Medicine-Life Balance and Other News

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

Howard Forman: Yeah. And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This is one of our periodic episodes without a guest. And again, there’s a lot of news to update each other about and our listeners.‌

I want to first start off by just mentioning we’re taping this earlier in the week. Tomorrow is Election Day. We are not going to talk about the election or politics today, but we know that a lot will happen between now and when this episode drops. Not to think that we’re ignoring—‌

Harlan Krumholz: Well, we did this on Monday. The markets are hot on this. You’re not going to make a prediction?‌

Howard Forman: Not going to make any predictions at all.‌

Harlan Krumholz: Okay.‌

Howard Forman: No.‌

Harlan Krumholz: Because we don’t want to be wrong.‌

Howard Forman: Don’t want to be wrong. Just want to talk about health and healthcare.‌

Harlan Krumholz: We talked a little bit about politics last time.‌

Howard Forman: Yeah, we did.‌

Harlan Krumholz: We got a little feedback.‌

Howard Forman: It’s important, I think, to talk about things that really are health and healthcare related, whether they are politics or not. But today, there’s a lot of topics we could talk about. In fact, my whole array of things I want to talk about is just infectious diseases.‌

Harlan Krumholz: I know.‌

Howard Forman: What do you got?‌

Harlan Krumholz: Those are scary topics. I don’t know why you’d go there.‌

Howard Forman: Yeah. They’re scary, but they’re also good. There’s good news there, also.‌

Harlan Krumholz: Okay.‌

Howard Forman: If you want to start off with the good news.‌

Harlan Krumholz: You know what, let’s start with you and the good news. I always like to start with good news.‌

Howard Forman: About, I don’t know, it was a year or two years ago, you talked about Norovirus.‌

Harlan Krumholz: Yeah.‌

Howard Forman: You reminded us.‌

Harlan Krumholz: I told you that’s one of my least favorite viruses.‌

Howard Forman: Yeah, exactly. It’s the diarrhea, vomiting.‌

Harlan Krumholz: Well, there’s no favorite virus, I guess.‌

Howard Forman: Yeah, exactly. But it’s a really bad one. It’s one that spreads so easily. Quite frankly, look, 700 million infections a year, 200,000 deaths annually. It’s not inconsequential, even aside from the discomfort that everybody else feels.‌

Harlan Krumholz: That’s why I won’t go on a cruise.‌

Howard Forman: I understand.‌

Harlan Krumholz: Well, besides the fact I get seasick.‌

Howard Forman: I understand that. It’s half of all foodborne outbreaks, also. It’s not inconsequential. The good news is that about—‌

Harlan Krumholz: What happens when you get Norovirus?‌

Howard Forman: You get bad vomiting, you get diarrhea, and you’re almost certainly going to spread it to anybody near you.‌

Harlan Krumholz: It’s one of the most infectious viruses that we know.‌

Howard Forman: It’s ridiculous. They’ve done mapping of this where, literally, somebody vomited in a restaurant. They showed the frequency of likelihood of getting Norovirus was if you were one table away, you had this frequency for it.‌

Harlan Krumholz: Oh, my God.‌

Howard Forman: Just absurd.‌

Harlan Krumholz: That would just be—‌

Howard Forman: Yeah. Anyway, we don’t want to discuss how it looks too much—‌

Harlan Krumholz: Note to self. If someone’s vomiting next to you in the restaurant, move away.‌

Howard Forman: But here’s the good news. The good news is that about a month ago, a paper was published that demonstrated the feasibility of a bivalent vaccine that is in development. It seems to work in animal models. It’s not beginning human trials. Twenty-five thousand individuals will enter a human clinical trial. I think it’s over something like six countries.‌

Harlan Krumholz: Is the idea that it’ll prevent it? We’ve got this flu vaccine that we know can mitigate it, but still, lots of people get flu. Is this one of these things that can actually protect us?‌

Howard Forman: It’s a good question. I don’t know the answer to that, but I would imagine that it would reduce the spread if it’s effective. But that’s what we thought was going to happen with COVID as well. And while it did a little bit, not a lot. So wait and see. But it’s nice to see we’re making progress on something that, while it’s not a catastrophic illness that is going to kill people, it’s definitely something that is devastating. I shouldn’t say it’s not catastrophic, 200,000 people die a year. But tiny fractions—‌

