Thomas Balcezak: Can Hospitals Recover from COVID-19? (Health & Veritas Ep. 36)

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, Harlan explains what the research says about the immunity acquired from a COVID-19 infection, and suggests a framework for thinking about exposure risk. Then they’re joined by Thomas Balcezak, chief clinical officer at the Yale New Haven Health System. They discuss the financial and human capital challenges faced by hospitals in the wake of the pandemic.

Thomas Balcezak

Yale School of Medicine

Thomas Balcezak
Chief Clinical Officer, Yale New Haven Health System
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

June 02, 2022

Listen now:

Links

“Protection and Waning of Natural and Hybrid Immunity to SARS-CoV-2”

“Medical Education in the United States and Canada” (The Flexner Report)

About Yale New Haven Health

“Mass General Brigham says it will reduce spending by $70m annually”

“US Mass Shootings, 1982–2022: Data From Mother Jones’ Investigation”

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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 Dr. Thomas Balcezak, the chief clinical officer of Yale New Haven Health System. But first, we like to check in on current health news. What has caught your attention this week, Harlan?

Harlan Krumholz: Yeah, I thought I’d get back to the pandemic and share just a little bit about a study that was published and then maybe give people a framework to think about their own risk. So, there was a paper in The New England Journal of Medicine, as you know, one of the top journals, that came out that was addressing this question that many people have, which is, “If I’ve been infected, to what extent am I protected from future infections? And if I’ve been infected, do I need to be vaccinated, or is it as good as a vaccination? Or how does this work?”

And investigators from Israel evaluated what we know to be the waning level of protection against confirmed SARS‑CoV‑2, COVID, among people who had previously had an infection or among people who were uninfected but had previously received the Pfizer vaccine. And what they found was that, yeah, I guess it’s no surprise that if you had been previously infected then you had a level of protection. Actually, it seemed like that level of protection might even have been better than the vaccination. But like the vaccination, it waned over time. And for people who were uninfected and got two shots, it was really important that they got that third shot in order to get at the same level of someone who had had, for example, one or two shots and had been previously infected. And the way I sort of fashioned it after looking at all the data was sort of that an infection is a little bit more than a vaccination.

So if you’ve been known to be infected, you can consider it like an extra vaccination. But like a vaccination, it’s not a lifelong protection. And many people have discovered that through what people are calling “breakthrough infection.” I don’t even consider them breakthroughs. They’re just another infection that people are experiencing.

So, now, particularly in the Northeast, we’re seeing a lot of people being infected, and a lot of them are wondering whether they should, “If I haven’t gotten the third, should I get the third or so forth?” and what I’m telling people is, “If you’ve had a confirmed infection, you can consider it sort of like you just got a boost. But you also need to know that this is going to wane over time.” And it looks like at six, eight months that people start getting in a position as if now they’re vulnerable again.

And by the way, even if you’ve been vaccinated recently, even if you’ve had a recent infection, in these data, there still are people getting reinfected relatively soon. So, when we talk about waning immunity, it’s not like everyone’s protected and then some people all of a sudden begin to be infected. But people are infected along the way. It’s just the risk starts to increase to the point where prior to the vaccination or infection. So, it’s not—people may say, “I was just infected. Now, I’ve been infected again just a month or two later.” Yeah, that happens sometime.

So, I just wanted to get to one other thing, which is a framework for decision-making. A lot of people are asking me, “Should I go out? Are there risks? How does this work?” And I say it like this. I said that you need to figure out whether you want to spend your risk on the things you’re doing. So, is it important enough for you to be among people? Is it a big family event? Is it something that you’re willing to take some risk for because of what you’re participating in? So if it’s a minimal thing, like I’m going to the store, I don’t mind wearing a mask. I don’t know. Keep wearing a mask. It protects you. But if you’re in a social situation where it’s important to you and you’re willing to take the risk of potentially being infected, then maybe that’s worth it.

