Crowded Emergency Rooms and Other News

Transcript

Harlan Krumholz: Welcome to Health & Veritas. Guess who I am?

Howard Forman: You’re Harlan Krumholz.

Harlan Krumholz: I’m Harlan Krumholz.

Howard Forman: And we’re in the studio.

Harlan Krumholz: And we’re in the studio together.

Howard Forman: As we do. I’m Howie Forman.

Harlan Krumholz: I love you, Howie. It’s so great to see you.

Howard Forman: I love you, too. And it is fun to do this. Once a month we try to do in-depth coverage of a bunch of topics.

Harlan Krumholz: And this is our birthday. This is our birthday episode.

Howard Forman: It is my birthday episode.

Harlan Krumholz: Exactly.

Howard Forman: It is truly my birthday.

Harlan Krumholz: Twenty-nine.

Howard Forman: Twenty-nine. Thirty-second year of being 29. I agree.

Harlan Krumholz: Happy birthday.

Howard Forman: Thank you very much, Harlan.

Harlan Krumholz: I know that millions of students make videos to send you over—

Howard Forman: I don’t know if it was millions, but I will—

Harlan Krumholz: How was it?

Howard Forman: Credit to Adam Beckman, who has a skill for bringing people together to do that.

Harlan Krumholz: And the Surgeon General was involved in that.

Howard Forman: Yeah, Surgeon General sent me a nice video and a whole bunch of other people. It was very, very nice. It was very kind.

Harlan Krumholz: Well, you know everybody wants to celebrate this.

Howard Forman: It’s good to celebrate good things. There’s enough bad things.

Harlan Krumholz: It’s good to celebrate good things.

Howard Forman: But we are in the studio, and we are here so that we can talk about topics that we don’t ordinarily have enough time to cover.

Harlan Krumholz: Yeah, I’m glad we have this chance.

Howard Forman: Yeah. And I want to start off with something about emergency rooms, something—emergency department—something that I have a lot of experience with, both as a patient and as a radiologist. But in the last week, a lot of separate issues have converged. One of them was that various pundits on social and other media, in order to play up the issue around undocumented immigrants, have somehow been using that as an explanation for why our emergency rooms are overloaded, and how we shouldn’t have to pay for them because they are taxing the system financially and physically. And by the way, turning away anyone from the emergency room is inhumane, in my opinion.

Harlan Krumholz: Just let me ask you, since you started on this.

Howard Forman: Yeah.

Harlan Krumholz: Isn’t this part of this idea that’s being promulgated that the Democrats are advocating for paying for healthcare for...

Howard Forman: That’s exactly right. Exactly.

Harlan Krumholz: But it’s actually payments to hospitals. It’s not—

Howard Forman: Mostly. I mean, there are examples where states are using their own money to pay for Medicaid for immigrants that are on a legal track, and then there’s emergency Medicaid available even for undocumented immigrants in certain situations. It is not a meaningful financial issue. But more importantly is, and this is what I want to get to, is ever since 2011 in class, I’ve brought up this CNN Town Hall episode where Ron Paul of all people are standing there with a few other people.

Harlan Krumholz: Ron Paul, just to remind people...

Howard Forman: Which is the father of Rand Paul.

Harlan Krumholz: Who’s the current senator from—

Howard Forman: The current senator. This is his father, who was a congressman who ran for president a few times and who is a—

Harlan Krumholz: A libertarian.

Howard Forman: Exactly, an avowed libertarian. And I remember this so well.

Harlan Krumholz: And physician. And physician, exactly right.

He was an OB/GYN, right? His son is an ophthalmologist, I think.

Howard Forman: God, you remember this well. That’s awesome. But I talk about this, because I remembered it. So I actually went back and I found the YouTube of it to make sure that I wasn’t making this up. Sometimes I change the story in my head, and I had it down to almost a syllable. What happens is, Wolf Blitzer basically says, “What do we do if a 35-year-old comes in, I think unconscious or about to die and doesn’t have insurance, should we let that person come into the hospital even if they don’t have money and they don’t have insurance.” Not about documentation. This is about insurance here. And you hear in the audience, someone’s like, “Yeah.”

Meaning, turn him away. And Ron Paul, to his great credit, says, “Absolutely not.” Of course we should take care of him. He doesn’t even get into the issues around EMTALA, which I’ll mention in a second. But he at least says the ethical and morally correct things, which is we’ve got to take care of people when they come to our emergency rooms. And as you and our listeners know, EMTALA, which is the Emergency Medical Treatment and Labor Act, it requires facilities that receive Medicare, which is essentially all, to triage and stabilize patients irrespective of citizenship, legal status, or ability to pay. So this is in law, this is federal law, and we’re approaching the 40th anniversary of EMTALA.

Harlan Krumholz: I mean, people, just to recollect on where this came from, people may think, “Well, you needed a law for this?”

