Barry Wu: The Questions to Ask the Elderly

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 closer to the truth about health and healthcare. Our guest today is Dr. Barry Wu, but we always like to check in on current or hot topics in healthcare. So lead us off, Harlan. What do you got?‌

Harlan Krumholz: Yeah, this an interesting thing happened this week. I don’t know if people noticed this, but the House Appropriations Subcommittee on Labor, HHS and Education dropped its, listen to it, 379-page report just last week. Now, people may not know about this because usually this goes without much notice. These House reports—as you know, because you’re an expert in this—the existence of this report is business as usual. I mean every year the House Appropriations Committee issues one of these statements, it’s usually a long statement, to go along with the spending bill, but what’s interesting this year is the tone and specificity of the commentary. It’s very different. In past years, this report has just included fairly standard language. For example, support the NIH, general encouragement of this or that. It’s not really getting in the weeds, but what you’re seeing here is much sharper language, stronger directive. And let me give you an example of some of what’s in this because I just think our listeners may be interested.‌

Howard Forman: Yeah, I haven’t read it. So I’m really curious to hear about this.‌

Harlan Krumholz: So one, they really get deep in replication and fraud detection, and so they double down on reproducibility and we’ve got a reproducibility crisis in science.‌

Howard Forman: Well, explain to our listeners what we mean by that, because that’s important.‌

Harlan Krumholz: So somebody comes up with a study, it gets published and somebody else tries to run the same experiment, they don’t get the same result. And even sometimes no one runs the experiment. We wonder whether they would get the same result. But it’s about not doubling down your own conviction about a finding when maybe it’s not—why aren’t we getting the same result? You think in science, there’s a universal truth and these experiments are designed to uncover those truths. But when people do the same experiments or use the same data and come to different conclusions, different results, it raises questions about the quality of the research or the way in which we’re approaching it or what are we doing here that’s leading to this uncertainty? And so in this report they’re talking about, that essentially—they’re alarmed that too many NIH studies can’t be replicated. That somebody has federal money, they’re coming out with a study, but what they found can’t be repeated when someone else tries to do it.‌

Howard Forman: And is that true?‌

Harlan Krumholz: Yes, it actually is true. But what’s interesting is, Congress is now getting involved in this, and they actually cited examples. And so they’re earmarking $100 million for NIH to run replication experiments. What that means is $100 million for them to repeat experiments that people who had federal money did to see whether or not they come up with the same results. So that’s just one thing. Another thing is that there’s this big push to fund the person, not the project. So Howard Hughes Research Institute does this, where instead of getting an application to say, “I want to do this study, I’ve got these aims, I have these hypotheses,” they are going to be identifying people that they want to invest in and let them have more freedom. They’ll have some accountability, but they will be investing in the person. They say, “Well you’ve got good ideas. We don’t want you to have to say what exactly you’re going to do, but we want to invest in you.” So that’s another interesting thing, in the degree of detail. They talked about the indirect costs. As you know, our—‌

Howard Forman: Right. That we’ve talked about.‌

Harlan Krumholz: ...school’s very interested in this issue, and so they want more transparency there. But I’ll just note one other thing. Howie, this, it seems very important to me, there’s skepticism about the National Academies. And basically the committee urged the federal agencies to be cautious about signing contracts with the National Academies. Now, for the listeners who don’t really know what this is about, there’s National Academy of Science, there’s National Academy of Medicine. This National Academy of Science, they were initiated by Abraham Lincoln. I mean these are a longstanding.... Institute of Medicine and now the National Academy of Medicine is more recent. But this idea that there was a group that brought together experts that helped guide the federal government is longstanding, and much of the budget comes from the federal government.‌

A group like the FDA will go to the National Academy of Medicine and say, “We’re struggling with a difficult issue. We wonder if you would bring together experts who would help provide us guidance.” And what Congress is now saying is essentially, “Well, we don’t think we trust those experts. And so we are urging you agencies not to send money to the National Academies and find other ways of getting expert input.” This will be terribly debilitating to this system that’s been in place for a long time. Now, like all systems, these can be better, stronger, there’s ways to improve, but this will be a big deal to this system. And by the way, these experts come from all over the United States. There are people across fields who have accomplished something in their career. So it’s not political, hasn’t been political historically, but this, maybe, administration considers some of their work to have been political, I suppose, and are steering the government away from funding them.‌

Howard Forman: So the first two points you bring up, though, I wonder, are those good things, maybe? Is there at least an argument to be made that investing in the replication issue and/or investing in some specific people might be a better strategy than the status quo?‌

