Robert Alpern: Creating an Inspired Medical School

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

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. We’re excited to welcome former dean of the Yale Medical School, Dr. Robert Alpern today, but first, we always check in with current or hot topics in health and healthcare, so Harlan, kick us off.

Harlan Krumholz: Yeah. Thanks, Howie. I’m always reading the newsletter that Katelyn Jetelina puts out. I don’t know if you’ve seen this.

Howard Forman: No.

Harlan Krumholz: She’s terrific. I really recommend people subscribe to her. She’s a top-notch epidemiologist who’s always on top of what’s going on in the country, but she had a little piece today about the surging Norovirus. So Howie, of all the viruses, you know which one I hate the most?

Howard Forman: Yeah. I mean, that’s the one, where you—

Harlan Krumholz: Norovirus.

Howard Forman: Yeah. Vomiting, diarrhea. That’s all I know about it.

Harlan Krumholz: Cramping and, oh God, it’s just gross. Here’s what really caught my eye, is that we’re in the months where it tends to surge, I guess, except on cruise ships, where from time to time it takes off. But in the general population, you get February, March, this is the time when in North America, Norovirus tends to surge a little bit. But what I didn’t realize was that she said that, because this is really sort of surging right now in the country, we can all expect that maybe 10% of the population will get sick from it at some point.

Ten percent of the population, I didn’t really expect that. So each person may be expected to infect maybe 2 to 7 other people. It can live on surfaces for weeks. It can be spread fecal, oral, and it’s sort of like, it can be direct contact, like shaking hands, touching door handles, or through foods, buffets, or aerosolize. If someone throws up into a toilet and the toilet gets flushed, it can aerosolize it and be transmitted. I mean, this thing is the worst thing ever, but it’s gotten me thinking. Are you shaking hands now?

Howard Forman: More than I would like to but less than I used to.

Harlan Krumholz: Should we just give it up?

Howard Forman: I think we should, but I have so many friends that seem to, when they meet me in the hospital of all places, the hand goes straight out, and there’s only so many times I can interrupt it with a fist bump.

Harlan Krumholz: Or an elbow. Elbow, like Larry David started, even before all this stuff. Larry David was, I think, a germophobe. I think I’m giving it up. I think I’m just going to start.

Howard Forman: It’s not a bad move. I can tell you that.

Harlan Krumholz: And then how about buffets? Are you still doing buffets?

Howard Forman: I have not done a buffet since before COVID.

Harlan Krumholz: But also, I’m just thinking this is another way Norovirus is being transmitted because somebody touches a piece of food or somehow they didn’t grab the tongs right. It’s kind of crazy.

Howard Forman: It is. Well, thanks for inspiring us with that, Harlan.

Harlan Krumholz: Inspired by Norovirus. Let me just say one more thing, because she was bringing this up, and I know these are just facts that I thought are good for people to know. Do you know that, actually, the Purell, the hand stuff, that actually doesn’t address the Norovirus?

Howard Forman: Well, you just killed my optimism totally now.

Harlan Krumholz: So actually, what people are saying, and what Jetelina was saying in her newsletter, was that you really need to be out washing hands. We sometimes are thinking now that we can just, in the hospital, actually, we just put this stuff on our hands all the time, but I think maybe we’re not washing them as much anymore, but you take Norovirus, it takes about 30 seconds of vigorous washing and rubbing with hot water and soap, if you’ve gotten it on you, to get it out. This is important, because it’s not just the hand sanitizer. Then, I’m even thinking when you get on planes and stuff, some people are very conscientious about wiping off the surfaces, and they do say these bleach-based products really should be used on surfaces, because somebody else was there. It can be there. So anyway, I’m raising Norovirus awareness this week.

Howard Forman: I know, and let me add this, because you didn’t give me a heads-up on exactly what we were going to talk about, but you told me it would be Norovirus, so I looked up one key fact, that even though it was originally called Norwalk virus, it is not from Norwalk, Connecticut. It’s from Norwalk, Ohio, just for our listeners who I know are anxious to know that.

Harlan Krumholz: Wait. I was talking about Norovirus. I think Norwalk virus is something different.

Howard Forman: Same thing. Let me see what it’s—

Harlan Krumholz: Is that right?

Howard Forman: Yeah, yeah.

Harlan Krumholz: I didn’t even know that.

