Lisa Sanders: The Art of Diagnosis

Harlan Krumholz: Welcome to Health & Veritas, I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University who are trying to get closer to the truth about health and healthcare. This week we’ll be speaking with Dr. Lisa Sanders. But first, what’s got your recent attention, Harlan?

Harlan Krumholz: Thanks, Howie. There’s just a couple things I thought would be worth going over this week before we get to Lisa, which will be a terrific interview. One is, I just don’t know if you noticed one more paper came out; at least one more preprint was published on ivermectin. And guess what it showed?

Howard Forman: It doesn’t work.

Harlan Krumholz: It doesn’t work. So anyway, this is an NIH study that randomized 1,206 people. They received study medication or placebo, and people were, on average were 48 years old and about 60% were women and many of them had received vaccine doses. But anyway, what they looked at was whether or not ivermectin would help in the recovery time, and it didn’t: 11 days for recovery in the ivermectin group and 11 days in the placebo group. I don’t know how many of these studies that we need to see, but this was another disappointing study for ivermectin. Now I’m wondering, did it really merit all of the money that we spent on the studies? But I guess it did, because so many people were using it.

Howard Forman: It’s a great question, Harlan. I think it was the Brazilian study that was the one that everybody hung their hat on and said, “It works.” And you start to wonder how much fraud may have been underlying that, or at least somebody not being methodologically clear.

Harlan Krumholz: Yeah. Yeah. I want to hop just quickly to the vaccinations. I don’t know, you may have seen this newsletter that Kate Jetelina puts out. It’s actually one of the best things. I like reading what she does, what Topol does. There’s a couple people out there who really are consolidating the literature, but they both actually had columns this week, I think Eric in Substack and Kate Jetelina in her newsletter. But basically, again, hammering home how the evidence for these fall boosters seems to be pretty secure, that there’s greater protection against infection and even maybe some transmission, broader protection that the antibodies we’re producing can see more parts of the virus and attach more strongly compared to the antibodies that we may have had before longer protection. And this week there were a couple new studies out of the U.S. and out of the UK that continued to basically strengthen the evidence behind it.

Two studies in the U.S. by the way and one out of UK that again was suggesting that we get this kind of protection. People need to just be thinking about this again in terms of risk. The way I take it, there are low-risk groups in our population that I’m not going to really go very far to try to persuade them about the vaccines. They’re unlikely to have problems, healthy younger people in general, but for older individuals or those who may be at risk, I can’t see any reason why we wouldn’t try to protect ourselves and why as physicians and public health advocates, we wouldn’t try to encourage people to get this vaccine. So I just wanted to hit that as we get to the holidays, if you have a loved one, particularly 60 and older, 65 and older, I mean really everybody should be vaccinated. The rates are higher in those groups, but lots of people being missed still.

Howard Forman: That was Eric Topol’s message in his newsletter. He said the best gift you could give your family over the holidays is to tell your loved ones, particularly those 60 and older, to get a booster, and couldn’t agree more. And I want to point that Harlan, this is happening at the exact same time that Governor DeSantis in Florida is encouraging the convening of a grand jury to investigate the Covid vaccines for misrepresentation and fraud and other things. And it’s disappointing. I mean, I think this is a dangerous precedent to have an executive official trying to encourage judicial officials to begin an inquiry when the scientific community broadly has not questioned the efficacy. Now, there are a lot of questions about reducing transmission, certainly less than we wanted it to be. Are there side effects? There are, and we’ve talked about them, but it’s a scary time that there are major, very well-respected authorities out there who are discouraging people from vaccines to this day.

Harlan Krumholz: Well, Galileo was questioned quite severely about his idea that the sun was at the center of our solar system.

Howard Forman: Took some time.

