An Ongoing Conversation about Health and Healthcare

Transcript

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

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get close to the truth about health and healthcare. Today is an exciting milestone. It’s our 200th episode.

Harlan Krumholz: It’s our 200th episode.

Howard Forman: And we’re in the studio. And we love to be in the studio.

Harlan Krumholz: Nice to see you, Howard.

Howard Forman: It’s good to see you. So we’re about to head into the holidays, and we’re going to do some brief updates. So what can you lead us off with?

Harlan Krumholz: Well, as we close out the year and as we celebrate our 200th episode, I thought I’d do something a little different. Every week I write an editor’s page for JACC. This is the cardiology journal that I’m an editor-in-chief. And some of those pieces really resonated with readers and sparked a lot of discussion. So today I thought I’d highlight maybe three of the most popular ones. I’ll do them one at a time. And each time it comes back to me, I’ll share one. So they touch on different parts of medicine from the personal professional. So how’s that sound?

Howard Forman: That sounds great to me. Let’s hear it.

Harlan Krumholz: All right, good.

Howard Forman: I’ve seen a few of them, but I would love to hear more.

Harlan Krumholz: All right. Well, the first one I wanted to reflect on was one I titled “The Day I Became a Doctor.” And this one was not about graduation or passing the boards or the conventional milestones that you might consider to be associated with becoming a doctor, but it was about, I don’t know, the moment that I realized what the work actually meant. And I reflected on a story years, years, years ago in clinic, early in my career. And I was very focused on efficiency, and I wanted to be a good faculty member. And they stocked our clinic full of patients. And the idea was that you would stay on time and you would get people through and keep the day moving. And that day, one of my patients was an older woman. She came in, I remember, dressed beautifully and carried herself with calm and dignity.

And I did what many of us do. I gathered a quick history. I figured out what she was there. I typed as she spoke. I moved the visit along. I did what, like I said, I was supposed to do. And I stood up to leave, and I noticed that she was still looking at me. I was at the door, and her look was sort of quiet and expectant. Not upset, just present. And for some reason I paused, and it felt like maybe the visit wasn’t really over for her. So I sat back down, and I asked her about her day. And she described a day to me that I didn’t know about, that she had been thinking about this clinic visit for a long time. She woke up early, maybe like five in the morning. She was a large woman, and getting dressed wasn’t easy.

And she had pulled out her best clothes, and she had taken her time to prepare herself to come. And then she waited for the shuttle that took her to the clinic. And then she had to get in a wheelchair to take her up to the floor in the waiting room. And then in the waiting room, she had to go to the bathroom. And so someone had to take her to the bathroom, and it was a whole ordeal for that. Finally, the appointment came and she came to see me. And it struck me that she had invested such hope and effort into the visit. And it made me realize in the discussion I had with her, she started to tell me a little bit more about her life and her concerns and the issues with her, that this was really what was important. And that for almost all of our patients, these are major events.

For us, it’s just the next patient. And I had almost missed it. You know, I’d always considered myself very patient-centered. At my medical school graduation, I’d given a speech about seeing through the patient’s eyes. But somehow through the socialization of my training, I’d sort of lost that and tilted away. And it was really at that moment that I realized it’s my job to understand my patients, give them some space, maybe make them smile, show real genuine interest. And I thought that was the day. And that’s why I labeled it “The Day I Became a Doctor” because that had changed everything since that day. And it really guides me throughout. So I wrote that, and I got a lot of positive feedback from it.

Howard Forman: Yeah, it’s very touching, and it really speaks to who you are, which is a very patient-centered—

Harlan Krumholz: But you must have also... I mean, even as a radiologist, I mean, there are people that—

Howard Forman: Look, as a radiologist, my best connections are with the clinicians, not with the patients. There are times you talk to patients, but I will say my best experiences as a physician is when I connect with clinicians about something complicated and realize that my interpretation didn’t align with the whole chart and that together, we come to a proper diagnosis. But not nearly the emotional connection that you get to have.