Harlan Krumholz: What?‌

Howard Forman: No, no. But a tiny fraction of the 700 million infections.‌

Harlan Krumholz: Two hundred thousand people die of Norovirus a year?‌

Howard Forman: Annually. Over the world, across the world.‌

Harlan Krumholz: Wow.‌

Howard Forman: Yeah.‌

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

Howard Forman: But for the most part, it’s a self-limiting disease.‌

Harlan Krumholz: I just wonder if we’re going to have to change our minds about these vaccines. I know there are lots of vaccines in development around a wide variety of illnesses.‌

Even I was hearing today that Shingrix, a highly recommended virus to prevent shingles, which can be a terrible thing to get.‌

Howard Forman: Pretty devastating.‌

Harlan Krumholz: It can also cause blindness; it can cause a whole range of things. Even people who get the Shingrix vaccine, you have to get two shots—about half of the people don’t show up for the second shot. You? You? Howie? What?‌

Howard Forman: I know, I know.‌

Harlan Krumholz: What?‌

Howard Forman: I know. I’m not going to go and tell our listeners the whole story. But I went for the first shot—‌

Harlan Krumholz: Oh my gosh.‌

Howard Forman: It was extremely reactogenicity for me, a lot of bad reactions.‌

Harlan Krumholz: What was the bad reaction?‌

Howard Forman: Just the typical bad reactogenicity.‌

Harlan Krumholz: Okay.‌

Howard Forman: But then, then, when I would have gotten the next shot is when I had a major medical problem.‌

Harlan Krumholz: Okay.‌

Howard Forman: I just never went back.‌

Harlan Krumholz: Then you just haven’t gotten back to it. All right. Any other good news you had?‌

Howard Forman: Yeah. I think a lot of the stuff to talk about is good news in a sense. We can go through them. But I’ll let you go first, and then I have some other things of interest to update.‌

Harlan Krumholz: You have a lot of other thing?‌

Howard Forman: Well, we all have a layer of good news, let’s put it that way.‌

Harlan Krumholz: I told you I wanted to talk about this article that was in The Wall Street Journal.‌

Howard Forman: Yeah.‌

Harlan Krumholz: That was really juxtaposing generationally doctors. And saying that there’s a whole generation of doctors, of which we’re a part of, that really saw this as a calling. You were going to wear a beeper, you were going to get woken up at night, you were going to have your life disrupted. This is really what your calling was. Then there’s a whole bunch of people who are younger who have different expectations.‌

Now I will say, it was this calling-versus-a-job kind of dichotomy, I don’t think that’s fair. I don’t think that’s fair. I think a lot of people coming up these days are, in fact, thinking of it as a calling. But they, again, have very different expectations. The interesting thing about this article is it was in talking with an older doctor. I don’t even know how to describe it. Someone who’s a ... this is our age.‌

Howard Forman: I know.‌

Harlan Krumholz: I guess it is just older.‌

Howard Forman: Older, yeah.‌

Harlan Krumholz: Someone maybe in their 60s or 50s. That there’s a bit of a frustration with the younger doctors, as they opt for roles that allow them more flexibility. Many people think there’s the shift is... away from being properly trained, and being properly committed. We hear this even with the hours thing. That people have forever said, back in the day when I was training, when I was doing, things were—‌

Howard Forman: It’s always changing. Medicine has changed a lot.‌

Harlan Krumholz: Well, this, by the way, it’s not I think resonant with consistent attitudes and families where you can have two very busy high-powered people. People need to have expectations of when they’re not responsible for work versus when they are responsible for work.‌

This idea of work-life balance, I heard a very interesting story the other day with regard to doctors. Sometimes there’s this job shaming, where people really are into their jobs and want to spend a lot of time on them, they want to figure out how they can balance other responsibilities and have a full life. But they get shamed because you’re supposed to be embracing a work-life balance.‌

There’s a lot of things I think going on in medicine sociologically. Both generationally, but also people trying to figure out what are these roles in the next generation. And I would say, a lot of the next generation do have different expectations of what ... it’s not that they don’t want to work hard, but they may want to have that flexibility, and know when they’re on and when they’re not.‌

