Margaret McGovern: Building an Integrated Health System

Harlan Krumholz: Howie, we’re back. Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University, and we’re trying to get closer to the truth about health and healthcare. Our guest today is Dr. Margaret, or Peg, McGovern, but first we like to check in on current or hot topics in health and healthcare. And for our listeners, it’s worth pointing out that Harlan and I spend at least two hours a week talking to one another, both during the taping, as well as before the taping, in order to make this product, and for the last seven weeks, we have not been making the product, and Harlan and I—

Harlan Krumholz: We’re missing each other.

Howard Forman: We’re missing. We had trial separation. It didn’t work out. We’re back together again.

Harlan Krumholz: Yeah. We’re back together. We’re back together.

Howard Forman: And here we go. So what do you have on your mind today?

Harlan Krumholz: Well, I have something I want to share, Howie, but first, let’s just take a minute. It’s September 11th, and I think this is going to be released on the 12th, but just to take a pause, I feel like sometimes we flash through this, but it’s still an important day in American history. I saw this thing on 60 Minutes about the FDNY, and you know what’s interesting about the Fire Department in New York, is that generations are part of this. It’s part of families over generations. It was a show about the children of people who lost their lives in September 11th—I’m going to start crying—who chose to go into the same profession and are honoring the one who fell but also continuing the family tradition. Anyway, just the most remarkable thing to see. I just wanted to take a pause. I remember it well, because I was in the air flying over New York on my way to D.C. You and I met each other in D.C. on September 11th.

Howard Forman: Randomly.

Harlan Krumholz: I mean, we ran into each other.

Howard Forman: But randomly, on the street. I mean, I remember it was the most stressful moment, and I looked up and there is this guy who looks like Harlan Krumholz, and I’m like, “It has to be an apparition.”

Harlan Krumholz: I was there for a conference. You were there for the RWA fellowship that you were doing. Remember, we ended up having lunch together?

Howard Forman: Chinese food.

Harlan Krumholz: At Strobe Talbott’s house, where you were sitting.

Howard Forman: Correct, correct.

Harlan Krumholz: And it was quite a time. What I also remember is how the nation pulled together in those moments, which is a contrast to what we’re seeing—

Howard Forman: That’s for sure.

Harlan Krumholz: ...at this moment. But anyway, it’s a moment to remember those who fell in that time.

Howard Forman: Yeah, no question. We’ll never forget that day, and I hope that people can get back to feeling that shared and common purpose that we felt after that day.

Harlan Krumholz: And it doesn’t have to be against a common enemy, but more for just being able to be connected, no matter who you are in the nation. Yeah.

Howard Forman: Yeah.

Harlan Krumholz: All right. Hey, let’s get to our guest.

Howard Forman: Dr. Margaret, also known as Peg, McGovern, is both the current CEO of Yale Medicine as well as the Deputy Dean of Clinical Affairs at the Yale School of Medicine. She also oversees the physician enterprise of the Yale-New Haven Health System in her role as executive vice president and chief physician executive. Prior to her leadership roles at Yale, Dr. McGovern served as the Stony Brook Renaissance School of Medicine’s dean of clinical affairs and oversaw the strategy and clinical programs of the Stony Brook Medicine Health System as vice president. She was also instrumental in helping develop the new children’s hospital during her time there.

I’m going to ask her to talk about her journey, but suffice it to say that she is one of the world’s experts on a genetic disease, acid sphingomyelinase deficiency, also known as Niemann-Pick disease, and in addition to that, built an auspicious and successful career in healthcare leadership. Dr. McGovern received her bachelor’s degree in biology at Stony Brook, and holds an MD and a PhD from Mount Sinai School of Medicine, which has now been renamed the Icahn School of Medicine and the Mount Sinai Graduate School of Biomedical Sciences. And so I want to start off, because most of the time when people hear that somebody’s an MD-PhD, they think about a combined degree program, a medical scientist training program, but you came to this from a different path. Can you start off just by telling us where you grew up and what motivated you to start off your career in basic sciences and sciences?

