Ryan Schwarz: Thinking Differently about the Primary Care Crisis

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. Our guest today is Dr. Ryan Schwarz. But first, we like to check in on current or hot topics in health and healthcare. And Harlan, hit it off.‌

Harlan Krumholz: You like to check in, don’t you, Howie?‌

Howard Forman: I do.‌

Harlan Krumholz: Well, I love to respond. Let me give you a couple of quick hits, and then there’s one main thing I wanted to talk about.‌

Howard Forman: Yeah.‌

Harlan Krumholz: So quick hits. So we have a new director of the NIH, and we have a new commissioner of the FDA. So I’m eager to see what’s going to happen now that the leadership is in place and hopeful that wise decisions will be made. But holding with bated breath to kind of see now because—‌

Howard Forman: They are, at least on the surface, very qualified people. They’re both professors, they’re both practitioners. Well, I don’t think Jay [Bhattacharya] is a practitioner.‌

Harlan Krumholz: So let me just say this. We’ve changed the definition of what qualified means, in the sense that it used to mean that you had run large organizations, that you had spent maybe some time in that organization.‌

Howard Forman: Yeah, no, that’s true.‌

Harlan Krumholz: But they’re smart, accomplished people.‌

Howard Forman: That’s what I mean. Yeah.‌

Harlan Krumholz: Who have no science. So, I mean, I think the bar has changed, and this isn’t to diminish them at all, but I do know in the past when names were raised, one of the first things people would ask is, “Well, have they ever run a complex bureaucracy? Have they ever had the experience?”‌

Howard Forman: And these are two huge organizations. This is not like a small little business here.‌

Harlan Krumholz: Highly, highly regulated. Highly regulated and especially on the FDA side, of course. But also the NIH, I mean there’s a lot of regulations that oversee what they can and can’t do, at least historically. So this is part of seeing what happens if you, you know, “Mr. Smith goes to Washington,” you’ve got good people. I believe both are good people, and they’re accomplished people and smart people, but not with the experience of bureaucracy. I think that some of this idea is that, yeah, bring people in who aren’t of the system and see what they can do. So I’m eager to hear that. So that’s the first thing. I don’t know if you have hopes about it.‌

Howard Forman: No, I think the only thing that I would add to that is that I do believe that both of them are well-meaning. I’m just concerned about in both cases they have been historic skeptics and skeptics can be really good—‌

Harlan Krumholz: Let’s say this, they’re not on the record as saying the organization shouldn’t exist, which in some of the other organizations where people have become leaders, they have said that.‌

Howard Forman: That’s right.‌

Harlan Krumholz: So anyway, we’ll see. I mean, like I said, I like to remain hopefully optimistic.‌

Howard Forman: Agreed.‌

Harlan Krumholz: Let’s see what happens. The second thing was, you and I both saw a headline this week that said NHS England is being abolished. And I think we both did a turn on that. Of course there’s an N.H.S. Scotland, N.H.S. Wales, N.H.S. Northern Ireland, but N.H.S. England is the Big Kahuna. That’s the National Health Service. That’s the administrative organization.‌

Howard Forman: And it’s not going away. I mean, the headline sort of made it sound worse than it is.‌

Harlan Krumholz: That’s right, Howie. And so people have seen this, it’s actually not meaning that the National Health Service is being abolished, but they are reorganizing. This may sound familiar to people in the U.S. They are reorganizing the administrative oversight and management in the hopes of gaining efficiencies. So that this is really about the organizational piece—not about that, but some people might have seen that. That was one thing when I first saw it, I thought, what the heck? But it’s really about inside baseball, about how they’re managing the system.‌

Howard Forman: Yeah, that’s helpful to clarify.‌

Harlan Krumholz: Okay, my third thing, this is the thing I want to talk about a little bit more, is that this week there was a critical development of health technology and consumer privacy. That was the bankruptcy filing of the genetic testing giant, 23andMe. So of course this is an organization, a company that was once hailed as revolutionary. Their collapse really is a cautionary tale about this intersection of technology privacy, ambition, and market realities.‌

