Deborah Rhodes: A Breast-Cancer Screening Breakthrough

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

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get close to the truth about health and healthcare. Today our guest is Dr. Deborah Rhodes, but first we always check in on current hot topics in health and healthcare, and there’s just too many to pick from Harlan, so—‌

Harlan Krumholz: Too many to pick. I wanted to ask you first what’s going on in the emergency department because it just seems like flu’s taking off like crazy and what, this is the highest, the most prominent flu season in 15 years?‌

Howard Forman: Yeah, since I think the swine flu.‌

Harlan Krumholz: Lots of people have died. Number of hospitalizations is quite high.‌

Howard Forman: It’s been a great COVID season. It’s been a bad flu season and we have, but I will say, in the ER, you don’t really feel it any differently than any other flu season. I mean, our ER is way overcrowded, and every other ER appears to be way overcrowded. I don’t think flu is what’s putting us over the top. Let’s say that.‌

Harlan Krumholz: Are we making any progress on figuring out this throughput situation in the emergency department? It just does seem like repetitively people are against the walls. It’s just like we can’t seem to solve the problem.‌

Howard Forman: We do not. We do not solve the problem. I think it’s a multi-part problem. And I think part of the issue is that we’ve got ever increasing demand and we’ve got a lot of backed up elective demand for elective bed use and that backs patients up from the hospital all the way into the ER, into the waiting room.‌

Harlan Krumholz: Just seems solvable. I don’t know, since we know it’s like that. I don’t know.‌

Howard Forman: I agree.‌

Harlan Krumholz: The other thing I think might be worth touching base on is this 15% overhead for people who I would think in our world, most people have been obsessed with this, but the federal government came out last week and said that the—‌

Howard Forman: On a Friday.‌

Harlan Krumholz: Friday? That’s last week.‌

Howard Forman: I’m just saying, on a Friday.‌

Harlan Krumholz: Oh, yeah. Friday night. Often these announcements are coming out late on Friday night. Yeah, you’re exactly right. And so when the NIH and some other federal agencies provide support for research, there’s two components. Actually, there’s analogous to what happens in the hospital, there’s a physician component and then there’s a hospital component. So in other words, the physician is paid for providing a service, but then all the services around that physician to provide the services are reimbursed separately. In research, what happens is, you put in a budget for what the research will do, maybe the reagents and whatever they need to actually do the research, but to actually conduct the research requires a little bit more.‌

Like it requires space and lights and people who are helping manage the grants and ensuring compliance with the grants and a whole infrastructure around that. In many institutions there are first—I mean now just let’s talk about laboratory sciences—it takes a lot to have first-class labs. I mean you’ve got the ventilation systems, the lab space. I mean it’s a big deal, and those are investments that institutions make. They amortize that investment over time, and that becomes part of the second part of the funding, which is called “indirect cost.” But I think that’s confusing. It’s really infrastructure, foundational costs to be able to provide the services. It’s sort of like I can pay for a driver and even a car, but somebody’s got to be paying for the roads or else...‌

Howard Forman: I mean, I think just for our listeners to know, accounting parlance is that direct costs you can easily attribute to the project. So you know that you’re using this researcher for 20% of their time to make this project happen, whereas indirect costs are a lot harder to specifically direct to a person because it might be the building you’re in or using a novel PET scan or a cyclotron.‌

Harlan Krumholz: So what happened was, the government made a decision that these negotiated rates, which by the way are always decided on by the federal government. There had been the history of asking you to submit information and there’d been a negotiation and a decision had been made, and there were many institutions like Yale who were around 60%. And this included all these things and they said immediately, across the board, everyone can’t charge more than 15%. And that sent shock waves through everyone because it was announced Friday night and said starting Monday we’re going to make this sort of drastic cut. And then this has been suspended by the courts right now as they sort of try to navigate whether this is legal and what actually can occur. But it did cause a lot of consternation.‌

