Dr. Lisa Leffert: Leading in Anesthesiology

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

Howard Forman: And I’m Howie Forman. We are 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. Lisa Leffert of the Department of Anesthesiology at Yale. But first, what’s got your recent attention, Harlan?

Harlan Krumholz: Yeah, hey, thanks, Howie. It’s great to be here. I just thought I would say a few more things about the pandemic. I always kind of preface this, but I know we keep coming back here, but it’s still of such intense interest I think within medicine and healthcare, and it’s where there’s so much action. There was an interesting article that was published in the Journal of Heart that leveraged the UK Biobank. UK Biobank is this gigantic repository of information. They did this really wise thing in the UK. They decided we’re going to go big, we’re going to enroll about 500,000 people in a study and many of them are going to consent to have CAT scans, MRIs, the whole range of measurements, and we’re going to follow them longitudinally over time. And the whole country’s only got, what, 35 million, so they basically took a big chunk of the country and got people to volunteer and be part of this national effort.

It’s just been a remarkable boon to research. In this case, what some researchers did was they identified people within the UK Biobank who within the first year of the pandemic had gotten infected, and they did this because they Howard Forman: were able to take this study database and merge it with clinical databases. As you know, in the UK they have a single-payer healthcare system, and so they’re able to link to large national databases to figure out who got infected. Then what they did was, they matched people within the UK Biobank who had been infected with SARS‑CoV‑2, with COVID-19, and with a couple people who had not been infected and then what they did was they followed them over time. What happened to these folks if we look long-term, and their interest was in answering the question that several people have raised, including my friend who’s looking at the VA databases, and asked the question, are they at increased risk of cardiovascular events long-term?

You get over COVID, but what about long-term? I mean, is there something else? And I consider this a form of long COVID, I mean, the one kind of long COVID is people have terrible symptoms, but another kind of long COVID is you may not be symptomatic, but maybe your risk is elevated. And so they looked at people who are not hospitalized, then they saw that they had, in the subsequent year, they had about almost three times the risk of having venous thromboembolism and an increased risk of death actually. This is matching for a lot of other factors. But if you had COVID, it increased your risk of death and increased your risk of blood clots. Then they looked at people who had been hospitalized, and they saw that these people were at increased risk of venous thromboembolism. That’s the blood clots often occur in the legs and can go to the lungs, heart failure, stroke, and death.

And so they’re raising an alarm. And I saw this as being very consistent with what came out of the VA. Well, let me say to anyone listening, this is not to freak people out. Most people don’t have these events. Even when you increase them by two or three times, that is a lot—relative increase. That’s a lot of increase. But when a few people per thousand actually have any of these conditions, most people are not going to get them. If you’ve been infected with COVID, it’s not that people should have a lot of anxiety about this or be fearful, but on a population level, it can have a big impact. And the question is, is this specific to COVID-19 or is this something that’s always followed infections? Because we know the flu has also been associated with heart attacks, that’s why the American Heart Association recommends people get flu shots.

And we know that pneumonia, for example, people hospitalized with pneumonia can have increased risk of cardiovascular events subsequently. Is this just about inflammation when people get infectious disease, it places them at higher risk? Or is there something special about COVID? We still have to unravel that. We’ve never looked so deeply at these other diseases as we’re looking at COVID. When we find something, we have to reflect back and say, is this about this particular organism, this particular virus in this case? Or is it something that is more general about infections that we need to be aware of? Now, because SARS‑CoV‑2, the virus for COVID-19, is so prevalent and so many people have been infected, if indeed infection then leads to increased risk, this may have a profound effect on the population effect, the number of heart attacks we see, the number of blood clots that we see in the population over the next couple years because of this.

Then this just adds more emphasis to the importance of modifiable risk factors. The idea that people should control their blood pressure, should be paying attention to their lipids, should be physically active, shouldn’t smoke, should watch risk factors for diabetes, the notion of the entire population, of doubling down on these preventable risk factors, these modifiable risk factors so that we can put people in better shape, because if we don’t, we might be facing sort of a spike in these kinds of events is going to be really important. Anyway, we’ll keep our eye on this, but I thought it was a very interesting paper. But anyway, we have to keep our eye on the sequelae, the long-term consequences of the infection and what impact that might have on people’s health and what we can do to keep them safe in the meantime.

Howard Forman: I just would add that one of the things that you highlighted is the fact that they have a national health service and they’re so much more capable than we are of doing this type of large analysis. We get to do it at the VA system level and some other smaller areas, but it is another downside of our current system.

