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Episode 102
Duration 34:31

The Latest on COVID-19 Vaccines, and Other News

Howie and Harlan discuss current issues in healthcare, including burnout at the hospital, the downsides to Medicare Advantage, and how AI is helping radiologists catch tiny blood clots.


COVID-19 and Vaccinations

“Newborn and Early Infant Outcomes Following Maternal COVID-19 Vaccination During Pregnancy”

CDC: Stay Up to Date with COVID-19 Vaccines

“Myocarditis and Pericarditis After mRNA COVID-19 Vaccination”

“‘On track’: 3 percent of Americans have gotten the new Covid shot, but the CDC director remains confident”

“COVID Shots May Slightly Raise Stroke Risk in the Oldest Recipients”

“Evaluation of Stroke Risk Following COVID-19 mRNA Bivalent Vaccines Among U.S. Adults Aged ≥65 Years”

“SARS-CoV-2 infection triggers pro-atherogenic inflammatory responses in human coronary vessels”

CDC: COVID Data Tracker—USA

Medicare Advantage

2023 Medicare Open Enrollment Guide

“How Health Insurers and Brokers Are Marketing Medicare”

“Benchmark Survey: Annual Family Premiums for Employer Coverage Rise 7% to Nearly $24,000 in 2023; Workers Contribute $6,575 on Average Now, But Potentially More Soon”

“Elevance Health Reports $13 Billion Profit and Insurer ups Forecast once again”

Mental Health in Healthcare

“Health care workers report increase in burnout, harassment since the COVID pandemic: CDC”

“Health Workers Face a Mental Health Crisis”

“Suicide Risks of Health Care Workers in the US”

“Stabbed. Kicked. Spit On.Violence in American Hospitals Is Out of Control.”

Artificial Intelligence in Healthcare

“Prospective Evaluation of AI Triage of Pulmonary Emboli on CT Pulmonary Angiograms”

“Artificial intelligence for breast cancer detection in screening mammography in Sweden: a prospective, population-based, paired-reader, non-inferiority study”

“AI Risk Score on Screening Mammograms Preceding Breast Cancer Diagnosis”

What’s a Normal Temperature?

“Defining Usual Oral Temperature Ranges in Outpatients Using an Unsupervised Learning Algorithm”

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

Email Howie and Harlan comments or questions.


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

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. We typically have a guest, but this week we decided to talk about what’s going on in the world of health and healthcare, and there’s always a lot to talk about. There were a couple of things that happened this week in the area of COVID prevention, treatment, but what I wanted to look back on is one paper that finally looked at outcomes for women who were pregnant when they got vaccinated.

And the reason why it was interesting to me is that we’ve pretty well established the safety of the vaccine in the women themselves, but we hadn’t had enough outcomes yet to look at the neonates. And they did this study in Canada, and the nice thing is it showed a reduction in deaths. It showed a reduction in ICU admissions, basically was across the board substantial improvement in the neonates that were born of these mothers. And I just want to point out, it’s hard work to do these types of studies, and the public has sort of moved on. No one’s talking about it, but I thought this was really important to get answers to.

Harlan Krumholz: Yeah, these are great studies, and it’s wonderful to see them published. So what was the time period they looked at? When was it that people were infected?

Howard Forman: So they looked at people who got vaccinated within one day of conception by checking dates through, I forget how many months during pregnancy.

Harlan Krumholz: But it was still fairly early in the pandemic. I mean, early after the vaccine was—

Howard Forman: Large numbers.

Harlan Krumholz: Look, I know this was an important question a lot of people were wondering about. They’re pregnant and should they take the vaccine. Would the vaccine be good for me personally? How about for the baby? And it’s great to have these answers, of course. One of the problems is that most of the clinical studies we have around the vaccines now are from an earlier period of the pandemic and the pandemic has changed. If you don’t mind, I think it’s good for us to just pause for a little bit on this vaccine issue. Let’s remind people who are listening what the CDC is saying.