Harlan Krumholz: I like the concept. I’ve been saying it for a long time. I mean, I think there are better ways to fund these grants. I actually wrote a note to Jay Bhattacharya because I had an idea that said, instead of putting together a grant application, send in a pretend research article that was published that would be the result of your work, the best possible article that could be produced if your work goes perfectly so that people could understand what they’re buying. And I said, I think another direction I suggested to him was to invest in people. Now this thing could go wrong, depending on what you are using to determine which people you’re going to fund.‌

Howard Forman: Right, of course.‌

Harlan Krumholz: So if you really do it based on science and promise and not on politics, then that could be great. But if it gets political, then that’s probably—‌

Howard Forman: Oh, I see the risk. I see the risk. I just want to make sure, for our listeners—‌

Harlan Krumholz: But I like the concept, and I like the focus on replication. So again, this gets to our strategy on this podcast and, I think, in our lives, which is, don’t reflexively react to something by who’s proposed it. Judge whether or not it’s meritorious. And in these cases, I think these are good things for even Congress to allocate money to or get involved in. The National Academies is an interesting thing. What I’d like for them to do is to get a little deeper into that. What do they think the issues are and why do they think it’s failed? So we can understand on what basis are they steering people away from them. But it’s an interesting move.‌

Howard Forman: The National Academy issue, I think, concerns me more than anything, partly because they did so much work on vaccines in the ’90s and early 2000s to advise us about things like thimerosal or about the link to autism and—‌

Harlan Krumholz: Well, when Harvey Feinberg was head of the Institute of Medicine at the time, I mean he had made a lot of his career talking about swine flu and policies around vaccines and things like that. Yeah, for sure.‌

Howard Forman: That’s what concerns me is it seems more politically motivated. I do not know about any particular bias of the National Academies. Maybe there is some, but having seen many, many, many of their reports over the years, the vast majority seem nonpartisan to me.‌

Harlan Krumholz: Yeah. So this will be interesting, a conversation that’ll occur as this gets debated and discussed, but this is a very different kind of document than before, much more prescriptive.‌

Howard Forman: No, I think it’s really important that you bring it up, and it’s really important that our listeners realize that we’re in an unusual time right now.‌

Harlan Krumholz: Yeah, let me just say, I’ll just finish this up by saying why it matters. So now Congress is signaling that how science is done—the reproducibility, the transparency, the incentives—matters as much as what science is done. And for biomedical researchers, I think this means that there will be new funding for replication studies, a possible shift toward these people-based funding and more scrutiny of the costs and governance than we’ve ever seen before. And I think some of this can be good. Some of this can be good. And let me say, all of it, I mean, I don’t know. We need to see how this is going to play out, but there are hazards and opportunities in all of it.‌

Howard Forman: I agree.‌

Harlan Krumholz: So hey, let’s get onto our guest, Barry Wu.‌

Howard Forman: Dr. Barry Wu is a professor of medicine at the Yale School of Medicine and co-directs the program’s introduction and capstone courses and also recruits and trains faculty for medical education. Dr. Wu serves as co-chair of the health committee for the Yale China Association, and he was recently honored with a mastership from the American College of Physicians. As the co-director of the Yale Connecticut Older Adult Collaboration for Health or COACH 4M Project, Dr. Wu’s current research centers around the 4Ms framework in geriatric education. In the past, his work has included studying medical error reporting and improving patient safety.‌

He received his bachelor’s degree in chemical engineering from Rensselaer Polytechnic Institute and his MD from the University of Rochester before completing both his internship and residency at Yale New Haven Hospital. So first, I want to welcome you, as you are a multifaceted individual who comes to us as both a geriatrician who is clinically involved in caring for patients, but also training our medical students, our physician assistants and others and residents in geriatric care. And I wanted to start off, though, because one of the reasons we invited you on the podcast, not just because of your expertise, but because of your active involvement in the first and last courses that our medical students take in professionalism. And what do you mean when you say “professionalism”? What does that mean? Because to some people, professionalism is about scolding bad behavior. For others, it’s about developing a personal identity within your profession. What do you mean when you say “professionalism”?‌

Barry Wu: Yeah. Well, in the old days I would say dressing in white coats, having a tie on, washing hands. Now I think it’s remembering why you wanted to become a physician, remembering the patient, putting the patient at the center, and you want to really think about taking care of the patient and their families, and professional is putting their interests above your own.‌

