Tara Lagu: The Doctor Won’t See You Now

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. Tara Lagu, but first we generally like to check in on health news. And Harlan, you forwarded me an article from Science that just came out, talking about the use of both genetic interventions, as well as genetic screening with embryos. And this is a very provocative survey, so I was just wondering if you could share with us what your high-level thoughts are on this.

Harlan Krumholz: Yeah, I’d sent you something, Howie, about this article that came out. It’s called “Public Views on Polygenic Screening of Embryos.” That may sound a little esoteric and a little nerdy, but what they did was they went out and they tried to understand what the public’s views might be on some of these new technologies that are enabling us to characterize the genomic heritage, essentially, of these embryos, and the idea that we’re on the cusp of a really potentially interesting and morally fraught era, where we can both characterize the traits of individuals, genetic traits of individuals before they’re born, and even have the opportunity to intervene on them. And they were likening this to saying there may be a sea change going on in public views that may affect the adoption of these technologies in ways that have been unanticipated. Some people might have thought—I thought—that people weren’t ready for this.

Look, people won’t even take vaccines. So I’m thinking, do people really want scientists working with genomes and snipping and doing editing? And I thought maybe not so much. But in this survey, they asked what is your willingness to use a service like this, being able to go in and do this polygenic risk evaluation, looking at the genomics. And then what about gene editing? This is really going into the genome, and rearranging the genes, or silencing some, or doing this and that, which can actually change the function of the genome and create different proteins. And what I was surprised to see was that about a third of the people said that they were willing to use gene editing. And almost as much as a half, particularly, and greater among younger people, were interested in this sort of characterization of the genome.

And I just found this absolutely amazing, and this was also true. They stratified it by what people’s education was. And higher education individuals actually were more avid for these new technologies. We are spending some time as a profession talking about the moral issues around this, but maybe not enough, maybe not enough. Because if the public is this ready for this, so many people are thinking this is okay, we’re going to have to figure out what parameters are around this. Are we looking for genes for intelligence? And if your baby doesn’t have those, you’re either going to do some editing... Or how about athletic ability, or good looks, or I don’t know what, I mean, I’m just saying these, as for example—

Howard Forman: No, I—

Harlan Krumholz: …our minds go to the fatal genetic diseases. That’s where it will start. Can we save someone like that?

Howard Forman: Sure.

Harlan Krumholz: But the potential for other areas is immense.

Howard Forman: Look, I mean, you and I grew up in a time where the term eugenics was in the news a lot, and it quickly became something that you don’t talk about, because culling the herd or picking and choosing who gets to survive and who doesn’t is not considered our value system. But at root, this can get there very quickly. And I think the beauty of the field of ethics, and really why I appreciate you highlighting this article, is that it’s not meant to be prescriptive. It’s not meant to tell us what to do, but it’s meant to illuminate issues and get people talking about them and understanding it more. And I agree with you, Harlan. I mean in the 24 hours or so since you first brought it to my attention, and I’ve thought about it more, we should be having a lot of conversations about this now and not waiting for commercial entities to be already building business models around it without the public understanding the consequences.

Harlan Krumholz: Well, what lengths will parents go to ensure that their child has every advantage? And one of the other questions, by the way, on this survey, had to do about the ethics of SAT prep. How do you think that advantage is? Is it ethical? Would you use it for your children? And in that case, almost 70% or so—

Howard Forman: Same people.

Harlan Krumholz: …said that was acceptable. A much higher percentage, but—

Howard Forman: Higher, but still.

Harlan Krumholz: Again, it’s another form of advantage, right? It’s another form of advantage saying that this isn’t just by the grit of your own effort but that you’re willing to be using spending money to get an advantage.

Howard Forman: One of the points that the authors made, Harlan, which I thought was really good, is that what you’re basically doing is permanently embedding the wealth, both in terms of gene code as well as physical money, into a family hierarchy so that over time it grows and everybody else falls to the wayside. It can create greater disequities over time.

Harlan Krumholz: Maybe one time we’ll have Jennifer Miller back on and some bioethicists and really have a deeper discussion about this.

Howard Forman: Great.

Harlan Krumholz: So hey, we’re going to have a great guest today and a super topic. So Howie, take it away.

