Deepak D’Souza: Perils of Cannabis and Promise of Psychedelics

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. Deepak D’Souza. But first, we like to check in on current hot topics in health and healthcare. What do you got?‌

Harlan Krumholz: Hey, Howie. So I like to talk about artificial sweeteners a lot. So there’s a paper that came out that really caught my eye lately.‌

Howard Forman: And again, for our listeners, you have been talking about this to me for over two decades. This is not a new thing for you.‌

Harlan Krumholz: Well, it’s a question of whether or not this is an issue or not for people who are using these strategies in order to try to lose weight or not. So the thing is, I think that’s so interesting is that we live in a world where people are choosing these diet sodas, these low-calorie snacks, sugar-free foods. And the goal is cutting calories, managing weight, controlling blood sugar. And yet at the same time that there’s been great growth in the number of products and their consumption by the public, this is the same period that’s seen obesity rates climb steadily.‌

So in the U.S., the use of noncaloric sweeteners, something like aspartame or sucralose or stevia, really started to rise in the late 1980s, exploded in the 1990s, right around the time that overweight and obesity became accelerated. And today, millions and millions and millions of people consume these artificial sweeteners daily, believing that they’re making healthy choices.‌

And I’ve written about it because there’s been a variety of articles that said, “This can disturb your metabolic system,” that there’s a question of whether or not these are effective at all. People have thought that in these association studies, seeing the people who are consuming more of these artificial sweeteners tend to be heavier, tend to have more overweight and obesity.‌

People say, “Well, of course, they’re the ones who are choosing these strategies.” But there has always been this kind of question of whether or not they might actually be contributing to the problem, even though again, people are thinking that they’re helping. And so the issue is whether or not they’re affecting biology in unexpected ways, particularly around the brain’s regulation of appetite and hunger.‌

And so in addition, disrupting metabolic regulation is actually affecting you and the brain in the same way that we have discovered that these anti-obesity meds, which we thought might be acting peripherally at first, are actually also brain meds.‌

So there’s a study that came out in Nature Metabolism that I think was worth paying attention to. And it wasn’t a diet study. It was a neuroscience study. And what they did was they had participants come in for three visits, drinking one of three beverages each time. One was sucrose, regular sugar. One was sucralose, this noncaloric sweetener. And one was with water as a control.‌

And the drinks were flavored in a way that you would think they would be able to figure out what they were taking. But it turned out that it was hard for them to figure out what they were taking. And they showed that the consumption of the sucralose versus the others, versus sugar itself, stimulated hypothalamic blood flow. Okay. So you say, “So what?” But it also stimulated greater hunger response.‌

Howard Forman: Yeah. Crazy.‌

Harlan Krumholz: And compared with water, it also had increased hypothalamic blood flow—but no difference in the hunger rating. So it was interesting that the sugar but not sucralose increased peripheral glucose levels, sugar levels, but was associated with reductions in this hypothalamic blood flow. So the idea is that the hypothalamus is integrally involved in this regulation of hunger and is important to when people reach thresholds. They say, “I’m full, or I want to try to eat more.”‌

And this study, which was really well done, this crossover design—again, it’s a neuroscience study. It’s not a diet study, and it is a single point in time as they’re looking at these responses, but it’s a very interesting study in the sense of being able to be well designed and also involve being able to test blood flow in the brain, and they suggest at least this noncaloric sweetener could affect key mechanisms in the hypothalamus that’s critical, that’s so important for appetite suppression anyway. So it’s again laying in that these aren’t just sort of flavors. They’re not just making—‌

Howard Forman: No. If you look, again, Harlan, just like for our show notes, we’ll put it in there, but it’s almost eight years since you wrote the article, “Why One Cardiologist Has Drunk His Last Diet Soda.” And separate from that particular article, you have raised many times the separate potentially inflammatory actions of some of the sugar alcohols, which are also in our foods and in our drinks at times. So I do. I think we need to be careful about what we put—‌

Harlan Krumholz: And I’ve largely cut this out of my diet, but I will tell you, toothpaste has these sweeteners.‌

Howard Forman: Yeah.‌

Harlan Krumholz: These sweeteners are ubiquitous. And I think that this study, in addition to the others that are growing, shows that the brain’s response to sweetness without calories may be fundamentally different than its response to real sugar and not necessarily in a good way for everyone.‌

And what’s so interesting when it first started, it was like, “Hey, we can simulate sweetness and no calories.” What a great thing. And now we’re finding out when you start mucking with the body’s physiologic system, you don’t necessarily get what you thought you were going to get.‌