I was disturbed, Howie, I’ve written about this, and I wrote about it to kind of just lay out what I thought these issues were. If we thought that this was going to be more money to researchers and that this could be ways to incentivize institutions to become more efficient, that would be a good thing. And we all think there are efficiencies that can be achieved, but this such dramatic cut is going to make it very hard for many institutions to be able to conduct research. Often they don’t have the buffer to do this and really, 15% to be able to float the system is far below what seems to be possible.‌

But here’s what bothered me. I was going to bring this up to you, Howie. So I was watching CNN the other night. I got to quit watching cable, but I still watch cable sometime to sort of see what people say in these discussions. And John [Chris] Sununu, the former governor of New Hampshire, goes on and says, “These overpaid lazy academics, their gravy train is ending,” or something like that. And it was the first time I really heard research scientists being disparaged like this. We are the envy of the world with regard to what we produce. Is there research that is funded that on the edge could be done differently? Could we be more productive? Sure. But there’s also been so much good come out of this, but you and I both know that it’s hard work to be a research scientist. I do not know colleagues who are sitting on their sidelines eating bonbons while these grants are coming in.‌

Howard Forman: And by the way, Harlan, like you wrote about in your article that we’ll have in the show notes, you pointed out where you talked about last week on the podcast, the research of Steve Waxman. Again, the fact that that is exactly what we’re talking about. We’re talking about the type of basic research—‌

Harlan Krumholz: ...that goes on to become the basis for therapeutics and for cures. Yeah, whole range of different products. Look, can we do better? Sure. Should we be experimenting with new ways to fund and incentivize and produce better research? Of course. But this feels like just a frontal attack on the research thing. There are so many things to talk about in healthcare that are going on. We talk about the flooding the zone. It’s hard to keep up with everything that’s going on, but this one hit really close to home. And it wasn’t a matter of just sort of protecting our turf. It’s more about saying this is a jewel and we’ve got to be thoughtful about how we proceed.‌

Howard Forman: I do hope that cooler heads will prevail because this would be a mistake. There’s no question in my mind that if this would prevail, if this would stay, that we will be less innovative. We will make decisions about some very advanced biomedical innovations and we will choose not to do them because they become unaffordable.‌

Harlan Krumholz: Things won’t be achieved. I think also, just to show you how skittish it is, by the way, I want to make clear because Yale has made this request that when we’re talking about this that we say these are our opinions—‌

Howard Forman: Of course.‌

Harlan Krumholz: ... and not necessarily the opinions of Yale. I would think that’s obvious. This show is about our opinions, not about, we don’t represent the university, but they want us to be really clear about this.‌

Howard Forman: Yes.‌

Harlan Krumholz: All right, well, I didn’t mean to start on such a sobering note. It’s just there’s a lot going on. But let’s get to Deb. She’s terrific.‌

Howard Forman: She is great.‌

Harlan Krumholz: Let’s bring her in.‌

Howard Forman: Dr. Deb Rhodes is a professor of internal medicine at the Yale School of Medicine and also serves as the Enterprise Chief Quality Officer for Yale Medicine, the Yale New Haven Health System and the Northeast Medical Group. An internist by training, she has been involved in groundbreaking research on molecular breast imaging to help better diagnose breast cancer. And before joining Yale, she held several leadership positions at the Mayo Clinic Cancer Center. She obtained her bachelor’s degree in history and literature from Harvard and her medical degree from Weill Cornell Medical College. She completed her internship and residency at Hopkins and then proceeded to participate in the Robert Wood Johnson Clinical Scholars Program, for which Harlan and I both have considerable contact with, but not with the Hopkins program.‌

And so first I want to just welcome you to the podcast. It’s really such a pleasure to have you join us today. And as I was doing my own reading to prepare for this, I learned a lot about molecular breast imaging, and I’m in radiology. You would think I would know a lot about it. And I watched your TED Talk, which is really a passionate talk from a little more than a decade ago, about it. And then I read what’s gone on since then, and there’s been a lot of progress. So can you tell our listeners what you have learned in your journey of following this novel imaging technique to where we are today?‌