So the CDC is basically saying that you should take the 2023-2024 updated COVID-19 vaccines, either Pfizer, which is BioNTech, Moderna, both mRNA vaccines, or the Nova vaccine, the only non-mRNA vaccine, to protect against serious illness from COVID-19. And they’re saying everyone age five years and older should get one dose of the updated vaccine. Children age six months to four years need multiple doses, and people who are moderately severely immunocompromised may get additional doses. So let me ask you, Howie, what do you think of these recommendations? I mean, is it too much to ask if you’ve been vaccinated?

Howard Forman: No, it’s not too much to ask. And I’ve been thinking about it. I’m probably going to get it. My thing is all about timing. As you know, the vaccines wane in their effectiveness and we were going through a peak several weeks ago. It seems like we’re in a little bit of a trough now. It’s going to pick up again. So I’ve been trying to time it out for a few more weeks, but my sense is based on what we know right now that the extreme weight of the evidence supports getting vaccinated even if you are as young as I am and otherwise healthy.

Harlan Krumholz: And good-looking.

Howard Forman: And good-looking, thank you. But I’m curious to know from your thinking because this continues to come up, and one of the findings I think the CDC raises is around cardiovascular risks with the vaccine versus with COVID and among young people. And a lot of people will say, “Well, if you’re in the younger age group, you don’t need to get vaccinated because the risk of myocarditis or pericarditis is high with the vaccine, particularly if you’re male, if you’re adolescent.” But it seems like the weight of the evidence suggests even that group should be vaccinated.

Harlan Krumholz: Yeah, I think this is a little bit tough. First of all, your point about COVID, we’re sitting in a period where it is going down. I mean, the whole United States, there’s about a 1% decrease in test positivity, about a 12% reduction in emergency department visits in recent weeks. The trends in hospital admissions are down, so we are getting to a quieter period. It’s interesting that you’re thinking about timing it based on that. Of course, you don’t want to wait so long that there’s a big spike and you miss it. I think a lot of people are sort of weighing risks and benefit. First of all, like I said, the evidence around the vaccines is all preclinical information. So I think what the FDA feels like is that we’ve proven it in clinical studies now every year. Much like flu, we don’t have to re-prove it. What we have to do is know whether or not this vaccine is helping to produce antibodies to the current threats.

Howard Forman: And we have good data on that for both mRNA vaccines and Novavax. We have good preclinical data on that, on the current formulation. And we have great clinical data on the original formulations, which by the way are no longer available. It’s not like you can still get any of the older vaccines.

Harlan Krumholz: So people are trying to say, lots of people get sick for a couple of days with the vaccine. By the way, I got vaccinated, I decided to do it, and I did feel sick for about 48 hours.

Howard Forman: I remember that.

Harlan Krumholz: So I was started trading off that. And then the vaccines themselves aren’t riskless, we have some acute things. In fact, there was just a report that came out of the FDA that talked about people who got the high dose flu vaccine concomitant with the COVID-19 vaccine. And for people 85 and above, they’re saying maybe there was an increased risk of stroke. I mean, I hate to even say that out loud, but—

Howard Forman: I know.

Harlan Krumholz: Preprint internet archive.

Howard Forman: I didn’t know that until you showed that to me. Now that’s a preprint, and it’s a tiny, tiny increased risk.

Harlan Krumholz: So it was about a 30% increase. But remember, the risk is—

Howard Forman: Tiny.

Harlan Krumholz: small, that 30% increase on very small doesn’t really mean a lot. And it’s a preprint, but it’s coming out of the FDA. So they have their own peer review internally. So when it becomes a peer review and it gives me a little more confidence. But again, the CDC makes the point that the risks of myocardial issues from COVID—

Howard Forman: Higher.

Harlan Krumholz: Is larger than the risks for any problems with the vaccine in their opinion. And those risks were usually in young males. So I think everyone’s trying to weigh these sorts of risks and benefits. I generally believe that if you are young and healthy, there’s little to gain right now from the vaccine, given the current state of the virus. Remember, the virus is very different than what it was in the beginning in New York and Connecticut where people were in line to get in ICUs. It was a lower respiratory thing. This is a different virus. So I’m a little bit at odds, but I definitely think people at high risk who might suffer complications or who are older, it’s a good idea.

