A Cheating Scandal, Abandoned Research, and Other News

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. Harlan and I have intentionally set aside several episodes each year to cover a broader range of important news in the healthcare and health realm. And so I want to start off today with something that has not made mainstream news but is well covered in medical Twitter right now. And that is a cheating scandal that arises out of Nepal. And there are so many reasons why this is really provocative right now, Harlan. But suffice it to say, 832 people, which is a huge number, it’s like eight medical schools’ size, who took their exams at this Nepal testing center, have had their scores invalidated. And as you and I know, these scores are required for you to be able to do a U.S. residency in order to enter medical training in the United States.

Eight hundred and thirty individuals have had their scores invalidated. And it is like a spy novel, in a way, because the combination of investigations that have gone on by this U.S.-based testing service to be able to discover that there was a cheating scandal going on. And let me just be clear for our listeners, there’s no question that cheating is going on. The issue is, have we found the right people and is it much, much larger than this 832 people that we’ve discovered?

Harlan Krumholz: Do they know whether all 832 were actually involved, or have there also been some people who might have been harmed because others were cheating?

Howard Forman: It’s unclear, the extent of this in so many different ways, and people have pointed out online that others have been harmed in a way because some of these people already got interview spots this past year that they otherwise might not have gotten, and that it’s crowded out other people from getting interview spots.

Harlan Krumholz: Yeah, this is such a high-stakes issue. I mean, it doesn’t surprise me that there are people who go to great lengths to try to figure out ways to game it, given what it is. There’s so many different ways to go on this story. I mean, for one thing, what do we think about testing in general? I mean, are these really good barometers of how people are going to do? I’ve known some extraordinary individuals, great investigators, kind human beings, really smart people who had test anxiety and had trouble passing these tests and wouldn’t get interviews.

I would call up program directors and say, “No, this person will be a star. I have spent a lot of time with them.” And basically, because their test scores weren’t good or because they failed one time, they basically said, “That’s how we screen, and we’re not going to consider them.” And I think in this new era of medicine as well, one of a lot of decision support and information science, whether or not you can take a test, whether you can memorize, whether you can regurgitate back what they’re expecting is in any way an indicator. What they say is, “It’s an indicator of medical student grades or it’s an indicator of—"

Howard Forman: It’s a predictor of how well you’ll do on the next set of tests.

Harlan Krumholz: “Or on the next set of tests.” But it doesn’t necessarily mean that you’ll be a great doctor.

Howard Forman: So I couldn’t agree with you more on those points, but let me push back in the other direction about why I think testing does have real value. I think that there are very few truly objective measures of people’s aptitude, knowledge base, and so on. There’s a lot of subjective measures and we’ve learned—and I’ve sat in admissions committees for three decades now—we’ve learned that there are some schools for which getting a 4.0 is very easy, other schools, a 3.3. I always think of UC Berkeley in this way. And 3.3 is a great GPA. So scores from the schools have to be measured against other scores at that schools, and not only that, by different courses at those schools.

So there’s not a lot of objective data that we can use when we’re evaluating our student applicants. Scores are one of them, and they are very much imperfect. And as someone who went to a city college and a state medical school and has sat on these committees, what I’ve observed is that the students that come from the least-resourced institutions, not Yale, not Harvard, not WashU or Vanderbilt, the way they can get a leg up is by doing well on this particular—

Harlan Krumholz: Yeah, but they select for certain characteristics. I mean, this is what bothers me. Look, you happen to be an extraordinary clinician and teacher and someone who had the ability to do well on these tests.

Howard Forman: Yes, I did.

Harlan Krumholz: So you could start somewhere and say, “I know that’s the hoop I need to jump through.”

Howard Forman: Yeah. For me, it helped.

Harlan Krumholz: And that ended up being a really important step for you and an important opportunity. But imagine that there are a lot of other people who would be equally skilled. I mean, in a way, what are we selecting for? And the question is whether or not these tests help in that regard. I was on the board of the American Board of Internal Medicine, who puts together the certification and recertification processes for physicians, internists, and subspecialists within internal medicine. And when I really saw it up close and personal, I mean the kind of esoteric questions, whether you could answer these multiple choice and do this pattern recognition—

Howard Forman: You don’t have to convince me. I mean, I agree with that.

Harlan Krumholz: And they do all this psychometric testing. They say, “Well, the test is valid for what it is.” But to me, whether or not it really screened out the people that you wanted to screen out, whether it screened in the people that you wanted to screen. And now, I’ll just give you one other thing. Again, you hear me, I’m banging on this drum of A.I. all the time. But in a world where we could actually go back to where people were interviewed and solving the kind of problems that you see in clinical practice—and we abandoned that because it was too resource-intensive.