Howard Forman: Right? You did.

Harlan Krumholz: “People come in the emergency room sick, and—”

Howard Forman: We needed a law for this.

Harlan Krumholz: “...we needed law to say, take care of them?”

Howard Forman: We needed a law for this.

Harlan Krumholz: We need this because a lot of the emergency rooms were trying to transfer people out.

Howard Forman: We call it “dumping.”

Harlan Krumholz: Dumping.

Howard Forman: They were dumping. Always, these—

Harlan Krumholz: Terrible word.

Howard Forman: But it’s what people say. They were anecdotal cases, but literally patients would be driven up to another hospital with a gunshot wound in them, transferred from one hospital because they didn’t want to take care of them.

Harlan Krumholz: Because they didn’t have insurance, and they didn’t think they were going to be able to recover the cost.

Howard Forman: Correct. Correct. So then separate from that was an article in The New York Times that received wide attention focused on a young man who saw—

Harlan Krumholz: An article just came out last week.

Howard Forman: Correct. And we will put it in the show links, as we try to do with everything. Sought care in a New York ER twice over a two-day stretch and then died at his school, seemingly lacking a full workup. Also subtly in the article where various failures, which we can talk more about in early-year residents not responding to automated pop-ups on the electronic medical record. The case is brutal. The worst part of course is that he died, but it’s not unfamiliar. Patients do in fact die after care in the ER, in the emergency department, even after appropriate care in the emergency department. In this case, the article at least suggests that the care was not appropriate. But it is very hard to judge that after the fact. And I know we’ll talk a little about that. Medicine is miraculous, but it’s not perfect. I bring this up. Since the volume of cases in the ED continues to grow, the acuity of care that must be provided seems ever-increasing.

And I think that our, right here at Yale, our emergency medicine, our trauma, our pediatric emergency medicine colleagues are amazing. They’re incredible. But I just worry that we are exceeding our capacity to provide the care that’s needed in an environment when non-emergency providers are less often available on short notice or after hours. I don’t think the public has paid attention to the fact that we’ve had this transformation in our lifetimes from care being given primarily in outpatient settings and doctor’s offices for all but the most emergent circumstances to ones now where much care is now relegated to urgent care centers and emergency departments. And I just think we’re at the breaking point.

Harlan Krumholz: Yeah. Well, we talked about this a little bit with Kate Halpern, ED physician who is president of the Iona Human Hospital. I mean, this is something that’s happening everywhere. It’s certainly happening here. This story, it’s a devastating story about this twenty-year-old: two visits, like you said, within 24 hours, both times told he had a virus and then next thing you know, he dies. I think it showed that kind of this collision of different forces, individual fallibility, how well can we pick up on things, the systemic overload of our emergency rooms and then how we manage diagnostic uncertainty.

Howard Forman: Yeah.

Harlan Krumholz: And Jeremy Faust, our friend and who—

Howard Forman: We’ve had him on the podcast.

Harlan Krumholz: ...Jeremy’s terrific, wrote about this this week. Jeremy’s an emergency medicine physician as well. And I think he reflects on, there’s some things in here which are an indictment of the system. There’s some things that just happen. I mean even despite best efforts. But these misdiagnoses are multifactorial. And the question is going to be, in an AI world and a world where technology’s emerging, this is my question, we begin to help get assistance to figure out better and better. How can we not miss things that are important?

Howard Forman: I agree.

Harlan Krumholz: And how can we get better pattern recognition? We actually were part of a study that was done at Yale with this system called eCART, where we were looking at over 360,000 hospitalizations across the seven Yale New Haven Hospital institutions. And we were comparing different models, and then also Epic had a system. There were a couple others, and you can get quite accurate estimations about who’s got sepsis, for example, this widespread infection that can be life-threatening. And I just think more and more what you’re going to see is this kind of information being an adjunct to medical care. Now, that’s separate from this other issue that’s going on in the emergency department, which we’ve talked about ad nauseum, which is people being in the emergency room for over a day, days sometimes, not even in a room, on the wall.

I mean, it’s an insult to their dignity. It’s a challenge to their medical state. These people are sick. It’s an added stressor. And the hospitals are doing their best. It’s all about throughput. But I just don’t understand why we can’t solve this problem. And I know we’ve got smart people and we’ve got a wonderful chief of emergency medicine, Arjun Venkatesh, but I know that they’re all working on this. But it just seems like it’s been what, decades old, you work in the emergency department, how long has it been that we’ve been having people just all along the walls?

Howard Forman: So I wrote the boarding article in The Wall Street Journal I think about 10 years ago now, and it was a—

Harlan Krumholz: “Boarding article,” meaning that...

Howard Forman: ...meaning patients boarding in the ER and why this is a big problem.