Howard Forman: Yeah. Two thoughts I had from reading that article. I was so glad when you said you were going to do it because rarely do I read the long articles in The Wall Street Journal, but this one I did.‌

Two thoughts. Number one, there is a sense when you’re extremely well trained, when you’ve reached the point where you have so much to offer from your training that you do want to give that back, and that is a sense of what I think of as a calling. In other words, you’re trained for it, you can make a contribution to society. There is a limited number of people like you that can actually do it. So it makes you feel like, “I’ve just got to give as much as I can give.”‌

The flip side of that is that there are a lot of people out there who really, I don’t even know if it’s just work-life balance, but just see the job. It’s a job. It pays well. “I do it, it’s a job. But I do it as much as I need to do it to sustain the lifestyle I want to have, but I don’t have to do it any more than that.”‌

If you talk to people, and it’s not just medicine, by the way. The article is obviously about medicine. But I have friends here at the School of Management, I’m sure you have friends in other professions around, who also are what used to be called workaholics. But if you ask them why they’re doing it, it’s like, “I’ve got all this creative energy, I have all this ability, I can do so much, and I’m only here on this Earth for a limited amount of time. Yes, I’ve made my children a priority. But at the same time, I don’t mind doing this because it brings me joy.”‌

I think there is a change culturally. Your point about shaming is absolutely true. I think the younger generation almost take pride in putting up the Heisman. “I don’t need to do any more than I want to do.”‌

Harlan Krumholz: Yeah. I think there’s a couple things that strike me. One is we have to take some responsibility for this in medicine, for how the work environment is these days. It pushes you—‌

Howard Forman: It’s hard.‌

Harlan Krumholz: More in that direction if your work is highly clerical, if there’s less time with patients. If there’s less opportunity to be using the skills you developed in medical school, but you’re really doing a lot less than what was necessary for your training, I think that also drives people to say, “I want to circumscribe the amount of time I spend.”‌

The more that we can create environments that energize people, let them feel that they’re making a difference in other people’s lives, give them the opportunity to invest in their patients, and to make that kind of contribution, I think the more people will gravitate in that direction.‌

It is also important that we recognize there are some people who, in that situation, will necessarily want to spend as much time as they can doing that work. There will be other people who always will be saying, “I’m glad to contribute, but I want to contribute within certain bounds.” We need, in the profession, to be able to accommodate both.‌

Howard Forman: I do worry though that this article begins to explain why the physician shortage is not going to get better sooner. Despite the fact that we’ve now spent two weeks in a row talking about why there is a physician shortage and how we might solve it, and how A.I. might solve the physician shortage, it does worry me that if this is the trend, if retiring physicians who used to work 60- to 80-hour weeks are being replaced by physicians who really are working 35- to 40-hour weeks, we’ve got a problem.‌

Harlan Krumholz: It may exacerbate it. I think technology may help.‌

Let me just raise one other point here at the end. Which is, if we really want women and mothers in the profession, right now we are not a very friendly profession for allowing the kind of flexibility that parents, I’ll include fathers. But let’s be honest, mothers often are carrying more of that responsibility. Their head space is filled with how they’re juggling. We need to work hard on figuring out.... That’s not a sign of weakness, that’s not people who aren’t invested in the calling.‌

Howard Forman: Yeah.‌

Harlan Krumholz: But the profession needs to say, “How do we build this properly so people can make the investment, but still fill other roles?”‌

Howard Forman: It’s another big factor because, if you go back 50 years, women were a small minority of physicians. If you look now, women are a slight majority in parts of the country of new physicians. We do need to actually think about this.‌

Harlan Krumholz: And families where you’ve got two doctors or two people pursuing high-powered careers, this just takes accommodation to be able to figure out how to make it work.‌

Okay, go ahead. You’re next.‌

Howard Forman: All right. More good news. A little less on the good. But H5N1, we’ve talked about it a lot. I have been following this a lot.‌

Harlan Krumholz: Yeah, you scared the bejesus about me about this thing.‌

Howard Forman: I’m still not calmed about it. But the good news is that not a lot has changed. I’ll still give you some really big updates.‌

The top-line numbers have changed. It’s now 41 human cases, almost equally split between cattle and poultry exposure. Then there’s this one case in Missouri. I was literally in Missouri when the news broke about the Missouri, so I’ve paid probably more attention than most.‌