Deborah Rhodes: Well, I think you’ve unearthed something that describes more about me in that I tend to follow my passion in my career into some unusual directions. And the way I became involved in molecular breast imaging is that I was a practicing clinician in a multidisciplinary breast clinic at the Mayo Clinic. And I noticed that many women were coming for care from far distances to get the all-clear based on a test that I knew did not have good diagnostic accuracy in women with dense breasts. Now, this was back in the 1990s, the early 2000s, and although “dense breast tissue” was a term common in radiology language, it certainly wasn’t anything that had entered the popular vernacular.‌

I had a chance conversation with a radiologist regarding my frustration about the lack of accurate diagnostic capability in women with dense breasts. And he suggested I speak with a physicist, a nuclear physicist at Mayo Clinic, who had just come back from a meeting in Israel regarding nuclear detection in cardiac disease. And so I did, I reached out to this physicist, and we had a conversation and he showed me this detector, which is a tiny little gamma detector. And I said to him, “Do you think we can adapt this for breast imaging?”‌

And so we started and began working together in I think the year 1999, 2000. And we developed this prototype that had no name and miraculously, I was able to, after some testing on phantoms, I was able to obtain a grant from the Susan G. Komen Foundation to test this in volunteers, in women who had benign breast lesions or malignant breast lesions. And it worked remarkably well. And then we made more and more updates to this prototype. And with each subsequent iteration, we were able to demonstrate higher and higher sensitivity of this detector. And so over the years, we’ve tested this now in three clinical trials, and we most recently attained an R01 NIH grant for a multi-center clinical trial of molecular breast imaging at five centers, enrolling 3000 patients.‌

And we’ve now completed that trial and we’ve demonstrated consistently now across multiple trials, and with every subsequent iteration of mammography technology, that molecular breast imaging continues to detect three times more cancers than mammography in dense breasts. And one of the themes of my TED Talk over a decade ago is, “Why have you never heard of this?” And I could say that the same is probably true today.‌

So despite the fact that the technology works very, very well, is no more expensive than a mammogram, and is also painless—unlike mammography—it is not something that has received universal uptake. I think that’s certainly true. That said, we use it at all three Mayo campuses. It’s a common tool in our diagnostic armamentarium. We do thousands of these exams for women with dense breasts every year, and we’ve detected innumerable cancers that I am confident would have gone undetected perhaps for years with the standard gold screening tests. So I am very passionate that we have introduced this additional option for women. And I do think that it still has a role to play, although with the adoption of contrast-enhanced mammography, the next frontier is to see which of those two techniques really has the better sensitivity.‌

Howard Forman: Can you just very briefly for our audience, explain the technique, though, just how molecular breast imaging is done?‌

Deborah Rhodes: Yes. So it really relies on gamma rays instead of X-rays to detect breast cancer. And in its simplest format, the advantage is that on an X-ray, dense breast tissue and cancer can look the same, but molecular breast imaging really exploits the behavior, the different behavior of tumor cells relative to the different appearance anatomically. And after the injection of a tracer that is preferentially taken up in rapidly proliferating tumor cells, the tumor is much more easy, it’s much easier to visualize the tumor using the gamma technique.‌

Harlan Krumholz: Well, I mean, actually I wanted to talk to Deb about quality, but since you started on this, Howie, I think maybe we can finish a little bit because it’s an interesting story. First I want to just ask, not everyone understands, what are “dense breasts”? Can you tell by looking at them? Or is it only that you can tell by imaging them or does anyone know they have dense breasts?‌

Deborah Rhodes: Not unless you’ve had a mammogram, and that’s what’s very difficult.‌

Harlan Krumholz: What is dense about them? What is it that’s anatomically different about people with dense breasts?‌

Deborah Rhodes: So it’s the relative proportion of fibroglandular tissue in the breast relative to fat. And there’s a rather arbitrary cutoff to say that if your breast composition has more fibroglandular tissue than fat, it is dense.‌