Harlan Krumholz: Yeah, but they’re just things that we do. I think that as we get on this treadmill of productivity—

Howard Forman: Yeah.

Harlan Krumholz: ...that we—

Howard Forman: Can’t lose sight of.

Harlan Krumholz: Some of the most meaningful pieces are the human pieces of what our jobs are.

Howard Forman: Yeah. That’s actually true.

Harlan Krumholz: What our calling is, not even job.

Howard Forman: I’m going to do quick hits.

Harlan Krumholz: Great.

Howard Forman: They’ll be very short, but hopefully they’ll be helpful. And they’re mostly just about current things. And I don’t think that we could not talk about mass shootings today. They outnumber days on the calendar in the U.S., according to Katelyn Jetelina, your local epidemiologist, our former guest, and others have said this as well. And this has been true for seven consecutive years. We continue to be an incredible outlier in terms of gun deaths and gun violence. And despite the awful news out of Australia this past weekend, we do know that the USA is still an incredible outlier in terms of firearm death per population.

Ten times the level of Australia is just one example. Australia has a much tighter gun environment than we do. And we’re triple the level of the nearest OECD nation. Our country seems ill equipped to truly deal with the unacceptable gun violence and gun deaths that occur in our country, but it should not stop us from considering even modest measures to reduce it. And I just want to remind our listeners, we’ve said it before, suicide remains the majority of gun deaths in the country each year, and every one of them is avoidable if we truly value life.

Harlan Krumholz: Well, thanks for bringing that up. Terrible week on this.

Howard Forman: Terrible.

Harlan Krumholz: And I think these things that we’ve seen, these hate crimes are just enormously disturbing. But like you said, it’s not just that. It’s the suicides. It’s also the everyday homicides that are occurring because often impulse crimes—

Howard Forman: It’s too easy.

Harlan Krumholz: ...impulse crimes.

Howard Forman: It’s too easy.

Harlan Krumholz: And we are an outlier. We’re an outlier.

Howard Forman: You want me to do another?

Harlan Krumholz: Do another.

Howard Forman: I’ll do a quick one. The measles outbreak in South Carolina, which you mentioned right when it started about two months ago, continues to be quite active. It’s now the third largest in the country for this year. While it remains possible for the country, for our overall country, to exceed total cases from 1992, the more important point is that we have ongoing outbreaks heading into the end of the year with outbreaks in South Carolina, Arizona, and Utah at the top of the list. Connecticut, our home state, is the latest with a case, but this is a case brought in from international travel. It’s not part of an outbreak.

Six states remain without cases. Undoubtedly, we will lose our measles elimination status next month when we confirm that there are 12 consecutive months of ongoing transmission. And one other point to make from this outbreak that I think we underemphasize, 4% of cases are in fully vaccinated individuals, or at least we believe them to be fully vaccinated. It’s just a reminder of why we need to stop the outbreaks. You’re not just protecting yourself. Yes, the vaccines are very effective, but they’re imperfect. But you’re also protecting those with waning immunity or immunocompromise.

Harlan Krumholz: How long ago had those people been vaccinated?

Howard Forman: Unclear. So we don’t get granular data. I hope that at some point, the CDC will actually report on a more granular level because that 4% number is very large, and we should understand that better because early in the outbreak, people would ask me, they’d ask you, “Should I get another booster?” And the answer is, until there’s an outbreak near you, you don’t need another booster. Maybe we do.

Harlan Krumholz: Maybe we do. And just remind us again, how does it compare now to maybe where we were two years ago?

Howard Forman: We’re vastly higher. The last big outbreak we had was five years ago, and it was a fraction of this one. This one is closest to the waning massive outbreak of the late ’80s and early ’90s when we first got to measles elimination status. And it’s sad—we’re going to lose it. Next year is going to be another large number. The only question is, is it going to be larger than this year or is it going to start to be waning?

Harlan Krumholz: Wow. Well, thanks for bringing that up.

Howard Forman: Sure.

