Tara Sanft: Life after Cancer

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 Dr. Tara Sanft today. But first, we’re always checking in on whatever’s the hot topic in health and healthcare. What’s on your mind today, Harlan?

Harlan Krumholz: Well, Howie, you’re the one who came to me and said you wanted me to talk about this pre-print that we had posted,

Howard Forman: Yeah.

Harlan Krumholz: On post vaccination syndrome from people who had received the COVID-19 vaccine. And so, hey, I’m glad to talk about it.

Howard Forman: Yeah, so let me just tell the readers a tiny bit, and let’s have you fill in the details here. You’re part of a much larger study of patients that have voluntarily enrolled and are providing information about their experience, both with COVID as well as those who want to voluntarily talk about their post-vaccine experience. And so you have individual, very detailed accounts of a large number of people telling you how long they’ve had their symptoms, what symptoms they have, and so on. So what are the key take-home messages from that?

Harlan Krumholz: Yeah, I mean, you might ask how do cardiologists end up in this space, but as we’ve discussed, when the pandemic came out, I, like many others, no matter what we were working on, sort of dropped things and saw whether or not we could be helpful and apply our skills. And in the course of that, I became aware of long COVID and started publishing some work in that and starting to work with Akiko Iwasaki, who’s amazing, been on the program, she’s an incredible immunologist. And we became aware that there were a group of people who seemingly had a syndrome that had many of the same features, chronicity and sort of so many different types of symptoms together, and fatigue, brain fog, that began soon after they had gotten the vaccine.

And these are not anti-vaxxers; they had gotten vaccinated, of course, and they were being largely dismissed by the healthcare system’s doctors. Everyone was afraid to do anything because the vaccine itself and the idea of vaccination had become so highly politicized that people were afraid that it would have an adverse effect on their careers if they start talking about this and would people get canceled or would they be considered to be on one side or the other? And I think that Akiko and I were really feeling that these people had been largely abandoned.

I mean, if people with long COVID were feeling sort of alienated from the system, you know, multiply that by a lot, even more by these people because nobody wanted to talk about it. And I’m fortunate enough to be working with someone like Akiko Iwasaki who sort of shared the same sensibility that I did, that we should follow the science, see what we can learn. And by the way, respect and honor that these people are reporting substantial symptoms and many of them were quite healthy before this happened. And it’s a mystery right now. What’s underlying it? How does it connect? So we expanded our study. We had a study of long COVID and we said, “Let’s start including these individuals as well.” And the pre-print represents a characterization of more than 200—the largest series to date—of people, their own reports of what they’re experiencing and what their lives are like and as a prelude to starting to do some more work with trying to do correlations between what they’re experiencing and with the Akiko’s lab doing deep immune phenotyping, trying to characterize underlying biological processes.

Howard Forman: And give our listeners some idea about what the symptoms they’re talking about and then how much this is impacting their lives.

Harlan Krumholz: We had about 241 people that were 18 years and older and had self-reported this. The group that we had, their average age was about 46, and it was kind of a mixed group with regard to their background and also with regard to the vaccines that they’d received. So it wasn’t just like these are only people who got Moderna or Pfizer BNT [Pfizer BioNTech] or even mRNAs—some people got the J&J vaccine as well. And sort of the median time from when they were vaccinated to when their symptom onset occurred was only about three days. And the variation of most of them had manifested by within a week. And we were applying these questionnaires. Some people had been having this syndrome for much more than a year by the time they got into our study and we’re reporting how are they feeling, so this is really a long-lasting syndrome and there’s this tool we use, sometimes it’s called an analog scale, but it’s simply on a paper on the computer.

It’s just 0 to 100 and is asking people if 100 is perfect health and 0 is the worst possible health imaginable, where do you see yourself on this spectrum? If you say this to average Americans, which includes people who’ve got things going on in their life with regard to their health, the average will be around 85 or so. And this group was 50, which is really quite impaired. And the most common symptoms that they reported were exercise intolerance and excessive fatigue, numbness, brain fog, and various other forms of neuropathies. And even beyond that, if you started asking what their lives are like, they’re feeling anxious and fearful and sort of overwhelmed by worries. 80% reported feelings of helplessness; almost 80% had severe anxiety or depression. And for so many of these people, this wasn’t what they were like before, when you talk to them and you hear their stories, but this is where they’ve landed.

