Kevin Billingsley: The Making of the Modern Surgeon

Transcript

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, and we’re trying to get closer to the truth about health and healthcare. Our guest today is Dr. Kevin Billingsley. But first, we always check in on current hot topics in health and healthcare. What do you have for us today, Harlan?

Harlan Krumholz: Yeah, first of all, I just wanted to say thank you to some of our listeners who reached out to me after last week. My mother-in-law did pass away after we had taped that issue. She was surrounded by love. The whole family was able to get together, and it’s a loss. Our hearts are heavy, but I do appreciate the people who sent a note, and that was nice. And I just wanted to express that to our listeners. It’s nice. We have a good community, Howie.

Howard Forman: That’s for sure. We think about you.

Harlan Krumholz: One of my favorite topics is AI in the future of doctors. You and I have talked about this before. So this resurfaced recently, and I think that it’s worthy of some attention. So you may have seen the headlines recently suggesting that AI can dramatically reduce the need for physicians. And you and I have talked about this, especially in radiology. And the debate’s not new. More than a decade ago, venture capitalist Vinod Khosla predicted that as much as 80% of doctors would eventually be replaced by machines—replaced.

And at the time, it sounded pretty outrageous, and it elicited quite a bit of static from the profession. But what’s interesting now is that pieces of that vision are beginning to appear in the real world. A striking example is unfolding in Utah. A startup called Doctronics is testing an AI system that can autonomously renew prescriptions for patients. Here’s how it works. A patient logs in, verifies their identity, answers a set of clinical questions, and the AI determines whether to approve the medication renewal.

Now you may think that’s not a big deal, renewing refills, but it has been the domain of healthcare professionals to do it. In this case, if the AI approves it, the prescription goes straight to the pharmacy. No physician reviews the case, no nurse practitioner, no—any advanced care individuals involved. And the price is about four bucks. So you can see why this attracts attention. Anyone who’s tried to refill a medication knows how frustrating the process can be.

Even with MyChart or all the apps that are available from the health systems, it still involves some steps. From the patient perspective, automating this task could be appealing. But many physicians, as you might expect, are raising concerns. And I think some of them are worth taking seriously. What sounds like a routine refill is actually a clinical checkpoint. When a doctor renews a medication, they’re often asking themselves questions. Is the condition still controlled? Has a kidney function changed?

Are there new medications that could interact? Is a patient overdue for lab tests or monitoring? These judgments are subtle and they often depend on the context, but they kind of bring the patient back into the healthcare system for that touchpoint. So there are also some hints of how a system like this could go wrong. In a report highlighted by Axios, researchers were able to trick the AI system into approving medication renewals by manipulating the answers to the screening questions. In other words, the system could be gamed.

Now, this doesn’t mean that AI cannot eventually handle these paths safely, but it underscores why independent validation and rigorous testing are essential before systems like this are widely deployed. The concern was also raised in a recent editorial in The Washington Post written by a trauma surgeon at Hopkins and a medical student. They pointed out that the main evidence supporting the system is a company-authored preprint. And you know how positive I am about preprints to circulate knowledge, but you have to understand preprints are for discussion.

They haven’t been yet peer-reviewed. So the company preprint that hasn’t yet been published in a peer-reviewed journal is providing the underlying evidence for this intervention and the underlying data have not been shared publicly. So this is pretty thin evidence based for something that’s effectively making prescribing decisions. And then there’s a regulatory question. If software like this is practicing medicine, well, this traditionally falls under medical licensure, or should we be thinking about it as functioning as a medical device that should be regulated by the FDA? Right now, these systems are operating in a gray zone.

At the same time, the broader healthcare industry is moving quickly in the direction. You may have also seen the headline that CVS just announced a partnership with Google to build AI-powered tools designed to function, as always, on healthcare companion for consumers. These systems aim to integrate healthcare data, help patients navigate care, and guide decisions between visits. So we’re seeing this kind of rapid shift. On one end, startups are experimenting with autonomous clinical decisions, on the other large healthcare and technology companies are building AI systems designed to guide patients continuously.

Stepping back, I think it’s important not to frame this simply as “AI replacing doctors.” That narrative’s too simplistic. This is a question of “how is AI going to transform medicine?” It can analyze enormous amounts of data, interpret imaging, monitor patients remotely, help manage routine aspects of care. Used well, these tools can actually expand access to care and allow clinicians to focus on the most complex problems.