And humans aren’t very good at consistency. But there was a day when in the American Board of Internal Medicine, you actually had a face-to-face interaction with a clinician. And are there better ways for us to do this? Both to give anyone, no matter where you are... because there is a bias towards Ivy League or certain prestige institutions, which is also not fair. So how do we begin to get to a fair system where people can get through, but it’s selecting out for the characteristics you’re looking for.

Howard Forman: So I agree with you, but again, what I will point out is if you’re at Yale, if you’re at Harvard, whether you’re wealthy or not, anything else, you have access to resources. You have access to personnel who will guide you, mentor you, and get you on that path that a lot of other students don’t have. And so what I’m saying is what you’ve said is all true that testing is imperfect, but it’s very Churchillian and it may be the least imperfect of objective measures that we could use for this purpose.

Harlan Krumholz: But not all measures are meaningful, not all—

Howard Forman: But there is a difference.

Harlan Krumholz: ... that’s meaningful can be measured well right now.

Howard Forman: But we do know that there are students that will graduate from a good school with a 4.0 index who cannot be a physician. They’re not inclined to the sciences. We are testing a little bit about physics and chemistry and math knowledge and logic in these exams. They’re imperfect, but they are testing something. It’s not just esoteric.

Harlan Krumholz: By the way, how much physics are you using in your... well, you’re a radiology—

Howard Forman: Bad question.

Harlan Krumholz: But I’ll just say that the kind of things, even the first two years of the curriculum of medical school, and then they’re being tested on Krebs cycle, organic chemistry, things like that, that no one remembers afterwards. Half-life of the memory of these things is pretty—

Howard Forman: But you’ve hit on the most important point though, which is, now what we’ve done is we’ve sucked these international medical students who want to get better training, who are all of a sudden up against, “How do I distinguish myself?” It’s only the grade [that counts], and they get sucked into a cheating scandal that maybe even culturally might not even seem like cheating. Most of this is about memorizing recall questions. That’s what it’s about. They get sucked into this. Now they’re caught in this scandal and their—

Harlan Krumholz: And their careers are almost over as a result.

Howard Forman: Pretty much.

Harlan Krumholz: So I guess you would say that you were in favor of Yale’s recent decision to reinstitute the—

Howard Forman: I was.

Harlan Krumholz: There’s going to be a requirement now. Is that what it is?

Howard Forman: Yes. But they’re giving more flexibility. So Yale—

Harlan Krumholz: Yale and Dartmouth, yeah.

Howard Forman: Right, is that Yale has reinstituted a requirement for standardized testing for admission to Yale, but it is no longer just the SAT or ACT. It is a number of other options that are standardized tests to be able to demonstrate your relative aptitude.

Harlan Krumholz: We’ll just finish this topic, but just the one thing I didn’t understand about that was that Yale came out and said, “We believe that this actually helps.” In a way, it was sort of the case you were making. But I thought one of the issues was that well-resourced students were able to pay money to get the extra tutoring and so forth. And so what was unfair was that they were getting a leg up on that advantage. Yale came out and said, “Actually, what we think is that for people at low-resource areas….”

Howard Forman: That’s my argument.

Harlan Krumholz: Really?

Howard Forman: Yeah, I mean, so here’s what I’ve used standardized tests for, when I’ve used standardized tests, whether it was on the med school admissions committee or for residency selection or even now, up until a few years ago at the School of Public Health, I’ve always used it to establish basic minimum competency. Are they going to do okay? I don’t need them to be a 528 on an MCAT or 99th percentile GRE. But if somebody on their overall record is somewhere like “Are they a 10th percentile or are they a 40th percentile?” Because if they’re 40th percentile, I can work with them. If they’re 10th percentile, with our curriculum—

Harlan Krumholz: Then they may not be prepared enough for it.

Howard Forman: ... they can’t do it.

Harlan Krumholz: All right, let me go to another topic, Howie, that I thought you might find interesting. Do you know Stuart Buck?

Howard Forman: I don’t.

Harlan Krumholz: Yeah, I’ve had the pleasure of getting to know Stuart over time. He was a vice president of Arnold Ventures, and he got his PhD in education policy at the University of Arkansas and has a law degree from Harvard Law where he was editor of the Law Review. And so he’s a guy who’s been interested in long time about how research is conducted, and spent a lot of time. I guess in my work with open science, I interacted somewhat with Stuart and in a grant that he provided to Yale called CRIT that Amy Kapczynski was lead on with Joe Ross.

