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Episode 73
Duration 37:31

Michael Ivy: Doctors and Mental Health

Howie and Harlan are joined by Michael Ivy, a surgeon and Yale New Haven Health's deputy chief medical officer, to discuss the mental health issues facing physicians and his own experience with burnout and depression. Harlan reports on new research casting doubt on the benefits of intermittent fasting; Howie explains how a new drug can help reduce the disproportionate rate of renal failure among people of African descent.

If you or someone you know is struggling with mental health, you can call 988 or text HOME to 741741 for 24/7 support.


“Are you napping too much?”

“Effects of Time-Restricted Eating on Nonalcoholic Fatty Liver Disease”

U.S. Department of Health and Human Services: Health Worker Burnout

Stanford Medicine: The Stanford Model of Professional Fulfillment

College of American Pathologists College: CURES Act Fact Sheet

“Inaxaplin for Proteinuric Kidney Disease in Persons with Two APOL1 Variants”

“Inhibiting APOL1 to Treat Kidney Disease”

Learn more about the MBA for Executives program at Yale SOM.

Email Howie and Harlan comments or questions.


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

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University, and we’re trying to get closer to the truth about health and healthcare. This week we’ll be speaking with Dr. Mike Ivy from Yale New Haven Health System, deputy chief medical officer. And before we check in on current health news, I want to just once again wish Harlan a happy birthday for yesterday, and I want to wish Miranda a happy birthday today. Miranda is our producer. We never get to let her speak, so I just want to wish you a happy birthday. Harlan gets to say it every week, but I just want to say how thankful I am for you and for Jenny and obviously to work with Harlan. So happy birthday.

Harlan Krumholz: Well, I try to say thank you many times to her so that she’ll be kind to me on the editing. I want to get a little more—

Howard Forman: Yes. Well, I hope you get to do something fun today, Miranda. So, Harlan, we’d like to check in on health news at this point. What’s got your attention?

Harlan Krumholz: Yeah, sure, Howie. And thanks for the good wishes. Actually, I decided to spend my birthday, my wife and I came down and spent it with my mother, the person who’s known me the longest in the world. And actually being in Florida, visiting her for a couple of days, just reminded me about how health information gets propagated. She brings to me a Harvard Health Letter that warns people about excessive napping and sleepiness. Now the intent is good, it’s trying to tell people to be mindful that if they’re sleeping a lot, maybe they might ask their doctor about it. Well, my mother comes to me and says like, “I’ve read this and I’m afraid to take naps now, because this is suggesting it causes strokes and everything.”

So it just emphasizes to me how important it is that we’re really clear in our messaging about health. And even when we’re well intentioned, it can be understood in ways that are not intended and cause harm. I mean, it was great for me to be able to reassure her, no, if you want to take a nap, you can take a nap. It’s okay. But even the Harvard Health Letter, she was sort of not understanding exactly what it meant and it emphasized to me.

The other thing I wanted to say today, you and I have talked about this a little bit, is we had another article that came out. So the importance of actually doing the experiments and getting the information. A lot of people have heard about intermittent fasting, that is this time-restricted eating. It’s where you’re basically told if you leave a certain amount of time where there’s no food that that has benefits to you above and beyond the fact that it might affect your caloric intake. And that by having periods of mini-starvation essentially every day, it sort of puts the body into a mode where it’s going to drive towards getting rid of bad things and emphasizing good things and help you live longer. And this has been a very big topic of attention.

There was an article that came out in one of the JAMA journals, JAMA Network Open, that asked, does this time-restricted eating help people who have this, what’s called fatty liver disease? So the people sometimes who are drinking a lot of alcohol who can injure their livers, but sometimes people, especially those who have obesity, can have fatty deposits occur within the liver, and those can cause metabolic problems for them. And one of the questions was, would this time-restricted eating, essentially intermittent fasting, help these people above and beyond calorie restrictions? So they took two groups and they made sure that they were taking about the same number of calories. Lo and behold, no benefit. No benefit to this intermittent fasting.

And this comes on top of an article that came out last year in JAMA Internal Medicine, another highly regarded journal, that asked, what’s the effect of time-restricted eating on weight loss and metabolic health in people who were overweight and people with obesity? And they randomized in that trial a bunch of people to having that period of fasting versus not. And lo and behold, at the end of that study, it didn’t confer any benefit, either on weight loss or cardiometabolic, you know, the sort of blood tests that we do that talk about whether or not they’re sort of heart health.

