Dana Dunne: Learning to Learn

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

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. Our guest today is Dr. Dana Dunne, but first, we always like to check in on current or hot topics in health and healthcare. And the first question I have for you, Harlan, is how are you feeling?‌

Harlan Krumholz: Oh, thanks, Howie. Yeah, I had this flu-like illness that lasted for about two and a half weeks. I thought I would never get rid of it, but I’m feeling great now. Feeling great now. Thanks.‌

Howard Forman: Yep. You look good. You look good. So tell me—‌

Harlan Krumholz: Thank you so much.‌

Howard Forman: ...what do you got on mind?‌

Harlan Krumholz: So this is our last show of the year, isn’t it, Howie?‌

Howard Forman: It is.‌

Harlan Krumholz: So what do you think were the top two stories of the year? I’m just curious.‌

Howard Forman: The years are blending together at this point. So I would have still said probably that GLP-1s and A.I.‌

Harlan Krumholz: Oh God, that’s exactly... You and I should be on, what, The Newlywed Game, because we would have exactly agreed. ‌

Howard Forman: We’re the odd couple. Yeah. Yeah.‌

Harlan Krumholz: So I wanted to end the year with a story on A.I. because something just came out a couple days ago in arXiv, which is the preprint server. This means it’s a place where academics can post research before it’s been through peer review. But let me tee this up for you. So imagine walking into your doctor’s office, but instead of a trusted physician making the call, it’s an A.I. system with superhuman abilities. This is what we’ve been talking about. Can this superintelligence—actually, medical superintelligence—emerge? In this new study, it’s a preprint again, meaning not yet peer-reviewed. Say it may not be far-fetched or as risky as it sounds, the OpenAI’s latest model, o1-preview, has achieved remarkable results in clinical reasoning. I think it’s going to potentially change the way medicine is practiced.‌

I keep saying this, and people keep wanting to push back, but I think it’s really true. So this study put this model to the test evaluating its ability to handle some of the most critical aspects of medical decision-making, generating differential diagnosis, reasoning through management plans, and triaging patients. And the results the AI didn’t just meet human standards—it surpassed them on tasks that demand complex reasoning. And I think we’re looking at this potential for this medical superintelligence to be at every doctor’s fingertips and to have dramatic implications in a very short period of time. ‌

And let me give you some examples. One of the toughest benchmarks in medicine is generating a list of potential diagnoses for someone who comes in with a complex set of symptoms. So someone comes in, and it’s not immediately obvious what they’ve got. They start listing off all these different problems. Maybe you’ve got a few blood tests, and you’re trying to sort your way through this. The researchers tested o1-preview on 143 challenging diagnostic cases patients with these complex situations that have been published in The New England Journal of Medicine. The A.I. included the correct diagnosis in this differential. We call it a differential diagnosis, just simply a list of diagnoses that could be what this person has. It was in there 90% of the time. This compares with 73% of the time by GPT-4, which has been the previous best one, but often much better than experienced clinicians. Howard, you would know, we read this in The New England Journal of Medicine, especially if it’s outside of our area of deep expertise, it can be hard to get it right, and this is actually solving it. I’ve been using it with medical students also in the clinic, and not this model but even GPT-4, and it’s pretty remarkable. For example, there was a case of a patient with symptoms pointing to a rare disease, Langerhans cell histiocytosis. I’m sure you can tell us all about it, but...‌

Howard Forman: It is a radiologic disease. So it is one of those things that we learn too much about. But yeah.‌

Harlan Krumholz: But the GPT-4 failed to identify the disease. Many clinicians wouldn’t even be thinking of this disease. And the o1-preview, not only did it identify it as the most likely diagnosis but provided a full and detailed list of alternatives and things that should be done. The response score of five out of five from evaluators, this is the way it can synthesize the information. On management reasoning, it was presented with a clinical case requiring decisions about what diagnostic tests to order or what management test steps to take. And again, pretty amazing, nearly identical to the very best clinicians with the right tests included. And it was rated as being right almost 90% of the time. You may say, well, that’s not a hundred, but clinicians are far from a hundred when this is a level of performance that you don’t often see. So again, documentation of clinical reasoning and so forth. It was only short on probabilistic reasoning, but what it could do was quite amazing.‌