So he’s got this thing called the Good Science Project, which is a pretty interesting effort where he’s trying to, in particular, to say, “What are we doing with our science policy in the United States and what could we be doing better? How could we, in some ways, be configuring this so that we’re better promoting the interests of science?” And he’s focusing a lot on NIH—but not exclusively. And so he wrote this blog piece, “Why Are We Screwing Over Researchers Who Make Innovative Discoveries?” And he starts by talking about how current funding federal law allows universities to patent discoveries made with federal funding. And you know about this, right? I mean, this is the way in which this sort of tech transfer thing has really taken off and...

Howard Forman: The origin of this, by the way, is that what we didn’t want to have happen is for universities to say, “Oh, the NIH funded this. And therefore, it’s really government use and anybody can use it. And nobody then commercializes it. Nobody feels the profit incentive to drive them to take this great innovation and commercialize it. This gives universities incentives to commercialize.”

Harlan Krumholz: Exactly. So there’s this Bayh-Dole Act of 1980 in which Congress sort of set this forth. And what Stuart says in this piece is that there are many empiric studies that show that innovation is greater when researchers have more control over their work. And what tends to happen is, as you and I know, if we invent something at Yale, actually, we don’t own it.

Howard Forman: Correct.

Harlan Krumholz: Yale owns it.

Howard Forman: If you’re doing it in your capacity, in your job, using Yale’s resources…. There is an exception to that, that if you discover something on your day off in your home, not using Yale’s resources, then Yale doesn’t own it. But for the most part, the real lab work, the big stuff that’s going on at Yale is Yale’s property.

Harlan Krumholz: So basically, these universities get the intellectual property, and then they usually are just licensing it. So he was looking at this list of licensing revenue of American universities. And University of Pennsylvania is at the top, at—

Howard Forman: Have no idea.

Harlan Krumholz: ... $1.2 billion in licensing revenue.

Howard Forman: Oh, my God. In the last year?

Harlan Krumholz: This is 2022, which dwarfs the next one, which is Emory, which has $279 million, Harvard at $152 million, New York University at $100 million. By the way, if you look down the top 10 or so, I’m not seeing Yale yet. So Yale’s lagging a little bit compared to some of these. But this issue that he’s bringing up is around the University of Pennsylvania, which is largely—that revenue is from the work on the vaccine, so the mRNA vaccine, which was really the work of Weissman and Karikó, who did this. But this thing about Karikó is that here’s what she told CNBC, from Stuart’s piece, “I was demoted four times.” She tells of her time at University of Pennsylvania, where she was a research assistant professor before eventually being pushed out. And all of her work was discouraged and demoted four times, to the point where she had no future there, and they sort of pushed her out. Meanwhile, now they’re making a boatload of money off her.

And Stuart just raises the question, is this fair? That basically, here’s someone who they didn’t really support. I mean, there may be many people here whose inventions are only the result of the largesse of the university and the support, but here’s someone who it didn’t. And the exact details of this licensing room between Penn and pharmaceutical companies is not really known, but it is known that the vast majority of that money is being made out of this particular thing. So I don’t know what you think about this. Is this a good bargain, that Yale and other universities actually own our work?

Howard Forman: It’s like everything else. It’s imperfect. We really want things to be commercialized. We want the innovators to be given incentives, and Yale does that. So they typically give the innovator some small percent of this amount. It’s not 100%, but it’s also not nothing. And then Yale should—or, in this case, Penn—should be working on behalf of the innovator to help them commercialize it. They should be finding a CEO; they should be getting the patent attorneys involved and everything. They should be investing resources.

Harlan Krumholz: And I’ll say, when I read this, that particular case does seem egregious. It was unfortunate they didn’t support her. Now they’re bragging about having her there. Of course, Drew Weissman was very important, the faculty member who also was involved in this, but I would say Yale... We had Josh Geballe on with us. Yale Ventures, honestly, I think they’re the best of this thing. In the end, Yale either takes a small amount of equity or gets involved in licensing agreements, but to me, they’re very fair. It’s a group that helps.

Howard Forman: They’re certainly trying to be. It’s very difficult, because don’t forget, on top of that, you have to balance the conflict of interests on NIH grants. So you get into trouble on that as well, where Yale does have a responsibility to preserve the integrity of the scientists who may be involved in the clinical trial or continuing to work on it, at the same time, trying to commercialize it. There’s lots of issues.

Harlan Krumholz: And most of us who are faculty have benefited so much from being here. There is a lot the university has done for us. So I’m just going to say from my perspective, especially with the Yale Ventures, it’s not just Yale Ventures. The history here, actually it goes before that, Jon Sodestrom before Josh was terrific. And so Yale’s got I think a history of doing this really well. But anyway, let’s go on. But I just want to say I thought it was interesting because it is true. Gosh, Penn’s making all this money for someone they essentially pushed out and didn’t support.