Howard Forman: You’re not just a physician, but you’re also a caregiver. And there was a very touching write-up about your relationship with your mother in Yale Medicine about two years ago, and Harlan and I both have experience with elderly parents who are thankfully functioning and continuing to enjoy much of life. And you too have a mother, who I understand is 92. Now I’m curious to know as a geriatrician, how do you approach not just your personal relationship, but how do you approach other people as they help their parents or other significant people in their lives navigate later years when the world gets smaller?‌

Barry Wu: Yeah, I think it’s a great question because the older population is the fastest-growing population, not only in the United States but globally. And so we need caregivers to be able to take care, and we’re not going to be able to hire enough people to come in to help. It’s really training people. That’s why this framework that they developed about eight years ago, it’s called the 4Ms. It’s very easy to remember, 4Ms, just they all begin with M. The first is “mobility,” making sure the older person is keeping as active as possible and preventing falls because falls are associated with so many morbidity.‌

The second M is “mind.” Really listening to see if they’re becoming more confused or they’re depressed. Is there any dementia? And being able to address that. So we have mobility, we have mind, and then “medications,” because as you get older, more and more medicines, there’s polypharmacy, your body’s not able to remove the medicines as well, they interact. And so you want to, instead of, as doctors, we prescribe, we want to de-prescribe. We want to get rid of those medicines. So we have mobility, mind, medication. And the last one is, what’s most important? Listening to hear what is the values, what’s most important to that patient. It could be going to the art museum or going to a Boston Red Sox game. Whatever’s most important, not necessarily more medicines and treating individual siloed problems, but really hearing what the values of the person is.‌

Howard Forman: And just as follow up to that, what is the role of family member caregivers versus the other communities around them? How do people navigate that, in your experience? Here I’m speaking more in your role of a geriatrician.‌

Barry Wu: Yeah. I would say this, that I once, at a geriatric conference, there’s this expert geriatrician on Alzheimer’s was speaking and he said, “Barry, what’s the best treatment for Alzheimer’s?” And we have these new monoclonal antibodies and all. And he says, “The best treatment for Alzheimer’s or any dementia is taking care of the caregiver. It’s really taking care of the family member or whoever’s taking care of, because they will provide the best care.” A family member will provide better care than any visiting nurse or anyone you can hire because you have a personal relationship.‌

My mom’s 92, lives in Pittsburgh, away from me, so I have cameras on her and I watch her. My brother’s close by, thankfully. And also about a year ago, she fell, is now wheelchair-bound. We had to get a visiting nurse to come in twice a day. Initially, she was very resistant because she’s such an independent person. But with time, she became more acceptant and now likes it because, kind of, she has to be able to have conversations with this person and develop relations. So as you get older, it’s hard to change, but I think having family members or friends in the area in addition to community service, whether that’s Alzheimer’s Association or an area agency, to take advantage of any help you can get.‌

Harlan Krumholz: I want to stick with this thing with your mom because I thought it was just so instructive, and it is an example how stories can be such great teaching because reading about you and your mom, it taught me a lot. To think about the things that you brought up, I mean it started with your commitment to your family, your dad telling you to take care of your mom, and it intersected with your life as a professional.‌

And you were trying to help her and at least, and I want you to just talk a little bit about this, but you realized that you really didn’t understand or couldn’t represent well what her priorities were until you went through this same exercise of trying to talk to her and understand that mobility and independence and how she valued that above other things. I just thought there were a lot of lessons in that. Even as a professional, these tools were helpful to you with your own mom, to try to help figure out how you could best support her through all of this. I mean, can you just talk a little bit about what that was like for you?‌

Barry Wu: Yeah, for sure. My dad died when I was a junior in high school, but before he died I remember him saying, “Be sure you take care of your mom, because she dedicated her life to me,” and to honor your mother and father. I’ve been taking care of her over these decades and it’s just been a privilege to do that. And I assume living long was her goal, but until I went through, there’s this thing called the Patient Priorities Care. It’s a system developed by Mary Tinetti and others, where you listen and you have questions that go over what’s important to the patient.‌

And when I did that with my mom, I learned, for her, what she really hated the most is her incontinence. And so being able to deal with the incontinence. It’s not so much living longer or relationship, it’s that incontinence that bothered her most. And then unless I went through those questions, I would never have known that. I made the assumptions. I should know her, I’m the oldest son, I know my mom, but I didn’t know my mom because I wasn’t really listening until I asked those questions and listened to her responses.‌