Anyway, the end of this, and I just wanted to share this with folks because they may have heard a lot about this intermittent fasting, the rigorous studies they are doing are kind of accumulating to suggest, it seems to be about the calories, folks, it’s not about the timing. And there’s lots of theories about timing and circadian rhythms and this and that, but when it comes to actually testing it in these experiments, so far it doesn’t seem to be holding up. Anyway, I thought that was kind of interesting.

Howard Forman: It really is incredible. I mean, this is not something that is just a few people are doing this. I’ve talked to any number of people who have either tried it for short periods of time or I know people that continue to do it right now after several years and they’re convinced—

Harlan Krumholz: Okay. I’ll tell you, I tried it. I tried it, Howie.

Howard Forman: I can’t do it. I can’t do it. How long did you try it for?

Harlan Krumholz: I think I tried it for a couple of months, and I just wondered if it would make me feel better, if it would help me lose a couple pounds. I didn’t find any benefit, but I didn’t know whether that was just me.

Howard Forman: It’s fascinating, though, how fast people are willing to try something without knowing how it’s going to affect them. And quite frankly, it could be harmful. We don’t know.

Harlan Krumholz: Yeah. But anyway, these studies, interestingly enough, it hasn’t panned out. There still needs to be more studies. So this isn’t definitive yet, just saying accumulating evidence isn’t supporting. So let’s get to Mike. We’re so lucky to have him as a guest today.

Howard Forman: Dr. Michael Ivy is the deputy chief medical officer at Yale New Haven Health. He began his medical career in the Navy training in surgery at the Naval Medical Center in San Diego and spent nine years in active duty, including deployments to the Adriatic Sea and South Korea. He then completed a fellowship at Yale New Haven Health System in surgical critical care and became chief of trauma burns and surgical critical care at the Bridgeport Hospital. At Bridgeport, he became vice president for performance and risk management in 2007, chief medical officer in 2012, and then served as interim president of Bridgeport Hospital in 2018 prior to his current system-wide role.

As if that’s not enough, he’s also the author, a co-author of dozens of scholarly papers, including some very highly cited ones, contributing to our understanding of how to manage trauma in burn patients. Dr. Ivy received his bachelor’s degree from Washington University in St. Louis and his medical degree from the University of Connecticut School of Medicine.

So first, welcome to the Health & Veritas podcast. You are a remarkable person and a good friend. And I can go on and on about why we’re so happy and lucky to have you here. But you’ve also been deeply committed to wellness and wellbeing for the entire staff of our system and particularly our providers, and this at a time when national measures of wellbeing among physicians are plumbing new lows. But you have been sharing your own deeply touching personal story from 2003 with audiences near and far. So can you start off and take us back to that time when you were top of your field, active clinically, chief of trauma burns and surgical critical care at Bridgeport and the associate program director for the Yale General Surgery Residency?

Michael Ivy: Yeah, so first, thanks Howie and Harlan, it’s an honor to be on the program. I really appreciate the invitation. So if you go back to 2003, really this story kind of starts in 2002 when I became the associate program director. The Yale surgery program had gotten on the wrong side of the changes, the revolutionary changes that were going on in GME at the time. And so it took a lot of extra work to get back on the right side of the changes. And at the same time, I was a very busy clinician.

Howard Forman: And for our audience, GME, “graduate medical education,” that’s our residency programs, right?

Michael Ivy: Correct. Yeah. And there was major changes going on back then. So by the summer of 2002, fall of 2002, I was pretty burned out. And then in the summer I became the chief of trauma at Bridgeport. That was just more work. And the guy who had been the chief became the chair. And so then there was even more clinical responsibility that we had to carry. I mean, Nabil [Atweh] did a great job trying to help us, but he wasn’t able to carry the same clinical load he’d been carrying in June or July. And so I think that we got pretty worn out. And you got to remember, this was old school. We were still doing 36 hours of trauma call as attendees.

Howard Forman: And you’re a former military guy, I mean, as much as you might have been a physician in the military, you’d been on the ground, seen catastrophes. You’ve sort of lived through a pretty hard life. This wasn’t totally outside of the realm for what you’d done before.