Howard Forman: Yeah, no, look, the CDC made a recommendation, as you said, for, is it five and above or six and above? But basically very young people, they went all the way down.

Harlan Krumholz: They say five years and older.

Howard Forman: And they clearly are... I mean, they do believe the weight of the evidence. They would not make that recommendation if they did not believe the weight of the evidence favors benefit over risk under those circumstances.

Harlan Krumholz: And you and I both have a lot of belief in Mandy Cohen, who’s running the CDC. She’s very smart and balanced, right? She’s not on one side. We interviewed Peter Hotez.

Howard Forman: Yep. He’s very strongly, emphatically supportive.

Harlan Krumholz: And knows a lot about these issues. There’s a variety of opinions, but I guess, I’m just doubling down on this idea. One, I believe flu vaccine is beneficial, also reduces cardiovascular risk, meaning that flu infection raises your risk of cardiovascular problems.

Howard Forman: I know you talked about this early in the podcast. I mean, I don’t think our audience probably... Neither do I even fully understand how much inflammatory changes in the body can influence your risk of heart attack or stroke. And that when you get flu, not flu vaccine but flu, and when you get COVID, your inflammatory markers and obviously inflammation as well goes up and puts you at higher risk for a lot of diseases.

Harlan Krumholz: And that’s right. And there’ve been studies by the way, even after a hospitalization for pneumococcal pneumonia, in the months afterwards, your cardiovascular risk increases. We think that has to do with the inflammation. Inflammation plays a very important role in cardiovascular, both acutely, that is, putting you at risk for a heart attack, and chronically, putting you at risk for atherosclerosis. So we think that there’s a connection. So of all of this information, Howie, I want to just bring you back to one thing, which is what’s happening in the country. So it seems like so far in our entire country, only 12 million people, about less than 4% of the population, have gotten the shot in the five weeks since it hit pharmacy shelves.

And what was even interesting to me was many more have gotten the flu vaccines. And just to sort of calibrate this, last year, only 17% of the population had the vaccine. Now this is in contrast, of course we know and there was such a great success, even though we talk a lot about people who didn’t take the vaccine, but there were administered almost 700 million vaccine doses. And of course, across the various different timing that people were getting, some people just got one, some people got two. And in the population of people 65 and older, very high percentage of people ended up getting the vaccine at least once.

Howard Forman: Look, misinformation is still a huge thing. We had Peter Hotez on, he talked about it, his book is about that. I don’t think you can overstate how much people have permanent scars in their brain about what they believe the vaccines can or can’t do. And unfortunately, it is also tied to politics, as we’ve talked about before.

Harlan Krumholz: And just sort of to end this discussion just to say what’s interesting, I think in Connecticut, about one in four people have gotten vaccinated. Remember I was saying in the whole country, it’s only about 12%. You go to a state like Alabama, you’re down around 7 or 8%.

Howard Forman: It’s crazy.

Harlan Krumholz: So it’s really unusual for people to get... the country is really split. Northeast is, I would say, doing much better. Let me just say this, there are higher rates of vaccination and maybe in our ecosystem in Connecticut, there’s a much stronger level of belief. And if you looked at this by age, you would see we’re doing a pretty good job with vaccination in older folks.

Howard Forman: And it’s accessible. I mean, if you think back to the early vaccination programs, people struggled to find a place to get it. It’s accessible now. So that’s a big plus. We should be proud of that, and I hope that we’re able to promote this because I think particularly for the elder population, there’s just no question that it’s beneficial.

Harlan Krumholz: And everyone who’s at risk should be doing this for sure. So Howie, what else is on your mind?

Howard Forman: Yeah, so look, it’s a very funny time of the year because I’m teaching insurance concepts in my class right now. I’m teaching Medicare in my class right now. And then in the morning when I turn on CNN, I’m just bombarded with advertisements for Medicare Advantage. If you watch any TV or even streaming, you’re seeing these Medicare Advantages. You’re seeing Joe Namath and every other celebrity on there. So it is Medicare Advantage open enrollment season. As we’ve talked about before, 51% of Medicare enrollees are now receiving Medicare through Medicare Advantage plans. Those are private Medicare plans. Aetna, Cigna—Aetna CVS—UnitedHealth Group, Elevance, at this...