Howard Forman: Dr. Tara Lagu is a professor of medicine at Northwestern University’s Feinberg School of Medicine. She’s a pharmacist, a hospitalist, and a health services researcher focusing on how to improve healthcare for patients, particularly those with disabilities. Her work has been published in journals including The New England Journal of Medicine, JAMA, Analysis of Internal Medicine, and the Journal of Hospital Medicine. She’s also senior deputy editor for the Journal of Hospital Medicine. And in 2019, she was awarded the Society of Hospital Medicine Award for Excellence in Research and was named one of the American College of Physicians’ top hospitalists for 2019.

She got her bachelor’s degree from Purdue University in pharmacy, and then did her MD/MPH degree at Yale in the School of Medicine, in the School of Public Health, which is when I first met her more than 25 years ago, if it can be believed. She completed her residency in general internal medicine at Brown and then was an RWJ, Robert Wood Johnson Clinical Scholar at the University of Pennsylvania from 2005 to 2008. So first of all, welcome to the show, Dr. Lagu. Tara, you’ve been a consistent investigator and advocate of the special challenges that face those of us who live with disabilities. Can you tell us what first got you to focus on this very often neglected population?

Tara Lagu: Sure thing, but first I have to say thank you, Howie and Harlan, for having me on this podcast. This is a great invitation. And what that intro didn’t say was all the successes in my career that I owe to you two. So thank you two for all you’ve done for me. You have been incredible mentors and friends for years. So the story is, I was actually, as you said from the intro, I work as a hospitalist. I was seeing patients in the hospital. In 2012, actually, I was discharging a woman from the hospital who had these two very attentive daughters, and they were up to date on all of her health information. They were all over the discharge paperwork. And I noticed as I was talking to them that she needed to see a subspecialist, a urologist actually, and that she hadn’t seen the doctor. It had been written in multiple discharge summaries that she needed to see this doctor.

And I said to one of her daughters, I’m like, “It’s just strange because you two are so attentive. You’re just so wonderful. You take such good care of her. Why haven’t you taken her to see a urologist?” And the daughter said, “Well, doctor, I’d take her to see a urologist, but I can’t find one who will see a patient who uses a wheelchair.” Initially I said, “Oh no, there’s a law. I’m a doctor. Let me make some calls.” But when I started calling around, I found out it was true that there was no doctor within 100 miles of her house who would see her, unless she came in an ambulance and was transferred from her wheelchair to an exam table by EMS. That would’ve cost her family more than a thousand dollars out of pocket. And that moment I was like, I was a Robert Wood Johnson clinical scholar, you two trained me. You taught me if there’s a problem, measure it. And so I started to do a study where we called doctors all over the country and we asked them if they would see a patient who used a wheelchair. And what we found—

Howard Forman: That was the secret shopper study, right? And can you just explain for our listeners how you do that? Because it’s fascinating.

Tara Lagu: It’s a method where you call pretending to be... In our case, we were pretending to be doctors making an appointment for the very patient that I had tried to get this appointment for a year before or whatever. And we had a script that we followed, and this is what they do for housing or other kinds of discrimination. You have a script that you follow and you answer the questions according to that script, and we tailored, we had a committee that helped us tailor that script to different kinds of doctors. So we could call different kinds of doctors all over, and we would just say like, “Hi, I’m a doctor calling from such and such, and I have this patient, and here are her limitations, and can I make an appointment for her at your office?” And what we found in calling doctors all over the country was that 20% of doctors nationally would not make an appointment for a patient who used a wheelchair.

Howard Forman: Wow.

Tara Lagu: Very few of those were because you couldn’t enter the building, though. It was a very small number that was about ramps. Far more often, it was about that they were unable to transfer the patient from a wheelchair to an exam table, or in some cases they said they didn’t have staff trained to do that, or they just didn’t have people in place who had the knowledge. And so as a result, although 20% said absolutely not, of the rest, about half said that they would transfer the patient in a way that is considered unsafe. And some of those, that couldn’t go in the paper, but some of those were just... We were talking to the office manager and we’re saying, “Okay, this patient’s coming. They use a wheelchair.” And the office manager would say, “No problem, we’ve got a parking attendant! They can come in, they can help transfer the patient.” And we’re all sitting there, “Wait, the ‘parking attendant’? If this were you, if you were that patient, how would you feel about that?”