So for centuries medicines advanced incrementally, better tools, better drugs, better systems, but this A.I. I think really represents a leap forward. I think we’re on the verge of having this medical superintelligence at our fingertips capable of really transforming healthcare delivery, and here’s the key. If it works, it means no matter where you live in the world, it will be like you’re right next door to one of the very best specialists. Actually, a tool that can exceed many of the best specialists in helping to do all of these things. So I think people listening to this, people will still have worries. The medical establishment is usually slow to change, but I think we’re going to be astonished how quickly this is going to be integrated into practice and how dramatically it could possibly change for very low marginal cost. I mean this is the thing, Howie, it’s not like $10,000, $20,000, it’s going to be low marginal cost.‌

Howard Forman: So what I would love to know, and it’s obviously downstream, we can’t test it now, is will this allow us to invert the model that we’re in right now, which is to say primary care docs take care of routine things and some coordination of care, but any type of problem, heart failure, diabetes, automatically we send them to specialists right now, or very often at least. This could invert the model because this could put the power back in the hands of primary care providers to be able to consider the entire gamut of diagnoses within even a specialty field and only go to the specialist for interventions or for refining a diagnosis.‌

Harlan Krumholz: This is going to raise the level of performance for everyone in the healthcare system to a much higher level than their current level of license. The license may say “I’m a primary care doc, I shouldn’t be handling something more complex.”‌

Howard Forman: But now you can.‌

Harlan Krumholz: Now you will be able to, because the person’s going to be like... I mean the model’s on your shoulder, it’s helping to guide you.‌

Howard Forman: No, I love that.‌

Harlan Krumholz: I think this is going to be a breakthrough in that respect. I also think patients are going to benefit from this because they’re also going to have access to this kind of power. So when you’ve got a bunch of symptoms, you’re sitting at home, you want to know, what does the—‌

Howard Forman: I totally agree.‌

Harlan Krumholz: ...model think.‌

Howard Forman: If a patient doesn’t have to go to five specialists to help manage their disease, they’re already ahead. So that’s fantastic.‌

Harlan Krumholz: Yeah, this can be... So anyway, it’s an interesting thing to end the year on, just was posted on arXiv by the way. Anyone listening, we’ll post it on our notes. But arXiv is outside of a firewall. Anyone can take a look at this paper. All right. Hey, let’s get on to our guests. This is going to be a great conversation.‌

Howard Forman: Dr. Dana Dunne is the director of the Yale School of Medicine Longitudinal Coaching Program, which was founded in 2022 to support students over the course of their time at Yale School of Medicine. During her time here, Dr. Dunne has also been an associate designated institutional official for the General Medical Education Office and the Associate Chair for Education and Academic Affairs at the Yale School of Medicine, where their focus on caring for patients with sexually transmitted diseases. Dr. Dunne is a professor of infectious diseases at Yale and is a founding and core faculty member of the Yale Primary Care HIV Training Track.‌

Dr. Dunne received her bachelor’s from the University of Washington and her medical degree from SUNY Downstate Medical Center before completing her residency and fellowship at Yale New Haven Hospital, where she was also chief resident. So first of all, I want to welcome you to the podcast. There’s a lot that we can cover. I have come to know you through the coaching program. So I think I want to first start off, since this is something really brand-new in medical schools in general, and you are the inaugural director, the founding director, and led the committee that led to a creation of the coaching program. Can you talk about why medical schools have evolved to have coaches involved in medical education?‌

