Dr. Nancy Brown: The Power of Mentorship

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 the Dean of the Yale School of Medicine, Dr. Nancy Brown. But first, what’s got your recent attention, Harlan?

Harlan Krumholz: Well, it’s Thanksgiving week. I think at the time when we get to the end, we can reflect on some of the things that we should be grateful for. What I thought I wanted to talk about today was one of the largest recalls in medical history. There was a really terrific opinion piece that came out in JAMA Internal Medicine led by Kushal Kadakia with Joe Ross and Vinay Rathi, who were shining a light on this issue that’s going on with Philips, and I think it’s under the radar nationally. But Philips Respironics had initiated really the largest medical device recall in history that’s affecting 10 million devices in the United States and 15 million devices worldwide. They recalled 14 models of ventilators and positive airway pressure machines.

These are largely used for sleep apnea but also for other things. They’re vitally important for patients. And they were recalling them because these were built with...there was a foam piece that was put into them. And then there was all of a sudden the appreciation that this foam could degrade and that because these are respirators, with the foam in there breaking down, people could be inhaling them and causing all sorts of problems. And it got to the point where these needed to be recalled. And it’s a Class I FDA recall, which is their highest level where it can be. It’s the most important recall.

And it involved three ventilators, six BiPAP machines, these are the bilevel positive airway pressure machines. And CPAP, continuous positive airway pressure. People may be familiar with this. But this foam degradation harming patients with toxic particles and emissions is a huge deal. And then as you go back into the history, you see that these things came on the market with very light evaluation within the FDA. They were predicated on prior devices, but it’s not clear when the foam was starting to be used in these devices and whether or not it was adequately tested.

And then there’s a whole nother feature to this that they write about that’s so interesting, is that Philips has trouble figuring out who’s actually got these devices. Many people with these devices may not even be aware of this recall and the danger and harm associated with it. And even though they should know and be able to contact people who have these medical devices, it’s another problem that has arisen. There’s this issue of how these are approved, there’s an issue of how fast can the problem be identified, there’s the issue of how well can people be notified. And then there’s a whole nother issue too, which is when can substitute devices be made available because these people have these devices to treat medical conditions and if these aren’t going to work for them, then what can we do for them to be replaced?

Anyway, I thought that this was just worth highlighting because I believe that this recall, which has got so many different facets to it, is going to be a stimulus to change. I think that people will start looking at this, there’s going to be a ton of legal cases, there’s going to be a lot of attention on this, but to this moment, I believe it hasn’t really risen to the level it should. And in part, that harms the people who may be using the device, don’t even know there’s a problem. But the largest medical device recall in history is I think going to be, I hope, a turning point for us to really address each of these concerns so that in the future we’re in a better position. So, Howie, we’ve got a great guest today, Dean Nancy Brown. Let’s get to it.

Howard Forman: Dr. Nancy Brown is the Jean and David W. Wallace Dean of Medicine and C.N.H. Long Professor of Internal Medicine at Yale School of Medicine. She is the first woman to lead the Medical School in its 212-year history. Prior to her appointment in 2020, Dean Brown was the Hugh J. Morgan Chair of Medicine and Physician-in-Chief of Vanderbilt University Hospital. At Vanderbilt, she established the Elliot Newman Society, which supports physician scientists, and co-founded the Vanderbilt Master of Science in Clinical Investigation Program.

Dean Brown’s research investigates how blood pressure and diabetes drugs affect the risk of cardiovascular and kidney disease. She was the president of the Association of Professors of Medicine and has been elected to the American Society for Clinical Investigation, the Association of American Physicians, and the National Academy of Medicine. She’s also a member of the American Association of Arts and Sciences. She received her bachelor’s degree from Yale College and her medical degree from Harvard. She completed her internal medicine residency and a fellowship in clinical pharmacology at Vanderbilt University.