Harlan Krumholz: So let me just go back. I think people still get confused about this. So you turn 65 and then you’ve got basically two options. And in the one option you’ve got lots of options. Just make this clear again.

Howard Forman: You turned 65 in this country and you’ve worked here for more than 10 years, you qualify for Medicare.

Harlan Krumholz: Oh, you have to have worked here for 10 years?

Howard Forman: Yeah, you have to have paid taxes for 10 years to qualify for Medicare.

Harlan Krumholz: I didn’t even know that.

Howard Forman: Yeah, you do that, you qualify for Medicare. And up until about 20 years ago, Medicare Advantage was an afterthought. Ninety-plus percent of people were enrolled in Part A—

Harlan Krumholz: When did it start?

Howard Forman: Medicare Advantage—really, we had Managed Medicare introduced in the eighties, and then they changed it. They started calling it Medicare Plus Choice. And then in 2003, they introduced Medicare Advantage as the name, it’s a rebranding, but basically Managed Medicare is what Medicare Advantage is. It used to be small numbers. It had a little peak in the Clinton era and then dipped down to like 10% of Medicare enrollees by the time Bush was elected in 2000.

Harlan Krumholz: And it was a cost containment strategy.

Howard Forman: Look, it’s been sold in different ways. To some people, people would say Medicare Advantage is a way of coordinating care. Like why should you have this fee for service? Wouldn’t we do better? I thought President George W. Bush made a really good point toward the end of his administration when he said, “You go through your job, you have managed care plans, you have private health insurance managing you. Why aren’t we doing that when you leave your job? Why can’t you have that in Medicare?” So Medicare Advantage is a continuation of what 95% of all employer-based plans are right now. It’s a continuation of that. And you get to pick what plan you want.

Harlan Krumholz: So you mean I should be thinking that my private plan that I get through Yale University is really a Medicare Advantage analog?

Howard Forman: It is, absolutely.

Harlan Krumholz: But they don’t pay for my dental, they don’t get as much as Medicare Advantage.

Howard Forman: No, but for instance, Kaiser is a good example. Kaiser people are in California in high numbers or insured by Kaiser. They get their care through Kaiser, and then when they revert to Medicare, they can get their Medicare advantage through Kaiser. And it’s—

Harlan Krumholz: And it’s no change.

Howard Forman: ... substantially identical with more features than Medicare itself provides. And the intuition as you pointed out is, wouldn’t it be nicer if you’re actually managing a patient’s care in a way that maximizes health and minimizes cost, maximizes quality, and so on? The intuition is good.

Harlan Krumholz: And for Medicare Advantage, are people paying anything for that?

Howard Forman: So in general, they’re paying less than they would pay for Medicare. Now remember, Medicare is expensive. If you don’t have an employee benefit and employers, about a third of employers still provide a retiree health benefit. If you don’t have that, you actually have to buy a Medigap policy just to make standard Medicare affordable for you. If you’re very poor, you’ll get Medicaid combined with Medicare. And then there are the near-poor people who don’t qualify for Medicaid, for whom Medicare can be really expensive.

Harlan Krumholz: So we shouldn’t be really calling Medicare universal coverage. It’s not universal coverage.

Howard Forman: Oh my God, it doesn’t have catastrophic coverage. The deductibles are high. If you don’t have these extra features, your deductibles are high, your copays are high, it does not have a catastrophic benefit. You can run out of the benefit. It’s really problematic.

Harlan Krumholz: So we really shouldn’t be thinking that in any way fully protects people from financial toxicity.

Howard Forman: ACA plans are better protective than Medicare if you don’t have those other features we talked about. So here we are, now we’re open enrollment season. Everybody’s coming after people to try to get them to enroll at the same time. In about four weeks, employers will have their open enrollment season. So people are contemplating insurance as well. And so, Kaiser just came out with two different surveys that I think are useful to just touch on quickly.