Dana Dunne: Yeah, so it’s really fun to be here to talk about this, and coaching is definitely taking off in medical education. Probably about a third to half of medical schools right now have coaching programs. They can look a little bit different, and there are a lot of types of coaching out there. People have certainly heard about wellness coaching or career coaching or leadership coaching, skill-based coaching. And some of the ones in medical school do incorporate some skill-based coaching. But most, and ours primarily is more learning-based coaching. So the other word for it is called a “portfolio coach,” and I think especially at Yale, it’s been useful because Yale has, as you may know, a long over 100-year system called the Yale System of Education, which gives students a lot of flexibility about how they’re going to learn and what they’re going to be involved in. And as such, the number of assessments had been not as many or as high-stakes as in many places.‌

So because of that and because there had been not much in the way in many medical schools of competencies, they would be a little bit lost: “How am I doing?” But also wanted to have those discussions in a way that was not going to be potentially with people who might judge them or might write their dean’s letter. So the coaching program was a great way and good timing to align with three things that the school was doing at the same time, which is to, on the heels of a strategic planning, come up with a competency system which was articulated to let the students know the domains that they would be reaching and the developmental milestones that would let them know they’re making progress, a dashboard to let them see, an increased number of formative assessments and coaches who were selected to not have any kind of judgment role in their life with whom they could develop the lifelong habit of reflection, being able to set specific learning goals. And this is really a special novel relationship and role at the school that we hope will help them really be their best selves and be able to more develop these lifelong habits of “Where are my gaps? How do I fill them?” Really, metacognitive, lifelong skills.‌

Harlan Krumholz: Well, this is really interesting to bring this in at this point because it does seem like a very modern and contemporary approach, consistent with a lot of things that go on in different companies, and as people sort of think ahead to, “How do we help people grow?” And there is this idea of, you’ve said about in some of the things you’ve written about developing this growth mindset in medical school. Can you share some of the challenges students face from transitioning from this performance-based mindset, which they’ve grown up in, to more of a growth-based mindset? And I think all of us probably grew up thinking a lot more about performance than actual growth. Can you share some insights about that?‌

Dana Dunne: Yeah, I mean you really hit the nail on the head, which is, we are fighting a very strong, increasingly strong current that comes from their entire upbringing often for students who are successful gaining entrance into medical schools, a performance-based orientation of learning. The gold star, the A+, the GPA, and to have them make that switch—really, like pulling a switch—to mastery-based learning where the “why” is not the gold star. The “why” is “patient care that’s safe and effective.” And “what do I need to do to get that” is hard for a lot of students. And I think this relationship, really intrinsic in the training that we hope to give the coaches, the framework that we’re using, this master adaptive learner model that comes from Bill Cutrer in Vanderbilt and others that rely on this increased metacognitive skills, is trying to remind them about the switch over to being more mastery. Like what do I need to know? Tapping into more internal motivations as opposed to external motivations, which is similar to a little bit of the performance to growth mindset and really—‌

Harlan Krumholz: Just to jump in, though, it seems to me like you’re actually preparing them for success in life, because one of the things that I’ve seen is, as people go through this system, they fall off a cliff at the end because they’ve been going from tier to tier where it’s all performance-based. There are very discrete indicators of that. They internalize that as their identity is getting A’s. Their identity is achieving this next thing put in front of them. And then when they begin their careers, it’s actually something quite different. I mean maybe in academics it is about still climbing a certain ladder, but particularly those who don’t put themselves in a hierarchical system like that. It really is about self-mastery, about your own motivation. Have you seen any early signs that the program is impacting people’s well-being or actually helping them to perform better because you’re freeing them from these surrogate markers, these sort of things that are gold stars, but actually a sense of actually “What do I need to master in order to be really terrific at, for example, taking care of patients?”‌