Harlan Krumholz: Absolutely. Hey, let’s talk to Lisa.

Howard Forman: Dr. Lisa Leffert is the chair of anesthesiology at Yale New Haven Hospital and Bridgeport Hospital and the Nicholas Greene Professor of Anesthesiology at the Yale School of Medicine. Dr. Leffert is a clinical expert in obstetric anesthesia and in the management of pregnant patients with comorbid, neurologic, and substance-use disorders. Her research focuses on neurologic diseases and vulnerabilities in pregnant women. From 2019 to 2020, she also served as the president of the Society for Obstetric Anesthesia and Perinatology, where she prioritized restructuring the board to enhance diversity.

Prior to Yale, she was on the faculty at Harvard Medical School and chief of the Division of Obstetric Anesthesia at Massachusetts General Hospital. She received her medical degree from Harvard Medical School and completed her residency at the Brigham and Women’s Hospital. First, welcome to the Health & Veritas podcast, Dr. Leffert. You come from a family of physicians, and yet you first went to work in healthcare management and consulting before medical school and wanted to do an MBA in medical school more than a dozen years before Harvard made such a degree a reality and never really expected to continue to be so deeply invested as you clearly are in clinical practice. Can you tell me, is that right?

Lisa Leffert: First of all, it’s delightful to be here with you today talking about my favorite thing, which is what I get to do every day. Secondly, you may laugh when I say this, but going into business was a little bit of a rebellion for me. Some people take time and go off to India and explore their inner selves, but for me and for my family, taking some time to check out business was a rebellion. And it was not so much that I wanted to rebel per se but more that I had sort of been raised to be a physician as my father had before him and I just wanted to be sure. Really, going into business was kind of expedient in the sense that I was up at Dartmouth College and there wasn’t much around, but there were certain companies and certain firms that came to Dartmouth to meet the prospective employees, and that was us, the college students and one group of people who came up were management consultants.

I went and got an interview, signed up, was fortunate to actually be awarded one because most of the people who were awarded those interviews had been economics majors and such. I was not. And I went to the interview and I thought, I love this. These people are smiling, they’re well dressed, and they’re flying all over the country telling people what to do. This sounds like my kind of thing. I signed up to be an associate consultant at Bain & Company. It was a two-year commitment. Secretly, I was thinking that I was going to go to medical school in a year, and actually I had a plan right at the beginning to take the MCATs. I had spread out the medical prerequisites being sort of a, what I like to call a hidden pre-med in college and had planned to take the MCATs right upon graduating from college.

Then I hit my first sort of obstacle in the road, which was the very same weekend that I was scheduled for the MCATs, they had a huge orientation weekend for the management consulting job, and I had to go. I went and I spent the first year at Bain and the second year at Bain, and I loved what I was doing. Most of my colleagues at that point went to business school. And that was when I said, I really care about healthcare, but I see that it is often people in business who actually direct healthcare. Why don’t I bring these two things together? And that was more than 30 years ago and this concept was not nearly as well accepted as it is now. I worked on that, and as you said, it wasn’t so easy.

Howard Forman: Can you just expand on that before I turn it over to Harlan, and just tell us, when you were in Harvard Medical School and you thought to do the MBA, but you already had a lot of background in business, what did you think the career was going to look like at that time? What did you anticipate your career looking like, let’s say now or 10 years ago even?

Lisa Leffert: Yeah, so there are some aspects of it that are not at all surprising and that is being heavily involved in how healthcare is delivered. Whether you want to call that healthcare administration or the business of healthcare, that was very much what I thought I was going to be involved in and was in fact from the beginning. However, although I felt honored to take care of patients, I didn’t have a particular subspecialty area that I was drawn to. And it took me quite a long time, really till the end of medical school, to decide to go into anesthesia. And it was partly because people from all over the place having done all kinds of crazy things, went into anesthesia, and I didn’t think I would still be taking care of patients, maybe not even after residency, not to mention 30 years later.

Harlan Krumholz: Sometimes we hit the jackpot in some of our recruitments and we certainly did bringing Lisa Leffert to Yale. I wanted to get to a pivotal moment. I was reading something about you that said you were sort of considering what specialty to go into and why you were making these rotations. There was a visiting junior anesthesiologist, Phillipa Hore, who influenced you, and you sort of reflected about how as a young woman at that time, she became sort of a role model for you. But I was just sort of curious, why was that such a pivotal moment, and what exactly happened that all of a sudden turned on the light and said, this is actually where I want to be in medicine?