Howard Forman: There’s no perfect out there but—well, what they did with her is particularly sad, but she’s come out on top.

Harlan Krumholz: All right, you’re going to take us through a measles story, right?

Howard Forman: Yeah, exactly. And again, I don’t want to make too big a deal of it. Last year, we talked about one polio case that never got beyond one polio case. And so that was a good news story. Measles is continuing to grow in the United States right now, but I want to focus in on Florida and not because their outbreak is particularly horrible. They just have eight cases as of yesterday. We’re recording this on a Wednesday. So eight cases as of Tuesday this week. And the reason why I’m bringing it up is the surgeon general there, for reasons that are beyond my comprehension, has decided to go against very mainstream public health practice.

How do you manage a measles outbreak? You have a measles outbreak at a school. You have a certain number of students in that school who are not vaccinated, and therefore, at very high risk of both getting and then transmitting measles. So you have a measles outbreak in Florida. It’s a relatively small outbreak. It’s at one school. And the surgeon general has decided to go against public health advice that has existed for decades now. And the advice is pretty simple. It says that if you are unvaccinated or otherwise might be capable of transmitting measles, you should quarantine for up to three weeks. It is known that the incubation period for measles is typically like 14 days. They extend that to three weeks. But he’s saying it doesn’t even matter, parents should make their own decision about whether the child should be sent to school. And that is so counter to good public health practice that it really begs the question of what is motivating him here?

Harlan Krumholz: So these are people who’ve been exposed but aren’t sick, that you’re talking about?

Howard Forman: Correct. And not vaccinated.

Harlan Krumholz: And not vaccinated. Yeah, measles is a tough one, the reproduction number, people may remember back when we were talking about this with COVID where we said each person might be able to infect like five or six other people. Measles is something like 12 to 18. So it’s probably the most contagious infectious disease that we know. And the other thing is that measles is not just a rash and fever. It can lead to very serious health complications, pneumonia, encephalitis, even death. And especially young kids or older adults, this can be catastrophic. We tend to try to get this thing called herd immunity where we’re trying... and people, again, may remember this from the COVID pandemic where we say, “Can we get enough people?” But for measles, it’s thought you need 95% or more.

Howard Forman: And by the way, this school probably has that. So one could say that the risk of sending these kids back to school is not going to lead to some massive outbreak, but the risk is that they do spread to an immunocompromised kid or a kid who got his vaccine but didn’t get full immunity and then brings it home. So there’s lots of secondary effects.

Harlan Krumholz: Yeah. And I think this just is going into these discussions that we’ve been having for a long time. I mean, I don’t know. What—did you think that we should have held kids out of COVID pandemic? I know it’s a different disease.

Howard Forman: For the beginning, definitely. I mean, I was on Twitter, went on record and said weight of the evidence seems to favor pulling kids out of school. Based on what little I know, and I’m not an infectious disease expert, I’m not a true COVID expert, it was just based on what little I knew, I felt like we kept them out of school a little, not a little too long, a lot too long. We became afraid.

Harlan Krumholz: And I think that we’re talking a lot about what the downstream effects are with math scores and other things. I think this is all going to be a balance, but it is true that this guy is way out of the mainstream. And it’s interesting. He is in a policy position in Florida, so whether or not he’s right or wrong, I think for us, we believe, based on the experts that we rely on, that this isn’t a wise decision. We’re in a moment in time where different states are pursuing very different policies. I think they’re becoming... I think this is true in COVID too because it’s almost an experiment. We’ve done work to show that the states that were most permissive in COVID probably, 20, 30% more deaths. There were tolls in actual numbers of people who died. I’m sorry to say that we may see that same thing again here.

Howard Forman: Yep.

Harlan Krumholz: Hey, I want to do a quick hit here just because there was something that came out yesterday. There’s a company called Viking Therapeutics that shot up 80% yesterday because they were produced positive results on one of their leading drug candidates for, that’s a GLP-1 agonist. And you and I have talked about these anti-obesity medications. Actually, it’s a combination med with GLP-1 and a glucose-dependent insulinotropic polypeptide, GIP.

Howard Forman: Oh, okay.

Harlan Krumholz: Kind of like what Lilly’s always been pushing forward.

Howard Forman: Is that—

Harlan Krumholz: Yeah, it’s a combo. Exactly. But it just gets to what we’re talking about. We’re going to be in this decade of remarkable innovation. And I do think that one after another, you’re going to start seeing these positive studies. What my question’s going to be is when we have such a large number of choices, will it drive down prices?

Howard Forman: That’s what I’m hoping.

Harlan Krumholz: Will it increase access?