Dana Dunne: Well, as Howie mentioned, the program is just a year and a half old. So at this point the leading edge of the students who have coaches are just starting their clinical work next month. So we’ll see how that translates and what kind of questions they might bring to their coaches to reflect on their performance. But we have evaluated the coaching program along coaching competencies both last year and this year. And they have, when answering questions about their coach’s ability to help them analyze their own motivations and be reflective about the ways that they best learn, feel like there’s a safe space to talk about what they don’t learn. They’re strongly in agreeing and agreeing more than 90% of the time. There are a few that don’t engage in coaching, but most are really embracing this program and its possibilities, I think, for them to really take off more than. They can limit themselves, I think, if they’re too performance-based. So I have great hope that we’re going to continue to track it.‌

Howard Forman: Yeah. And I do want to just reflect for our audience, you talked about the Yale System, it’s just worth mentioning because I’ve been here 28 years, Yale famously had no tests. In other words, the students went through for two full years, and they would tell you that they had no tests, there were exams that they could take and they didn’t count for much. So this has been a big transition for the students. And then there’s a curricular redesign that occurred probably about 10 or 12 years ago that resulted in only 18 months of preclinical coursework before they actually go out in the ward. So there are a lot of reasons why we’re expecting more and more from our students even in a shorter and shorter amount of time. And I just wonder from your point of view in the role that you play, how is it that we’re able to train medical students in the same or less time now than we did 60 or 70 years ago, when the volume of information is so much greater? Do you have any concerns, or is that to be expected?‌

Dana Dunne: So when you’re talking about the training is now shorter, are you specifically talking about that pre-clerkship period then that was 24 months is now 18 months because the total amount of time in medical school is the same currently?‌

Howard Forman: Yeah, no, I’m saying it partly because I think NYU has gone to a three-year school. Yale, certainly, because of compressing the preclinical time to 18 months, theoretically students are able to now do joint degree programs more easily. There’s a lot of things that just would perplex someone on the outside who knows that the medical knowledge base is enormous now compared to when I was in medical school. How do we do that? I mean, I have my own answers, but I’m curious.‌

Dana Dunne: The way I would think of it is in two different ways. One is if you embrace competency-based medical education, which is a 20-year-old concept in the States now, that instead of deciding what that they should know is like, what are they going to be able to do, and how are they demonstrating that? And so as long as you have a set of competencies, you’ve articulated if they can do it, some are able to probably do it in three years and some might take five. It’s messy to implement that really wholeheartedly in the U.S. in many places because it doesn’t match with when residencies come up. The other thing I would say is, it’s increasingly important—and I think we are doing this and other schools are as well—is to teach them how to access the information, how to nimbly be that metacognitive person too. And we also, I think, for a long time had been giving them a lot of extraneous information that wasn’t really necessary. So honing in on really what’s necessary, how to access the rest, I think is... and having the competencies is potentially making it less time overall.‌

Harlan Krumholz: I want to jump in about this point of psychological safety. You’ve spoken about psychological safety as a cornerstone of a safe learning and working environment. Maybe you can explain a little bit what this means in the context of medical education in clinical settings. And also, there has been, I think, some pushback on this idea that maybe we’ve overdone this idea of psychological safety and, of course, Howie experiences this in his classroom all the time about finding the right balance. Do you have to tell everyone like, “Hey, I’m about to talk about X, and that could be a trigger for you?” Or there are these areas where people are bringing up... I just wonder what your... maybe you can just start with, what does it mean to you when you talk about this, and how is it being incorporated at Yale?‌

Dana Dunne: Yeah, I mean there may be some different definitions that are out there. I mean, I think the classic one, Amy Edmondson from the Harvard Business School, I think, coined it in her doctoral work 20-something years ago, an organization that blends trust and respect. So in my reading of it and the way I like to apply it is more in an organizational culture as opposed to a microclimate that you and I can have and you could get better at from faculty development, say, for example, with how you would be individually to make a climate. And I got interested in this because I do a lot of faculty development to help people do feedback better, be better at that conversation. And I would go around and still find that faculty weren’t being honest in their evaluations because they didn’t want retribution or they... a number of things and residents would not be honest also because they would also be concerned, how is it going to be used if it’s going to come back to them. So it was one of these Peter Drucker, is he the one that gets quoted for “culture eats strategy for breakfast”?‌