Harlan Krumholz: Instead of getting them into a hospital room, they are actually, you’re calling it “boarding.” They’re actually—

Howard Forman: That’s what they call it. That’s what they call it. It’s the technical term.

Harlan Krumholz: I mean for listeners, I’m just saying, they’re—

Howard Forman: That’s right. We have a term for it.

Harlan Krumholz: Their hospital stay is in the hallway in the emergency department.

Howard Forman: And by the way, to put this in perspective, and we touched on it again, as you said, with Dr. Halperin, we have so many social ills out there that there are legitimately, particularly in the dead of winter, there are patients that are coming to our ER because it is the place that they can get a sandwich. It is the place where they can lie down safely for a few hours. We don’t have a mechanism by which to tell these people that, you know what, even though you have diabetic ulcers, even though you have all these other problems, since today, all you need is a sandwich and lying down, we’re going to turn you away. We just can’t do that. That’s one set of ills. And the other is that as our population ages more and more, we have more and more individuals that do require acute interventions, tuneups and so on, where they’re going to bounce back no matter what we do. Or maybe we could do better in the outpatient setting, but we don’t have the incentives set up to do that.

Harlan Krumholz: I just wonder if we should be benchmarking our communities saying how many hospitalizations per capita do we have? What’s the real demand? How much of this is being driven by social issues? What kind of investments need to be made to decompress that? But I sort of feel like we don’t set a goal for ourselves. What would a healthy community look like? Age-adjusted, how many hospitalizations should there be? And then where should we be making investments to reduce the number of hospitalizations that are necessary? I think I’ve told you before, I talked to the board at the hospital one year and I said, “Our goal should be to be able to shut half our beds, because we’ve improved the health in our community.” And that wasn’t received very positively.

Howard Forman: I mean, look, I walk through downtown, because I live there, all the time, and I see so many people afflicted with substance use disorders, many of whom that if you had tapped them on the shoulder would qualify to come into the emergency room. Some of them are practically unconscious. There is incredible need. But most of those needs tend to be social needs, and we’re not meeting them. And so we meet them in the hospital.

Harlan Krumholz: A repetitive theme on this program as we talk about, even when we were talking about insurers investing in food subsidies and so forth.

Howard Forman: That’s right. That’s right.

Harlan Krumholz: All right. Hey, let’s turn it to something else. So there was news this week that Peter Marks, who until recently was the nation’s top vaccine regulator at the FDA, has joined Eli Lilly.

Howard Forman: And by the way, for our listeners, again, he’s our former colleague.

Harlan Krumholz: Yeah, no, he was here, and he was among us.

Howard Forman: And he took, this is not a political appointment that he had at the FDA. He decided he wanted to go into the regulatory space and he rose up in the FDA.

Harlan Krumholz: He was a terrific leader there. And now he’s left to join Lilly to lead molecular discovery and infectious diseases. He was the one, really, who drove Operation Warp Speed.

Howard Forman: That’s right.

Harlan Krumholz: And, again, one of the leading accomplishments of the first Trump administration, but was forced out just recently, and he wrote a remarkable letter when he left that says that he accused Kennedy of wanting “subservient confirmation of his misinformation and lies.” These people who are leaving the government, very respectable people like Peter Marks and people from the CDC, are really, as they leave the door, they’ve got very strong words for the administration.

Howard Forman: He was the first among now many who have actually said that. So this has been confirmed by the most recent CDC director.

Harlan Krumholz: So I’m raising this because Peter, who we both have admiration for, is getting a little bit of heat now because people are talking about this. Again, revolving door from the FDA, Patrizia Cavazzoni, who is also head of CDER, the drug group, joined Pfizer. But I see this as a little bit different. I mean, these people were kind of put in a position where they were forced out. They had to leave the organization. I don’t know.

Howard Forman: I have no qualms with it. I do think it’s unseemly for the public, but I tend to think that I have no personal qualms with it. These people develop subject matter expertise over the course of a lifetime that can be put to good use in the public or private sector. He did not want to leave the public sector in this case, but he did. What are his options at this point? There’s nothing in the public sector. It’s not like there are state-based FDAs—the best option for him is to go to work for one of the pharmaceutical companies. And honestly, if that’s what he wants to do, he should be allowed to do it. And if he went to work for a university, people would also point that there are somehow conflicts.

Harlan Krumholz: Yeah, I think the issue is whether or not you think someone has been currying favor while they were in the official government position that put them in a better position to make the transition.

Howard Forman: I’m sure they have, but on the other hand, this would be an awfully long game if that was his original intent.

Harlan Krumholz: It would be an awfully long game. And I agree with you. I mean, look, he wants to make a living. He’s got an opportunity to have a job that contributes. Scott Gottlieb also.

Howard Forman: Absolutely. Board of directors of Pfizer.

Harlan Krumholz: That’s right.

Howard Forman: And also working for other venture firms.

