Lee Schwamm: Smarter Healthcare Systems With AI

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. Our guest today is Dr. Lee Schwamm, but first we always like to check in on what’s a hot topic or a current topic in health and healthcare. Harlan, what do you have today?

Harlan Krumholz: Well, Howie, today I want to talk about the compounding of anti-obesity medications like Ozempic and Wegovy. That’s an interest of yours, isn’t it?

Howard Forman: Look, I’ve been fascinated, but you’re the one who brought it to the podcast in one of our earliest episodes. So I’m fascinated by this topic on a lot of levels. So—

Harlan Krumholz: Well, and for people listening, we’ve talked a lot about these drugs, but today I want to talk about the compounding of them. So these medications are really game changers in the fight against obesity, and we’re learning that they’re having tremendous impact on a wide variety of other disease conditions, either by mitigating, even curing, reversing. It’s amazing. And so Ozempic and Wegovy, which are based on semaglutide, and then there’s... Lilly produces a drug, Mounjaro or Zepbound based on tirzepatide, have really shown incredible results in helping people lose weight and improve their overall health. And I’ve told you before, I really think about them as health promoters. It’s not so much about “is it making you look better” or even weight loss, it’s about what is it doing for your cardiometabolic system and to what extent is it improving your health. So the thing is, their popularity though has led to a significant problem: shortages.

And of course there are a lot of people who don’t have obesity who are using these drugs these days. So there’s a lot of things going on, and they’re being used for diabetes. People with diabetes also use these drugs. So there’s a lot of pressure on the supply chain for these medications. And it’s so bad that I heard that this week there was somebody who was trying to get the drug from CVS and they were told it’s nowhere to be found. No CVS has, right now, any of these medications for—at certain doses. They said, even with... “Do I have to go to New York or Boston?” It’s really not in this part of Connecticut right now. So that’s what people are facing. In response to these shortages, many people are turning to what are called “compounded” versions of these medications. So what is that? That’s pharmacies that really actually mix and create these medications for each patient and now are producing these to meet this high demand.

And so what we mean is, when Novo Nordisk produces Ozempic, they’re doing so in big factories under a lot of scrutiny, and they’re producing their product that you’re buying, and so is Lilly. But the fact is that, even though they are covered by patents, people can get the materials that produce these drugs and in their own pharmacies actually create medications that they can distribute.

Howard Forman: But just for our listeners to be clear, this only will apply if the FDA has asserted that there is a shortage in the drug, if not—

Harlan Krumholz: In a shortage period. So that’s why when you see on TV, people are advertising, “Hey, we can get you like Ro or Hims and Hers,” that they’re saying they can get you these medications. Largely what they’re providing are medications from compounding pharmacies, not from the Novo Nordisk and from Lilly. So let’s talk about the regulatory framework a minute that allows this to occur. As you said, Howie, the FDA oversees this under the Drug Quality and Security Act of 2013. Now, this was passed in response to a really tragic event that had occurred the year before when... people have been compounding drugs for a long time, but there had been a contaminated compounded steroid that led to an outbreak of fungal meningitis. I don’t know if you remember that, Howie.

Howard Forman: Well, we talked about it on the podcast a few months ago, as related—

Harlan Krumholz: Oh, that’s right. We did. That’s right. We did.

Howard Forman: Because of the issue in Mexico.

Harlan Krumholz: So this resulted over about 60 deaths. So imagine people were just getting something from the pharmacy, and the fact that this was contaminated led to 60 deaths. So Congress passed this statute that created two categories of compounding pharmacies, and the numbers they gave them were, they’re just called 503A and 503B. For this A, they’re traditional compounding pharmacies that make medications tailored to individual patients based on specific prescriptions, and they’re regulated primarily by state boards of pharmacy. So, Howie, these are not overseen by the FDA. And the final—

Howard Forman: And they’re meant to be local, I believe. Because the FDA really deals with interstate commerce. The compounding pharmacies were meant to be local. That was the original intention.

