Wolfram Goessling: Lessons from the Other Side of Cancer

Transcript

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. Our guest today is Dr. Wolfram Goessling. But first, we like to check in on current hot topics in health and healthcare. Harlan, what do you got today?

Harlan Krumholz: Yeah. Well, first let me say I’m really excited about our guest, our new—it’s hard to still say “new,” he’s been here for a little bit—chair of medicine, just a terrific person, wonderful scientist, and a person of great wisdom and stature. But look, I want to talk to you about something we’ve brought up before on previous episodes. So, this is something happening in Utah right now that I think is going to matter much more than many people realize. I don’t think enough people are really tracking this story. This, again, another AI thing, you know how much I’m on AI stuff. But this isn’t about AI helping doctors write notes, summarize charts, listen in the room, and all this stuff. It’s not even about AI helping with diagnosis, like for what we call “decision support.” This is about a state creating a pathway for AI to participate directly in prescribing medications to patients.

And this isn’t in some theoretical way. It’s in-real-world pilot that’s already underway. So, again, I’ve mentioned this before. Utah’s partnered with a company called Doctronics to test whether an AI system can handle one of the most common tests in medicine. It’s a routine thing. It’s just renewing prescriptions for people. And this is annoying for a lot of people. You got to call or you do…A lot of times MyChart can handle it, but you got to renew prescriptions. Think about how much time it takes in clinical practice. If you add up all those minutes, staff follow-up, physician sign-off, all this stuff, and it’s repetitive. It seems like it’s primed for AI. So, on the surface, this makes a lot of intuitive sense. So, why not automate it? But here’s where it gets interesting and where I think there’s something to learn.

Utah didn’t just approve a tool. They created what’s called a “regulatory mitigation agreement,” essentially a sandbox where certain rules can be relaxed to test new approaches. They’re leaning into technology like that. And in this agreement, the agreement that they had with this company, the state explicitly allows the AI system to authorize prescription renewals—not to suggest them, not to tee them up for physicians, not to draft them—authorize them. So, we’ve talked about autonomous systems within medicine. This is the beginning because it’s interacting with the patient and it’s acting, but even more striking, and I think this is what we should be paying attention to, the state agreed, listen to this, to forego enforcement of certain laws that would normally define this as practicing medicine, as long as the company followed simple rules that it had put down for the pilot. That’s a huge step.

So, we’re not asking here whether or not AI is simply helping clinicians. This is where it’s actually providing an envelope of activity, where it can be actually doing something and saying, “We’re not going to call it practicing medicine to renew a prescription.” And let me just say, if you look at the list of prescriptions that they can renew, they didn’t pick sort of simple, entirely safe things. It’s a long list of medications that are quite complex and cover a wide range of clinical conditions. So, the system is structured in phases. In the beginning, every AI decision is reviewed by a physician. So, this Doctronic starts out with a physician checking what it’s doing, overseeing it. But then there’s a phase where physicians review decisions after the fact. And eventually the idea is the system performs well enough, moves to more limited sampled oversight, but is actually acting on its own.

So, there are lots of safeguards. There’s—from an engineering perspective, it’s quite sophisticated. But to see things like anticoagulants like apixaban and rivaroxaban, drugs where dosing and monitoring really matter. Antiarrhythmics like flecainide, steroids like prednisone, these are medications where context matters, and yet we’re going to put this in the hands of the AI. And so, this has made clinicians very uneasy, not just because of the technology but because of how this decision was made. In this case, the medical board in Utah was not involved in the approval process when the pilot launched. They found out after the fact, and now they’re raising all sorts of concerns about safety, oversight, and accountability, which is really what was in the news this week as the Utah board stood up and said, “What’s going on here? You didn’t consult us. Who gets to decide when AI is ready to take on parts of medical practice?” And by the way, like I said, Utah’s describing this as “We’re not even going to call it medical practice because we don’t want it to be overseen by the regulations that do that.”