Harlan Krumholz: People bring up Rob Califf going to Verily. This isn’t new. Yeah, I don’t know. But in this case in particular, I think, being in a position where he was sort of forced out, I felt.

Howard Forman: I also think it’s somewhat different if you’re going to work for a pharmaceutical company to lobby for them to be their government relations person than it is if you’re going there to offer scientific expertise.

Harlan Krumholz: You can also say he knows a lot about regulation, but he may not be the most welcome person at the FDA right now. So I mean hiring him literally is not—

Howard Forman: Good point. Good point.

Harlan Krumholz: ...not an opportunity to then have influence at the FDA, I don’t think. I mean, it’s going to be harder given the way that he left.

Howard Forman: It’s an excellent point. Yep. So we talked about hydration spas in episode 123 when we featured Margo Harrison.

Harlan Krumholz: You’ve got the best memory of all time.

Howard Forman: Hydration spas.

Harlan Krumholz: That’s right. They sound lovely.

Howard Forman: Well, this is where people go if they have a headache and they get an IV in their arm and they’re treated for that somehow. We talked about the lack of regulatory oversight, the overreach of offerings. Remember the—

Harlan Krumholz: Oh, you mean it’s not like sitting in a sauna. It’s actually getting IVs.

Howard Forman: No, it’s getting IVs and—risks and real risks that come with it. And right after that show I offered to my students, because we had classes.

Harlan Krumholz: You offered them hydration therapy!

Howard Forman: Well, not quite. I offered them an option to work on a project around hydration therapy. And one of them, Anisha Sivakumar, took me up on this. And we talked about how to systematically collect data at the state level and also to do a secret shopper study to see the real-world experience of patients who might encounter these spas. And we brought in our colleague Joe Ross, because he has far more experience and expertise on FDA regulations.

Harlan Krumholz: And what about your friend, Harlan Krumholz?

Howard Forman: We did not bring my friend Harlan Krumholz in on this one. We also brought in Isabel Wang, another Yale medical student.

Harlan Krumholz: Oh, she’s great.

Howard Forman: She is great. That’s right. And then we brought in Peter Lurie. Peter’s an executive director of science. Anyway, paper was published in JAMA Internal Medicine this week. I wanted to highlight a few of the findings. It’s nothing—

Harlan Krumholz: In JAMA?

Howard Forman: In JAMA.

Harlan Krumholz: Congratulations, Howie.

Howard Forman: Thank you. Thank you. Most sites offer add-ons for hydration therapy, whether it is magnesium, glutathione, vitamins or GLP-1s, most of the sites aren’t just giving you an IV, they’re giving you add-ons that can add up to thousands of dollars. It is rare for the sites to offer backup to their health claims—not surprisingly. Only a minority of sites offered to explain the risks. Medical supervision was soft at best in most sites. And regulation, as we suggested in the podcast, is lax at best. And mostly just absent state by state. And by the way, Connecticut’s particularly bad.

Harlan Krumholz: How did you collect the data?

Howard Forman: So we did secret shopper surveys.

Harlan Krumholz: Oh, I love the secret shopper approach.

Howard Forman: Five different places—

Harlan Krumholz: That’s great.

Howard Forman: ...in all 50 states, plus the District of Columbia. We also surveyed websites and we looked at regulations state by state for every—

Harlan Krumholz: So you had a bunch of questions as a secret shopper saying—

Howard Forman: I did it methodically. And that’s where, look, Joe Ross made this paper so much better. He really helped us hone in and make this extremely methodical.

Harlan Krumholz: Reproducible.

Howard Forman: Reproducible, reliable, and all that. And I was just happy because we took it from the podcast.

Harlan Krumholz: Yeah. Plus you had students. That’s terrific.

Howard Forman: The classroom. Exactly. It was great.

Harlan Krumholz: Congratulations.

Howard Forman: I just wanted you to know that I do, I don’t talk about my research much, because it’s honestly, not who I am.

Harlan Krumholz: No, this is a big deal.

Howard Forman: But when it’s fun, it’s fun. Yeah.

Harlan Krumholz: But let me ask you this. So what are the implications? What is your take-home on it?

Howard Forman: I think that there really does need to be regulation, presumably mostly at the state level because the FDA has limited authority to do that. And look, the State of Connecticut I think is a good example. I think it’s incumbent on state public health offices to be paying attention to this issue, and at least having some accountability. It should not be a Wild West out there. And by the way, in some of the quotes of the coverage of our article, I forget what’s called, the American Health Spa Association or whatever. These guys are in favor of regulation. They see this as something where you need some more organization. It should not be that just anybody can hang an IV bag and stick it in your arm.

Harlan Krumholz: Well, since you’ve got the machinery set up, why don’t you look towards stem cells next?

Howard Forman: It’s a good question.

Harlan Krumholz: I’m just saying you’ve got this methodology and approach. There’s a lot of things out there that are poorly regulated and deserve to have a little light shone on them.

