The Physician Shortage and Other News

Harlan Krumholz: Howie, welcome to Health & Veritas. It’s just you and me, baby. We’re on today together.

Howard Forman: I know it, and it’s a fun thing. We’re not in the studio together, but we are virtually together, which is the closest thing we can get.

Harlan Krumholz: We couldn’t get to the studio today. They’re fixing it up, I guess. I don’t know.

Howard Forman: So again, for our listeners, we’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This is one of our periodic episodes without a guest. Quite frankly, we’ve had some really nice feedback about these episodes, so we’re trying to do them on a regular basis and there’s a lot of news and updates to share with our listeners today.

Harlan Krumholz: Yeah. Howie, why don’t we shake it up? Usually, I’m the one who starts on the first one, but I know you’ve got a couple things. So, hey, why don’t you kick off today?

Howard Forman: There was a really nice kind review on Apple Podcasts from a listener named Gosia, and I’m just going to summarize what the query was because they didn’t just leave us a nice review. They had a question for us, which is great. Point is, we have a physician shortage. It’s very difficult to get an appointment to see a physician in a timely manner in most parts of the country. You and I have both talked about this, and it continues. We also have many individuals who would happily come to this country to practice medicine and are already fully trained or willing to train—both categories. So, why can’t we do better here? It’s a huge topic. We probably should spend even more time on this than we will today.

But as a start, I just wanted to talk about some state-by-state responses that make an awful lot of sense and so far seem to be getting some more traction and acceptance. So, first of all, there are big challenges to coming to this country to practice medicine if you were trained outside of the United States. By the way, there are two categories. There are people who are U.S. citizens who train outside the United States. They at least don’t have visa hurdles. Then there are those who trained and were born and are citizens of other countries, and they face enormous hurdles to come to this country. Nonetheless, about a quarter of all practicing physicians in this country are international medical graduates, and we need them desperately.

So, almost 18 months ago, the State of Tennessee passed a law that allowed for a provisional license to be offered to physicians who had already achieved independent practice in their country of origin, subject to some fairly standard requirements, including that a residency program exists at the hospital that they’re going to practice in, even though they would not be a resident trainee. That’s the usual pattern. You come to the United States and you have to repeat the residency program. Here, you just have to be at a hospital that has a program. It offers much more flexibility to these already trained physicians. By the way, Illinois passed a similar law that takes effect this coming January, but it limits the opportunities to underserved areas.

Florida and Virginia seem to be close behind, and there are many other states that are passing bills that could have similar or related effects. A lot of questions remain, by the way. Number one, should we limit this to only underserved areas? Are we making appropriate protections for these people, so that hospitals don’t take advantage of them? What are the responsibilities of the training programs that exist on site alongside these new physicians? But I think this is heading in the right direction, and at the very least, we need more access to these and other alternative pathways. What are your thoughts on this, Harlan?

Harlan Krumholz: Well, let me get this straight. You just said Tennessee, Florida, Virginia.

Howard Forman: Illinois.

Harlan Krumholz: Howie, I can’t start talking about this without getting into what’s going on right now with all the discussion about immigrants. So, you’ve got states who are contemplating whether or not for doctors we should be relaxing the rules. We have a presidential candidate who’s vilifying immigrants in the most heinous ways. He is not just talking about keeping immigrants out of the country or building a wall or banning Muslims from entering the United States as he has in the past, but he now warns that these migrants have invaded, they’re destroying the country. Somebody at his rally recently in the midst of one of these diatribes yelled, “Kill them!” There’s a broadside against Venezuelan migrants.

Howard Forman: He’s talking about mass deportations, which is just frightening.

Harlan Krumholz: I mean, deportation is one thing. It is horrible, but I’m just saying that he’s also positioning them as evil and in ways that is reminiscent of the worst of human history with regard to calling people non-humans. So, this, I will just say first and foremost, I find extraordinarily disturbing. On the side of doctors, I’m always mixed about this because of the brain drain issues and what it means. Let’s get in these doctors to help serve us. That being said, I do like the idea of being able to open our borders to people who can follow the pathways that we’ve put in place, that allow people to contribute to our society and become Americans, ultimately—many of them.