And you know, I’m avid for this. I should say as disclosure that I’ve been deeply interested in this area. Our group team is working on this. Earlier in another podcast, I talked about the ARPA-H ADVOCATE program where the government is going to support the development of autonomous system, and our team’s applying for that program. So that’s a disclosure. But the goal here, I think for all of us who are working in the area, is not about replacement.

It’s about building systems that extend the reach of healthcare professionals and help us to support patients between visits, improve the performance, improve the outcome, and figure out the right place for AI, where it can safely operate and actually make a difference in people’s lives. The innovation’s essential. So I think ultimately the question’s not going to be whether they transform medicine, but whether our evidence and oversight will keep pace with the speed of technologic change.

Howard Forman: I think that’s great. I really appreciate you talking about that, Harlan. I worry a lot that with pretty much a trillion dollars or more of capital investments in AI right now, and just this enormous, enormous momentum behind AI on so many levels, mostly outside healthcare, but within healthcare, that, not to push the metaphor too far, but medicine could get steamrolled.

I mean, I think what you’re describing is an example of the technology, the application getting way ahead of the technology and potentially harming people. And it’ll be interesting to see whether society is willing to tolerate potentially big mistakes and real harm as that train continues to move.

Harlan Krumholz: With every great technologic introduction, cars, planes, everything.

Howard Forman: People die.

Harlan Krumholz: The beginning is a rocky period where issues are being worked out, and you’re absolutely right. Our goal here should be to do everything we can to mitigate the harm and to augment the possibilities. But—

Howard Forman: Yeah, the potential. Absolutely.

Harlan Krumholz: ...the profession cannot stand by as passive observers. We really need to invest. And one thesis I have is that people with deep healthcare knowledge need to be involved. People with a deep commitment to patients need to be involved. And yes—

Howard Forman: Agree.

Harlan Krumholz: ...our current system has lots of opportunities for improvement, but we can’t say we’re going to just move fast and break things. This has to be done the right way. It has to be done the right way.

Howard Forman: No. Excellent.

Harlan Krumholz: All right. Hey, let’s get on to Kevin Billingsley. This is going to be a great interview.

Howard Forman: Dr. Kevin Billingsley is a professor of surgical oncology at the Yale School of Medicine and the chief medical officer at Smilow Cancer Hospital within the Yale Cancer Center. Dr. Billingsley specializes in multidisciplinary surgical care for tumors of the liver, pancreas, bile ducts, and other gastrointestinal organs and is an international leader in hepatobiliary cancers. His research centers on improving clinical systems and developing new approaches to deliver high quality multidisciplinary cancer care.

He earns his bachelor’s degree in biological sciences from Stanford and his medical degree from Johns Hopkins before completing internship and residency at Argonne Health and Science University, followed by a research fellowship at the National Cancer Institute and a surgical oncology fellowship at Memorial Sloan Kettering. He later earned an MBA in healthcare management from OHSU. And I want to first welcome you to the podcast. And as I was thinking about what we would talk about today, I was thinking you and I graduated medical school at the same time, and surgical care as seen from a radiologist has been transformed over that time.

Laparoscopic surgery was mostly in the lab when I was in medical school, and it’s just not just mainstream, it’s the way that we practice so much surgery right now. And then you have robotic surgery, and I don’t even think the public understands what that means. So I wonder if you could just start off by taking us through what you’ve witnessed from your training until today in how we manage cancer and how technology has helped make that safer and better.

Kevin Billingsley: Yeah. First off, just great to be here. I’ve been looking forward to joining you and Harlan for several months, and it’s really a pleasure. It is a big change. I do liver and pancreas surgery, which is some of the most complicated abdominal surgery, and it involves working around big blood vessels and organs that are vital. And we are now doing many of these operations robotically. And it is a clear step forward, and these are operations that I don’t think... now, there are some surgeons doing them laparoscopically, but not very many, and they were very long and fraught with difficulties with learning.

And now these are in the minimally invasive arena, and they’re much more accessible. So it has been a journey. It’s very exciting. I think lots in the future. There are some caveats. It’s not all rosy, though. This is—for your audience—one of the things that I would say is just offer the reminder that surgeons are not always entirely transparent about where they and their organization are in these complicated learning curves. And all of these operations that are done robotically, the team needs to have a fair bit of experience under their collective belt to really have true expertise. This is an area where I quite honestly feel like we are not as regulated as we optimally should be.