It was founded in 2006, hard to believe it’s been almost 20 years ago that Yale graduate Anne Wojcicki founded 23andMe. And really Anne is a force of nature. I’ve had the pleasure of meeting her a couple of times, and I visited 23andMe maybe 10 or 15 years ago and talked to her there. And she had impressive vision, to empower consumers by providing affordable access to their genetic data, and really to democratize genetics.‌

I mean, this was at the very beginning of the consumerism movement in healthcare. So she was really leveraging off of that. And the testing kits went from nearly a thousand dollars down to about $99, and really transformed how people understood their ancestry and health risks. But this journey, this very ambitious journey faced significant hurdles over the years, including ethical controversies. There was regulatory setbacks from the FDA. Most notably, there was a massive cyber security breach in 2023 that compromised personal data of nearly seven million customers. You may remember that.‌

Howard Forman: Yes.‌

Harlan Krumholz: There’s this whole thing about people identifying Ashkenazi Jews that hit close to home. According to industry analysts it was really, all these things were just headwinds, but it was really about investor impatience and really a steady decline in stock value that ultimately led to this Chapter 11 bankruptcy filing. And you may be noticing on the web, but lots of people were saying, “Well, what’s going to happen to the data?”‌

And the California Attorney General, Rob Bonta, has issued an urgent consumer alert advising individuals to invoke their privacy rights and delete their genetic data from 23andMe and have them destroy any stored samples. Senator Bill Cassidy emphasized similar concerns, and there’s this proposed Genomic Data Protection Act where people are saying this company has this. The cost of the company, which at one time was valued at market cap of maybe $6 billion, is said to be around $20 million now, but that means somebody could swoop in and for $20 million acquire all of this data.‌

You could ask what the value is, but for people whose own genetic data is within this repository, they may have some concerns, and who’s going to get, what’s going to be their issues? Anne has stepped down now as CEO. She has expressed an intention to bid to reacquire the company. Her story is very intertwined with this. I know that she’s very emotionally tied to this, and like I said, it’s about a vision, about her hope of seeing this. And I have a lot of respect for what she’s doing. So this is a lot of lessons around innovation, privacy, corporate accountability, and what I think still is a good idea, but somehow still has yet to be achieved. Have you been following this story? Have any thoughts about it?‌

Howard Forman: I mean, look, good ideas are not necessarily good companies, and even good companies are not necessarily explosively valued. This in a very short amount of time, I mean, the company came into existence 19 years ago, as you pointed out, but it only went public like a year ago or a year and a half ago. It was a very short amount of time it went public, and that’s when it had the $6 billion valuation today, real time $15 million valuation.‌

Harlan Krumholz: It’s down to fifteen, is it?‌

Howard Forman: Fifteen.‌

Harlan Krumholz: Maybe you and I should bid.‌

Howard Forman: Right. No, I joke with people that it’s affordable for people, if you could get the shares it would be affordable to get, the problem is it’s burning so much cash so quickly that even if you magically could buy it, let’s say you could buy it for $25 million today—‌

Harlan Krumholz: Yeah, you’re buying all the liabilities with—‌

Howard Forman: Right, you have to be able to come up with at least another two or three hundred million dollars just to create a runway so they don’t run out of money by the end of this year. So there’s a lot there. And as you point out, the risks right now are enormous. I’m a user; I signed up for it several years ago, and they offered these kits to physicians for free. I have followed it as a curiosity—‌

Harlan Krumholz: Wait a minute, I didn’t get that deal.‌

Howard Forman: Well, you should have, you should have. This is why you have to talk to me more often.‌

Harlan Krumholz: We’ve been talking.‌

Howard Forman: And it’s been fascinating for me. I’ve learned a lot from it. Some of its just curiosity. Some of it is the ancestry.com component of it, where I’m discovering cousins that I hadn’t been in touch with in a long time. There are fun parts of it. She never figured out or they never figured out the business model, how are they going to make money? Is it a company that’s trying to help develop new pharmaceuticals? Is it a networking company? Is it a company that, as you said, is democratizing people’s control of their own genetic information? It’s not clear, and it’s still not clear. And like you said, we should all hope that companies like this thrive because the innovation is valuable to all of us. But right now I think the risk is much higher than any outcome benefit.‌