Harlan Krumholz: All right. Let me bounce back to one of my editor’s page. So this one’s a little bit different. I really wanted to emphasize something that I thought is undertaught. And I titled this one “When Your Patient Dies.” And I wrote about the first time this happened to me as a young student working in the ICU at Mass General and caring for a patient for a couple weeks. I had a month rotation, and there was a patient who I’d cared for for a couple weeks and he suffered a terrible complication and despite all our best efforts, passed away. And when he died, I remember thinking... you know, I was sad and that the work was done. But then next thing I knew that we were in the hallway talking with the patients, and I felt wholly unprepared. You know, no one had even ever told us. How do you handle a situation like this? What kind of communication do you do? And as you fumble through it, you can make things worse. And I started realizing that the patient shifted from the patient in front of us to the family because you can have the opportunity to preempt pain. And over time through these kind of painful experience, I learned an approach that I wanted to share, which was a simple several steps, which are always genuine, but kind of help frame it, which is to tell people that first honor the person. Acknowledge the individual who mattered in the sense that you knew who they were and the death mattered.

Second, if true, reassure them that the patient didn’t suffer unnecessarily. And by the way, that should be our responsibility—to make sure people don’t suffer unnecessarily. But try to assure the family that this wasn’t a painful death. And then this is maybe the most important thing. And this is why I wanted to write this piece because I learned it over time is that when something like this happens, people often blame themselves. They find sometimes the oddest things to blame themselves for. I remember a wife who told me, “I shouldn’t have served him soup last night. It must have been the soup,” or something.

And when you first hear it, you think it’s a little bizarre that someone would think that, but then you realize that people are grasping for cause. What did they do? And you can release them from that blame. You can tell them that there was nothing that they did, that this had nothing to do with them. And then finally, if I can, I try to just recognize the love in the room. If there are people who are surrounding, waiting expectantly hopeful that things wouldn’t have turned out this way. Or even if someone’s at the end of their life, you can acknowledge the fact that they were fortunate to have people like this around them.

And so I heard from many readers who said that it did help them and that actually for us as clinicians, we often also need to process this because we’re experiencing the trauma in some ways too, especially if we start blaming ourselves for what happened. So anyway, I was really proud of that piece. I was glad that it resonated. And these are just some things that have been on my mind that I’ve taught over the years that it gives me a chance to write about.

Howard Forman: Look, I think death is probably one of the biggest reasons why I ended up in radiology. I found loss was too painful for me. It was just very, very hard for me to process it. I to this day think the psychic pain, the moral harm that comes to physicians from having to be part of this essential part of life is a huge challenge, and we do not prepare people for it.

Harlan Krumholz: And we ought to acknowledge... I mean, that’s why I remember doing oncology, pediatric oncology. I mean, the people who do that, who do become, I think, very good at this kind of communication, but also incur a lot of the...

Howard Forman: They go to funerals.

Harlan Krumholz: Yeah. Yeah. It’s hard. All right. What’s on your mind next?

Howard Forman: We are seeing a massive outbreak of flu in the United States right now. It’s flu A, it’s influenza A, it’s H3N2. And as we previously reported, this is a mutated version that appears to evade some of the expected protections of the current flu vaccine. We don’t have a lot of data on that, but that’s what we think. We’re seeing a surge in cases in the United States and in our own emergency department at Yale, we’re seeing a lot of cases, particularly among kids right now, and kids just will eventually spread to the adults. From the clinicians I talked to, there are many cases among the vaccinated, but the sense is that they are less severe. That’s anecdotal at this point. One related item to highlight, in August of this year in The New England Journal of Medicine, there was a study that confirms and augments our understanding of the value of the high-dose influenza vaccine for those 65 and older.

It seems to reduce hospitalization substantially compared with the usual dose. Even in a season where we believe the vaccine may be less effective than ideal, it still has protections and I’m going to continue to urge anyone who is as yet unvaccinated to get their flu shot now.