And it’s I guess no surprise a year into this, the healthcare system not knowing what to do with them, not being able to get help, often being dismissed and having a chronic syndrome. These people are in a bad state. And so just to give you a sense, we also asked them about their treatments. Most of these people have tried 20 or more treatments, a wide range of things to see if they could get help, and yet they’re still suffering. And so our thought is, “Let’s try to help make visible that there is a group of people, we don’t even know how large, that’s experiencing this kind of thing, and let’s proceed with the science to see if we can uncover underlying causes, help relieve the suffering, and even understand eventually how to prevent this problem and avoid the politicization of it.”

Howard Forman: Yeah. No, I mean it’s very disturbing, and it’s amazing that you’re able to collect this type of data. And I hope that there’s going to be an ongoing assessment, not just of your population but of others, to be able to really nail down what the causative factor is, as you point out in the article. It could be the actual vaccine; it could be the way it’s delivered. There’s lots of possibilities about this, and we need those answers.

Harlan Krumholz: And your heart breaks when you talk to these people. At the very least, I want to give them some hope that there are people interested in helping and who believe we will make progress together if we can work together. So thanks for asking about that, Howie, but let’s get onto our guest. We have a great guest today.

Howard Forman: Dr. Tara Sanft is the chief patient experience officer at Smilow Cancer Hospital, director of the survivorship program at the Yale Cancer Center and an associate professor of oncology at Yale Medical School. She’s the panel chair for the National Comprehensive Cancer Network, where she leads the development and publication of survivorship guidelines. Her research centers on the impact of healthy lifestyles on cancer as well as the quality of life after cancer.

In addition to practicing medical oncology, Dr. Sanft is board-certified in hospice and palliative medicine. She received her undergraduate degree from Laurus College and holds an MD from the Medical College of Wisconsin. She completed her residency and fellowships in Northwestern before coming to Yale. So first of all, I want to welcome you to the podcast, and you are, as we say, sort of a quadruple threat. You’re a clinician, you’re a teacher, you’re a researcher, and you run programs. And you and I have talked frequently about the communications programs that you’re involved in. And I want to tie that together with a recent paper that you published with Dr. Winer, the head of the [Yale] Cancer Center, on basically bringing joy back into medicine. And that’s an odd topic considering that you’re doing that in the context of taking care of some of the most vulnerable patients. Do you want to speak a little bit about communications and bringing joy back?

Tara Sanft: Yes. And just let me start by saying thank you so much for asking me to be a part of this podcast. I’ve been a fan for a long time and I’ve listened to lots of episodes, so it’s a real honor.

Howard Forman: Thank you.

Tara Sanft: Burnout in healthcare providers is not a new subject, but it’s really gotten a lot of attention, especially since the pandemic has hit. And oncologists are not immune to burnout either. And so Dr. Winer and I have been talking since he arrived about burnout and how we can combat feelings of exhaustion, depersonalization, cynicism, things that come along with burnout. And we both feel very strongly that the way we communicate with our patients can help bring a more, sense of connectedness in these moments where we feel very connected, which mitigates burnout and, again, motivates us to come back and do more in this healthcare system that is full of intricacies and technologies that sometimes feel like they’re working against us. What we can control is the way we communicate with our patients and with each other.

Harlan Krumholz: Well, one thing I want to ask you about this is that we were in a period where it seems as if burnout’s gotten just so much worse. I mean, I appreciate this idea about the strategies that need to make a difference, but when you really look at the root causes of what’s going on, what do you think is driving it? Because sometimes I worry that.... And by the way, I love that idea. I do think you’re right. Being able to talk to patients in certain ways and the training and the certain cadence and the feedback is an important facet of medicine. But we were like developing newer strategies, I mean even like people, you know, let’s have quiet rooms and meditation and let’s do all these things, but that there’s some underlying pathologies that are driving doctors to feel like they’re becoming more of a commodity, that they’re feeling more alienated from the system, that they’re feeling, that they’re being asked to do things that may not be in the best interest of their patients or society in the service of a business model that’s around them. They’re becoming part of a big industry. What’s your perception? Because you spent a lot of time thinking about wellbeing, about these root causes and what can we do to actually address these sort of underlying issues.

