Reunion Kick-Off with Khullar, MD '14 and Forman, MD

Transcript

• 00:00Good afternoon.
• 00:05Welcome everybody.
• 00:06I'm sure we will have stragglers.
• 00:07I'm Nancy Brown, Dean of the School
• 00:10of Medicine since February 1, 2020,
• 00:12which means that I'm in my 4th year,
• 00:15but it's all been fairly compressed
• 00:17by this little thing called COVID.
• 00:19So this is our second in person
• 00:23reunion and the weather has
• 00:26cooperated and great turnout.
• 00:28We're expecting a big number and
• 00:30so really glad that you're here.
• 00:33I'll share that tomorrow morning at
• 00:35I think 9:30 I'll be presenting a
• 00:37state of the school so that you can
• 00:40hear a little bit about what we're
• 00:42up to and you'll I hope for take of
• 00:45all the other events and tours as
• 00:48well to see what's going on here.
• 00:51I'd also encourage you to explore New Haven.
• 00:53It's changed a lot becoming sort of
• 00:56the IT city and attracting young people
• 01:00who aren't even affiliated with Yale.
• 01:02So it's it's really terrific.
• 01:05I want to thank you for your support,
• 01:08particularly those of you who are volunteers.
• 01:11It makes a huge difference.
• 01:13It makes a difference to our
• 01:15current students,
• 01:15and we'll talk more about that as well.
• 01:18And I'll be sharing with you some
• 01:21introductions tomorrow of some
• 01:23new of a new alumni liaison whom
• 01:26you'll have an opportunity to meet.
• 01:28You have been very generous over the
• 01:32years and I'll tell you that since July 2018,
• 01:36the gifts from our alumni total
• 01:39about 4.6 million,
• 01:42much of that focused on financial
• 01:44aid for our students and we are well
• 01:47on our way to making Yale School of
• 01:49Medicine debt free a priority for us.
• 01:52And so thank you for that as well.
• 01:59So now I'd like to introduce our
• 02:02guests and starting with Drew Coolar,
• 02:05who is a class of MD,
• 02:08class of 14 and left us to go up north
• 02:13to MGH and Harvard Medical School,
• 02:16but where he also received a
• 02:19degree from the Kennedy School,
• 02:22a Masters in Public Policy.
• 02:23And Drew has been very engaged in
• 02:28the Center for Public Leadership
• 02:30in thinking about policy around
• 02:36professionalism. In particular,
• 02:38he's recognized by LinkedIn as among
• 02:42the top ten healthcare professionals
• 02:44under 35 or was recognized as that.
• 02:47I I I think we should just say it.
• 02:50You know that that's true because
• 02:52by the National Minority Quality
• 02:54Forum as 40 under 40 in leadership.
• 02:57So we'll keep going up as the age
• 03:00goes up and a number of other awards.
• 03:04I I think you had a chance to see some
• 03:07of his articles from The New Yorker and
• 03:10other and and medical journals as well.
• 03:12Gemma, New England Journal.
• 03:15Thinking about topics from
• 03:17professionalism and burnout,
• 03:19and particularly thinking about the impacts
• 03:22of COVID-19 beyond the pandemic itself.
• 03:24But in terms of how we
• 03:28how we respond to those stresses
• 03:31and what implications it has
• 03:34for everything from economics to
• 03:37how we train medical students,
• 03:41conversing with Doctor
• 03:42Cooler will be our own.
• 03:44Doctor Howard Foreman and Howary
• 03:46is something of a fixture here,
• 03:49not just here in the School of Medicine,
• 03:50but across the university.
• 03:53Sharing truly in one single person.
• 03:56Embodying our collaboration
• 03:58directs the MDMPH of MD, MB.
• 04:01A program also has a rule in
• 04:03the School of Public Health,
• 04:05obviously a a role in the
• 04:07Department of Radiology.
• 04:08He cohosts a podcast
• 04:10called Health and Veritas,
• 04:12and I've had the privilege of
• 04:15participating in that podcast and I
• 04:17will tell you he's probably the most
• 04:20prepared interviewer I've ever had.
• 04:23He's worked in the US Senate as a
• 04:25health Policy fellow on Medicare
• 04:28legislation and a constant proponent
• 04:31of evidence based responses to COVID.
• 04:34So I'm gonna stop talking and
• 04:36let these two bright minds
• 04:40stimulate your thought as well.
• 04:41So thank you
• 04:42very much. Thanks very much and
• 04:48really, sincerely thank
• 04:49you all for being here.
• 04:51And feel are we on? Yep. Okay.
• 04:53And let me just say that we're
• 04:55going to have time for questions.
• 04:57So if anybody has questions,
• 04:58just sort of at some point put your hand
• 05:00up and I'll make sure I get to you as well,
• 05:02because we want this to be
• 05:04as interactive as possible.