Harlan Krumholz: Meant to be, but still they can distribute broadly the B ones. So there’s 503A and 503B are known as outsourcing facilities. And these can produce larger quantities of these medications without individual prescriptions. So again, the smaller local ones are getting an individual prescription and are making the Ozempic for you, essentially, wouldn’t be Ozempic, but it’s this—Ozempic.

Howard Forman: The active ingredient. Right.

Harlan Krumholz: The active ingredient. With the 503B are making just large quantities, and then when a prescription comes in, they can distribute, they are regulated by the FDA, there’s more oversight. But here’s an important thing: Compounded drugs are not FDA-approved.

Howard Forman: Right. Correct.

Harlan Krumholz: So that’s wild. People are actually getting products that are not FDA-approved. They don’t review these drugs to evaluate their safety effectiveness or quality. So there’s a whole bunch of people and a high percentage of people throughout the country who are now getting these anti-obesity medications through compounded pharmacies without knowledge of whether or not these are highly effective. They’re basically Wegovy knockoffs. And the question is, “Are these knockoffs as good as the real thing?” People don’t know. And so let alone whether or not these can be made under non-sterile conditions or whether they skip essential contaminant tests, there’s a whole bunch of stuff around it. And the interesting last thing about this is, but because they’re being made like this, they’re actually much cheaper. So there’s the shortage issue, but there’s a high incentive for people who have poor insurance to actually use these pharmacies because rather than costing a thousand bucks a month, these can be selling them for a hundred to several hundred dollars a month.

And that affordability is driving many people to opt for these. And so the concern is at the risk of safety. So the take-homes I think here is that for anyone who’s actually using these medications, you need to know the difference between the well-studied highly regulated FDA-approved medications and these compounded versions, which may vary substantially, haven’t been really tested, are not FDA-approved, are addressing the shortage. But you can’t be 100% assured that this is the same as the real thing.

Howard Forman: And different delivery systems, by the way. They use, instead of prefilled syringes that are a fixed dose, you have to draw it up yourself. I mean, it’s different deliveries.

Harlan Krumholz: Sometimes, by the way, that’s one thing that’s leading to the shortage is actually the delivery system—

Howard Forman: I know. Yeah.

Harlan Krumholz: ... because the companies are making enough of the drug, but they’ve got to be able to have enough of these syringes. And one of the things I was looking up online, I was looking at some of these companies that are providing these services, it was impossible to tell where they’re getting it from. And by the way, most of these components, they’re coming from companies in China that are selling them—

Howard Forman: That’s right. APIs.

Harlan Krumholz: ... in companies you’ve never heard of. Maybe some of them are actually even working with Nordisk or Lilly for them, but presumably with a little greater oversight. So I just wanted to introduce this because many people are not realizing that this is a whole side industry that’s being developed to address the shortage, but the oversight’s very different than from what is coming from the companies. By the way, the companies are suing in many cases, trying to constrain this market.

Howard Forman: Right. Well, we’re going to see what happens. What will really be interesting is when supply comes online, and these companies are no longer allowed to distribute it under the shortage agreements. So—

Harlan Krumholz: Well, people have been saying that this is creating a lot of revenue for the companies, so it’s likely to go away once this goes away. So it’s inflating their valuation. But the question is, “Is it sustainable?”

Hey, let’s get on to Lee Schwamm. It will be a great guest today.

Howard Forman: Dr. Lee Schwamm is the associate dean for digital strategy and transformation at the Yale School of Medicine as well as the senior vice president and chief digital health officer for Yale New Haven Health System. In these roles, he promotes the equitable adoption of virtual care as well as the development of a novel system-wide digital health strategy. Before coming to Yale, Dr. Schwamm held various leadership positions within the Mass General Brigham Health System and Harvard Medical School. He is widely recognized as a leader in both telehealth and stroke care and has helped shape many of the guidelines and journals in these fields. He has received some of the highest honors within his field leading the transformation of stroke care globally. He holds a bachelor’s degree in philosophy from Harvard University and a medical degree from Harvard Medical School. He completed his internship at Beth Israel Hospital and his residency in fellowship in neurology at Mass General Hospital.

