Kristen Nwanyanwu: Vision and Equity

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. This week we will be speaking with Dr. Kristen Nwanyanwu. But first, what’s got your attention, Harlan?

Harlan Krumholz: Well, Howie, there’s a really important paper that came out in The New England Journal of Medicine yesterday that I think is worthy of note, and not just for the men. And the reason I say that is because it was a study of screening strategies for prostate cancer.

And it’s important because we’re trying to figure out how to prevent cancer. We’ve got lots of different ways to screen. And in this case, we have a blood test that’s imperfect at best that people take frequently, men of a certain age take frequently. And yet there’s still controversy about whether or not it’s beneficial. It’s sort of a little bit like mammography in the sense that there’s people who feel strongly on all sides of this.

But the question is whether measuring a prostate-specific antigen—PSA, people may know about PSA screening—can actually decrease the rate of cancer. But it goes beyond that, which is, so people end up having an elevated PSA, elevated prostate-specific antigen, and then what do you do?

It gets elevated maybe above, for people who are in the know, say above three. And then should you be watchful, waited? In other words, should we just monitor, check it every year? Should we do an MRI scan? And under what circumstances might we progress from an MRI scan to a biopsy?

And again, men of a certain age, it’s pretty common for them to have undergone biopsies of their prostate in an effort to sort of discover whether or not they have cancer. And there’s still a lot of questions about whether that makes any difference. So in this study, they studied almost 40,000 people who were 50 to 60 years old who underwent regular prostate-specific antigen, PSA screening. And those who had three or higher underwent magnetic resonance imaging, MRI—something in your field, Howie—of the prostate.

And then a third of them were randomly assigned to a group that underwent systematic biopsy and it’s as well as any targeted biopsy. So what they did was, a targeted biopsy is, “I see something, I’m going to try to take a piece of that.” A systematic biopsy is to say like, “Well, let’s start punching holes in different parts of the prostate and see if we discover anything.” And the remaining were just, underwent a MRI-target biopsy only.

The primary outcome was who had clinically insignificant prostate cancer? And then who had significant prostate cancer? And so the interesting thing was, first of all, for example, in the whole group, there weren’t that many cases of prostate cancer. It was 0.6% of those who were in this experimental group that underwent the MRI. And then they also did the systematic biopsies, ended up with a diagnosis of clinically insignificant prostate cancer, compared to 1.2% in the reference group.

And also with clinically significant cancer, there was no really difference between the groups. There was no significant difference between the groups. And so basically people were saying as a conclusion here that you could avoid these systematic biopsies where you’re just going blindly in different parts of the prostate, in favor of an MRI-directed, -targeted biopsy for screening and early detection.

Makes a lot of sense. So basically saying if you see something, it’s worth getting. If you don’t see anything, then just kind of going into the prostate just because there’s a high PSA test and just sort of sampling, randomly sampling different places doesn’t really pay off. I don’t know, what did you think of this paper, Howie? I know you took a look at it.

Howard Forman: Yeah. First of all, I think what strikes me as amazing is that we’re 35 years into prostate-specific antigen screening, and we still don’t really know precisely what we’re doing. And it’s useful for our listeners to know prostate cancer is somewhat unusual, in that it is practically an expected disease of aging in men. If you live long enough, most men will have some prostate cancer in their prostate gland at death, but it won’t be killing them.

Harlan Krumholz: Maybe we shouldn’t even be calling it cancer. I mean the word cancer is so charged.

Howard Forman: Right. It’s a disease of aging, is that these cells start to look a little unusual, but in most cases it’s not going to kill them. But the surgery is, even under the best surgical hands, is a huge intervention. It leaves a large number with some degree of incontinence; it leaves an even larger number with impotence. There is a risk of mortality. It’s a long recovery.

And so our goal should be to operate only on the people for which the prostate cancer is actually going to kill them or otherwise interfere with their life. And this paper gets us a little bit closer to avoiding doing some of those surgeries and some of those pre-interventions that really aren’t necessary. But again, 35 years in and we’re slowly making this progress, and this is what science is, it takes time.

Harlan Krumholz: And I just sort of like the lesson to say that screening, if you’ve got a reason, you see something, you want to see whether or not it represents prostate cancer, that might be a good thing to do. But when you don’t see anything, sort of blindly going into the prostate, you’re just like taking 10, 12 punctures in order to try to see whether you can just by luck, find something. It never made sense to me, anyway. But anyway, it’s good to see a study out that helps guide things. And anyway, I wanted to share this, just out yesterday.