Harlan Krumholz: Yeah. And sending good thoughts to Anne. It’s hard if an entrepreneur is so deeply invested and you tried so hard and she’s in the difficult straits so as a company with an idea that was ahead of its time, it got very popular, but gosh, this has got to be a devastating blow.‌

Howard Forman: Dr. Ryan Schwarz is an internal medicine and pediatrics physician who currently serves as the chief of the Office of Accountable Care and Behavioral Health at MassHealth—Massachusetts Medicaid and CHIP program. He has also held other leadership roles at MassHealth, including chief of the Office of Payment and Care Delivery Innovation, senior director of Delivery System Policy, clinical lead of the COVID-19 Response Command Center, and the director of Policy for Accountable Care. Previously, he was a founding member and chief operations officer at Possible, a nonprofit healthcare, public-private partnership with Nepal’s Ministry of Health and Population that provides integrated healthcare services for over 200,000 patients per year.‌

He has served as a technical advisor to the Global Financing Facility and World Bank and is a faculty member at Harvard Medical School and Ariadne Labs, joint center for health systems innovation between Brigham and Women’s Hospital and Harvard Chan School of Public Health. Dr. Schwarz received his MD and MBA from Yale in 2011. It is during that time that I got to know him well before completing an internal medicine and pediatrics residency at the Brigham and Women’s Hospital and Boston Children’s Hospital.‌

So first of all, I want to welcome you to the podcast. It’s really great to have you here. And I wanted to start off by asking you, what is your current perception of the primary care field writ large? Because I hear people talking about how we have a shortage of primary care physicians. There are other people that will say we have a shortage of primary care providers. I’ve now just learned from reading one of your pieces that actually the number of primary care mid-level professionals, not physicians, is actually declining now. Where do we stand in the workforce?‌

Ryan Schwarz: Thanks, Howie. Thanks, Harlan. It’s a pleasure to join you both today. I appreciate it. Effective public health systems run off of effective primary care systems, and when we look at health outcomes anywhere in the world, the countries that have the best health outcomes also directly correlate to the best, most high-quality, most accessible primary care systems. Unfortunately, the United States is a laggard in that situation. Over decades and decades, the United States has consistently under-invested in primary care systems relative to many of our peer countries.‌

When we look at the United States currently, and certainly here in Massachusetts, and I believe I can speak for the Connecticut statistics as well, where you guys are, we have seen year-on-year increasing difficulty in residents throughout the Commonwealth, throughout the country, having access to primary care. What does that look like nationally? Nationally in 2022, 31% of adults and 13% of our kiddos didn’t have a routine source of primary care, and that was up from 24% of adults and 9% of kids in 2012. So one decade before, 7% on adults, 4% increase on kids. Here in Massachusetts, we did a survey in 2023, 41% of respondents throughout the Commonwealth reported difficulties accessing primary care. This has increasingly gotten worse and worse.‌

Harlan Krumholz: Just say that again, Ryan. What percent?‌

Ryan Schwarz: Forty-one percent.‌

Harlan Krumholz: Forty-one percent have trouble accessing primary care.‌

Ryan Schwarz: Yeah, we have a, I would say statewide, Harlan, a primary care dire shortage, and others before me who are much smarter have said primary care is in crisis across the country and certainly here in the Northeast. And that is for a multitude of reasons, which we can talk more about, but we have a shortage of primary care providers, and we have increasingly created primary care as a career that is unsustainable, is not viable, and has led to dramatic burnout across the workforce, leading to people who are in primary care, who joined the primary care field to serve, who don’t find it to be a sustainable career and are either cutting down their clinical time or leaving year-on-year, and that’s a nationwide as well as a Northeastern trend.‌