Harlan Krumholz: Kaiser Family Foundation.

Howard Forman: Yeah, thank you. One is their annual employer survey, which I talked about last year at this time because I get very excited by this. And I think a couple of the big upshots from that—higher prices this year, much higher than last year. It’s sort of a rebound. Last year, inflation was very low on employer benefits. And the other thing is that they’re starting to actually track abortion benefits now. And seeing that employers are really struggling to figure out how do they deal with this? Because a lot of employers or multi-state employers, some states don’t have abortion, some states do. How do you deal with that?

Harlan Krumholz: Wow. What’s our way out of all of this?

Howard Forman: Look, you and I have talked about this before. There is no easy way out of this. We had Katherine Baicker last week and she suggested Medicaid for All. Why aren’t we expanding Medicaid more into the market? And there’s some really good reasons for that, but that will keep us in a two-tiered system. And by the way, financial toxicity, as she pointed out in Medicaid, almost zero. They can’t collect.

Harlan Krumholz: Yeah. So that’s kind of a better system. Let me just put a cap on this topic. So there are all these private companies that are offering these Medicare Advantage plans. It’s the only place in healthcare where I see profits out the Gazoo. I mean, Elevance just announced billions of dollars of profits in the quarter. Of course, every time I see UnitedHealthcare come out, I mean, it’s some gazillion amount of money that they’ve made in profits. Meanwhile, hospitals, everyone else is getting squeezed. What’s your feeling about that? How is it that this system is configured that these large companies are just making so much money?

Howard Forman: So Medicare Advantage, when the newest configuration came in, it was intended to create a profitable opportunity, that was 2003...

Harlan Krumholz: A big profitable opportunity.

Howard Forman: ...for the health plans to get them to come into the states that you wanted them to move into the states. We are now at critical mass. It is unclear to me why Medicare Advantage continues to be so profitable and that we allow it to be profitable. Since the taxpayer are paying for this. I think this is something that Congress can take up. I think that we should be doing more about it. I want to say the other Kaiser survey just points out these commercials do not feature disabled individuals. They do not feature chronically ill individuals. They feature Joe Namath. They want to show you vitality because they want the healthiest people to sign up.

Harlan Krumholz: That’s interesting. Well, we’ll have to keep an eye on all this. I do think people should have a right to profits, but they should be reasonable profits, especially if largely the revenues are coming from the federal government. We’ll see what–

Howard Forman: I agree with that. I will say when I see true innovators profiting, I think that’s okay when I look at these plans and I think, are they really innovating in some substantial way that deserves that profit? And the answer, by the way, is mostly no. They’re not saving the system a lot of money.

Harlan Krumholz: Hey, I want to bounce over to another topic just to get your thoughts on this. So this week, the CDC came out with something about burnout. We’ve talked a lot about burnout, and I just wonder if people who aren’t in the health profession and think like, “Are people just whining in healthcare? Everyone’s suffering no matter what job you have, no matter what your circumstances post-pandemic, it’s just hard. But a lot of us are just still dealing with reentry, a lot of remote work.” And by the way, let alone world events, which you turn on the news and you can’t help but to feel a little depressed and scared and anxious. But this is about healthcare workers, I think it’s important in the sense that it’s hard to deliver on the highest-quality care if the workers are feeling this.

And what they came out and said was that healthcare workers saw an increase in poor mental health during the past 30 days from about three to almost five days a month over that 30 days. So they’re asking over the last 30 days, how many days have you had poor mental health? And it’s almost five days. The percentage of workers who reported feeling burned out compared with 2018. And again, all professionals probably experienced this, but in the health profession, one in five we’re up to now from about 1 in 10 to 1 in 5. And if they ask almost 50% of the health workers reported feeling burned out often or very often, that was about a third in 2022. I mean, it can be stressful in this. And let me just raise one other issue, which is that they’re also reporting a lot of harassment at work. And so, this becomes another issue.