Howard Forman: Yeah. No. So well said. Really important.‌

Harlan Krumholz: All right, well, another thing is that since we’re on a neuroscience day, we’ve got a great guest coming up.‌

Howard Forman: Oh, God, yeah.‌

Harlan Krumholz: Yeah. Let’s get to him.‌

Howard Forman: Dr. Deepak D’Souza is Vikram Sodhi ’92 Professor of Psychiatry at Yale and a staff psychiatrist at the Veterans Affairs Connecticut Healthcare System. Today, he’s not speaking on behalf of the VA because he’s also director of the Schizophrenia and Neuropharmacology Research Group at Yale and the inaugural director of the Yale Center of Cannabis and Cannabinoids, a research center that investigates the effects of cannabinoids on neurodevelopment and mental health.‌

Dr. D’Souza also directs a psychosis research program that spans the VA and Connecticut Mental Health Center where he integrates clinical care, research, and education to advance treatment and understanding of serious mental illnesses. He is a leading expert on the relationship between cannabinoids and psychosis and on the pathophysiology of schizophrenia.‌

His work also explores how psychedelic compounds interact with the brain, and he has conducted numerous clinical trials to investigate treatments for psychiatric conditions, including depression, schizophrenia, and cannabis use disorder.‌

He received his medical degree from St. John’s Medical College in Bangalore and completed his psychiatric residency at SUNY Downstate, followed by a postdoctoral fellowship in psychopharmacology and neurosciences at Yale.‌

First, I just want to welcome you to the podcast. I’ll just say by way of background for our listeners, Harlan and I have spoken several times about the use of psychedelics therapeutically and as importantly about cannabis and the use and abuse of cannabis and sort of the emerging literature on that. And neither of us are an expert on that.‌

And so I went to look for who would be the expert on that, and you are not just obviously Yale’s expert but a world expert on this topic. I want to start off with a deep dive question, and that is how concerned should the public be with the ever-increasing use of higher-potency THC or tetrahydrocannabinol-containing products that are now widely available due to increasing legal use in many states?‌

Deepak D’Souza: First, thanks for inviting me. I do think there’s good reason for us to be concerned about the increasing availability and the increasing potency of some of these compounds. Just to put things in perspective, the potency of cannabis back in the 1960s and ’70s was about 4% THC. Currently, the average THC content of cannabis is closer to 18%. That’s a fourfold increase, but there are a number of products out there that have a THC content of almost 95%.‌

Howard Forman: Oh, my god.‌

Deepak D’Souza: So that would be more than 20 times potent than what was available in the 1960s and ’70s. And what’s important for us to realize is also a lot of the information that we have about the risks of cannabis date back to a time when cannabis was a lot less potent. And so it can give people an impression that cannabis is a lot more benign than the current forms of cannabis and cannabis products are.‌

So it is a cause of concern. I think it’s a cause of concern from maybe four perspectives. One would be the impact of these products on the developing brain, as in young adults, the impact of cannabis and these products on the development of serious mental illnesses such as schizophrenia and bipolar disorder, the impact on addiction as in cannabis addiction or cannabis use disorder. And then something that most of us can relate to is the impact on driving and what that might be. So I would broadly categorize those as the main risks that we should be concerned about.‌

Harlan Krumholz: I wonder if—gosh, it’s so great to have an expert on. I’m so glad to have you today because there’s so much misinformation about this. And maybe we could just start just as a level setting for listeners. They hear about cannabis. They know these things are being sold in stores. They see various different types of products, gummies, inhaled products. Can you just lay out for a minute, a lot of people are taking CBD, some people are hearing about THC. Can you just explain to listeners a little bit about... because cannabis writ large has got both these agents, but maybe you can just sort of disentangle this for us.‌

Deepak D’Souza: Sure. So one of the challenges with people understanding the risks of cannabis is that cannabis contains almost 500 distinct chemicals. The most interesting compounds in cannabis are Delta-9 THC and cannabidiol, and so we refer to them as THC and CBD. Most of the psychoactive effects of cannabis can be attributed to Delta-9 THC. In contrast, CBD—‌

Harlan Krumholz: The THC, as people might have heard—‌

Deepak D’Souza: THC, correct. In contrast, CBD or cannabidiol doesn’t really produce psychoactive effects, meaning to say you’re not going to get high using CBD or smoking CBD or consuming CBD. But CBD has interesting effects, which maybe we’ll get a chance to talk about.‌