To put a couple more specific points on this, one of the key drivers of this is ultimately underinvestment. And when we look at OECD peer countries, countries that have better health outcomes, longer lifespan, whether you look at high blood pressure, diabetes, other health outcomes, other countries that consistently outrank us in those types of measures, we see that they also invest dramatically more in their primary care systems than the United States says.‌

Some of those countries invest 10% to 15% of their overall healthcare dollar in primary care systems. In the United States in 2022, that number hovers around or a little below 5%. So 2–3x difference between the United States investment in primary care and some of our peer countries who are significantly outpacing us in terms of their health outcomes. In Massachusetts, excuse me, in 2024, we were about 6.4% in primary care. We’ve edged that number up slightly, but it continues to be a significant underinvestment in primary care.‌

And we know that we see this also in our health outcomes here in the United States consistently year-on-year, getting worse, and access to primary care consistently year-on-year, getting worse. More to the point, a recent study looked at what does it look like to be a primary care provider in 2025? Actually I believe the study came out last year, but they looked at the number of hours a primary care provider would need to work in a given week to effectively take care of the members that were in their panel. So if they were to appropriately do all of the types of screening vaccinations, routine physicals, as well as follow-up care, what would that take? The number that this study came out with was 26.7 hours per day, 26.7 hours per day to effect—‌

Harlan Krumholz: Let me just do a fact check. I think that’s more than the number of hours. I just want to check on that.‌

Howard Forman: Most days.‌

Ryan Schwarz: More research is probably needed, Howie, but I think that’s a fair assessment.‌

Howard Forman: Yeah, that’s crazy. That’s crazy, 27 hours to get all the work done.‌

Ryan Schwarz: And I think that really underscores in a very salient way, what does it feel like to be a primary care provider? And we look at the workforce, we shouldn’t be all that confused, that it is very difficult to encourage and recruit more providers to come into primary care, as well as to sustain those providers who are already in primary care to continue working. And so what all of this really leads to is that we really need to start fundamentally thinking about the primary care system in a different way, if we hope to start to change these trends. And happy to talk more about that, Howie.‌

Harlan Krumholz: Yeah, that’s a great start. So let me ask you this, Ryan, first of all, it’s such a pleasure to have you on the program, for people listening. I mean, here’s someone who’s really dedicated to transforming primary care through these value-based models and thinking differently about the work and really drawing on what, as far as I can read and we’re just meeting, but your extensive experience building innovative healthcare solutions domestically and with Possible, the company you founded globally.‌

And it’s really, Massachusetts is lucky to have you as someone who’s thinking about this. But I just want to know if you’re thinking radically enough, because here’s what’s on my mind about primary care, and my background in this is when I was in college I spent a semester in North Carolina, where they had an Office of Rural Health Services, and they had a real shortage of primary care throughout the state in the rural areas.‌

And there was a guy by the name of Glenn Pickard at the University of North Carolina who started the very first physician assistance and nurse practitioner programs, and recognized that a high percentage of what’s being done in primary care could be routinized, it could be algorithm-based. And then of course there’s a very important part of primary care that really needs, is more complex, needs a lot of things. But if you think about primary care, there’s issues around navigation, there’s an issue around coordination, and there’s an issue around for a lot of people, this algorithm-based care, which is what led to the minute clinics and other things trying to leverage this, largely unsuccessfully so far, but that way.‌

And now with you’ve got AI coming in, you’ve got the capacity to actually elevate people from their level of training to even a bit of a higher level to what they’re capable of doing, and to be able to automate a lot of the functions that traditionally reside within primary care. But shouldn’t we be trying to develop an entirely different model about how we’re going to deliver this care? Because as we know, there’s just been a match; primary care, again, is failing to attract people.‌

The work itself is hard, as you’re suggesting, the payment is not competitive to how it gets for sitting in a dark room and not having to even talk to any patients and can garner with that. And should we be just thinking completely differently about how we’re going to organize this and not really depend on the traditional models, let alone the payment models changing, the value-based care? But I mean, to what extent are you thinking that that’s a way forward here?‌