So first of all, it’s not even the first time we have you on the podcast because you helped bail us out during our live event just about eight weeks ago, and I appreciate that. But this time we were prepared for you because our great research assistants prepared the dossier, and I learned a lot more about you. And I wanted to start off with the really touching tribute that was given to you at the AHA when you received, I think, one of their highest honors or their highest honor. And part of it was the fact that your son, who I believe is or was a medical student at the time, was part of that tribute. And one of the things that struck me is from knowing what I knew about you before that I’ve always thought of you as this amazing investigator and a leader in innovation, but what I didn’t realize, just how transformative you’ve been in individual encounters with patients in stroke care.

There’s a testimonial from a patient in there as well. I want you just to reflect on what it’s like to have a career where you’re really firing on all burners, where you’re truly doing patient care at the highest, highest, highest level, and also one of the most highly cited stroke researchers and telehealth innovators and so on. If you could just start off with that.

Lee Schwamm: Well, if I’d known, I would’ve told my mother to join the podcast! Thank you. That’s a very generous introduction. There is a way in which I feel like the work that I do is part of what I was supposed to do if I was a doctor. I think for all of us who practice medicine at the bedside, first of all, you realize right away what a privilege, what an honor to have such an intimate engagement with patients and their lives and their families. You meet them at moments of tremendous vulnerability. You have this incredible window into their soul and an opportunity to make such a big difference in their life. And you start to feed that machine. It just is what gets you up at three in the morning when there’s an acute stroke. It’s what takes you to clinic every week despite the burden and all the other challenges of practicing medicine.

But then you quickly start to realize, well, there’s only five work days in a week, and there’s only 46 or to 50 weeks of work in the year, and a new patient I see for an hour. Like, that’s not that many patients that I will touch in the course of a year. And if I attend on the in-patient service, I can multiply that by a bit because I see more patients a day in that context. But you quickly realize if you really want to have an impact in people’s lives, you’ve got to go upstream. And actually it’s one of the things about Harlan that I have so admired over the decades is how he has gone upstream to really change the levers of care delivery, working with CMS, and building out core. There’s no question that space, that transformation space is an opportunity to change care for millions of people, not just hundreds or thousands of people.

So I feel fortunate that my work enabled me to accomplish in that space, but even if it hadn’t been successful, I still feel we all have an obligation as clinicians and, especially, as physicians to manage every patient who we encounter with that disease. Not just the person in our waiting room, but it’s the person who’s hoping to get in to see you six or eight or 10 months from now. How do you help manage that patient within that same envelope? So I guess, that’d be my long and short answer to that question.

Howard Forman: Great.

Harlan Krumholz: As great as Lee is, he’s actually married to someone... okay, I’m going to say is even greater. She’s amazing. She’s a world-renowned anesthesiologist who leads our department of anesthesiology, and every time I get the chance to interact with her, I’m just so impressed. And I wanted to ask you, Lee, because more and more there are families where both people are extraordinarily talented and have aspirations to have a high-powered impact on the world. And I’m not saying one way or the other, but in your case, you have two people who really are so high-achieving. What was the secret to your ability to navigate that, given you both must have been so busy professionally and you have a wonderful family, how did you do it?

Lee Schwamm: Thank you. It’s a nice observation to make and it’s one that I try to reinforce a lot with the people that I mentor. I mentor a lot of junior faculty, many of them women, which is that you can’t just carve off your private, your personal life as some extra slice of pie you get for dessert if you finish your day job of your role as a physician. We used to say in residency, the later you stay, the later you stay. You can stay till midnight every night, but you’re not changing the world by staying till midnight, where you have a life, you have a family, you have other commitments that you have to prioritize. But I would say the secret to our success in that regard is... and my wife is Lisa Leffert and she’s the chair of anesthesia.

Howard Forman: Oh, actually, I’m sorry.

Lee Schwamm: That’s okay.

Howard Forman: I didn’t mention—

Harlan Krumholz: And the former guest of the podcast, say that.

