Dhruv Khullar: The Physician-Journalist

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

Howard Forman: 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. This week, we’ll be speaking with Dr. Dhruv Khullar, but, first, we always check in with current health news.

Harlan, you brought up this company to me yesterday. Tell our listeners about this. I’m fascinated after looking into this a little bit.

Harlan Krumholz: Yeah, I just said to you I thought it’d be interesting for us just to talk for a little bit about this company called Hims & Hers Health. This is one of those telemedicine companies, direct-to-consumer virtual care companies, so that basically an individual can initiate a contact with this company in order to get care. What was interesting about them was that they focused on areas that maybe people would feel were stigmatizing, that you could approach them for medication about erectile dysfunction or about baldness, depression. The company is doing pretty well. They reported out a 57% year-over-year revenue in the third quarter this year at about $226 million—that’s a quarter—compared to $144 million last year, and a reduction in their net loss. They’re still a startup, so they’re still not quite to full profitability.

I raise this because I’ve talked to you before about the way in which our information networks work now in healthcare. In the olden days, you learned to trust an individual. You went to a doctor, and that doctor earned your trust over time, and you would begin to disclose things to that doctor with the knowledge that that doctor could keep your confidence. Sometimes there would be things that you might discuss with that doctor that you wouldn’t want to say to anyone else, including even just things like, “Hey, I’m thinking of leaving my spouse” or about my sexual identity or about depression or erectile dysfunction, a whole range of things.

In this world today, if I disclose that to a doctor, it goes into the electronic medical record, and any other doctor, any other healthcare provider who claims to be part of that network who’s providing me care can access that. Even when I stub my toe and I go into the emergency department, that person has access to my full record. In a way, I think it has a chilling effect on the trustworthiness of medicine, and this company, as I perceive it, is, what, people going around their healthcare system. Instead of going to my doctor and saying, I’ve got a blah, blah, blah, whatever issue, and maybe I’m a little embarrassed about but I want to get treatment for, you’re able to call this company and you have to trust this company’s not going to have a breach and not going to do anything with your data.

It means that now, if I have something, if I have depression and I don’t want that in my Yale New Haven Hospital record, I may come and stub my toe and I don’t want people to know, I don’t want everyone to know this. I can go to this company separate and get that treatment, but it starts to fragment everything, so who can you trust and who can you disclose to? I’m curious what you think about it, but I think they’re responding to a need. Why do people have to go to this company for stigmatizing illness, one that they’re maybe ashamed or embarrassed about? Because they don’t feel they can trust their own system. I don’t know. How do you think about this?

Howard Forman: There’s a couple of things that came to mind for me that were fascinating. First, in class, I often say, in a provocative way, “I’m not sure if I was in charge I would do this.” I often say that we require prescriptions for way too much. We should be allowing people to purchase certain drugs without prescriptions and, other than controlled substances and other than antibiotics, everything else I have a much more libertarian view about. It made me think like that’s what this is getting around to some great extent because they’re letting you get antidepressants, they’re letting you get erectile dysfunction drugs, they’re letting you get hair loss drugs basically by giving you a prescription after a very brief encounter.

A lot of it is just online information and then a very brief encounter, so that simultaneously worries me, but it also feeds into my idea that maybe we’re requiring too much of people in order to gain access to some very accessible drugs, things that otherwise should be very accessible. The greater point which I had not thought a lot about until you mentioned it to me was this issue of privacy. I think maybe I’m too much of an open book so I’m okay with everything being in my medical record, but, you’re absolutely right, when I was a much younger person, I may have been afraid of telling somebody something and having it in my chart. Even something about being gay would have been something I would have been afraid of revealing in a medical record at that time. There is room for us to figure out how do we protect people’s information in a way that gives them a level of security and still gives them the full access to the medical system.