First, welcome to the Health & Veritas podcast, Dean Brown. You arrived at Yale for the COVID pandemic, literally almost exactly synchronous with that, but also in time for your 40th reunion from Yale College the next year. But in between, you’ve had an amazing journey as a scholar, a leader, a mentor. I’d love to go back to 1979 or 1980 and ask what Nancy Brown, Yale College student, was contemplating for her career. What did she think she would be doing in 2022?

Nancy Brown: First of all, thank you, Howie and Harlan, for the invitation to be here. But I will answer and be completely honest. Nancy Brown, in 19… even ’81 when I graduated, had no idea. I thought perhaps I might go into medicine, but I actually took a year off and worked in the energy business, actually, in Boston. But I was influenced by a mentor, a man named Ethan Nadel who was here at the Pierce Foundation and with whom I had done work, who said, “You really should not close the door on medicine and should leave that open.” After about six months of working, I realized that I did want to go into medicine and started to proceed to apply to medical schools.

Harlan Krumholz: One of the things that I wanted to talk to you about—so appreciate that you joined us here today—as a leader in medicine, I’ll just say, first of all, as a leader and then I know as the first woman who’s led Yale ever in the entire history of the Yale Medical School, I know that you must have a keen commitment to the idea that we need to be able to find pathways to fill our leadership in every different level of professorship with women. More than half our classes in medical school are now women. And yet we still lag in being able to create the kind of opportunities and pathways.

And there’s a whole bunch of reasons, some structural, cultural, that continue to provide headwinds for women to be able to be successful within academia. And I just wondered how you think about this. What should we be doing differently, and how can we create an environment for everyone? Everyone can achieve the best aspirations for their careers, but in particular, look at those groups that have encountered more headwinds, honestly, and for which I still don’t think that we’re doing enough to be able to create an environment that helps to support their success.

Nancy Brown: Our success is enhanced by having a rich group of people, a diverse group of people who are more innovative and creative coming from different perspectives. And I think the fundamental way to achieve that is by providing mentorship and sponsorship of talented individuals and what I would call proactive retention. Traditionally, in academic medicine, we’ve been a little bit passive about developing people. We attract great talent, we throw them in and say, “Hope you swim and don’t sink!” We lose talent that way. What we need to do is first of all, cast a wide net, identify, as I say, diverse talent, recruit them, but then nurture our talent so that they succeed. And so we’ve put in place structures to do that, to have regular mentorship meetings. I think each of you has done this very well in your own careers, but it’s not so widely done.

And the other things that we need to do are create a sense of community. I think we have some affinity groups at Yale that are incredible at doing that. I would point out MORE, which is our faculty group of underrepresented faculty. If you are a faculty member thinking about challenges, there are some that are unique to your identity. If a group of women are talking about how you network, the topic of how do I travel when I have young children? Might come up. If you’re in MORE and you’re thinking about how do you balance all of the hundreds of invitations you’ve had to serve on committees, the perspective may be about how you say no from someone who has experience doing those things. That’s also an important element.

And then leadership development, which has to be developmentally appropriate. But for example, I participated in an organization called ELAM, or Executive Leadership and Academic Medicine, a wonderful program to promote development of women and to help us think about even the possibility that we might serve in leadership, which may not occur to us.

Howard Forman: I want to follow up on the point about leadership because you have this—and you may not even remember because I think it’s two years ago now—but you have this wonderfully intimate interview on the “It’s Your Yale” website, and it really demonstrates humility that I think leaders don’t often demonstrate. And one of the questions they asked you was, “If you could solve one human problem in today’s world, what would it be?” And you said, “Communication, listening.” It may not be the answer you had in mind, this is your words, but a lack of listening and dialogue underlies many other problems. A lot of the reason why Harlan and I started doing this podcast is because we agree that communications is something that we need more of in healthcare and leadership. We need to all be doing better at listening. And I’m just curious, what advice can you give young professionals, whether they’re in healthcare or not, about how to develop better listening skills and how also to develop better communication skills?