Lee Schwamm: She was recruited here first. So the wisdom goes to Nancy Brown and her colleagues for having the foresight to recruit Lisa was really... it’s about taking turns. There’ll be different moments in your life where different things are important to you and your spouse or your partner, or if you’re a single parent to the people that you rely on to help you. And you’ve got to be willing to take turns. And we did that in our lives through the raising of our kids and how we structured our day. And I have to say, I consider myself extremely lucky because my wife had to be in the OR at 6:00 a.m. a lot when we were first raising kids. And I didn’t.

Now, I didn’t think it was possible for me to say to people at work, “I can’t make an 8:00 meeting, I have to drop my kids off at school.” But because I had to, I had the foundation of this fantastic relationship with my kids and their friends, and I walked my kids or drove them to school pretty much every morning from elementary school through high school, and that created this fabric in our family of, “Yes, mommy and daddy work hard,” but we’re always available.

Howard Forman: I wanted to go back to the administrative role you have here now, the digital health leadership role. You were an early innovator in digital health. I mean, much of the guidelines and the development, the processes around stroke care and telestroke services are built on either work that you’ve done or work that you’ve collaborated with. I’m curious to hear how you, through the pandemic, where we’ve gone through, and I know you arrived late in that cycle, but we’ve gone through this cycle of telehealth where telehealth spiked a lot during the pandemic. Now it’s waning. There are some incentives that have caused some of the waning to occur. I’m wondering what should the public look forward to in the future in terms of institutional telehealth delivery?

Lee Schwamm: Yeah. I want to just give us a little bit of perspective. Because if we never had the pandemic and we launched this concept of telehealth and we managed to get some reimbursement for it, and we saw 15% of all ambulatory volume shift to telehealth, we would be getting the Nobel Prize in Sweden. People would be like, “Oh my God, it’s the fastest adoption of anything we’ve ever seen. How did you do that?” So this spike of COVID when no one could see the doctor in person was great for breaking down some of those barriers, those energy of activation barriers to get people to try. What I think we have seen, and I’ve had the privilege of actually testifying before Congress twice on this, is if you don’t have a permanent runway for reimbursement, you cannot make the fundamental structural changes you need as a health system to really capitalize on the value of telehealth and other forms of virtual or digital care.

We can’t reap the benefit unless we know that we can get rid of that building. We don’t need a clinic in that building anymore because that clinic is virtual. We could repurpose that space. We could move to a virtual-first approach, for example, where before you went to the doctor’s office, you did a visit first by virtual, and if it can be solved, you’re done. And if it can’t, you came in for the rest of what was needed. We have opportunities to fully redesign how we deliver care, and I do not believe that an incremental approach to trying to digitize our current broken healthcare system will be effective. We have to start from understanding what is the problem statement, what is it that we need to deliver, and then how can we deliver that in the most effective manner possible? Our payment system does not make this an easy journey because our reliance on fee-for-service payments and the differential margin of certain types of care versus other distorts what works to deliver that care.

When you lose money on 80% of what you do and you only have to make it back on the 20%, it’s very distorting to your priorities and your care delivery. So what I would say is, the analogy I often use is when I first got a digital watch, it was just digital numbers of what a watch could do, and now I have an Apple Watch that can do 85 different things, we need to redesign the digital watch for healthcare so that we can deliver all sorts of channels of content, of knowledge, of expertise. And I would say that one of the most exciting things for me right now about generative AI is the opportunity that it offers us to start thinking about getting upstream in that patient journey, delivering better information before there’s a problem, triaging patients to the right solution when there is a problem, resolving a lot of the issues before they have to hit some doctor’s in-basket.

We need to do what every other industry has done to remain competitive, which is to make the system smarter so you don’t rely on the goodwill of people or the willingness to stay to midnight in order to get the work done.