• 05:06First, I just want to thank
• 05:07Drew for doing this.
• 05:09I've known him for I think about 15
• 05:11years now or something in that range
• 05:12because I first met him right in
• 05:14between college and and medical school.
• 05:16He went to Yale College as well.
• 05:19And I just want to say that his career,
• 05:21you can't even capture it in a
• 05:24simple introduction because he
• 05:25has been very thoughtful about
• 05:27how to prepare himself to have a
• 05:30career in both communicating the
• 05:33way we think about medicine,
• 05:35the way we think about healthcare,
• 05:36how we can improve healthcare,
• 05:37but also doing the scholarship that informs
• 05:41our decision making around healthcare.
• 05:43And he's also a practicing clinician
• 05:45as well and he is well worthy of being
• 05:48the the best selling writer that he is.
• 05:50And we're really fortunate to have him here.
• 05:53I want to just start off by talking about
• 05:56this role that you've taken because you know,
• 05:59you're nine years out of here,
• 06:0110 years out of your original
• 06:03graduating class.
• 06:04You went to the Kennedy School to
• 06:06get this public policy degree.
• 06:07You started writing at a very early age.
• 06:10You're a grant funded researcher
• 06:12in an academic department and
• 06:14you practice clinical medicine,
• 06:16but your writing really touches the
• 06:18soul of individuals by pointing
• 06:20out the challenges,
• 06:21whether it's about COVID misinformation
• 06:24or whether it's about something like
• 06:27the end of the pandemic and and why
• 06:30that is and is not good for people.
• 06:33How did you know so early on that
• 06:35this is what you wanted to do?
• 06:36Like tell us a little about what
• 06:38what informed your decision making
• 06:40at each step of the way.
• 06:42Yeah I I just,
• 06:43I just want to start by saying how,
• 06:45how special it is to come back to Yale.
• 06:47And I'm sure all of you feel the
• 06:49same way and you know been in a
• 06:51number of different places at this
• 06:52point and different institutions.
• 06:53But every time I come back it just
• 06:56reminds me that this is a place
• 06:58that it is really special and has
• 07:00helped me in my journey and and
• 07:02helped countless other people.
• 07:04And I would be remiss if I didn't
• 07:05say that how we is one of the
• 07:07people that really has helped me
• 07:08do the types of things that I want
• 07:10to do in my career and give me the
• 07:12encouragement to do so and so.
• 07:13So I I want to start by by
• 07:16acknowledging that you know,
• 07:18I I it's hard to say exactly
• 07:23when I think about the path.
• 07:24It wasn't actually something that
• 07:26I have been thinking about and had
• 07:28it all sketched out ahead of time.
• 07:30I think you know Steve Jobs who
• 07:31said it's much easier to connect
• 07:33the dots looking backwards than
• 07:34forwards and that certainly has
• 07:36already been the case for me.
• 07:39I think I always had a sense
• 07:41that I love clinical medicine,
• 07:43but I also wanted to think about
• 07:45the system around medicine and
• 07:47why we are either able to provide
• 07:50excellent quality care or less
• 07:51than excellent quality care.
• 07:53And what are the determinants
• 07:54of those things.
• 07:55And once you start,
• 07:56you know, looking into that,
• 07:57there's an endless number of
• 07:58things that outside of the hospital
• 08:01room contribute to our ability
• 08:04to care for people in the way
• 08:05that we want to care for people.
• 08:06And so for me,
• 08:07that was kind of the the motivating
• 08:09force and and took me to the Kennedy
• 08:12School to to try to understand
• 08:13some of the policy levers there.
• 08:15I took a number of writing classes.
• 08:17I looked up to people like Oliver
• 08:19Sacks and Atul Gawande and
• 08:20and to Darth the Mukherjee.
• 08:22These people who I thought so
• 08:23beautifully were able to capture
• 08:25what it meant to be a doctor,
• 08:27but also communicate both the
• 08:29challenges and the joys of the
• 08:33profession to a very broad audience.
• 08:34And so that has been something
• 08:36that that I've tried to start
• 08:38doing in my own career,
• 08:40I will say just as an aside.
• 08:41So I've had conversations with Vivek
• 08:44Murthy when he first came to Yale,
• 08:47with Mandy Cohen when she first came to Yale,
• 08:49and with you and a lot of other
• 08:51people as well, but three people
• 08:53that you may be familiar with.
• 08:54Mandy Cohen was just nominated
• 08:55to be head of the CDC yesterday.
• 08:58And I do want you to know you're
• 08:59in the category of Mandy Cohen
• 09:00knowing what you wanted to do,
• 09:02like my memory of what you wanted
• 09:03to do aligns very well with this.