So, on one hand, Utah’s created a situation where innovation can move quickly, generate real-world data, solve real problems, but it’s also raised a lot of questions, raised some hackles, and it’s going to raise this question of what is safe enough before deployment. And the most practical question of all, if something goes wrong, who’s responsible? The company, supervising physician, the state? These questions are all going to be hanging out there. So, anyway, I think this is something worth paying attention to. I was surprised when I first learned Utah did this, and I’m mixed about it because on one hand, I want to see these pilots go forward. And like I said, this is built so clinicians are overseeing it in the beginning. On the other hand, the medical community has to be brought along with this, where else there’s going to be a big fight and that in the end slow us down.

Howard Forman: Yeah. There is a pain point for patients. I mean, patients want to get their prescriptions refilled, and they don’t necessarily want to have to go into the doctor’s office every time. But I do think there’s a middle ground where physicians are actively included. And if you want to use AI to inform the physicians about which patients are higher- or lower-risk for follow-up, do it, but you got to at least address the pain point as well.

Harlan Krumholz: Yeah. And this is a situation too, but what kind of error rate are we going to tolerate? Physicians aren’t perfect.

Howard Forman: That’s right.

Harlan Krumholz: The health system’s not perfect, currently.

Howard Forman: That’s right.

Harlan Krumholz: So, what standard are we going to hold it to? So, stay tuned to this. Hey, let’s get to our interview. This is going to be great.

Howard Forman: Dr. Wolfram Goessling is a physician-scientist and the Ensign Professor of Internal Medicine at the Yale School of Medicine. He’s also the chair of the Department of Internal Medicine, Chief of Internal Medicine at Yale New Haven Hospital, and physician in chief for medicine across the Yale New Haven Health System. Dr. Goessling is a Pew Biomedical Scholar whose research focuses on understanding how the liver develops, repairs itself, and gives rise to cancer. His lab was among the first to use zebrafish to identify biological pathways and molecules that could lead to new treatments, and he has worked with the Framingham Heart Study to help identify genes linked to liver and kidney disease. He earns his MD and PhD from the University of Witten/Herdecke in Germany, completed his residency, including serving as chief resident in internal medicine at the Brigham and Women’s Hospital and fellowships in medical oncology at Dana-Farber Cancer Institute and gastroenterology at the Massachusetts General Hospital.

Harlan Krumholz: Well, I want to ask Wolfram what he thinks of Howie’s German. How did he do on the pronunciation?

Wolfram Goessling: I was impressed.

Harlan Krumholz: Yeah.

Wolfram Goessling: Thank you, because typically people swallow that last E in the city where my university was, so I’m impressed.

Howard Forman: Let’s just say that it didn’t come naturally. I had to learn it. I’m not going to take too much time. Before coming to Yale, he was the chief of gastroenterology at Massachusetts General Hospital and the Robert H. Ebert Professor of Medicine at Harvard Medical School. Now, that’s the reductive bio. Let me expand on this a little bit. He is a trumpeteer. He is a scholar. He is a mentor. He is a much-loved teacher.

Harlan Krumholz: You mean he plays a trumpet, not that he’s a Trumper.

Howard Forman: He’s not a Trumper. He’s a trumpeteer.

Harlan Krumholz: Okay. Trumpeteer.

Howard Forman: He’s more awards than we can fit in this intro. And he’s somebody who has written a book and participated in an extraordinary documentary about his own courage and experiences with cancer. And we want to get to talk about the department, your research, your hopes and dreams for Yale, but I just want to start off by asking about you. How are you today?

Wolfram Goessling: Thank you, Howie. And thank you for that very kind introduction. I’m doing well. Thank you.