Nancy Brown: Developing better communication and listening is a lifelong aspiration. I don’t think anyone does it perfectly. It’s so important to every aspect of our lives, whether it’s our own personal relationships or how we function in community. Closely aligned with that is the concept of curiosity. I think if you are genuinely curious about other people, you will ask them questions, you will start to learn things about them that may surprise you. And we all have biases, whether we like to admit that or not. Asking those questions and showing curiosity will, I think, soon melt those biases and allow you to see somebody as an individual human being.

The same is true when groups are negotiating. Everything we do in life is a negotiation that we are... we may have a concept about how we solve the social problems that face us today, and someone else has a different concept. Listening to what that person’s concept is and starting to frame why we have whatever beliefs we have and do that back and forth, I think, is critical. And we’ve lost some of that.

Howard Forman: And on the communication piece, what is the role of physicians and scientists to become better communicators? Because some of us are better than others, some are very deep in the science but don’t spend as much time on the communication piece.

Nancy Brown: I think all physicians and scientists should be bilingual. And our translators…recently have heard Alan Alda talk on this subject. And of course he’s dedicated his later years to promoting communication about science and to training scientists and physicians on how to communicate. And it really is being bilingual, having a vocabulary and remembering what it was like before we had training as physicians and scientists. I have no other family members who are in medicine, and I’m constantly reminded by my family members about speaking in English. These are bright people, and I have to translate.

Harlan Krumholz: I wanted to go back a little bit into your career a bit, and I think when people look at you now, it’s intimidating. You’ve been so successful, you’re doing so many different things. You’re leading a great institution and doing it well. I wonder if you can give... we have a lot of, I think, students and more junior people who listen to this. And can you give some sense of what might have been a turning point for you? Was there a point in your career where you weren’t sure that this was going to work out or that you were reaching a point where it was a pivot, and I don’t know, and how did you navigate it? I sometimes think that it’s helpful for folks to hear that the path isn’t always so clear and it’s not often easy and that there are moments of doubt that sometimes get in. I don’t know. Did you have any of those? Were there points where you wondered about that?

Nancy Brown: Certainly, and I will comment that Vivek Murthy was here [at Yale] recently and did a wonderful interview and he spoke eloquently to this topic that the pathway is not always linear and we all have moments of doubt. I would say for me, the critical juncture was the transition from having career development awards to having an independent grant, the so-called RO1 [NIH Research Project Grant] and being on a bit of a time clock because I had to get that grant to remain on the faculty. And that’s a bit of pressure. I remember at the time, my husband, who was a businessperson, saying, “Okay, let me get this straight. If you don’t get a grant, you’ll become a full-time clinician and make more money. And that’s called failure?” But it was extremely stressful.

I had several grants in place. I had one that was scored and was easily rewritten, I thought. And then I had another one which was a complete flyer, really taking a risk. I got the score on the resubmission back first and it hadn’t budged, so it wasn’t going to get funded. Got it back on Christmas Eve, I think, or the day before Christmas. Was home for the holiday and I received a phone call from…our associate vice chancellor for research, who had heard that my grant hadn’t been funded and who called me up to say, “You need to pick yourself up and get back at it.” Which was a remarkable phone call that she took that time. The other grant, what was the “flyer,” got funded, and then things took off.

But I think the function, the way we pass it on is to play that role for other people because we all stumble. It’s hard. And if it weren’t hard, it might not be worth doing. We need to make it easier for others.

Howard Forman: You pursued a fellowship in pharmacology, which... I’m a radiologist, so I wouldn’t necessarily say I know what the exact breakdown is, but the vast majority of people doing a fellowship after internal medicine choose a clinical field. And so pharmacology is less common. What motivated you to do that? And it’s clear, you’re still to this day, this year, publishing senior-authored papers that follow your career consistently. What motivated you to do that, and what lessons did you learn from that choice?