Harlan Krumholz: Did you go back to WashU?‌

Howard Forman: I did.‌

Harlan Krumholz: Yeah.‌

Howard Forman: I was literally there on that day.‌

Harlan Krumholz: That’s your place, right?‌

Howard Forman: That’s my place, WashU in St. Louis, Mallinckrodt.‌

But the good news about the Missouri case is that, at the beginning it was, okay, one woman who they couldn’t figure out how she got it, so they worried that it was human-spread. And then, five people taking care of her in the hospital came down with flu-like symptoms. And then, her roommate or somebody who she’s living with also came down with symptoms. This starts to get a little worrisome.‌

The CDC, it took them about six weeks, seven weeks, the CDC did a very thorough investigation. What they discovered were none of the people in the hospital tested positive for H5N1 by serology, and none of them tested positive by nasal swabs. The housemate tested positive by serology on, I think, one of three tests. They’re not even certain it’s a true positive. But even if it’s a true positive, they believe that the exposure was probably a common exposure, like both of them were out kissing pigs, I don’t know. We’ll get to that in a minute.‌

Harlan Krumholz: Okay.‌

Howard Forman: Like we’ve talked about before. It’s possible, getting close to poultry without realizing it.‌

That’s really good news. Because I will tell you, if you were in the muck of people talking about this, the concern about the Missouri case was very—‌

Harlan Krumholz: You mean on social media?‌

Howard Forman: Social media, but also on STAT News. Helen Branswell, who has been covering this fantastically, they were getting a lot of concern about it.‌

One more thing that also has come out in the last few weeks is that a pig tested positive for H5N1. Now this is different than what we talked about in Minnesota a few weeks ago, where it was an H5N1-V, which is “variant,” different thing. This was this bird flu in a pig, which apparently is very—‌

Harlan Krumholz: You’re saying it jumped species?‌

Howard Forman: That’s the concern. Pig apparently is closer to human than cows, or at least that. This was a big concern. Let me also give you good news on this one. Our friend and colleague, Michael Osterholm at the University of Minnesota.‌

Harlan Krumholz: Yeah. He knows a lot about this topic.‌

Howard Forman: He knows a lot about this stuff. He has come back and said, “Yes, there’s a pig.” A backyard pig, by the way, in Oregon. That’s the one that got tested positive. But he is not sure that it’s anything more than nasal swab that they got. If it’s nasal swab—‌

Harlan Krumholz: I usually call that a “snout swab.”‌

Howard Forman: I’m sure you do. Yes. Because you are the swineologist, or whatever it is.‌

But the point being that it may be contamination and not that the pig was systemically infected. They’re doing an autopsy on this poor pig.‌

Harlan Krumholz: We should be reassured. For the moment, we can be reassured by this.‌

Howard Forman: All of this gets right back to what you said a long time ago, which is, we’re not worried because there’s still nothing that says human-to-human transmission.‌

Harlan Krumholz: Great. Okay, that’s good news.‌

Howard Forman: Give me something else.‌

Harlan Krumholz: All right, back to me.‌

Howard Forman: Yeah.‌

Harlan Krumholz: Hey, I was just thinking I wanted to get back to one more thing about that Wall Street Journal article. I am so impressed. Our department of internal medicine, run by our friend Mark Siegel, and also a large group of individuals,... I will say that, at Yale, there is a specific focus on how to create this flexibility and to understand how to bridge this gap. Anyway, I just wanted to give a shout-out to them too, because I know this is top of mind for them.‌

Howard Forman: Oh, it’s true. Look, they are a humanist-driven program. They care about people, just across the board.‌

Harlan Krumholz: I think they’ve done a great job figuring out how to ensure that people are trained really, really well, but that the program itself is—‌

Howard Forman: Humane.‌

Harlan Krumholz: Is humane.‌

Howard Forman: Yeah.‌

Harlan Krumholz: All right. I wanted to come back to you. You’ve heard me talk about this from time to time. This issue about whether or not corporate America could take over primary care.‌