Michael Ivy: Right. No, that’s certainly true. I mean, deploying is hard, and I’d been through a number of trying experiences, but this just didn’t let up. So then I think by the beginning of 2003, we’d been telling ourselves we were burned out because that was a phrase being used in the trauma world, even in the early 2000s, probably because we were working ridiculous hours. You constantly feel like you’re letting the people that you care about the most down. You’re not there for the little league game, you’re not there for the school concert, you’re not there for the ballet recital, you’re not there for anything at home. You’re missing dinner a lot. You’re working a lot of weekends and holidays and nights. And then at work, if you do want to get home, you’re like, “Hey Phil, can you do this gallbladder for me? Really, I need to be home for this parent-teacher conference. I got to get out of here.” It just seemed like every day, month after month after month and—

Harlan Krumholz: When I hear it, I sometimes think that this system has historically exploited people in that way because the people drawn to medicine are people who want to give, are empathic or want to help out, actually always want to pull their load. And I’ve often felt like you can... I mean those of us in academia, let’s just take the academic place. We’re sort of on a fixed salary. I mean, there may be bonus parts to it, but it’s mostly fixed. And it’s sort of like the idea is we can just keep adding to that. We don’t have to hire more. People will just continue to take it. And we give lip service to the idea of wellness, but we don’t always walk the walk with regard to that. And it’s hard.

We talk about safe spaces, but it’s really hard for someone not to feel like I may be letting other people down or especially junior people, sacrificing my career if I raise this because if I show any weakness at all, people are going to perceive me as not someone they can depend on. And navigating this where we can help people both be the heroes they want to be, but recognize part of it is being true to yourself and what you need. After you’ve been through all of this, where do you land about trying to find that balance so you can give that messaging and do it in a way that’s supportive? Because I will say, even to today, even through COVID, I see people coming in to work sick.

Michael Ivy: Yeah, you do.

Harlan Krumholz: They don’t want to call somebody and say, “I need coverage.” Those words are so hard for a doctor to say. “Look, I’ve got a cough.” And I’ve seen it. You think through COVID, just for protection of patients, we’d be saying, “Do not come in if you are sick.” But still, not because they don’t care about the patients, but because it’s so ingrained in us not to raise our hands and say, “I should be home today.” You’re in a position of leadership, how are you navigating that? Because it’s just hard because it’s so intrinsic to the way the profession is built still to today.

Michael Ivy: Yeah. I think that’s part of the challenge. Right, Harlan? It’s structurally part of what we do every day. And again, I think an important part of what you just said is what happens is, you blame yourself. I’m not blaming the hospital for not hiring a couple other trauma surgeons. I’m blaming myself for not being there for my family and my colleagues. Really, you put it on yourself. I got to be able to step up. I got to do this. And that is not a healthy approach to this. I will say I think that the younger generation has a somewhat better perspective on this than we do.

Harlan Krumholz: But the system, just a follow-up, one quick thing is the system is not built for this flex. So in a way like... I asked this question. When they were hiring the last chief of cardiology, I just said, “I’m just curious, when are you getting someone to come in here?” How many cardiologists do you think you need to care for people with cardiac disease in our catchment area? What is the reasonable expectation of a workload? And how many people do you need? And what kinds of people? Nurse practitioner, everything. Who’s done the simulation? How does it look? But in the end, actually no one’s done that simulation. And as the demand goes up... and we’ve got, by the way, a three- to six-month wait-list for cardiology appointments in Yale Medicine.

So everybody feels this pressure that there are people we’re letting down. I mean, there’s letting down your family, there’s letting down yourself, but there’s also letting down the people who are in queue who are hoping to be able to see somebody. And it takes a total restructuring of our world in a way to be able to start thinking in like how many hours is reasonable to ask somebody professionally to put in? And of course on the academic side, the expectation, I have to sit down with trainees and say, “If you do X, it’s enough this year,” because no one tells them what enough is because it’s an infinite amount.

Michael Ivy: It is.

Harlan Krumholz: And that’s a whole nother side of burnout on the academic side, which is you can’t ever do enough. I’d say part of my job is to say, if you do two papers this year, that’s enough. So let’s figure out what the two most important papers are and do it. Don’t feel like, “If I did two great papers, I just wish I’d done four. I wish I’d done eight.” It kills me when I hear people, and I will say this, in women, it manifests even more deeply, even more deeply. And I hate to make gender issues here, but it is, sometimes one of our jobs is going to be to tell people what’s enough out of you as a professional.