Howard Forman: Yeah. Also known as Norwalk virus, also known as winter vomiting Disease.

Harlan Krumholz: You mean people were blaming this on Connecticut too, in addition to Lyme?

Howard Forman: Well, I think that they might have thought it was Connecticut, but it really is your home state of Ohio that had the first—

Harlan Krumholz: Norwalk, Ohio?

Howard Forman: Norwalk, Ohio. Yeah.

Harlan Krumholz: Oh, my goodness. Well, that’s a good, fun fact. I didn’t know that.

Howard Forman: There you go.

Harlan Krumholz: Let’s go on to our former dean, Bob Alpern.

Howard Forman: Dr. Robert J. Alpern is a nephrologist by training and the current Ensign Professor of Medicine in Nephrology at the Yale School of Medicine. He was the dean of the Yale School of Medicine from 2004 until 2020. Before coming to Yale, he had served as chief of the Nephrology Division at the University of Texas Southwestern Medical Center and then later the dean of Southwestern Medical School. Throughout his research career, Dr. Alpern has been predominantly focused on proteins used for kidney transport. Aside from the many accolades of Dr. Alpern’s teaching and research career, he’s an elected member of the National Academy of Medicine and sits on the boards of directors of the pharmaceutical companies AbbVie and Abbott.

He obtained his undergraduate degree in chemistry from Northwestern, his MD from the University of Chicago Pritzker School of Medicine, and completed his residency at New York’s Columbia Presbyterian Hospital in internal medicine, followed by a fellowship at UCSF, where he stayed on the faculty for several years before moving to the great state of Texas. Piece of trivia for everybody to know, that is where Dr. Alpern and Dr. Krumholz overlapped, in their time at UCSF, although I’m not aware that they worked together directly, but I bet they did at some point, even if they didn’t know. So I want to start off, though, I always like to learn something new from our guests, and I would like to start off by just learning, where did you grow up, and what got you interested in the path to medicine?

Robert Alpern: Okay, so I grew up on Long Island, and I wouldn’t describe myself as being highly academic in high school. I went to Northwestern. I was interested in chemistry, and I think they had five Nobel laureates in the chemistry department.

Howard Forman: Wow.

Robert Alpern: So that’s why I went there, and that was a great move. I would say that Northwestern transformed me into an academician. There were an enormous number of role models that were so impressive to me, and I wanted to be like them.

Howard Forman: And you went directly into medical school, so you must have made that decision relatively early.

Robert Alpern: Yeah, so I had gone there as a pre-med, but really loved chemistry. I would say those two things drove me in the future. From there, I went to the University of Chicago, and I was just more and more kept developing role models. The University of Chicago at that time, probably in most of the top medical schools, everyone was an academician. There was almost nobody who practiced. I remember talking about general internal medicine. There was one faculty member who was committed to general medicine. The students loved him. He was our best teacher, but everyone else was doing clinical work and research, and I met a lot of people who I wanted to be like.

Then, I was in New York. I wanted to get back to New York, so I came to Columbia for my training, and that was an amazing residency. We were, in those days, every other night on call in the IC, and the easy rotations were every third night. Then, I got interested in nephrology, membrane transport, and using chemistry. The best program was at UCSF, so I was actually one of the few people who didn’t want to go to San Francisco, but I wanted to stay in New York, but the best program was at UCSF, and so I went there and then fell in love with San Francisco, and then planned to stay there, and then the opportunity came to go to Dallas.

Harlan Krumholz: One thing I wanted to ask you about was, you led it for 15 years or so, right? You’re in this position. Everyone’s coming to your door, you’re the most important person on campus, and then you transition. I wonder if you could give us some wisdom about what were the lessons you learned about how you moved from being the dean, and in that position, to you didn’t retire, you’re still active, but it’s a very different thing. How did you prepare for it? How did that go when you woke up the next day? “Okay. Now I’m no longer dean.” I mean, there’s some relief probably, but also you’re not the person everyone’s vying to see anymore.

Howard Forman: But we are. We are.

Harlan Krumholz: We are.

Howard Forman: We always are. We always are.