Harlan Krumholz: There’s a long history of this, but it is disappointing when the evidence is so strong that these vaccines really were major miracles really in the time that they were produced, the lives that they saved. And yet to have it be politicized this way. By the way, he was in favor of vaccines at the beginning, so I don’t know, maybe he’ll subpoena himself to talk about what his views were before. All right, let’s pivot and talk to Lisa, and I’m real excited for this interview.

Howard Forman: Dr. Lisa Sanders is an associate professor of internal medicine at the Yale School of Medicine and a practicing physician but oh, so much more. She’s a medical author, a journalist, she writes the “Diagnosis” column for the New York Times Magazine section, which covers medical mystery cases. Her column inspired the hit TV series House, M.D., for which she served as a consultant. She’s released books such as Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis and Diagnosis: Solving the Most Baffling Medical Mysteries. In 2019, she collaborated with The New York Times on a widely acclaimed eight-hour documentary series on the diagnosis process for Netflix. Dr. Sanders received her bachelor’s degree in English from the College of William & Mary. And after graduation she worked at ABC and CBS. And at CBS she won an Emmy Award for outstanding coverage of her breaking news story for coverage of Hurricane Hugo.

She then enrolled in Columbia University’s Postbaccalaureate Premedical Program and received her medical degree at the Yale School of Medicine. And I just want to say the most important thing I have to say today is that my father has been asking about when we’re going to have you on the podcast for many, many months at this point. So thanks for being here, just for my dad. I wanted to start off with you. You have had an unusual path to medicine and you’re frank in talking about it, but I’d love to hear your thoughts reflecting back now. You graduated here about 25 years ago or so, and I’m curious to know when you first planned this journey to transition from journalism into medicine. Did you have this in mind, and how has it been different from what you expected?

Lisa Sanders: That’s an interesting question. But first can I say, Howie, please tell your father that the check is in the mail.

Howard Forman: Yes, I will.

Lisa Sanders: So did I think that this is going to be what I did? No, when I decided to go to medical school, I thought I loved television, but I thought it was a little bit boring. It was a little repetitious. And so I was ready to do something new and different. And one of the things that I thought was a plus about going to medical school and becoming a doctor is that the process was also going to be something different. So I would do medical school and then I would do residency and then I would be some kind of doctor. And I thought, “Oh, so that’s going to keep it various right from the start.”

And I didn’t think of myself as continuing a career in journalism, certainly not television journalism. I thought that was done and I was moving on to the next part. But I have to say, when I did my internal medicine rotation and went to this meeting that happens every day called resident report and saw how they presented a case from the time the patient entered medical care until a diagnosis was made, that blew my mind. Blew my mind!

And I thought, “Oh, this is important,” because I covered medicine when I was in television. I covered it for seven or eight years and I thought I understood medicine, but it turns out I didn’t know bupkis, nothing. I certainly didn’t know anything about that. I figure if I didn’t know about it, who does? Anyway, so that started me on my journey, and I had no expectation that that’s where I would go, but that’s where I found myself.

Harlan Krumholz: Well you’re a gem in medicine now. You’re someone who helps those who have lost hope to help their stories be told about what happened and how in so many cases, solutions and answers were found. And maybe that’s led many others to be helped too as they’ve heard those cases. But you and I talked about this, so I said to you, “So, are you Sherlock Holmes?” You said you’re not Holmes. Who are you?

Lisa Sanders: I am not Sherlock Holmes. If you’ve ever read Sherlock Holmes, you know that he, except in two cases, does not tell his own story. His story is told by his close friend, the physician Dr. John Watson. Dr. John Watson is a doctor who writes about people who make amazing discoveries. Mostly his good friend Holmes. That’s who I am. I am the doctor who writes about these doctors who make these important diagnoses. Every now and then I’m that doctor, but it’s like Holmes telling his own story. It’s rare. Most of the times I tell other people’s stories.