Lisa Leffert: We were in the ambulatory part of the surgical area. There was a lot of interaction with patients, and I felt like the way she conducted herself was with authority but without arrogance. She was quite comfortable with the anesthetic plan and whatever had to happen in between. She had gravitas, I guess I would say, despite being fairly junior. She interacted with the multidisciplinary team that was there quite well. And if I were allowed to say it on a public forum, I might use a four-letter word and say she had her stuff together, she just had it together, and she sort of commanded the room, but not in a loud and obnoxious way.

Harlan Krumholz: It’s amazing how we get influenced by these sort of what seemed like random interactions, but they can have profound effects on the rest of our lives, rest of our career.

Lisa Leffert: Here’s the best part of the story. I was speaking in Australia right before COVID and somehow, I don’t even remember to be honest how the connection was made, but she ended up in the audience of the talk and I told the story and got to be with her afterwards. Thirty years later, I re-met her, and she was exactly what I pictured she would grow into and was just as cool as she was then as an early faculty.

Howard Forman: I want to pivot to the topic of actually the work that you do. As I mentioned before, we started the podcast today, it was almost exactly a year ago in one of our first episodes that Mary-Ann Etiebet, a physician and an MD, MBA graduate of Yale who’s now the executive director of Merck for Mothers, was our guest. And she talked passionately about the challenge of maternal mortality in the United States. The topic that keeps coming up, it’s a health equity challenge, it’s a multidimensional problem, and you’re a leader in this, but you’re coming at it from the point of view of an obstetric anesthesiologist, and you’ve been part of the policymaking apparatus, and you’re part of the research into this. Can you tell us a little bit about what drove you to this topic and what are the things that anesthesiologists are doing to have a positive impact, both in reducing mortality but also in reducing the disparities that persist?

Lisa Leffert: Yeah, no, I love that you asked that question. I’ll say personally, women’s health has always been an interest of mine, starting from very young. I was never sure how it would manifest, but that was always an interest. I technically got into obstetric anesthesia because one of the reasons why I came over to Mass General as a faculty member was they were starting in OB anesthesia units. There was an opportunity to be there at the beginning of it. I would say that as anesthesiologists, we have a tremendous ability to impact maternal care. Peridelivery and peripartum is very high-risk time for women in general. Not to say that you can’t very safely have birth and do well, but if you look at the morbidities and the mortalities, that time is quite pronounced for that.

And much like I described, Dr. Hore, in the way she was able to pull things together to have a broad perspective. She wasn’t tunneled down on just which anesthetic are we giving. That’s how I see us as obstetric anesthesiologists. We are doing many things at the same time. We are providing pain control, we’re providing anesthesia, we are watching the big picture of what’s going on. We’re running codes and hemorrhage resuscitation if we need to. We’re doing research on every aspect of all of this that you can imagine. And we’re working with our multidisciplinary colleagues to really learn whether it’s on the job in the moment, whether it’s debriefing cases that do and do not go well, whether it’s simulation, whether it’s research or whatever else, to really get at the root of what’s going on here.

I mean, unfortunately women are often not the subject of research unless it’s pregnancy-related research. And whereas it’s great to have pregnancy-related research when you don’t have women as part of research or pregnant women as part of research that informs the rest. Our knowledge base is severely restricted, and it’s remarkable that something that happens to half the population, we still have major gaps in our knowledge about things as simple as preeclampsia, not that they’re simple in their ideologies, but common as preeclampsia, preterm labor, and things like that.

Howard Forman: Can you just, for our listeners, just tell us a little about what is preeclampsia and how does it vary in different populations? What are the things that an anesthesiologist can play a role in there?

Lisa Leffert: So preeclampsia is really important for two reasons. First, let me define it. Preeclampsia is defined as hypertension or high blood pressure in the context of pregnancy, 20 weeks or beyond, and it has associations with it. It’s really a multisystem disease. And the associations that come with it are manifestations of dysfunction at the endothelial level, which means in your vessels at the smallest level. And if you think about that happening all over your body, then you begin to think of what might go wrong at each place. In the kidneys, you can have kidney dysfunction; in the heart, you can have pulmonary edema or fluid leak; in the liver, you can have some liver dysfunction; in the brain, you can have dysfunction, bad headache, seizures, and other things. And those are just things that can happen during the actual pregnancy or the recent postpartum period.

But the other thing that we know is if you have this entity, it is predictive of several things later in your life, things like high blood pressure and things like heart attack and things like death, and there are risk factors for this. And as you said, there are disparities in this in terms of people from certain racial and ethnic groups. Now, is that because they’re genetically different? Is that because of the circumstances in which they live, and if they lived in different circumstances, that would be different? We don’t know. There’s a lot that we don’t know.