Howard Forman: Yeah, no, I thought it was useful. And look, we’ve been doing MR research on the prostate for over 30 years right now. And it’s not as quick as people think it is, but hopefully a step in the right direction.

Harlan Krumholz: Yep. Hey, let’s get onto our guest.

Howard Forman: Dr. Kristen Nwanyanwu is an ophthalmologist and Associate Professor of Ophthalmology and Visual Science at the Yale School of Medicine. She specializes in vitreoretinal surgery, and her research focuses on diabetic retinopathy and access to eyecare. Dr. Nwanyanwu is the principal investigator at the NIH-funded Sight-Saving Engagement and Evaluation in New Haven, or SEEN program, which seeks to decrease preventable blindness and diabetic retinopathy.

Dr. Nwanyanwu is also the founder of Eyeful, a luxury lifestyle brand that designs products for eye doctors, that we’ll hopefully talk a little more about soon. She received her bachelor’s degree in African American Studies and Biochemistry at the University of Michigan. She received her medical degree and MBA at the University of Pennsylvania and the Wharton School, respectively. She completed her master of health science through Yale’s YCCI Junior Faculty Scholars program.

So I want to start off by talking about your core clinical and research interest, which is diabetic retinopathy. We have an audience that, from my point of view, learns an awful lot about individuals, but sometimes they don’t learn a lot about what medicine is like. And diabetic retinopathy is a very serious and increasing problem. Can you tell us a little about what is it? What could we do to prevent it? And how do we monitor it?

Kristen Nwanyanwu: Sure. Diabetic retinopathy is one of the devastating complications of diabetes. And the risk factors for diabetic retinopathy are glycemic control, duration of disease, and then a whole host of other things. Some of them that are systems, metabolic risk factors, but also the social determinants of health and the life things that we know cause advanced disease in other areas.

I became interested in diabetic retinopathy when I fell in love with the eye. And then I also have a spirit of activism and advocacy and social justice. And to me, I was able to marry my level of ophthalmology with something that was available for me to be able to use some of the skills that I had had to fight for people to fight for their best vision. And so I spend a lot of my time doing that. And I get to pair all of that together, and it’s just a really awesome gift.

I’m a surgeon. I’m a vitreoretinal surgeon. And the reason that I pursued beyond a residency in ophthalmology—so, ophthalmology residency requires a year of internship, three years of ophthalmology, and then to become a retinal surgeon, you have to do two more—and so I added those two because I really wanted to be at the very severe levels of diabetic eye disease. And so you need surgery if it gets to be that bad. And I wanted to be able to treat that whole spectrum of disease—but hopefully through my work, put myself out of business.

Howard Forman: Since you touched on it now, I want to just briefly touch on the activism point that you mentioned. Because you became activated during I think your undergraduate years when the University of Michigan was facing or maybe had just faced the affirmative action case. Can you just briefly talk about that? Because I think it informs a lot of our other dialogue.

Kristen Nwanyanwu: Sure. So I was actually an intervener for the case in high school.

Howard Forman: Wow.

Kristen Nwanyanwu: From the perspective of an underrepresented student who would benefit from the critical mass of Black and brown students and that would be able to benefit from that environment in school, honestly. And so just an intervener in a case is someone that comes from a different perspective. So not exactly the plaintiff, not exactly the defendant, but someone who says, “Wait, I have a stake in this game too.”

So I was approached by an organization to be able to participate in that. And so when I got to University of Michigan, I wasn’t sure I was going to go to U of M, but I lived in Ann Arbor. So when I got to University of Michigan, it was a natural extension for me to kind of join the activism that was going on about access to education, about diversity, about all of the things that were important to me. And it just made sense.

So I spent a lot of time in the Black Student Union. We organized buses to D.C., we organized protests around the administrative offices. And my mom used to always tell me she was—I’m the first doctor in my family—and she would say, “I don’t think doctors do that.” And I told her, I was like, “Well, this one does.”

And I think that’s kind of how I’ve lived. That’s kind of how I’ve moved through the world in the work that I do. And the people that I gravitate towards kind of have that feeling and their work that they do is bigger than treating patients. And the way that I am an activist is through my disparities work, through my health equity lens, through kind of thinking about how people access care. And it’s just an honor to be able to do that at such a high level, honestly.