Harlan Krumholz: What about just giving people the choice of who do I want to know what about me? There could be a doctor who cares about you; you have a strong trusting relationship that you’re willing to disclose things to—again, not even afraid, but just maybe inhibited from sharing—but this person earned your trust. You’re willing to talk to them about it. Of course, in psychiatry, the records are sequestered often and aren’t available broadly within the medical record, but for medical things or even psychiatric issues that you might disclose to a general medical school doctor does become part of the record.

I think we have to be thinking about tiered consents so that, if I stub my toe, for a woman, that person doesn’t need to know I had an abortion. I mean, there are just certain things that you may want to keep private or only disclosed to certain people. What I’ve heard doctors tell me is, “Well, how am I going to care for people if I don’t get all the information?” I think that this Hims & Hers is showing you that, if you continue this system, people will find ways outside of the system to get that care, and then you won’t have access, and it’ll be fragmented. Anyway, I think we’ll continue to talk about this over time, but it is something that is different about our health system today that I think we need to grapple with.

Howard Forman: I do really encourage our listeners to go online and look at their website because it is fascinating to me. I think it’s hims.com and then forhers.com or something like that. I’d never looked at it until you told me about it, and it was fascinating to see how far you can go with certain diseases for getting very quick care.

Harlan Krumholz: Well, and we’re seeing this, by the way, in the anti-obesity medications also, companies that are coming up specifically for you to go to them. Now, you may think that’s easier, but it also, for some people, they just won’t talk about taking those medications. By the way, last thing because I know we’re going to get to a great guest today, today, tirzepatide, the drug that’s made by Eli Lilly, that is one of the major anti-obesity drugs, but has never been approved for obesity up until yesterday. We’re recording a day in advance what’s going to come out on Thursday on Wednesday. This was now approved for obesity, so interesting.

The semaglutide, which is the Wegovy/Ozempic drug—Wegovy is the one that’s approved—they just put a different name on it for obesity. By the way, they’re going to change this name for tirzepatide which is known as Mounjaro. It’s going to be called Zepbound or something. It is a drug that people have been using as an anti-obesity drug, now officially approved or now are officially, two of these GLP-1 receptor agonists that have been so effective. This week—and we’ll talk about it next week—at the American Heart Association. The select trial is going to be discussed and likely published and will show that semaglutide that’s already been announced by the company reduces the risk of cardiovascular disease in people with obesity and a history of heart disease by as much as 20%. That’s just not weight loss now. That is actually improved outcomes. It’ll be very interesting.

Howie, let’s get onto our guest.

Howard Forman: Dr. Dhruv Khullar is a practicing physician and assistant professor of health policy and economics at Weill Cornell Medical College. He’s also a contributing writer at The New Yorker, covering healthcare topics from COVID-19 to convalescence from disease to AI in mental health treatment. His popular press writing has also appeared in The New York Times, The Washington Post, and The Atlantic. With an emphasis on the intersection of data and narrative and its impact on policy, Dr. Khullar’s research focuses on value-based care, health disparities, and medical innovation and has been published in many leading journals, including JAMA and The New England Journal of Medicine. He received his bachelor’s and MD degrees from Yale and, during his medical school training, also received a master in public policy from the Harvard Kennedy School. He completed his residency at Massachusetts General Hospital in 2017.

I want to start off. You have this great paper on convalescence. That’s one of your most recent long=form pieces in The New Yorker, and the title is “Why are We So Bad at Getting Better?” It resonates with me in a huge way, and I know it will resonate with Harlan as well, because Harlan and I talk about this a lot very often with regard to me. I’ve had two catastrophic hospitalizations, surgeries, and nobody gave me better advice during that time than Harlan did. Harlan was the one who constantly reminded me that the body does not recover instantly, that there’s a loss of cardiac reserve, and that you have to recover and that sleep is so important, so many things. He’s sort of my surgery and hospital doula. I’m wondering about your thoughts about how do we do better and give our audience a little taste for what that article talked about.

