Eric Winer: A Cancer Doctor's Journey

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. We’re excited today to welcome Dr. Eric Winer. But first we always want to check in on hot topics in health and healthcare. And Harlan, I showed you something that I couldn’t understand. I asked you if you’d be willing to talk about it, and I think you’re willing. So go ahead.

Harlan Krumholz: Yeah. No, I’m glad to. Of course it has context because I’m about to become a journal editor, and so you showed me a paper, and let me just talk about that paper first. It’s an interesting paper. It’s a paper about the association between hearing aid use and dementia. There’s been a lot of talk about what people can do to prevent dementia. Dementia affects so many people and so tragically. And the idea is that as people begin to lose their hearing, they get isolated and maybe the lack of stimulation accelerates cognitive decline and can be a contributor to dementia.

So a bunch of folks got together and took advantage of the UK Biobank. I’ve talked on the show before about my interest, how much I really believe that the UK Biobank, which is a big study in the UK of over 500,000 people who have volunteered to give a lot of information about themselves, to undergo a lot of exams, and ultimately to create a database that anyone in the world can use to generate new knowledge and lots of people were taking advantage of it. It’s a beautiful open science approach. And so these investigators were able to take advantage of the UK Biobank data, and they were addressing this question because there’d been a lot of data collected within the UK Biobank, both about dementia and about hearing aids and so forth. They could use this. What it found was what we might have expected, was that in people with hearing loss, that if they were using aids, they could reduce the risk of dementia, that up to 8% of dementia cases could be prevented with proper hearing loss management. Well, this sounded like great news.

Howard Forman: It’s huge.

Harlan Krumholz: Plus in our country, we’ve just got new policies about giving people access to hearing aids. And all this is great. People celebrating this finding. Lo and behold that this thing came out in May to some fanfare.

Howard Forman: Seven months before we’re taping now, in one of the best journals in the world.

Harlan Krumholz: Well, and not Lancet writ large, but Lancet has a bunch of journals.

Howard Forman: Public Health.

Harlan Krumholz: So then on November 27th, Lancet was informed by the authors that this paper, there was an error that was introduced in the output settings of their programming, leading to errors in the analysis which render their findings and conclusions false and misleading. Now, the author stepped forward and they happened to have discovered this, but it raises so many different questions, which is in this era of a lot of existing data, this group didn’t generate the data, they simply wrote the code to analyze the data and someone in their group, who was responsible for writing the code to whatever their processes were, wrote code. Somehow that was an error.

Howard Forman: And the only way it was discovered, Harlan, I think, is because somebody else came to them or we’re trying to replicate their findings probably with the same data and couldn’t do it.

Harlan Krumholz: Right. So the good news is that this data is available for anyone to use. And so anyone could try to replicate anyone’s work that did this. Often people aren’t sharing their code. Increasingly, some groups are. We’ve shared our code in many studies, but how do you protect against this? So I’m going to become a journal editor. I mean, someone submits a paper. Should we be demanding that every paper that’s submitted like this has two independent people doing the analysis and then making sure that that analysis agrees? Well, that’s resource-intensive.

The authors need to stand behind it. But if someone hadn’t come to them or if they hadn’t come to the conclusion that this is flawed, I mean it would sit in the literature and no one would even know. And if this data were not publicly available, then no one would ever have been able to check it.

Howard Forman: And this is an example where it’s confirming our bias. We expected this result. And so when it found this result, people probably less skeptical than if it had found the opposite result.

Harlan Krumholz: It’s a question of how do we proceed? So much of science can’t be replicated. Honestly, there’ve been a lot of studies that have come out that said there are findings, and then other investors can’t replicate them. But some studies are hard to replicate if the data aren’t in the public domain, if it’s not an open science mentality, if it’s a big experiment like a clinical trial and those data aren’t made available, then it can be hard to know whether or not what they did was right or not, whether the code was written correctly.

Again, what gives me chills is to know there must be many papers out there where there have been some errors but haven’t yet been discovered or retracted. Kudos to the authors for coming forth with this once they learned of it. I think the right thing was… in retraction, for people who don’t know, in the medical thing, it’s basically withdrawing the paper from the medical literature. It’s announcing that this paper should not be relied on or used. In many cases, by the way, Howie, we had this whole thing where there can sometimes be fraud that’s associated with retraction. This is a different flavor of retraction. This is where there was, I’ll call it an honest error it seems, and now they’re pulling it back. But anyway, I think it should be another thing within science, which is as we continue to think, I want to continue to push open science. That was one way this was discovered, so that’s good. But we’re going to have to continue to think about how we defend the scientific literature against errors and make sure that we can do that.