Margaret McGovern: I was always interested in science from, really, first grade. So one of my favorite books was a little book that, in very simple terms, explained scientific principles. It was given to me by my aunt, and I cherished it. This was always my inclination. Sort of baffling to my parents, who didn’t expect their daughter to be pursuing a math and science kind of education and path, but I wanted to be a scientist, and I majored in biology in college, so very traditional route to enter a science career, and applied out of college actually to a PhD program in genetics, which was my interest, because I really saw myself as being a bench scientist for my career.

Now, I happened, and this is a lot of serendipity in my career journey, happened to do that PhD at Mount Sinai, where even when I did my training there, translational research is what they were all about, right? So from the very beginning in my PhD training I was interacting with physicians, with families, with the patients, affected with the diseases that we were studying at the basic science level. I think if I hadn’t chosen to do my PhD at Mount Sinai, it never would’ve occurred to me that I really want to also get the medical degree and be able to see that whole portfolio and translation, really the bench-to-bedside work.

Howard Forman: Can you just tell us how you pivoted even to medical school, because it’s not the natural path?

Margaret McGovern: Yeah. Well, it was actually, I was riding on a bus down Fifth Avenue and had been starting to look at, “What am I going to do upon completing the PhD?” and looking at postdoc opportunities and just sort of had this revelation that that’s not what I want to do at this point. I want to go to medical school, I want to get that additional training, I want to have that kind of different dimension to my career. I spoke to my mentor, who was the head of genetics at Mount Sinai at the time. He was immediately supportive. Also, had to go home and tell my husband, “Gee, I want to go to school for four more years and then do six years of clinical training.”

That was a harder conversation, frankly, but got there, and I applied to medical schools all throughout the New York region, but staying at Mount Sinai had a lot of advantages. I was able to continue my research interest, even when I was in medical school, because I had done the PhD there and taken a lot of classes with the medical students, I’d have to take them over, so that really was very helpful. I think that was the good, right decision for me, and I had a great experience there and was able to attend that mentorship from my PhD program to see me through medical school, and I think that was the right path for me to take.

Harlan Krumholz: Peg, I wanted to ask you a little bit about, talk a little bit about this leadership style you have, and I’ve seen it—highly effective, because you don’t beat around the bush. You get right to the point, and yet everyone knows about your deep commitment to the endgame here, which is actually elevating our clinical care, doing a better job for patients and having a sustainable program that can continue to grow and serve the academic mission, but can you talk a little bit about this? Because, as Howie said, you start in basic sciences, you make these transition into leadership positions. How did you develop this style? How do you think about the way that you both motivate people and provide that leadership?

Margaret McGovern: I’ve given that a lot of thought since I arrived at Yale two years ago in July, because entering a new, very complex organization like this, both the school and the health system, I spent that entire first summer just meeting literally hundreds and hundreds of people, and those are kind of superficial meet and greets, and it takes a while to develop the relationships. It was a banner day for me that I celebrated when I was in a big, big meeting and said to myself, “I know everyone in this room. I figured out who they are and what they do here,” but I do know. I think I have good insight into my leadership style. I am direct. I like to be efficient.

I’m a pragmatist, because you got to be practical to do this work, but I’m also aware that it takes time for people to get to know me, to understand what motivates me, and that, where my values are and where my passions lie. I think all of that aligns very well with what we’re trying to do here, as an enterprise with the health system, what we’re trying to do in the school, and that I think that I have this deep understanding and respect for the academic mission and for the life of a School of Medicine faculty member, and as well the life of a clinician in the community, who’s also contributing to the mission. I think that I’ve become much more reflective about the leadership style piece over the past decade, as I’ve held more and more leadership positions. I flex between styles. That’s a standard question when you interview somewhere for a leadership position like, “What’s your leadership style?” I don’t have one, right?

So during the COVID pandemic, and I led Stony Brook’s response to the COVID pandemic, it was extraordinarily difficult work, as we all know. I didn’t have time to lead by influence. I was out in front and bringing everyone along with me. But now, here in this environment, where there’s such amazing talent and just such extraordinarily intelligent people, that’s not the way to lead here. The way to lead here is through influence and from behind. With my team, I’m behind them. I’ve got their backs. I want them to grow. I want them to bring their creativity, and I’m just sort of there. If I see them really straying somewhere that’s not aligned with what we’re trying to do, I’ll pull them back in, but just letting them have that freedom, that is not my natural inclination, frankly. I’m a little bit like to control things, and I can’t control everything, so that’s come, I think, with me maturing as a leader to let my team run with it. Sometimes they don’t make the exact decision I would, but that’s okay, but I’m there to make sure things don’t go off the rails.