Ryan Schwarz: Yeah, thanks, Harlan. I think you’re absolutely spot on, and I think if we keep doing the same thing, we should expect the same results, which is a continued decline in the primary care workforce and our ability as a population to actually get good healthcare. I can talk a little bit about what I think some of the key drivers are and then just as a foil, what we’ve been thinking about in Massachusetts.‌

Howard Forman: And what you think it could look like in 10 years as opposed to just continuing to have this same conversation in a decade.‌

Ryan Schwarz: Yeah. So I think you’ve named a couple of things that are really important, but just to elevate and kind of call out, one, we have a workforce problem, and when we think about workforce, I normally divide that into two buckets. We have a pipeline problem, which is the people coming into the workforce, and we have a workforce retention problem, which is once someone has committed their career to primary care, these are the people that they genuinely want to be here, they want to serve patients day in and day out.‌

We need to be able to identify ways to support them to make that career viable, sustainable. And most importantly, joyful, people don’t go into primary care because they’re looking for money, that is not, “they become interventional cardiologists or they go to Wall Street.” People go into primary care because they want to serve, but we need to be able to make that career sustainable and actually joyful, so that they can do their job.‌

And Harlan, you talked a lot about what we generally think of as integrated team-based care, and I think this is absolutely what they were talking about in North Carolina that you were referencing, and a lot of where I think we need to go in the next, I mean you said 10 years, I would say we need to start this work yesterday, and we really need to be there in five years. What does that look like? Well, the first thing that we need to start doing is we need to get that 26.7 number down to a actually viable number.‌

We could debate until the cows come home what that number actually looks like. But most importantly, we need to increase investment in primary care so we can build supports around the primary care provider, so that 26.7 number comes down to a reasonable number. But more importantly, when we think about it from a patient perspective, from someone who is walking into a primary care clinic, that they are getting the right care at the right place at the right time in an accessible way.‌

What does that mean practically? What is that going to look like? Well, first off, you already mentioned nurse practitioners and physicians associates, absolutely need more of those in primary care. And there’s good evidence to demonstrate that, especially for chronic disease management, there’s excellent evidence to show that NPs and PAs can provide very effective care in the same way that MDs or DOs [doctors of osteopathic medicine] can.‌

But it also isn’t just about NPs and PAs, it’s about behavioral health workers, it’s about community health workers, it’s about care managers, it’s about care coordinators that can wrap around a primary care provider in a team-based approach such that the primary care provider is a quarterback, so to speak, and can help direct the care and focus on some of the most complicated health needs, advanced kidney disease, advanced congestive heart failure, but routine blood pressure management, routine diabetes management, a lot of that can be done as a team.‌

Diabetes nurse educators are an evidence-based-driven and well-proven asset in a primary care team that can help primary care providers really provide additional wraparound services to help their patients achieve better health outcomes. That’s I think what the care model needs to move towards is that team-based integrated approach, and what you were referring to in North Carolina. But there’s one key challenge there, which is the way we pay for primary care completely disincentivizes and frankly doesn’t make feasible or possible that type of a care delivery system right now.‌

And so in Massachusetts, this is really where a lot of our focus has been, in 2022 we capitated primary care, and what does that mean? So as of about two years ago now, for any person who receives Medicaid services and has primary care, the primary care provider is no longer paid a fee-for-service visit. In other words, if Ryan walks in to see his primary care provider, that provider gets 50 bucks. We’ve done away with that. We now pay primary care providers across the state a per-member per-month capitation rate.‌

So we pay them say 50 bucks a month for every person who is attributed to their practice, regardless of whether that person ever walks into the clinic or even walks into the clinic that year, and they get a consistent and reliable revenue stream that is not attached to the visit or who does that visit. Every month they’re getting a big check for all of the patients that they’re responsible for taking care of. And that money goes to the practice and the practice—CEO, the practice administrator. and the providers—can decide, how do we use this money to take care of the population of patients that we need to take care of, right care, right place, right time?‌