Howard Forman: I think so.‌

Dana Dunne: All of the strategies for our learning platform, deadlines that you need to fill this out by this time, for faculty development, all the strategies were being swallowed by the organizational culture that does not have trust and respect. And so my point that I think that needs more attention, but potentially more funding for institutions. Before I get to that, I want to address your point about “Can it be too comfortable.” She has a great chart that I’ve seen in some of her... In the Harvard Business Review articles that she’s penned and I don’t know if there’s a link to show notes, so we could put it, but—‌

Howard Forman: We will.‌

Dana Dunne: ...it essentially has how complex and how highly accountable is your system and what is... on the X-axis it might be “What is the accountability in your organization?” And if you have not a lot of complexity and not a lot of accountability, there can be a lot of apathy. But if you’re really having a lot of support but not a lot of accountability, it can be nice and comfortable and we’re going to have tea and I’m not going to expect anything from you. But if you have a lot of accountability and no psychological safety, you’ll have anxiety, which can limit learning and lead to error and burnout and worse. But it’s that sweet spot of high accountability and high safety, which is that zone of proximal high-output optimal learning. So it is really about expectations, but it’s matching that for the learner to know that we are there for them and we are in their corner, et cetera, not trying to—‌

Harlan Krumholz: Yeah, I always thought about this as we should have a place that’s safe for us to challenge each other. I mean the question is, can we be honest with each other? But this phenomenon you talked about, I’ve experienced, of course as we all have, which is you’re giving evaluations and it’s just easier not to raise issues about performance because people appeal or they’re going to question whether there was, you were biased or do you have something against them, were you fair? And creating an environment where people can feel free at every level of the hierarchy top to bottom. And people feel like we can be honest with each other in a constructive way, in a joint effort to improve us all. And by the way, this can be 360’d, we’re really actually looking for feedback. But one of the things also is on the promotion side, I’ve sat in promotion committees where they’re going like, wow, this person got some critical comments. They aren’t all accolades—‌

Howard Forman: Shocking now. Yeah.‌

Harlan Krumholz: And I want to raise my hand and say kudos to that person who created a culture where people felt that they could say the truth because none of us are perfect in those instances. And in many cases, it’s like safety issues. The more errors that you identify actually represents a stronger culture because you’re looking for them. If you’ve actually gone to your students and say, “No, please tell the truth. If there are areas I can improve, I want to hear them, then you’re not going to get a perfect rating because people are going to be trying to help you get better.” But if in a promotion committee is going to interpret that as saying, “Well that person’s not one of our best teachers because our best get a 100% rating.” All of these things have to be attended to, it seems to me. Is that some of what you’re working on?‌

Dana Dunne: Oh, totally. And I want to first of all say this is a problem across probably not just the U.S. I mean U.S., Canada in medical education and I remember talking to a student who’s graduating, he came from a musical background and potentially even maybe a military background as well, but I know definitely music, and where he’d gotten a lot of feedback, coaching on his skill of... and he was amazed, I don’t know if he used the word “appalled,” I’m inserting that, that there was in such a high-stakes field that there was this vacuum, and he wanted it obviously. How can I get better? How can I get better? So I think that the public presumes that this is what training is for mastery learning, deliberate practice. What are our goals? How am I doing? Give me the feedback, I improve, and this whole cycle. But the fact that we don’t give feedback because of all these concerns that you’ve labeled is I think a critical problem that we need to solve.‌