This can be threats, bullying, verbal abuse, actions from patients or coworkers linked to hostile work environment. I mean, people are feeling at wit’s end about this. And I am concerned because I’m also reading that in larger numbers. People are talking about leaving the healthcare profession. And there was a stat here that in 2022—from the CDC again—the percentage of health workers who intended to look for a new job increased to 44%. There was always a certain amount of churn, maybe about one in three, but we’re nudging up to 50% of turnover and a lot of people are just leaving the field. So, I don’t know.

Howard Forman: I want to add one point to that because this was something I thought about talking on the podcast a few weeks ago, and that is we’re seeing a very similar elevation in suicide rates among healthcare workers.

Harlan Krumholz: Oh my goodness.

Howard Forman: And interestingly enough, not among physicians per se but among all the other people that you mentioned, specifically registered nurses, health technicians, and other support workers, even much lower down the professional ranks, we’re seeing substantially elevated risks of suicide among this. And I do think that we are underestimating the harm that is occurring to this population, and it imposes costs because if people leave the profession prematurely, that increases the cost for us to be able to continue to maintain the workforce.

Harlan Krumholz: And I’m really glad you brought this up. We’re not just talking about physicians. Of course, everyone is essential in these healthcare teams, and healthcare professionals is a broad term. There was a 2022, I’m going to now pivot to something, and I also saw this in The New York Times, an op-ed on the emergency department where in 2022, American College of Emergency Physicians survey of doctors said 55% said that they’d been physically assaulted almost all by patients with a third resulting in injuries, 85% had been seriously threatened by patients. And these risks are even higher for emergency department nurses, with over 70% reporting, they’d sustained physical assaults work. Now you work in the emergency department, you do your shifts there. So this must be something that you’re observing as well.

Howard Forman: Oh, yeah. Look, not infrequently we’ll have somebody sent over for an X-ray after they’ve been pummeled by a patient.

Harlan Krumholz: One of our healthcare workers.

Howard Forman: Yes.

Harlan Krumholz: Really?

Howard Forman: Generally nurses... we have a huge presence of security in the emergency room because people that are under duress, sometimes people that are either intoxicated or under other influence, people that are having an acute mental health crisis can be dangerous to others. It is not—

Harlan Krumholz: But it seems like this is just part of the incivility that’s occurring. Right? It’s increasing. And in this thing, the person who wrote this op-ed said, “I don’t know anyone who works in the emergency department who hasn’t suffered from violence there.”

Howard Forman: I believe that.

Harlan Krumholz: Yeah. So I think we have to be thinking about this including what are going to be the strategies. And the CDC came out with a whole bunch of stuff. We need to value work care safety and health, ensure adequate staffing, trained supervisors, model and support taking time off. These are all good recommendations, but I fear that I’m not sure that they’re going to bridge the gap.

Howard Forman: You shared that with me, and I did particularly appreciate the fact that we need to model the fact that it’s okay not to work 90 hours a week. It’s okay to take vacation. All too often you hear people—

Harlan Krumholz: Not to come in sick.

Howard Forman: Exactly. We don’t do a great job of that. There’s still a culture in medicine, not just among physicians, among everybody, that you’re tough enough to work through this. You will power through this. Physicians in particular who do shift work that is scheduled sometimes way in advance feel it is an imposition on others if they all of a sudden have to call in sick. We have got to change that.

Harlan Krumholz: So I think my final thing on this is that I think this requires a redesign of healthcare work processes, not meditation seminars at noontime or yoga sessions in the morning. I’ve seen some of this sort of wellness intervention, not to diminish them, but I really don’t think that’s what people are looking for. We’re going to need to redesign work really and ensure the safety. By the way, this harassment thing is just unacceptable. We have to be able to–while respecting the patients—but we need to keep people safe.

Howard Forman: Yeah, no, I got very sort of inspired about a paper that I saw in radiology and it was very funny because they came to the opposite conclusion I come to from it, which is that AI software product—which we by the way use at Yale, I have no connection to it other than the fact that we use it—reduces the misrate of what we call subsegmental pulmonary emboli by 59%.

Harlan Krumholz: What’s a subsegmental pulmonary emboli?

Howard Forman: So pulmonary emboli, which can be an acute cause of death and definitely are.