Howard Forman: And by the way, I’m just looking at this while we’re talking. This has already been cited 24 times in published works.

Harlan Krumholz: So people are using it to whatever else they’re doing afterwards.

Howard Forman: Right. So anyway, I’m fascinated by it and I really do look forward to learning more about the editorial process from the work that you’ll do for JACC.

Harlan Krumholz: Yeah. Thanks for bringing this up, Howie. So let’s get to our interview. Eric Winer’s an amazing person. I’m so happy we’re having him on today. Eric, what year did you graduate? Didn’t you graduate in ’79 or...

Eric Winer: ’78.

Harlan Krumholz: Oh yeah. I was ’80. That’s why I said—

Eric Winer: Yeah. I was ’78, and then I started in graduate school in Russian studies and dropped that and took pre-med courses. So I started—

Harlan Krumholz: I wanted to talk about Wolfgang Leonhard.

Eric Winer: I took the course.

Howard Forman: By the way, let me introduce—

Harlan Krumholz: How often do I get to talk to someone who majors in Russian history? Not very often. Not very often.

Howard Forman: Okay. Here we go. Dr. Eric Winer is the director of the Yale Cancer Center, the president and physician in chief at Smilow Cancer Hospital and the Alfred Gilman Professor of Pharmacology and professor of medical oncology as well as the Yale School of Medicine’s deputy dean for cancer research. An internationally renowned expert on breast cancer, Dr. Winer has published over 350 original manuscripts centering on both basic and translational research with the aim of developing new therapies for breast cancer treatment.

Before returning to his alma mater, Yale, in 2022, Dr. Winer held senior positions at the Dana-Farber Cancer Institute, Brigham and Women’s Hospital, and Harvard Medical School. In addition to serving as chair of the board for the American Society of Clinical Oncology, he has held numerous national leadership and advisory roles and has been lauded many times over for his work as a mentor and team builder.

He holds both his undergraduate and medical degree from Yale University, and he completed his training in internal medicine and services chief resident at Yale New Haven Hospital before proceeding to a fellowship in hematology and oncology at Duke University School of Medicine. So first, I want to just welcome you to the podcast and say... as we were saying before we began taping, our amazing research assistants or students prepare these great dossiers.

Rare is one as filled as yours is. And the backstory of your career is fascinating. And while I want to get to talk about breast cancer and how we treat it, I would love to hear about your journey from being a Russian literature major at Yale to being a professor at Yale in oncology and deputy dean.

Eric Winer: Well, I’m not sure I ever thought as an undergraduate, as a medical student that I would ever be back here. And certainly it was not my life’s goal to be a cancer center director. Fundamentally, I’m somebody who is a real doctor at heart. I like taking care of patients. I still take care of patients. And perhaps the most meaningful work I’ve done in my entire career is the work I’ve done in examining rooms with individual patients. I’m a breast cancer doctor, and that’s all I’ve been for the last 30 or so years.

That said, I knew a long time ago that simply taking care of patients and not asking questions about how to make that care better wasn’t going to be enough for me. And so early on in my first faculty job at Duke, I recognized that I needed to do research as well.

In truth, at Duke I thought that I was incredibly useful to everybody there and that I was a respected doctor and a beloved member of the community. But I thought I was pretty useless anyplace else. And then I started getting offered jobs and wound up spending most of my career at Dana-Farber Cancer Institute, where I built a large breast cancer program. I was able to do so because I had so many great people around me. I was given a lot of resources. And the most important of those resources, of course, are the people who I got to work with.

After a certain point in time, essentially a quarter of a century, I thought it was time to move on. And this position at Yale came up and I was recruited to it. It was clear to me after my first conversation with the dean that if they offered the job to me, I was going to take it. So here I am now two years into my tenure as the cancer center director and leader of the cancer hospital. I think there’s just tremendous potential here, and I look forward to it.