Howard Forman: You were recruited here into a traditional deputy dean of clinical affairs and chief executive of Yale Medicine role. That’s been the role for at least the decades I’ve been here. Once you got here, and not very long after you got here, a decision was made at the institutional level that we needed to have better alignment of physicians within the hospital, who are not affiliated with the medical school within the Northeast Medical Group, who are employed by the hospital health system, but not by the medical school as well, and the medical school needed alignment, and you were asked to take on this, basically, chief physician executive role for the entire health system and the medical school. For our listeners, it’s really important to understand these are two completely independent, not-for-profit entities. So they’re not naturally run by one person. When did you first realize that you were going to take on that role, and was that daunting to you to realize you’re going to take on something that had never been done before?

Margaret McGovern: So you’re right, that transition happened. I was only six months into my tenure here, and Nancy Brown, the dean of the School of Medicine, and Chris O’Connor, CEO of Yale New Haven Health System, talked to me about this role. Frankly, I think they sort of had it in mind, and didn’t clue me in until after I was here, that this was what they saw as the natural evolution of their work together to be real partners and align the school and health system interests for purposes of the clinical mission. It just made such perfect sense to me that, frankly, I sort of more wondered why wasn’t it always this way? Why wasn’t there a singular leader trying to craft what’s the enterprise strategy for clinical services and how they’re going to be staffed? And because it wasn’t that way, there were all these deep silos that the employed physicians of the health system, the clinicians in the School of Medicine, and we still have a lot of work to do here, don’t know each other, there wasn’t trust there. There wasn’t true collaboration. In some cases, they were actually competing with each other. That doesn’t serve anybody, so I really saw it as this would make my job, that I was initially hired into, easier to really have the whole portfolio. I think that there’s been significant opportunities identified to improve how we function, and this just really does make a lot of sense. Frankly, I got to tell you, that if I was limited to the CEO of Yale Medicine role, I mean, I think the Dean’s Office role is very interesting. There’s a lot of interesting things to do with that in terms of mentorship of our clinical faculty. It probably wouldn’t have been a big enough role for me. I think I would’ve gotten a little bored with it, and that this is really interesting, has rich opportunity, and is really helping to drive that really essential, important alignment of the School of Medicine with the health system to really have us both realize the full power of this combined enterprise.

Harlan Krumholz: One of the central challenges, I think, currently is how you can configure the proper incentives for people, and we’re trying to maintain a mission-driven profession where people come in and they’re committed to their patients and doing their work, but we are needing to quantify their efforts in different areas in order to reward productivity. We have this RVU system, which we’ve inherited, that many people feel has robbed the profession of a lot of the mission because people are just sort of focusing on, “How do I get enough work units?”

For people listening who don’t know about these relative value units, it was something developed out of the Harvard School of Public Health when it was a Harvard School of Public Health way back when by Bill Hsiao. That was an attempt to sort of quantify the productivity that web doctors had produced, and so create interchangeable units among different types of physicians, that you could say you did X number of RVUs. It was a common currency of effort. As you think about how to configure this at Yale, how do you align incentives so that we both get great productivity, high quality, and good patient care, and people don’t feel like they’re cogs in a machine, where they’re just pushing this out? It’s got to be a tough balance.

Margaret McGovern: It really is, because on the one hand, we’re running a business, and you have to run the business very judiciously. You have to be a good fiduciary of all the assets, including the revenues. On the other hand, I would never want our physicians, clinicians, our advanced practice providers, or anyone to feel reduced to an RVU number on a page, that their contributions cannot possibly be encapsulated, messaged, and communicated based just on an RVU number, which is tied back to their so-called productivity. I think that that’s a nuance that really has to be in how we talk about this. And in fact, in the School of Medicine, most of the compensation plans are not foundationally RVU-based. What has happened in the relationship, the flow of funds between the health system to the School of Medicine, which we just redid funds flow last year, is that the clinical department revenues are based on the overall number of RVUs the department is producing, but it is up to the chair to decide how to compensate the faculty.