Dhruv Khullar: Sure. First of all, thanks for having me on, Howie and Harlan. It’s a real honor to be with you and to be chatting today. The article on convalescence really came out of this understanding that I experienced during my own medical training, which was that we work so hard on treating people when they come into the hospital or the clinic. Increasingly, over time, we focus a lot on prevention as well, but if you divide illness into prevention treatment and recovery afterwards, there’s relatively little attention that’s given to recovery even though it’s a huge part of actually helping people feel better. Part of it came from my experiences with patients and understanding that our job in caring for them doesn’t end after you’ve prescribed an antibiotic or after you’ve done a procedure but rather seeing them through the whole process, and part of it came from a recognition that, during medical training, we don’t do a good job of helping clinicians understand how to help people through that journey.

This is actually very different than it was a century or two ago. In the article, I talk a lot about the Victorian period and how convalescence and recovery was almost revered during that period. Now, part of that is they didn’t actually have a lot that they could do in the way that we can today. I mean, we have drugs and procedures that would be unimaginable 150 years ago, but I do think we’ve lost something when we give up on this idea that it’s not just about prevention of disease, it’s not just about treatment, but it’s about seeing people through to better health.

Harlan Krumholz: Yeah. Actually, I love that article. Actually, I love almost everything that you write. What’s your process when you decide you’re going to do an article like that? I mean, you’ve become an expert by the time you write the piece, but how do you go from somebody who’s got an idea, feels that this is an interesting area to when your knowledge crystallizes enough that you can really educate others about it when you yourself may not have been an expert at the start?

Dhruv Khullar: It’s a great question. I often start by just thinking about something that I really want to learn about. In medicine and healthcare more broadly, there’s so many issues that come up from time to time that you just realize that you haven’t looked into and you don’t have a good handle on it. I find the best way that I’ve ever been able to learn about something is to write about it. Really, when you’re writing a piece, or at least when I’m writing a piece, 90% of the writing and the thinking happens before you sit down. You’re getting your mind in a place where you feel like you’re able to say something new and different and important and push a conversation forward. That takes a lot of just understanding what has already been written, what is already known about this topic, what people are saying about it, and so, for me at least, a lot of the work is up front reading and learning, talking to people about an issue before I get anywhere near the Word document and start writing.

Howard Forman: You are a scholar as well as a lay writer. There’s not many people who’ve done that, quite frankly. Atul Gawande probably is one of the few people that have been able to do that, but you are first authoring papers in prestigious journals on important topics related to value-based medicine, related to health policy topics in healthcare. How are you able to segment your life in such a way that you’re able to commit huge energies to these projects and still huge energies to writing and still be an active clinician as well as a husband and father?

Dhruv Khullar: I guess there’s a tactical answer and a philosophical answer, and the philosophical answer might be that that I feel each of these things feeds into the other things. When I think about seeing patients or I think about doing research or writing and communicating to a broader audience, something I see in the hospital might spark an idea for a research paper. Some collection of research either that I’ve done or other folks have done might be the inspiration for an article in The New Yorker that I want to communicate about an issue to a broader audience. I don’t see it as three separate things that I’m doing, but really one whole that comes together in a really interesting way because each of those disciplines informs the other thing.

The more tactical answer is that you get good at time management, but you also get good at figuring out how to partition your time in a way that you have, at least for me, long blocs of time where you’re focused on one activity so, in a broader sense, everything feeds into everything else. On a day-to-day or hour-to-hour, what I find most helpful is being able to spend two or three hours consecutively on one topic and not do a lot of task-switching, and so I will block off an entire afternoon just for writing or bunch all my research meetings into one morning. My clinical work is such that it is able to be divided by a week, and so I might be on service for a week or two weeks and then not be on service for a couple of weeks. Tactically, that has been really helpful keeping everything up in the air.