Harlan Krumholz: When I read your excellent column, and always I find it riveting to follow the course of these individuals and to know that there’s going to be an answer at the end or something. Most cases—not all, actually by the way—in most cases there will be resolution. I think that there must be thousands of people like this who never find resolution that in fact those people may be the lucky ones. That somebody, they found some astute person who made some astute observation that led to resolution and identification of something that no one else had seen before. It makes for great drama, but I worry that the quality of our healthcare is such that there are many people who fall through the cracks and actually don’t get that. You said how energized you were by this residents report, the way that we teach doctors to reason and to identify diagnoses, but are we really doing it the right way?

In this era of technology, and I know you’re a person who really loves the person-to-person interaction, this sort of old-school medicine, but I wonder whether or not we’re doing a disservice not to figure out how we can take the data that’s generated about the patients and help doctors perform even better so that many of these lessons aren’t lost. And it’s not a matter of just reading your column and remembering something that happened to someone else, but that we’re more systematically ensuring proper diagnosis. How have you thought about them? I mean, there’s no one who’s talked more about diagnosis over the sorts of their career than you have, but what can we do to do better? Because these people are lucky enough to find answers. Not everyone is.

Lisa Sanders: Well, let me just say that never in the history of medicine have your chances of getting the right diagnosis been greater. And I would not suggest that doctors are not doing their jobs. Doctors are doing incredible things with an unbelievable amount of information and amount of information that grows every day. So I agree that technology ought to be there and, to be honest, technology is there not enough and it’s not perfect, but patients often Google their symptoms. I write my column knowing that some people are going to read it in The New York Times, but it lives forever on the internet. And somebody who has legs that don’t let them stand up straight is going to go to my column and one of the things that they’re going to see is the possibility that they have this orthostatic tremor that keeps people from standing up or all these other interesting things. And I’m not the only person who’s doing it. So I think there are resources for patients. It’s not enough.

Howard Forman: You and I have in common a former medical student who unfortunately passed away way too young, but you wrote about him being central to diagnosing a patient probably 10 more years ago right now. But I remember how excited he was that he was part of your story and I haven’t heard you talk about that part of it, how much you’re elevating the common man and woman in medicine who are part of these essential teams that make diagnoses. I’m curious to hear what feedback you get from them about being part of the story.

Lisa Sanders: Well, first of all, that was one of my chief complaints about House is I don’t write about a single genius “Sherlock Holmes” like House. I write about all these doctors because we all live for the possibility that we will make a terrific diagnosis. I remember one of my great mentors, I asked him if he’d seen any good stories lately and he said, “No, it’s strange. I guess I’ve been kind of tired and distracted. I haven’t really been paying attention.” And I thought that was so great because of course that’s what it is. We know that they’re all out there waiting to be discovered. And the doctors who I write about, I hope good things happen to them. I’ve only heard good things from them, but most of the time they just move on with their life and we don’t really connect until they find another great case. I really encourage repeat offenders.

Harlan Krumholz: Talking about House, I’m intrigued by your involvement in it. And what was your experience of it? I’ve told you also, one of the concerns was that actually people see House as someone to emulate, of course his manners and patient interactions weren’t something that were, I think, something to think that you would want to emulate. But what was your experience working with them, and how did you think about the evolution of that character?

Lisa Sanders: Well, first of all, people, when House was on the air—he’s been off the air for a decade, but when he was on the air—people would go, “Aren’t you worried that he’s going to be a bad role model for medical students and they’re going to treat patients with a kind of personal disregard that House does?” My feeling is, “Are you kidding? Anybody who thinks that they can learn how to be a doctor by watching a TV show should be dropped from the core. I mean really you should know better by now.” But I have to say, I loved working with the writers and the producers on House. I thought it was a hoot. They were so smart, so thoughtful, so funny. And so they would call me or send me emails and say, “What about this? Or what about that? Or do you have any good ideas for this person?”