Howard Forman: So, I’ve watched the documentary, and we’re going to put it in the show notes. To me, it is the most compelling experience I’ve had watching any film, honestly. I was compelled to watch it. I never got up and I was able to watch it, even though it’s in German with English subtitles. And I learned a lot about you, about your family. And I also learned a lot about how cancer is treated in America and the challenges and the progress we’ve made. What are the biggest lessons through these 13 years that you have now been a survivor of a generally lethal cancer?

Wolfram Goessling: Yeah, that’s a good question. And just for background, when I was diagnosed with this super rare cancer that was in my face called angiosarcoma 13 years ago, things were going really well. I had a young lab, I had a young family, I had really just started my career and things were great and I had almost no worries. And this really stopped me dead in the tracks. And I think what, back then and today, I think one thing it taught me is that I probably already had resilience in me. This was one situation when I was forced to show it, but also to really see who in my environment, in my community at work, how many people were there to root for me, to help me. And that was really amazing. And I came back and come back from this experience really with a feeling that I have deeper friendships and also appreciate life. And really every day a new special gift. And with that, also feel like every day counts, and I want to make it count.

Harlan Krumholz: I want to just come on top of Howie just to pause for a second on this documentary and what you’ve been through. People talk about this paradox of bad things happening, but actually good things happening too because of the change in the perspective. You’re kind of alluding to that. I mean, how do you seize each day? I mean, is it something that on one hand you want to say, “I kind of don’t want to be aware of because I want to just live my life,” or is it something that you say, “I can’t not be aware of it, and it’s how I manage it.” I’m just curious how that works for you.

Wolfram Goessling: Yeah. No, I think that’s a really good point. There are days when I would like to ignore it. I mean, you see my face. I can’t escape the reality of what I’ve been through. It’s literally written in my face, but at the same time, I do think it is something and the experience, (a) it helps me really galvanize my energy and my focus. And then what you said, Harlan, about making that film is cancer amongst all the diseases that really affect us and our patients still has stigma and anxiety attached to it. And so, I felt in making that movie or contributing to it is if I could just help one patient or one family member to find strength and hope, that already was enough. And I do think that gave me resolve and strength to actually open up and tell that story.

Harlan Krumholz: So, one thing that’s interesting to me since you’ve come, you really have had a major impact. And anytime I talk to people about you, you know what they say? They go, “Oh, Wolfram, he’s a great guy.” You’ve come in here with some vulnerability. I mean, in a sense you didn’t come in, guns blazing, “I know what I’m going to do.” You came in saying, “I want to listen and learn.” And you really have accomplished a sense of... these transitions aren’t easy. People get used to people. Gary Desir’s a great guy too, and he led wonderfully for a long time, and then there was a transition. And you’ve just managed this so well. When you looked toward coming to Yale, how did you plan for that? Because you’ve been so successful at Harvard. You had such a long and illustrious career.

I know from other people I’ve talked to in Boston, you have strong supportive relationships, people who care deeply about you. Had a lab that was going great. So, then you make this big change. How did you prepare for it? What was going through your mind as you thought, “I’m going to step into this new position?”

Wolfram Goessling: Yeah, it’s an interesting question, Harlan, because I’m definitely not someone who I think ever had a 10- or 15- or 20-year master plan. And so, I approached this transition pretty much as I approach my everyday in that whether I see a patient or whether I sit with some of my lab members and discuss data or plan experiments, and that is, what’s right in front of me is sort of both the most important and the most informative. When we sit at a patient’s bedside and we listen to them and their stories and their symptoms, it is that information and combined with our experience and knowledge that enables us to do the next step. And so, as I was thinking about coming to Yale, which I was and still am both excited about and grateful for, I sort of had that same plan and anticipation in that there’s only so much you can plan ahead.

I didn’t know any of you. I didn’t know any people in my own... very few people in my department. And I felt like, “I’ll go there with everything that I have and I know and I’ve experienced and I’m just going to do the same.” And I sit down and listen and try to meet people and learn about both the symptoms and the issues and the complaints that we as individuals and maybe as sections and department have, and then respond to it.