Howard Forman: Yeah.‌

Harlan Krumholz: The issue is that we know that there’s a primary care shortage. My gosh, even in New Haven, with the density of docs we have, it’s almost impossible to get a primary care doctor. My mother-in-law moved to Boston from Providence. She was, just by luck, able to get it. There was an opening where they said, “We’re taking new patients”—it lasted about 15 minutes. Then they closed off, and they’re no longer taking new patients. She got in. But it was going to be heck to try to figure out how to get a primary care.‌

As you remember, between “minute clinics” and then these, Oak Street and Iora...‌

Howard Forman: Right.‌

Harlan Krumholz: ...there were all these new-age, new approaches to try to figure out how to handle primary care. Bring in technology, make this focus on the patient, do all these different things. And then they started getting bought. Amazon bought One Medical, and Walgreens bought VillageMD. They were all of these different kind of things. These things started to skyrocket in valuations.‌

Howard Forman: We can come back to this. But just to point out for our listeners, most of them are different models. Some of them are targeted at sicker-than-average Medicare Advantage patients. Some of them are targeting the retail, low-cost, in-the-store type. And then there’s One Medical, which is really targeting richer people who are willing to pay more.‌

Harlan Krumholz: Who took Iora. Didn’t One Medical, I think they ...‌

Howard Forman: Oh, I forget which one is which now.‌

Harlan Krumholz: Yeah, there’s so many of them. But you remember, we talked on the show about how Walmart, they had built brick-and-mortar, they had this whole thing all planned out, and then they withdrew from the market.‌

Well anyway, the thing I wanted to bring up today was Cigna, which had a 2.7, B, billion-dollar investment in VillageMD. And had already written off, I don’t know, $700 or $900 million of it, decided to take it to zero. In their last earnings call they said, “We’re writing this off.”‌

Howard Forman: Worthless, worthless.‌

Harlan Krumholz: Completely. Howie, you’re the business guy.‌

Howard Forman: Yeah.‌

Harlan Krumholz: What does it mean when a company says, “We’ve made a $2.7 billion investment, and now on our books, we’re going to value it at 0.”‌

Howard Forman: It means they made a huge, huge mistake.‌

By the way, I just checked. You’re correct. Iora and One Medical....‌

Harlan Krumholz: This is fascinating. There was a lot of talk about Walgreens also, because they co-invested in VillageMD. Then in August, there was a lot of word on the street, articles saying that they were exploring options to divest its stake.‌

This is amazing. Multi-billion-dollar company in this whole direction of being able to provide primary care, this company is going to zero. I don’t know, what is at stake? Is it possible to create a business out of primary care?‌

Howard Forman: I don’t know. I will say, I’ve been very skeptical. Zeke Emanuel talked about this in one of his books a number of years ago, and touted the fact that this can be profitable.‌

The one observation I’ve made is that the only places we’ve seen them be profitable is the Medicare Advantage space, for which there’s a lot of financial hanky-panky that goes on. I’m not certain it’s real. Although I have friends in that business—we’ve interviewed some of them—who are convinced, so I don’t want to take it away, but I worry about it.‌

Then there’s the rich people component. I think One Medical/Iora working within Amazon, if you’re a wealthy person and you want to pay a subscription to be able to access immediate telemedicine consultations and be able to pay those costs as they come, that’s probably profitable as well. But a huge percent, it’s not a majority but it’s a large plurality of primary care right now, is delivered to the poorest people in the country through our community health centers nationwide.‌

Harlan Krumholz: Yeah. I can tell you, by the way, Iora didn’t start wanting to cater to better-off people. It wanted to create greater access.‌

Howard Forman: Yeah.‌

Harlan Krumholz: The last point I’ll make about this, which is I think important, is that many of these models were about this value-based care. That these groups were going to go at risk. They were going to say, “We’re going to cover a certain number of people, we’re going to take care of them, and we’ll do it for a certain cost.” This capitated model, value-based model. Seemingly, they have not been able to make it work. I think for people listening, some people may be using some of these services, the question will be their sustainability.‌

Howard Forman: No, it genuinely worries me because I do think we’ve always had a two- or a three-tiered system. But all of this movement that’s going on seems to only convince me more and more that they’ll be tiers. And that if you’re in the lower third of the population, maybe the lower half of the population, you’re mostly relegated to community health centers and so on. If you’re in the large middle class, let’s say, you’re going to struggle to find good primary care, and you’re going to resolve mostly to see specialists in lieu of primary care providers.‌