Harlan Krumholz: I wanted to follow up with, first of all, that’s such an important area, and I know that it’s an area of intense interest for many people around Yale as well, and it’s great to have these teams working on this. I wanted to pivot to one last thing before we end. I read an editorial that you wrote on a paper that was examining pay disparities in anesthesia, and I thought this was such an important topic. What was interesting to me was that you were describing a series of articles, one that was in that same journal and work that had been done previously using the American Association of Medical College’s data in which you were looking at differences between men and women in anesthesiology in their pay.

There were profound differences, really large differences. But of course, some of these differences are explained by where people are working and what their experience is and total number of hours worked and the type of cases that they do and the payment models and the places they do and the type of employment. All of this stuff we know, and it’s usually thrown back at us saying, “Yeah, but there’s lots of reasons for this.” But in the course of these pieces, both the research article that was in that journal and the work that had been done previously, there was an unexplained gap. Now, you’re in a position of some power, so how are we going to fix this? How did we get here and what are we doing about it and how can we be accountable for actually fixing it?

Lisa Leffert: I’m going to start with, I like sort of the punchline first, I changed everyone’s salary. I came here, and I changed the salaries, period. Yep.

Harlan Krumholz: Wow.

Lisa Leffert: With a raise, and that’s the way to do it if you possibly can. Everyone’s held harmless in the sense that no one has a decrement, but if you were already higher, you didn’t get a raise. If you were perpetually underpaid, you got a big raise and you just have to make it right. I’m a big believer in, you can talk about things and you can sort of hand-wave and everything, but in the end of the day, you either do the right thing or you don’t do the right thing. That’s the first thing.

Harlan Krumholz: You’re completely confident now that you have no pay disparity?

Lisa Leffert: I am completely confident that I have a transparent system which is benchmarked to the double AMC, a certain percentile. It is academic rank–based, assistant to associate professor. And in my department, we happen to not have a big disparity in academic rank. Now, part of that is because so many people are assistant professors, which is not a good thing. If it is biased at all, it is biased by the fact that we have senior people who have stayed assistant professors for a long time, and this compensation plan rewards them less.

Harlan Krumholz: There are also disparities in professor level. We don’t have representative numbers of women in senior academic positions.

Lisa Leffert: We do.

Harlan Krumholz: Maybe we do.

Lisa Leffert: We do.

Harlan Krumholz: Yeah, we do.

Lisa Leffert: We happen to. I mean, if we didn’t, then my plan would not have worked as well. We happen to have the same number in both. But it’s not as large a number as we should have either men or women. Is this perfect...

Harlan Krumholz: And just to note, there was a woman head of anesthesiology before you came.

Lisa Leffert: That helps.

Harlan Krumholz: By the way, having women in leadership positions often can help address these disparities as well.

Lisa Leffert: Yes. Yes.

Harlan Krumholz: I mean, anyway.

Lisa Leffert: But to your point, in my former role, I was on track to be the only female professor in the department ever except the person who came from the outside to be chair. This is an unusual situation, but I think the important underlying point is, first and foremost, you’ve got to make a move. You got to change it. And I will absolutely say that it has been my own personal experience and the experience of the many, many people that I know, both men and women, that there is a disparity because people are paid different amounts, period.

It’s not hard to understand. It’s not just that their academic ranks are different and they’ve had a trajectory that’s not as linear and all of that. I once read something that was super interesting, which they said, even the small negotiations that people will do with their first job. So men are more likely, to their credit, to come in on their first job and ask for more. Even that small difference, when you amortize that over a career...

Harlan Krumholz: It amplifies, right?

Lisa Leffert: Exactly. So it’s not all—we all are party to this.

Harlan Krumholz: And how was it accepted by the faculty when you said, “I’m coming in and making this change”? How do people react?

Lisa Leffert: Well, first they said, “What’s the catch? There’s got to be something.” I think it was met with a lot of positive, I think it was hardest for the senior people who were of low academic rank. There’s always, true equity is very difficult, you’re always rewarding something. But from a gender standpoint...

Harlan Krumholz: Well, that’s terrific. That’s terrific.

Lisa Leffert: ... just do the job.

Harlan Krumholz: And I know Howie was working on this in radiology as well. That’s just terrific to hear that you did that, but I hope it spreads and scales, people take a look at what you’ve done and that others will follow on.