Howard Forman: Harlan has taught me an awful lot over the years about making sure that there’s a relationship built between the physician and the patient about decision-making and shared decision-making in general. And when I watched your movie, it was brought to very sharp relief because there are several different scenes where discussions are about “How far do you want to go with certain types of treatment?” And they even talk about playing the trumpet and the effect it might have on your lips. And that was striking to me about like, these are real decisions. And here’s a doctor who’s been advising people, you’re a trained oncologist, you’re a researcher, you’re a hepatologist. How has that changed your feeling about how you deal with patients, or were you always very patient-oriented? I mean, it’s hard to ask that question because we all like to believe we always were this way, but having gone through my own fairly catastrophic medical problems, I changed a lot. I wonder how you feel about that.

Wolfram Goessling: Yeah, I hear you, Howie. So, the day I found out about my diagnosis, as I said, I was in full swing, including having a busy clinical practice focusing on liver cancer patients. And my administrator at the time, who I told about my diagnosis because I needed to find my colleagues to take care of my patients. And she said, “Wolfram, this will make you a better doctor.” And I responded, “I do think I’m a good doctor, and I didn’t sign up for an extra class to become a better one.” But I do think in retrospect and with the experience that I’ve made myself is... as you go through a process and the path of illness as a physician, I think you see things that you always thought you knew, but you actually didn’t ever really thought about and experienced.

And so, the experience, as you highlight, Howie, making therapeutic decisions for me, but obviously guided by and ultimately anchored by my treatment team, made me realize how often I might have said things to patients, fully wanting for them to understand what I was trying to say, but that they may not have received that message. One critical example for me was we had a group meeting with all my physicians in one room, which I think was a huge privilege for me to have that and talk to my radiation oncologist, plastic surgeon, primary care doctor. They were all in the room. And afterwards, it was a two-hour meeting and we laid out the entire treatment plan for the next three months. And I left the meeting somewhat despondent and said to my wife, Helle, who was there with me, “Now we spend two hours to talk about how I’m going to die.”

And she said, “No, no, no. We talked two hours about that you’re going to live.” And I had completely misunderstood, misinterpreted, and misjudged the outcomes of these meetings. And I’m educated and in the field, and I think I was so emotionally distraught that I didn’t actually understand what was being said. And that is, to me, one of the biggest revelations or experiences where I feel all of us, when we talk to patients, obviously we want to make sure that they understand us, that they understand what the plans are and the outcomes. And we do our best, I think, every day to do that. And here I was, and I was surrounded by these experts who all cared about me deeply and that didn’t get through to me or I didn’t hear them, what they said.

And so to me, making sure that our patients understand what we say, I think has become really important. And so what I do now, and I have changed in that, that before a patient leaves my office, that I summarize what I think is going on, and then I have them say it in their words, what they take home from what’s going on. And it takes extra time, takes extra effort, but it’s also, it’s one extra way to make sure that we stay connected.

Harlan Krumholz: That’s just extraordinary that the teach-back approach, where you’re asking them to recount what their understanding is, is an extraordinary thing to incorporate but also to internalize for yourself that I think I often think that in that moment, it can be impossible for patients to truly listen because there’s so much anxiety, there’s so much fear, there’s so many things going on in their head that somehow we need to find ways to circle back out of the context of them visiting us, but finding other ways because it explains why so many times we’re talking to our colleagues and saying, “I just don’t understand why they didn’t understand me. I said it as clearly as possible.” And it’s because it’s not just about words being transmitted, it’s about emotion and everything else that’s on that person’s mind. You expressed it so beautifully.