I think that that’s great, but again, this brain drain issue. I also think it opens up this question, why aren’t we doubling the size of medical schools? I mean, if we’re really thinking that doctor shortage is a big deal, then what are we doing to address that at its basis? Because there’s a lot of talented people who apply to medical school who can’t get in right now. If that’s an issue, why aren’t we doing that?

Howard Forman: Look, and you and I talked about this, I think, on one of the very first podcasts we did, medical education in the United States remains extremely expensive. Most medical schools, most universities that have medical schools, have them as so-called trophies. They’re things to be proud of. They enhance the reputation of the university. Nobody has ever, to the best of my knowledge in a domestic medical school, figured out how to make money on the education piece.

Harlan Krumholz: By the way, if we’ve got great medical schools, why aren’t we helping to train people also for other countries as well and exporting that expertise? What are we doing to democratize the ability for people to become doctors? So really appreciate that we got the comment. It’s complicated for sure, but I’m sorry, you just triggered me about this issue about immigration.

Howard Forman: This is why I love the podcast, Harlan, because I honed in on answering this question in a way that I do in class. You brought us back to the world that surrounds us right now. I think you raise many points, but both of those big points are really important, brain drain and the current political climate.

Harlan Krumholz: What’s a principal reason we’re great? The reason we’re great is because we’ve attracted people from all around the world who have sought a place where democracy is number one, where people have rights, where they can work hard and succeed. We shouldn’t be thinking of immigration as an evil. The way that he’s disparaging individuals, it just is reprehensible.

Howard Forman: No, I agree with you. I am glad you brought us back.

Harlan Krumholz: You can be for Republicans or against. You can be for or against. But in this particular instance, let alone the craziness of eating cats and dogs, I mean bizarre, bizarre ideation.

Howard Forman: It is, it is.

Harlan Krumholz: I’ll just say, last thing, which is there were concerns raised about Biden’s mental state. For some reason, he [Trump] gets a free pass. I really think if you listen to what’s going on, it should worry people just as much about capability to serve.

Howard Forman: Yeah, we could spend the whole podcast talking about the political race and we will, I think, in the next couple of weeks try to give an update on what is at stake in healthcare before this election. So, give me something, Harlan. What’s interesting this week?

Harlan Krumholz: I’ve got a couple things here today about AI. I hope you don’t mind

Howard Forman: Of course.

Harlan Krumholz: ...I continue to be amazed and fascinated by. The first one is I want to talk about a fascinating preprint from DeepMind on a system called AMIE, A-M-I-E, the Articulate Medical Intelligence Explorer. Have you heard about this at all?

Howard Forman: No, I’ve not.

Harlan Krumholz: Yeah, so well, you’re going to be hearing a lot about AMIE, I think. This AI was designed to assist doctors in diagnosing complex conditions. Let’s unpack this a little bit. This particular preprint was focusing on this issue of whether or not AI ultimately is going to help democratize subspecialty access. So, the problem is straightforward. There just simply aren’t enough subspecialty doctors to go around, and they were focusing on cardiology. In cardiology it’s especially true for complex and life-threatening conditions like hypertrophic cardiomyopathy. Now, this is this genetic abnormality, a thickening of the heart.

We all learn about it, but there are people who specialize in this condition and there really are a lot of facts to know, new treatments, new diagnoses, new ways to classify the disease, new kinds of testing. So, even cardiologists may not be as skilled as those who’ve really dedicated their lives to become subspecialties in this. This disease is particularly important because it can lead to sudden cardiac death in young people, and it’s often undiagnosed. So, this is where this AMIE comes in. The idea is that AMIE can support general cardiologists.

Now realize this. This isn’t about saying you’ve got primary care people who aren’t cardiologists, but among cardiologists the knowledge has become so specialized that it is worthwhile for additional expertise to be garnered, which you can only usually get within tertiary care centers, advanced academic centers where these people exist. But this AI can assist general cardiologists by helping them interpret complex text results, also take electrocardiograms, cardiac MRIs, genetic tests, and offer diagnostic and therapeutic recommendations. So, they tested this using real-world data from over 200 patients who were suspected of having genetic heart conditions. They compared AMIE’s performance against board-certified general cardiologists in 10 different domains.