Harlan Krumholz: One thing I wanted to ask you was about the issue of blindness in this country because I sort of have the feeling that people don’t think about it that much anymore. I mean there was a period of time where, I don’t know, it was sort of more on the radar and especially associated with diabetes.

I mean as we’ve gotten better in treatment of diabetes, I would’ve thought blindness has gone down in terms of a major threat to folks. But I wonder if you can just give us a sense of what is the state of sight in the country today? I mean, is it a major threat? What is it that is happening with regard to the trends in sight in the United States today?

Kristen Nwanyanwu: We are just talking about this, and we talk about it in terms of social determinants of health, actually. And we talk about it and who has access? And the number one cause of preventable blindness actually in the world is undiagnosed refractive error, honestly. It’s like people that need glasses that don’t get them. So there’s still a fair amount of that, very small, but there’s still a fair amount of that.

And then with regards to diabetic retinopathy, which is my expertise, as we have gotten better with glycemic control, we definitely have gotten better decreasing the amount of preventable blindness. But what we also see is that there’s a chasm between who has access to great care, and all of the technological advances, and the new generations of medications, and who can manage their glycemic control, and then who cannot. And the blindness that is from diabetes is disproportionately in Black communities, it’s in Latino/Latina communities, and it’s in indigenous populations. It’s in places with low resources, and there are clear reasons for that.

And so what I’ve noticed is that while the rest of the community is moving on to this other stage of management, there’s a large subset of folks that to me, it feels left behind. Recently I was giving a talk at the American Diabetes Association, which I’ve become active in. And these wonderful researchers were talking about all their advances, and they have great videos on how they use our continuous glucose monitoring to make sure they stay in range. And it’s just the technology that they had available to them to allow them to have a more normal life.

I found myself feeling very envious, honestly, because I think about my patients that I see in my clinic that have retinopathy, that are losing sight in their 30s, and there’s so many of those things that aren’t available to them. I think that the organizations like the American Diabetes Association have changed to try to focus more on equity and the policies, I think that’s big P, I mean we’ve heard a lot about insulin costs and things like that, but I think also access to technology because continuous glucose monitoring is a game changer. And so access to technology is something that’s really going to be important too. And we will see even further decrease in blindness, amputations, and otherwise, once we’re able to one, say out loud that these are the chasms that we have.

Two, get the appropriate data in all those different spheres about where we’re missing? And what are the levers that we need to be able to move that around? And then three, to be able to be in community and engage community about how we can create solutions that work better there?

Because I have an anecdote. I had a conversation with a 19-year-old who was in the juvenile justice system. And he had recently come for a check for his eyes, diabetic retinopathy. Didn’t have it. He had improved his A1C being in juvenile justice system by five points, better, A1C down 5%, which is crazy and amazing. Perfect, great for his heart.

But what he said about continuous glucose monitoring was that he didn’t want chips inside of him or the technology wasn’t something that he was interested in. And so what I explained to him about, I explained to him and sent him to the website of all these other folks that are living these lives with these wonderful devices, to talk to him about what’s available. But it’s just, it’s there. It’s in those conversations, it’s in community. It’s figuring out how we can get the best to folks that would benefit from it the most.

Harlan Krumholz: I was in a talk this morning where Rob Califf, who’s the FDA Commissioner, was reflecting on a few things. But he quoted something from, he said he thought it was from Ed Young from an Atlantic article where he said, “Technologic solution walks into the penthouses of America and diseases seep into the cracks in America.” And sometimes these advances that help prevent things only do go to the penthouses and not to folks who could need it most.

You wrote in one of your pieces, “In our health system, Black, Latinx, and Indigenous persons and those with less socioeconomic privilege go blind at a disproportionate rate compared with White, more privileged individuals.” It’s what you’re reflecting on now. But can you give us just some sense of what is the proportion? What is the extra risk that’s borne by Black, Latinx, Indigenous persons and those with less socioeconomic privilege? What is that multiple? How much more at risk are they of going blind in this country than those who are more privileged?

Kristen Nwanyanwu: Good question. When we look at the numbers, it’s hard to tell exactly, but usually about two or three more times, honestly. And oftentimes the—

Harlan Krumholz: That’s big, that’s a big number.