Harlan Krumholz: I wonder if you could just give the listeners maybe a sense of your journey as a writer. Let’s just isolate that because I think it’s so interesting to me. You come to medical school, you get an MBA, you’re on this track, you also have these research skills that are growing, but you decide to commit yourself to the art of writing and actually are able to gain a position at The New Yorker, a preeminent position to do that kind of writing and hone your craft and to communicate and teach people. How did that work? I mean, it’s not easy to get a position like that at The New Yorker, arguably the best place in the world if you want to do long-form pieces. What led you to that decision about, “I’m going to commit myself to this,” and then being able to find a position like that?

Dhruv Khullar: Yeah, very early on, high school, early college, I knew that I wanted to be a physician. I mean, that was the core of what I wanted to be and still how I see my identity as someone who cares for other people and wants to learn the art and the science of medicine. My father was a doctor, and that’s a well-known risk factor for going into medicine yourself. I always had this inclination in part by people like yourself and Howie that I wanted to try to contribute the knowledge that we get from seeing patients to broader audiences, and that could be within the academic community through research or that could be to lay audiences.

Over the course of medical school and then more centrally in residency when I felt like I had a lot more to say, a lot of it was just freelancing. I would have an idea, I would see something in the hospital, I would be engaged in some kind of research and really feel this desire that I wanted to communicate that to people, and so I was freelancing and writing op-eds and columns and really started writing for The New Yorker during the COVID-19 pandemic. I was caring for patients during the first horrific wave in New York City and was spending all my days in the hospital and then would open up the laptop at night and almost as a kind of cathartic process write about what I’d seen, how I was feeling about caring for people who often we didn’t have a lot of good treatments for at that time, and a lot of that writing ended up making its way into The New Yorker.

Harlan Krumholz: I want to correct myself. I said MBA. Of course, I meant MPP, master of public policy was the degree that you got, not an MBA as Howie said. Like I said, I recommend to people to take a look at your body of work, but one particular thing that you wrote I thought that was very important... Well, all of it is important, but what does a heat wave do to your body? You had written also another piece about air quality and hazy days of summer and trying to encapsulate this. Can you share with the listeners a little bit about what you took away from that research, because I really believe that climate change is going to have profound impacts on health and is going to require us to be thinking differently about the role of the environment and its impact on so many different diseases, but also just the way the body reacts to heat? What did you bring away from that work that you were doing?

Dhruv Khullar: Yeah, I mean, I think it was always obvious for the past few decades in a research and a statistical sense that climate change would have drastic impacts on human health. I think we just have felt it so viscerally over the past few years. Part of what I’m trying to do here is not necessarily advocate for a particular policy, although I do think we need strong policies to address the threat of climate change; it’s really to awaken in as many people as possible the idea that this is happening, that this is going to be one of the central challenges of the next few decades.

That in and of itself was awakened in me. I’ve always been interested in climate change broadly, but I read a book by Kim Stanley Robinson called Ministry for the Future. The opening chapter of that book focuses on kind of an apocalyptic heat wave in India. It was the first time that it just brought home what it would be like actually to live through something that was really unlivable. It just so happened that, later that year, India did have the worst heat wave in its history, and the temperatures reached 120, 121 degrees. Birds were falling from the sky, dead. People were having trouble working, living outside, and a lot of the population does live outside.

I had a chance to go to India during that and report on what it would be like. The real purpose of that in my mind was to help people understand that this could and will be a bigger part of our future and we need to be taking the steps now to stem off the worst of what could happen.

Howard Forman: Yale Medical School has an unusual number of people going on to careers in writing. I mean, I could probably come up with an enormous list, but just on our own podcast, we’ve had Lisa Sanders and Randi Epstein and, in years gone by, Shep Nuland, many, many people over the years. Was there something during the curriculum? Was there some reason why you are drawn to writing that Yale either helped with or maybe even sponsored you in some way? What causes that to happen here?

Dhruv Khullar: I’m not sure it’s something that was in the curriculum per se as so much as that the curriculum allows people to investigate what it is that they’re most passionate about. I think it’s more a general impetus to think about the contributions that you could make and then the space to explore those things during medical school and, ideally, beyond.