Harlan Krumholz: I’ve heard people say to me, Howie, that they have heard that there’s not a good match, just as you’re saying. I just wonder when someone’s telling you that... I mean, I know you’re saying anecdotally people are saying this, but people are pulling that out. What do you say?

Howard Forman: I think people misunderstand what it means to say it’s less effective. It doesn’t seem to reduce spread as much as prior flus. More people are getting flu than you would expect given that they’re vaccinated, but it is almost certainly the case and every bit of evidence suggests that the severity of the flu that you get when you’re vaccinated is less than the severity if you are unvaccinated.

Harlan Krumholz: So your recommendation: get vaccinated.

Howard Forman: So particularly the flu shot. I think the flu shot’s a no-brainer. And unfortunately, the flu vaccination rate in the country is at a decade low and particularly—

Harlan Krumholz: I think people are losing the enthusiasm. By the way, we’re mandated to get it. I’ve got my flu shot—

Howard Forman: I got my flu shot.

Harlan Krumholz: And I got it anyway. I think it’s a good idea.

Howard Forman: Yeah, no, I’m happy to get it. I’m fortunate enough that I’ve never had a reaction to it. So to me, the cost of getting it seems to be de minimis or none.

Harlan Krumholz: Great. Got another quick hit?

Howard Forman: Real quick on COVID, just to say, it is taking off, but unlike flu, we’re not seeing evidence of a particularly virulent outbreak this year so far, but we are beginning to see this outbreak. It’s just too early to say any of this convincingly. And vaccination rates are down considerably, even way below flu vaccination rates. So we may yet see some indirect evidence of how effective these vaccines are, even if it’s from seeing the effect on the unvaccinated. It’s not too late to get the vaccines. And if you were waiting to get a COVID shot, now it seems to be the right timing.

Harlan Krumholz: I don’t know if you saw the write-off Pfizer made this week, largely about their COVID business, which would be, I guess the vaccine and Paxlovid.

Howard Forman: Paxlovid, right.

Harlan Krumholz: You know, that’s what their expectations.

Howard Forman: But look, we may still have a big outbreak this year. It’s hard to predict these things timing-wise. It is definitely taking off now. How far it peaks, have no idea. Flu is going to peak very high.

Harlan Krumholz: And your recommendations to people about COVID vaccine?

Howard Forman: Sixty-five and older, I still think that if you have any significant comorbid condition, you should get it. When people ask me in other categories, I personally think that the benefit probably exceeds the risk, but I think every person has to make their own decision. For the youngest groups, I tend to tell people no. I certainly have not encouraged my daughters. I don’t believe they’ve been vaccinated. I wouldn’t encourage any adolescents to get—

Harlan Krumholz: Infants, babies?

Howard Forman: I wouldn’t encourage them. I mean, not at this point, but I do think RSV and the flu, yes.

Harlan Krumholz: Yeah. Great. Okay. I’ve got my third editor’s page. So let me just say, so the last of the three, I wanted to choose something a little more structural and policy-focused. This one’s called “Rethinking Physician Certification,” and this one really resonated, at least in the cardiology community. For decades, certification has shaped a physician’s career. It determines hospital privileges, insurance participation, perception of credibility. People put it on their wall. And the system we have was created for a very different era. It asks clinicians to memorize obscure details rather than demonstrate reasoning and judgment that rely on everyday practice. And there’s little evidence that it’s ensuring high quality. There’s really almost an absence of evidence that what we’re doing to do certification is actually helping patients. I know the system very well because I served on the Board of Trustees of the American Board of Internal Medicine. Actually, while I was there, I was continually advocating for reform.

I actually led a task force about what the future of certification should look like. And in that, I emphasize that, for example, if you’re a cardiologist, there are some things you should know cold. You should be able to do that. We should be able to list them. You should be able to memorize them. You should be able to know them and master them. But for the vast majority of things, you need to be able to be familiar. You need to know where you need to get that information. You need to be able to leverage the resources around you. And you need to be able to demonstrate that you know how to take care of complex patients. The assessments should be more real-life. Clinicians should have access to the evidence and tools that they actually have in real life. We shouldn’t have this illusion that this is all about memorization.