Harlan Krumholz: I’m always taking detours. Let me try another detour here, because I’ve heard you speak about Ambient.ai, and you and I both have a lot of admiration for Shiv Rao and what he’s done with Abridge. I’ve had the privilege of seeing that company from the very beginning, and there are many others getting into this space. It’s becoming quite active. Ambient.ai, for people listening, is the idea that Alexa or Siri, there’s something that you can talk to but listens to you and your interactions, for example, with doctors that can help translate that into notes or actions or even could be done before you see the doctor. So these companies have developed very keen ways to listen and then to translate that into action.

Some people are uncomfortable with that. I mean, they’re in a personal interaction with their physician, one-on-one, and yet there’s some technology around them that’s listening and translating. Tell me a little bit about your thoughts about where’s this going? Is this going to be standard in healthcare? How are patients accepting it? What’s going on? What are we doing with it at Yale New Haven Hospital? I think we’re part of an important pilot with them. Maybe you could just explain a little bit about your thoughts about this technology and where it’s leading.

Lee Schwamm: Yeah. So like you, Harlan, I’ve been following this field for a long time. In fact, I started being interested in voice dictation when it first came out in the late ’90s. And I remember, in fact, my first dictation ever to IBM via voice was the product. And I said, “I’m”—this is like a neurology note—“55-year-old gentleman presents with a lesion in the corona radiata.” The corona radiata is a portion of the brain that connects the surface of the brain down to the centers of the brain. And the text that came back from the voice transcription was “There is a legion in the corner of Arabia.” So I’ve followed this field for a long time. We got really good about 10 years ago, five years ago with voice transcription really becoming 99% accurate. At 95% or 90% accurate, it’s just not worth it. There’s too many typos. Too many substitutions.

But when you get to that, when you reach that threshold point, things really start to change. And there are human transcriptionists just don’t exist anymore except maybe in courtrooms. But what’s happened that’s so transformational with these large language models and with this ambient documentation concept is these aren’t just transcriptions of words; these are translations of concepts. And so this is what we teach medical students how to do, listen to a conversation, ask questions, and then summarize it in a way that they can be consumed by others to help guide clinical care, diagnosis, treatment plans, etc. I think that, and I would just call this, ambient sound because I think sound is just the first part. I think ambient movement is going to become a very important part of how we monitor patients. Now we have some form of ambient movement already. We wear our devices that track whether we’re moving forward or backward in space, but increasingly we’re going to think about, are we upright or are we lying down? And if you fall with an Apple Watch suddenly and you don’t move, it’ll call 911. So we—

Harlan Krumholz: And just for people listening, when you’re using this word “ambient,” when you put it in front of this, what do you mean by that?

Lee Schwamm: Yeah. I mean, I almost think about it like atmospheric, like air conditioning. You only know it’s broken. You never know when it’s working. It creates an environment around you in which passively information can be collected and processed. Because for the first time, we have so much computing power and the ability to push that power right to where the user is located, that we suddenly have an opportunity to take advantage of what I often call digital exhaust. We have all this signal, all this message coming off of us all the time, but we’ve just let it just float up into the atmosphere and disappear. Now we’re going to be able to capture it.

In our in-patient environments, we will, I think within the next few years, have devices that can sense when a patient is likely to get out of bed, to sense when a patient is becoming delirious based solely on how their movement is changing. Is it periodic and varying or is it reducing across all spheres of movement? Is it hyperactive? I think there’s a lot of information that we just don’t collect. And it’s why this concept of remote monitoring or continuous monitoring, I think is, I’ve moved away from those terms. I really talk about patient-generated health data, and I think our ability to capture it, curate it, structure it, and then analyze it in a way that is actionable, that is the big challenge of the next decade. And lots of people are excited about that.

Harlan Krumholz: And one just quick follow-up is since we’re using it now, what kind of reactions are you getting from patients? I assume it’s announced when someone comes in the room, we’ve got this system operational. I mean, how does it work? And just quickly—

Lee Schwamm: Yeah, absolutely. “So Howard, it’s so nice to see you. Harlan, it’s so nice to see you today. We have this new technology that’s powered by AI that can help me pay attention to you and spend my time focused on you during the visit, and it’ll help me prepare my note when we’re all done. Once the note is finalized, shortly thereafter, the recording disappears. That is never saved. Is it okay with you if we use that during today’s visit?” Ninety-nine percent of patients are fine with that.