Harlan Krumholz: And what is a pulmonary embolus?

Howard Forman: Clots typically traveling from your legs, but they can travel from anywhere. They go through your heart and they go out to the lungs and they limit the ability for you to transport oxygen into your blood. And so, people—

Harlan Krumholz: And can be quite devastating.

Howard Forman: Right. And the symptoms are typically acute, shortness of breath, chest pain, sometimes dizziness, very serious.

Harlan Krumholz: So it’s a highly consequential diagnosis.

Howard Forman: Right. Large pulmonary—

Harlan Krumholz: And we can treat it.

Howard Forman: Exactly. And not only can we treat it, we can treat it in newer and better ways. We used to just treat it with anticoagulation, blood thinning. Now we actually can go in and remove clots in some people. It can be very consequential. People to this day still die from pulmonary.

Harlan Krumholz: So your point is it’s important to get it right.

Howard Forman: Right. Smaller clots, we still don’t know exactly how to manage them, but we do know the weight of the evidence says treat even the small clots and subsequent pulmonary emboli are the smallest clots that we can see with human eye.

Harlan Krumholz: And subsegmental, you’re just saying in the very distal part of the lung.

Howard Forman: Right. We talk about central, we talk about segmental, and then we talk about subsegmental.

Harlan Krumholz: So why is the end of the branches?

Howard Forman: But it’s within the human eye to see. So we have software now that helps us see those. And let me just say with all humility, I miss them periodically and with our AI program, it will show them to me. And then I go back and I look at it and I’m like, yep, it’s there. It’s not that it sees something that I can’t see with my eye, it’s that it sees something that I can miss with my eye. So when this reduces—

Harlan Krumholz: It never gets tired. It’s always doing the work, right?

Howard Forman: And it takes the same amount of time. It’s never feeling rushed—59% reduction in the miss rate from these things. And I just thought that—

Harlan Krumholz: And by the way, what was the gold standard in this study? How did they know that it was there?

Howard Forman: They had a consensus of the radiologist going back and looking at each of these studies. I think they had two separate authors go back and look at each one to make sure that they had agreement with the report and with the findings of the AI program. So that was one thing that came out. I thought that was a big finding. That’s exciting to know that we’re doing that. Similar to that is the findings we’re getting with breast imaging, which most people talk about mammography. And what we’re finding is that AI can be a true additional benefit and assistive technology for breast imagers. Now in Sweden, they have a pattern of having two breast imagers read every mammogram.

The first one picks up most of the findings. The second one picks up some extras. They decided, why don’t we take away the second person and introduce the AI program that they have, and what do they find? Four percent improvement in pickups of cancer with no degradation in any other way. With one less person working, you’re getting better outcomes across the board, which, this makes intuitive sense to me. And then the last paper related to that shows that we can actually go back and look at people diagnosed with a breast cancer and you’ll discover that you could have picked it up earlier if you had only been using an AI program.

Harlan Krumholz: Spectacular. First of all, kudos to Sweden to having two readers in the beginning.

Howard Forman: Correct.

Harlan Krumholz: By the way, I was recommending that at Yale for pathologists after I had a situation where there was a misread. And I said, “Why isn’t every consequential path double-read, independently blinded?” So they wouldn’t know what the other person had to say.

Howard Forman: And what’s the answer, Harlan, and why aren’t we doing it?

Harlan Krumholz: Well, I think when there’s a high-stakes decision, we have to be sure that we’re right. And that can’t be just reliant on any single individual. But I love what you’re telling me, and it fits with my construct of us like pilots. And in the early days where there was really weak instrumentation in the cockpit and there wasn’t a lot of decision support and augmented kinds of assist to make sure that the pilots were going to not make mistakes, there were mistakes, human error was rife. And as it got, we didn’t say, I want to fly from New York to San Francisco without a pilot. I want a pilot there.

But I wouldn’t want that pilot not to be assisted by every single way that their performance can be enhanced. And what you’re describing to me is where I hope medicine’s going to go, which is how do we enhance the performance of every single individual. It’s like having another expert on your shoulder and weeded out all of these errors that are inevitable when we’re dependent on a single person who could be tired at the end of a shift or distracted or whatever. Or just that their skill level isn’t where it could be, but we can help them get to a higher level through a wide range of assistive technologies. And I’m just hopeful that we get to that point.