And I’ll just quote one thing from one of Amy Edmondson’s books she wrote called, I think it’s The Fearless Organization is the name of the book. She does some case studies in various places that score highly in being a psychologically safe environment, radical candor, free to disagree, driving creativity. This one CEO of an organization said, “If somebody has feedback from me that could help my performance improve, and they didn’t give it to me, I feel like that would be unethical.” And I just think about our trainees, and I feel like it’s unethical, especially for patient safety, that we wouldn’t be availing them of that and so helping the culture support that is a priority.‌

Howard Forman: I don’t want to finish this without talking... I did your bio at the introduction and I really skipped over some big parts and I did... so I wanted to ask you about that. You’ve had an unusual academic career. When you finished your residency here, you didn’t just join the academic world and become a professor and lead the coaching program. You also practiced out in the real world, private practice for a while. And in other related settings. Can you speak to what motivated you to do that, what it was like to transition back to an academic setting, and how you see yourself now?‌

Dana Dunne: Yeah, it was definitely not all planned, but when I finished my fellowship here, we rotated at a community hospital nearby and a position came up really unexpectedly at a time that timed well with when I was going to be needing a job. So we were able to teach the fellows, but it was putatively a private practice association. Adopted, then got pregnant with a person who ended up having significant special needs, and then adopted again. So I had three daughters, one with a lot of special needs. So it just became clear to me and then it was the case for 10 years that I needed to be very part-time. So I just worked a day or two a week at the city STD clinic, thus my STD plush toys in the background. For those who can’t see, I use those to quiz the ID fellows when they’re interviewing, see if they’re worth their snuff.‌

Howard Forman: For our listeners. You have little stuffed animals that represent—‌

Dana Dunne: Yeah, little spirochetes, et cetera. But I will never regret it. It derailed what I thought I was going to do, but I would never, never regret the best ortho ID consult compared to “will my daughter be able to speak” and advocate for her. And once she ended up being in a residential school, eventually—again, it was like you said, 17 years after I had been a fellow—my section chief found a biomedical reentry grant. So that was 15 years ago; I feel like I came back as the oldest assistant professor. Tried to give my syphilis [work] for a couple of years, that stuff that he was into and I was into, and then since these teaching jobs became available. But I do recognize the utility of talking about that occasionally, just for any trainees who might feel like you need to have a straight and narrow path.‌

Howard Forman: Yeah, I mean there are too many people I think outside of medicine or maybe outside of our medical school who just don’t realize that there’s a lot of different pathways to a lot of different types of jobs. Harlan staffs our free clinic. I mean, a lot of people do a lot of different things in this medical school. Well, we are really fortunate to have you in the role that you’re in, but also as a colleague, I will say this, if it’s not violating HIPAA at all to say this, that in retrospect, after we met over the coaching issue, I did discover that you were my ID consult in 2010 when I was a patient in the hospital with sort of a catastrophic event. And so it should be—‌

Harlan Krumholz: And it wasn’t a catastrophic STI, it was a catastrophic other kind of event.‌

Howard Forman: As what?‌

Harlan Krumholz: I’m just saying. She’s a specialist.‌

Howard Forman: Oh, yes. No. Thank you. No, that’s right. That’s right. No, she was in her general ID role, not in her STI role. Thank you. Thank you. Yes. After being in the hospital for 13 days, I think that—‌

Harlan Krumholz: Not that there’s anything wrong with you.‌

Howard Forman: Exactly. Exactly. But anyway. No, I really do... It is remarkable to know people in so many different roles, hopefully not as their caregiver, but in your case, you have been. So I appreciate you in so many ways. Thanks for joining us.‌

Harlan Krumholz: What a delight to meet you. What a delight to meet you.‌

Dana Dunne: Well, thanks for having me. It’s great to have an opportunity to talk about medical education.‌

Harlan Krumholz: Wow. I really enjoyed talking to her.‌

Howard Forman: It was fun.‌

Harlan Krumholz: She’s terrific. I hadn’t had the chance to meet her before, and so impressive. But Howie, last show of the year, we’re going to get to... You’re on deck here. Ready?‌