Harlan Krumholz: Kevin, it’s such a pleasure to have you on. You really sit at this intersection of clinical mastery, leadership, systems thinking, and really importantly, human connection with patients. You sort of bring all this together. So I was very excited to have you here. A lot of people who are listening, we have a really broad audience, and many people are not in medicine and their only contact with surgeons is what they see on TV or what they’ve read.

I wondered, you do these highly complex liver and pancreatic operations. I wonder if you could share with the audience a little bit about when you’re about to begin one of these complex operations, what’s going through your mind at that moment? What does it feel like when you walk in the room? Because people are often saying these are like athletic events. And yours are particularly long, arduous, technically challenging. How do you prepare yourself? What does it feel like to walk in the room? How do you manage that?

Kevin Billingsley: No, these are great questions, and there are things that I think about not only in terms of surgery, which is a performance, if you will, but the other things that we do as clinicians and leaders, and you mentioned kind of athletic participation. And I do tend to think about this. There are some parallels to training, fitness, preparedness that run in kind of a parallel way to what I would describe as training for some physical or athletic event, meaning a combination of mental preparation as well as a commitment to maintaining the physical stamina and integrity that you need to have to do a somewhat physical job year after year after year.

Surgery is physically demanding. Even these robotic operations where you do it sitting down require both physical and mental stamina. So I am always preparing a day ahead of time and particularly reviewing the images, which are really, they are our roadmap for these operations. So it’s making absolutely certain that I have all of the anatomy and patient specific nuances clearly in my mind. And I think we talk about robotic surgery; this is where understanding the anatomy and a visual reconstruction from detailed imaging is even more important than open surgery because we’re not looking at a big open field with our hand in the abdomen.

We are relying entirely on the images and the representation of the anatomy through the robotic viewing console. So lots of preparation a day ahead of time, lots of team preparation. All of this is a team sport, making sure that the team has all the equipment they need in the room. And one of the things that I do enjoy about being a surgeon in an academic center is that I’m always thinking about how am I going to bring my trainee along. In almost everything I do, I have a surgical resident involved. I’m usually doing the operation, but they’re participating with me and helping me, and I want to make sure that they’ve thought about what we’re doing and that they are getting a good educational experience out of it and it’s productive for them.

Harlan Krumholz: Let me ask just one quick follow-up on this. So I think this is such an interesting thing, and it gets to Howie’s question too about how surgery has changed. Let’s say we’re all blessed with certain skills, and one of the skills that a great surgeon would have is dexterity, the ability to have in mind what needs to be done, see the field, feel, and be able to execute on those skills and talents within the surgical field.

Now, you’ve seen a transition of surgery to a point where the real premium is on your mental model, your visualization of a representation of what’s going on. You’re no longer in the field handling in that dexterity. It’s a different kind of dexterity, but it’s also importantly about whether you can see in three-dimensional space in your mind something that’s being shown to you on images, which wasn’t necessarily the skill that the surgeons in the 1960s and ’70s had in my field, when a DeBakey or Denton Cooley, when their...

These were giants in the field, but their skill set was different than what the very best cardiothoracic surgeons might have today, and maybe even more so in your field than it would be in cardiothoracic because you’re dealing with laparoscopic often, robotics more, but in structural in my field, when they’re dealing with valves in particular. So what do you think about that? Because you actually have to develop a whole new set of skills, and some people aren’t naturally talented in that way to be able to see that representation.

Kevin Billingsley: That is a hundred percent correct, Harlan. And I think this is where surgeons who are kind of in my generation have in some cases struggled with transition into laparoscopy and robotics because it is a completely new mental model of the anatomy. When you do an open operation, whether it’s cardiac or abdominal, you are looking down on the target from above.

And often we will use magnifying glasses to help with the optics, but when you’re doing a robotic operation, the camera is down at a lower angle. And it’s what I call changing from an overhead to a street-level view. And if you’ve been doing it for years and years with one mental model, it requires a, almost a cognitive rewiring and it’s a new set of skills and it’s a new framing.

Less, as you point out, less emphasis on kind of the fine motor dexterity, which is what the robot is really great at. You can do very fine motions under control without any tremor, which is hard to do with the human hand. But it’s understanding the anatomy in that new representation. And there can be pitfalls. There are surgical injuries and unfortunately the literature is rife with complications from robotic surgery that are really, when you get down to the root cause, anatomic misunderstandings.