Howard Forman: I know we’re getting to the end. This is such a terrific interview. I actually wish we could go on and on. I think maybe my last question, because I know we’re need to close up, is you wrote a really nuanced piece early in the pandemic about the struggle to define long COVID, and you’ve been writing a lot about the pandemic since, but I know that you are also doing research in this area. You’re part of Project Recover, a more-than-a-billion-dollar effort by the federal government to try to bring more insight to long COVID, and you’ve published on this topic. I was just wondering where are you in your thinking now about long COVID both from your research and from your reporting?

Dhruv Khullar: It’s a huge topic, and it’s such an important topic. I think it’s something that requires so much nuance and thoughtfulness because it’s something that affects so many people’s lives. On the one hand, it’s the case that it’s undeniable that many people in the United States and around the world are struggling with the long-term effects of a COVID-19 infection. On the other hand, we don’t want to make it appear that it’s something that when you receive a COVID-19 infection that it’s a foregone conclusion that you’re going to have these long-term effects. I think a lot of the writing during the pandemic, it really struggled to strike the right balance between helping people understand in a clear-eyed way the risks that are potentially occurring after such an infection, but also making clear that not everyone will experience these consequences and ultimately figuring out ways to help people improve.

Thinking about where we started this conversation with regard to convalescence, that’s a huge part of this is that we developed treatments. I remember, very early on in the pandemic, dexamethasone became clear as a very effective treatment, and then there’s remdesivir and a series of other medications, including Paxlovid. There’s still more I think we need to do to help people recover with long COVID. I think that, again, this recovery initiative is a huge step in the right direction, but there’s more that needs to be done to make sure that people really do achieve full recoveries and are able to get back to their lives in the way that they want to.

Howard Forman: The field of medicine is very lucky to have you, and I also want to say that our students at Yale are lucky to have you. You’re going to come back here tomorrow to meet with some of my student groups. You generously give of your time to mentor people and to support them in their careers, and I really appreciate that greatly. Thank you for joining us.

Dhruv Khullar: Well, I’m looking forward to it. Thank you so much for having me.

Harlan Krumholz: Yeah, this was really great, really great. Thank you so much. Howie, that was a terrific interview today. I’m so glad that we brought them on again another one of your wonderful mentees. It’s always great to see how wonderfully they’re doing in the world. Let’s get to your topic this week. What’s on your mind?

Howard Forman: Whether it’s a presidential election year or midterm election year or even “an off-election year” like this one, our elections have enormous consequences and obviously true also for health and healthcare. This week, we saw healthcare play an outsized role in the election results. In Ohio, voters strongly affirmed the right to abortion, much to the surprise of pundits from two years ago. In Virginia, voters strengthened Democrats’ control of the legislature in what was seen as a proxy for protecting abortion rights. In Kentucky, the Democratic governor, Beshear, was reelected by a substantial margin despite being in a strongly GOP state presumably in order to fight for some abortion rights in a state that currently has some of the strictest restrictions, tightest restrictions in the country.

While it was a loss for healthcare, the GOP Governor of Mississippi, Tate Reeves, was reelected by less than 5% in a state that former President Trump won by 16% just three years ago. Why was it a loss for healthcare? Because the Democratic challenger, Presley, was running on a platform of Medicaid expansion.

Harlan Krumholz: Howie, I was interested in that race. Was it really tied that closely to Medicaid expansion?

Howard Forman: Yeah, it turns out, in Mississippi, it’s something like 90% or more of Democrats and 80% overall of the state want Medicaid expansion. It’s not a hundred percent clear they want this for purely the best reasons, but as we talked about just a few months ago, their rural hospitals are in grave danger. A lot of them are shutting down. People worry about this, and so Medicaid happens to be a big issue in Mississippi, and the governor has resisted calls to do that.