Tara Sanft: Yeah. And Harlan, let me just say, I think that you digest these topics so quickly and you can see the big picture and the root cause. We are working in a broken healthcare system, and by no means do I want to suggest that if you just change the way you communicate, everything’s okay. I think that’s absolutely not the message I would want to send. I think that we are human beings taking care of other human beings, and a lot of that is lost, especially in the “superheroes work here” era. Everyone pitch in, everyone do more in a system that’s inefficient and driven by a bottom line that really doesn’t match the complexity of the care that we give.

That being said, what do we control? Me, you, any of us who are interacting with each other in clinic and with our patients. And we can certainly control the way we bring ourselves to the clinic. And again, we can talk a lot about how we keep ourselves healthy, but how we treat each other and then how of course that translates into really being present fully in the moment with the patient, hearing them, making them feel seen, heard, and understood and cared for, which I think for most of our colleagues, this is why we were coming into a field like this—to help people—and we lose track of that sometimes in this broken system.

Howard Forman: Can you speak briefly to the experience of your oncology patients over—Harlan mentioned the pandemic, you mentioned the pandemic—but over the last five years, cancer care was extremely and broadly disrupted early on in the pandemic and then we had backlogs and so many problems in our healthcare system right now. You are aware of patient experience in your specific role for the Cancer Center. What take-home messages have you gotten about the patient experience as opposed to the physician experience now?

Tara Sanft: Yeah. There are so many, way too many to talk about here today, but let me give you one example that comes up repeatedly. In my breast cancer population, I see survivors—people who aren’t with cancer right now but are nervous that the cancer could come back. And what the pandemic did was disrupt routine mammograms. I heard something around 60,000, let’s say, in our system. That might be wrong, but it was an astronomical number that had to be canceled and rescheduled, and we are still feeling the aftereffects of that. Patients were used to, pre-pandemic, a very efficient and reassuring system where they would come in, they would get their imaging and they’d have some idea when they were done like a little pink slip. Everything’s pretty normal, and it wouldn’t be the official result, but it would be a prelim read. That all got disrupted. And again, very difficult to just flip a switch and get back to that.

So we’re still feeling the anxiety around waiting a few weeks for a mammogram result to be released. And then don’t forget, in the midst of all of this, the federal law went into place that allows patient direct access to their charts. Not only are they not walking away with a warm handoff—“Everything looks fine, don’t worry, you’ll get a formal letter in the mail”—but now they might get an alert on a Friday night in their MyChart system and it says, “Needs additional imaging,” and now there’s no one to call. So there’s multiple things going on at once, but that’s one example of the tumultuous rollercoaster ride that patient experience has been affected by the pandemic.

Howard Forman: And suffice it to say, across the board, we’re not back to normal yet, even though we’re almost exactly four years into the pandemic now.

Tara Sanft: I mean, to borrow a phrase from survivorship, I think we’re in a “new normal,” unfortunately, right now.

Howard Forman: Yeah.

Tara Sanft: Yeah.

Harlan Krumholz: Yeah, just listening to you just makes me so glad you’re our patient experience officer at Smilow. I mean, it’s just so obvious that you’ve got this sort of way to communicate and care deeply about the patients. It’s terrific. I want to pivot a little bit to this survivorship issue. We’ve talked about it before on the program. It’s such an important area. I mean, there are millions and millions of people who are in sort of a post-“the initial phase of cancer and cancer treatment.” They’ve gotten through sort of a dangerous early phase, but now they’re not exactly cured. They’re survivors, and maybe some of them are even cured, but they’re left sort of “post.” And your most highly cited article focuses on the financial issues around this. And I was interested to see, this is something, by the way, you’ve gotten more than 400 citations on this article that you were part of, that it looked at the impact of financial burden on cancer survivors’ quality of life.

And yet I was surprised in this, you looked at over 2,000 patients and just about 9%, a little less than 10%, answered that there had been a lot of financial problems caused by their cancer care, that it was less than 10%. As the cost of cancer therapies go up and as people are put in a position to have to bear more of that burden, I’m thinking that this is weighing heavily on a lot of people, and if they don’t survive, obviously they don’t have to worry about it. But these survivors, the successes that we have are still leaving them with a complication of healthcare that they’ve got to grapple with. As you’re thinking about patient experience, sometimes we’re focusing on “how were the interactions” and “how do people feel about how they were treated.” But as you also look at survivorship, are there things that we need to be doing to help to protect people in this “post” period, especially those who may be financially at risk and have lived because of these wonderful new drugs but also are now burdened by cost associated with it? What are you finding about that?