Howard Forman: I guarantee you there are students that are listening to our podcast today and if anyone wants to reach out to do that, we will engage them on that topic. I like it.

Harlan Krumholz: Think there’s a lot of good stuff. There’s a lot of good stuff in there. All right, so look, I wanted to pivot to some other things that are happening out there that in this week there was some news on, so blood pressure drugs. So right now, maybe more than any time in decades, you’re really seeing a renaissance of efforts around drug development in the area of blood pressure. And AstraZeneca in particular is riding a wave. They had sort of transformed themselves into an oncology powerhouse, but it’s doubling down on cardiovascular and metabolic disease. And our friend Mikhail Kosiborod, I don’t know if you know this, Mikhail is actually leading all the non-oncology drug development work at AstraZeneca now.

Howard Forman: I did not know that. I knew he was in Kansas at the Heart Institute somewhere there.

Harlan Krumholz: Yeah. He’s gotten this big job, and I’m really proud of him. He’s just doing a terrific job.

Howard Forman: That is great.

Harlan Krumholz: AstraZeneca now is a strategic area, thinks that they’re going to be aiming for $80 billion in revenues by 2030 with about 20 new drugs expected by the end of the decade in this area of cardiometabolic. And one of them is this drug Baxdrostat, which is an oral drug that blocks aldosterone synthase. I’m going to talk to you a little bit about this in a second. But this is one of the enzymes that drive salt retention and causes hypertension. And in two large Phase III trials, it lowered blood pressure by nine to 10 millimeters of mercury compared to placebo. And because of its longer half-life, it evened out the peaks and troughs of blood pressure throughout the day. And they’re very excited about it. They think it’s going to be an important drug. And this is just one of many. So there’s this aldosterone synthase inhibitors that block the production of aldosterone, which is a hormone that caused the body to retain salt and water. There are these mineralocorticoid receptor antagonists that prevent the same thing from acting on the target in the kidneys.

There are certain substances which cause blood vessels to constrict, which can raise the blood pressure, endothelin receptor antagonists. Those are coming down the pike. RNA-based therapies, these are things which we may be able to give people like once every six months, and aminopeptidase A inhibitors. So I’m just listing and people are probably going to just hear that and go like, “What in the heck is all those names?”

But I’m saying that, and I’m not even getting to all of them. There are more because you’re seeing this capital going towards one of the biggest problems in the world, hypertension. And what’s interesting is these may be now a whole line of effective drugs, but one of the main reasons we’re not controlling blood pressure is because we’re not identifying it. People don’t know they have it. And even the drugs that are pennies a day, which could be effective at reducing mortality and morbidity, are just not being employed. So I think it’s going to be interesting to see what happens when we have a whole new group of medications that may be more effective, but they’re going to be a lot more expensive. What advantage are they going to bring? Are people going to use them, and will they help us actually overcome this stalled progress in treating hypertension, which continues to cause so much suffering.

Howard Forman: And just for our listeners, and for me quite honestly, this is not my field, but my recollection is that if you go back 20 years, we used to say if your blood pressure was below 140 over 90, you didn’t have anything to worry about. And now we are much more aggressive about trying to have a lower blood pressure for most people. Is that somewhat correct?

Harlan Krumholz: That’s a very interesting way to phrase it, because actually people aren’t more aggressive. Meaning that we are stalled in what our national blood pressure is and the percentage of people who have hypertension, high blood pressure, and the percentage of people who have hypertension who don’t even know they have hypertension. I mean—

Howard Forman: No, no, no, I’m not saying we are—

Harlan Krumholz: No, I’m just saying we haven’t, but what’s happened is the evidence has progressed.

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

Harlan Krumholz: So what we’ve recognized is lower is better.

Howard Forman: That’s what I was asking.

Harlan Krumholz: And that if we can get people under 130, actually they have much better outcomes than the people who are just a little bit over 130. And both of those would have been considered to be nonhypertensive in the prior era. But we’ve moved to an era where the guidelines—and the guidelines just came out in August—the new guidelines for hypertension are doubling down on this idea that we should not be content at 140 over 90. But we should be thinking about under 130 over 80 and 120 over 80, 120 over 70.

Howard Forman: And this is better. But we’re not doing it.

But it’s not dissimilar from where we once were with cholesterol, where we used to think if you’re over 200, you have to treat it. If you’re under 200, we’re not going to worry. And then over time we realized getting people lower and lower was helpful.

Harlan Krumholz: That’s right. But we have made progress. More people are on statins and cholesterol levels have continued to drop. There still are people who are being overlooked. But in hypertension, it’s just mind-blowing, because again, since about 2010—I’ve talked about this 2010 one—we really flattened out on progress for cardiovascular mortality, but since about 2010 also in hypertension, if anything, it’s gotten a little bit worse in the country. So the evidence says we should do more, doing more. We should get people to lower levels, and we just don’t seem to be making progress. So that’s what I’m raising. Is the problem really medications or how we’re implementing evidence? And if these new medications come out, will they be a net positive, will people use them, or are people going to say, “Well, I’ve actually got inexpensive strategies that we aren’t even using, and we should be starting there”?