Another important distinction is that we know that THC produces its psychoactive effects by having actions or activating receptors in the brain that are termed cannabinoid receptors or brain cannabinoid receptors. You see, our body has basically two kinds of cannabinoid receptors, brain cannabinoid receptors, which are referred to as CB1 receptors, and another set of cannabinoid receptors that are present mainly in the periphery, mostly on immune cells, and they’re called... those are CB2 receptors.‌

So THC, it activates both CB1 receptors—the receptors in the brain and receptors in the periphery. Cannabidiol, on the other hand, doesn’t produce most of its effects by activating any of these cannabinoid receptors. It seems to produce effects by many different mechanisms which we are only beginning to understand.‌

In that sense, we would refer to it in pharmacology as being a “dirty molecule,” as in, it binds to many, many different receptors and may produce its effects by having actions at many different places in the brain and in the body. So just to summarize, Harlan, CBD does not make you feel high. You cannot get addicted to CBD, and that is in contrast to THC, which produces the psychoactive effects.‌

Harlan Krumholz: And this is my final follow-up in this, Howie, because I know you’ve got lots of questions too. So just because we hear a lot about CBD, I’ve often thought, is it really exerting an effect or is it a placebo effect? Is there actually an effect of CBD that has been isolated?‌

Deepak D’Souza: That’s a very, very good question. I think that in certain models, for example, certain rare forms of epilepsy, there is convincing data that CBD that’s currently commercially available under the brand name Epidiolex has been shown to be efficacious in a very rare form of seizure disorder that occurs in children.‌

So there’s some data for that. But CBD has been used or tested in so many different disorders that have nothing in common with them, don’t have any common pathophysiology, which raises some people like yourself to suggest that maybe it’s just having a great placebo effect. What we do know is that it’s a lot less benign. And as you know, we often think about drugs or the usefulness of drugs as balancing the good effects with the bad effects.‌

So you could have a drug which is a great chemotherapeutic drug, which is used in the treatment of cancer, which may produce really bad side effects. But because it kills this cancer, we are okay with using that drug. And on the other extreme, you may have a drug that doesn’t produce any harmful effects, but also doesn’t produce any beneficial effects. There are questions about its beneficial effects. And so one might think about CBD as a drug that doesn’t produce too many bad side effects, but some people like yourself wondering whether it does produce any beneficial effects.‌

Harlan Krumholz: Maybe, we can say the jury’s out a little bit about this.‌

Deepak D’Souza: The jury is out a little. I can speak about CBD in psychiatry. There has been quite a bit of interest in the use of CBD in the treatment of anxiety disorders and even schizophrenia. But I think the science is just not there as yet to support any efficacy of CBD in at least these two disorders.‌

Howard Forman: Let’s use that then as a level setting for the question of THC and cannabis itself, because it seems like we do have tremendous evidence of the harm or at least the risks associated with THC use. You talked about potency at the beginning, but there’s also been specific clinical trials both about the effects of cannabis in normal individuals as well as in people with known schizophrenia. Could you comment a little bit about an abbreviated version of what we know about the effects of cannabis, both good and bad? THC particularly.‌

Deepak D’Souza: So I think it’s important for us to understand that this is not new information. The French physician, Moreau de Tours, wrote a treatise almost 200 years ago, published in 1845, where he described psychosis occurring in people who used hashish in Paris. And the descriptions that he provided in that treatise, if you showed them to psychiatrists in this current day and age, they would say, “That’s clearly schizophrenia” or “That’s a psychotic disorder.”‌

So that observation linking hashish or cannabis to psychosis was present almost 200 years ago. And then in my country of origin, India, when the British colonized India, they noticed a relationship between heavy cannabis use and people who are ending up in the so-called asylums that had been built in then. And they had a special commission called the Indian Hemp Commission, which actually was tasked to look at this relationship.‌

And they concluded, this is back in the late 1800s, that heavy use of cannabis was associated with, in their terminology at the time, “mental instability and insanity.” Those were the words they used that time. They didn’t have the word schizophrenia at the time.‌

So we’ve known this for a very long time. There are human laboratory studies that have been done, several groups have done studies showing that THC can induce symptoms that resemble some of the symptoms of schizophrenia. And in people who have established schizophrenia, THC can worsen their symptoms.‌