Michael Ivy: Yeah. So I have a couple comments. One is, I think part of the way out of this is just what you’re doing, which is mentoring the people that are working for you and with you to say, “Look, you need to set limits. Two papers is enough, it’s enough.” Don’t get too out of balance. I think that’s an important part.

Howard Forman: What turns it around for you? When do you start to get involved in self-care, and how does that translate into the work you do now?

Michael Ivy: Yeah, Howie, I mean, like a lot of people, I had to bottom out. I mean, I had a plan on how to end my life and I was struggling with it every day. I didn’t. I had three young kids at the time, and I was not going to leave them. But that didn’t mean I didn’t struggle every day. But despite that, I mean I know this sounds crazy, I did not think of myself as depressed and suicidal. I really thought I was burned out and struggling. And I think that’s just because the stigma’s so great. So then one day I’m driving into work, we used to round at the SICU [surgical intensive care unit] at the VA as well.

Howard Forman: When you say rounding, just for our listeners, you’re talking about visiting each of the patients, discussing their cases with your team.

Michael Ivy: And I remember a lecture from med school about, well, if people have a plan on how to commit suicide, they need to be seen urgently. And that is the first time I’m like, oh, oh. I mean it was really one of those—

Harlan Krumholz: I mean, you were driving in and you recognized, I actually have a plan to end my life. And that’s when you, the light went off and said, oh my goodness. Maybe that’s—

Michael Ivy: That’s exactly right. That’s exactly what happened. I’m like, oh. And I’m like, what am I going to do now? Of course, like everybody else, I went in and rounded and then I called Ronnie, right?

Harlan Krumholz: That is just such an emblematic thing. “So what did you do next?” “I went in and rounded.”

Michael Ivy: Rounded, yeah.

Howard Forman: Exactly. Because you had to.

Michael Ivy: Because I had to do it, right? And then called Ronnie Rosenthal, who was the chair of surgery at the VA at the time.

Howard Forman: We all know. We all think he’s terrific.

Michael Ivy: He’s great. Right?

Harlan Krumholz: Terrific. Yeah.

Michael Ivy: And I said, “Hey, Ronnie, I’m struggling. Do you mind if I come up and talk to you for a while?” And so I went up and talked to Ronnie and I just broke down.

Harlan Krumholz: Oh my goodness.

Michael Ivy: Ronnie is a very empathetic person, and I hadn’t talked to anybody at that point about this.

Harlan Krumholz: Well, thank goodness you did.

Michael Ivy: Yeah, no, I think that’s right because I think reaching out to her, that was, I mean, lifesaving, certainly life-changing for me. So then I took a couple of weeks off and started therapy and gradually got to the point where I saw things differently. We stopped doing elective surgery. We stopped. That freed up a lot of time. Then we actually started going home the morning after call rather than staying because the residents were going home first thing in the morning and we were staying all day. I mean there’s a big difference between getting home at 10:00 AM and 6:00 PM.

Harlan Krumholz: One quick thing is this doesn’t derail your... you go through this thing. Amazing. It doesn’t really derail your career. Your career continues to climb. Most people are concerned it’s going to derail. Do you have lessons for people who look at you and try to say, what should I take from this?

Michael Ivy: Well, I do think it changed the arc of my career a little bit. I mean, again, I had no complaints about my career, but I didn’t become a chair anywhere. I really shifted away from some of the clinical stuff eventually, five years later or so. It was a while down the road. I think there are a few things that I tell people. One is, a lot of times there’s stuff going on outside of work. One is, you may have health problems and it may be because of those health problems... I had this uveitis problem that I was having, and it turned out that sleep deprivation was making it worse. It wasn’t until I was not taking a lot of call that I realized it. So I was like, I got to stop taking a call. So that was one big shift. So you got to take care of your health.

Two, if you have kids at home who are struggling with some chronic condition, again, that’s another reason for you to stop and go like, your career may need to change if you want to be able to be there for your family, who needs you. And so I think, I mean those are a couple of the big pieces of advice I give.