It’s going to be a very interesting time. These new drugs, like I said, help the body get rid of excess salt and water. They relax blood vessels; they block hormones and proteins that raise blood pressure. There are all sorts of fancy biology. It’s beautiful, it’s elegant. It’s not going to do any good if all it is is knowledge without really helping.

Howard Forman: I have a good corollary to this in the global health area. And the reason why I say it’s a corollary is this is not elegant. This is just beautiful. And that is—

Harlan Krumholz: Okay. I can’t wait for this.

Howard Forman: This is fun. Researchers in Uganda conducted a fascinating study that to me just shows the brilliance of our global public health researchers. In rural sub-Saharan Africa, mothers often carry their young children on their back in these cloth wraps.

Harlan Krumholz: Yeah. You see that.

Howard Forman: You’ve seen pictures, right? I’ve seen that. Yep. These same parts of the world see enormous exposure to malaria we’ve talked about before on the podcast. But suffice it to say that the biggest thing we talk about is these bed nets that protect the children from getting—

Harlan Krumholz: Yeah, keep the mosquitoes out.

Howard Forman: Exactly. But once the child is out of the bed, you don’t have those protections in place anymore. So when the child’s on the back of the mother, no similar protections, the investigators pre-treated the wraps that they wrapped the children in with something called permethrin.

Harlan Krumholz: Yeah, permethrin. Yeah.

Howard Forman: It’s a mosquito repellent.

Harlan Krumholz: Right, exactly.

Howard Forman: And then randomized the mothers. So that 200 had the permethrin wraps, and 200—

Harlan Krumholz: Yeah, I can never pronounce that either.

Howard Forman: Two hundred did not, right?

Harlan Krumholz: Yeah.

Howard Forman: And they found, the results were just incredible. Sixty percent reduction in clinical malaria.

Harlan Krumholz: Come on.

Howard Forman: Sixty percent from this very minimal intervention in this high-risk group. And the safety profile was favorable. There were some infrequent mild reactions.

Harlan Krumholz: You hear something like that, and you wonder, why didn’t anybody think of that before?

Howard Forman: So malaria kills 600,000 people a year, 95% in Africa, most occurring in children below the age of five. And here you have a relatively inexpensive innovation that has—

Harlan Krumholz: When they wash it, does it wash out or they have to keep treating it?

Howard Forman: They pre-treat it, they talked about the mechanisms by which they could pre-treat it, re-treat it I should say. But they did it. It was practical.

Harlan Krumholz: Where was that published?

Howard Forman: In New England Journal of Medicine just about nine days ago.

Harlan Krumholz: Oh, my God. I missed that.

Howard Forman: I know. I did too! I got it in my hard copy, and it said it was published on the 26th of September.

Harlan Krumholz: That’s a great article.

Howard Forman: And it just drew me into it.

Harlan Krumholz: All right, I’m going to read it.

Howard Forman: I love it. Yeah, it was very cool.

Harlan Krumholz: All right, I want to shift gears here to still flurry of movement of AI for physicians. And I think what’s happening now is this sort of race for what’s going to be the Google for Doctors. And as you know, we’re moving from search to LLM-based, the way people are finding information. And one of the biggest headlines recently, we talked about it on the show, was OpenEvidence, which raised over $200 million in a series B that pushed its valuation to $3.5 billion. And for people listening who don’t know what this is, it is simply a website or an app you can use where you ask questions and it brings up medical knowledge and gosh, it knocks it out of the park repetitively. It’s an extraordinary platform that’s growing rapidly. A lot of the residents are using it, people using it in research.

Howard Forman: And why do we like it better than ChatGPT? What’s that feature?

Harlan Krumholz: They document where they got the information.

Howard Forman: Because they show the references.

Harlan Krumholz: Yeah. And I think the way that they give you three or four paragraphs that answers your question, they give you the references. I thought you were going to ask me the underlying architecture.

Howard Forman: No, no, no. I wouldn’t know that.

Harlan Krumholz: They could be using this RAG architecture.

Howard Forman: That is, it’s RAG, but that’s what it means where it pulls from qualified sources.

Harlan Krumholz: I also think it’s about having Agentic AI on top of the foundation models, but I don’t know particularly what they’re doing.

Howard Forman: Now you’re above my pay grade.

Harlan Krumholz: But anyway, the point is that people, it’s grown remarkably fast. Because people are finding it really easy, and it’s giving them more complete information than regular search. So at the same time, Doximity, which is a very popular physician platform that people use to exchange information—

Howard Forman: Are you on Doximity? Do you interact on Doximity?