Tara Sanft: Yeah, so thanks for bringing this topic up. I know it’s near and dear to many researchers’ hearts, and it is a real lived experience that I don’t even think is accurately yet characterized in all of the literature. Qualitatively in my Survivorship Clinic, which I’m in right now, actually on a hiatus here doing the podcast, but just this morning, listening to a long-term survivor diagnosed in 2011 who’s had job insecurity for the past decade and now just was recently laid off. And when you listen to this patient and say, “What do you think was going on?” she said, “I think it was my health issues that contributed to no longer being needed in my job.”

So there’s all of that wrapped up. There’s the inability to fully contribute to work at various times after diagnosis, maybe even decades after because of the long-term effects, all the doctor’s appointments, all the worries and concerns. And then there’s the employees who may be coming at this from some angle that feels totally legitimate, and yet the patient’s perceiving that “it has to do with me and my medical condition, and now I’m again in an insecure place.” And again, a broken system that really relies on coverage insurance-wise through your employment. So now she’s also facing having to find another way to get herself covered.

Harlan Krumholz: What are a lot of your work... around trying to help people grapple with the fatigue that they’re feeling or the cognitive issues? You have to try a whole bunch of strategies. I wonder if you could just share with us what are some of the most effective ways that you’re helping people? And do you think that they also have relevance to people who don’t have cancer? I mean, are you uncovering some strategies that you think might be helpful for all of us as we both talk to patients or even in our own experience? What’s worked best for you?

Tara Sanft: Yeah. So well, as it relates to let’s say, fatigue or cognitive function, you mentioned both of those. We have a multidisciplinary clinic that is able to be offered to any patient. If there’s patients listening, it’s always open to any patient. We mostly focus in that after-treatment period where things like fatigue and cognitive function, they should be resolving, and if they’re not now, it’s becoming a bother, because usually in treatment there’s a certain amount of tolerance of these types of side effects. But for some people it takes months—and I could say even outsized years, rarely—but it can happen where things are just not bouncing back, right? And so we have in our clinic a dietician, a physical therapist, a social worker, and a medical professional—myself or a physician’s assistant. I have to tell you, the healthy diet and exercise can go a long way for many of these things. Now it’s not a panacea, but optimizing your health can certainly improve the perception of these side effects.

So exercise has paradoxically been shown to improve cancer-related fatigue. Rest does not do that, but exercise does. Proper exercise can help you sleep better, sleeping better helps your cognition, and we actually have a neuropsychologist that we refer to in a cancer and cognition clinic. So we try to optimize everything and also use our specialists who are treating other neurological problems for things like cognition and fatigue. There’s sexual side effects that we see. Now, healthy diet and exercise may help some of that, but then there’s some really targeted specialist interventions that we need to refer to. So a clinic like this really takes people in, listens to what’s their struggle, tries to optimize their health within their expertise, and then refer out to the people when it’s a little bit beyond.

Harlan Krumholz: Let me just, one quick follow-up, though, because I’m curious. I think these are just the kind of clinics we need, by the way, not just in cancer, but there’s a whole range of other people including, for example, people with long COVID, a whole range of people that would benefit from these high-touch multidisciplinary approaches. They really come to bear on the various different aspects of their health. Is it a viable, from a business perspective, when you go to the health system and you say, “I want to invest in this.” Are they interested in you growing this? Are they saying, “This is really losing money” and then “This is a problem with our health system that we can’t invest in these kind of strategies because they’re not as profitable as just giving chemotherapy where there’s a big margin and you can bring people in.” Can you just share your thoughts on this?

Tara Sanft: Again, I think very astute observations. And just to add to that, couldn’t you imagine a previvor clinic where you take the highest-risk people, you try to intervene before a diagnosis happens? And now if, God forbid, something happens, they’re in great shape to handle whatever’s coming down the line. Again, we all should be living healthy diets and exercise and sleep patterns and all the things, but there are adults who get certain pieces of information who want to make this teachable moment really worth their while. And I could imagine many settings where that would apply here. But in terms of your question about investments, “loss leader” is what we’ve been called for a long time.... We don’t make money, but gosh, we are a signature program that draws patients in from all over, and we still get people who travel across state lines and regionally.