Nancy Brown: My chair at the time suggested that I do it. [Laughs] No. And so John Oates, who was another... the theme here is mentorship and sponsorship. And so a man named John Oates who had been chair when I was joining the faculty, had founded the Division of Clinical Pharmacology and was counseling me about career directions and said, “Why don’t you take a look at this?” It’s a bit of a unique division and a unique area, but basically I’m an internist and we use a lot of drugs in internal medicine. I happen to study antidiabetic and antihypertensive drugs and how they prevent heart disease. But what clinical pharmacology actually was, was a division of translational medicine. It was shared by the Department of Medicine and the Department of Pharmacology, so a clinical department and a basic science department. And so before we talked about clinical and translational research the way we do today, it was happening there. And so I learned how to do hypothesis testing in humans safely and rigorously. But what I practiced was actually hypertension. I saw patients who had resistant hypertension.

Harlan Krumholz: It’s really actually quite interesting to think about that. That was translation medicine before actually translation medicine was a thing, is a pioneering, actually, approach. We want to thank you so much for being on with us. I want to ask you a closing question. When you come on to be a dean at a place like this, do you have an idea of what you want the legacy to be of the deanship? We don’t know how long it’ll be. Maybe it’ll be 20 years, maybe you’ll do 30 years, maybe you’ll do 40 years, but however many years you do, do you have an idea of how you want this place to be different? It’s been in place so long, you’re coming in, of course all deans are stewards in some way, but you get a chance to shape this big ocean liner and to move it in new directions. Are there things that you think about that... every day you’re involved in the details, I know, but on a broader scheme, the arc of the impact that you’ll have at the school, have you thought of what that will be?

Nancy Brown: Very much so. When you take on a new job, you have to understand the organization you’re joining. And a large part of the early days is getting to know the organization and the people in it. And Yale is unique and wonderful in many different ways. One is the excellence of our people and the excellence of our science, particularly our basic science traditionally. I learned as I got here that our translational clinical research was equally phenomenal.

Harlan Krumholz: Thank you.

Nancy Brown: You’re welcome, Harlan. But a second important element of what makes this place great is that we’re part of a larger university. And that ability to... and actually COVID brought that out, our ability to collaborate across campus in new ways. As I think about where we are going, at some level we think about investments in specific areas of science. We are investing, as you know, based on the university strategic plan in neuroscience, inflammation, data science, a very important investment, as well as some cross-cutting themes.

But I think more importantly, we are investing in infrastructure and people in ways that I hope will have a lasting impact on the institution. People development is a major cross-cutting theme that includes putting in place infrastructure for physician scientists. It includes making sure that every faculty member gets adequate mentorship with our faculty development annual questionnaire. It includes investments in all of the things we talked about earlier in terms of diversity and creating community. Recent work we’ve been doing on improving the quality of life for our research track faculty, staff, on and on, students. Related to that is some pretty mundane stuff like putting systems and analytics in place so that we can track what we’re doing. When you have a bunch of really talented people but you don’t have systems in place, we can spend a lot of time spinning our wheels. Imagine if we don’t do that and we’re really just moving forward toward one goal. That’s also a cross-cutting goal.

I’d say another one is breaking down silos. Academia, we’re set up with departments, but again, the most... the space of innovation is when two people come together from different fields to solve a problem and they’re looking at it with a different lens and there’s an aha moment. And so creating the opportunity for those kinds of things. We made a Office of Team Science to help promote opportunities to bring together groups that have never worked together. We’re trying to do more strategic planning and do it differently than we’ve done it before to get us in that space. Those are some of the examples. And it may be hard in 20 or 30 years to say, “This was the thing,” but I hope there will be two or three things that make this place even better than we are today.

Harlan Krumholz: No, I really love that, especially the Team Science. If we can give people credit for working together in very constructive ways and get away from the idea that there has to be singular superstars but actually they’re superstar teams and that we can figure out ways within academia to get credit and understanding people’s contributions. I think all those... I think that’s terrific, really terrific. The investment in people is so obvious and appreciated. It really is appreciated. I think it’s helping to build for the future.

Howard Forman: And there are few places that are a better environment for trying to do that than Yale, where we have a single campus for so much. It’s great to have you back and to have you come full circle. And we really appreciate you on the cusp of Thanksgiving. I say thanks for joining us.