Harlan Krumholz: I don’t.

Howard Forman: I don’t either. I’m on it, but I don’t understand why it’s as popular as it is. But they seem to have latched onto a lot of apps.

Harlan Krumholz: But I think they do a lot of things that docs like. During the pandemic, they offered then a simple app that could do telemedicine that was going to be HIPAA-compliant. And they seem to be smart, but they just paid $63 million for Pathway Medical, which has its own AI ecosystem because they think people are going to go to Doximity for answers. Then meanwhile UpToDate, which became the sort of online medical textbook

Howard Forman: Everybody uses UpToDate.

Harlan Krumholz: But I think that OpenEvidence was going to make, like are people going to use textbooks anymore when you can sort of create your own de novo chapters by asking questions of OpenEvidence. So now they’ve just launched an up-to-date expert AI to try to compete with in this world. I think this is going to be a very interesting space to watch: What are doctors going to gravitate to? What are they going to trust? What’s the quality of information that’s going to be produced? Lots at stake because these are eyeballs from doctors and that’s information that people are willing to pay for. These are going to be big business models, billion dollars of companies potentially, but it’s an arms around trust, accuracy, and distribution.

Howard Forman: Unlike the other AI bubbles that are out there. And this may in fact be part of that bubble, but I love seeing competition in this space. It is not good when any one vendor just dominates it. And that’s the only fallback. I am happy that UpToDate is in there. I’m happy Doximity is in there and OpenEvidence clearly—

Harlan Krumholz: And there’ll be more. Also, Elsevier’s got one—there’s going to be more.

Howard Forman: Epic is going to figure out how they can, right, yup.

Harlan Krumholz: Epic’s going to figure this out. So I agree with you. And then just like in the search wars, people gravitated at Google because they tangibly felt they had better results. Whoever’s going to win should be because we feel we’re getting the answers that we need.

Howard Forman: That’s right. And look, I don’t think Google was the first. I mean I think when we think back to these things, Yahoo had the lead there. Yahoo is like the lead in search.

Harlan Krumholz: How about Ask Jeeves? Ask Jeeves.

Howard Forman: Ask Jeeves. That’s right. And Bing. I mean these are all out there, and they certainly were competitive, but Google won that, at least at the time. I want to give a real quick public health update on syphilis, in particular congenital syphilis. Just to remind our listeners, we don’t talk about it enough. We did cover this in the podcast either one or two years ago. But even though there’s a decline in reported syphilis cases, we’re actually witness to a 700% increase over an 11-year period in congenital syphilis, which is just a horrible disease and one that is a hundred percent preventable. And it just should remind us all as we talk about these great strides in global health domestically, something that is 100% preventable is leading to thousands of children being born with a disability that they should not have.

Harlan Krumholz: I think that’s a great point since you’re going to go on a public health note, let’s do some quick hits here at the end.

Howard Forman: You got it.

Harlan Krumholz: I just want to know your view on what’s going on at the CDC this week. CDC formally endorsed the recommendations from the new RFK Jr.–led panel that’s going to roll back several longstanding immunization practices. They removed its previous blanket recommendation for all adults 65 and older to receive COVID vaccine. For parents, the CDC effectively eliminated the option for combined measles mumps rubella varicella vaccine. I don’t even understand this exactly because the manufacturers only produce these combined vaccines. And then there came something even more striking where the acting CDC director, who also serves as deputy secretary at the Health and Human Services Department, that RFK Jr. runs, then called on manufacturers I think on Twitter, in a tweet, in a tweet on Twitter—crazy—or X to break up the MMR shot into three totally separate vaccines, which goes along with something that President Trump mentioned.

Howard Forman: Which is a horrible, horrible thing to do. I mean, number one there is—

Harlan Krumholz: And there was a guy, Howie Forman, who commented on this on X also.

Howard Forman: I did comment on X. I mean it is a horrible thing. I mean I couldn’t stop myself. I really couldn’t because it’s a horrible thing to do. Number one, we know that parents already have trouble getting to the doctor every three months, every four months. When a child is newborn it’s already a struggle. By breaking it up your bas—

Harlan Krumholz: By the way, especially people who are working hourly jobs and—

Howard Forman: Absolutely!

Harlan Krumholz: ...under stress.

Howard Forman: You’re encouraging noncompliance. And secondly, there is zero evidence. There is not a scintilla of evidence that the combination has any harm. It only has benefit. And we’ve proven that in other parts of the world. I think that when you compare monovalent vaccines, that being one at a time versus combination vaccines, compliance drops, not surprisingly. So there is nothing to be gained, only harm. This seems like literally an effort just to undermine our vaccine successes.