And so I said, I think that there’s a time for a change, plus it should be less expensive and it should be more affordable for everyone. Now you think “Doctors, well, they’re all making a lot of money,” but the truth is that this can be quite a burden for people, especially for junior people. And when you have this one high-stakes exam, some people just freeze up. Should they be precluded from being physicians because in that moment they have test anxiety or something else happens, they’re sick that day. So anyway, I really was calling for reform and change in sort of fundamental ways. It elicited a huge response. Many physicians put into words something that I’ve been feeling for years, that they just feel totally frustrated by this. And so anyway, that’s just another one that I wrote.

Howard Forman: You’ve been on the right side of this issue for at least two decades. You brought this up to me the first time two decades ago. And as a radiologist, we go through the same process, and I don’t believe we get it right either. It’s not nearly close enough to reality.

Harlan Krumholz: And in the piece, I talk about other countries. I mean, nobody quite does it like we do. And at least ABIM, they made enough money. They were able to spin off a foundation with hundreds of millions of dollars. I said they should have given refunds or given the test for free for decades after that. So we’ve got an issue. I think we have to solve it. It’s just too convenient to say people need to keep using the system we’ve always used.

Howard Forman: Yeah. Last piece for me. I wanted to offer some good news to close out our segment or at least close out my segment.

Harlan Krumholz: Oh, yeah. I love good news.

Howard Forman: I’ve been reading a bit more these last few weeks and one topic that was covered was the health effects of yoga. And as you know, I am a huge fan of yoga. I find it helpful physically, and it grounds me. So I’m probably 20 or more years into doing yoga on a regular basis, and I hope to keep the streak going. So here’s some evidence about the health effects of yoga. There’s evidence that it has a positive impact on back-related function and pain, somewhat comparable to other exercise interventions. There’s evidence that it may reduce anxiety and depression symptoms. They’re a little less confident about this one. I tend to think it’s true, though, anecdotally. In those over 65, yoga appears to improve gait speed and lower extremity strength and endurance. And yoga has been found to alleviate some symptoms associated with autoimmune disorders.

And there is some evidence that it improves or helps retain cognitive function as we age. I am the first to admit that some of these connections may have more to do with the social aspects of yoga or the motivations of the participants, but there is very little downside and quite a good number of upsides to make this an easy activity for me to continue to support.

Harlan Krumholz: Well, that’s terrific. I’m so glad you’re participating in that. Do you think that it’s yoga or... I mean, if people did stretching or—

Howard Forman: That’s what I’m saying. I don’t know.

Harlan Krumholz: What’s the active ingredient here?

Howard Forman: I will tell you that yoga for me personally is a combination of stretching. It’s a combination of core building.

Harlan Krumholz: Breathing.

Howard Forman: Breathing. And it’s also a centering process. The only time that I can go to sleep within 90 seconds lying flat on my back in the middle of the day is at the end of yoga when we do savasana. I mean, it is miraculous. And I joke with people after it that I have about a 95% to 99% track record of falling asleep during that time.

Harlan Krumholz: And how long are your classes?

Howard Forman: An hour long, but the last 10, 12 minutes are this relaxation phase.

Harlan Krumholz: And for people listening who think they might want to start, how long did it take you to become competent in yoga?

Howard Forman: See, that’s the great thing about yoga is you can walk in there and be completely incompetent. It took me years to feel like I could get half or two-thirds of the poses right, but it’s nonjudgmental. I mean, it’s like you’re in there and there are people there that are absolute experts. Every so often someone’s like, “Oh, and by the way, that’s a yoga instructor over there.” And then there are people that are doing it the first time and however they do, it works.

Harlan Krumholz: So people don’t have to be nervous that “I don’t know how to do it.”

Howard Forman: No, I think it’s just such a fantastic, communal thing to do. And for some people, they do it alone, but for me it needs to be in a group.