Harlan Krumholz: Well, this is the discordance between, what’s the ROI? So there’s a financial ROI, but then there’s a patient return on the investment, right? In my view, your clinic probably gives an enormous patient return on investment. People come in having trouble, it makes a huge difference in their lives. But because of the lack of congruence between the financial incentives and the payment systems and what’s actually returning value to patients, you’re saddled with this term “loss leader” as if the only way that we really understand you is whether or not... “What’s your P&L, what’s your profit and loss is?” And by the way, bless the system, they’re still investing in it, even though they lose money on it. But Howie, you’re the expert on health policy. This where we need your help.

Howard Forman: So look, this is where I was going with it next, is there are relatively few survivor clinicians, survivorship clinicians out there. It’s certainly not like this enormous specialty right now. Our system is not structured around this. We have, even in value-based programs, we’re not structured around this right now. Are there things that we could be doing from a policy point of view to be able to create structures that encourage the care of survivors through experts in survivorship as opposed to having to have eight specialists worrying about different organs in their body?

Tara Sanft: Yeah. This is really timely right now because actually the Moonshot initiative that’s sponsored by the Biden administration is actually having focus group meetings right now. After this podcast, I will join that meeting where we are a group of experts who are providing content and helping to prioritize what the Biden administration will look to for cancer survivorship care. And the theme that we’re trying to highlight is the complexity of this care and the fact that it needs to be valued in all ways. There are other governing bodies, like accreditation bodies, that are now incorporating more survivorship elements into their standards. You have to value this with reimbursements. You have to force programs to look at the whole patient and really, in order to be accredited, offer certain things.

Now, exercise is sort of a no-brainer. It’s been proven over and over again to help in every aspect of care. So that’s an example of one that’s recently been adopted into the National Accreditation Program for Breast Centers, for instance. So to be a comprehensive breast cancer center, you must show that you’re offering exercise across the spectrum, from diagnosis through survivorship. Is that enough? I mean, it’s way more than it’s been. So I think that policymakers, accrediting bodies, and then cancer centers and academic medical institutions and community hospitals will start to pay more attention to this if the masses demand it.

Harlan Krumholz: Well, this has been a great opportunity to visit with you. Is it true by the way that you’re an Iowa Hawkeye football fan?

Tara Sanft: Yes. I was born and raised in Mason City, Iowa. The home of the Music Man, Meredith Wilson, but and I am a Hawkeye fan as well, especially the women’s basketball.

Harlan Krumholz: That’s been with Caitlin Clark, that’s been quite entertaining. My biggest memory of University of Iowa game—I’m from Ohio, I grew up in Dayton, Ohio—and there was an Ohio State–Iowa game where, isn’t there a children’s hospital that overlooks the stadium and the kids can watch the game? I don’t know if you’ve seen.

Tara Sanft: That I don’t know—

Harlan Krumholz: So yeah, but anyway, they upset the Buckeyes, but there were all these kids looking at it from the children’s hospital. It was just quite a—

Tara Sanft: Well then, it’s all worth it, Harlan, in my opinion.

Harlan Krumholz: It was all good. I wouldn’t say it was all good, but it was all good. It was all good. But anyway, it’s such a pleasure to have you on today, and thanks so much for sharing this, and we wish you the best—

Howard Forman: And thanks for bringing in the Music Man reference because now I have the song “Trouble” in my head.

Tara Sanft: Now we all do. Now we all do.

Harlan Krumholz: I wanted you to hum “76 Trombones,” if you don’t mind, Howie.

Howard Forman: Exactly. That could be next. Thank you very much.

Tara Sanft: Thank you for having me.

Harlan Krumholz: Thanks so much, Tara.

Tara Sanft: Thanks again.

Harlan Krumholz: Well, that was a terrific interview. I so enjoyed having her on and hearing about the various things, the survivorship clinics in particular. But Howie, this is your part of the podcast, so what’s on your mind this week?