So, they put together a way to assess performance, things like diagnosing the condition or recommending further tests or outlining a management plan. One of the most compelling cases where AMIE outperformed the cardiologists involved, for example, a 69-year-old patient with suspected obstructive hypertrophic cardiopathy and, again, genetic heart disease, but it can be subtle and deadly, particularly if undiagnosed. The general cardiologists reviewed the patient test results, which included an echo and a Holter, which looks at the heart rhythm. Based on this finding, they determined they didn’t have a genetic heart condition, said no referral was necessary. But AMIE saw it differently.

It flagged a few subtle but important indicators that the cardiologist had missed, identified some of these things, and said, “Ultimately, this patient needs further referral and evaluation.” Then what they did was they took the assessment by general cardiologists—the assessment by AMIE—they took it to the subspecialty cardiologist and they had them rank what was going on. You could see that AMIE’s more comprehensive analysis was deemed to have provided a better assessment and recommendations for the patients—in essence, for the general cardiologist providing a safety net—capturing signs of this life-threatening condition, and helping them make better decisions. So, this is fascinating, Howie.

What is “the doctor of the future”? We talked about the person in the loop. We’ve talked about this last week and whether or not these recommendations can help, but here was, it actually being tested in a rigorous fashion and this thing turned out to be on your shoulder, could be quite useful in making sure we don’t miss important things.

Howard Forman: Is it something that you think gets attached to the EMR, the EHR, electronic record that then has a pop-up button for somebody and tells them, “You should be thinking about this”? How does this work in practice right now?

Harlan Krumholz: That’s a really good question. We call these kinds of packages decision support tools. They’re decision support tools. What we’re learning too is that you can have really good information, but you’ve got to figure out, where does it fit in the workflow of the clinician? If you put it in the wrong place, it can be ignored or it doesn’t really help. So, I think we’re still in the midst of trying to figure out how to optimize that, but I think just like great athletes want to take advantage of every single thing that’ll help them improve, we’ll get to a position where no doc will want to operate without it, just like no pilot wants to fly without the computer systems and autopilot that ensures safety and the likelihood that they’re going to land safely, that the doctors will get into a position that we’ll be wanting these tools, and then it’ll be up to us to figure out how best to place them so that they don’t obstruct us or tell us something that’s obvious, but they help us to do a better job.

Howard Forman: Yeah. Well, that’s great. I mean, this is only about three years into this active phase of large language models and AI in medicine being actively used, and it’s been a lot of progress.

Harlan Krumholz: Yeah, I can only imagine where we’re going to be in five years. So, I think these are all prototypes, what could happen, but even the prototypes are sometimes working really well.

Howard Forman: It’s exciting.

Harlan Krumholz: Yup. Okay, what’s next on your set?

Howard Forman: So this is a story from STAT News. You and I talked about it briefly yesterday. So, adrenoleukodystrophy is an X-linked metabolic disease, which means it only affects boys. It’s a known genetic mutation. We’ve identified it and it leads to a failure to break down certain fatty acids in the body. Cerebral adrenoleukodystrophy develops in 35% of these boys before adulthood and leads to neurologic dysfunction, cognitive decline, and early death without treatment. It is devastating. It’s a bad, bad disease. Bone marrow transplantation, a stem cell transplant from a matched sibling is the only other existing treatment for this group, but it’s only available to about 20% of all patients. So, along comes a gene therapy.

By the way, it’s from Bluebird Bio, a company that we have talked about before in the podcast with regards to sickle cell disease. This new gene therapy is seemingly highly effective for the treatment of this disease. In fact, most treated patients at six years had no functional impairments. This seemingly was a better outcome than even the patients who had the stem cell transplant. So, this is a huge advance for a lethal and terrifying disease, but—the “but” is huge—more than 10% of the boys, 7 of the 67 study thus far have developed a hematologic cancer. Whichever form they get, either the milder form or the actual acute myeloid leukemia, it’s effectively a cancer diagnosis. All seven of those kids have been treated. Six of them had a good result, but one died from the treatment.

So, even the treatment is harsh, but it’s seemingly effective. Now, this is a really rare disease. It only affects about one in 15,000 male births. That means that roughly a little more than 100 such children are born every year and roughly 35% of them will have these cerebral symptoms. So, learning how to treat them is important. It also means that we’re learning how gene therapy works in vivo or running many experiments at the same time, not just about this disease. Look, I have no qualification to talk about how the genes get to where they’re supposed to get, what viral vectors are used and why it’s challenging. I’ve read about it, but God, it’s very complicated. But this is the cutting edge of treatment for many genetic diseases right now, and it’s a great opportunity for us to learn.