Harlan Krumholz: And nothing better than someone who was an undergrad here, Howie, to really understand how to bring all this together.

Howard Forman: Yep, exactly.

Harlan Krumholz: Thank you so much.

Howard Forman: Thank you very much.

Harlan Krumholz: And happy Thanksgiving.

Nancy Brown: Thank you, guys.

Harlan Krumholz: Howie, that was a terrific interview. Let’s pivot to the next part. What’s on your mind this week?

Howard Forman: This is a topic that we haven’t talked about on the podcast, and that’s antimicrobial resistance. So this is something that occurs when an infectious agent develops the ability to evade treatment by a previously effective antimicrobial. We mostly talk about things like antibiotics for bacteria, and that’s mostly what I’m talking about today. More than 5 million people die annually from antimicrobial resistance, and this number is expected to double over the next three decades. And this is larger than the documented annual death toll from COVID, to put that in perspective. This is a big problem. The World Health Organization declared antimicrobial resistance as one of the top 10 global health threats facing humanity, which is also to say this is a global problem. So misuse and overuse of antimicrobial is the main driver of antimicrobial resistance. And there are many strategies to deal with it and prevent it from getting worse. But among them are getting patients and their prescribers to recognize the importance of not overusing antibiotics. And in fact, when I teach about the pharmaceutical industry—

Harlan Krumholz: And Howie, when you say “antimicrobials and antibiotics,” are you using that word interchangeably or you’re thinking about them—

Howard Forman: For today, I am, but antimicrobials obviously include antivirals and others. But for today, I’m sort of mostly talking about antibiotics and about bacterial infections. In my own class I emphasize the fact that I could imagine a lot of drugs becoming over-the-counter as opposed to prescription. But controlled substances and antibiotics are the two that I draw a line at because we need to have a gatekeeper. We need to make sure that doctors do not over-prescribe and that patients do not prescribe for themselves.

Pharmaceutical companies can also do more, and they could innovate, and that’s something that we really count on them to do. But the incentives for drug companies to develop novel antibiotics to help reduce the risks of resistance are actually pretty low. If they do their job well, the population that ends up being treated is really small and the ability to make a profit similarly small. And so there’s a lot of cases of companies that did seemingly the right thing. They developed a new antibiotic and then they go out of business because they can’t survive despite the fact that the drug itself gets approved. Companies have generally avoided the space because it’s not lucrative. In this situation, in similar situations, there is a good argument to be made for government investment. And so enter the PASTEUR Act, which stands for, as a snappy title, “Pioneering Antimicrobial Subscriptions to End Up surging Resistance.” So this is bipartisan, both parties. It is—

Harlan Krumholz: Oh my God, how do they get that in PASTEUR? That was incredible.

Howard Forman: I know. The attempt to market is not embedded in our Congress. It is bipartisan, both parties. It is bicameral, both houses of Congress have supporters to this legislation. And it’s been introduced to create a Netflix-like model where the federal government pays a prescription or to pay to guarantee a certain revenue stream to the drug companies in exchange for them meeting fairly stringent requirements for novel drug development. In other words, the government pays different companies to bring novel antimicrobials and antibiotics to market and make sure these are at least marginally profitable, even if they’re not going to turn out to be blockbusters.

But there are many colleagues who you and I both know well who’ve taken different sides on this issue. And the issues to me seem addressable, though the positions taken seem very resolute. There are literally petitions out there. Ultimately, it does appear we need federal and probably global funding to develop these drugs that could save many lives and afford better global health. And a subscription model seems like a novel, testable approach. And I’m hoping that we’re going to see both sides bridge the gap to achieve this noble goal.