Howard Forman: I wonder if you could say a few words about, we had Thomas Gill on in the past year on episode 173, I think, and the challenge for geriatrics is both reimbursement, meaning it’s not a lucrative field to be in. We don’t have enough of them. And it’s also like, what is the model for delivering care when there’s such a shortage of geriatricians? What is the model for delivering geriatric care in America? Is it to have specialists who are only available for consultations or how do we fix this and what should we be doing?‌

Barry Wu: That’s a great question, Howie. I don’t think we would ever train enough geriatricians to provide the care that is needed. And that’s why what I’m in is into education, and this COACH grant is a HRSA grant providing education to everybody. And so now we’ve integrated into the first-year class. So the first-year medical students, the first-year PA students, their very first interview with the patient is doing this 4Ms and saying this.‌

So no matter what profession you’re going into, you’re going to be dealing with geriatric, patients 65 years and older, people. And whether it’s you’re dealing it in your specialty or at home, as you said. And the more we can train people to listen to what’s important to the person, to see their mobility, to see if they’re getting confused at all and trying to remove as much harm as possible, remove as many medicines as you can safely, preventing falls. If you have rugs that they can fall and break a hip, that’s associated with such high morbidity. So you want to do prevention, prevention, prevention and education. So everybody needs to be trained in this. I would say this: it’s like CPR. I would think that we need to be training geriatric concepts like CPR, that we train everybody in.‌

Harlan Krumholz: So let’s just break this down. For people who are listening, because I think this would be instructive. So the 4Ms: what matters, matters; mobility; mentation; medication. So just tell us. That seems simple, but okay, how do you actually apply it?‌

Barry Wu: Yeah, so that’s a great question. I think the way to teach it is more asking questions, open-ended questions. So I would say, “Mom, what’s most important to you?” Or, “Mom, what bothers you the most?” To get an idea of what matters most? “Mom, how’s your walking? Do you need any help with any walker or wheelchair? Mom, how’s your thinking?” Or you can detect if they’re having problems with their memory. Just recently, she goes, “I don’t remember what happened on 9/11.” And I’m like, “Oh, okay.” So you listen in to hear how their mind is. And I also think, especially in older people, really listening if they’re depressed. How’s their mood? Do they seem sad? Because treating and dealing with depression in an older person is very important. And then—‌

Harlan Krumholz: Medication?‌

Barry Wu: And medication, trying to at least know the list of medicines they are, and then thinking about what was the goal of the medicine. So being aggressive medication in a younger person is probably the right thing because they’re looking for longer life. While in an older person, they may be looking in for quality of life. So you try to remove any side effects from the medicines or the medicines that you—‌

Harlan Krumholz: Are these 4Ms, as you teach them, they’re all just about asking questions? For example, I get it on what matters most to you. That one seems obvious to me, but mobility and mentation, you can actually test that directly.‌

Barry Wu: Yes.‌

Harlan Krumholz: So in this case, when you’re teaching it to the students, are you saying, “Let’s test the mobility. Let’s test the mentation and their cognitive abilities?” Or are you saying, “This is really just about in your interview, talking to people?” but not— ‌

Barry Wu: No, no. Yeah. Yeah, great question. I think early on, it’s questions, but as they go on in their training, there are tests. So for dementia, we call it, you draw a clock and you put—‌

Howard Forman: Oh, the mini mental?‌

Barry Wu: ...and you say three words. The mini mental, yeah. So you can assess. Or depression, how’s your mood over the past two weeks? Are you feeling depressed at all? So there are questions to assess these things and walking, you can see how fast they walk—‌

Harlan Krumholz: So my only other question, shouldn’t we just automate this? So before everyone’s visit, also the people should be prompted. I know, whether you are in favor of chatbots or whatever kind of thing, but I mean sometimes I think these things can be primed before the visit and you can then build on them in the visit. You’ve already collected some information. I’m just saying, we should require that every pre-visit, we’re assessing these things in appropriate age populations, but that these are things that we should be able to track over time and are required.‌

Barry Wu: Yeah, I agree. I think that you could totally utilize artificial intelligence for a lot of these things. So I think they can be helpful. I think in Japan, they even have robots taking care of patients, like robots are taking care of patients. But also think about the importance of the human relationship and having human contact and dealing with a human being. And I think that’s particularly important with family members. You would want to have a family member there or something like that, if possible.‌

Howard Forman: Well it is really nice to see, I mean your work goes the entire lifespan because you are about generativity and development of professionals and you’re also about helping care for the elderly and most vulnerable among us. And I sincerely appreciate all that you do for the medical students and for educating me and others.‌