Harlan Krumholz: What’s the downside of a state accepting the Medicaid expansion? What would be the reasons not to do it besides showboating about opposing the legislation?

Howard Forman: The biggest reason is really the fear of a bait and switch. The biggest fear is that, while the federal government is willing to fund 90% of the Medicaid expansion now, that at some time in the future it’s going to go dramatically down to 50% or 60% and the state is going to be on the budget for this very large population. That is the most logical explanation. I personally think it’s mostly ideological, as you alluded to before. If you wanted to have a true justification, there’s a long history of our Congress passing a bill at one time and 10 or 20 years it looking very different. If I were a state, I’d be worried to some degree that it’s a bait and switch over time.

Harlan Krumholz: That’s interesting. The Ohio result really interested me. I’m from Dayton, Ohio, as you know. Both with respect to abortion, I mean now a solidly red-state Ohio is not even in play anymore, but yet they voted in ways on abortion and on marijuana—

Howard Forman: Yeah, marijuana.

Harlan Krumholz: ... that’s more traditionally associated with a blue state. I don’t know. How did you perceive that?

Howard Forman: Yeah. Look, they both passed by a similar margin. There are already people in Ohio that are talking about how if abortion wasn’t on the ballot, maybe marijuana wouldn’t have been approved, but it’s hard to make that supposition at this point. Look, we talked a year ago, if you remember, pretty much right after the election, about magic mushrooms. Now we’re talking about marijuana. Maybe it is high time for us to talk about that, pun intended.

Harlan Krumholz: “High time.” High time, right.

Howard Forman: Marijuana is something that we should talk more about on this podcast. It used to be an illicit substance. People used it, but generally briefly in their youth and regular users were small in numbers, and now it’s growing in numbers in huge ways so that now it’s a $34 billion industry. It’s growing fast. Eleven percent of young adults use it daily, and that is double the rate of one decade ago, and we know way too little about the long-term effects. There were two abstracts reported out of the American Hospital Association this week that showed that marijuana use may be associated with cardiovascular adverse events.

Harlan Krumholz: Yeah, but, I mean, I think about this. I wonder, did it have an effect on alcohol use which I think is, as you know, talk about something that’s dangerous for society, number of lives lost and lives disrupted and so forth, is it minimizing in some ways the use of alcohol? We also have this problem in this country of many people who are casual users of marijuana ending up going to jail, I mean, really having their lives destroyed because of our legal system.

Howard Forman: Yeah. I mean, look, in general, I’m completely in favor of legalization of it, but I just think that, as we’re legalizing it, we should be looking carefully about how do we inform the public about something that we just don’t have great information on.

Harlan Krumholz: Yeah. Yeah, we should have a better idea of what the trade-offs are. That’s amazing, the statistics of the growth, but we’ve got local experiments because many states have approved it. It’s almost like a cluster randomized trial where different states at different times, and we should be able to see what the impact has been on populations.

Howard Forman: Hopefully, not a bad impact.

Harlan Krumholz: Yeah, really great. Thanks for the discussion, Howie. I mean, of course, you’re so knowledgeable about the elections, but it’s so interesting how health has become such a centerpiece of these elections and maybe likely to continue.

Howard Forman: Our votes matter.

Harlan Krumholz: Yep, they do matter. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: How did we do? Give us your feedback or, to keep the conversation going, you can still find us on Twitter or X, but you can also email us at health.veritas@yale.edu.

Harlan Krumholz: On Twitter, I’m going to keep calling it Twitter, I’m @hmky... because that’s what I want to remember it as because the X part I think is like, yeah, it’s changing, but @hmkyale. That’s H-M-K-Y-A-L-E.

Howard Forman: I’m @thehowie. That’s @, T-H-E-H-O-W-I-E.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management and with the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and to our producer, Miranda Shafer. They are amazing.

Howard Forman: They certainly are.

Harlan Krumholz: Talk to you soon, Howie.

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