Howard Forman: That’s what I’m hoping.

Harlan Krumholz: And will we get to a better moment? Because right now, we’ve got tremendous drugs, but there’s so many people who can’t get access.

Howard Forman: Absolutely. And look, in a perfect world, we would be completely equitable in terms of how we distribute them. But in our imperfect world, I would rather have a slightly less effective GLP-1 sold for a dramatically lower price to populations who otherwise couldn’t afford it than not having it at all. So I’m hoping we do get a lot of competition and that just like there was Lipitor and Crestor that were better than Zocor, here, we might have certain GLP-1s and GIPs that are better and some are worse, and hopefully, they’ll price differently.

Harlan Krumholz: And just hold onto your seat. I mean, there are two things that need to happen. One, a cultural shift in how we think about obesity. It’s a disease. It’s not a lack of willpower or people who are just weak. And I will just say my current thinking about this is as I see this having an effect on blood pressure, on lipids, on all cardiovascular risk factors, I think, “Gosh, we’ve been in the clinic treating the manifestations of obesity but not the root cause.” And these medications are going to give us the ability to go straight to the root cause, treat obesity first, first line drug, treat obesity, and then, by the way, as a side effect, people will lose weight. But I’m just saying we’re treating the cardiometabolic condition, the neuro condition of obesity. And then you’re going to see the risk factors improve. And then the questions, they may not even need to have antihypertensives—

Howard Forman: Right. Or diabetic medications.

Harlan Krumholz: ... and drugs and so forth, the risk will go down substantially. So this is going to be an interesting, interesting time.

Howard Forman: Yeah, I’m excited by this. I was very happy to see that. It’s the more, the better. At this point, we’ll learn a lot. So here’s a topic that I picked because you know a lot about it. And it’s a pre-print. So some people would say, “Why are you spending time on a pre-print? Pre-prints haven’t been peer-reviewed yet.” But this is a pre-print from a collection of pretty impressive trialists and scientists. And it basically says that 22% of academically led—so from universities—clinical trials in Nordic countries from 2016 to 2019 did not report their results to the public. Any results to the public.

Harlan Krumholz: What was the percentage?

Howard Forman: 22%. So almost more than one in five are not reporting out. And I’m just going to start off by asking you, why is this a problem? And then tell me about why it’s persisting.

Harlan Krumholz: Well, as you know, this is an issue that our group started writing about 15 years ago. And it started because of the involvement I had in the Vioxx trial. Vioxx trial actually taught me so much because we got to see so much behind the scenes.

Howard Forman: Remind people because it’s a long time now. What was Vioxx?

Harlan Krumholz: So Vioxx was a pain reliever. It was one of these non-steroidal anti-inflammatory drugs. It focused on a COX-2 mechanism. So it was a different mechanism than what aspirin, for example, or Motrin and so forth. And thought to be highly effective, but also to affect the bleeding system so that it promoted clot formation. And a lot of this was not known to the public at the time. So then there were a series of lawsuits against Merck that were saying that there was information that was held back from the public that was important that might have led people not to be treated. And some of these people suffered heart attacks. So I got involved in this. I’m not someone who gets involved in many legal cases, but this one I got involved with because I wanted to surface the information that I had seen that was sequestered. It was part of the court proceedings.

And ultimately, with Joe Ross, we ended up writing maybe 10 articles about this that appeared in many high-profile places. But one of the things we learned, and it indirectly led us to research around open science because we recognized that there was actually information that was held by the company that never saw the light of day. But then we started seeing that this isn’t just about companies, but actually, in academia as well, there was a lack of transparency around results from studies. And we did a series of studies that was showing low publications or even higher than what you’re reporting now among these.

And we ultimately said, “Well, let’s look at the NIH.” And in 2014, we published a study that said that if you look at trials funded by our tax dollars, the NIH tax dollars, and you said, “What percent of them are published in peer review biomedical journals within 30 months of finishing?” So on the registry, they said, “We’re done with the study.” But within now, almost two and a half years later, what percentage of them have been published? Fewer than half. I thought of this as a betrayal of people who had entered into the studies. And these aren’t the drug companies. These are actually largely academics. And it was hard to figure out, like people lost steam on them or they didn’t like the results.

Howard Forman: So it’s not really a conspiracy theory because I think the first inclination is, oh, the drug company’s suppressing this. So it’s not...