Harlan Krumholz: Fibroglandular tissue would be that tissue that produces milk, or... what is fibroglandular tissue?‌

Deborah Rhodes: Yes, it’s essentially, in its easiest definition, the non-fatty components of the breast.‌

Harlan Krumholz: The non-fatty components. And does the size of the breast correlate with the density?‌

Deborah Rhodes: No. Well, it does in the sense that that weight correlates with density. So very thin women are more likely to have dense breast tissue, but the actual breast size doesn’t correlate with breast—‌

Harlan Krumholz: But one thing, this is—Howie, I never thought we were going to go in this direction on this podcast—but let me just ... it’s since you’re an expert. I’m kind of curious about, I would think that people with obesity might still have an absolute amount of fibroglandular tissue—‌

Deborah Rhodes: You could have—‌

Harlan Krumholz: But they have a lot more fat because they are dealing with obesity. Do you care about, in a breast, the absolute amount of, is it the proportion that really matters or is it how much actual—‌

Deborah Rhodes: Well, it’s even more complicated than that in that it really is all about real estate in the sense that if your tumor happens to be located in an area of the breast where you have—‌

Harlan Krumholz: It can be obscured by this.‌

Howard Forman: That’s it.‌

Harlan Krumholz: By the density. And so the more that you have the density, the more that you might be hiding it. Is that it?‌

Deborah Rhodes: That’s correct. And so you can have a breast that’s not considered dense and still have your tumor masked by an island of density that makes it invisible on the mammogram. You literally cannot distinguish it from the surrounding fibroglandular density. And we’ve got extraordinary images from our molecular breast imaging library that demonstrate that these tumors have probably, in fact, been there for years and they just were not visible on the mammogram.‌

Harlan Krumholz: So do you have evidence that people who are presenting, for example, with false negative mammograms or more advanced cancer have often been the ones who have had these tumors obscured?‌

Deborah Rhodes: Absolutely. Absolutely.‌

Harlan Krumholz: I think there’s a good literature about this, right? That’s the whole thing about the density. Sometimes I say it’s a long run for a short jump. Here’s my short jump. So if you’ve got a better mousetrap, you know because you work in quality, I mean, that’s what I was saying, you’re an expert, a national expert in quality and are doing so much leadership here. A lot of the issues in quality are about implementation. We’ve got actually something we know that works, but it’s somehow not getting integrated into practice. Now you’ve got something that actually you’re a side hack in a way, like something you were work—and was your main thing for a long time that you really care about, but it’s not being widely used. What do you see as the impediments of moving it from the better mousetrap to something that actually now everyone’s using the better mousetrap?‌

Deborah Rhodes: The last 20 years of my research life have been a baptism in the complexity of introducing a new technology. That should be driven almost exclusively by the validity of the technology as proven in rigorous multicenter clinical trials as the currency of validity. Unfortunately, and this was a topic a decade ago in my TED Talk, particularly when it comes to breast imaging, there are many, many, many other factors in play. And one of those is very large, very lucrative imaging companies that already have a standard, a gold standard technology.‌

Another is the breast societies, the breast imaging societies, and the training in the gold standard methodology. And there are many, many other factors. And I’m not saying that any of these factors is nefarious, it’s just that collectively it contributes to a momentum that is very, very difficult to disrupt, particularly as an outsider, which we were. We were an internist and a physicist who saw a problem and an opportunity and developed a solution that was very much outside the mainstream. And I will fully acknowledge that there were aspects of this technology that needed improvement. For example, at the beginning, the administered radiation dose was too high, so we made innumerable modifications to the system and the software in order to permit lowering of the radiation dose to what is now a safe level. The exam also takes more time to perform than a mammogram. But if you were, and we have asked women, “Would you prefer a more accurate exam that takes a little bit longer,” the answer is—‌