Harlan Krumholz: I see two things here. One is, can we adopt more responsible approaches? It’s hard. Patients come into the office and they expect to get antibiotics. They’re in pain, and they want to get something. It’s hard to talk people through the idea that the antibiotics may not help them, actually may in the end hurt them and that they shouldn’t be using them because people are just trained to think about that. And then the reality that we’re starting to see the emergence of these resistant organisms and actually the need for new antibiotics. On one hand, trying to think about how we slow the use of antibiotics. On the other hand, we still are going to need the next generation that’s going to help us put ourselves in a position where when our own defense systems need assistance, we can give them that assistance by providing the medications that are necessary. I think that’s a really, really good point, and I appreciate you bringing that up. I wasn’t actually aware of that at all.

Howard Forman: Yeah, it’s fascinating. And I’ll leave it to our listeners to see who’s taking which side. We’ll make sure we post a couple of the appropriate references about it. But these are smart people. This is not one of these issues where you could say there’s smart people on one side and crazy people on the other; smart people on both sides. And I’m hoping they bridge the divide.

Harlan Krumholz: Howie, just thought we take a minute here at the end. It’s Thanksgiving week, we’re coming actually taping this a day early so we can come out on Wednesday and let everyone enjoy their Thanksgiving. Maybe even a couple people take a listen. And I thought we would just take a minute to express some gratitude. That seems to be always a good thing. In fact, there’s some... some people have produced studies that say that taking a little bit of time for gratitude can actually improve your health. You want to go first, just express a little gratitude? I’ll follow you and then we’ll get to the outro.

Howard Forman: Yeah, I really appreciate that, Harlan. I am deeply appreciative of the privileges and opportunities that I’ve had in my life. And all of them have been created for me by the family around me and both the students and the supporters, mentors, advisors, sponsors around me that have allowed me to get to this point in life. And I realize how unique it is to be of an age where I have nearly adult children who are thankfully healthy and two parents who are thankfully healthy and have brought a lot of joy into my life. And I’ll get to see everybody including my siblings over this holiday. And so I’m truly, sincerely thankful for that. And I am also thankful for our team here, including Jenny, Miranda, and you, for allowing me to be a part of this experiment that we’ve been party to.

Harlan Krumholz: My God, Howie, that was such a broad based sense of gratitude. I don’t know how I can catch up to that. I’ll just start by expressing gratitude to you for our weekly shows and our long term friendship and for the love, to Miranda and Jenny for their contributions to the program. And like you, I have a lot that I’m grateful for. My family also and friends and for relationships and for the teams around me and all the students who I get a chance to work with and many more. I think it is a moment for us to take and thank the teams and people and everything that makes our lives worthwhile. And I’m sure that that kind of moment that we can pause and reflect on actually entirely helps us, gives us a little bit of humility around how fortunate we are.

Anyway, hope to everyone else, that you get a chance to take a moment and reflect on what you have gratitude about. And we appreciate you being listeners of Health & Veritas. And in fact, you’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: How did we do? To give us your feedback or to keep the conversation going, you can find us on Twitter.

Harlan Krumholz: And by the way, Howie, we should have said, we’re grateful for our audience, for people who—

Howard Forman: That’s for sure.

Harlan Krumholz: …listen to us, give us comments, who—

Howard Forman: We wouldn’t do this if not for the audience. And I will say that to those people who’ve reached out over the last year to you and to me, we really appreciate that. It has given me a boost every time that we get a nice note from somebody that I couldn’t even imagine knew about our podcast sending us thanks and telling us that they listened to it.

Harlan Krumholz: And as you said: for now, we’re still on Twitter. I’m @hmkyale every week. Now we’re going to have a Twitter watch to see how that’s going. But 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 healthcare 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 where you can check out our website at som.yale.edu/emba.

Harlan Krumholz: And by the way, we’re also grateful for our guests. I should have added that too. Health & Veritas is produced with the Yale School of Management. Thanks to our amazing researchers, for whom we’ve got great gratitude, Jenny Tan, and to our producer, Miranda Shafer. Talk to you soon, Howie. Happy Thanksgiving.

Howard Forman: Thanks, Harlan. Happy Thanksgiving to you and everybody out there. Talk to you all soon.