Howard Forman: Can I ask you, your current role does include wellbeing and wellness, but I’m totally impressed and sort of emboldened almost about like, I’ve had my own mental health issues in my life. I don’t really talk about them enough. I’ve talked about them in small groups, but you have actively now gone out and told this story to larger, larger groups near and far. And I think it’s incredibly important. We need to destigmatize mental health issues globally, but we certainly need to within our profession as well. Was there a moment that triggered this that said, “I just got to do this, it’s the right thing to do”? What caused you to start talking about this?

Michael Ivy: Yeah, that’s a great question. When I first stepped into this role, one of my daughters was a peds resident out at St. Louis Children’s Hospital and tried to see if Wash U has any programs or offerings we don’t have. And they don’t, or they didn’t. You know what I mean? There’s only so many cards in the deck. We all have the same cards. However, Julie had a great insight and she says, “You know, Dad, when people come and they say, look, if you’re struggling, call this person. If you’re struggling, email this person. If you’re struggling, go to this office.” And she said, “They never say, and when I struggled, this is what I did.” And she said, “If we want to decrease the stigma, people got to get out there and they got to say, ‘This is what I did.’” I mean, my kids know I’d been depressed. They were not that young at the time.

Harlan Krumholz: What a lot of wisdom, what lot of wisdom she has.

Michael Ivy: Right? Yeah. That was a lot of insight. So that’s kind of what got me to doing this, Howie. I mean I—

Harlan Krumholz: I’ve almost never seen it, Mike. I mean, just what you said, people telling people what to do, but to make yourself vulnerable and to be so authentic about what your experience has been, it is just one of the most breathtaking and remarkable things. And I do think it does unlock for a lot of people the thought that I can actually talk to someone.

Michael Ivy: Yeah. No, thanks, Harlan. I was literally on the phone earlier today with the American Hospital Association talking about trying to do this for them. Again, one of the stated goals at the AHA is to decrease the stigma associated with acknowledging that you have struggles and that you need to get help.

Harlan Krumholz: Do you see this as connected to the larger issue, people are talking about a burnout, or is this more a profound and extreme situation where people are maybe a combination of the external stressors, but internal stressors? I mean, I’m just trying to separate because we do know that 30 to 40%, maybe more, of doctors will report burnout. And you know the numbers better than I do. But is this part of that or is this a subset of that?

Michael Ivy: I think this is a subset of it. And the talking part of what I say is like, look, you don’t have to wait till you’re suicidal to ask for help. It’s okay to reach out for help if you feel like you’re burned out. And so I think it is a subset of the overall work, but I think it’s a necessary change in the culture. I really do. And I think it’s part of the culture that is changing. I mean, if you got on the floors, there was a time where people had just acknowledged that they were on SSRIs or they’d started. It’s a lot more open than it was even just a few years ago.

Howard Forman: Well, have you gotten responses from individuals after giving a talk like this?

Michael Ivy: Yeah. No, absolutely. After I gave the talk for the first time, I got an email from one of the surgery residents, and it almost brought tears to my eyes.

Howard Forman: Sure.

Michael Ivy: People reach out to me periodically now after I give the talks. Either some people reach out immediately, other people reach out weeks or months later sometimes. And they frequently have something else going on. They have a kid who’s sick or a parent who died, those kinds of things. But yeah, that’s part of the deal here.

Howard Forman: And just briefly, since this is what you do right now, what do you see as the strategies that we can take as a system in your organizational role to help our physician workforce cope better and hopefully have a more enjoyable life?

Michael Ivy: Again, I buy into that Stanford Model. I mean, again, they trademarked it. I’m not the only person who buys into it. I think we’re all pretty resilient. There’s more you can do to increase resilience, and we have programs trying to support that, but there’s not going to be a lot of return there because people are pretty resilient to start with.

Howard Forman: Can I stop you for one second and just tell us, when people say the Stanford Model, what do they mean by that and why is it called the Stanford Model?

Michael Ivy: Stanford Medicine has a model where the factors that kind of play into burnout and healthcare are related to the work, the culture, and personal resilience. Again, I think the challenge is... the programs on resilience are the easiest, and I encourage people to do it. I mean you should try to take care of yourself. But again, I think that people by and large going into healthcare are pretty resilient. And so there’s not a lot of return there. Two, I think we are changing the culture. We are, and this is part of that effort, making it okay to ask for help, making it okay to call in sick when you need to. I mean, those kinds of things. But the work is a lot. There’s enormous productivity pressure on people. It’s enormous.