Howard Forman: Being a cancer patient has got to be one of the more shocking things for most people. Working in the ER, we occasionally diagnose people at that moment. And in my own mind as a radiologist, it’s chilling to realize that someone came in for what they thought was a bellyache and now has a diagnosis that requires surgery, chemotherapy, or some combination with radiation therapy, who knows. What advice can you give people about how they can sort of slow things down and take a proper approach to their own care when faced with a new diagnosis of cancer?

Kevin Billingsley: Yeah, I appreciate this question. I’m going to start by saying that one, we are fortunate that we now have an incredible array of very powerful treatments and technologies and diagnostic tools to bring to the care of our patients with cancer and supporting their families. That being said, I think the really vital center of cancer care is the relationship between the clinician or clinicians and the team, including nurses and the patient and their family.

And the thing that I tell people is “take a few deep breaths” because it is very easy to get on the cancer care train and wind up going someplace that you may not need to go, or it’s not the best program for you. And fortunately, most cancer diagnosis, there are exceptions to this, things like acute leukemia, GI cancers with bowel obstruction, but 80 to 90 percent of the time, patients and families and caregivers have the opportunity to step back, take a breath, talk to friends, solicit advice, and get one opinion or several opinions about what is next, where to go.

And I really encourage people to pursue expertise, and in the case of surgery, certainly technical experience, but you got to feel good about the people taking care of you. And you got to feel good about them. You have to feel a connection. And I think there are enough great oncologists out there that if you or your family is in a situation where you think, “Oh, this person’s really smart, but they’re not engaging me in the thinking and decision making. They’re not listening to me deeply and I don’t feel good about this,” push the pause button.

Harlan Krumholz: Let me just, extending that a little bit, you’ve spent a lot of your career thinking about how cancer care systems work and what works best and what doesn’t. And you’ve been in many cancer hospitals. When you walk into a hospital, what tells you that it’s going to deliver excellent cancer care? What are the things that you notice that say to you, “This is probably a good place”?

Kevin Billingsley: Well, I mean, great question. There are certain kind of structural elements that you need to be looking for. Are there multidisciplinary teams in place? Is care provided by groups of people who are truly focused on whatever area of disease treatment that you are going to see? In other words, and we’re on this, we are very committed to this here at Yale and Cancer Center, and Smilow is creating very focused subspecialty teams. For example, if they’re treating leukemia, is that all they’re treating? They’re not a general hematologist, but they’re a leukemic expert and they have a nursing team who specializes in that.

And same with the solid tumors. So is the organization cultivating the depth of expertise in the narrow area that we need to really deliver the most current therapy? But Harlan, let me talk about something that’s a little harder to put your finger on, but I think probably as important, how do people talk to each other and relate to each other within the organization? What is your sense of how the physician, APP [advanced practice provider], and nurse are relating to each other? Do you feel like they can finish each other’s sentences? Are they a seamless whole? Do they like each other? Those are kind of squishy things and hard—

Howard Forman: That’s a great point, though. Yeah.

Kevin Billingsley: ...to put a metric on it.

Harlan Krumholz: I love that. I really love that. Yeah. Great.

Kevin Billingsley: But great teams love caring for patients together. There’s deep trust. They finish each other’s sentences, they fill in for each other.

Harlan Krumholz: So how do you create that? How do you create that?

Kevin Billingsley: Oh, gosh. It’s what I spend a lot of every day thinking about. I think that it is strong leadership from a high level in the organization that prioritizes it. And within each team, the ability to flex and bend, care for each other as well as the patients. And honestly, this is one of my concerns with our current medical environment is much of our care is virtual and teams become asynchronous and disaggregated.

And this is one of the things that has happened with the electronic medical record and things like secure chat and electronic communication is teams are communicating with each other virtually. And I do think my own bias, I’ll say, is in great organizations, we find a way to get caregivers together as much as possible at the bedside, in the clinic, and even outside of the hospital.

Howard Forman: As we get to the end, a quick question, what is your advice to people to avoid becoming a cancer patient? I mean, a lot of cancer is unavoidable, but a lot of it may be avoidable. What are the types of behaviors that you think people can practice that may reduce their risk of having cancer?