Robert Alpern: Yeah. So that’s a really interesting question that applies to so many disciplines. I think the scary thing about stepping down from a position like Dean is it’s irreversible, and so you really don’t know what’s on the other side, but you know that once you move to the other side, there will be no going back. You kind of are in the center of everything, and you have all this power, and everyone wants to interact with you, but it’s a lot of work. I have to say I have a much better vision of the transition, now looking back, than I had then looking forward. But there really is a time, I think both of you will remember this, when I first came to Yale. The medical school had a $35 million a year deficit. Everyone was demoralized. There was just a general feeling that Yale was living off its reputation and that we really couldn’t do anything and the administration would never fund anything.

And so, the first five years were really exciting, turning that around, and probably the most exciting five years of my entire career. I actually was astonished. So we were the poorest school at Yale, and the university was supporting us. Then, in 2008, with the recession and having improved the finances with the hospital, the health system, and the stimulus package, we were suddenly the wealthiest school at Yale. Actually, because of Rick Levin’s support, he never took our money, but he certainly wasn’t going to give us any more money after 2008, but we had enough to do it. Then, I would say the second five years was a five years of just continuing to develop the programs that we had started. We now had money, and we could really invest in things like the clinician scholars. That was a lot of fun. Then, the last five years became more of a plateau. You’re kind of maintaining what you’ve done, which is tough. It’s not that it’s an easy job to maintain it, but it’s less exciting.

Howard Forman: I wanted to just make sure that our listeners understand it’s not just a financial turnaround that you executed. You did massive fundraising for the endowment. You built a clinical practice, partly through hiring people to develop the Yale Medical Group, which is an enormous subspecialty medical group of the Yale faculty, and you recruited, retained, and built physician scientists. I just wonder if you want to just touch on how you prioritize those things. Even if the bottom line is one driver, it’s certainly just an end of the means.

Robert Alpern: Money becomes a big thing when you’re a dean, because you need it to do things, but knowing what to do with your money is just as important, maybe more important. One of my great mentors, Donald Selden, always emphasized the fact that the thing that separated great academicians from not so great was taste. Science magazine wrote an article about him on the rise of Southwestern Medical School, and they emphasized money. He walked into my office, threw the magazine on my desk, and said, “This is the worst article I’ve ever read.” He said, “They think just because we had money, we became great? Everyone had money. We had taste. We knew what to spend it on,” and that’s true. So I think that’s an important thing, because if you just want money, you can hire a businessman to run the medical school. And so, my feeling always was that Yale should be great. We should be a leader in everything we do, and that should be defined very broadly as a medical school. I’m a basic scientist, and I think that that leads me to wanting really great basic science, and Yale—

Harlan Krumholz: Yeah, that was a bias you had. That would be my only complaint about you, basically. No, no, no. Anyone listening, I’m saying it tongue in cheek, but I think Yale’s got a balance, but yeah, I know that you had that orientation.

Robert Alpern: Yeah, and frankly, in my younger days, most medical schools had that orientation. Then, I would say there was a transition to include clinical research, and there was a period where the top academic institutions were expanding to that, but still the best clinical care was frequently provided outside of the universities, and that had to change.

Harlan Krumholz: Just to say one of the interesting things is, actually, it strikes me as you described this, that you actually had two jobs. You were actually doing work at two institutions. When you first got here, you had a turnaround to do, and then once you got it to a certain point, you were doing a sustaining success job. You know what I mean? It was sort of a different job than what you first started off. One thing I want to ask you was, as you think back to when you accepted this job, of course you were dean at UT Southwestern, so you had experience as being dean. What happens the day after you accept the job that prepares you to develop the approach you’re going to take at a new place?

Robert Alpern: Yeah, so at Southwestern, when I became the dean, it was already an incredibly well managed medical school. State schools do not allow you to run deficits. It’s not an option. You run a deficit, the next year you’re not the dean, and the dean before me was amazing. So it was actually a difficult decision to leave a nice, safe job at Southwestern to go to a risky job here, but one with amazing potential, and so I came here and had to figure out how to create an inspired medical school and to turn the deficit around. Rick Levin gave me a lot of money, when I came, to be able to start investing and to be able to start saying yes to faculty when they had good ideas, but it wasn’t going to last forever. So the first three or four years, I had the resources and just had to decide how to spend it. Rick Lifton told me that he always worked a lot with Carolyn Slayman. Before I got here, Carolyn was so nice to work with, but in the end, she could never give you money, because she didn’t have it. He said, “Everything changed when I got here, because Rick Levin gave me money, and I was able to let Carolyn then say yes to people,” but we knew we had to turn that around, and we found a lot of financial inefficiencies.