Howard Forman: All across the board.

Michael Ivy: Yeah. In every field. I think Epic and Cerner and those guys get a bad name, the electronic medical record, but it’s more than that. The documentation requirements for billing purposes and for malpractice purposes, that’s a lot. It’s a lot for people to go out of their way to do all that extra time and documentation, and I think that that... and again, and just all those concerns, it’s a Sisyphean task. I mean, we feel like we’re making progress, and then the Cures Act rolls out and then all of a sudden we’re like, “Oh, you’re killing me!” And then we got to try to figure out how to make those changes.

Howard Forman: Just for our listeners, the Cures Act, you’re talking about reporting requirements or what specifically in the Cures Act?

Michael Ivy: Well, I think the reporting requirements. Because of COVID, everybody got onto portals so that they could ask their physicians questions. And once you start getting access to all the lab data immediately and all the radiology readings immediately and you don’t necessarily know what they mean, it’s just generated a lot more traffic. I mean, again, it’s a necessary step in the right direction, but we were in no way ready for that. I mean, if it had come at a different time, maybe, but right in the middle of, or not in the middle maybe, but toward the later ends of this COVID pandemic, it hurt us a little bit.

Harlan Krumholz: Yeah. Well, let me just say what a pleasure it is to talk to you, Mike, and how much of a difference you’ve made both locally to us but I know also around the country. This is an immense health contribution you’ve made. I mean, you’ve written papers, you’ve treated patients, but actually you’re helping people in the profession so much and others beyond, like you said, all professions are affected by this. But ours, I think in particular right now is in a very, very difficult situation, and your voice is just so important and needed. Thank you for joining us. Thank you for sharing with our listeners, and we look forward to having you back sometime in the future, just keep talking about this.

Michael Ivy: Okay. Thanks a lot, Harlan. I really appreciate it. Yes.

Howard Forman: Thank you.

Michael Ivy: Thanks, Howie.

Harlan Krumholz: Well, that was a terrific interview, Howie. Every time I hear Mike Ivy, I’m just so impressed, and he’s got such an important message. But let’s pivot to the next part of the podcast and get to what’s on your mind this week.

Howard Forman: Sometimes I have dour news, but today I bring you an incredibly hopeful breakthrough in science that has it all.

Harlan Krumholz: Love that. Love that.

Howard Forman: I know. We need good news. It’s about health equity, precision medicine, genomics, and the hard work of so many scientists with a lot of potential to make lives better and even save money. So here it is.

Black Americans are 13% of the U.S. population. They make up 32% of cases of end-stage renal failure. That makes them at least two and a half times as likely as non-Black Americans to have end-stage renal failure. There are many reasons for this, and we’ve sort of weighted our explanations towards social and structural determinants of health, like income, education, early management, and access to hypertension and diabetes care, et cetera. And all of these things remain contributors, or at least we think so, but they aren’t the whole story.

In the last decade, we’ve discovered that individuals whose ancestry is in sub-Saharan Africa, particularly West Africa and particularly even Nigeria as one region, have a substantially higher likelihood of having a specific genetic variant, which we call APOL1, G1 or G2. You may ask yourself why this gene is so disproportionately affecting this population? Well, it turns out that this gene is actually protective against trypanosomiasis, which is also called sleeping sickness, a brutal disease that until very recently was responsible for tens of thousands of deaths and a lot of extra morbidity as well. So put a different way, that gene or those genes conferred a selective advantage in the past. It allowed people to have a more higher likelihood of surviving into their reproductive years.

But it turns out that when you have two of these gene variants, you have a sharply higher risk of at least one and probably many more forms of kidney disease that ultimately lead to organ failure, renal failure. So not a lot could be done over the last decade because modifying the gene’s not really feasible. And there are other reasons why it’s difficult. But then in last week’s New England Journal of Medicine, investigators tested a small-molecule drug, and I use that term to mean a chemical that you could basically take orally as opposed to having to be injected and something that ultimately could be inexpensive. And it had a dramatic impact on one of the intermediate steps leading to renal failure in these specific patients. So both in a mouse model and then in a small sample of humans, there was significant improvement in proteinuria, which is protein in your urine. And in this population it was tested after they already had symptoms.