Howard Forman: Right, right. Unbelievable.

Harlan Krumholz: Well, you’re doing such important work. I got, really, I think my best orientation to this issue working with Gretchen Berland, an internist at Yale now who is at UCLA as a clinical scholar who ended up putting cameras on wheelchairs for people with disability and produced a movie called Rolling that really shows what the world looked like from their perspective. And it was just so striking to me. I had the privilege of working with her on that. She won awards with it, it got shown in many different venues. I hope that it was good for education, but I did feel that there’s so much more to be done.

Your work is really extending that. You did a survey where you’re trying to elicit themes. I mean, you actually did a qualitative research where you’re trying to understand perspectives. And you said that many physicians expressed explicit bias towards people with disabilities. Explicit bias. We all are familiar with the implicit bias and the idea that unintentionally, or people not meaning to, are then made aware of some things that they’re doing which are causing harms. But can you just expand a little bit on that? Because I was struck by that statement.

Tara Lagu: Sure, absolutely. So a couple comments on what you just said. One is, yes, Gretchen Berland’s, if you haven’t seen the movie Rolling, see it. It’s, I believe, free on YouTube, and it’s an incredible take on what it was like—

Harlan Krumholz: Yeah, it’s just amazing.

Tara Lagu: ... to move through the world if you were a wheelchair user. She actually won a MacArthur Genius Grant in part because of that work, and I do think it changed minds about what the world must be like if you are a person with a disability. So I think that was extremely important work that laid the foundation for some of the work that we do. And honestly, I’ve been meaning to call Dr. Berland because I think we need to return to some of her methods moving forward, but we’ll talk about that later. So after the study in 2013, I spent a couple of years, I wrote a sounding board for the New England Journal with Lisa Iezzoni.

And in that I said, this is about—we’ve got to get accessible tables into clinics. We’ve got to get scheduling systems up and running so that we know when patients with disabilities are coming. And then in 2015, we did a study where we looked at clinics that had accessible tables and clinics that didn’t, and we asked patients about their perceived quality of care and how often they were examined. And after I had spent two or three years talking about “This is all about tables, this is all about procedures,” I thought my New England Journal article was going to change the world. That study where we looked at two clinics with and without accessible tables had a very interesting finding, and that was that perceived quality of care was no different in clinics with and without accessible tables for people with disabilities, and they were not more likely to be examined by their doctor.

So all of a sudden, my mantra that “this was all about equipment…” was really not proving true. At that moment, Lisa Iezzoni, my collaborator at Harvard, and I talked about this, and we were like, “You know, this is about more than equipment, more than training. We have an attitude problem.” And of course, Gretchen Berland’s work already told us that. We knew that. There were real attitudinal biases, like problems and biases against people with disabilities based on the work that we saw in that movie. But at that point, we said, “Okay, let’s write a grant to think about how to study this in a more systematic way.” And that was the grant that we proposed that was a series of focus groups where we had doctors in a virtual room talking about their attitudes towards people with disabilities, followed by a survey, followed by a series of interviews with advocates about what we should do next.

Howard Forman: One of the things that was striking to me is that physicians with disabilities are also discriminated against. And one of the observations I’ve had being on the admissions committee at the med school for many years, and just through experience, is that we have underrepresentation among the physician core of physicians with disabilities. I remember well, us discussing in the admissions committee whether somebody who is deaf could become a physician, or how they could become a physician, and so on. And thankfully there are accommodations, but I’m wondering, even though that wasn’t your paper, if you could comment on what are the structural barriers to improving this right now?

Tara Lagu: You are right. This is a multi-layered problem. So this is about, we have not enough people with disabilities who work in medicine. We potentially have biases in some medical schools against admitting people with disabilities. That may be in the form of technical standards that don’t allow people to even apply or get in. It may be more subtle. Then we have the problem that we don’t include education about how to work with people with disabilities as part of medical education. It really doesn’t earn a lot of time in the curriculum. We’re all often told there’s just not time to add to the curriculum.