Harlan Krumholz: People are fine with it. And my final thing, so I saw Mayo and Epic announced something with Abridge. Is that similar to what we’re doing or is it different?

Lee Schwamm: Mayo announced that they’re working with Abridge and Epic on a nursing documentation project. This has been mostly focused around physician and provider. We’re also working with Abridge on nursing documentation pilot as well. So we’re all working together. But Mayo was quick to announce their—

Harlan Krumholz: I feel like Mayo’s just got the big PR engine. We’re actually doing a lot of the work. They’re the ones pushing out the press release.

Lee Schwamm: No shade on them. But yeah, they do a good job of publicizing what they’re doing. And a lot of times I think we are more inwardly focused—

Harlan Krumholz: But I’m just so impressed by all the initiatives you’re doing in AI. It’s really amazing.

Lee Schwamm: Well, I just think it’s also... I just want to add one amazing benefit of this partnership. But part of what you get when that note is done and that visit is over, is an after-visit summary that is meaningful and patient-friendly. Not just a list of your medicines and whether any of them change, which is what our default is today, but an actual summary of what the doctor said, what they found, and what the plan is. Everything we would want to have the patient walk away with can be converted in that after-visit summary. And I think that’s an example of a place that we have neglected or even abandoned that is unacceptable. We must do a better job of helping that patient engage with their care after they leave the office.

Howard Forman: What’s your favorite thing about New Haven now that you’re here?

Lee Schwamm: My favorite thing about New Haven—and I know everyone says the pizza, it’s not what I’m going to say—it’s actually East Rock. We live in the East Rock neighborhood, and there is something just amazing about walking up to the top of East Rock and looking down on this beautiful city with this river running through it. It’s a view of New Haven that I never imagined existed until I actually did that. And we do that with some frequency together, my wife and I, and it’s a very special part of New Haven.

Howard Forman: That’s a good choice. Well, really appreciate you joining us for the podcast and for being at Yale and for being such a great friend.

Harlan Krumholz: Yeah. We’re so lucky you’re here. So lucky you’re here.

Lee Schwamm: Well, this is a great ego boost. So whenever it’s like in the middle of February when I’m really down and low, I’m going to come back and have the same organized—

Harlan Krumholz: You can come back and listen to the podcast—

Howard Forman: Come back anytime. Come back anytime. Thank you.

Harlan Krumholz: It’ll be posted online. You can listen to it every week. Hey, that was a terrific interview.

Howard Forman: Yeah. That was fun.

Harlan Krumholz: I’m so glad we had him on. But, hey, Howie, now to your part, what’s on your mind this week? Just before the hiatus, last time people were going to be able to hear Howie for about a month. Share your wisdom.

Howard Forman: And I too am going to come back to an old topic, but it keeps having updates, and that’s bird flu or H5N1.

Harlan Krumholz: People love when you talk about bird flu.

Howard Forman: I look on TikTok, it’s the single thing that gets me the most attention.

Harlan Krumholz: It’s like part of your greatest hits.

Howard Forman: I realize, but people keep asking for more, and I keep coming back. So a reminder of what we already know. This virus does spread from birds and from cows to humans, and it has generally in humans been associated with mild symptoms, like flu-like type symptoms and mostly conjunctivitis. That’s what we’ve seen. No long-term harm in any of the existing farm workers during this outbreak right now. But we do know it’s highly infectious. And by the way, we are now up to a hundred million poultry having either died or been euthanized during this outbreak. A hundred million. There are 168 dairy herds in 13 states that have been similarly affected. And then you have all the wild birds and everything else as well, mammals as well. But we have some real new news also to tell you about. So first of all, if our listeners remember a few weeks ago, I talked about the fact that the state of Michigan was going to do a seroprevalence study.