Harlan Krumholz: There’s so many questions to ask you, and your personal journey is one that I think Howie is going to come back to because I think it is poignant and important in understanding sort of your drive to make a difference in medicine. But I want to talk about Tsarevich Alexei Nikolaevich. And I think that for people listening, this was the last heir apparent to the throne of the Russian Empire. And Alexei was born in 1904, the youngest child and the only son of Emperor Nicholas II and Empress Alexandra Feodorovna. The point was that this child was born with hemophilia. His great-grandmother was Queen Victoria.

So these were all intermingled families. You know this story, so maybe you can tell us a little bit about why it’s interesting and the role of Rasputin and how it brought down the whole royal family? Because actually the reliance on the healing and so forth, the Romanov Dynasty fell because of hemophilia, in a way. Right?

Eric Winer: Well, that was certainly the contention of a book called Nicholas and Alexandra written by a man named Robert Massie back in the early ’70s. Robert Massie was a historian, I believe at Princeton. And interestingly, his oldest son had hemophilia, which was what made him interested in writing about this. But it was a really interesting time in Russian history. And when I read Nicholas and Alexandra in high school, I immediately became fascinated by it. And the truth is that that is the period of Russian history that I studied.

Now, of course, the backstory is that I too have hemophilia. And so my interests all end up being self-oriented since I got interested in Russian history because of hemophilia, and I became a doctor because of having hemophilia and having spent a large part of my childhood at Boston Children’s Hospital, mostly as an outpatient but not infrequently as an inpatient as well.

Howard Forman: Much as for breast cancer patients, the progress that has been made for hemophilia and for you personally over the course of your life is almost miraculous. Life has changed for people born with hemophilia today versus when you were born. Do you want to speak to how that informs your own passion for research and advancement?

Eric Winer: Well, so as you know, I’m a complicated individual. Hemophilia actually evolved tremendously—hemophilia treatment—by the time I was in high school, and suddenly the refractory concentrates, and I went from being a really pretty sick kid to a relatively normal high school student. I couldn’t play a lot of sports. But other than that, I was like most kids. And I was able to go to college.

I actually thought that was probably the end of the story and that I would live my life taking Factor VIII concentrates or whatever better came around. And in fact, I remember very well my first year in medical school, I was driving from Boston to New Haven with two friends in the car and one of the friends leaned over the front seat and said, “Well, so your hemophilia is really sort of a non-issue. You’re fine now.” I said at that moment, I said, “Yeah, that’s true, except you never know quite what it does to you to inject the blood of thousands of people into your vein every other day.”

And of course the rest of the story is predictable. But by probably 1979, I was almost certainly infected with HIV. I don’t know for sure it was 1979 other than the fact that I had an illness then that I think was my primary illness. As someone who used Factor VIII constantly, I think that it’s pretty likely that I was among the first people to be infected. I didn’t officially learn for a few years after that, but I spent much of the 1980s and 1990s dealing not with hemophilia but dealing with the fact that I had and still have HIV. At a time, it was pretty challenging. I think many people remember that time, but—

Howard Forman: Very well. And just to be clear, it was a lethal disease at that time. I mean, I was a medical student also, and for us to visit patients on the floor, it was just a lethal disease, which makes everything that you’re talking about that much more miraculous.

Eric Winer: Well, it was a lethal disease. I mean, so at first people didn’t think it was a lethal disease and then they suddenly did and it really was a pretty bad disease. It was a bad disease with a pretty horrible way of dying as well. But then the thing that was maybe even more lethal about HIV was the way it was viewed by our society.

So I got married during my residency. We found out officially that I had HIV about a year after that. We went on and had three children. There was a little controversy by the time we got to the third, when all of our friends thought we were out of our mind. What was hard was that I couldn’t talk about this with anybody other than my closest friends. I was used to talking about hemophilia, like I had brown eyes or blue eyes, and suddenly there was this topic that I couldn’t reveal because there was so much stigma.

I was fired by my dentist when I was a resident because he claimed that his office staff wouldn’t let him take care of me. I remembered both the sense of abandonment but also this sort of vaguely guilty feeling like there was something wrong with me. And that’s really how we lived our lives for the latter part of the ’80s, the ’90s. When I took my job at Dana-Farber in 1997 on my first interview, I told them about my health issues and I said, “I think I’m pretty good for five years. I won’t give any guarantees beyond that.” And I never, ever assumed. In fact, I never dreamed that I would be alive today. I thought that almost certainly I wouldn’t be around.