Harlan Krumholz: Well, let’s be honest. In most major medical centers, the primary care are a loss-leader.‌

Howard Forman: That’s right.‌

Harlan Krumholz: They bring people in who end up, when they have more expensive tests and procedures, end up creating margin for the systems. We’ve seen before that, people were peeling off high-margin areas. Orthopedic surgery.‌

Howard Forman: Totally.‌

Harlan Krumholz: Areas that were high-margin. That was what the arbitrage opportunity was.‌

Howard Forman: Yeah.‌

Harlan Krumholz: “Let’s peel off high-margin.” But primary care was never a high-margin business.‌

Howard Forman: No.‌

Harlan Krumholz: It needs money to be able to—‌

Howard Forman: Medical peels off the high-margin part of that business.‌

Harlan Krumholz: Well, okay, the high-margin of the ...‌

Howard Forman: Yeah, of that business.‌

Harlan Krumholz: Of that business, yeah.‌

Okay, what else we got?‌

Howard Forman: Also, good news. Although again, it may start off sounding like bad news. But I think most of our listeners are aware right now that there was an outbreak of E. coli, of a highly infectious, lethal type of E. coli, O157H7. Thirteen states, 90 people, one person died, all seemingly related to McDonald’s Quarter Pounders, I think. The cases started in late September, they peaked in early October. They seemed to have waned. The numbers I just gave you are a tip of the iceberg, because we know a lot more people got it, but they just didn’t have a severe disease from it.‌

By the way, tens of thousands of people get this every year, so this is just one outbreak. But it’s just a good example of, the CDC swoops in, is able to work with local authorities, state authorities, and the McDonald’s to identify the cause for these connected cases. They eventually figured out it was the slivered onions on the Quarter Pounders. They stopped the company that was, provided the slivered onions to McDonald’s from distributing it to anybody for a time being, while they continue to investigate. They’ve proven that the patties themselves are safe.‌

Harlan Krumholz: It was one store?‌

Howard Forman: One company.‌

Harlan Krumholz: One company. How many stores?‌

Howard Forman: Well, according to this, it’s 13 states.‌

Harlan Krumholz: Oh, 13 states. Wow, that was bigger than—‌

Howard Forman: And hundreds of McDonald’s.‌

Harlan Krumholz: I hadn’t been paying a lot of attention to this.‌

Howard Forman: Yeah, slivered onions. Who knew? I didn’t even realize slivered onions were uncooked, and that’s part of the problem. Because E. coli outbreaks are, more often than not, raw foods, not—‌

Harlan Krumholz: What happened to people who ate it?‌

Howard Forman: One person died. Two people with hemolytic-uremic syndrome, which as you know is a near-lethal—‌

Harlan Krumholz: It’s a devastating disease.‌

Howard Forman: Devastating. Twenty-four more were hospitalized over that.‌

Harlan Krumholz: That’s a big deal.‌

Howard Forman: It is a big deal. For our listeners, two other things. The two most recent E. coli outbreaks of substance, organic walnuts and raw cheddar cheese. It just reminds me, because we’ve talked about raw milk and the risks of raw milk. Be careful what you’re buying out there, when you’re talking about raw milk in particular or products made from raw milk. Raw cheddar cheese is a product from raw milk. While we’re not talking about H5N1 here, we are concerned that you could get E. coli more likely from raw cheddar cheese than you could from anything else.‌

Harlan Krumholz: Wow. That’s fascinating. All right, I got one more here to end on.‌

Howard Forman: Yeah.‌

Harlan Krumholz: There was a very interesting paper that appeared in the Harvard Business Review. It focused on how startups survive, let alone thrive, in this world of A.I. It was posing the question. Is this a moment where there will be a Google... We have Open A.I., for example. That’s big. But is this a massive opportunity for startups? What will happen in this?‌

They were making the case that, for a lot of these early-stage companies, what they really need to do is find these strategic partnerships. That is, they want to go to transformation, the real key here is going to be the power of data and compute resources. I would say also, distribution channels. It’s hard for something starting brand-new to be able to have the wherewithal to either get the capital nowadays. It’s not as easy as just starting in the garage and having a good algorithm and getting moving but that this is going to be about being able to pair.‌