Harlan Krumholz: Yeah, well you certainly made your mark on the public domain, and I think it does. It’s going to be very, I hate to use the word interesting. It’s going to be I think an unfortunate consequence of all this. That there’s, let alone what the policy is, the nation now is really fragmented. They don’t know who to trust, who to listen to. They don’t know what to do.

Howard Forman: This is a non-physician who is basically puppeting our president, who does not even lay claim to having any specialized—

Harlan Krumholz: We’re not driving a consensus in the country about the right thing to do. And this really does concern me.

Howard Forman: And by the way, measles, right now, we’re up to 1,563 confirmed cases in the country with three months to go. 1992 had 2,126 cases. And I would not think it impossible for us to exceed 1992. So we’re already at a 32-year record. We might be at a 33-year record and this all ties together—

Harlan Krumholz: And people have died.

Howard Forman: And people have died. Three people have died from this outbreak alone. A fourth person from a remote measles exposure.

All right, look, I want to end on the Nobel Prize.

Howard Forman: That’s nice. We need a Happy Meal.

Harlan Krumholz: Good note. So we just heard this week that Mary Brunkow and Fred Ramsdell and Shimon Sakaguchi were given the Nobel Prize in medicine and physiology. And I thought I would just quickly just help people know. This is about discovering how the immune system keeps itself from attacking the body’s own tissues but also, by connection, help us understand autoimmune disease to a greater extent. So Sakaguchi first described in 1995, a tiny subset of our immune cells, the T cells, just about 1 or 2% of the total that suppress overactive immune responses and maintain tolerance to ourself, keeps our body from attacking ourself, and when those are missing or malfunctioning, that’s when the immune system can attack itself. And that’s so interesting to me because what’s like only 1 to 2% of these specialized cells—they’re very important cells and there are many different subsets of them—are really kind of keeping us in balance. And when they malfunction or go missing, the body can start attacking itself. And then in 2001, Brunkow and Ramsdell, in a private company, discovered that mutations in a single gene, this FOXP3, caused fatal autoimmune disease in mice and humans. And two years later, Sakaguchi showed that this was the master switch that turns ordinary T cells into regulatory ones, essentially defining the role of these specialized regulatory T cells that do it. So they’re sort of like bringing together how does it work on the genes? How does it work on this thing? Anyway, this has all fundamentally changed immunology because it explained why immune tolerance—that is the fact that we don’t attack ourselves, our defense system—doesn’t have friendly fire on the usual basis. But why also when that fails, all these autoimmune diseases start up and look, this was decades of work born from careful observation and persistence. I thought it was a wonderful story. So I just wanted to mark that. But also we’ve had good news in New Haven. It’s not exactly medical.

Howard Forman: Well, partially, partially, partially New Haven.

Harlan Krumholz: Well, the Frederick W. Beinecke Professor Emeritus of Applied Physics, Michael Devoret

Howard Forman: Who lives at Berkeley, but I mean

Harlan Krumholz: We’ll claim him!

Howard Forman: We’re claiming him. Absolutely.

Harlan Krumholz: He was one of the three people who was named for the discovery of macroscopic quantum mechanical tunneling—that sounds very esoteric—and energy quantization in electric circuit—that sounds quite wonky—but it’s what enables quantum computing, which a lot of people think within the next decade will be the way that

Howard Forman: It’s what’s driving innovation—

Harlan Krumholz: Which will unleash remarkable opportunities and potential threats.

Howard Forman: Threats.

Harlan Krumholz: But congratulations to him.

Howard Forman: Yeah, it’s very exciting.

Harlan Krumholz: Congratulations to Yale for having some connection, even if he’s not living in New Haven anymore.

Howard Forman: I know, I know. It’s very exciting. And I think it’s a credit to Yale that we were part of it. I mean, he was on our faculty here for this research. It’s just that he retired and now I think is at Berkeley.

Harlan Krumholz: It’s all actually part of many faculty working on this. Steve Gerben’s an example, Rob Sholkoff. And there’s actually, by the way, a company that’s spawned out of Yale that’s working quantum computing that could make a big difference in world. Very cool. Very, very cool.

Howie, what a great opportunity for us to talk together. 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, keep the conversation going. Email us at health.veritas@yale.edu or follow us in any of social media, and we’d love to respond to your comments. And we got some nice comments this week from a listener, and we’re going to try to incorporate some of that more discussion about social determinants in a future episode.

Harlan Krumholz: Yeah, give us your feedback. We love it, and it helps people find us.

Howard Forman: 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/emda.

Harlan Krumholz: Health & Veritas is sponsored by the Yale School of Management, Yale School of Public Health. We’re fortunate to have two superstar undergraduates, Tobias Liu and Gloria Beck, remarkable producer Miranda Shafer. And I’ve got the best co-host in the world, the Howie.

Howard Forman: And we get to do this together, Harlan. I mean, I truly appreciate you.

Harlan Krumholz: Talk to you soon, Howie.

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