Harlan Krumholz: It’s such an honor to have you on, and I think listeners so appreciate your candor about this and the realities of what you faced. There’s something else about this, which many of us, as we’re trained to be doctors and socialized into medicine, we become distant from what it’s like to be a patient for the issues that patients face and the sort of power differentials, the shame, the stigma, all of these things. You must bring that every day to every patient encounter you have, that sensitivity to what it’s like to be on the other side of the bed.

I think a question, what does that mean to you in your patient interactions and how do you teach those of us who haven’t been in your shoes to have that level of sensitivity to the kind of things that patients face?

Eric Winer: As the president of the American Society of Clinical Oncology last year, I had to give a presidential address and I talked about these issues. And one of the things I said, and I think this is really, really important, is that to be a good partner with a patient, it doesn’t mean that you have to have experienced being a patient or have to experience illness. But I do think you have to tap into some vulnerable side of yourself. I believe that the minute you scratch below the surface, you realize that everybody has got something in their life.

And whether it’s a parent who was abusive or a child who’s been ill or so many other things, there just aren’t too many people who live perfect lives with cute houses and white picket fences around them. Life is messier than that. And so I don’t want to pretend that somebody has to be me to be a great clinician. I think there are many ways of getting there, but I do think there’s some vulnerability that you have to be comfortable with.

I don’t often talk about my own history, my own medical history with patients. At this point I do occasionally because it’s in the public domain and anybody can read about it. Having had the experience of having young children and thinking I wasn’t going to live long enough to see them grow up is something that does give me a perspective when I talk to people with advanced cancer.

Howard Forman: Breast cancer is one of the oldest cancers we’ve known about. It’s also still one of the most common cancers that we have in the country, and it remains fairly lethal. We still have too many cancer deaths and certainly a lot of morbidity from it. If we go back, I guess 150 years, maybe more, I don’t know, we primarily treated it with surgery. Now, I think the emphasis has been on using receptors to inform chemotherapy and other parts of the treatment. What are going to be the next big leaps forward in eradicating breast cancer mortality and morbidity?

Eric Winer: Well, we’ll be there, and we’ll be there sooner than we will be with many cancers. The vast majority of women with breast cancer don’t die from it today. Our treatments are remarkably effective. There are still 40,000 deaths a year in the United States, and so that’s a large number. Although given the fact that there are well over 200,000 cases, again, it’s clear that most women don’t die from it. And the tragic part of it is that of course, those deaths are not evenly distributed across the population.

And if you are a woman of color or somebody without financial means or education or insurance, or you’re somebody who is unpartnered, and I can just go down the list, but anything that makes you a little different from the majority puts you at risk of not getting adequate care. And beyond that, I think we’ve learned when it comes to race that it may not just be about getting adequate care. It may be about other aspects of society, of the structural racism that exists. So I think one of our huge challenges from a breast cancer standpoint as our treatments get better and better is figuring out how we’re going to make sure that those treatments are delivered in an equitable way across the population. So I think that probably within 10 years we will be able to say for a woman who can get treatment and can stay part of that treatment, that there’s almost no need for a woman to lose her life from breast cancer. But the bigger challenges are going to be the social ones.

Harlan Krumholz: We’ve covered so many things across a wide range. I know we’re getting to the end, and I just want to say one thing that may be on people’s minds because they’re seeing it in the newspaper all the time, and that’s about the shortages of chemotherapy drugs. What’s your take on this? Is it really as bad as what we’re seeing in the newspaper? And are there actually people who are at risk of dying in a sense or accelerated disease because they can’t get what they need?

Eric Winer: I think in some cases that actually is the case. The problem, as people may or may not understand, has been with generic drugs that are incredibly inexpensive but for which there is not a profit motive on the part of a company. And so many centers have had shortages of drugs like, and I’ll just name a few names, of cisplatin, and carboplatin, and methotrexate, and these are all what you might call old-fashioned drugs, but some of them are still used for some cancers and are lifesaving for some of those cancers. It’s a big problem and it’s not any... it’s hard to know quite what the solution is, although there are a number of steps that can be taken. We are in desperate need of having some sort of national stockpile.

We need to figure out how to distribute these drugs more evenly, and we probably need to provide some incentives to manufacturers to actually produce the drugs. There was an article in the New York Times just this week on this topic. It almost seems unbelievable, but it is the truth. Thankfully, it’s not affecting most patients with cancer because these drugs are not used for everyone. But we do need to get it fixed.