Harlan Krumholz: I actually thought the problem was worse within academia where there was no accountability. And by the way, you could get funded for a trial, run a trial, and then put in a next grant to get funded even though you actually hadn’t delivered the result to the public on the last trial. Now, in the decade in the United States, things have actually gotten better. There’s been more attention that Yale itself has, for example, has invested. We actually have people we’ve hired to ensure that trials are registered and to try to chase folks around making sure that they’re publishing the result. But I think there ought to be greater accountability such that if you haven’t finished your last trial, you haven’t published it, you shouldn’t be eligible for another grant until you can show that you’re going to share that information. But seeing this 20 some percent, I mean it’s bothersome, one in five is horrible, but it has been even worse. And among the very best NIH now, I remember Rob Califf starts talking about “small crappy trials.”

Howard Forman: He’s the head of the FDA right now.

Harlan Krumholz: Now, he’s head of the FDA, but a really renowned trialist at Duke before that. And Rob was saying, “Well, should they be published? Some of these are crappy trials.” He uses that word, “crappy trials.” And I say, “Well then come public with it.”

Howard Forman: Yeah, put them in a pre-print if you have to.

Harlan Krumholz: But still, we should see the results. So yeah, it’s a thing that’s been going on for a while.

Howard Forman: Great.

Harlan Krumholz: Hey, look, I wanted to talk about something else that really interested me this week that you may have caught in the news. And that was a 93-year-old widow of a Wall Street financier. And this individual, actually former faculty member at Albert Einstein School of Medicine, donated $1 billion with instructions that the gift be used to cover tuition for all students. There was a nice New York Times article about this. It turned out that her husband had invested in Berkshire Hathaway, the Warren Buffett fund, very early on. He was also a financier but had done obviously very well. And this generous donation really aims to cover the tuition of all medical students addressing the sort of crippling debt that many people experience. And I wanted just get your thoughts on this. NYU of course had gotten a big donation previously and had gone tuition-free. I mean, we are one of the few countries in the world that saddle people—I think we’re the only one maybe that saddles people with such debt. I talk to people in Europe and Canada, other countries, Australia.

Howard Forman: It’s either cheap or free.

Harlan Krumholz: Or free. We put people in a position where they leave needing money.

Howard Forman: I know.

Harlan Krumholz: Needing money just to become whole.

Howard Forman: I will tell you just quickly that the thing that brings a smile to me is, how did I hear about this story?

Harlan Krumholz: Your mother?

Howard Forman: No, my daughter.

Harlan Krumholz: Oh, your daughter.

Howard Forman: My daughter loved this story as soon as it broke and said, “Isn’t this great?” And she’s not pre-med, she’s pre-law, but I think she was inspired by the fact that this woman had done such a wonderful, selfless thing. But I immediately tweeted about it because I do that still now, even though I’m not a big Twitter fan anymore. But I’ll still tweet about it. And what I said is, “We need accountability though for the school.” Now, compared to NYU, this is a very different school.

Harlan Krumholz: Oh, it’s in the Bronx.

Howard Forman: It’s in the Bronx.

Harlan Krumholz: Montefiore, which is a safety net hospital.

Howard Forman: A very poor population. It is 60% female medical students, but it’s otherwise a relatively normal New York distribution of race. And the opportunity here now is to get better representation of students at Einstein because right now, in America, you have to be able to have some wherewithal to be able to go far enough to go to medical school without bankrupting yourself. You can do, as I did, go to a city college.

Harlan Krumholz: Is it also true the medical schools actually need some people who are paying the full freight in order to make this? Because if they give scholarships to... I mean, they have to have a certain percentage.

Howard Forman: Of course.

Harlan Krumholz: So then this takes that away from you.

Howard Forman: So I did the math just to prove it to myself. And it turned out exactly right, that for about 100 or 120 medical student class, you need an endowment of about $1 billion to make it free for everybody.

Harlan Krumholz: So for all listeners with a billion, Yale is looking for a donor.

Howard Forman: You could do it.

Harlan Krumholz: And we can go tuition-free too.

Howard Forman: And we probably wouldn’t put your name on the med school, but we’ll put it somewhere.

Harlan Krumholz: Oh, by the way, that was a very interesting thing. She first of all wanted to be anonymous. They said, “We don’t want you to be anonymous because your story, your personal story...” By the way, as a faculty member, she was devoted to people in need. I mean, she was a beloved faculty member who was committed to social disenfranchisement, social…. And so they wanted her to come. She didn’t want that. And by the way, you can buy your name on a medical school for like $200 million. So for much less money, she said, “You know what? There’s no better brand than Albert Einstein. I don’t want it changed. I’m giving it...” Anyway, all of it’s nice. I think what it is is not just a financial contribution but really a bold statement on the values of accessibility—

Howard Forman: It’s just a great story.

Harlan Krumholz: ... equity and healthcare. Anyway, I think it also challenges us how to be creative with philanthropy. And it’s just a nice, big signal. But you’re absolutely right. It’d be very interesting to see what Einstein does about this.