There have been a number of recent large epidemiological studies that have been done, multinational studies, showing that if you use cannabis daily and if you use high-potency cannabis, and in this particular study, “high-potency cannabis” was defined as cannabis containing 10% THC, your risk of schizophrenia was almost six times greater than if you didn’t.‌

Now since that study was published, not even 10 years ago, 10% THC cannabis is no longer considered high-potency! It’s considered pretty modest-potency cannabis. I don’t think there have been any studies that have been done to my knowledge looking at the very high-potency products like 90% and 95%. But if I had to guess based on my understanding of the literature, I would expect that we would see a much stronger signal.‌

Howard Forman: One last follow-up for me on that topic, what do we know or what do you understand to be the effects of THC on the developing brain for those that are taking it before the age of 25, before the age of 20, or even younger than that?‌

Deepak D’Souza: So there are a couple of important things to keep in mind about the risks of cannabis in young people. So most young people are spending their time in school or college, and these scholastic activities require learning and memory. These are important cognitive functions for scholastic activities. And one of the most reproducible and reliable effects in the laboratory is that THC disrupts learning and memory.‌

So just from the perspective of acute effects of THC, if you are acutely stoned, it’s going to be hard for you to learn new information and retain that information. Now, moving beyond that, what is—what are the impact of cannabis on the developing brain? All of us, whether we’ve ever used cannabis or not, and animals including dogs and mice and rats and Guinea pigs have cannabinoid receptors in their brain. So the question is, why does the brain have cannabinoid receptors? It’s obviously serving some very important normal function.‌

It’s not there because you’re eventually going to get high. It’s there to serve an important normal function. One normal function that this brain cannabinoid system plays is in telling neurons how to connect with each other, how to preserve neurons that are necessary, and how to get rid of neurons that may not be necessary.‌

As you know, the biggest change in the brain occurs during adolescence, where, let’s say, you’re born with 200 billion neurons. There’s an important pruning process that occurs during adolescence where the number of neurons are reduced, such that necessary neurons are strengthened and unnecessary neurons are removed.‌

This brain endocannabinoid system seems to play some role in this pruning process. Now, when you perturb that normal brain endocannabinoid system by bombarding it with THC—that happens when you smoke cannabis—that you can imagine how that might lead to long-lasting consequences on the developing brain.‌

Our brain makes THC-like substances. We call them endocannabinoids. The first of which that was discovered is called anandamide, named after the Sanskrit word meaning bliss. And the way the system operates is that anandamide is produced on demand in the brain and released in a very, very narrow radius, within micrometers. And it’s also inactivated within milliseconds.‌

In contrast, when someone smokes a joint, THC enters the entire brain, and it bombards and activates cannabinoid receptors in a manner that is nonphysiological. So you can imagine how exposure to cannabis during adolescence may lead to long-term consequences. The million-dollar question is why some people seem to be more vulnerable and not others. And so I think given that our brain continues to develop and only matures by the age of around 25 or 26, the developing brain, the brain may be much more vulnerable to these effects of cannabis.‌

Howard Forman: I would be remiss not to talk about the large part of your work right now and the reason why you’re the Vikram Sodhi Professor of Psychiatry, and that is your work on various psychedelics and particularly ayahuasca and the active chemical in there, which I believe is dimethyltryptamine.‌

Deepak D’Souza: Correct!‌

Howard Forman: I’ve been trying to remember that all day and I keep forgetting it. Okay. And the reason why I bring this up is, first of all, I think it’s worth mentioning that you are not only the first Vikram Sodhi Professor, but you are also an Indian American, and having the first Indian American chair that was named at Yale, and that very successful Yale graduate is deeply invested in this idea of understanding the medical uses of dimethyltryptamine. Since we’ve talked about the ill effects of THC, can you talk about the emerging evidence about the positive effects of these psychedelics of all types in the treatment of psychiatric conditions?‌

Deepak D’Souza: Sure. So thank you, Howie. That’s really important. I would start off by making a very clear distinction between cannabis, cannabinoids, and psychedelic drugs.‌

Howard Forman: Thank you.‌

Deepak D’Souza: The psychedelic drugs that I will refer to are drugs that include dimethyltryptamine or DMT: psilocybin from magic mushrooms and LSD. Everyone knows LSD. So there is a lot of interest in the psychedelic drugs as potential treatments for a variety of neuropsychiatric disorders, including major depressive disorder, post-traumatic stress disorder, certain substance use disorders, and even migraine headaches if you consider that as part of neuropsychiatric disorders.‌