Lisa Leffert: Yeah, I mean, as I said, it is better if you can do it in a situation where you can give some raises because it is very hard to decrease people’s salary.

Howard Forman: We’re out of time today, but I want to say that we didn’t even get to cover the issues that you’ve been involved in terms of faculty leadership development, your mentorship, your involvement with students, and I can’t thank you enough for joining us today, and I look forward to talking to you more and bringing you back.

Harlan Krumholz: I think we need a whole season if we really want to cover all the things that she’s done.

Howard Forman: That’s right. Thank you.

Harlan Krumholz: Thank you so much. It’s been great to have you on.

Lisa Leffert: It’s a total pleasure, anytime.

Harlan Krumholz: That was a great interview, Howie. I really enjoyed having her on the show. Let’s pivot to your section here, and what’s been on your mind this week?

Howard Forman: Yeah. So this is just something that comes at every year, but it’s worth highlighting, and that’s this annual survey of health benefits that looks at what are the average health benefits that employers of all sizes offer their employees and what does it cost? I don’t think that the average employee out there actually realizes the magnitude of these costs. I just want to quickly highlight them for our listeners. Average family coverage now is $22,463, and the employee contribution to that is over $6,000. That works out that $12.50 an hour for a full-time job—just paying for health insurance, right? For the majority of people in this country, this represents a substantial part.

Harlan Krumholz: Say that one more time, Howie, the out-of-pocket costs are?

Howard Forman: Well, no, that’s the out-of-pocket cost would work out to be $3.40 an hour. But the total cost of coverage for a family policy, it is typically we say family of four, but it’s typically any family size three or bigger is $20,463, which is $12.50 an hour. However much that’s contributed by the individual or the employer, $12.50 an hour just to buy the insurance, doesn’t pay for the deductible, doesn’t pay for the copays, doesn’t pay for other types of out-of-pocket expenses. Just for the insurance. It’s a lot of money. We don’t often think about it, but it’s a big part of the cost of compensation, and remember, a lot of people don’t even get health insurance. For individual coverage without a family is $7,700 and we now have 29% of the population signing up for high-deductible health plans.

Some of them are forced to sign up for them, some of them choose to sign up for them. High-deductible health plans have essentially plateaued about 29% of the population, approaching one in three. And just remember, the minimum deductible for a family of four policy in one of these plans is $2,800. And so I think the reason why we’re not seeing more uptake is that people realize that it might as well not be insurance if they’re going to have a $2,800 deductible. Less than half of all small firms, that’s firms less than 50 workers, provide health insurance. That’s down from 62% when Obamacare passed, and large employers in general still do offer health insurance to about 98% of their workers. But low-wage workers, as you might imagine, are least likely to get health insurance from their employers. I’ll give you one bit of good news out of this and then balance that out.

But one bit of good news is the slowest rate of increase this year, about 1% of any year in the last few decades. But the evidence already suggests that this was just a one-off, probably due to the pandemic and that rates are going to be substantially higher going forward. I brought this up because you’ve talked about financial toxicity, both in terms of the clinical studies you’ve done but also in a larger sense about our healthcare system. And you just talked about a national health service in England where financial toxicity is mitigated. Here, this is not even once you access the system, this is what it costs to buy health insurance, and it’s very expensive.

Harlan Krumholz: Just amazing. And the reason I was also just focusing on the out-of-pocket was the workplace costs are draining society in ways that are often not as visible. The out-of-pocket costs even at that level can have a devastating effect. And you may know that on some of the papers that we’ve written about financial toxicity, we’ve shown that the people who are hit the hardest actually are insured, actually are insured. And the reason is because if you look at the amount of money they’re spending on healthcare, and that’s the combination of their premium and their out-of-pockets so that they’re responsible for, so what they contribute plus that it just is taking up an untenable amount of their total income and then so placing their families at tremendous risk.

So people have this idea that just have to get people insured, but we so under-insure people in this country, and then we still charge them these kind of fees that they’re responsible for. It ends up being devastating for so many. Anyway, thank you so much for covering that. I think it’s a really, really important topic. 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 keep the conversation going, you can find us on Twitter—at least for now!

Harlan Krumholz: But nevertheless—for now—I’m @hmkyale, that’s hmkyale.

Howard Forman: And I’m @thehowie. That’s @T-H-E-H-O-W-I-E. You can also email us at health.veritas@yale.edu. Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the health care track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs, or you can check us out at our website at som.yale.edu/emba.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Jenny Tan, and our producer, Miranda Shafer. As always, they are terrific. Talk to you soon, Howie.

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