Harlan Krumholz: Yep. It’s been great having you on, and it’s great to learn more about teaching at Yale.‌

Barry Wu: And thank you both for all that you do. And thank you for this podcast, which is four years old. It’s wonderful.‌

Harlan Krumholz: What a decent individual, and it speaks volumes about his relationship with his mom and how he takes care of her, calls her every day at the same time. We didn’t discuss that, but it’s in the article, and honestly it’s an honor to know somebody like that. But hey, let’s get onto your part of the podcast. I’ve been missing it. Since we didn’t do it last week, we had Topol fill the whole thing, and I’m really missing because it’s been weeks and weeks. Howie Forman, what’s on your mind this week?‌

Howard Forman: All right, I have one slightly longer thing and then one very short thing I want to touch on, both of which I think are important. So the assassination of Charlie Kirk is the most recent example of violence committed against a public figure, and we’re seeing an enormous range of response. There are people who attempt to justify it. There are others who are less than sympathetic and there are extreme efforts to either martyrize or otherwise demonize. We’ve watched this play out after the murder of Brian Thompson, the CEO of UnitedHealthcare about 10 months ago, after Governor Josh Shapiro’s home was the subject of an arson while the family was inside on Passover, when a Minnesota House speaker was murdered along with her spouse, when the president was shot during the campaign, and when insurrectionists stormed the capitol on January 6th and many other similar events, I’m sure I’m leaving out a lot.‌

Violence and particularly gun violence are a public health issue, and we should be thinking of ways to reduce it with the evidence that we have, including reducing access to guns, particularly those who seem prone to using them against others. But I bring this topic up not because it’s surprising that bad people will do bad things. That seems a given. I bring this up because I think there’s a seismic change in society around tolerance for violence. And some of my concerns arise from surveys around college students that came out last week. Last week, a large national survey from FIRE, which is the free speech organization for education, did a survey on campus at a large number of campuses and noted that 34% of surveyed students nationally felt that there are times when violence is justified to halt speech. And that 34% figure is up from 20% just three years earlier.‌

And by the way, at Yale, the figure is 27% currently, so lower than the national number, but still pretty high. Separately on Tuesday last week, prior to the Kirk assassination, Martin Luther King III was on our campus for a sponsored event at the Yale Political Union, where he defended the proposition that “violence is never the answer.” And by the way, I agree with him: violence is never the answer. After the debate, a vote was taken among the attendees, and the vote came out 55 to 28 against that proposition, with one voter abstaining. So very similar to the earlier numbers that I mentioned, where people seem to tolerate the idea that violence is helpful or could be useful, either rarely or sometimes.‌

Harlan Krumholz: But Howie, couldn’t it be in that context, when you say violence is never the answer, someone would say, “Well, if you lived in Nazi Germany, what’s your choice?” The violence sometimes, I’m just saying that they would, so the people are really just indexing on an imaginary situation where we have A Handmaid’s Tale or something, you know, where it’s like—‌

Howard Forman: I will say—‌

Harlan Krumholz: ...as opposed to in our current society, where we say we’re not at a point where people should take up arms against each other. That’s unacceptable.‌

Howard Forman: But I want to point out, in the first case, we’re talking about for speech issues only. In the second case, it’s more general. In the second case, I still believe violence is about a proactive attack with intent to harm. It is not about defense. No one’s saying that you shouldn’t be allowed to defend yourself, but there’s a difference between saying that people have a right to have a gun in their house to defend themselves versus people have a right to have a gun so they can go out and hunt people they think have wronged them without going through our judiciary system.‌

Harlan Krumholz: A hundred percent, but that’s not how the question was phrased. I’m trying to give our college students some credit that there might be some people who are misunderstanding the question because those numbers are extraordinary.‌

Howard Forman: I know, but here’s the question. This is the exact question, word for word: “How acceptable would you say it is for students to engage in the following actions to protest a campus speaker?” And the question is, using violence to stop a campus speech, that gets 34%.‌

Harlan Krumholz: Okay. I’m just blown away by that.‌

Howard Forman: I know. I am too.‌

Harlan Krumholz: I mean, I was struggling to understand it in some way, but that’s just ... that’s scary.‌

Howard Forman: I think social media has made it easier for us to see otherness, and those outside of our in-group are consistently dehumanized. I don’t have easy answers to this, but I think the first step is we have to acknowledge that we do have in-groups, and we need to do more to reach out to people outside of those in-groups. And again, I just want to say for the record, for me, violence is never the answer to stopping someone from expressing themselves.‌