Howard Forman: I hope that they’re able to commit themselves to serving the community, to serving underrepresented specialties, underrepresented areas. There are things they could do that they could build into this.

Harlan Krumholz: So you don’t think they should just take the best students?

Howard Forman: No, I don’t. I think they should actually aim, even if they’re imperfectly, they should aim to get students who are committed.

Harlan Krumholz: So they should do social engineering?

Howard Forman: A little bit of it, yeah.

Harlan Krumholz: Okay. Interesting.

Howard Forman: Particularly for their community.

Harlan Krumholz: Okay.

Howard Forman: Yeah. By the way, Kaiser does that and Geisinger, I think, does that. Yeah, yeah, yeah.

Harlan Krumholz: Elicit your preferences.

Howard Forman: Yeah, yeah. Exactly.

Harlan Krumholz: So I know you want to get into this IVF thing. Let’s hear what you got to say.

Howard Forman: Yeah, real quickly, I think everybody has probably heard at this point that the Alabama Supreme Court, in reading the statute in Alabama, decided that if you destroy an embryo in a lab, you have murdered a human being. They’ve equated an embryo with a human being and essentially assigning personhood to a very early embryo. An embryo is before nine weeks; then it becomes a fetus. So this is really early on. And this has enormous ramifications because Florida, as you can imagine, was already marching down the train track toward passing an unborn child bill that would have passed right about now, if not for the Alabama court ruling. And that would have put Florida in the same path as Alabama, which means IVF and most advanced reproductive technologies are off the table now.

Harlan Krumholz: Let me ask you a question, just because I struggle with this a little bit. There’s the issue about the pragmatic issue, which is I want people to have access to IVF. Does it bother you at all when people just discard embryos?

Howard Forman: Of course. So look, it bothers me—

Harlan Krumholz: I mean, it bothers me.

Howard Forman: Of course.

Harlan Krumholz: I don’t know how to even think about it.

Howard Forman: No, so I think everything else, life is life. There are different types of life that are out there. We afford people different things with puppies than we do with humans than we do with sheep and cows and other animals. And I think that we should be thoughtful about what we do with any type of living tissue, right down to a tree, frankly. And we obviously afford different priorities for them. But once you start to say that something is a human life, and if you have a religious foundation that then says that is sacred, it becomes a whole different ball of wax.

Harlan Krumholz: Well, it has great implications for abortion. I mean, if you’re going to go back to that, I mean, that’s how I feel. I think women should be able to choose. I think that people should be able to choose. But do I feel sad and hurt for every abortion? Of course I do.

Howard Forman: I think that we have to respect the fact that women have to have autonomy over their own bodies and have to be able to make those decisions. But it doesn’t mean that we can ignore the fact that conception results in some type of cellular development that could be a human at some point. And by the way, we should feel that way when someone miscarries. It’s a lost life. There’s so many different ways that you can lose a life. It doesn’t have to be intentional abortion. It could be spontaneous. But this is the greatest conflict here because now, you have a group of individuals that very much want IVF because it is, quote, “pro-life,” it’s developing new life. And now, they’re in complete conflict with the fact that the very nature of IVF means that you’re going to be destroying some, quote, “lives” as well.

Harlan Krumholz: Yeah. Stay tuned on this one, right?

Howard Forman: Yeah. It’s very contro—

Harlan Krumholz: So as we’ve sort of wind up here, I thought you might want to say a few words. You and I have kind of been involved in this Faculty for Yale, which has attracted a lot of tension. Some good, some not so good. Well, you want to just explain to listeners what this is?

Howard Forman: So there’s been a group of faculty members, including you and I, but it started off with probably 20, and it grew to somewhere in the mid-hundreds now, that have come together with some common concerns and ideas about what we can do to help Yale continue to excel and continue to fulfill its promise as an institution of scholarly knowledge, development, and transmission. And even this podcast fits into that idea of transmitting knowledge to the outside world, to the inside world, and so on, and educating people. And the two things that were most important to me in this, and things that I only came to believe more passionately about in the last few years, are free speech principles and institutional neutrality. And both of them, I think for listeners that might say, “Oh, those make sense,” they’re very controversial. I mean, there are reasons why I can understand people taking different viewpoints.

I do not come to this in a simple way. Institutional neutrality very simply says that Yale as an institution should take a position on only matters that influence Yale’s mission. Again, scholarship, education, transmission of knowledge. If you’re outside of that, Yale should not come out with a statement about its own political or social position on that—unless it influences Yale’s mission. And then the free speech issue is really that the best thing we can do on this university is have a free discussion. You and I do not have to agree on every topic, but we’re willing to talk about it. We might even provoke people to say, “You idiots, you totally wrong on this.” Good for you. Tell us why it’s wrong and let us rethink that. Let’s convince each other with the courage of our convictions and the passion of our arguments, not by shouting people down or telling somebody they can’t speak or, last point, students being afraid to speak in class for fear that they may get censored.