Kristen Nwanyanwu: ...way that we see it is also different, so yeah. And we oftentimes don’t see it as soon. So those folks are oftentimes diagnosed later in stages as well, in the stage of the disease. So by the time you get to them, you’re already further along in the disease process as well, which is also pretty devastating.

Howard Forman: So I wanted to pivot just a tiny bit to a paper that you wrote describing the current state of ophthalmology faculty in the United States. And you pointed out that ophthalmology is the third worst in terms of representation of underrepresented minorities.

And what struck me about it is that the two worst specialties were orthopedic surgery and my specialty, radiology. And I’m very aware, it’s a visibly aware problem in radiology. But I’m curious to know what you think, how are you diagnosing the problem? And what are the solutions? Because I know you’re part of helping think about those solutions.

Kristen Nwanyanwu: There’s a large, well not a large body of work, but a long body of work in ophthalmology to try to figure out pipeline. That’s where we spend the most time. The National Medical Association—which is the Black doctors association—Ophthalmology Section has a 20-year-old partnership with the NIH. Where they bring those underrepresented in medicine and also those that are doing work in disparities and equity to the national meeting every year.

They introduce them to the program officers in the NIH. They also introduce them to each other. And so I actually have a cohort of folks that I met when I was an intern, where we have kind of progressed together along this journey, and at the last meeting I was at, they brought 100 underrepresented students to the meeting to give posters and to come be in community with all of the rest of us.

I think part of it is that, and then one of my colleagues that’s been working with the AAMC for a long time and is an ophthalmologist, is Dr. O’Rese Knight. And he talks about holistic review because we are really having to identify what are the real characteristics that makes a great ophthalmologist?

And some of the things that we have solved for previously are not what makes great ophthalmologists. And figuring out exactly what those are, and how to be inclusive in the next generation to include folks that will amplify the care towards our populations that are now not getting enough care, and to increase that congruence, is something that’s really important. And so he is talking about how to figure out who should be in that next generation. What are the important pipeline components there?

Harlan Krumholz: The one thing I wanted to ask you also was you wrote a piece about addressing disparities in ophthalmic research. And you wrote something I thought that was very interesting that I wanted to explore with you a little bit. And you called for increasing, you and your colleagues called for, increasing research funding to study health disparities and for researchers from minority groups. To particularly fund people from these groups as part of this research.

And there were issues you called out, which I think are really important, which have to do with the idea that it seems like that if you look objectively at the funding strategies within the NIH and who gets funded, that there has been a systematic bias against investigators of color. And this to me was very striking when it came out of the NIH. And I’m not sure whether they fully have addressed it.

But there’s another side of this was, when should—so we should correct that for sure—but when should race be considered in funding decisions in terms of race of the investigator? I was trying to get to that from your piece. I mean when is that legitimate and important to be part of the consideration in the funding decision around a particular topic?

Kristen Nwanyanwu: Oh, that’s interesting. I think I appreciate your thoughtfulness, Harlan, because I don’t think I ever have really thought about and made that exact jump. So I think it’s important. I think race is important because it influences the questions.

For me as a Black woman, the questions I ask are definitely influenced by my life experience. And if we think about Dr. Camara Jones always talks about the system of advantages and the systems of disadvantages. And there is a certain set of disadvantages that I have endured. Now I’m in an Ivy League institution, there’s a certain set of advantages that I have also endured. But I don’t ever think I conceptualize kind of how that comes into play or how we would be able to put that into systems.

And I think there are places that are trying to do that. So I am familiar with the AIM-AHEAD Initiative. Are you familiar with this? It’s an artificial intelligence initiative funded by the NIH, but housed at North Texas, to try to increase the underrepresented voices in AI, actually in AI and health research.

And the way that they’re doing it is that they’re partnering with minority-serving institutions and trying to build capacity on a PhD level to be able to advance that science from those perspectives. And so I think that that’s a lens that we can use and for places that predominantly serve those areas. But I really want to make sure that folks have the opportunity to ask their questions.

Currently, if we have an iris registry in ophthalmology and there’s only a certain subset of folks that can access that. There’s a lot of different reasons for that. But part of it is because we know that data. Oh, we get to talk about data! And we know that data can generate a lot of revenue. I have worked with Optum database before, and there’s a lot of value there and you can sell data.

And so I think part of this is who has access to those data, and then who can ask the questions? And I think if you change who can ask the questions and you broaden that pool of who can ask questions of these specific databases, you may end up with a different story going forward. But exactly how you would do that with race, I’m not sure.