So I bring this up mostly because every treatment, whether it’s a vaccine or a food even, but every treatment that we put in our body has risks associated with it. We need to weigh those risks against reward. Taking the risk of a hopefully curable cancer against the certainty of early death is one that individuals should at least be allowed to consider. We can spend other episodes talking about affordability, but I just wanted to highlight the incredible nature of this advancement, but also remind our listeners that risks abound.

Harlan Krumholz: I’m really glad you brought this up, a really fascinating story. Just for listeners to really understand this, as Howie says, this is about a mutation gene that normally helps the body break down certain fats. Because the body can’t break these fats down, these fats build up in the brain. So, what happens? Well, usually, boys start showing symptoms between the ages of four and eight. So, imagine you’ve had a... what, apparently healthy child and the child’s progressing. But between four and eight, they begin to struggle with things like walking, talking, hearing.

Howard Forman: Exactly.

Harlan Krumholz: Then without treatment, they get worse rapidly. They lose ability to walk and talk within a few years and ultimately progress to death. It’s a heartbreaking condition. Bluebird Bio comes up with something that, by the way, was an alternative for kids who didn’t have a matched sibling donor. So, it was really expanding the number of people who could be treated. Now they’re seeing down the line, which is... By the way, it was fairly effective. Eighty percent of the people treated with this were perfect, were continuing to do well during follow-up and weren’t manifesting the problems here.

Then now, like you said, 7 or so of 67 patients had developed this years later, years later. I think many people would make this trade. Even though this is a devastating complication, I think it would be a mistake for the FDA to take this out of circulation. But at the same time, this is something that’s a challenge to figure out what’s causing this, how can we prevent it and mitigate it, and what can we do for these individuals? But it’s a really great example and a tragic one where something that turned out to be quite good ends up something that has long-term complications. But those are treatable cancers too.

Howard Forman: Exactly, exactly.

Harlan Krumholz: At least there’s a shot for people to be able to be cured of those.

Howard Forman: I hate to put it in these stark terms, but as a society, we are going to learn so much from every one of these kids that is being treated because we’re learning more about how the cancers are induced because they’re doing genotyping every time it happens to figure out what went wrong and then we’re learning how to treat it. We will probably get better, not just for this genetic disease, but for others in the future. So, these kids are really contributing to science as they’re also being treated.

Harlan Krumholz: They’re being given a shot. They’re being given a shot that they wouldn’t otherwise have.

Howard Forman: Absolutely. So, what else? What do you got, Harlan?

Harlan Krumholz: All right. Well, I’m going back to AI. I’m going back to AI. So, I want to talk about one of the most influential minds in artificial intelligence. I’ve raised this before with you about Jeff Hinton. Remember I talked about the New Yorker article where they did the interview and he’s had this remarkable career. So, here’s the interesting thing. He just won the 2024 Nobel Prize in Physics for the work he did, which was foundational to the work that we’re seeing today with ChatGPT and all the large language models. I mean, he was one of the pioneers here, but here’s the twist. The man who helped pioneer AI is also now warning the world that his creation could pose serious risks to humanity. So, lots of people call him the Godfather of AI.

He along with John Hopfield won the Nobel Prize for this work on artificial neural networks. This is the technology that drives modern AI systems like ChatGPT. Hinton’s research has been called revolutionary. I mean people really look to him and that work to opening up this entire field. These systems are everywhere now in your smartphone, medical diagnostics, self-driving cars. But Hinton the visionary has spent the last few years sounding the alarm. Let me just give you an example, Howie, because this really puts it in, I think, relief.

During a recent interview, he was asked about his concern about future AI. He said, this is a quote, “I think we’re at a bifurcation point in history where we need to figure out if there’s a way to deal with that threat.” What threat is he talking about? Well, he believes that AI could develop its own subgoals, objectives that humans never programmed it for and pursue them independently leading to potentially dangerous problems.

Howard Forman: Fully autonomous.