Harlan Krumholz: And how many times a week do you do it?

Howard Forman: Twice.

Harlan Krumholz: Twice.

Howard Forman: Yeah.

Harlan Krumholz: Yeah. Oh, that’s fantastic. All right, maybe I’ll try.

Howard Forman: Look, I think it’s worth trying.

Harlan Krumholz: All right. So before we end, I just want to take a moment to reflect on this day. Our 200th episode, that’s a lot of weeks and a lot of conversations. And for me, it’s been a privilege to show up every week, explore topics that matter. Howie, you know how much you mean to me, and—

Howard Forman: It goes right back at—

Harlan Krumholz: The main thing for me, honestly, if you ask me in the end is, we’ve been friends for a long time, but this has solidified our connection, enabled us to talk, to share, brought us together. Anyway, I didn’t want to get too sentimental about it, but I want our listeners to know how much this has meant to me with you being together with me.

Howard Forman: Oh, no. We are a team, and it is hard work. And for those that listen to it, we have fun with it, but we actually do take it very seriously—

Harlan Krumholz: We care. We care.

Howard Forman: We want it to be good.

Harlan Krumholz: And you know, sometimes we’re simpatico and sometimes we’re not—

Howard Forman: We work it out.

Harlan Krumholz: ...but we care deeply about each other—

Howard Forman: We always work it out.

Harlan Krumholz: We love each other.

Howard Forman: Yeah. Yeah.

Harlan Krumholz: I also want to thank all the students who have been part of the journey, that you’ve pulled in, the students, has been amazing. All superstars, their questions, insights, curiosity has made the show stronger and more dynamic. Thank our producer, Miranda Shafer, who does extraordinary work behind the scenes and makes each episode better. That’s so appreciated. Our sponsors, the School of Public Health, the School of Management, they’ve been unwavering in their support.

Howard Forman: They have.

Harlan Krumholz: To Ben Mattison and Jonathan Weisberg and—

Howard Forman: Kayla Stein—

Harlan Krumholz: Yeah, Kayla Steinberg and the teams at School of Public Health and SOM that support us and have helped us. We really are so grateful to them. And then I’ll just come back to you. You are really the... I say this at the end. I’m not joking when I say “the best in the business.” I mean, you are insightful, you’ve got humility, you care deeply, and everybody who comes in here is better for it. So thank you—

Howard Forman: And we do it for our listeners. I mean, look, we are two very different people, and we bring those talents, I think, to the room. And I think our listeners appreciate it. That’s why we do it. And I personally just want to say enormous thanks around this holiday season. Wishing everybody happy holidays and a happy and healthy new year. And we are very grateful to our listeners as well as all the people you mentioned.

Harlan Krumholz: To the listeners, thank you for your time, your interest, your trust. Howie, I think we got to do the regular outro.

Howard Forman: Yeah. We should do the regular outro.

Harlan Krumholz: Okay. 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, to keep the conversation going, email us at health.veritas@yale.edu or follow us on any of social media, and Instagram is our favorite one right now. With Tobias and Gloria leading the way, we have a growing account.

Harlan Krumholz: And give us your feedback. This year we’ll hear from Stephen Shafer. We hear from Charlie Torre. We love hearing from our listeners. Feel free to reach out. Also helps other people find us when you post it online.

Howard Forman: We really do appreciate it. Health & Veritas is produced with the Yale School of Management, Yale School of Public Health. To learn about the Yale SOM’s MBA for Executives program, visit som.yale.edu/emba. To learn about the Yale School of Public Health’s Executive Master of Public Health program, visit sph.yale.edu/emph.

Harlan Krumholz: And our superstar students this year, Tobias Liu and Gloria Beck. Gloria’s with us today, our outstanding producer I mentioned before, Miranda Shafer. And to the best in the business, Howie Forman.

Howard Forman: Thanks, Harlan. Happy holidays to you and happy holidays to everybody.

Harlan Krumholz: Talk to you soon, Howie.

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