Some do have an RVU-based component to their comp plan, others don’t, or it’s just related to incentive payments, but I think this fundamental radical change in funds flow between the health system and the School of Medicine has aligned the incentives of those two parties, which was essential. So the school is going to bring to bear the clinical talent, the expertise, the innovation, the research, but also be accountable and responsible for productivity, and do that in a reasonable way with benchmarks that are relevant for an academic faculty member. So there’s many ways to incentivize our faculty, and I think RVU-based payments should not be the whole story. I mean, there’s other contributions that need to be recognized and valued, and there’s some physicians that were never going to knock it out of the park in terms of productivity or booking RVUs, but we’ve purposefully invested in the clinical programs they’re involved in because they align with our mission, and some of our mission, we’ll lose money. I mean, that just comes with the territory.

That’s okay, as long as you have that balance of things that are paying the bills with things that we want to do, because it’s within our mission, it’s what we think is the right thing to do, because we’re trying to serve our community. A lot of thought has to go into this, and I think one of the interesting parts of the Dean’s Office role I have, and now trying to bring this spirit a little bit over to the NEMG [Northeast Medical Group] physicians, is really making them feel valued, included. I especially enjoy meeting with the mid-career clinical type faculty, who are great at articulating the challenges they have, realizing what’s important to them or what clinical programs they would like to help grow in their own portfolio, and what are the speed bumps they encounter in this complex environment and doing that work? Those are the kinds of people that we really want to be supporting, incentivizing, and giving them the time to do that work. I think that’s an important piece of this that we don’t want to lose. We cannot reduce our faculty to an RVU number. I think it’s a huge mistake.

Harlan Krumholz: By the way, I just want to pause. I just love that response. I really think it would actually be one that all of our faculty should hear, because it’s such an important core principle here, and to hear someone in a leadership position, as Peg is, articulate that so clearly is really great, is important.

Howard Forman: And I want to follow up in that vein. We operate in a competitive market for physician labor so that we basically have to offer competitive salaries for different types of physicians, even though we know that salaries differ tremendously by specialty. You come from pediatrics, which is historically an under-compensated specialty. Harlan and I both operate in specialties that are better compensated. These are national—

Harlan Krumholz: Well, I’m not paid anything like a radiologist. I just want to say.

Howard Forman: Of course not. Yeah, no. But these are—

Harlan Krumholz: Listeners know that Howie is a radiologist, I just want to say.

Howard Forman: Yes, yes. These are big national issues though, in terms of how do we maintain pediatrician workforce, a primary care workforce, and so on, in the face of the fact that salaries are so much higher for subspecialties and so on. I’m wondering what role you can play locally and maybe nationally in helping us right-size those salaries in a way. I’ll just say, when I first started here 28 years ago, I was in charge of one of the committees for the medical school, and I remember almost watching a surgeon and a neonatologist come to blows over this issue, and it just sticks with me. People are not content with these differentials.

Margaret McGovern: This is a tough issue, because a lot of it obviously is tied back to how these different specialties are paid by the payers, and there are huge differences. I mean, the fact is that our payer system still values procedures. If you’re not a proceduralist, that it’s extraordinarily difficult to drive a lot of revenue, and it’s more hand-to-hand combat, right? To drive that revenue, you need to support yourself, and we see this very powerfully in the community. I mean, community-based primary care physicians in both adult and pediatric medicine have a very difficult time making a living, and this is a problem for all of us.

These are your first stop when you have a medical issue, and it’s increasingly difficult for these kinds of folks to be able to survive and be independent in the community, and as a consequence, what we’ve seen, of course, over the past decade, is a lot of migration of those physicians to employment models with health systems, private equity, you name it. There’s some risk in that approach too, so this is a difficult issue. Is this one that I see getting solved in the near future? Like no, because it is really tied to the payment systems. Now, internally, one could try to right-size salaries, but then you’ve still got the whole rest of the world not doing it.

Howard Forman: That’s right.

Margaret McGovern: So how do you attract a surgeon? How do you attract the kinds of procedural type of docs you want when they can go somewhere else and make a lot more money? So it’s very, very difficult, but I think that the pay scale for primary care is definitely creeping up, because it’s so difficult to recruit and retain these physicians and others, the APPs that also practice in that space, that to be competitive, those salaries definitely are drifting up, but that differential is always there.