But you have to think about the consequence. And the consequence is a combination of how healthy you are, what would be the risk of you getting infected. This variant is much less risky than prior variants for people who are otherwise low-risk. What they’re risking is getting sick for a few days and having to isolate. And then, so that consequence might be, “What have I got planned for the next week? What is it I’m doing? Am I going on vacation? Have I got important meetings? Have I got some events that I wouldn’t want to miss?”

So then that might be more important than thinking, “Am I going to end up in the ICU?” which for a healthy person is now much less likely. But it’s about whether or not, just like you would think about the flu, for example—if I got the flu next week, how big a deal would that be? Well, it may be a big deal if it’s my daughter’s wedding. It may be a much less of a deal if it’s just an ordinary week.

Howard Forman: Yeah. And it’s such an important point that we are still collecting what seems to be very simple data, data that you would almost think we would know three months after the vaccination program began. We’re still collecting that. And one of the questions I still have, maybe it’s a little less relevant now, but early on the sense was that vaccination was more homogeneous protection across the population and that infection was more highly variable with some people having fairly effective immunity and some people having lower levels of antibodies. And even that, I don’t think we have good data on it at this point because we’re not doing the type of rigorous clinical trials, prospective trials where we’re drawing blood from people immediately after infection to measure antibody levels, so a lot of questions.

Harlan Krumholz: Yeah. And even without the antibodies, we do know that some people are still protected. So, that’s why not recommending people, “Hey, go have your antibody levels checked,” because—

Howard Forman: Yeah, that’s true.

Harlan Krumholz: ... it’s not a great proxy for their viability.

Howard Forman: It’s not just antibodies.

Harlan Krumholz: Yeah.

Howard Forman: No, absolutely. But so many questions yet to answer, so thanks for doing that.

Harlan Krumholz: Yeah. Yeah. Let’s get on to Tom.

Howard Forman: So, I’m really delighted to introduce Dr. Thomas Balcezak, who is the chief clinical officer for Yale New Haven Health System. He was named chief medical officer of Yale New Haven Hospital in 2014, named chief medical officer of the Health System in 2016. And over the last two decades, he’s served in various leadership positions at Yale New Haven Hospital, including senior vice president, patient safety and quality, associate chief of staff. He’s also an associate clinical professor of medicine, a lecturer in the School of Public Health at Yale University. He received his medical degree from the University of Connecticut, master’s of public health from our School of Public Health. That’s when I first met him, and he’s also trained in internal medicine at Yale New Haven Hospital, where he also served as chief medical resident.

I want to say a couple of things first, and that is that I first met him when he took a class the first year I was ever teaching at Yale in 2001. And he was—

Harlan Krumholz: Yeah. How did he do, Howie? How’d he do?

Howard Forman: And he did really well. He got the highest grade in the class. I keep his exam.

Harlan Krumholz: Highest grade in the class?

Howard Forman: Well, yeah. He did. He did.

Thomas Balcezak: It was Howie’s first year. He wasn’t really sure what he was doing.

Howard Forman: Listen, let me finish my spiel. But I do want to say that ever since that time he has been a guest lecturer in that class. He is a much-loved teacher. He is a great mentor. He is someone who I’ve referred students to, either from undergrads, from graduate students, as well as our medical students, and has always offered his support and counsel, which I value a lot myself, too.

This health system that he is clinically charged with is a challenging health system to deal with. I’m going to turn it over to you, Harlan, for the first question, but I have a lot of questions today about how do we manage in the time post-COVID?

Harlan Krumholz: Yeah. Well, first of all, what a pleasure to have Tom. Tom, thanks for taking the time with us and just to share with folks. I have such great admiration for the work you do, and you’re such a good friend. I really appreciate having you here and feel that we’re lucky. But what I wanted to start out with was, you’re chief medical officer for the Yale Health System. People may wonder, “What is this job, chief medical officer?” And for people who aren’t in the know in hospital administration, health system administration, this may seem like an unusual title. So, can you tell us, what is this job, chief medical officer?