It’s not recognized by accreditation agencies like LCME [Liaison Committee on Medical Education] as being an important topic that medical schools should include in their curriculum. It’s not part of graduate medical education. There’s a hidden curriculum that gets conveyed about attitudes and biases that we learn going through. And then you have the additional problem of the system itself is structured in a way that disadvantages both people who are trying to provide care as a person with a disability or receive care as a person with a disability. So we have problems of education, culture, access, and a health system that actually disincentivizes taking the time to provide accommodations. So this is a huge problem, and I’m going to have to work on it for the rest of my life.

Howard Forman: Yeah, I’ll just add, Harlan and I just had a conversation over the last 12 hours by email about this very issue, that our system incentivizes against care for the most complicated patients.

Tara Lagu: Yeah, and I actually just published an op-ed in Undark earlier this month about this exact issue, and I should describe the findings of the focus groups before I even talk about that. But basically, so we sat three focus groups of physicians chosen for geographic diversity, for subspecialties diversity, for diversity in men versus women, and other kinds of characteristics. And we asked them questions about their attitudes towards people with disability. And what we found was shocking that over the course, and these were... granted, these were two-hour-long focus groups. We asked a lot of questions, but towards the end when we asked physicians like, “Well, so what is your approach towards working with people with disabilities?,” in two of the focus groups the conversation really derailed, and physicians in the group started talking to each other. And one said, “Well, I’ve thought about this a lot. Now I just tell people with disabilities who call me that I’m no longer taking new patients.” And then another doctor in the group says, “No, no, no. I say I don’t take your insurance.” Another person says, “No, no, no, you can’t say that. I say you need more care than I can give you, so I’m not the doctor for you.”

Howard Forman: This is, yep.

Tara Lagu: We had research staff, and to just describe how upsetting this was, we had research staff who had to watch these again and again, because they were helping with transcription. And more than one came to me in tears because they felt so discouraged and upset about the attitudes that they saw physicians portraying in these groups.

Harlan Krumholz: What’s the next proximate thing we can do to address this? Because this is really blatant discrimination. I mean, the medical profession, you also say at another point here how this really violates the general principles of what medicine’s all about. I mean that this exists, but by the way, there are people with disabilities…we could go in a lot of different areas too: people with obesity…there’s lots of groups that get this, but this disabilities issue, I think, is central because it takes more time. There have got to be accommodations to be able to get the information. So what’s your milestone for this year? What are we going to get done this year on this topic?

Tara Lagu: Well, I will say that this... Nobody goes to medical school with the purpose of discriminating against vulnerable populations. We all interview people from medical school all the time, and everybody goes in really idealistic. So what happens between the moment they enter medical school and the moment that they’re seeing someone in their practice as a full attending, facing the problems and demands of our existing healthcare system and making this terrible, probably illegal, certainly unethical, and really vile decision?

And I think the answer is there’s a whole series of things, from education to culture to the pressures of having to see a certain number of patients in a very limited time, to a reimbursement system that devalues talking to patients, accommodating patients, and spending time with patients. And so we have to work on all of those things. Whenever anybody asks me, “What can I do today?” My answer is, “Learn disability etiquette. Speak to people with disabilities in the way they would like to be spoken to. Always ask. Ask people how they would like to be identified, ask people how they would like to be referred to, ask about accommodations.” I think making any interaction as patient-centered as possible is one quick thing.

Harlan Krumholz: Now, also an issue here is that some disabilities are overt, easy to observe, and recognizable. And some people have disabilities, as I was suggesting, it could be hearing or other things that are never even inquired about. I’m sure that this adds risk. I mean, the ability to elicit the right information, to do the proper examination, even decisions about sending people for testing can be influenced by people’s thoughts about how difficult that could be.

Tara Lagu: You raise great points. There are visible and invisible disabilities. We need to accommodate all disabilities. We are required by law. One of the things that health systems can do, and this is something that we as clinicians can push for, is to collect information on disability and need for accommodation. This is something that can be incorporated, if you use Epic, into the Epic MyChart app. It can be incorporated into, and we’re actually working with Epic, to incorporate collection and documentation of disability and accommodation needs and having designated fields for that that can be built into the system so that we can at least know who these patients are and know when they’re coming. The fact that we don’t know who they are and don’t know when they’re coming is part of the reason that we do such a bad job of caring for people with disabilities.