Harlan Krumholz: This is Skynet from The Terminator. For example, if an AI was designed to achieve one task, it might decide that to succeed, it needs to gain more control. We’ve actually already seen this in some examples of the AI. Did you see this example, where what it needed to do was to get someone to get through a CAPTCHA and it deceived someone that it was interacting with to do that on its behalf? So that human could give it access to a program. He’s compared AI’s rise to the Industrial Revolution saying, “Instead of machines exceeding human strength, we now have machines that can surpass our intellectual abilities.” He said, “We’ve had no experience of what it’s like to have things smarter than us.”

I’m going to end on this one. Here’s one of those more chilling quotes. It’s not inconceivable that AI could wipe out humanity. So, I’m only saying this because this is the guy whose work spawned this stuff has been now honored with the 2024 Nobel Prize. It’s not a crackpot. He was within Google. He was working on a lot of stuff. He quit and he’s walked away. Anyway, I think it shines a light on this tension between the excitement, and I have a lot of excitement about what this can do for good, but also the need for us to be able to monitor carefully what’s going on and how we can best ensure that there aren’t any unintended adverse consequences. I think about Ines and Sophia and Tobias who are working with us or just finishing college. What are they going to see over their lifetime?

Howard Forman: I know, I know.

Harlan Krumholz: How will this evolve, and what will they be doing to ensure that this becomes a tool for good, ensuring humanity is able to optimize the benefits from it, but not in any way become victim?

Howard Forman: Not to mention that the implications for the workforce, even if it doesn’t destroy all of us, the implications for the workforce become enormous as well. Because so much of what is highly skilled, what students at Yale trained to do are probably things that are replaceable in the not-too-distant future.

Harlan Krumholz: But also this is coming up even in discussions with a union who says, “Do not automate our tasks.” Well, I think that’s going to be an impossibility in the future. So, the question is, what are we doing to retrain? What opportunities do people have? It’s a fascinating future. So, anyway, I thought, congratulations to Geoffrey Hinton. We should probably listen to him also as he expresses his concerns.

Howard Forman: Yeah, absolutely. I’m going to give this one really to you, Harlan. I’m going to ask you a question. I told you about this in advance so I’m not surprising you with it. But a group of investigators in Canada looked at publicly reported payments to reviewers of manuscripts to some of our most highly prized journals and found to nobody’s great surprise that a large percent of them had received payments from industry, some for research, but others for giving lectures or attending events, etc. I bring this up mostly to ask you how you think about this, given that you are now an editor of a deservedly highly respected set of cardiology journals.

Should this concern our listeners that while peer-reviewed authors have much to disclose as to potential conflicts of interest, the standards for reporting by often anonymous reviewers—not anonymous to the editor, but anonymous to the people who read the journal—are much, much lower? What should we be thinking about that?

Harlan Krumholz: Well, thanks for bringing this up. I have been concerned as I took on the journal, that maybe too much power was being given to the reviewers in the sense sometimes the associate editor who may been handling the manuscript may not have deep expertise in that particular area, finds two reviewers and feels the need to yield to them because they have gaps in their own knowledge about where this is placed in the field. One thing that we’ve done at JACC is to say, “I want to bring in more voices, more people participating in the reviews.” So we have our editorial board, we have our reviewers, and now we’re growing large numbers of consultants.

So, we’re doing rapid interchange with, as these articles come in, with the notion that the more people involved, the more eyeballs on a particular paper, the more points of view that are out there. It places something in the proper context. It gets you away from the idea that somebody’s got bias. It could be biased because of relationships with industry. It could be biased because they’re in a fight with someone. It could be biased because it threatens one of their core beliefs. There’s lots of ways that bias can manifest themselves.

What’s important is that we cherish reviewers, we cherish their input, but also, we’re bringing in more voices of people with expertise, so that we can place in perspective what might be an understanding of who’s on what side and what views do people hold. In the end, as a journal editor, we’re really trying to judge based on what we see in front of us. How important is the question? How relevant is it to patients and clinicians and to the field and how well have they executed on it? To what degree are they presenting it in a way that makes the case or at least advances the field? So whether you’re famous or not, I want to suspect that everyone’s got some bias, and in a way, we want to just be able to evaluate what’s in front of us and get a lot of different input.