How do we think about moving away from the MD is the only person who gets paid and therefore needs to see all of the visits to, we have a bucket of money that we know reliably every first week of the month we were going to get a check. We can balance payroll off of that, we can plan our budgets for the next year, and we can hire maybe some community health workers, maybe a licensed clinical social worker to do some behavioral health management, maybe a diabetes nurse educator to help our diabetes patients. And none of those people need to worry about billing fee for service in this model, they instead need to focus on how do we achieve the optimal health outcomes for the patient population that we are responsible for.‌

Howard Forman: We’re getting close to the end. You’ve been so generous with your time. It’s great to hear all this. I want to hear whether or not, now at the end, you’ve got optimism for where we’re going. These challenges and headwinds are substantial. The uncertainty in the current environment is high. We have spent more and more money every year in healthcare without evidence of a return for the health in the U.S., at least for the last decade. Let me ask it like this. What gives you optimism for the future that we’re going to be able to solve these problems?‌

Ryan Schwarz: I remain very optimistic, and I frequently think that if those of us who are in healthcare or those of us who are in public service aren’t optimistic, we’re not doing our job. We have the good fortune and the good privilege to be able to be in these roles and to be able to serve. And with that comes an enormous accountability and responsibility that we have to remain optimistic and we have to keep pushing ourselves to...‌

Harlan, to your point earlier, start thinking differently about what’s not working so that tomorrow hopefully can be better. And you’re right, there’s a lot of reason for self-doubt. There’s a lot of reason for us to be very skeptical and cynical about the current system as it works. And we would be doing every patient we serve a disservice if we weren’t optimistic and continuing to push ourselves to make the system tomorrow much better than it is today.‌

Howard Forman: I want to just echo, Harlan, in saying thank you so much for joining us and giving us the time and also just being very generous with the many, many students, both medical students and others who we have sent your way over the years. You are a great mentor, as well as a clinician and leader.‌

Harlan Krumholz: It’s such a pleasure to meet the people that he’s mentored over the years, and see how well everyone’s doing.‌

Ryan Schwarz: Well, Howie will leave a legacy of literally hundreds and thousands of people that he has helped build our careers for. And I think it is people like Howie that help us remain optimistic.‌

Howard Forman: Save that for the eulogy.‌

Harlan Krumholz: He’s a rare bird. He’s a rare bird.‌

Howard Forman: It’s great to have you—‌

Harlan Krumholz: Good to see you. Thank you so much.‌

Howard Forman: Thank you, Ryan.‌

Ryan Schwarz: Thank you. It’s a pleasure.‌

Harlan Krumholz: That was a terrific interview with Ryan Schwarz. But now to arguably one of my favorite parts of the show, Howie Forman. Howie, what’s on your mind this week?‌

Howard Forman: So last week we talked about med school admissions, and I promised we’d give an up, update on the match. So last Friday was the official release of match results for the Yale medical students.‌

Harlan Krumholz: How timely, we can figure out what did happen with primary care.‌

Howard Forman: Exactly. Exactly. And for most medical students around the country, and actually a lot of other physicians around the country, and it is an exciting time, and even at a time of sort of instant gratification of logging onto websites, this one generally occurs in a communal setting with medical students congregating and collecting their residency match altogether. And I think most of our listeners understand that our medical students are, for the most part, bound by this matching process to a single program as a result of about a six-month process that ultimately leads to programs and students ranking their choices to maximize outcomes for both.‌

And to the best that I can count, Yale, I think we have about 84 people matched this year. And I want to just give a few notable findings from Yale’s Match and then I’ll just talk more generally. Number one, 23 people are going into internal medicine, and one of those is doing, as Ryan did, a combined medicine and pediatrics residency. Only three more people in total are going into pediatrics from Yale. Only three are going into general surgery and only one is going into family practice. Again, primary care is not the top of people’s list. Sixteen are going into highly selective surgical subspecialties: four dermatology, five ophthalmology, nine anesthesiology. And this is consistent with national trends.‌