The American Society of Clinical Oncology, multiple other groups are working on this. I know it is something that the FDA is aware of, although the FDA feels that it’s by no means their, entirely their problem. So it is going to take work.

Howard Forman: Well, we just want to thank you so much for joining us and sharing both your wisdom as well as your own personal story with us. And we are grateful to have you at Yale and leading the cancer center. You’re a role model and inspiration.

Harlan Krumholz: A hundred percent. Well, it’s such an honor to have you here and so appreciate that you came on the program.

Eric Winer: Thanks.

Harlan Krumholz: And it’s just been so nice to visit with you. Well, that was a terrific interview.

Howard Forman: That was awesome.

Harlan Krumholz: For him to be able to show that kind of vulnerability and talk about his own history like that, it’s inspiring.

Howard Forman: Agree.

Harlan Krumholz: We’re lucky to have him here. Let’s get onto this next section, Howie. So what’s on your mind this week?

Howard Forman: Yeah. So you and I talked a little about this several times during the year, but so every year, this time of the year, our Centers for Medicare and Medicaid Services, we call it CMS, they issue their annual report for national health expenditures. It’s a backward-looking report, but it’s also the single snapshot of the U.S. healthcare economy that we get every year. So now we’re looking at 2022. So it’s over a year old, but still really useful to summarize it.

I want to just summarize positive findings from it because it’s the end of the year, and I want to be positive. So we are at an absolute low in terms of uninsurance. Only 8% or about 26.6 million people were uninsured in 2022 to combination of Medicaid coverage, expanded employer-based coverage, and even Obamacare exchanges. Medicaid itself covered 91 million individuals last year, and it did so at lower cost than we otherwise would have expected, and that has a favorable impact on state and federal budgets.

Medicare enrollment was up to 63.7 million individuals. And there too, costs grew less than we would have expected, less than inflation. Overall healthcare spending is now $4.5 trillion. This is substantially lower than the estimates offered over the last decade, which I’ll come to in a second. And it’s 17.3% of the overall economy, but that’s the lowest percent in also almost a decade.

And prognosticators, including me, have always warned about increasing costs, and instead we’ve seen them a lot lower than we expected. So these figures include all spending. You and I talk about, “Where do they get these numbers?” This is everything, including out-of-pocket spending for Tylenol at the CVS. I’ll give you a sense of just how far off this is from what we expected. In 2011, the journal Health Affairs on their blog, they wrote, and I’m quoting this now, “By 2020, healthcare spending is projected to be 19.8 percent of GDP, nearly one-fifth of economic output, increasing from 17.6 percent in 2010.”

All healthcare spending will reach $4.64 trillion. Notably, we’re two years past that window and we have substantially lower percent of GDP and substantially lower spending. Some of it is probably the unexpected rewards of Obamacare—not all of it. Some of it is the type of innovation that you have been promoting in your work at CORE and other investigators been promoting in terms of value-based delivery models. And some of it may be just hard to explain, but it is good news. It has a lot of repercussions throughout the healthcare economy that are favorable for us. So I just wanted to start us off with something good.

Harlan Krumholz: Yeah. Let me just ask you a couple quick questions about this. What about the role of the pandemic in all of this? What were your thoughts about that? I mean, that’s still in the public health emergency that period. What are your thoughts about that?

Howard Forman: We had a huge bounce in spending in 2020 and a smaller bounce in 2021. And now we’re seeing sort of—

Harlan Krumholz: “Bounce” meaning increase.

Howard Forman: Yeah, bigger increases than we would have expected. But now last year, this—2022—even though we still had pretty bad outbreaks, we were spending less. Presumably we’re back to an equilibrium for elective surgeries and other procedures. We’ve talked about on the podcast before that, unfortunately we lost a lot of very elderly people to the pandemic. Some of those people were the highest-cost spenders; that may be some of the impact. Hard to tease it all out. All we know is that this is not a pattern that just emerged after the pandemic. It started well before that.

Harlan Krumholz: How accurately can we estimate healthcare costs? I mean, this is information from a lot of different sources.

Howard Forman: So with a full year lag, we do pretty well. But there is no question, 10 years from now, they’re going to be talking about 2022 and they’ll be using different numbers than I just reported. So they’re constantly revising them. But pretty close, Harlan. We are pretty good at capturing these dollars.

Harlan Krumholz: And you think this is going to cool the efforts to actually get rid of waste and cause fundamental reform? When people are going to say like, “Hey, look, costs are taking care of themselves. They’re not increasing as fast.”