Then the article goes into saying there are really going to be a lot of opportunities here in service provision. That startups can add value by offering A.I.-driven services. They’re really taking foundational models or the foundational resources and then translating them into something that becomes to have value. This model requires startups to think about in end-user services that can potentially be capturing a more extensive market share.‌

I think it’s also that there are going to be increasing questions about what is responsible use of this A.I. Any company that goes into this is also, it’s not the Wild West.... Well, it is still the Wild West, but it’s increasingly going to have oversight and concern. So again, why these strategic partnerships for anyone who wants to get into this.‌

It’s a gold rush in some ways. But in other ways, again, with the need for data, the need for compute resources, and the distribution channels, it’s a question of who’s going to be able to find the slipstream to be able to get traction.‌

Howard Forman: You worry, in a world where the biggest tech companies are now trillion-dollar or multi-trillion-dollar valuations. By that, I’m talking about Meta, Google, Apple.‌

Harlan Krumholz: Microsoft.‌

Howard Forman: Microsoft, thank you. And nVidia, but put that aside. But they’re such big companies at this point that they can dominate the space. They can monopolize access to capital in many ways. They can jump-start almost anything that they want.‌

Harlan Krumholz: Look at Apple. They have the hardware, they have the network, they have the distribution channels.‌

Howard Forman: They can do it all if they want.‌

Harlan Krumholz: It’s an immense advantage.‌

Howard Forman: Absolutely. And they collect the data in ways that other companies, well, Google can and Meta can, but not nVidia can. I wonder about how that is anticompetitive. People do talk about, when you’re too big to compete on the same level as these other companies.‌

I’ll just give you one thing along those lines. Elon Musk put out a prompt for his followers, or for anybody on Twitter, X, to submit X-rays and CAT scans into his A.I. model, which is called Grok, G-R-O-K.‌

Harlan Krumholz: Grok, yeah.‌

Howard Forman: And asking them to test this.‌

Harlan Krumholz: Grok has special meaning to computer science.‌

Howard Forman: I don’t even know.‌

Harlan Krumholz: When you grok something, you really try to—‌

Howard Forman: It’s good?‌

Harlan Krumholz: You understand it.‌

Howard Forman: Oh, okay. Good. Okay. I didn’t know what it meant. But the point is, he’s putting all of this into this now. I wonder, he’s not as rigorous as others would be about saying, “Hey, let’s make sure there’s no patient data on this. Let’s make sure you’re being very—”‌

Harlan Krumholz: If people give it to him, you know.‌

Howard Forman: That’s what they’re doing. People are, just because of the power of this one man, are feeding information into this system. He has a comparative advantage as well.‌

Harlan Krumholz: He does. Indeed he does.‌

Howard Forman: Yes.‌

Harlan Krumholz: Indeed he does.‌

Howard Forman: Yeah.‌

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

Howie, this is a lot of fun. I’m so glad to have the opportunity to talk with you.‌

Howard Forman: It is fun when we do this. I really do. I hope our listeners appreciate it. I hope they’ll give us feedback about this episode, about all of our episodes.‌

By the way, we really, as we’ve proven, we really will respond to your questions. Whether you put them on a review, whether you put them on a reply on social media, or whether you send it to us at health.veritas@yale.edu.‌

Harlan Krumholz: Yeah. For folks listening, we’re sponsored by the Yale School of Management and the Yale School of Public Health. We’re assisted in amazing ways by our producer, Miranda Shafer, and by our student researchers and supporters, Sophia Stumpf, Ines Gilles, Tobias Liu.‌

Howie, we’re finishing here, before the election. Let’s just at least have a wish for a smooth, peaceful—‌

Howard Forman: Peace, yeah.‌

Harlan Krumholz: Election Day. And that we get a rapid result.‌

Howard Forman: That’s it.‌

Harlan Krumholz: And that we can coalesce as a country. This sounds like a dream.‌

Howard Forman: No, I agree with you.‌

Harlan Krumholz: When this drops...‌

Howard Forman: I hope that, by the time people listening to this episode, that there is a peaceful path ahead for all of us.‌

Harlan Krumholz: Yeah, for sure. Thank you, Howie.‌

Howard Forman: Thanks a lot, Harlan.‌

Harlan Krumholz: Talk to you soon.‌

Howard Forman: Talk to you soon.‌