Harlan Krumholz: Yeah. You and I were invited to a dinner where this was first discussed, and at that dinner, there were a lot of opinions that were expressed that I didn’t agree with that were—

Howard Forman: Me too.

Harlan Krumholz: ... different. But over time, this group kind of coalesced around the two principles that you said. And the group consists of people who might be considered more on the right side or the left side of politics but still could find common ground…. you know, it emanated from the fact that the university could come out for Ukraine or against what happened with George Floyd, was starting to take these positions, and for many of us, that didn’t seem to be an issue until we ran into the October 7th issue where there was really highly polarized views within the university. And there was a question of whether or not we were fostering an environment where people could express those opinions.

But the university itself shouldn’t take overt positions because while we may be happy on some days, we would be unhappy on other days. And it’s not clear that they even had a process to do that, that would be one that everyone could agree on. I was always concerned about this thing because what are the red lines? If just taking those university professors saying somebody calls for genocide of Jews, is the university going to tolerate that? And the question was really what’s hate speech and so forth. But in the end, I was convinced through all of this that we should stand for dialogue, for free speech as much as possible. Of course, you can’t, you know, “fire in a theater.” There’s certain things that are out of bounds, but for the most part, we should be fostering environment where that kind of opportunity exists and where the university isn’t on one side or the other, but is trying to help foster these discussions. That doesn’t stop faculty from advocating programs that are pushing certain things.

Howard Forman: That’s a good point. Important point. We’re not saying the faculty should shut up. We have faculty on this campus that have the entire spectrum of beliefs and have stated those beliefs. And there are people on this campus that have said things that to me are hurtful, but I would not shut them down. I would not—

Harlan Krumholz: And we saw that in COVID.

Howard Forman: That’s right. That’s right. And COVID also, we had a variety—

Harlan Krumholz: We had people who were promoting ivermectin. I mean, nothing could be further than what we believe, but we also didn’t suggest that person be fired because they were reflecting on their science. I mean, what they thought, we thought that science was wrong, but it was up to us to argue that. Right? Not to...

Howard Forman: And on the institutional neutrality point, people should understand that it’s what you don’t say that is also problematic at times. When does the university saying nothing actually say something? And people may read into that too much. So the institution should be as quiet as possible.

Harlan Krumholz: And we were moving to a thing where you almost expected every day for them to come out on the topic of the day—

Howard Forman: Whatever happens.

Harlan Krumholz: ... and where the university stand. I just think that’s unrealistic also. Right?

Howard Forman: Right. So a lot there, and I hope our listeners, we’ll link a couple of things in there for people to see about it. It is, I think, a more controversial topic than we give credit to at times, but I’m very happy to assign that as—

Harlan Krumholz: Well, I think some of our colleagues assigned a certain valence and position to this where it’s really meant to defend their rights to be able to say what they think as well.

Howard Forman: Yep.

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 to keep the conversation going, you can find me on Threads in general. I’m @T-H-E, the number 4, M-A-N, that’s @the4man.

Harlan Krumholz: And I promised to reemerge on social media sometime soon. But meanwhile, I still am on Twitter or X @hmkyale. That’s H-M-K-Y-A-L-E.

Howard Forman: And you can also email us at health.veritas@yale.edu. Aside from Twitter, Threads, our podcast, and LinkedIn, by the way, I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs, or check out our website at som.yale.edu/emba. If you like the podcast, even if you don’t like the podcast, seriously, no, please, we’re getting some more ratings. It’s really very good for us. The more you rate us, the more the algorithm will draw people to see us.

Harlan Krumholz: We love the algorithm!

Howard Forman: We like that. Right? So please rate us, review us on whatever podcast platform you’re using.

Harlan Krumholz: I don’t know if I told you Howie, but today, I walked out the door and I told my wife, “This is one of our sessions.” And you know what she said? “Oh, I love those sessions when you do that with Howie.”

Howard Forman: It’s fun when we do it in person like this.

Harlan Krumholz: Yeah, yeah, yeah. It is fun. And I really appreciate you. Health & Veritas is produced with the Yale School of Management, the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and to our producer, Miranda Shafer. They’re terrific. We love them, we appreciate them, and they—

Howard Forman: And we get to see Ines today in person.

Harlan Krumholz: In person, here with us.

Howard Forman: Yep, yep.

Harlan Krumholz: Talk to you soon, Howie.

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