Harlan Krumholz: Yeah. I’m with you. ‌

Howard Forman: I do want to give a real quick update on one policy issue, if you’ll allow me.‌

Harlan Krumholz: Yeah, please.‌

Howard Forman: And that is the ACA premium subsidy tax credits are set to expire on December 31st, and Congress is in the midst of negotiating over this. Democrats are making this a line in the sand in order to gain their votes, and on October 1st, government shutdown looms if they don’t get the votes. I can’t speak to whether this political tactic will work, but it’s an important policy that affects millions of Americans. And disproportionately, I might add, those living in non-Medicaid-expansion states. In fact, the greatest impact will be Florida, Texas, and Georgia. And we’ve talked about this before, but just briefly, these subsidies are provided to individuals who buy insurance on the Obamacare or ACA exchanges. Since 2021, enhanced subsidies have been provided to individuals to make these policies more affordable. And the benefit has been that millions more have been enrolled on the exchanges with more affordable options.‌

The enhanced subsidies were initiated with the American Rescue Plan of 2021 and continued with the Inflation Reduction Act of 2022, but they will end this year, and if they end, we expect at least 4 million people will become uninsured, and millions more will see their premiums go up by as much as 70% or, I think, more than 70%. Suffice it to say, this appears to be an important position to take for House Democrats. I hope they succeed, not for partisan reasons but because I think it’s the right policy. A one-year extension costs about $30 billion, and I don’t expect Congress will do more than a one-year extension at this point. This is something to follow your news every day right now.‌

Harlan Krumholz: So I’ll just come in on this side. If I were a political consultant to the Democratic Party, what I might say is if you’re risking a government shutdown that will be blamed on you and that will ultimately give more power to Trump.‌

Howard Forman: Yes.‌

Harlan Krumholz: If you say, “We really have no choice. The Republicans are the majority. They own all three branches of government,” and I say that guardedly about the Supreme Court, but the Supreme Court, in general, has been, they don’t “have” the Supreme Court, but it’s going in that direction and people need to see the consequences of the Big Beautiful Bill. And if people don’t like it, they will vote in the midterms differently. But to intercede now is to cause a big ruckus, to be ostracized, and to be blamed for a shutdown and will make it harder for them to recover back and will play more power to the White House I’m just saying, if I were a consultant to the Democrats, I might say, “This isn’t the moment. Look at the long game here, and you need to win back Congress in order to have an opportunity to exert power.”‌

Howard Forman: You’ve perfectly laid out the two different viewpoints. One is that Democrats need to stand up and put a line in the sand about something and say they stand for this and let cards fall where they may and hopefully actually get this because, as I said, Texas, Florida, Georgia, and a lot of other red states benefit from this, if they can get it. The flip side, as you said, is they could let the cards fall where they may and let this be adjudicated next election.‌

Harlan Krumholz: Still articulate their alternative, but what they’re going to say to the public is, “Elect us if you don’t like this,” as opposed to try to manage it within Congress with something that will result in a shutdown. What they could start saying to people is, “We have a different vision and in order for this vision to win, you have to vote for us.”‌

Howard Forman: I agree with you. I mean, I think that’s the way to think about it.‌

Harlan Krumholz: Until they win elections and get back in this thing, it’s going to be difficult for them.‌

Howard Forman: It’s true. This is going to be followed very closely over the next two weeks.‌

Harlan Krumholz: Very close. It’s hard for me to imagine we’re not going to have a shutdown, but we’ll see.‌

Howard Forman: Yeah.‌

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, email us at health.veritas@yale.edu or follow us on any of social media.‌

Harlan Krumholz: And we appreciate your feedback. Please feel free, go on the sites, helps people find us, and we always enjoy hearing from people.‌

Howard Forman: We certainly do. And if you have questions about the MBA for Executives program at the Yale School of Management, reach out via email for more information or check out our website at som.yale.edu/emba.‌

Harlan Krumholz: And thanks to the Yale School of Management, the Yale School of Public Health, for all of their support. We wouldn’t be here without you. Thanks to our superstar undergraduates, Tobias Liu and Gloria Beck. Thanks to our marvelous producer, Miranda Shafer, and to the best co-host ever, Howie Forman.‌

Howard Forman: I appreciate it, Harlan. You’re the best as well. Thank you very much.‌

Harlan Krumholz: Talk to you soon, Howie.‌

Howard Forman: Thanks Harlan. Talk to you soon.‌