I would try to steer them towards accuracy. I didn’t always win. In the third season I remember Tommy Moran, one of my favorite writers ever, wanted to indicate some sort of oral genital contact between two consenting adults. And so he had the guy get bacterial vaginosis in his mouth. I said, “Tommy, that’s never going to happen. First of all, bacteria don’t like that environment. Those bacteria second of all, if they did, they wouldn’t be called bacterial vaginosis. It would have some other name.” And so I gave them a few other—I said, “Why don’t you make it gonorrhea?” Some of these other things, other possibilities. I wrote him this long email, and he wrote me back like two lines and says, “Yeah. Mine’s funnier.” And it was.

Howard Forman: Yeah, right.

Lisa Sanders: So I mean, I tried to be accurate, but only to the extent that it didn’t interfere with entertainment, which is of course what the show is about.

Howard Forman: You have continued to practice clinical medicine and most of the medical writers I know don’t, or they’ve really phased it down earlier. I’m curious to know, and you certainly don’t need it for the writing you’re doing because you’re well informed and you know what you’re doing. What keeps you going?

Lisa Sanders: Oh, I love my patients. I love seeing patients. I love, I don’t know, I just love it. It’s fun. It’s great when somebody comes to you and says, “I have a problem with this,” and then you work with them to try to figure out what it is and how to take care of it. I was just on the phone today with the one of my patients who I’ve known forever and he has pretty bad cirrhosis, decompensated cirrhosis, and he was saying, “I was just taking my pulse the other day,” that you get patients who take their pulse every day, “And it went down to the 40s and I’m really worried I haven’t been taking the beta blocker that I desperately need, so I don’t have another esophageal bleed, but I can’t take it because I’m worried that it’s going to make my heart stop and I’ll die in my sleep.” I’m like, “Okay, that’s an interesting problem.” I mean it’s always interesting and it’s always human and I love that. You can’t get that any other place.

Harlan Krumholz: I wondered if you want to maybe talk a little bit about what you’re thinking about doing next. I know that you’re about to embark on a new phase of your clinical career, and I don’t know if you wanted to talk about it a little bit.

Lisa Sanders: Absolutely. I love my patients and I hate saying goodbye, but I am saying goodbye to my patients because I’m moving into a new area of medicine. I’m going to set up and then run the Long Covid Clinic. To me, this is just an extension of something that I do all the time, which is take people with unusual symptoms and try to help them figure it out. In some ways we know where the symptoms are coming from. They have long COVID now, they have symptoms afterwards, and yet we really have no idea what drives most of this disease process. We have thoughts, we have theories, we have possible treatments, but we don’t know anything. And that’s exciting being on that frontier of trying to figure things out. That’s something new and different for me, and I’m very excited about the possibilities.

Harlan Krumholz: Yeah, I think we’re so lucky that you’ve decided to move in this direction. I think the field will benefit so much. But just wondering, I mean, do you have any trepidation about this given that we’re at such an early phase of understanding how to help people who are stricken by so many different symptoms and for which there’s so much mystery around exactly what’s causing it and how to help?

Lisa Sanders: Well, of course it’s terrifying to look at a patient straight in the face and go, “I don’t know. Not only do I not know, I don’t know anybody who does know, and I don’t know what we’re going to do about it,” but I’ve been doing that for a long time. People come to me, I don’t seek them out, but patients all the time come with symptoms that we can’t understand. And here’s how you can tell as a doctor that you don’t understand when your second thought is, “Well maybe it’s all in their head.” That’s when you’re up against it. And so I think it’ll be hard. I am worried that I don’t have that much to offer, that we don’t have that much to offer. But I don’t know. I have confidence that I’m going to be able to help at least some of them.

Harlan Krumholz: That’s true.

Howard Forman: Going back to your writing, you are one among a long line of great Yale medical writers. I mean, it’s an incredible history. It’s hard to explain. Maybe you can help us understand it better. But I also want to point out, you’ve been an incredible mentor to so many people in the current Yale faculty who also do writing. What advice do you have for people in medicine about if they wanted to become Lisa Sanders or if they wanted to do different types of writing or journalism in medicine?