Let me... It’s a little bit related. One thing that Howie and I talk a lot about on the program is how fast medicine is changing. And it’s not changing and tacking toward necessarily the high-touch side, more toward the high-tech side. And you have immense responsibility in training the next generation. I mean, you actually have broad responsibility for training both scientists and clinicians and sometimes clinician-scientists, but on the clinical side, people graduating medical school often say, “I don’t know what their life is going to be like in 10 years.” I mean, there’s going to be so much that’s changing. How are you thinking about how this department should be preparing people for a future that’s unfolding in real time just before them now? And we’re at such an important inflection point that everything’s hard to predict, but how are you thinking about that from an educational point of view?

Wolfram Goessling: Yeah, that is a hard question and an important one. And the good thing is, as we make predictions about the future, no one will remember what I said. So, I can…safe and be wrong, but I think, Harlan, as you highlight, we are changing on so many aspects in medicine. It’s not just new drugs and new technology. And I think what our trainees today experience is definitely a different environment and world than maybe all of us have experienced during training. And certain aspects I think are really for the better in terms of work hours and a more measured approach to responsibility. We had a grand rounds last week by one of our outgoing chief residents, who talked about how we used to teach procedures at the bedside and how we should be much better and more deliberate and safer going forward. So, there are definitely aspects, I think, in medical training where we have evolved and are more methodical about how we teach and what we teach.

But on the other hand, and I think what you’re alluding to is, there’s certain aspects where maybe the way our field is changing is not linear, right? It may be not so easy to foresee what treatment paradigms and practice settings may even look like in five years. What’s the technology we are going to use? Are we going to see people in person? Are we going to only see them on-screen first? And how we prepare our learners, our trainees, our students, our residents and fellows for that. I do think, and maybe this will come across as old-school, and I could definitely be wrong on this, but to me, and I’ve said this out loud to everyone around me because I really believe this, and the wisdom as we take care of our patients really comes from the bedside. It comes from both the interaction that we have with our patients, making that connection that we talked about earlier, and really making an assessment of what is going on with our patients.

And that part cannot change, in my mind. We might change the media with which we connect with our patients, certainly patients who live in hard-to-reach areas in this country that may not always have the ability to see their physician in person. It may be aided by technology that can give us additional information in real time as we interact with patients. But at the baseline, I think medicine is really a connection between two people, one, the caregiver, and the patient. And I hope we can emphasize and highlight that enough and continue to do that here at Yale as we train the next generation.

Howard Forman: Speaking of training, your background, your training is so unique. You have a PhD, you’re board-certified in oncology and gastroenterology. You are working in hepatology, looking at the liver and looking at disease of the liver, and specifically you’re looking at diseases that right now are taking off in the world because of alcohol-related liver disease and other metabolic related liver diseases. Those lead to inflammation, those progress to things like cirrhosis, and that can then progress to hepatocellular cancer or liver cancer. I’m amazed at how you prepared yourself so well for a world that really does have this vast need for both the research to get answers as well as treatments for people that currently have it. Can you speak to two things, then? One is, how did you have this prescience to prepare yourself that way? Because nobody else has. And then where do we go with this right now? Do we need more people trained that way?

Wolfram Goessling: Well, I’ll tell you the honest story rather than the one that is the retrospective story on how we always make the right decisions when we look in the rearview mirror. I always loved the liver from med school. I wanted to understand how the liver works and functions. And when I started my training, residency training, it was clear to me and my program director and the GI chief that I was going to go and do a GI fellowship. And we had an intense oncology experience in our residency training. And one night, three, four months into my internship, I was on bone marrow transplant and I was on call overnight and sat down with a young woman, a teacher, a mother of two who had just received a bone marrow transplant for leukemia. And we were talking about life and her desire to be alive and see her kids.

And I knew nothing about bone marrow transplants, but I did sit by her bedside and held her hand. And that morning I came out of that bone marrow transplant unit and I thought, “That’s what I really want to do, hold people’s hands when they’re in crisis.” And I wanted to be an oncologist. And then I realized gastroenterologists can’t give chemo and are afraid of chemo, and oncologists are afraid of icterus and the yellowing of the eyes. And so, I figured I needed to understand both. And it has served me well. It gave me another year really at the bedside and understanding and learning about my patients. And that was a privilege and a gift. Although I did oncology first and my second year starting on July 1, I started gastroenterology and our oldest daughter was born on July 6th of that year. And as I went to start my second fellowship, my wife asked, “Can you remind me again? Why are you doing that and what the importance of that is?”