And the allure of these drugs is that most of the treatments that we have for neuropsychiatric disorders need to be taken for weeks for their effects to emerge, number one. Need to be taken daily, often for very long periods of time because these are chronic illnesses. And what these psychedelic drugs or the allure of these psychedelic drugs is the idea that perhaps just one or two exposures to these drugs may lead to long-lasting therapeutic benefits.‌

And so this is the reason why there’s a lot of interest in these drugs. I think that it would be fair to say that while promising, we still need to have much more evidence. I think we are still in the research phase. It’s fairly nascent. And what do I mean by that?‌

For any drug to pass muster with the FDA, you need to do clinical trials that involves hundreds, if not thousands, of patients. We are not yet at that point with these psychedelic drugs. There are many small studies that have been done. Some of the studies are getting bigger, and there are a number of unique challenges to doing these studies. Some of the unique challenges include how do you blind these studies if you want to do a gold standard double-blind study?‌

Because the difference between these drug placebo and the drug is so marked that both the patient and the person doing the ratings immediately unblinded. So that’s an important issue. The other is the issue of expectancy. If you believe with zeal that this is what’s going to cure you, CBD will cure you or anything will cure you, and we haven’t done a good enough job in conducting these studies to account for the important role of expectancy.‌

So that’s the other thing. The reason I am very interested specifically in DMT is that most of the studies that have been done have been done with psilocybin and LSD. And with both those approaches, psilocybin and LSD administered orally, and when administered orally, the effects last, for example, psilocybin, six hours or six to eight hours.‌

And the tradition has been you have to have two people sit with the person for that entire period of time. I run a very busy clinic, and there’s no way that I would be able to get two of my clinicians to sit with someone for six to eight hours. That’s just not implementable.‌

In contrast, DMT, which is the principal active constituent of ayahuasca, is administered intravenously, and it lasts for about half an hour to an hour. And so we are developing this DMT paradigm with the idea that hopefully we can develop something that can be implementable on a much larger scale.‌

Harlan Krumholz: We’re getting to the end, but I have just one question about this. So these drugs, they have so many different effects. They’re hard to predict. Some people react acutely to them. There are questions about whether they can have long-term sequelae. How does the IRB, how does the group that’s in charge of the ethics of these studies, view you? What kind of restrictions do they put on you as you try to test these? Because I just can’t imagine... it must be very difficult to satisfy all of the regulatory requirements to be able to do these kinds of studies.‌

Deepak D’Souza: That is a great question. And for once, I’ve been asked a question that someone seems to empathize or sympathize with the—‌

Harlan Krumholz: I do. I do.‌

Deepak D’Souza: These are very, very challenging studies to do, and it’s really unfortunate because a whole generation of young researchers are likely not going to enter this field because of the crushing regulatory burdens. I have to comply with drug enforcement agency, the FDA, and several IRBs. Then we also have to usually convene a data safety monitoring board. We spend a huge amount of time and effort complying with this.‌

To give you an example, one of my studies that one DMT study took a total of three years to get all the necessary approvals. Three years in the lifetime of a junior researcher is the difference between making and breaking it. So it’s not for the faint-hearted. You really have to be patient and think about the long run.‌

Howard Forman: We could have you come back and probably do four more episodes. You are fantastic.‌

Deepak D’Souza: Thank you.‌

Howard Forman: And we waited a while to get you on the podcast, and it was worth it. I hope you will come back and join us again, and I appreciate the work that you’re doing.‌

Deepak D’Souza: Thank you. Thanks for inviting me.‌

Howard Forman: It’s so nice to meet you. It’s just terrific. Just thank you.‌

Deepak D’Souza: Thank you.‌

Harlan Krumholz: Hey, that was a terrific interview. Thank you so much. Howie, you are the one who thought to bring him in.‌

Howard Forman: I’m glad we did.‌

Harlan Krumholz: So great to meet him, and you guys get so much wisdom about these things and really notes of caution honestly, about a lot of these.‌

Howard Forman: People need to heed this. I really hope they heed this.‌

Harlan Krumholz: Yeah, about the cannabinoids. I mispronounced when I first said the cannabinoids.‌

Howard Forman: Right.‌

Harlan Krumholz: But also these psychedelic drugs are so much to learn and it’s so hard to study. But look, let’s get to your part of the podcast, Howie. What’s on your mind this week?‌