They did that study, and they found zero cases, zero cases among asymptomatic individuals tested for exposure to H5N1. And by the way, they separately tested for more usual flu viruses, and they did find incidence of more usual flu viruses in those farm workers. So this is pretty good. This means that we’re not seeing a lot of asymptomatic disease out there, or maybe not any, for what we know. There’s now 10 humans infected with this outbreak, 11 if you go back to 2022; none of them have been serious. And the outbreak in Colorado has turned out to be much worse than originally indicated. We now have seven farm workers infected via poultry, six in the last week. And the question really is, why? Is it due to the very, very high temperatures in that area right now, the specific conditions in Weld County, Colorado, or is something else changed?

It does appear that this outbreak in Colorado, largely tied to poultry but also to dairy farms, is the same virus that is going back and forth between cattle and poultry. So it’s not like we have separate types of viruses circulating. It seems to be the same one that’s moving back and forth and infecting humans that work there. The latest poultry outbreaks of note are three live bird markets in Miami, Florida. So you may not be thinking about this, but there are live bird markets in some communities, and apparently in Miami, Florida, is one of them. And those were found to be infected, and hundreds of birds were euthanized there as well. The CDC is showing no indications of unusual flu activity anywhere in their general tracking and specifically in the states that we’re talking about. And to reassure our listeners who keep asking about this, we are actually doing a lot.

I know there are naysayers out there that are suggesting that our nation isn’t taking this seriously enough. If you do a reading of what the Department of Agriculture is doing, what the CDC is doing, what local public health authorities and local agriculture authorities are doing, they’re doing a lot. Which brings me back to the ongoing theme. Number one, there is no current threat of human-to-human transmission, meaning we’ve not seen a single case, zero, of human-to-human transmission. If this were to change, I would be much, much more concerned, and I would be worried. All evidence does suggest, however, that this will eventually occur, and the longer we allow it to mutate within herds of cattle or other mammals or even birds, the more likely it becomes. But every year that goes by, every month that goes by, buys us time to know how to prepare for this.

Better than that would be if we could eradicate this from our farms right now and slow up the transmission so it’s not occurring in the near future. I expect that when we get back from break, we’re going to have a lot more to report. But still, the two main pieces of advice I can give people, besides not worrying, is no unpasteurized milk and no cheese made from unpasteurized milk. What do you think, Harlan?

Harlan Krumholz: Well, I love your admonition not to worry. That only makes me worry. When somebody tells me, “Don’t worry,” that makes me worry. But—

Howard Forman: Yeah. It’s fair.

Harlan Krumholz: But there are a lot of people who are deeply devoted to unpasteurized milk and unpasteurized cheese.

Howard Forman: It’s a belief system. There’s really no strong evidence of benefit, but there are people that believe there are immune benefits and other nutritional benefits.

Harlan Krumholz: Yeah. Well, thanks for keeping us posted. I think we can watch this, but of everything you said, I love what you said that there’s no evidence of human-to-human transmission. Let’s hope that that keeps going.

Howard Forman: You got it.

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, email us at health.veritas@yale.edu or follow us on any of thesocialmedia.

Harlan Krumholz: And let us know what you think. We’re about to go on hiatus, so our ears are wide open. We’re ready to learn what can we do better. And if you rateus, it helps other people find us

Howard Forman: Really does. Really appreciate it.

Harlan Krumholz: And we appreciate it.

Howard Forman: Yep. And if you have questions about the MBA for Executives program at the Yale School of Management, reach out via email for more information or check out our website at som.yale.edu/emba. As Harlan said, we’re going to go on hiatus right now for the month of August. We’ll be returning in the month of September. In the meantime, though, we will continue to respond to your inquiries and comments, and we look forward to reading them and hopefully getting back to you in September.

Harlan Krumholz: Health & Veritas is produced to the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and our producer, Miranda Shafer. I hope they have a wonderful hiatus because they work so hard—

Howard Forman: Absolutely.

Harlan Krumholz: ... and they help us so much.

Howard Forman: Yep.

Harlan Krumholz: Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Have a great summer. Talk to you soon.