I mean we’ve had conversation on data governance before, which I’m really totally into and we have to follow up with that. Because I think that that’s also important to the other end of the data. And communities that have been historically excluded and how to include them in not only the data governance but also the profit sharing that comes from data, as a way to build generational wealth, I think is also something that’s exciting to be able to think about, too.

Harlan Krumholz: Yeah, no, I think there’s a good point. Just to feed in one second, Howie. Just because when you’re in the group and you’re talking about should this group be favored in some ways? It can often be difficult. I’ll say from my perspective, look, we’ve got to be honest about what our history is. And also where we are today with regard to numbers of investigators, the diversity of voices, and the perspectives that people bring to the research.

So I sort of think that this is something to consider, and it may disadvantage some others in some ways. But it’s incumbent upon us to create opportunities across a broad swath of people of different backgrounds and history. But you can’t get away from the structural racism in this country. That people have been systematically disadvantaged for years. And even when you don’t think it would happen anymore, then you study it systematically, and you say, “It’s still happening, still happening.”

And so I think it’s something that is fair for us to be able to say that, “Yeah, we are purposely taking into account the kind of a value that people bring to studies, both from their background and as well as their scholarship.” Of course, the questions have to be good; the science has to be strong. But given equivalent opportunities then we should be leaning and recognizing that one of the goals of the funding is to help create diverse group of investigators. I mean it is, it just simply is.

Howard Forman: I want to end up on, without forgetting to talk about Eyeful. Because you went to Wharton a few years after I went to Wharton, but you got your MBA there. And my experience is that I almost can’t find a physician that doesn’t have some type of startup. But your startup is very interesting and maybe you can tell our audience about how it meets a need, why you did it, and what you’ve learned from it so far?

Kristen Nwanyanwu: So when I was a new faculty member, I used to wear a full suit to clinic as a retina surgeon. And then I’d pull up this case that had my lenses in it that looked like it got ran over by a truck. And I was a young-looking surgeon trying to get people to believe that I could do great surgery on them. And I didn’t believe that that inspired confidence, this run over by a truck.

So I went on Amazon and I looked to see what I could find, and I couldn’t find anything. And the lens case companies vertically integrated, so they make the cases for the lenses and there were really no other options. And so two years later I looked again; still couldn’t find anything. So then I called my Wharton friends, I said, “Hey, how do you make something?”

And so I started down that path of asking my friends, “Your ideal lens case, what would it have in it? What would it include?” Proud to say we just launched our newest product, which is actually our case, subspecialty case that has room for all the different lenses. It’s secure, it’s beautiful.

And I think it’s a fun space because I am not a drug company, and I’m not in pharma, and I’m in, kind of in fashion. And so I get to be in different rooms. So I get to be in the business side, but I also don’t have a lot of rules about what happens when I’m chatting with people about my company. And people are very into it.

So my dream is to be a leading luxury brand for doctors. So we’re going to do loupes cases. And people are always telling me what they think it should be. And you should have to have something that’s elegant and be a doctor anyway.

So it’s a lot of fun. I have had events at the academy and lots of different conferences and people are really into it. It’s some people like crochet, but my baby is building Eyeful, and it’s a beautiful, beautiful journey.

And I’ll say when I left business school I was like, “Oh, I chose medicine.” And I think I thought I would leave it behind. But business has permeated so many of the things that I do, from building interventions to thinking about cost-effective strategies for equity to even doing Eyeful. And it’s just been a beautiful journey, and I just love being on it. I’m having a blast.

Howard Forman: Well, I want to say because our listeners won’t get to see what you look like, but you are elegant and you deserve to have elegant around you. So I appreciate that you’re filling that need. I want to thank you so much for joining us on the Health & Veritas podcast. You are an amazing person.

Kristen Nwanyanwu: Thank you all.

Harlan Krumholz: Well, that was great. Kristen’s amazing. Howie, let’s get to the next segment. So what’s been on your mind this week?

Howard Forman: Yeah, so it’s a fun thing. You and I both noticed this on, maybe I noticed it on Twitter, but both of us seemed to notice that there was a lot of chatter about this novel technology called ChatGPT, which was released just last week. So it’s very new.