Howard Forman: Yeah, I’m going to keep it short today. I just want to talk briefly about a Medscape survey that comes out every year that gives us some visibility on physician salaries. And to be honest, the survey itself is not the greatest methodology, but the good thing about it is it’s every year, it’s about the same in terms of numbers of reports, and it collects similar data. So it gives us some comparative analysis over time.‌

Overall, physician compensation was up about 3%, relatively similar between specialists and primary care docs. Orthopedic surgery, radiology, plastic surgery, and cardiology are now at the top of the list at over $500,000 for each. And primary care specialties were near the bottom of the list, with all below $300,000 in average income reported. The average work week was reported around 50 to 51 hours per week with minimal variation between specialists and primary care. And that’s the averages.‌

Obviously, there are wide variations for individuals. A minority of physicians feel their pay is adequate, and there is little difference between specialists and primary care providers in that regard. And the gender pay gap remains wide, with men earning almost $100,000 more than women. And the gap is narrowest for primary care providers and widest for specialists.‌

The Great Plains part of the country pays the best, and it’s notable that some of the highest cost-of-living areas do not pay marginally better than many of the lower-cost areas. And so I guess preferences matter a lot here.‌

And 40% of physicians find extra income outside their primary jobs, such as picking up extra shifts. We’re doing short gigs in other parts of the country. So overall, there’s nothing really surprising here, but I do think it’s important to note that there is enormous variation.‌

There are physicians making well more than a million dollars a year in their clinical practice. And there are also many people earning substantially less than the numbers we’re presenting here. But we are still seeing this huge variation between procedural fields, surgical fields, and the primary care specialties. And we pay an awful lot of lip service to trying to augment the primary care workforce. We talked to Ryan Schwarz about this and many others over the last year. We pay a lot of lip service to it, but we’re not making a lot of success in achieving greater parity between those specialties.‌

Harlan Krumholz: Well, thanks, Howie. It’s always interesting to look at this. I think for the public looking at it, they’ll see that doctors in their view are still doing quite well.‌

Howard Forman: Certainly not poor.‌

Harlan Krumholz: It’s interesting to me at a time of burnout, where people are feeling that they’re working so hard, that still 40% of the doctors are seeking additional compensation outside of their main job. That’s a big number. And I don’t know whether it speaks to loans or other financial obligations or that doctors just tend to live large. I don’t know what…‌

Howard Forman: I think it’s also that doctors wait a long time to earn any real income. And so they feel like they have this brief window to earn money.‌

Harlan Krumholz: It could be that. The thing that still I wonder, what you think about is when are we going to get to the point where we say, “We’ve got to move away from this system that is so heterogeneous with regard to its rewards for individuals and is leading to this perverse distribution of physicians”? You showed it before when we talked about the Match, so that the high-paying sort of lower-burden specialties, the ones in a sweet spot, are attracting many, many people into those fields, especially at the top medical schools. And it just seems unfair within our profession.‌

Howard Forman: I agree. I agree.‌

Harlan Krumholz: It’s sort of like it’s grandfathered in. It’s like we’ve got this situation, and nobody knows to how to get out of it.‌

Howard Forman: We have enormously powerful stakeholders that have every reason to want to maintain the status quo and not enough mobilization for a large number of primary care providers and their patients for—‌

Harlan Krumholz: Frontline providers, it’s hard work, it’s grueling, and it’s not clear that there should be others in our system who are so much better compensated when the effort is similar. And then you’ve talked about the gender gap as well. There’s lots of issues in that, and we don’t seem to be making any progress.‌

Howard Forman: No.‌

Harlan Krumholz: We need to devote a whole program to thinking about solutions about this, think of who can get on and start talking about these things.‌

Howard Forman: Everybody thinks they have solutions, but the solutions haven’t worked so far. So I’m hoping someone has some good ideas.‌

Harlan Krumholz: Yeah. Well, thanks for bringing it up, Howie. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.‌

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, email us at health.veritas@yale.edu, or follow us on any social media, including specifically LinkedIn or Bluesky, where we’re most active at the current time.‌

Harlan Krumholz: And we definitely want to hear your feedback, questions, your own experiences. We are getting emails from folks. We really enjoy it, and everyone should feel encouraged to reach out and contact us.‌

Howard Forman: Absolutely. 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: Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Inès Gilles and Sophia Stumpf, Tobias Liu, and our new addition to the team, Gloria Beck. Welcome, Gloria. It’s so great to have you on.‌

Howard Forman: It really is.‌

Harlan Krumholz: And our spectacular producer, Miranda Shafer. Talk to you soon, Howie.‌

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