So, you could also say that maybe I just couldn’t decide what was more important. And so, here we are. I do think our approaches to patients, and I think I’m by far not the only one, people have trained in different specialties or specialties to understand the diseases of their patients better or give more specialized care. But on the other hand, I also think in the last 20 or so years, we as a field have realized how important it is to come together and share our opinions and our experiences and approaches and provide a team approach to patient care in a much more cohesive way than maybe we’ve done before. So, I’m not sure everyone.... You know, you can put that training on multiple shoulders and probably achieve a similar or better outcome.

Harlan Krumholz: I want to go back a little bit just to your experience with healthcare on the patient side, because as Howie was asking you to reflect on what did it do to change you, but how about your view of American healthcare? Because there’s an idealized view where actually things work well and when they work well, they’re beautiful. I mean, you do have this connection with another doctor or with a team, but even for us who are privileged as being within healthcare, when we or our loved ones are intersecting with the healthcare system, not necessarily with the single person, but with the system writ large, we run into headwinds that also we don’t perceive well when we’re clinicians because we’re kind of doing our piece but we’re not recognizing the kind of headwinds that our patients are experiencing at every different turn. How’s that made you think about what we need to do and did you have lessons for all of us to think about, about how we need to change what we’re doing at a system level?

Wolfram Goessling: Yeah. Harlan, this is a difficult and a loaded question. And as I look outside the window across to our School of Medicine, there’s probably also a lot of people who may have different opinions on this one, but I’ll tell you how I think about this. So, as a patient, and I certainly had that, right? As a patient you’re in crisis. You may not understand how fast you need help. I mean, I did, but you need an answer. And sometimes that answer doesn’t need to be, “Oh, you need surgery tomorrow or you need to start chemo the next day.” The answer can also also be, “I think you’re fine and if I see you in six weeks, you will still be fine.” But having that answer is not always available. I do think from a... our health and healthcare system is in crisis and I think that’s undisputed.

And I used to think, having grown up in Germany, that maybe it’s just the way we have organized healthcare, and maybe if we had just one-payer healthcare, it would be the answer. And I do think I look at my home country, Germany, I look at a country like the UK with a nationalized healthcare system, they’re in crisis too, right? And access to healthcare and problems within... it’s not unique to New Haven and Yale and Connecticut or the United States. It’s really a problem that different healthcare systems with totally different setups all struggle with. So, a problem that big, how can I possibly have a solution for that? I do think though from a patient perspective, I feel the need to have that next step in a plan and that next step can be, “You need surgery in three weeks.” That next step can be, “I’ll make an appointment, and I’ll call you back tomorrow afternoon when I have the answer.” I think it’s that short, that feedback to know that the next step is possible, I think is key.

And I also know that therein lies the huge challenge. One, on some of my productive days, I feel like what I’m really doing is I’m like a scheduler-in-chief because many of our colleagues, Harlan, as you alluded to, have the same problem accessing our healthcare system. And so, I often feel if we can’t even be our best for our own colleagues, and this doesn’t mean to give privilege or preferential care, it’s more like these are our colleagues we care about and we can’t even be at our best for them. How can we ever be at our best for our patients? And so, I feel we need to find system solutions where we can be at our best for both our colleagues and any patient who we have so that they feel... we do care about our patients. I know that, but that they actually feel that we care about them.

And I do think for us as a system level to see some of the data that we have in terms of how long does it take on average to make an appointment in a specialty, they may not give the personal experience of a patient waiting for that answer and that appointment. But some of those data may inform us about the enormity of the task and also help us to see where we have made progress. So, I do think we have to hold ourselves accountable on some of these metrics to make sure that we’re moving in the right direction.