Kevin Billingsley: Yeah, I think that there’s a lot of some basic practical things. I think we’ve learned that managing your weight throughout your lifetime is helpful. I think there is certainly a pretty clear emerging evidence that, particularly in North America, as we gain weight, we get metabolic syndrome, which means that we put weight on. And this is more men than women. We put it on in our abdomen. It has an inflammatory effect and can increase the risk for a number of cancers.

Then there are the obvious things. Smoking, smoking, smoking. No. Please, no smoking, no vaping. I am a huge believer in the power of exercise, not only as kind of a cardiovascular disease prevention mechanism but also an overall wellness and immune augmentation program. And that is almost any kind of movement, walking, dancing, gardening, resistance training, cycling. And this is one of these things where I think the data is clear even for patients who are diagnosed with cancer, the introduction of an exercise program improves their survival and their quality of life.

The last thing I will say is that alcohol is certainly in the national conversation. I’ll just share my own perspective. I think that there’s little doubt that alcohol has a carcinogenic capability. Is there a threshold dose that truly becomes dangerous? Don’t know. I enjoyed a glass of wine with dinner last night. I think there’s some point at which you try not to drive yourself crazy with anxiety over every little indulgence, but yet I would encourage the public to really either eliminate or very prudently moderate their consumption of alcohol. So I think those are the top items.

Howard Forman: This has been great.

Harlan Krumholz: Good advice. You just made our listeners healthier. Thanks, Kevin.

Howard Forman: Yeah.

Kevin Billingsley: I hope so. I hope so.

Howard Forman: No, this has been great. We really appreciate everything that you—

Harlan Krumholz: What a pleasure to talk to you.

Howard Forman: Yeah.

Harlan Krumholz: Yeah.

Kevin Billingsley: Well, I really—

Harlan Krumholz: Thanks so much for joining us today.

Kevin Billingsley: ... enjoyed my time with you all, and I hope to keep in touch.

Howard Forman: Yep, absolutely.

Harlan Krumholz: That’d be great.

Howard Forman: Thank you. Oh, he’s such a good guy.

Harlan Krumholz: Yeah, he’s a good guy. Really great to have him on. But Howie, one of my favorite parts of the show, what’s on your mind this week?

Howard Forman: Yeah, so the Annenberg Public Policy Center at the University of Pennsylvania released the study this week or a survey this week, I should say, on attitudes towards public health agencies and officials and others. There was some surprising and some unsurprising findings. The happiest finding I thought is that primary care doctors continue to have high respect among the public, but some other features are much more concerning. So Americans have far greater confidence in career scientists than in public health agency leadership right now.

And this is even more stark when you consider that only 38 and 42 percent of individuals have confidence in RFK and Mehmet Oz, compared with 54% in Anthony Fauci, Tony Fauci. Pointedly on vaccinating newborns for hepatitis B, Americans say they are more likely to accept the advice of the American Academy of Pediatrics than the CDC by nearly a four to one margin. That’s a huge margin. And public trust in the FDA, CDC, and NIH continues to fall since the inauguration of President Trump.

The results, which are weighted to represent the population of the United States, are all interesting, and I encourage our listeners to read the full survey. But what can we do when faith in our usually respected leaders and public institutions is waning? And at least one answer comes from the recent newsletter of our former guest and current friend, Katelyn Jetelina, who offered some advice with her colleague, Dr. David Higgins. This specifically with regard to vaccinations and how to speak with your friends and neighbors who may not otherwise align with you politically.

And just a quick points on this. One, “don’t lead with science and data,” which I thought was a little surprising. When people feel like their values are being challenged, facts alone rarely change minds. Start with shared values, then let the evidence support the conversation. Two, “Begin with common ground. Most parents, regardless of their politics, want their kids to be safe at school and for school to run normally. Saying ‘I just want to make sure schools aren’t shut down for weeks because of a preventable outbreak’ is something almost everyone can agree with. Start there.” And “if someone,” and their third point, I’m quoting all of this from their letter, “if someone brings up studies or claims that seem to contradict the evidence, resist the urge to debate every detail. Instead, acknowledge the concern and emphasize that what matters is the totality of the evidence.”

There’s much more in their newsletter, but I found the advice to find common ground challenging in the abstract but then easy in the example they offer. Who among us would want schools shut down again? My personal urge is, in fact, to try to rebut, cherry-pick data or speak to overwhelming evidence every chance I get. But what should matter is the outcome, not the process. And these two authors offer a path forward for all of us that is quite frankly different from what I’ve probably been doing.