Thomas Balcezak: Yeah, sure. But the medical organizations in the United States, hospitals in particular, they really go back to, how they’re organized really goes back to the Flexner Report. And shortly after the Flexner Report came out, they realized that not only was medical education in need of a tremendous overhaul, but—

Harlan Krumholz: Just to anchor people, the Flexner Report is what, like 1910?

Thomas Balcezak: Exactly.

Harlan Krumholz: You’re referring to a report that was from a hundred years ago, right?

Thomas Balcezak: Exactly. I mean, Abraham Flexner was asked by Congress to look into the proliferation of poorly trained physicians in the United States. There were medical schools all over the place. I think there were over a thousand medical schools in the United States at that time. And he came back with this report saying it needs to be overhauled and there needs to be a way of having oversight around medical schools, and the same with hospitals. And from that report, you can tie almost directly back to that the evolution of how hospitals have come about and now health systems.

Shortly thereafter, they created this idea that hospitals should have a governing body, a fiduciary body made up of individuals that had that institution’s best outcomes in their hearts. But it also needed a group of physicians. It needed a medical staff. And they come up with this idea that the medical staff, although independent of management, needed to be overseen by the governing body. And sitting in the role between the medical staff and the governing body was this idea of chief of staff, and in some institutions, depending on where they were and what their druthers were, they would elect the chief of staff. Some would be employed by the hospitals, selected by the medical staff, what have you.

And over the last hundred or so years, as you mentioned, this was about a hundred years ago, this role evolved. And it became this idea of a chief medical officer, where it was recognized that in the management of a hospital, now a health system, there needed to be a senior physician executive, because most of the management post-Flexner of hospitals was non-physicians, non-clinicians. They were people who were in business, people who had a background in medical economics and other things, thinking that ideally, folks that are physicians should be focusing on the patients, should be focusing on healthcare, whereas the business of a hospital, the idea of running a business that has human resources and finance and treasury and supply chain and all of those things that are necessary to run a business, physicians aren’t really very good at that.

But yet you need a chief physician executive to be able to inform the management structure of the hospital and also relate the clinical enterprise to the board, to the management staff, and really be the communication between the medical enterprise and the management enterprise.

Howard Forman: Can you tell me, when the pandemic began for us, when we started to see cases, when everything started to slow down, the transformation of both our hospital and the health system happened very, very quickly. Can you give our listeners some sense of what the mechanics of that were, and how do you think about that when you have a health system that is, quite frankly, funded by private and public sources, but those are not sources that are flexible? It’s not like you’re going to get extra funding during the pandemic. How do you think about getting ready for something that you’ve never experienced before?

Thomas Balcezak: Well, I mean, I can tell you our personal experience and from talking to my colleagues around the country, I think many of us had very similar kinds of experiences. One is, as Harlan mentioned, the Yale New Haven Health System is about a $6 billion system. It spans about a hundred miles, which is the coastline of Connecticut. It has seven inpatient campuses and five hospitals, about thirty thousand employees, and just over six thousand physicians that are on the medical staff. So it’s a pretty large enterprise.

But in terms of American healthcare, we’re only about a moderate-sized health system, but we have a couple of, I think, defining and unique strengths. One is that our partnership with the Yale School of Medicine and the faculty really has given us a clinical depth and breadth which I think is world-class. The other thing, too, is given our geography, given our relationship with the school and our presence as a academic medical center and our aspirations to be an academically based health system, it’s attracted a level of leadership and employee really at all levels that I think is second to none.

And we’ve also been successful. We haven’t had tremendous margins, but in the world of not-for-profit healthcare, we’ve been good. We’ve been healthy. We have about a 3 to 4% operating margin every year, which allows us to have a pretty healthy balance sheet. So, we walked into the pandemic in January of 2020, knowing that it was coming, with I think a lot of strengths, clinical strengths, operational strengths, and financial strengths, which we needed each of, as March rolled around and the pandemic really hit with full force across our health system.