There is much more to do to test this in a larger sample in an asymptomatic population, in a randomized controlled trial, and to confirm that this will reduce the risk of renal failure. But the evidence is pretty compelling for this moment, and we need to look ahead to more. Renal failure is very costly. It’s about $120 billion a year. I looked it up today. It shortens life expectancy substantially. It burdens an individual with either maintaining an organ transplant or receiving dialysis for the rest of their life. We also have an organ shortage in our country relative to demand. So while procuring organs from living in cadaveric donors remains a priority, it will never meet the current demand for transplants. So reducing the likelihood of renal failure through this or another pathway reduces demand for organs, it improves the lives of those who would’ve been affected, it saves money. It ultimately benefits all of us.

Harlan Krumholz: That’s really interesting, Howie. I mean there’s lots of facets to this. One is that we’re entering in this era where there may be, like gene-directed therapy, we have that in cancer, I mean it’s very common obviously, but there may be other diseases where we will be looking at people’s genes and making determinations about what’s the best way to treat them, even anticipating illness. And increasingly, I believe that people are going to be sequenced. So it’s going to be part of your database, it’ll be something you carry, you’ll know what it is. And as insights come out about how to leverage your data, whether it’s telling you what you’re at risk for, what you might respond to, that’s going to be common. So we’ll only have to do it largely once. I mean, maybe it happens a couple of times as sequencing gets better, more precise, more expanded, but in general, people will be able to leverage off of that information.

Essentially what you bring up about Black Americans, it is important, and I know that you agree with this, the understanding now is that race is not genetically bound.

Howard Forman: Correct. Right.

Harlan Krumholz: It’s a social construct.

Howard Forman: Correct. Yeah.

Harlan Krumholz: But it is still true that there are some genes... We’re all from sub-Saharan Africa actually, in truth.

Howard Forman: That’s right.

Harlan Krumholz: But it is true that there are some groups where there are some mutations that tend to track; you’ve got Tay-Sachs in Jews, for example…

Howard Forman: Correct. The Ashkenazi Jews.

Harlan Krumholz: So finding this right messaging for the public is really also important so that people don’t think that... Largely there’s overlap of all of our genome.

Howard Forman: Correct.

Harlan Krumholz: What’s not overlapping is relatively minor in comparison. But anyway, I don’t know, you might have a comment or a thought about this, but I also just wanted to clarify that—

Howard Forman: No, I mean it’s fascinating. In my reading about this, it was fascinating because they make the very clear point that obviously the gene was acquired effectively after the migration began. And that’s why this group has it and so many of the people that migrated out of sub-Saharan Africa tens and thousands of years ago don’t have it. So it just shows you how dynamic we are and we are accumulating both bad and good genes over time. This one is protective against trypanosomiasis. And so it had an advantage for a long time. We can treat trypanosomiasis now. We can prevent it now. Now is the time we have to figure out how to get rid of the bad effects of this. And the first step will be proving that this is true. And the second step is, as you say, screening for it appropriately.

Harlan Krumholz: But importantly, we’re not making any sort of point that rates as a genetic construct.

Howard Forman: No. No.

Harlan Krumholz: It’s just that there are some genes that do follow along in those ways.

Howard Forman: And that I think it’s hard for people to appreciate the fact that the biology of a Black person and a White person is exactly the same. But we all, whether we’re White, whether we’re Black, whether we’re Indigenous South American, we have accumulated genes that accumulate regionally and aren’t necessarily expressed globally.

Harlan Krumholz: And I do believe that the social determinant effects tend to dwarf actually differences in biology in terms of—

Howard Forman: Generally.

Harlan Krumholz: ... health outcomes. But a topic for the future, and I’m sure we’ll revisit this with a lot of experts. But thanks for sharing that.

Howard Forman: But at least it gives us hope. Gives us hope.

Harlan Krumholz: Very interesting. Very interesting paper. 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 @T-H-E-H-O-W-I-E. You can also email us at 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 And I want to just point out, we have some exciting news from the School of Public Health coming up in just a few weeks, so stay tuned for that as well.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Jenny Tan, who is amazing, to our producer, Miranda Shafer, who is also amazing, and it’s her birthday today. Happy birthday, Miranda! Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan, talk to you soon. Happy birthday again to Miranda.