Harlan Krumholz: And to make sure we find the right metrics. I love the idea about accountability and then the idea of the broad base. Sometime I’ll come talk to you. I’ve got these ideas about how we can transform the quality metrics from... and I was part of a lot of this, but we took a turn from implicit to explicit review. And what we did in that was become very reductionist in what we collected. We defaulted to variables and case report forms to pull out information from the chart and we tacked away from holistic assessments of, actually were we responsive? Did we exhibit a true caring environment? Did we help them to make the decisions that were aligned with their preferences, values, and goals? And I think we can find a path back and the technology can help, but if we continue to just measure productivity or just to focus on things that are easily measured and quantifiable outside of what we know still is meaningful, then we’ll be in the wilderness still.

Wolfram Goessling: And just to highlight that, Harlan, and I didn’t mean to say, just because we can measure some easy metrics that they are (a), the right metrics to do, but also that what you said about productivity has really stuck with me. And I’ll tell you this one story, if you allow me. When I had a recurrence of my cancer five years ago and I needed another cancer surgery in my face, I had a CT scan five days before, just to make sure that I didn’t have any metastatic spread and that I was ready to go for surgery. And it turns out on that CT scan, I had acute appendicitis and needed to go in the middle of the pandemic with a COVID test that delayed my surgery, needed to go and have emergency appendectomy. And my cancer surgeon stayed with me during that entire surgery, looking through the laparoscope to inspect all the surfaces of my internal organs and the omentum.

And his point was that he could see better with his eyes than any CT scan could, whether there were any micro seeds of metastases in my abdomen. And he also, for his own learning, wanted to see how I was on checkpoint inhibitors at the time, how internal organs look under checkpoint inhibitor therapy. Now, the fun fact is, this was a four-hour surgery. I had a difficult positioned appendix retrocecally, and it was hard. And he stayed for that entire four hours. He had no measurable productivity, right? There’s no RVU associated for a surgeon being in the OR just looking and watching his colleague take the appendix out. But to me, it was the epitome of both caring and academic pursuit that I think we all need to remind ourselves is important, right? That we do things that matter to our patients that make us better for the next patient. And I think that’s one of the key aspects of what we do in academic medicine and in patient care.

Howard Forman: Before we wrap up, I do want to follow up on the trumpet, because you were a longstanding member of the Longwood Symphony Orchestra at Harvard or in Boston. I want to know, are you still doing that, or do you play down here? Have you joined the Yale Medical Symphony Orchestra yet, or?

Wolfram Goessling: Yeah, it’s a good question. So, full disclosure, right now I’m not playing in an orchestra and it is life is real and these transitions are real and it has been the transition to come to Yale has taken a lot of energy and time. And it’s also energy and time that I’m willing and eager to spend. And so, we had planned, my wife, who plays violin in that orchestra, we had planned to take a year and settle and not be active in that communal and organized way. Turns out, and you mentioned it earlier, right? I had 10 facial surgeries and my trumpet playing is not like it was when I was in my twenties, and that’s okay, but it’s still fun. And it’s also turns out, great physical therapy for my face. And so, I do play and I enjoy it. And I have both eagerness and optimism (a), to connect to other musical colleagues here at Yale and do continue to make music.

Howard Forman: That’s great. Well, we are so lucky to have you. I mean—

Harlan Krumholz: And you’re making great music with the Department of Medicine. I just want to tell you that it’s metaphorically, but you’re making great music with us. We appreciate it.

Wolfram Goessling: Thank you.

Harlan Krumholz: Thanks for coming.

Howard Forman: Thanks very much.

Wolfram Goessling: Thank you so much for having me. This was really fun. It was fun to talk to you.

Harlan Krumholz: Thank you.

Howard Forman: Oh, he’s incredible.