Given our proximity to New York, we really saw a rapid ramp-up in cases in March. And really every part of this organization, from our treasury to our operating teams to our clinical teams, really stepped up, and we organized, like most institutions, around an incident command structure. We had both incident command structures at the local delivery networks across our five hospitals, but also coordinating across our health system. We brought a small group of individuals together to make some very important high-level decisions. One is that we were going to pay whatever needed to be paid to whomever in order to get the equipment, product, staff in our hospitals.

So, you saw the supply chain disruptions. And at one point we went from... you know how supply chain folks will tell me I got this wrong, but I know on an order of magnitude, I’m right. We used to spend about 60 cents on a N95 respirator—you know, those blue 3M respirators. It went at one point we were spending nine dollars apiece. So, we paid whatever we had to pay in order to make sure our staff were safe. We paid bonuses to our staff. We didn’t let anybody go. And as you know, we stopped doing elective surgeries. Our ERs stopped seeing patients, because people were home. We didn’t furlough or lay off anyone, because we knew that as the patients came back in, we would need those people.

And then on the organizational front, we stood up, for example here in New Haven, two brand-new full ICUs. We turned over two floors of the Smilow Cancer Hospital into fully functioning ICUs, with all the attendant stress that that created on all of our operating teams, including our ICUs, our physician teams. And every single group stepped up, because we had in the bank that equity of talented staff, talented clinicians, and also the assets and resources to be able to do that.

And you all, I know, had your own part in it, Howie, whether it be in radiology or, Harlan, across the physician enterprise. You saw it yourself, but that’s nothing you could have prepared for with three weeks. It took ten years of equity to be able to have that readiness to be able to respond.

Howard Forman: Can you just give our listeners a sense though, in the entire time you’ve been at Yale prior to the pandemic, did Yale New Haven Hospital ever lose money?

Thomas Balcezak: No. For the last 40 years, we’ve never lost a dime.

Howard Forman: And since the pandemic, can you give the listeners some sense of what... And I don’t want to reduce this just to financial impact, but I want our listeners to have some understanding of just how dramatic this is. What is the financial status of the hospital for 2020, 2021, and 2022 and beyond?

Thomas Balcezak: Not great. As I mentioned, the supply chain costs have really hit us hard. The loss of electives in 2020 put a big crater in that year’s operating budget, as well as the fact that we paid bonuses and other things without the flowing of revenue.

So, the stimuluses that were paid in 2020 brought us to about a break-even. But in 2021, as those stimulus money, federal stimulus money has dried up, and now certainly in 2022, now they’ve completely dried up, we’ve seen growing operating losses each of the last two years. So, we’re headed into our third year of substantial operating losses.

This year, we will likely on that $6 billion base budget likely lose between $300 and 350 million, which we have a balance sheet. We’ve got about two hundred days’ cash. But those dollars on the balance sheet, those are our future investments. Those are our next generation of clinical programs, equipment, Howie, and the next MRI scanner is in that money. If we don’t have that healthy balance sheet, we don’t have the dollars to invest in programs, capital buildings, and so forth. And unfortunately, healthcare is extremely capital-intense. And unlike almost virtually any other industry, every generation of scanner, computer, it costs more. We haven’t seen the kind of Moore’s Law.

Harlan Krumholz: Moore’s Law. Yeah.

Thomas Balcezak: Yeah, where every generation of scanner is more powerful and less expensive. Yes, it’s more powerful, and absolutely it’s more expensive. And that’s really, I think that’s pretty unique to healthcare.

Harlan Krumholz: Well, Tom, we’ve heard from the Ascension health system. They said they lost $800 million in a quarter. Cleveland Clinic just came out and said that they’re losing $185 million in a quarter. Some of that’s lessening of revenues, but increasing costs; nursing, labor costs are going up. And in part, the health systems are also under attack because you necessarily have to provide services across a wide spectrum. Some things you make money on; some things you lose money on. And the private sector is coming in to pluck out the parts of the health system that have higher margins, that are also leaving health systems which are stalwarts of the community in a weaker position.