Howard Forman: Yeah, I just want to close this out briefly with some good news, and it relates to cancer, honestly. The news itself is not too surprising, by the way. It’s the magnitude that surprised me, and that is that just in the last decade, cigarette smoking has gone down by almost 75% among 18- to 24-year-olds, and by almost 50% among 25- to 39-year-olds. This is an enormous public health success that has been achieved without making the use of tobacco products illegal. There are many factors that have contributed to this, and the authors acknowledge, the authors of the paper and JAMA, I should have said from the beginning, that summarize this. The authors acknowledge that they can either account for how much e-cigarettes may have contributed to the decline or might be substituting for real cigarettes, but it still appears to be a wholesale shift in a culture of cigarette smoking that has existed in this country for over a century and has been on decline for a while, but still very, very prevalent as recently as two decades ago.

The problem still persists among the oldest age groups 55 and up, so there’s still much more work to be done. But it should be noted, smoking rates peaked in 1965 among men, 1985 among women. Peak lung cancer rates peaked in 1984 in men and ’98 in women, which is just highly consistent with the known lag between tobacco cigarette exposure and presentation with lung cancer. Lung cancer remains the number one cause of cancer death in this country, and it’s number three in terms of total cancer cases. And cigarette smoking remains the most important modifiable factor for this disease. But this news suggests that further declines in lung cancer are ahead of us. And to me, all of this is good news. It’s a credit to the field of public health, which made this a very, very high priority about 60 years ago and has continued to fight the good fight on multiple fronts against this disease.

Harlan Krumholz: I’m so glad you brought this up today, Howie. We do need some good news, and too often on this podcast, we’re talking about things that depress us or that we think really need to get better, and moments we see this today, so this is really timely. As you know, the British American Tobacco Company, the maker of Lucky Strike cigarettes, fell just 9% on Wednesday to a 12-year low when it announced a $25 billion pound non-cash impairment for some of its U.S. tobacco brands. That’s equivalent to $31 billion at current exchange rates.

Howard Forman: Yeah.

Harlan Krumholz: And that’s because the brands that this company acquired as part of a takeover of Reynolds—you remember Reynolds, with Pall Mall, Newport, Natural American Spirit, Camel—these were worth $67 billion pounds on the company’s books at the end last financial year. And because of what you’re talking about, I mean, believe it, for a long time, we’re trying to take down these tobacco companies, and the quitting is actually making this happen as the number of cigarettes sold in the U.S. declining by, as you said, 4% to 5% annually for years as fewer people take it up. So this is being reflected in the business side too, is this shrinkage is accelerating, and Marlboro’s the U.S. owner, Altria, is also having this.

Howard Forman: Yeah.

Harlan Krumholz: And the vape thing, as you know, is getting regulated too, so.

Howard Forman: Yes. And it’s going down also, as we talked about a few months ago, it’s gone down. So vaping has stopped peaking, and the worst vaping has disappeared.

Harlan Krumholz: So this is something, and it’s a major shift and I think our hope could be... now, again, in the life expectancy tables, we’re not seeing the manifestation of this yet. But again—

Howard Forman: But it’s the young people, it’s the youngest people.

Harlan Krumholz: Right. Exactly.

Howard Forman: So we should see it downstream.

Harlan Krumholz: We should see it. Exactly. Exactly. So I’m optimistic that we’ll get that benefit shown out in public health, population health. So I’m saying it’s nice. It’s great.

Howard Forman: It’s good to have some good news.

Harlan Krumholz: Yeah. Hey Howie, I’m so glad you brought that up. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how’d we do? To give us your feedback or to keep the conversation going, you can continue to email us at health.veritas@yale.edu. We’ve been getting questions, we’ve been answering them, and we’ll continue to do so. But you can also continue to find us on social media, including LinkedIn, Threads, Facebook, and even on Twitter still, even as it’s called X.

Harlan Krumholz: And I’m at H-M-K-Y-A-L-E. That’s @HMKYale.

Howard Forman: And I’m @theHowie. That’s at T-H-E-H-O-W-I-E. Again, you can email us, and we’ll follow up. 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 or go to our website at som.yale.edu/emba.

Harlan Krumholz: Health & Veritas is produced with 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. We’re so, so grateful to work with them.

Howard Forman: Very much.

Harlan Krumholz: Talk to you soon, Howie.

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