Harlan Krumholz: Great segment, Howie. Really good advice. Very good reflection. I want to get back to this survey that you mentioned. So the exact question was, how confident, if at all, are you that blank is providing the public with trustworthy information about matters concerning public health? I think it’s a neutral question. I don’t think it’s biased. I don’t think it’s putting people in a position to answer either way. Vis-à-vis my conversation at the beginning of this about AI and how it’s going to roll out. The question is, who’s going to trust it? Who’s going to trust it?

And when I look at this survey and how confident, if at all, are you that blank is providing trustworthy information? And I’m asking what percent of people saying they’re very confident. They feel very confident in it. They feel, in other words, comfortable about it. RFK, 9%. Oz at CMS, 7%. Leaders of federal agencies, 5%. But the other thing that struck me, NIH, oh my God, you would think people would be very confident that NIH, the bastion of science—12%.

Howard Forman: Scary.

Harlan Krumholz: And when you go up, though, even the most, your own primary care physician is under 50% that you’re very confident they’re providing trustworthy information. Now, you could say, “I’m going to combine very confident and somewhat confident,” or however you want to do it, but I’m looking for people who are very confident. Who can they trust? That’s what “very confident” means to me.

Howard Forman: That’s a valid point.

Harlan Krumholz: And we’re now in a position where people are getting their own information from many different sources, including from disreputable misinformation sources.

Howard Forman: Yes.

Harlan Krumholz: And we don’t have one group identified that more than half the people have said they’re very confident that’s where I can get trustworthy information. And that’s bananas.

Howard Forman: It is bananas.

Harlan Krumholz: That’s bananas. And—

Howard Forman: And this is where we’re at, but this is where we start from. This is my—

Harlan Krumholz: This is so we’ve got to build back.

Howard Forman: Right.

Harlan Krumholz: We have to go back with transparency, clarity, integrity. But Howie, if we can’t build back from this, we’re never going to be able to address a public health threat because no one’s going to know who to listen to.

Howard Forman: I couldn’t agree more. And I’m worried. We watch measles right now, there’s going to be something else down the line. We’re not in a great position in our country. And by the way, this is a global phenomenon. It’s not just a local phenomenon. So.

Harlan Krumholz: And by the way, it’s within our fields too. If you ask any cardiologist, “Who do you trust to tell you straight what to do?” I don’t think that there is any way anymore, a place. You say AHA, ACC, or organizations, meaning American College Cardiology, American Heart Association. I mean, American Heart Association, by the way, fared better than most here, but only a third of people said they’re very confident the American Heart Association is providing them with that kind of information. So yeah, we got to build back, Howie, because there needs to be ways where we say there are voices that you can be very confident are giving you trustworthy information.

Howard Forman: That’s right.

Harlan Krumholz: Again, not that you would follow them, but you’re just... the question is trustworthy information. They’re informing you. You can trust what they’re saying. That’s all. It’s not saying, “I’ll follow them.”

Howard Forman: This is us. I mean, look, we’ve been doing this podcast for almost five years now. Health & Veritas, truth, light. This is what we’re trying to bring to people.

Harlan Krumholz: Oh my God, they should have put us on this questionnaire. I’m sure we would’ve got 80%. I’m sure we would have.

Howard Forman: We get 1% because people don’t know us.

Harlan Krumholz: No, no. People who would know us, they would rank us. All right. I’m going to end on that high note. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, email us at health.veritas@yale.edu or follow us on any of social media, including our Instagram account.

Harlan Krumholz: And give us feedback. Let us know how we’re doing. Let us know what we can do better. We always love that feedback.

Howard Forman: Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. To learn about Yale SOM’s MBA for Executives program, visit som.yale.edu/emba. And to learn about the Yale School of Public Health’s Executive Master of Public Health program, visit sph.yale.edu/emph.

Harlan Krumholz: And we always like to give a shout-out to our superstar undergrads. Today, we’ve got Tobias Liu, who did a great job with us today. We have Gloria Beck. Donovan Brown has joined us. We have an amazing producer, Miranda Shafer, and I get to work with the best in the business, Howie Forman.

Howard Forman: You’re always very kind, Harlan. Thank you very much.

Harlan Krumholz: I only speak for truth, only speak... Talk to you soon, Howie.

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