What do you see happening in the next five years to strengthen the position, the financial position of health systems, and what will have to happen in order for them to get on firm financial standing, given this environment? It’s not just the pandemic.

Thomas Balcezak: Yeah, it’s a great question, and I wish I had the crystal ball. I think everyone’s wondering what exactly is going to have to happen.

And you mentioned something, you said an interesting thing. You said “stalwarts of their community.” I’m curious about what you mean by that, because we know that there are some institutions like ours that take care of everyone without regard to the ability to pay, that we’re both a community hospital, the safety net hospital, and the tertiary, quaternary hospital.

And I think in the United States in particular, we have sometimes, and depending on the community you’re from, segmented those populations. And I’m not sure that’s the right thing to do. Oftentimes, I think in healthcare management circles, it’s talked about how America has the best sick care system in the world. If you have a serious condition, a rare condition, there’s no place anywhere else in the world that you probably want to be other than the United States.

But we do fall down on some of the basic metrics around quality of care for basic conditions, particularly around basic common conditions and our ability to plug people in and get regular, preventative, and maintenance care, particularly around chronic conditions. And maybe this is an opportunity for us as a nation to sit down and look differently at how we do things. I don’t have a lot of hope that we will do that. With all of the challenges that we’re facing, I don’t know that this is number one, except insofar as I think the cost of healthcare has gotten people’s attention. We’re now, what, 18% of GDP, Howie, somewhere in that range? And as a GDP hog, we’re really starting to crowd out other parts of the economy.

Harlan Krumholz: Well, if hospitals start failing, I mean, I think it will precipitate. But Howie’s one of the world’s experts on this issue of financing.

Thomas Balcezak: And I think that there is no more revenue. I think that the institutions that you’ve referenced are some of the premier ones in the United States. I mean, you sent me the article about Mass General Brigham, which combined with their announcement of a staggering loss this past quarter, they’ve also submitted the plan about how they’re going to become less expensive. Wow. And there is no more revenue to be paid to Mass General Brigham. So, how do you reconcile those? And it’s a really good question.

Howard Forman: It does seem that something truly pivotal, transformative happened with this pandemic that has made it very difficult for our largest institutions and probably our smaller ones, even more so, but we just don’t hear about it in the press every day, much more fragile. And I am concerned because it is not just Yale New Haven Hospital and Mass General Brigham and, as Harlan said, Ascension. And you can go on and on. But we’ve got big challenges ahead.

What do you see on the staff end of things? When you think about well-being, when you think about wellness, it’s almost like the term burnout and physicians are matched in article after article for almost a decade now. The pandemic probably made it worse, but we sort of accepted that it was an acute phase problem. What do you think we can do? What are the proactive things that listeners as well as us in the profession can do that can mitigate this?

Thomas Balcezak: You guys, tough questions today. Do you always ask tough questions?

Harlan Krumholz: Only to you, maybe.

Thomas Balcezak: I’ll take a page from some of Harlan’s foundational research, which is, there are places and pockets where there isn’t burnout, where there are people who are really energized by their work. I look at the two of you who continue to be more energized every year, year after year, because you find meaning and purpose in what you do, because you’re inspiring a new generation of folks that are going to come behind us and do great things.

What can we learn from those positive deviance? What can we learn from where there isn’t burnout? I think we spend a lot of time looking at where the problems are and how can we solve them. Maybe we need to start spending more time looking at, where are there opportunities for us to emulate successes?

And I think, by the way, I don’t think the burnout and the ennui and all the other things that we’re seeing in healthcare is solely in healthcare. I mean, I look at my two kids and the jobs that they’re pursuing, and they tell me about the same challenges in their very different industries than healthcare. But I think it’s a nationwide societal issue. I don’t think it’s just unique to healthcare. I think healthcare has some unique issues to it, and I think the pandemic and the financial challenges and some of our other societal issues have laid bare some of those things. But I don’t think it’s unique to us.