But the transparency is important. I think that in medicine, it is very important that you understand what relationships people have, but whether you have them or not, almost everyone’s got certain biases about what they think is true. So, as journal editors, it’s important for us to maintain our focus on how well have they done what they’ve got and how important is that question to readers in the field.

Howard Forman: Also, just for our listeners to know, peer reviewers do really a tremendous service to their profession and to society by doing what are almost exclusively free work for these journals. For me at least, I’ve learned a lot by being a peer reviewer. I find it satisfying, but nonetheless, it’s always a substantial amount of time for something that has a relatively low reward factor.

Harlan Krumholz: I’d like to think it’s for the field. It is for the journals, but it is trying to use your expertise to help elevate the science and the field, help journals make good choices about what’s worth progressing to publication. But yeah, it’s a big issue. I mean, I think reviewers need more credit. There need to be more visible credit in academia for that community service. There’s no question about it.

Howard Forman: Good. What do you got next, Harlan?

Harlan Krumholz: Yeah, I just wanted to highlight a paper that our team published in JAMA Network Open this week led by Jeremy Faust and Benjy Renton. That was on a topic that has been at the forefront of discussion since the pandemic began, which was that of racial and ethnic disparities, the degree to which racism and social determinants are dictating massive differences in risk of succumbing to the virus. What we found was examining more than 10 million deaths that occurred during the entire public health emergency. So, this represents the most comprehensive look at the public health emergency.

We analyzed all-cause mortality rates, meaning we looked not just at deaths that people attributed to COVID, but whether or not there were excess deaths overall during the time of the pandemic because there was a lot of misclassification. It was hard to tell. This includes ones that get labeled or don’t get labeled. But we’re asking the question, “How many more deaths occurred than would have occurred had the pandemic not happened because we’re projecting based on historic norms?” Then we’re looking at different groups to see how that excess mortality varied by whether you were a Black person or a Hispanic person or white person, Asian person. The disparities are really stark, Howie.

Across all age groups, American Indian and Alaskan native and Hispanic populations suffered the greatest relative increases in mortality. When we really look in on working age adults aged 25 to 64, it’s even more alarming. We found that American Indian and Alaskan native people in this group had 45% more deaths than expected. Hispanic people, 40% more than expected compared to pre-pandemic periods. Then I’m going to quote you something, even more Black people in these younger age groups represented only 14% of the American population. Fifty-one percent of the excess deaths occurred in this group.

If you look at the overall population, if the excess mortality rates of all these groups had only been at the level of white people in this country, which, again, were elevated, of course—every group experienced excess mortalities. But if instead of far exceeding that excess mortality in the white population, it had all been the same, we would have saved 252,000 excess deaths. They could have been prevented if the rates had been the same as in the white population. So, the real question is what have we learned from this? People have been talking about disparities. We’re now really highlighting the absolute numbers of deaths.

By the way, over 23 million years of potential life lost during the pandemic as a result of this, overall. These disproportionately affected these communities of color. Have we learned, if we have another pandemic, what we’re going to do to prevent this disparity in excess death? By the way, we’d want to eliminate excess death in general. But what we did was, we had elevated in one group and massively elevated in other groups, especially affecting younger people. Howie, we got to figure out a way to address this. We didn’t do a good job. We didn’t do a good job.

Howard Forman: No. It was so obvious right from the beginning, and it may have gotten slightly better as the interval went over. At least that’s what I’ve heard, but it was horrible throughout.

Harlan Krumholz: I’m not seeing any plans to say what we would do differently. This is what disturbs me.

Howard Forman: No, I worry about that as well. Let me give you one quick one before we go, Harlan, if you will.

Harlan Krumholz: Yeah, please.

Howard Forman: So the Kaiser Family Foundation issues an annual report on employee health benefits. I may have even mentioned a couple of weeks ago, and I usually give a full update on it. But today because we’re pressed for time, I’m just going to look at one single factor that they looked at because it’s relevant to what you and I talk about, and that’s GLP-1 drugs again. That’s the tirzepatide and semaglutide that we’ve talked about so many times. Twenty-eight percent of the largest employers now cover GLP-1 drugs for weight loss. Meaning not for diabetes.

Harlan Krumholz: Say that again. What percent? What percent?