Lisa Sanders: I’ve been unbelievably lucky, and anybody who thinks that luck is not an important part of their career really isn’t paying attention. So I’ve been unbelievably lucky, but luck comes to the prepared and one of the things that you have to be prepared for in writing is rejection. And you just have to ignore that. When I first proposed my “Diagnosis” column to an editor, he was very nice but he was not interested. And after a year, he went on to his next opportunity and the guy who replaced him was interested and that’s how my column came into existence. If the first editor hadn’t left, I would’ve never started on this and I would be doing something else. Still seeing patients but maybe something else. So I think the thing to do is to just keep trying and not to think if you’re rejected, there’s something wrong with my product or there’s something wrong with me, or there’s something wrong with how this is written.

If you get rejected a lot, two or three or four times, then it’s time to go back and revisit and think, “Maybe I’m not expressing myself as clearly as I thought, or maybe I’m not making this point as clearly as I thought.” You might show it to somebody else and get other people’s input. But the point is that you have to keep trying. Doctors are thoughtful and careful and in the presence of some of the most important things that are happening in the world right now, we need to get our expertise and opinions out there. Other people have no problem having many, many opinions about lots of things they don’t know squat about. We who know should be out there in the world.

Harlan Krumholz: As we get to the end here, I just wonder if you could give people maybe a sense of the process that you follow. Your columns are so remarkable. I just wondering how does it go? I mean, maybe you hear about a situation, but then what do you do next? I mean the columns are so rich, they’re detailed. It seems like you talk to everyone related to that particular case and situation and how do you do it?

Lisa Sanders: So the first thing is when I hear about a case is I reach out to the doctor because of course nobody is allowed to give me any personally identifiable information about their patient without the patient’s express consent. So first I reach out to the doctor and ask him if he would please contact the patient. And then once they get permission, I contact the patient. And the patient is a huge source of untapped information, especially among doctors. When doctors talk to each other, the patient is hardly even mentioned. And that’s crazy because that’s where a lot of the interest lies, and certainly that’s where all the surprises lie, is how the patient interacts with their disease. So to me, that’s a source of information. And whenever I’m surprised or worried about something, then I know, “Oh, that’s where it’s interesting and exciting. That’s where I need to go.” Something that goes, “Oh really?”

Sometimes it turns out not to be true. The column that I’m working on now, when I first heard about it, the intern said, “This guy was insane, he’s 19, but when he got this symptom, this crazy rash, he looked it up, and he totally identified what he had. And the patient told me the same thing.” When I talked to the intern again, she’s like, “Oh no, he really didn’t know all that much.” So I don’t know what happened to change the story, but when a story changes like that, it’s like, “Oh, well that’s surprising.” But it’s always fun. It’s always interesting.

People always have something really cool to say if you give them long enough. So my technique when I’m interviewing somebody is I say—I learned this from Auguste Fortin, who just left our faculty, who just retired.—I say, “Tell me what happened from the beginning,” and then I just shut up or I make a few encouraging noises, nod, because I want to hear it all. I say, “Tell me the story that you would tell your mom or your friend. I want all the gritty little details,” and people are happy to give them to me and I’m happy to hear them.

Howard Forman: I think in a time for where there’s so much uncertainty and where people have developed a very high level of skepticism about public health and healthcare, one thing I can say is that you have a tremendous amount of trust built around you because you do seem to be very transparent about the way you portray stories, and I’m very grateful for that. Just as a last quick question, has there ever been a case that truly just shocked you? Like that you didn’t believe it at all and had to convince yourself it was real?