Harlan Krumholz: Okay. I want to pepper you with a few quick questions. We’ll do a rapid-fire round. I just have a couple quick ones. What’s been your best day on the job?

Thomas Balcezak: Anytime I have someone who I’ve worked with and mentored and I see them successful in being promoted.

Harlan Krumholz: That’s great. What’s your worst day on the job?

Thomas Balcezak: Worst day on the job, I think you’ve shared some of them with me. We lost early on in our patient safety journey the husband of a friend and a coworker, and it laid bare where our challenges were in communication and patient safety. And to have that laid bare in such a way was so much a tragedy, but also I think it was personal as well as professional.

Harlan Krumholz: That was maybe one of my worst days, too. Tell me about, why is building cars something that you enjoy on the weekends?

Thomas Balcezak: Because, I find deep purpose in... No, I don’t find any deep purpose and meaning! It’s exactly the opposite! It’s meaningless and purposefulness, but I love being able to have that has a beginning, middle, and end, and you can create something out of nothing with your hands.

Harlan Krumholz: That’s great. Howie, how about you, any?

Howard Forman: Well, so I’m still curious about in the job that you have now compared to the job that you started in twenty-plus years ago when you worked in the office of Peter Herbert and tackled specific topics, what is the biggest time consumer of a chief medical officer right now? Because there are the chief of staff roles in credentialing. There’s the safety and quality roles. There’s clinical operations. What do you find the most of your time being committed to on a daily basis?

Thomas Balcezak: Listening. I spend a lot of time listening. Now, my direct involvement in most projects is relatively limited, and I’m usually operating through a team of individuals. It’s really important to me to get a deep understanding of what it is they’re working on, what challenges they’re facing, what barriers they’re running into so that I can really define the right question in order to answer.

I think two things have really saved my skin so many times. One is making sure that we get the old Jim Collins, get the right people on the bus and put them in the right seats. And once you do that, the only other job that I think is incredibly, incredibly important is listening carefully to what they have to say in addressing their challenges as they raise them. But if you can do those, in my opinion, if you can do those two things right, find the right people and organize them right and then listen to them carefully, I think your success is almost guaranteed.

Harlan Krumholz: Well, that might be a good place to end. And I would say, Tom, you’re one of the best listeners I’ve ever seen and your commitment to the people around you is unmatched. It’s really unmatched, and I think it’s a lesson for the rest of us. I definitely think it’s been a road map for how you’ve been so successful in what you’ve done. I want to just thank you for taking the time, and it’s been really great to talk to you.

Thomas Balcezak: Well, thanks.

Howard Forman: Thanks very much, Tom.

Harlan Krumholz: So, Howie, that was a great conversation with Tom. Let’s go to our next segment, which is, what’s on your mind this week? What’s occupying your thoughts?

Howard Forman: Well, it’s the same thing on both of our minds. You brought this up last week right after, in the aftermath of the second mass shooting in a row. Everybody is talking about this, but we know this is not really a new problem. It’s not a limited problem.

So, I was looking into this just data-wise, and Mother Jones magazine, which is a left-leaning magazine generally, but they maintain a very methodologically consistent database from mass shootings in the United States. They track mass shootings where more than three people are killed. They exclude mass murders that stem from a robbery or gang violence or domestic abuse in private homes. It’s a much more limited definition than other databases, and it allows them to look at these indiscriminate terror attacks much more cleanly.

And there’s some obvious findings. We all know this, but it’s good to just summarize that it’s almost always men. Of the last 50 such events, only one was exclusively a woman perpetrator. More likely using semiautomatic weapons, including both AR-15 and handguns is the most common examples. They’re mostly legally purchased, and they’re increasingly younger individuals. Of the last 10 such events, six were aged 21 or younger.