Howard Forman: Twenty-eight percent of the largest—

Harlan Krumholz: Only 28%. Only 28%. Wow.

Howard Forman: Yeah. Meaning that they don’t require other conditions. Weight loss alone can be the condition, but these firms also are telling us in advance they’re worried about the cost, and the majority of them are already trying to contain the utilization by either requiring case management or enrollment in a weight loss program or a fitness program or something similar. I just highlight this because we’ve talked about from a society perspective, how expensive this is. We have not talked about how employers might respond to this.

You’re going to see every employer trying to figure out how to thread this needle properly, so that they can help their employees be healthier, take advantage of the incredible benefits of these drugs, but also not break the bank on their health benefits. I’m sympathetic to them. I know that it’s nice to say that they should pay for everybody that might benefit from it, but I also know that it’s very expensive. Ultimately, it does come out of total compensation. Wages are suppressed when we spend more on benefits. So, it’s a data point that helps us get started on thinking about this. We’re going to get more data over the next few years about how employers approach GLP-1 drugs.

Harlan Krumholz: Now, I think it’s interesting, FDA-approved for people with obesity, which we’re now appreciating as a disease associated with more than 200 other diseases, and yet the vast majority are not covering it.

Howard Forman: Correct.

Harlan Krumholz: By the way, more than 100 million Americans could benefit from these medications, given that obesity affects 40% of the U.S. adult population. This is something we’re definitely going to have to deal with. It’s something to keep an eye on. I think it’s unfortunate that there’s so many people who could benefit but find it financially untenable because of the current situation. That’s it. Hey, I just want to get in one last quick recommendation. Can we do it?

Howard Forman: Yeah, of course.

Harlan Krumholz: So people want something to read. I just wanted to point them to a very quick read in JAMA. There was A Piece of My Mind, it’s a section of JAMA where there’s personal reflections. Someone wrote a piece called “So Visibly a Mother: The Emotional Balance of Parenthood in Medicine.” This was a very reflective piece by Dr. Emily Pinto Taylor, a really powerful narrative that explores this often-invisible balancing act of being both a mother and a professional in what really is a demanding field. She really reflects on a moment when a medical student thanked her for being so visibly a mother.

This comment, I think, resonated deeply with her as she describes motherhood as being something she always felt pressured to keep in the background throughout her career. It couldn’t be something to talk about how our profession could do so much better to support mothers. There’s a need for us to be thinking about how we can structurally fix it. It’s personal to me for lots of reasons, but not the least of which is that my daughter’s a medical student and is pregnant and also reflects to me on what that’s like and the pressures that she feels in the way in which our profession treats her.

Howard Forman: I agree. I will say in radiology, where people are able to read studies while they’re pumping milk, it has always humbled me that so many people do that and that we don’t even make it easier for people. So, that I find people having to find the room where you could lock a door. We do not have a system in place that accommodates... It shouldn’t even be accommodating, but allows women to just be at the stage of life that they’re in when they have infants at home or neonates at home. We’re not good at it. I mean, there’s a lot of people that think “paternity leave,” “maternity leave,” they talk about “leave.” We should be thinking about how people can live in their jobs while being a mother or father immediately after birth.

Harlan Krumholz: So for anyone who’s balancing a career and family life, this piece I’m just going to refer you to. It offers, I think, a profound reminder that we don’t need to hide these parts of our identity. It’s a moving and thoughtful reflection. I really recommend it.

Howard Forman: It’s a great piece. By the way, Harlan, congratulations on the birth of, I think, your fourth grandchild.

Harlan Krumholz: My fourth grandchild.

Howard Forman: Congratulations. That’s great.

Harlan Krumholz: So, so excited. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

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

Harlan Krumholz: We want to hear your feedback, like we said at the very beginning. Tell us about your experience. Give us your questions. We always read your reviews and it also helps others find us.

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

Harlan Krumholz: Health & Veritas is produced by the Yale School of Management and Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and our producer, Miranda Shafer. Talk to you soon, Howie.

Howard Forman: Thank you very much, Harlan. They are great. Talk to you soon.

Harlan Krumholz: Oh, my God. I forgot to add that part. They are amazing.

Howard Forman: They are amazing.

Harlan Krumholz: But thank you very much, guys, and we’ll see you next week.