Harlan Krumholz: They always say yes, I’m sure, right?‌

Deborah Rhodes: Yeah.‌

Harlan Krumholz: But do you have a company that’s trying to do this, and what’s the vehicle to get people to be able to access it?‌

Deborah Rhodes: There is a company behind this. It’s not a company that’s known for breast imaging. And that has also been a great limitation. And if I were to embark on this journey now when I know so much more, I would do it very, very differently. But I rather naively approached it as a scientific question. And it’s much, much more than a scientific question.‌

Howard Forman: You were rather emphatic 14 years ago in saying that you did not wish to have any financial benefit or conflict in advancing the science here. Are you then saying that if you had to start again, you might’ve decided to commercialize this as an investor entrepreneur?‌

Deborah Rhodes: Personally, I would not. I think that I have a strong bias against that. As you probably have ferreted out already, Howie, I was raised in a highly academic family, I would say, and my father always maintained that maintaining impartiality from a scientific standpoint was commensurate with maintaining economic independence from that. And I personally believe that. I know that’s not a very modern notion and that now it’s considered perfectly acceptable to do both, but that is just a very strong bias that I have. So I don’t regret that decision in any way, and I wouldn’t make it differently. What I would do differently is I would partner with mainstream companies to promote and invest in this.‌

Harlan Krumholz: Right. So then my question would be, if you’ve really put yourself in a position where there’s not financial gain... Howie, are we doing this here?‌

Howard Forman: I’m happy to always talk about this topic. I don’t want to—‌

Harlan Krumholz: No, no, no, no. I’m asking you, are we doing the technique that’s being done at Mayo?‌

Howard Forman: No, I actually wanted to ask her that as well. And we certainly can. I mean, I don’t believe we’re doing it in large way. What you described at Mayo certainly is not going on here.‌

Deborah Rhodes: And the reason for that is very interesting, and that is because Connecticut was really the first state to embrace supplemental breast imaging, meaning doing mammography plus something else. And the reason was because of an extraordinary woman who was from Connecticut who started a website called Are You Dense? And it was meant to educate women about the dangers of missed cancer in women with dense breast tissue. She was just a pioneer in this. And her story was that she had gone for a mammogram and a few weeks later she got a letter saying, good news, your mammogram was normal. And a couple of days after that, she went to see her gynecologist for an annual checkup. The gynecologist felt a lump, referred her for an ultrasound, and lo and behold, she had Stage 3 breast cancer—after a completely normal mammogram.‌

Howard Forman: Wow.‌

Deborah Rhodes: She said to her doctor, her gynecologist, “How is this possible? I just had a normal mammogram.” And the gynecologist said, “Well, Nancy, you have dense breast tissue.” To which she responded, “How is it possible that you know this about me and I don’t know this about me?” And that’s what led her to launch this very impactful website. However, she assumed that it was the ultrasound that found her cancer, and she and I would actually very respectfully argue about this. The ultrasound didn’t find her cancer—her gynecologist did. And a screening ultrasound is a very, very different test from a diagnostic ultrasound where you already know where to look.‌

Connecticut has, in my opinion, unfortunately translated that story into the idea of doing screening breast ultrasounds on women to find cancers that go undetected on mammography. And I don’t think the literature supports doing that. I think that the number of additional cancers that are detected through screening ultrasound relative to the false positives that are detected does not justify that as a standard approach. And yet, when I moved to Connecticut from Minnesota, I was told that I could not even schedule my mammogram unless I also scheduled an ultrasound at the same time because I have dense breast tissue. And that is a very unusual policy that seems to be quite specific to the state of Connecticut.‌

Harlan Krumholz: Deb, this has been a fascinating podcast. I’m getting to the end, but I don’t want to miss the opportunity to talk about your day job. You lead us in quality at Yale and you, at Yale New Haven at the health system, and are really such an inspiring force to get us to improve. Of course, I’ve worked in quality for a long time and I’ve seen a lot of people, I’ve rarely seen someone with your skill and energy and ability to navigate really a challenging area because people don’t like to hear that there are quality issues that need to be addressed. People like to assume in medicine that they’re all doing their best in practicing hard. And what we’ve tried to do is to both respect the professionalism but at the same time bring in place accountability so that we can continually strive to do ever better and can do that in measurable ways.‌