By the way, it’s also part of the reason that this is an unacknowledged health disparity population, because we can’t even do the basic health disparities research to know where the gaps are. So I mean, I think in the short and long term, advocating for more data collection so we know who people are, where they are, and what their accommodation needs are. From there, working to incorporate into clinical workflows, accommodations, including accommodations for hearing, communication, mobility, mental health, and other disabilities. I mean, there’s a wide range of things that we have to do. And I think on any given day, any given clinician can make a difference just by acknowledging the humanity of the person in front of them, having some sense of the etiquette, and asking people about what their needs are and how they want to be spoken to.

Harlan Krumholz: Well, what is the role, do you think of telemedicine in this world? Because it did seem to me that there’s a possibility that for people who have mobility issues, not that you would want to rely exclusively on it for any given patient, you have to calibrate it to the need, but this still could be, as we’ve moved into this era, quite a big help for some people.

Tara Lagu: I definitely think telemedicine was a breakthrough in some ways, and there certainly are conditions that you can manage almost exclusively with telemedicine. Some of the mental health care has improved, the access has improved during the COVID era because of telehealth, I believe. But there’s lots of reasons why people have to be seen in person, why people still need radiology and procedures and all kinds of things. And so I think balancing when and how we use telemedicine, and a whole realm of research is going into that. How do we best use telehealth? How do we use it in a way that’s most effective? And I think there are times when, certainly for people with mobility disabilities, that is an advantage. And not having to take three hours of public transportation to get to an appointment is a huge, huge deal. On the other hand, I think if it means that we then exclusively see people with disabilities by telemedicine, then we have a problem.

And so it’s a matter of finding the right balance. I guess my other question as I left this is, the attitudinal barriers and the bias that was expressed in our focus groups was a huge driver of some of the publicity that we’ve received, some of the recognition the study’s gotten. And so to me, I don’t think we can leave this topic without saying we’ve got to address attitudes and bias on the part of physicians and other healthcare providers. And I think some of that’s education. Some of that is that people feel very unable to accommodate people with disabilities because they just don’t even know the basics. So some of it’s education, some of it’s culture, some of it, as you mentioned earlier, is bringing more people with disabilities into our profession so that those folks can help teach the rest of us and set a precedent that this is part of normal life.

And I think that’s really important too. And I think there’s more to do. I think we need to figure out what exactly was driving some of the comments that we got in that study. And some of it is the incentives in our system that we have to address. Some of it is, and this has been a big topic of debate, if you have a person who needs an accommodation, should you be paid more for that visit? Should that alone make it a higher-complexity visit? And there are people in the disability community who say yes and people who say no. The people who say no say, “It should not be an extra cost to accommodate me.” On the other hand, for the physicians, if they could code for a higher-complexity visit, they might be more willing to see the person, it might be...

And so I think finding the balance in that for us, and figuring out how to incentivize people without being disrespectful is really important. Let’s be honest, for most people who encounter the healthcare system, whether you have a disability or not, it can often be unpleasant, inconvenient, frustrating, difficult. And so it’s only the people with disabilities who experience the most extreme version of that. But all of us get the downsides of the system we live and work in. And I guess my feeling is there are lots of reasons to improve our system, not just because it’ll help people with disabilities but because it’ll actually benefit all of us. And that includes the physicians who are providing care.

Howard Forman: The noble laureate Pearl Buck is quoted as saying something along the lines of, “The test of a civilization is how it treats its helpless members,” and by that statement alone, we’re failing right now that test, and I’m just really so pleased that you are doing the work that illuminates this problem and helps us address solutions for it, and I could not be more pleased to call you a colleague and a friend, and that you are helping to achieve greater justice. So thank you and thanks for joining us today.

Tara Lagu: Well, thank you. Let me say, I think that I got a lot of my values and my approach to my work from the two of you. So thank you for all that you’ve done for me and for your mentorship over the years. Because I really do think you’ve set a precedent for how to go about research. Harlan, I don’t know, 15 years ago you wrote an editorial that was called “Be Bold” or something, ask the tough questions. And I mean, this question from the start was always bold. No health system that you work in is all that enthusiastic when you start uncovering problems, even if they’re national problems. So it required a little boldness. So I appreciate that you two set an example.