Howard Forman: I am too. But really, I thought that these were big leaps forward in demonstrating the proof of concept.

Harlan Krumholz: That’s terrific. Hey, let me just hit one more thing before we end this, it has been great conversation. So I’ve often said medicine’s now in information science. You know it’s all about the data. And there was a cute paper that came out in JAMA Network Open that I wanted to talk to you about, and I wondered if you saw. So Howie, what’s the normal temperature for a person?

Howard Forman: It is 98.6 degrees, precisely.

Harlan Krumholz: Yeah, of course, we learned that, everyone taught us, 98.6. And so, we say, well, you’ve got an elevated temperature or your hypo temperature which is lower than average based on this 98 point... I don’t even know exactly where that came from, but there was a study in which they looked at over 600,000 adult outpatient encounters to define what is the normal temperature. So now in this world of digital data, they’re able to pull together all this data. And what they reported was the range of mean temperatures from coolest to warmest was range from in healthy people who are just getting their temperature measured from 36.2 Celsius to 36.9 Celsius. Of course, for people listening, we tend to talk about it in terms of Celsius in the medical world, 98.6. Remember people who are thinking about—

Howard Forman: My age, right? No, I know.

Harlan Krumholz: Right, 37 Celsius is what—

Howard Forman: Exactly 98.6.

Harlan Krumholz: But what was really interesting to me about this is when they took it all the data, it may be and it makes sense that we each have our own normal temperature, and that there was this variation. And by the way, variation varied by time of day and by age of the individual. I’m just thinking also that probably each person has their own set point not within a normal range, but to suggest that there’s a one single point that represents this word, quote, unquote, “normal” for the entire population, actually, as you think about, doesn’t make sense.

Howard Forman: And it starts to really explain things better. For me, during COVID, I had a digital thermometer at home and I could care less about the absolute number. All I wanted to know is that it was a certain number, that it was the same time of day, same number, and it varied for me by about two degrees between morning and evening.

Harlan Krumholz: And this study would validate that actually that happens for most folks. I think it’s a fascinating thing. And I also think people have different ranges of responses. For example, if my wife gets sick, she gets a fever, she can get a high fever. I never get a fever. Never. I mean, I can get...

Howard Forman: You get angry.

Harlan Krumholz: ... sick with flu. Thanks, Howie. But anyway, I just think it’s interesting. There’s so much more for us to learn. We think we’ve been doing medicine for a long time. Even something as simple as what’s the normal temperature and how does it vary during the time of day turns out to be still something we’ve got to learn about. So anyway, this has been delightful for us to be able to just visit today, Howie, I think we’ve got to do this more often.

Howard Forman: It’s been fun.

Harlan Krumholz: 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, you can still email us at or you can still find us on Twitter, on LinkedIn. I know that you’re lurking about it on Bluesky and on Threads. Now I don’t know if we want to tell the audience that’s true, but it is a fact.

Harlan Krumholz: Yeah, I haven’t really revved up on those. I got to tell you, I’m still going to call it Twitter. I’m having trouble leaving Twitter because there’s a large community out there. I still learn a lot of things, but I just get disgusted by more and more stuff that especially there’s so much misinformation weeks around the Middle East and so forth, and yet there’s a lovely community of people who I’m part of on there.

Howard Forman: I know. Still, every time I go onto another platform and find nice people to talk to, I’m reminded that I do have a base.

Harlan Krumholz: It’s going to take a while for this.

Howard Forman: Yep.

Harlan Krumholz: So on Twitter, I’m at still @ H-M-K-Y-A-L-E, that’s @hmkyale.

Howard Forman: And I’m @thehowie. That’s @ T-H-E-H-O-W-I-E. Again, you can email us 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

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. What an amazing team we’re lucky to have, Howard.

Howard Forman: We are very lucky.

Harlan Krumholz: Yeah. Talk to you soon, Howie.

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