Gun violence is a public health problem. It is a serious cause of death and harm to the population. We’ve just for instance last week learned that firearm deaths overtook motor vehicular trauma as the leading cause of death in children, and it is something that is directly impacted by public policy or the lack thereof.

And even suicide, which might seem to be an individual health problem, turns out to be a public health problem. Access to guns makes suicide more likely and more likely to be successful. We cannot eradicate suicide, but we can definitely reduce its numbers, and it’s clear that once someone is over the acute crisis, the likelihood of future successful suicide is reduced.

So, to me, there are three ways to think about this problem and the possible policy solutions embedded in that. One is just as a pure health and public policy issue for which there are clear-cut strategies that we could take that would reduce gun violence. Two, we could see it as it seems to be as a political issue where gamesmanship by elected officials has an outsized and unusual impact. I continue to hear people on the left tell me that unless we have X, Y, and Z, we shouldn’t vote for something. And then on the right, people who will not vote for anything. The majority of people in this country, the vast majority of people in this country, actually do want evidence-based change, but the politics favors inertia.

And then as a legal and constitutional issue we’re making any and all of the changes that we want to make will run up against constitutional and other challenges, which have to be considered. So, I’m very aware that most gun owners are responsible and also that it is fairly settled precedent that gun ownership is a right protected by the Second Amendment, a constitutional right. But that is where my support for gun owners ends. We can do an awful lot to maintain safe gun ownership.

I want to list just a few policy items that are clear in that they would save lives. Will they save all lives? Absolutely not. But will they save lives? Yes. So, if we were truly a pro-life society, we would limit private ownership of guns to 21-year-olds or maybe even 25-year-olds and older. We would carefully track sales of ammunition. We’d stop selling machines of deaths, such as AR-15 or similar semi-automatic weapons, except under highly regulated circumstances.

We would put in place red flag laws that allow authorities to take weapons and rights to weapons away from those who express danger to themselves or others. We would do careful and universal background checks with intentional delay in purchase. We would want there to be a pause between the time that begins the process of getting a gun and actually gets it. And we would require gun safes and place liability squarely on the owner for failure to protect their weapons. And we would also consider removing the liability shield for gun manufacturers if other measures cannot be taken. There’s so much evidence that they’re actively marketing these weapons to high-risk groups.

So, much as we’ve talked about with other topics in healthcare, I fear that we will see little or no action after this latest tragedy. We’re fortunate that in the next few weeks we have upcoming guests who are experts and scholars in the area of gun violence, and I look forward to hearing them as well. But I’m curious to hear your thoughts on what is obviously a complex topic, and I’m trying to be very reductive in my ideas. But I’m curious to hear your thoughts on this as well.

Harlan Krumholz: Well, look, I’m disturbed that the United States is such an outlier here. I mean, it’s not like you can say that this is just the way things are. I mean, look, we are far and away an outlier in the world population with regard to gun deaths. And I do want to raise one thing that kind of bothered me about what was going on in Uvalde, which is it became this singular focus on the police response and blame for them.

And look, there’s a need for us to understand that response and to take it apart and help to understand how to improve for the future. But it seemed to me to distract from the major issue that this person burst into that school with body armor and a high-powered assault rifle and was able to inflict that kind of damage in a matter of just minutes. And in its root, we need to think about this as a public health problem.

Thanks for sharing that, Howie, and thanks for the thoughts about policies. I mean, I hope people are listening. 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 H-M-K-Y-A-L-E.

Howard Forman: And I’m @thehowie. That’s @thehowie, T-H-E-H-O-W-I-E. Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the healthcare track and founder of the EMBA 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/emba.

Harlan Krumholz: And we’re grateful for the support of the School of Management. They really are sponsors for this, and it’s great that they’ve done that. Thanks to our researcher, Jenny Tang, and to our producer, Miranda Shafer. Talk to you soon, Howie.

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

Department: Faculty Viewpoints

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