Lisa Sanders: I mean, I’m surprised all the time. It is amazing. And you make it sound like that’s crazy and extreme, but hearing about weird symptoms that go with diagnoses, sort of what I specialize in, I think the one that sticks out to me the most is this woman who had chronic vomiting and lost 50 pounds over the course of a year as people tried to figure it out. And she was diagnosed, of course, I love this, by her primary care doctor who had been unavailable to her for some of these hospitalizations. And the primary care doctor walked in and go, “What’s that thing in your throat?” And she had fluoride hyperthyroidism, which can occasionally show up as nausea and vomiting, but—

Howard Forman: Wow.

Lisa Sanders: She was not born in the United States. And people who are not born in the United States have a much higher rate of having goiters than people who are born here where we have iodine in our salt. So I kind of can’t believe that something as common as that got missed for nearly a year, but I kind of understand it. And most of the best cases is where it’s like, wow, but you kind of understand it. I mean, I don’t write about dumb docs. We have all made dumb mistakes. We have all had bad days where we’re not our best self. And the days when you wish you could undo things that you did or make yourself think things that you didn’t think, I don’t write about those because that’s not interesting to me. What’s interesting to me is when smart, hardworking doctors are thinking about a problem and sometimes get the answer and sometimes don’t, because that’s where it’s really interesting to me.

Howard Forman: Well, thank you so much for taking the time to be with us. This has been terrific. And Harlan, we have to have Lisa back on the show sometime.

Harlan Krumholz: Oh, I hope so. And happy holidays to you, and I look forward to hearing more about the clinic as it goes online.

Lisa Sanders: Me too.

Howard Forman: Yeah, clinic’s going to be great, Long Covid Clinic at Yale. Lisa Sanders running it. It’d be great.

Lisa Sanders: All right. Look forward to it.

Harlan Krumholz: Well, Howie, that was just super as expected and now we’re getting to this part of the show, which I always enjoy, which is hearing your views and what’s on your mind this week.

Howard Forman: Yeah, so following the theme of medical journalism, I guess major news outlets reported quite widely on errors in misdiagnosis occurring in the emergency room. This came from an Agency for Healthcare Research and Quality study that’s still being developed. It’s not finalized yet, but the first sentence in the New York Times article was, “As many as 250,000 people die every year because they are misdiagnosed in the emergency room.” The CNN headline even was a little more provocative: “More than 7 million incorrect diagnoses made in the emergency room every year.” Just one day earlier, the daughter of the well-regarded CNN anchor Jake Tapper wrote a piece in CNN Opinion on her own emergency room misadventure, getting a delayed diagnosis of a ruptured appendicitis. So I worked in an emergency room. I was there last night. I’m surrounded by colleagues who do the same, and they’re actually delivering care directly to the patients.

I’m mostly reading imaging studies, so it’s easy to come at this from a defensive position. So I’m going to try not to do it. But suffice it to say that many errors in many adverse events continue to happen in the hospital and outpatient setting every day. And I’d like to believe we’re getting better as time goes on. And the evidence does suggest that we are, but also important to frame these data points properly. Emergency departments see over 130 million patient visits a year. The vast majority of these are getting quick and timely, accurate, and impactful diagnoses. And the emergency departments have become the de facto multi-specialty clinic of the 21st century. So we can argue about the cost, which is high in the emergency room, but the ability to deliver complex diagnosis and therapy in a single setting is extraordinary. The story told by Alice Tapper about her ruptured appendicitis is concerning. A young woman presents with abdominal pain that she describes as a surgical type of pain, but it was not even interrogated with ultrasound despite the pleading of her and her parents.

And quite frankly, it reminded me of the narrative that you and I talked about by Professor Tim Snyder of Yale, the historian and leader in understanding fascism. He wrote a book about healthcare. He wrote a book, Our Malady: Lessons in Liberty from a Hospital Diary, about his own horrible encounter, in our own emergency room. His viewpoint was made worse by hearing inhumanity all around him. There’s no way I can excuse or explain either Alice Tapper’s case or Professor Snyder’s case because I don’t know all the details, but we can certainly hope for better. There are obvious cases of disease that are reasonably well defined, and we like to pat ourselves on the back for making some unusual diagnoses. The world of Lisa Sanders, where diagnoses are not obvious in all patients, is much more common than we give it credit. Evidence-based guidelines for diagnosis and treatment help a lot, but humans don’t always read the owner’s manual and they present in weird ways, as she mentioned, toward the end of her story with the patient with a goiter causing diarrhea and, I think, and nausea.