Harlan Krumholz: The pediatrics is interesting too, because that also means those are people who aren’t going into pediatrics specialties too. It’s not just the primary care, it’s the pathway in, right.‌

Howard Forman: That’s right. It’s the feedstock. Absolutely. And I want to just go through a few more things and then we can just talk about this. Bryan Carmody is a nephrologist at Eastern Virginia Medical School who does a really good job summarizing this stuff throughout the year and particularly this time. So some of what I’m giving you comes from him, but some of it I’ve just gleaned from the match result. Emergency medicine went from being one of the most competitive residencies pre-COVID to seeing an absolute collapse in 2023. And it has recovered somewhat, but it is far from recovered. Pediatrics, as you just mentioned, has become less and less competitive over time.‌

And there is reason to believe the trend’s going to continue. And Bryan explains why that’s the case. Family medicine had the most unfilled residency spots in the country as a percent of spots available. Dermatology remains one of the most competitive specialties. And in the same vein, ENT, neurosurgery, orthopedics, plastic surge—yhighly, highly competitive. And that seems not to be changing. Graduates of osteopathic medical schools are doing better and better in the match, even as they are one of the fastest-growing components of the match along with international medical graduates who are non-U.S. citizens.‌

Now I want to emphasize, there’s very little that is truly surprising here. The most “competitive” applicants, and I’m putting “competitive” in scare quotes or whatever you want to do, are disproportionately chasing the most lucrative fields and mostly avoiding fields like pediatrics and family medicine. And while Ryan gives us, while Dr. Schwarz gives us some hope for primary care in the future of our frontline, I’m really cautious about what medical students are doing because they seem to be marching to the beat of different drummers.‌

Harlan Krumholz: I thought it was interesting to me. First of all, thank you, Howie. That’s a great summary. He has this figure where he’s really kind of showing two axis and identifying the most, I think competitive schools in the country. And I’m not going to say better or worse, but just to say medical schools that have been historically understood as the leaders in biomedical science and medicine, traditionally Yale would be like one of those, and looking at where are those people matching. And it’s just what you’re saying reflects exactly what you’re saying about Yale, which is they’re being drawn to dermatology and surgical subspecialties—‌

Howard Forman: Anesthesiology.‌

Harlan Krumholz: Anesthesiology and so forth. And of course these could be a combination, if you looked at the combination of where do you maximize income and minimize our commitment, that’s where those people are tacking to. And so if we want to attract people broadly, Howie, I think we need to restructure the reward system in medicine.‌

Howard Forman: A hundred percent. A hundred percent.‌

Harlan Krumholz: Why should the people on those front lines be the ones making the least and yet—‌

Howard Forman: And sacrificing the most.‌

Harlan Krumholz: Sacrificing the most. So this is, maybe the economists would tell us, “Of course you’re going to expect this,” but it’s really interesting that these schools that are the ones I think in particular, they didn’t contrast it with some of the others, but you can only guess if that’s what these schools look like, there’s some balancing from the other schools.‌

Howard Forman: No question. And the osteopathic schools are the other side of the coin. I mean, not that they’re inferior to medical schools, but they tend to be less competitive than the most elite medical schools, and they’re making very different choices.‌

Harlan Krumholz: Yeah, very interesting. Very interesting. Thank you, Howie. We’ll put a link so if people want to see more from Brian in this report, they can go there.‌

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

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

Harlan Krumholz: Absolutely. We want to hear your feedback, questions. Reach out to us. We always enjoy that, and we’re always trying to get better. So if you got a suggestion first to get better, please let us know.‌

Howard Forman: Please do. And if you have questions about the MBA for Executives program with the Yale School of Management, reach out via email for more information or check out our website at som.yale.edu/emba.‌

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management, the Yale School of Public Health. Thanks to our fabulous researchers Inès Gilles and Sophia Stumpf and Tobias Liu. Tobias is with us today, did an amazing job helping us prepare for this one. And to our producer, the wonderful Miranda Shafer. Talk to you soon, Howie.‌

Howard Forman: We are grateful. Talk to you soon, Harlan. Thank you.‌