Howard Forman: Yep. Yep.‌

Harlan Krumholz: Tell us what’s on your mind here. Give us a little something to kick off the end of the year.‌

Howard Forman: You got it. In the spirit of that season, I thought I would share positive news as you did in the intro. Before our Thanksgiving episode I did offer thanks for many of the successes, and there’s even more we could talk about. But rather than look backwards, I thought we could look forwards to something that our governor of Connecticut, Governor Lamont, has initiated with the support of the legislature. So on December 23rd, this is coming up in a few days, and by chance it is my father’s birthday. Happy birthday, Dad. Qualifying individuals in the state of Connecticut will receive word that their medical debt has been canceled or erased. So first, some facts for our listeners. Nationally, $220 billion of medical debt is currently outstanding affecting approximately a hundred million adults. That’s more than one in three adults. So that means that the mean debt is about $2,200 worth, enormous spread, and $2,200 is life-altering debt if you’re low-income.‌

And until very recently, this type of debt could prevent you from getting a mortgage, a car loan, or a credit card. Individuals are known to avoid getting necessary care if they carry or might acquire medical debt. And they’re more likely to have depression or clinically significant anxiety if they have medical debt. And as you and I, Harlan, have discussed on many occasions, there’s considerable financial threat to individuals from our healthcare system itself. This falls disproportionately on the poor and the near poor and due to disparate endowments disproportionately on Hispanic and Black individuals. So what has our governor done? So he first proposed this about two years ago, and the legislature passed this into law in May, and we now have a mechanism to buy back that debt from those who are least likely able to afford it and also those who are most harmed by it.‌

Those with incomes below 400% of the federal poverty level—that’s around $135,000 for a family of four or about $60,000 for an individual—and those who have more than 5% of income represented by medical debt. The first group, the first tranch of patients or individuals, will receive their letters on December 23rd, as I mentioned, absolving them of $30 million of debt at a cost to the Connecticut Treasury or taxpayers, however you look at it, of a mere $100,000. They did this by partnering with a nonprofit called Undue Medical Debt. We’ll put that in the show notes as well, which buys back medical debt at a deep, deep discount.‌

This organization has already bought back, nationally, $15 billion at a net cost of about $150 million. Most of it, raised donations. Connecticut’s partnership with this organization aims to alleviate $650 million in medical debt at a cost to the treasury of about $6.5 million. This is a policy proposal with huge bang for the buck targeted at lower-income individuals with huge human impact. It may not be the Christmas, Hanukkah, Kwanzaa, or Festivus miracle, but for these individuals, it may feel that way. It doesn’t solve the problem of our high-cost system, but it does nibble away at the financial harm.‌

Harlan Krumholz: So I didn’t quite understand. First of all, it’s something to celebrate, but I didn’t quite understand how the dollars all worked out. So you’re saying a lot more debt is being eliminated than it’s going to cost us as a state.‌

Howard Forman: Correct.‌

Harlan Krumholz: Can you just connect those dots for me?‌

Howard Forman: Yeah. So when you go to a collections process, when you get to the point where the hospital is basically saying, okay, I don’t think I’m going to collect this 100,000,000 or this debt outstanding is starting to be hard to collect, they’ll typically go to a collection agency. Those collection agencies will buy the debt at a fraction of the actual dollar cost and then seek to collect on it as an investment. So they may buy $5 million of medical debt and they’ll try to get $500,000 back on it. Some of that debt is almost impossible to collect already. And so they will start writing down the debt to pennies on the dollar.‌

And so there’s a market for this debt that already exists. There’s a literal financial market that already exists. And this organization that I mentioned, Undue Medical Debt, is actually already in that market to buy down the most depressed price debt. And you might say to yourself, “Well, why isn’t it written down to zero?” Because you’re always able to capture something from people who are just in agony over the fact that they have debt. So they’re still trying to pay it off, but the reality is that if you’re impoverished and you’re carrying even $5,000 of debt, at some point, people give up trying to collect from you. And so even if you get one cent on the dollar, that’s more than 0 cents on the dollar.‌