What do you think is the most important thing on the horizon for continuing to elevate the quality in healthcare broadly? Because we’re under such stress financially; people are burned out. There’s all these sort of new systems people are dealing with. AI is coming into our lives. Where do you see this going? Because we still have a way to go for the very basics in quality. We still haven’t conquered our ability to create highly reliable organizations that just function without error and for which patients can be safe. It’s a constant battle for that.‌

Deborah Rhodes: Well, Harlan, I think that’s very well said. It’s sobering, certainly, but very well said. And ironically, I guess I got into quality much the same way I got into molecular breast imaging, by following a passion. You’ll remember that I didn’t come here to be the chief quality officer. I came here to develop best practice detailed algorithms to improve global quality safety, to minimize unnecessary variation, and to focus on process efficiency. And through those, we convened 24 expert clinical multidisciplinary groups across all domains of medicine. And we began the work of building these very detailed pathways that elucidated best practice for virtually every condition that we treat. And this was an enormous amount of work. And what we realized along the way was, by elucidating these best practice standards, getting in a room and figuring out: What are we doing now that we shouldn’t be doing? What do we need to be doing? How do we need to build the infrastructure to support the delivery of best practice? In doing this, we were improving quality in a way that was meaningful to clinicians.‌

I think where the field of quality has struggled is by reducing the concept of healthcare quality to a few measures of things that go wrong and that doesn’t resonate with clinicians. What resonates is how do we deliver best practice for every condition we treat, and how do we build systems so that things don’t go wrong, rather than focusing on measuring what does go wrong? And by flipping that definition of quality and really delivering it more holistically to the practice, to everyone, I think it’s resonated in a way that it didn’t historically.‌

Harlan Krumholz: This has been such a pleasure. We’re fortunate to have you here. This podcast took some interesting turns. We learned, I learned a lot I didn’t expect to learn when I woke up this morning. And thank you so much for joining us.‌

Deborah Rhodes: Thanks very much.‌

Howard Forman: Really. Such a pleasure meeting you and getting to talk about these topics. Thank you.‌

Harlan Krumholz: Clinical scholars rock, Howie.‌

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

Harlan Krumholz: Well, that was a terrific interview. And actually I’m glad you started talking about the work that she’d done with breast imaging because it’s just a fascinating thing and also that her career was focused there and now she’s head of quality. It’s an interesting journey she’s been on. But let’s get to the part I want to hear about today in addition to everything we’ve done. What’s on your mind?‌

Howard Forman: Well, I hope it’s not too sobering, but obviously—‌

Harlan Krumholz: Oh no, please.‌

Howard Forman: I know, I know. Congress is in the midst of considering massive tax and spending changes, and many of these may well codify some of the issues we’re talking about. It wouldn’t surprise me. For instance—‌

Harlan Krumholz: Is Congress still relevant, by the way? I thought all these decisions are made by executive fiat.‌

Howard Forman: Well, he’s certainly trying to make those decisions, but it does seem that Congress wants to codify the USAID and the NIH changes and other grant changes. And so I’m actually welcoming this. I think it’s good to have an honest debate. You said it in the intro, we should be critical of our own policies. We should look to make them better, make them more efficient, so on. But that would be, this would be the constitutional path to doing so as opposed to, as you said, putting it purely at the will of the executive, which then becomes like a king. There are many, many, many areas where healthcare may well be affected by this budgetary decision-making. I can’t even hone in on just one, but I do think it’s important to just remind our listeners about what is at stake for some of the lowest-income individuals.‌