But it wasn’t enough to turn the $35 million-a-year deficit around. It took me about a year, maybe two, to figure out that the key was the relationship with the health system and that we needed to support the health system better. We needed to make them more profitable, and they needed to then take that money and invest it back in the medical school, some of it, and some of it to build clinical programs, but some of it to support academic programs, teaching, and research. If you’re familiar with the economics of a medical school, you basically lose a lot of money on research. The more grants you have, the more money you lose. You lose money on education. Even though tuition is high, with 100 students a year, you can’t balance an educational budget from tuition. You make money on the clinical practice, and Yale was not making money on the clinical practice, so we were really strong in the two things you lose money on, but not so strong in the things you make money. The key thing was Marna and I developed this incredible relationship.

There were times when I really needed money, and I would ask the hospital for money, and all of Marna [Borgstrom]‘s people would say, “Don’t give it to him,” that this is a medical school responsibility. I remember Marna coming to me once and saying, “Bob, everyone is telling me not to support this. Just tell me. Do you need my money for this?” And I said, “Yes, I do.” She said, “You got it,” and that was just typical of our relationship. And so, I think, in many ways, we built up our clinical faculty, which really helped Yale New Haven Hospital and Yale New Haven Health System, and helped them really take over the state and become incredibly strong. We got so strong clinically that they had no choice, and all the doctors who never would’ve come near Yale, suddenly we had clinical departments that welcomed them and respected them, and we knew we had to do that, and we knew to get them. You know what happened in cardiology; a lot of the private groups came in, and that all made the hospital and the health system more profitable. And then, Marna understood that, and she wanted to help me succeed.

She cared about the academic reputation of Yale. She always said, “I’m a Yale graduate,” so that’s what turned our finances around, was increasing the size of the practice, increasing revenue from the practice, getting hospital support, and then being able to use it. When RWJ [Robert Wood Johnson Foundation] Scholars pulled out of the program, the RWJ pulled out, and basically said the four schools could support it themselves. Five years earlier, we couldn’t have done that, and it still wasn’t an easy decision, but I said, “This is a program that has made Yale great.” I mean, if you look at our division of general internal medicine, and your program and other programs, they were great because of what the RWJ Scholars gave us, and it needed to continue, and it turned out to be, supporting that was among one of the decisions that I’m very proud of.

Howard Forman: Thank you very much for joining us today, and hopefully we’ll be able to have you back.

Harlan Krumholz: Absolutely. Thank you.

Howard Forman: I hope to see you again more often.

Robert Alpern: There you go.

Harlan Krumholz: Howie, that was a great interview with former dean Alpern, but let’s get to what is my favorite part of the show, which is hearing what’s on your mind.

Howard Forman: Yeah, so attention deficit hyperactivity disorder is a very common diagnosis in America and worldwide. To put it in context, the prevalence among children and adolescents in the U.S. is around 9.8%, and it’s 4.4% among adults in the U.S. And there’s a host of associations felt to contribute to this condition. Parenthetically, we can’t discuss today, social media may be one of them. While our listeners may probably be well aware of the main symptoms including the impulsivity, the inattention, and emotional dysregulation, they may not be aware that these patients have a twofold increased risk of premature death, two times increased risk of premature death compared with patients without this diagnosis. The mechanisms of this increased risk include accidental poisoning, suicide, criminal behavior that results in harm, obviously in death. This increased risk is comparable to the increased risk associated with type 2 diabetes.

So, in short, consequential. There are pharmaceutical and non-pharmacologic treatments for ADHD, and there are continued concerns that this may be overdiagnosed and/or overtreated in our country and elsewhere. And again, for all listeners, I think you and I have said this many times, all medications come with risks, including long-term consequences, and we should be cautious about making sure that we diagnose and treat properly, so as to minimize bad outcomes and maximize both short- and long-term health. It was really good news to see a large study from a Swedish registry that looked at all-cause mortality and specific-cause mortality in patients who were treated for ADHD and found that a substantial reduction in mortality, even in the two-year interval that was studied for patients treated with pharmacological therapy, was found. Importantly, there was a statistically significant decrease in unnatural cause of mortality. Again, that’s the suicides, the accidental poisoning and so on, and no evidence—no evidence—of an increase incident of natural-cause mortality, which people had worried about.