It allows you to basically enter questions or simple instructions. And in a matter of a few seconds to maybe a minute, a fairly well-done paper answer is delivered to you. And what is GPT? GPT stands for “generative pre-trained transformer.” It’s a type of language model that uses deep learning techniques, machine learning, to generate natural-sounding texts.

So ChatGPT, it’s a chatbot that uses a GPT-based model to generate responses to user input. So I was skeptical that this could be anything interesting because most of my life, people have talked about what AI could do and being able to have a conversation with something. But I tried it four different ways. I gave it four assignments.

I asked it to suggest 10 different topics for our podcast. I asked it to write a letter to an insurance company pleading to cover physical therapy. I asked it to write a short letter at a third-grade level supporting daily exercise. And I asked it to create a frequently asked question list for diabetics around what they should be thinking about and why they should do glucose monitoring?

And I’ll be honest with you, this blew my mind how good it is. And I’m not going to waste people’s time with all of them. But just to say they were all equally good in their response. And I’m going to quickly read you, maybe too quick, but I think you’ll get the idea. The insurance company letter. This is generated by a chatbot:

“I am writing to explain why physical therapy is necessary from my patient, a 50-year-old man with severe back pain. Physical therapy is an effective treatment from chronic back pain as it can help to improve flexibility, strength, and range of motion. It’s particularly important for my patient who has been experiencing severe pain and limited mobility due to his condition. In addition to providing relief from pain, physical therapy can also help to prevent the development of more serious conditions such as muscle atrophy or joint stiffness. By providing targeted exercises and stretches, physical therapy can help to reduce the risk of these complications and improve my patient’s overall health and wellbeing. Furthermore, physical therapy is a cost-effective treatment option, as it can often reduce the need for more invasive and expensive interventions such as surgery. By providing coverage for physical therapy, you can help to ensure that my patient receives the care he needs to manage his condition and improve his quality of life. I strongly recommend that you approve coverage for physical therapy for my patient as it is a necessary and effective treatment for his chronic back pain. Thank you for considering my request.”

And so I’m just blown away by this. And I was curious to know what you thought. I know you played around with it a little bit, and just curious to know what your thoughts are on how far we’ve come with AI now?

Harlan Krumholz: I think this is a historic moment in the history of computing and it’s because of the way that the application is configured. I challenge anyone take a look. You could say like, “Yeah, write a tweet about dogs.” You can say, “Write lyrics to a song about Howie falling in love, using the style of Jay-Z.”

Howard Forman: Exactly.

Harlan Krumholz: I mean, you can say anything, and what it comes back with is amazing. Not only that, it’s almost instantaneous. People are using this. I’m going to say, I’m going to start using this in place of Google search because you want to know an answer to something? You basically are just querying this thing. But it’s people using it to write letters.

The question is, will it start writing scripts? How will it replace people? But I liken this to, well, plagiarism may be harder to detect under these circumstances. I liken it to when Mosaic was released, well, you finally had an interface with the internet that allowed you to search the web.

And people may remember Mosaic coming out in the early ’90s as a precursor to... [Marc] Andreessen was involved in this, it was to all the browsers that followed. I’ve never seen anything like this. And anyway it’s on OpenAI. You develop an account, you can go into the ChatGPT—

Howard Forman: It’s free.

Harlan Krumholz: ... and give it a try. It’s free. And just mark my words, this is—

Howard Forman: I agree.

Harlan Krumholz: This is another moment where we’re going to have to figure out how can we handle the technology? Because it changes everything. You didn’t even have to draft that letter, that letter’s perfect. Send it.

Howard Forman: Oh, I know. I know. And when I got my frequently asked questions about diabetes monitoring of glucose, I thought to myself, maybe they just found this on someone else’s site. So I took the entire text and I ran it through the plagiarism software that Yale purchases commercially just to see what it was going to find. Because it does a really good job. And it has less plagiarism in it, so-called plagiarism, than a typical paper. It has little parts of it where phrases are used, but it’s not plagiarized, it’s generated.

Harlan Krumholz: It’s incredible how it can jump to different styles and its versatility is a match. Hey, it’s a new world, Howie. It’s a new world. It’s a new world.

Howard Forman: It’s exciting.

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 find us on Twitter.

Harlan Krumholz: @hmkyale. That’s HMKYale.

Howard Forman: And I’m @thehowie. That’s at 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. Or you can check out our website at som.yale.edu/EMBA.

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

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