And a reminder that Medicaid is an extraordinarily impactful program. And if you combine Medicaid with the Children’s Health Insurance Program and the subsidies for the Accountable Care Act exchanges that people call the Obamacare exchanges, you’re talking about over a hundred million people and over a trillion dollars in annual spending. Federal spending alone is over $600 billion a year in this category, which makes it a big target for budgeteers who have said they won’t touch Social Security, they won’t touch Medicare, and they can’t touch interest on the debt. So other than defense, this is the biggest budget item there. And so while President Trump and Elon Musk are attempting to cut complete departments out of the future budget, those savings that they’re trying to make are actually small compared to anything they can do to defense or health programs if they so choose.‌

Unless our listeners misunderstand, most of these attempts at cutting Medicaid in a serious way will fall on poorer states disproportionately, places like Kentucky, West Virginia, Kansas. Many others would be hard hit by Medicaid cuts no matter how they are structured, which is to say this is not a done deal. Everybody thinks that this will just happen, like the NIH cuts seem to just happen. But optically speaking and just looking at them from the point of view of politics, it’s going to make it really hard. Some of the things that people are talking about are things like work requirements, but these save very, very little money. Restructuring the Medicaid program completely might save substantial money but would really hurt the states and the individuals that they serve.‌

So in the coming weeks, we’re going to hear a lot more of it. I want to remind people Medicaid covers 39% of all children, 44% of all non-elderly adults with disabilities, 60% of impoverished non-elderly adults, and covers the majority of skilled nursing facility beds in this country, as well as institutionalized adults and children. It’s also a laboratory for change. And I would caution everybody to follow this closely and reach out to your representatives as needed because we should be looking to preserve these important programs.‌

Harlan Krumholz: You know, Howie, of course, we are in these very interesting times. Things are moving so fast. The thing that I think about is that we need to be able to embed accountability in everything that we do so that we understand what, there may be benefits, there may be harms, there may be unintended consequences. And somehow in the speed to make all these changes, we have to be clear about how we’re going to evaluate what happened. And I don’t know if you have thoughts about this, but it just is really important that we’re going to be able to quantify what the effects are.‌

Howard Forman: Right. And I think also right now, the public opinion is very favorable to the president of what’s going on. I mean, I think we in our communities may not be favorable, but the public is excited about seeing someone who is telling the public that he’s cutting wasteful spending, he’s cutting fraud and all that. I personally think that we should always seek to root out fraud, abuse, reduce spending, be efficient. What I’m seeing right now is not that. What I’m seeing right now is a lot of loud rhetoric but meaning very, very little. And if these cuts go into force, people will suffer.‌

Harlan Krumholz: So we just need to keep an eye there. I think it’s a really good point, though. If I do watch cable, I see people coming and saying, “Well, Americans aren’t going to like this, aren’t going to like that,” but his approval ratings are the highest they’ve been, and so he’s getting everyone passed through the Senate.‌

Howard Forman: That’s right.‌

Harlan Krumholz: This is a moment where they are going to be able to do the experiment. They are going to be able to do these things. And so we just need to be able to be watching carefully so we understand what the impact is.‌

Howard Forman: That’s right.‌

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, email us at health.veritas@yale.edu or follow us on any of social media, particularly LinkedIn and Bluesky right now.‌

Harlan Krumholz: And we really like to hear your feedback. We love it when you guys reach out to us and also helps us to understand what we can do better and helps people find us if you rate us on any of the platforms, please, we’d love the engagement.‌

Howard Forman: Seriously, do. 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 fortunate to be sponsored and supported by the Yale School of Management, the Yale School of Public Health. We want to promote them as outstanding institutions and we appreciate that they are the ones who are helping us stay on the air. And we also want thank our superstar Yale undergraduates who are just terrific researchers today. We had Sophia Stumpf, but we also have had Inès Gilles and Tobias Liu, and our amazing producer, Miranda Shafer, who—‌

Howard Forman: She’s always there for us.‌

Harlan Krumholz: Makes us sound great. Thanks so much and talk to you soon, Howie.‌

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