So these are common diagnoses presenting in uncommon ways. And as we’ve been taught, when you hear hoofbeats, don’t immediately consider zebras as the animal that’s coming at you. So I bring this up because 35 years of working in clinical medicine has been really humbling for me. I frequently see imaging findings that I’ve never seen before. Last night was yet one more example. You and I talked about it before the podcast began. Diagnosing a patient is much more challenging than fixing a car or a computer, and the consequences are far more serious. So I’m glad to see this gets more attention, but I really hope the media would be more cautious in creating content that might inadvertently undermine the great work that so many of our colleagues do every day.

Harlan Krumholz: Yeah, I think you raised a lot. Oh boy. There’s a lot in which you, you’ve said, and I think we should ask, by the way, to have Tim Snyder on our podcast.

Howard Forman: I thought about that.

Harlan Krumholz: He’s got some story to tell and yeah, it’ll be interesting to explore that with him. I don’t even know where to start on this. I’ll just say this, that I do think that, as I suggested to Lisa, that medicine has the potential to start putting in place the kind of technology that can elevate our levels of performance. And we’re working on this right now with work that’s trying to identify within the EHR [electronic health record] actionable insights that can both elevate the performance of the physician and give the patient the kind of information they need to be able to make the right choices about themselves. There’s no reason for people who have specific clusters of symptoms, which are almost invariably associated with important diagnoses, to be missed. And by the way, that’s true in acute disease. It’s true in chronic disease. And so I’m hopeful that in this next era we’ll be able to be using data science in ways that actually makes us much better and stronger.

There’s another piece to this though, which is the emergency department tends to be a neglected part of our healthcare system. It’s under-resourced. People are lining the walls; the throughputs aren’t good. Look, you’re a management science guy, Howie, and we should be trying to apply 21st-century science to how we manage this part of our healthcare system. It puts people at risk, I believe, in a way because people are stretched so far in the chaotic nature that can characterize the ED but—

Howard Forman: I just want to emphasize though for the audience that even under the perfect circumstances, it is a very complicated situation to diagnose a patient. It’s not always, even now with all the information, there are several patients just from this past weekend that I’m not certain that we have the final diagnosis on.

Harlan Krumholz: So I would say, so is going to the moon, so is going to the moon. So’s a lot of other mission-critical things. So is running a nuclear power plant. There are lots of things that are complex. There are things that are thrown at you. I just think we can do a lot better job than we are. And it’s not about, by the way, taking it away from doctors. It’s about helping doctors and nurses to perform at ever higher levels because they’ve got the instrumentation, the data, the support around them so that they can do better. That’s anyway a world that I think we might go to. But thanks for sharing that. And there is some controversy about that number. That number seems to me be a bit of an overestimate from the emergency medicine department. But anyway, there’s probably more to come on that as time passes. 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 H-M-K- YALE.

Howard Forman: And I’m @thehowie. That’s @thehowie. I also want to give a quick shout-out to my father who’s turning 90 this week and wishing Merry Christmas and Happy New Year and Happy Hanukah and any other holiday that you might be celebrating at this time. You can also email us at health.veritas@yale.edu. Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs, where you can check out our website at som.yale.edu/emba.

Harlan Krumholz: And everyone should know that Howie’s parents are truly amazing people, teachers, down to earth, just as you would expect. And happy birthday, Mr. Forman, happy birthday.

Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Jenny Tan, and to our producer, Miranda Shafer. We are so fortunate to be working with them. Happy holidays to all of you, and talk to you soon, Howie.

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