever reason, or has been previously criminally prosecuted, but already published, wants to give money? And you have this paper talking about how to think about that, which I think is highly relevant to nonprofit institutions, including healthcare institutions.

What are your thoughts on that?

Harlan Krumholz: You mean, whether we should take money from oligarchs? Is that the—

Howard Forman: That’s one question. I mean, it’s not... I think the oligarchs just gets you thinking about it, but it’s also, do you take money from somebody who’s been released from jail? Do you take money from... I think you start the paper off talking about the Sackler family as a great example of that. Not an oligarch, but an impugned name and rightfully impugned.

Lauren Taylor: Yeah. That’s right. Thanks, Howie. Yeah. So this was a big part of my dissertation work at Harvard Business School. This was how I tried to bring together a training at Harvard Divinity School and Harvard Business School, was thinking about what, if anything, is the problem with dirty money? And I think some people, many times it’s my economist friends, will say to me, “There can be no problem. There’s no such thing as dirty money. Money is a fungible unit of exchange. It carries no moral valence.”

And so I started from, can I really make the case that there’s something other than baseless moral panic to the discussion about dirty money? And I think where I landed is, there is something there, and it’s not just baseless moral panic, for two reasons. One is, well, first I think it’s important to say what we typically describe as donations are really two-way exchanges, right? To say something is a donation makes it think that I give something to Harlan, but it kind of hides the fact that generally in a donation, Harlan’s giving something back to me.

So then we have to ask ourselves, what’s Harlan giving back when Harlan is a nonprofit and I’m a donor? And I think there’s two things that generally cover the territory. One is he gives me influence, and this is the kind of conflict of interest that I think gets talked about in health policy the most, right, with pharmaceutical companies trying to wine and dine doctors, and they’re gaining undue influence over the doctor’s prescribing habits.

The second piece, which is I think a little bit more novel, is to say the other thing he gives me often is recognition and public recognition. And this is the naming of the buildings or the saying, “ExxonMobil is our corporate citizen of the year.” And that’s a nontrivial benefit that donors get and that donors can then use to go on and potentially continue a track record of things that we think are cutting against the public interest. One example is Jeffrey Epstein used routinely his record of philanthropic donations in court cases when he was on trial as a sex offender. And he said, “Oh, judge in court, you need to really think about all of the good things I’ve done.” And so when nonprofits accepted that money, they were giving him that ability to make a case in court.

And so that’s really what the paper is about, is trying to be very specific about what the potential harms of accepting “dirty money” are, and then try and lay out a framework for nonprofit boards and senior managers to try and reason through what I think is ultimately a cost-benefit analysis. I don’t have a strong deontological stance or a sense of, there’s clearly a bright line here, that you can’t accept these types, but you can accept these types. It’s all highly contextual, but I just tried to map out a bit of a strategic framework for how people would think through the choice.

Howard Forman: You have really fulfilled sort of Yale’s dream of “Lux et Veritas,” light and truth. And it’s just such a pleasure to have you on the Health & Veritas podcast. So thanks very much for joining us.

Harlan Krumholz: Yeah. Thanks so much, Lauren. It’s just so terrific to hear you and learn from you. Thank you.

Lauren Taylor: Oh, thank you guys for having me. This was fun.

Howard Forman: So Harlan, is there anything that’s been of particular interest this week?

Harlan Krumholz: Well, I mentioned that piece in The New England Journal of Medicine about Paul Farmer before, and there’s another interesting article in The New England Journal of Medicine this week, the April 14th issue. So Howie, what do you think is the best way to treat a ruptured Achilles tendon?

Howard Forman: I have a... It’s funny. I saw the article, and I know a lot about this because of radiology, which is diagnosis, but not a lot about treatment. I mean, weekend warriors get this injury. And I would’ve presumed that sewing it up is the best repair.

Harlan Krumholz: Oh my God. I wouldn’t have thought that there was any question about that. Maybe this thing breaks, and then don’t you just go in, open up the heel, stitch it back together and then let somebody heal, and then heal their heel, and then go through rehab and get better? We only have seen this thousands of times with star athletes who then... It’s happened to Kevin Durant, Klay Thompson in basketball. I mean, I don’t know if any of those you are following. But there’s a long list of people. And it usually by the way is when they’re just standing there. I mean, it’s not actually that someone hits them, and something happens about the tendon weakens and then it ruptures.

So I was surprised to see a paper that was questioning what I thought was... I thought, “This is silly. Don’t even need to study this.” So people make fun of studies. They often say, “I don’t need to study whether I need a parachute to jump out of a plane to survive because obviously, I don’t need to run a clinical trial on that. If the plane’s up in the air and I’m going to jump out, I’m going to do better if I have a parachute.” So people make fun of studies where they go, “Why in the heck would you even do that study?”

So they did a study in Sweden where what they did was they randomized patients who had ruptured their Achilles tendon. And it turns out that there is an approach to treating it, which is nonsurgical, so that you can actually have a non-operative approach. Let the thing just heal on its own, put people in a cast, and then put them through rehab. And also, by the way, there’s a way that you can open up the heel and sew it up, and there’s a way that you can do it with minimally invasive surgery, make a very small incision into it.

So they actually randomize them to non-operative treatment, open repair, or this minimally invasive thing. And again, I would’ve thought this as, “Really? You’re going to do this?” And they got 526 patients who were included in the final analysis of this, where they were actually able to randomize them. And it was very interesting. Their average age, it was about 39, 40 years old, interestingly, right? Because this is when people rupture their Achilles tendon. About three-quarters of them were male, and they weren’t particularly actually obese or a little... In these days, a body mass index we talk about is 27. It’s not markedly obese folks, or maybe a little heavy compared to prior eras.

But anyway, they do this study, and lo and behold, at the end, there’s no difference between the three approaches. It does turn out if you’ve had non-operative, there’s a slight increase in the risk that you may re-rupture it, but there’s also some complications that are associated with the surgery itself and undergoing surgery and so forth. So it’s really more a matter of what the individual’s choice is, but this, again, points me to, why we need to do the trials. Why we need to study almost everything we do in medicine. Because this would’ve been an example of something where I go like, “Wow. Isn’t this just evident?” And I can go down a list of hundreds of studies where lots of people thought something was evident, and it didn’t turn out that way. And this is good centers doing good surgery, well-done trial, and bang, all three of those approaches got about the same result.

Howard Forman: That’s a really interesting study, and it just points up how little we know, just how little we know. We’ve been doing this surgery for decades at this point.

Harlan Krumholz: Oh my gosh. And it just, again, points the fact that we need to build this into our care. That is, when we really aren’t sure, where there’s not strong evidence, we should try to get everyone to be part of randomization and really try to learn together what are the best approaches? Can’t just assume it.

Howard Forman: Right. Right.

Harlan Krumholz: 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 this on Twitter.

Harlan Krumholz: 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.

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

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

Department: Faculty Viewpoints

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