Harlan Krumholz: Like I said, people say, “Oh, Wolfram.” That’s what I got to say. “Oh, Wolfram.”

Howard Forman: He’s great.

Harlan Krumholz: Terrific individual. He’s doing a great job at Yale with the department and we’re really fortunate. We’re really fortunate to have him.

Howard Forman: For sure.

Harlan Krumholz: All right. Hey, Howie, let’s get to your section, one of my favorite parts of the podcast. What’s on your mind this week?

Howard Forman: This is a quick hit. Between 2007 and 2013, Finnish investigators Sihvonen and colleagues randomized 146 patients age 35 to 65 who had knee pain but no radiographic evidence of osteoarthritis. They didn’t have clinical arthritis, just pain. They were assigned to either arthroscopic partial meniscectomy, partial resection of the injured meniscus or sham surgery in patients where arthroscopy identified a defect in the meniscus. And importantly, all patients underwent arthroscopic examination regardless of their assignment. So, when I say sham surgery, it’s not as alarming as it might sound. They all had a scope inside their knee to begin with. So, now, 10 years later with follow-up, the findings hold, just as with the results published in the original trial in 2013, there is no statistically significant benefit from this widely used procedure. In fact, looking at the direction of findings, even without statistical significance, the meniscectomy group had a higher likelihood of subsequent knee replacement, higher likelihood of clinical knee osteoarthritis, and a lower likelihood of being free of knee pain, both at rest and after exercise.

The one category where sham surgery appeared worse was the likelihood of needing a repeat arthroscopy. But again, that difference was not statistically significant either. The authors rightly concluded that we should continue to question the efficacy of this procedure. And I’d add, when someone asks where we can find savings in healthcare costs, consider this. Roughly 700,000 of these procedures are performed every year in the United States at an estimated cost of $4 billion annually. That might be one of the first places worth looking.

Harlan Krumholz: 700,000 for this indication.

Howard Forman: And there’s no evidence that it works. Now, look, maybe there are subgroups where it does work, but we’re having a hard time finding that in large data.

Harlan Krumholz: And what’s the argument people make for persisting with this?

Howard Forman: I mean, my understanding is that basically you have a problem, so you see this meniscal defect, and I think most orthopedic surgeons that do this probably believe that in their hands by selecting specific patients, they can make you feel better. And sure enough, almost anything gets better at a certain rate no matter what you do. And that’s what this control shows.

Harlan Krumholz: Yeah. So, it just gets to where does the preponderance of evidence.... Do you have to prove benefit, or do you have to prove no benefit? But a lot of us think when you’re talking about procedures, you should have to prove benefit.

Howard Forman: Expensive ones. Yeah.

Harlan Krumholz: That’s extraordinary. Extraordinary. Thanks for bringing that, Howie. That’s an amazing... it’ll be in the show notes. People should take a look at it. It’s just amazing.

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 any of social media, including our dedicated Instagram account.

Harlan Krumholz: Yeah. And we love your feedback. We’ve been calling this a listener challenge. Everybody just give us a little bit of feedback. Come on to the sites where—

Howard Forman: We appreciate it.

Harlan Krumholz: ... the podcast is posted. It helps people find us, gives us information. We appreciate it.

Howard Forman: Health & Veritas is produced with the Yale School of Management at the Yale School of Public Health. To learn more about Yale SOM’s MBA for Executives program, visit som.yale.edu/emba, and to learn about the Yale School of Public Health’s Executive Master of Public Health program, visit sph.yale.edu/emph.

Harlan Krumholz: And a hat tip always to our superstar undergraduates, Gloria Beck, Donovan Brown, Tobias Liu—Tobias is about to graduate sometime soon—to our fantastic producer, Miranda Shafer, and I’m always grateful to be able to work with the best in the business, Howie Forman.

Howard Forman: Thanks very much, Harlan. Right back at you.

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

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