Howard Forman: They are not going down. So even though you’re correct that it’s a little bit of the edges off when things aren’t going haywire, the actual cost is so enormous right now that you still hear firms and governments talking about cutting budget in other areas because healthcare costs are so high.

Harlan Krumholz: And such a large percentage of... just take the state of Connecticut, I mean a large percentage of our healthcare budget is either state employees or Medicaid.

Howard Forman: Correct.

Harlan Krumholz: And take the towns. I mean, in my town, there’s so much pressure on the budget because of those kinds of things.

Howard Forman: Exactly.

Harlan Krumholz: I have one last one here. So actually Congress, as dysfunctional as it is, was able to put together a healthcare legislation in the House, at least.

Howard Forman: In the House, yeah.

Harlan Krumholz: I was just kind of wondering, is this a big deal? How should we be thinking about this legislation?

Howard Forman: This is almost like an indictment on a legislative process. So to understand this, all you have to know is that when Obamacare passed, they were going to reduce payments to hospitals that used to pay for the uninsured. And since Obamacare was so taking care of the uninsured, at least we hoped it was, we no longer had to make these payments to hospitals. Well, the hospitals immediately pushed back and said, “You’re wrong. Our costs are still high. You have to keep paying us these payments.” We call them DSH payments, disproportionate share hospital payments.

So the hospitals have lobbied to reverse it every year. They’ve never gone into force. And so what was coming up right now is those cuts would’ve gone into force, I think January 1st if they don’t pass this piece of legislation. And the hospitals pushed back against that, and Congress looks at it and says, “Well, where am I going to find whatever, it’s $10 billion to pay for this.” And so what do they do? They pull out of their pocket small savings that they’re aware of, that they’re not putting into legislation until they need it.

Here they needed to save money, and so they went out and changed some of the payment policies around pharmacy benefit managers, some of the policies around other types of infusion therapies and so on, to save the money they needed to in order to justify reversing the cuts to hospitals. And that’s all this really is. It’s a budget-neutral piece of legislation, for the most part.

Harlan Krumholz: So we shouldn’t get excited about it. It’s not major healthcare reform.

Howard Forman: It’s not at all, no.

Harlan Krumholz: Yeah. So that will kick the can.

Howard Forman: That’s what we’re doing. Absolutely.

Harlan Krumholz: Hey, thanks so much, Howie.

Howard Forman: Sure.

Harlan Krumholz: Good to hear your views on this stuff.

Howard Forman: Thank you.

Harlan Krumholz: You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can always email us at health.veritas@yale.edu and we will answer those emails or talk about them on the program. You can also find us on social media, including Twitter.

Harlan Krumholz: Yeah, I’m at H-M-W-Y-A-L-E. That’s @hmkyale.

Howard Forman: And I’m @thehowie. That’s at T-H-E-H-O-W-I-E. Aside from Twitter and the 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 and a co-founder of the Pozen-Commonwealth Fund Fellowship and Health Equity, which is a fully-funded EMBA fellowship for providers with a focus on closing disparities in health. And it is accepting applications right now to start in the summer of 2024. To learn more, reach out to me or go to som.yale.edu/pozen. And of course, always reach out via email for more information on all of our innovative programs.

Harlan Krumholz: There’s nothing better than to be a mentee of Howie, so if anybody is listening that wants to do these programs—

Howard Forman: Right back at you. Thank you.

Harlan Krumholz: ... it’s a great opportunity. Health & Veritas is produced with the Yale School of Management, the Yale School of Public Health. Thanks to our producer, Miranda Shafer, and our researchers—I’m going to say this without a gusto—

Howard Forman: No gusto.

Harlan Krumholz: ... just to say their names, Ines Gilles and Sophia Stumpf. Those of you listening, I was saying, the listener had told me that I say it so well.

Howard Forman: I like it with gusto.

Harlan Krumholz: I say it with gusto, and that’s because I want to get their names right every time. But Ines Gilles and Sophia Stumpf, and they are amazing. We’re lucky to work with them.

Howard Forman: And really happy holidays to you, Harlan, and to our entire team. We are so fortunate to be able to do this, and we love our listeners. I’m wishing you all the best of the holidays and a Happy New Year.

Harlan Krumholz: Happy New Year. Happy holidays.

Howard Forman: Thanks, Harlan.