Harlan Krumholz: And just for people, the APPs are nurse practitioners and the physician assistants, and these others who are non-physicians with delivering clinical care, so not everyone will key off on that. So this has been an amazing interview. I’m so happy to have had you on today. Just as we sort of get to the end, I wonder if you could just project five years in the future. So we’re still in the dynamic time. You’ve got this clinically integrated network, where we’re really trying to get more collaboration and coordination. You’ve hired a population health officer, who’s going to be focusing on trying to really get us all rowing in the same direction and stronger as a result. What do you see? What’s your five-year arc here? What would we look like in five years if things go really well and you feel like you’ve been successful with your team?

Margaret McGovern: Well, I would see that we have a fully mature clinically integrated network, and a clinically integrated network is a separate legal entity, and its purpose is to drive quality and value, value being code for containing the cost of healthcare, but to do that, always with an eye that you’re still delivering high-quality care, and I always begin the conversation about CIN with the word quality. That comes first, and secondary is that we’re doing the work and delivering on value, because we’ve built the infrastructure to help physicians take care of their patients in a highly efficient way. So what does a mature CIN look like? It’s that the faculty and the employed physicians of the health system are working together seamlessly on a common quality platform. They’re sharing information, metrics, and lessons learned.

But further to that, we’ve been able to engage with community-based physicians to join our clinically integrated network, also engaged with us on that common quality platform, and it becomes another vehicle for us to expand our physician footprint outside of an employment model. So that’s extraordinarily important to do. I also think that five years from now, we will see, in some of the work that we’re carrying forward, and I think the Access 365 work is a good example of this, which is focused on accessing the services we provide and going through the care journey seamless and easy for patients. That’s not the current state here or in most places, frankly. This is a huge piece of work that we’re carrying forward, and it addresses something. I mean, I don’t particularly like the word, but people will use this.

There’s been a big rise in consumerism among patients. I don’t call it “consumerism.” I call it “patients reasonably expect that they should be able to conveniently access their care, and that there should be respect for their time, and that we have to see ourselves more as a service industry because we are.” That, particularly in academic health centers, was not always the philosophy and approach to interacting with our patients. Academic medical centers across the country have really woken up to, “We need to address this. You’re not just the ivory tower where patients are coming for the most high-acuity esoteric care, but you have a whole portfolio of programs that you need to give convenience and you need to be considerate of your patients,” so some would call that consumerism. I would call it just good behavior.

Harlan Krumholz: And do you see this, one of the principal pain points are these wait times, wait time to get a primary care doctor, wait time for cardiology appointment. Do you think we’ll be able to address that through these greater efficiencies?

Margaret McGovern: So we are addressing that through our Access 365 initiative, that the executive sponsors for that work are myself and Pam Sutton Wallace, the president of Yale New Haven Health System. That’s how serious we are about doing this work, and we are very involved in the day-to-day management of being successful in this work. So this will, first of all, will optimize our processes. We are coordinating better how to make appointments, how to even portray, we are on digital front door and our websites, what physicians do we even have here? If you look today on the health system and the school websites, you will find different information about the same human beings. So we’re aligning that information so patients can understand who’s here, who can help them.

Current state today in some areas, because doing this work in eight waves, and we’re in wave three at the moment, a patient may have to call three or four different phone numbers to make an appointment for all the appointments they need for one incident of care, so these are the things we’re trying to eliminate to make this just easy, seamless, not just for patients, but also for our referring physicians, for our own internal staff. All of the processes are extraordinarily cumbersome, but there’s no doubt in my mind, and I tell everyone who will listen to me about this, even when we’ve done all that work and we’re realizing a lot of opportunity out of it, and a lot of benefit, we’re going to find areas where we just don’t have enough clinicians, and you can’t accommodate the demand. So then, you make a purposeful decision, “All right. Do we feel it’s our responsibility and that we need to meet all that demand?” And if the answer is yes, then you need to hire more clinicians.

Sometimes the decision is, “Okay. This is an area where it might make sense to expand access to that service through the CIN with community-based physicians,” so we go that way, but now at least we’ve developed all the tools to make those kinds of decisions. You’re not stuck with one model. So I think that this is absolutely essential work, and it really touches every corner of the organization, from finance to operations, to the physicians and their satisfaction. We also have to do all this work, being very attentive and sensitive to not overburdening our clinicians and giving them the tools to be successful. I think we’re incorporating that into this, so we’re asking our primary care physicians in NEMG to have panels with higher-acuity patients and do more with those patients, but then we need to give them all the support services so the busy work they’re doing gets off their plate and onto someone else’s.