Now, as usual, we should all offer the same caveats that more studies are going to be needed and valuable, that correlation doesn’t imply causation, and that there are limitations, but it’s a good moment to remember that we are treating these people not just to make their immediate lives more manageable, their school and work life more successful, and their behaviors more socially acceptable. It’s also saving lives, apparently. The last point I want to make is that diagnosis and treatment of ADHD is, not surprisingly, hugely variable by race and ethnicity. While White, non-Hispanic children are the most likely to be diagnosed, Asian children are the least likely, less than half the rate of White children, so it constantly behooves us to figure out why these differences exist and to make certain that access to diagnosis and treatment is equal so that lives can be saved, irrespective of race, ethnicity, and socioeconomic status.

Harlan Krumholz: Hi. So is this study talking about actually pharmacologic treatment and linking that?

Howard Forman: Yes, and so they clearly point out that there are other treatments besides drugs, but this is only looking at pharmacological treatment.

Harlan Krumholz: Yeah, because I’ve been really impressed by the cognitive behavioral therapy, the non-pharmacologic approaches that people have also been able to institute for this. I mean, this is a very interesting study. Obviously, it sounds observational. I think we need trials in this area to really fill out this kind of work. But there’s also been a lot of good work around using this cognitive behavioral therapy as an effective treatment for managing these symptoms.

Howard Forman: And they highlight that, and they also say it’s a limitation, because it’s possible that the same people who are getting the medicines are also perhaps more likely to be getting cognitive behavioral therapy or other nonpharmacologic interventions, but still, the magnet, the size of the study in terms of people, hundreds of thousands of individuals, is just impressive. While it would be great to be able to do more prospective clinical trials in order to power them to the tech, the types of changes we’re talking about is almost impossible to do a true, randomized controlled trial.

Harlan Krumholz: Yeah. I would say when we’re looking at events like mortality, that’s going to be almost impossible. But it does seem like we still need a lot more evidence for many of these common causes of—

Howard Forman: I agree.

Harlan Krumholz: …distress that are related to mental health and ADHD, for an example, and to help start these new strategies. I just feel like there are lots of designs we can use, medications, plus different variations of cognitive behavioral therapy, and a lot of these outcomes are continuous. It’s sort of, how well is the functioning? What has happened with regard to organizational skills, impulsive behavior?

Howard Forman: Exactly,

Harlan Krumholz: And just people’s general satisfaction with life. We ought to be finding a way, where almost everyone is in some way in a trial, where we’re trying to figure out what the best ways are.

Howard Forman: I mean, I’ll just say for me, I was rather embarrassed, to come to the knowledge even, that I always thought of this as a short-term problem. Like, you have it, this is what you need in school. You might need a little help as you transition to adulthood. I never thought about the fact that if you don’t treat this, a lot of these people are more likely to engage in criminal behavior, more likely to get involved with substances of abuse and so on, and so it gives me more of an imperative to think that we must intervene. Whether it’s pharmacologic or non-pharmacologic, I think, is still a good question, but it makes me feel there’s even a greater imperative for us to diagnose these people properly.

Harlan Krumholz: Yeah. At the very least, it should increase our respect for the many ways that this is unraveling people’s lives and the kind of harms that it’s causing. Thanks for bringing that up today, Howie. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

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

Harlan Krumholz: And we very much want to hear your feedback, questions, hear your own experiences, give us suggestions, all ears.

Howard Forman: And if you have questions about the MBA for Executives program at the Yale School of Management, please reach out via email for more information or check out our website at som.yale.edu/emba, and if you like the podcast, and even if you don’t like the podcast, please rate and review us on your favorite podcastapp. We always read your reviews, and it helps other listeners find this, and I really appreciate those who have been rating us recently.

Harlan Krumholz: Health & Veritas has produced the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and to our producer, Miranda Shafer, terrific people who are just doing an amazing job week in, week out.

Howard Forman: Yeah. I couldn’t agree more. I am so thankful to have them. By the way, they’re on break right now, but Sophia is still working with us today.

Harlan Krumholz: Yes, we appreciate that, too. Talk to you soon, Howie.

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