Harlan Krumholz: No, that’s fine. Actually, it was “Be Brave.” It was “Be Brave.”

Tara Lagu: Oh, be brave.

Harlan Krumholz: Yeah, yeah, yeah. But be brave and bold. I like that together. What a pleasure to work with you over the years. Tara, thank you so much for joining us.

Tara Lagu: Thank you both. I’m so appreciative. It’s so good to see you two. And this should not be the only way we see each other.

Howard Forman: I know. We’ll make plans.

Harlan Krumholz: Exactly. Well, that was a great interview. I really enjoyed hearing her, and she’s working on such an important area. Let’s pivot to the next part, Howie and you had, I think, listened carefully to this State of the Union address, and it was quite a spectacle, basically the back and forth and the yelling and all that stuff. But amidst that, there were some really substantive things that were discussed. This issue about the dispute between the president and Democrats and congressional GOP over whether... well, what will the parties do with regard to Medicare and Social Security, and this issue about saying that there may be some cuts and there’s just going to be needed cuts. And anyway, can you bring some clarity to this? Because there just seems like a lot of smoke here, and I’m actually confused about it a little bit.

Howard Forman: Yeah, it’s very frustrating because... so without going into too much detail, there’s multiple parts of Medicare, but there’s one, which is one of the biggest parts, for the hospital fund, which will run out of money sometime in the next decade. It might be as soon as four years from now. But it’ll definitely happen if we don’t intervene. And that would be a very bad thing, because it will be just like the debt ceiling, just like a lot of things. It could create chaos for an awful lot of people. So we want to avoid that. And both parties have solutions to this, and they’re not even consistent within the parties, by the way. But the problem is that both parties have, on the margin, cut Medicare at times. And what do they mean by “cutting Medicare”? Most of the time what they mean is just cutting spending on Medicare, and as you and I have talked about, there are parts of Medicare where we have wasted money. Where we have overspent for things, where we’ve overpaid for things, created profitable opportunities that were in excess.

And so on the one hand, we want us to run a Medicare program that’s more efficient. I think we all understand that if you were to raise the age of Medicare entitlement or if we were to stop covering some things in Medicare, that’s a more legitimate definition of what it means to be cutting Medicare. And I think we all probably would also agree that raising taxes is not cutting Medicare, and that also could fix the Medicare problem. And I just think our representatives and our president need to have a lot more clarity about what their goals are for the Medicare program, because I don’t think that you or I want to see Medicare go bankrupt. I think most people would like that not to happen. And there’s basically two solutions to it. One is to cut spending on it. The other is to raise taxes. And I think we need to be clear on what we’re proposing and not to demonize one party or the other if in fact their main goal is just to make Medicare sustainable.

Harlan Krumholz: Well, and some of us think how fast can we track to reducing the age for Medicare? I mean, it’s—

Howard Forman: That’s right. That’s right.

Harlan Krumholz: So this debate’s going about almost in an opposite direction of what I think a lot of us think can happen in the country. And as we talked to Jeff Sonnenfeld about that, this healthcare in this country is such a big tax on businesses. Imagine what could happen with regard to innovation and the flourishing of business if you were to lift off that responsibility from businesses and put it where it appropriately sits, which is within government, and let government ensure that people aren’t going to be harmed by getting sick, and have that financial toxicity and risk and concern. But yeah, it’s interesting to me that even while there is some rumbling still, I mean about trying to get more people covered, there’s some people who seemingly want to cut back on the coverage and make it more difficult. 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: I’m @HMKYale. That’s H-M-K-Y-A-L-E.

Howard Forman: And I’m @theHowie. That’s @-T-H-E-H-O-W-I-E. You can also email us at health.veritas@yale.edu. 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, or you can check out our website at som.yale.edu/EMBA.

Harlan Krumholz: Howie, how many people have graduated from that program over the years?

Howard Forman: It’s a good question. I would say that we’re probably somewhere in the one thousand range, more than 1000. It’s getting up there.

Harlan Krumholz: That’s incredible. That’s incredible.

Howard Forman: Yeah.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Jenny Tan, and to our producer, Miranda Shafer, they are absolutely amazing. We’re fortunate to work with them. Talk to you soon, Howie.

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