Howard Forman: We really appreciate you and for joining us.

Harlan Krumholz: Yeah. We’re really fortunate to have you at Yale, and thanks so much.

Margaret McGovern: Thank you. Thanks for inviting me.

Harlan Krumholz: Well, that was a terrific interview. I’m so glad we had her on. She’s so articulate. Great leader at Yale, but Howie, I’ve been waiting for weeks and weeks.

Howard Forman: I know.

Harlan Krumholz: Seven weeks for this.

Margaret McGovern: And there’s so much we could cover, Harlan, but I—

Harlan Krumholz: What’s on your mind this week?

Howard Forman: Yeah, just H5N1 remains a major public health story, even if the press, the mainstream press at least is covering it right now, and there are new updates. So as you recall, we had a concerning outbreak of H5N1 bird flu, also known as highly pathogenic avian influenza. You’ll hear it referred to it in all these different ways, since early this year. When I last updated, we had mentioned that 10 farm workers, 100 million poultry, and 168 dairy herds had been affected during this outbreak. While the numbers have moved up, it has not been that dramatic. 1% more poultry have been affected, and by “affected” I mean they’ve either died or were euthanized. I don’t mean to make light of this. We’re now up to 13 farm workers affected, with 9 of them from poultry farms in Colorado. There are, however, 18 new cattle herds infected with H5N1, with the most being in Colorado and the newest being in three separate herds in California.

Now, California is especially concerning, because it is the nation’s number one source of milk, and because they have been particularly cautious and careful with the cows, knowing how easy it would be to spread, but on the good news side of things, only six new herds have been infected in the last 30 days, including the California ones, I believe. Unlike other areas, California dairy farms are huge, and they don’t have the same risks of cattle being transferred between farms because of that. They also have been seemingly hard at work, cleaning the milking equipment to prevent spread and cleaning trailers when they do need to transport cattle. But even that has not been enough, so this is one bit of news that keeps the concern high. The biggest recent news on this front is the discovery of a patient in Missouri with H5 avian influenza.

This case was detected through surveillance of patients testing positive for flu and was not associated with a specific animal outbreak. In fact, Missouri is one of the states that has not had a single cattle herd test positive, and part of the reason is Missouri doesn’t test their cattle very much. They’re still doing genetic testing on this specific case. It may turn out to be related to wild bird outbreaks that have occurred in Missouri or something entirely different, even possibly from contaminated milk or dairy products, but there’s no indication, no indication at all of human-to-human spread, which is what we dread most at this point. And again, what are we worried most about? We’re worried about eventually getting to the point of human-to-human transmission. No evidence of this for right now, but at this point, we still don’t know how this particular individual in Missouri got the disease.

So are we doing enough? No. I have previously mentioned that the state of Missouri is not actively testing enough. They seem to want to hide their head in the sand on this. It’s not a good thing. Maybe they have no infected cattle, but they really don’t know because they’re not testing, and it would be great to see the CDC continue to organize their efforts and coordinate with state public health and agriculture officials to establish best practices and create incentives for more effective testing and quarantining or isolation, as needed. You, Harlan, have asked me before when I think this could affect us, and obviously, nobody knows. It could be next month, or it could be next decade, but I think we all would look foolish if we’re not actively learning and preparing for the worst while hoping for the best.

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

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

Harlan Krumholz: And we always want to hear your feedback questions or your experiences with these topics. If you like the podcast, if you don’t like it, rate us, review us. We’re looking for feedback, and it also helps people find us.

Howard Forman: Yeah. And look, if you have questions about the MBA for Executives program at the Yale School of Management, reach out via email or check out our website at som.yale.edu/eMBA.

Harlan Krumholz: Health & Veritas is produced at the Yale School of Management in the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and our producer, Miranda Shafer. They are back from vacation. They’re raring to go, and we’re so lucky to have them.

Howard Forman: And for Sophia and Ines, this is their senior year of college, so wish them the best of luck.

Harlan Krumholz: Yeah. Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Talk to you soon, and welcome back, everybody.