Harlan Krumholz: And just for calibrating, I mean, I keep going back to the stat that more than 50% of Americans do not have $500 in cash available to meet an emergency expense.‌

Howard Forman: That’s right.‌

Harlan Krumholz: So just to highlight what you’re saying, that’s a catastrophic amount of money for people to be on the hook for.‌

Howard Forman: No, I agree. And look, one of my sound bites that I use in my classroom is that the median Medicare beneficiary has an income of about $30,000 for an individual. There’s a huge number of people that are in the high-cost category to begin with who actually have very, very limited income available to them. If they don’t have vast savings, if they’re relying on a pension or a social security check, they’re not easily able to handle a catastrophic cost of any type.‌

Harlan Krumholz: Yeah. Yeah. And who came up with this idea? I mean, it’s a great deal, by the way, we still have a deficit in the state. Right?‌

Howard Forman: So Undue Medical Debt, which had a prior name [RIP Medical Debt], I wish I could remember it right now, and they’ve renamed it. They’ve been operating for a while, and they’re actually, like I said, paying down a good amount of the debt over time. And I’m going to probably make a small donation at the end of the year because I really actually am pretty excited about what they do. Like I said, Governor Lamont first raised this about two years ago. The payback is enormous. When people think about ways to help the underresourced populations in a state or at the federal level, there’s few things that people argue more about than the fact that helping people with medical debt who are impoverished should be at the top of the list, and so there’s even some federal plans to do things like this as well.‌

Harlan Krumholz: Haven’t we got a great governor? I mean, he’s just done...‌

Howard Forman: He’s been amazing, Harlan. He’s a graduate of our school of management, so he has a connection to Yale. So maybe I just sound biased, but he’s been an extremely successful governor—‌

Harlan Krumholz: We should have him on the podcast and talk about this with him.‌

Howard Forman: That’s a great idea. That’s a great idea.‌

Harlan Krumholz: Yeah, we should. He’s a terrific guy, and I think we in Connecticut are lucky.‌

Howard Forman: It’s good idea.‌

Harlan Krumholz: It shows the impact of good government. He’s done so many good things, and by the way, he’s got bipartisan support in this state. It’s remarkable.‌

Howard Forman: We’re going to make it happen, Harlan. That was a great idea.‌

Harlan Krumholz: Yeah. Yeah. You’ve been listening to Health & Veritas, our last program of the year, with Harlan Krumholz and Howie Forman.‌

Howard Forman: How did we do? To give us your feedback or to keep the conversation going, email us at health.veritas@yale.edu or follow us on any of social media, including Bluesky and LinkedIn.‌

Harlan Krumholz: Your feedback is important to us. If you can find ways to let us know what you think, post on any of the platforms, give us some information. We love it, and it also helps people find us.‌

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

Harlan Krumholz: And we are privileged to be sponsored by the Yale School of Public Health, the Yale School of Management. We are fortunate to be supported by our producer, Miranda Shafer. The amazing Miranda Shafer and our students, Sophia Stumpf and Inès Gilles and Tobias Liu. They are terrific, amazing, and we’re so lucky to be working with them, and I’m so lucky to be working with you, Howie.‌

Howard Forman: Absolutely, right back at you. And I also want to give a quick shout out to Miranda Shafer’s father, who has a birthday today as we’re taping this. So happy birthday—‌

Harlan Krumholz: That’s great.‌

Howard Forman: ...to Miranda’s dad.‌

Harlan Krumholz: That’s great. All right, I’ll see you in 2025. Talk to you soon, Howie.‌

Howard Forman: Thanks, Harlan. Talk to you soon. Happy Holidays and New Year to our listeners.‌