• 09:05Vivek Murthy, on the other hand, not at all.
• 09:09He has turned out to be an
• 09:10amazingly compassionate physician,
• 09:11but he never mentioned Surgeon General,
• 09:13never mentioned public service
• 09:14even at that time.
• 09:15So I do want to credit you
• 09:17with actually knowing that you
• 09:19wanted to go in this direction.
• 09:20We had that conversation
• 09:22about a public health degree,
• 09:23a public policy degree or a
• 09:25business administration degree
• 09:26very early on in your time here.
• 09:28And you chose wisely,
• 09:29as they say.
• 09:30And you started writing with some really
• 09:32senior smart people in the field.
• 09:34And that informs some of the
• 09:37stuff that you've worked on.
• 09:39All of you have come through
• 09:41the sort of medical industrial
• 09:43complex one way or another.
• 09:45And one of the things that
• 09:47I've observed and perhaps been
• 09:48embarrassed of a little bit over
• 09:50the last 15 years or 16 years is
• 09:53that when I teach my undergrads,
• 09:55you know,
• 09:56starting when Obamacare was passing,
• 09:57I started saying we're going to be moving
• 10:00to a value based healthcare delivery
• 10:02approach away from volume towards value.
• 10:05And I said this emphatically
• 10:07because everybody I talked to is
• 10:08telling me that and when I had my
• 10:10one chance to sit in the White
• 10:12House and opine on that topic,
• 10:14that's what we all said.
• 10:15So it must be true.
• 10:17And now 1516 years later,
• 10:20we are still very much a volume
• 10:22based healthcare delivery system
• 10:24and you've written a lot about
• 10:25this and I'm just wondering what
• 10:27your thoughts are as to what
• 10:29might be the trigger to help us
• 10:31really make more of a move toward
• 10:34population health improvements,
• 10:36value based care as opposed
• 10:38to a volume based system.
• 10:40Yeah, it's a great question.
• 10:41I mean when I was in medical school was
• 10:42when the Affordable Care Act was passed.
• 10:44And so I very much bought into
• 10:46the idea that valuebased care,
• 10:48accountable care organizations,
• 10:50all these changes in the
• 10:51healthcare delivery system,
• 10:53we're going to solve healthcare in some way.
• 10:55And if anything over the past 10 years I've,
• 10:57I've just recognized the need for humility
• 11:00when when you approach an enormous,
• 11:02you know several trillion dollar
• 11:04industry and and think that there's
• 11:05going to be one solution that that
• 11:07that moves us in the right direction.
• 11:09You know, I think you and I have
• 11:11talked about the fact that you
• 11:13know valuebased care seems like an
• 11:15important part of the solution.
• 11:17I mean the alternative of having only
• 11:20fee for service medicine has gotten us
• 11:22to kind of the place that we are now.
• 11:25On the other hand,
• 11:26you know you really have to squint to
• 11:28look at the successes for valuebased payment.
• 11:30I mean,
• 11:30there are some certainly successes,
• 11:33but the challenges of measuring quality,
• 11:35of incentivizing things at a
• 11:38national level are are astronomical.
• 11:41And so you know a lot of this comes
• 11:44back to the idea for me at least,
• 11:46of approaching these things with humility,
• 11:49having pilot projects,
• 11:50creating the evidence base through
• 11:53probably randomized trials of
• 11:55these policy interventions before
• 11:57you roll them out more broadly.
• 11:59And and you know,
• 12:01in a way it's a good lesson that I
• 12:04think there has been some progress
• 12:05but but certainly nowhere near,
• 12:07I think what I thought was going
• 12:09to be the case in 2009 or 2010
• 12:12whenever we started on this journey.
• 12:14So,
• 12:14and Speaking of humility,
• 12:16your writing is infused with humility.
• 12:19Like you talk about things without
• 12:22judgment and you're you give people the
• 12:26substance to to think about tough topics.
• 12:29And I'm wondering,
• 12:30in a time where misinformation and
• 12:33even disinformation is so pervasive and
• 12:36everywhere around COVID, to this day,
• 12:39the amount of misinformation that is
• 12:42believed to be fact everywhere is so deeply
• 12:45entrenched in a part of the population.
• 12:48But you will continue to
• 12:51put out deeply thoughtful,
• 12:53lengthy pieces that require
• 12:54an enormous amount of effort.
• 12:56Trying to push back on that,
• 12:58Can you tell us a little about both from
• 13:00your writing as well as from your research,
• 13:02What can we do to counter the the
• 13:05epidemic of misinformation out there?
• 13:08Yeah, It's another great question.
• 13:09I mean, I think the first thing to say is,
• 13:12you know, one of the reasons that
• 13:14I love writing is because I I
• 13:15always feel it takes me to a more
• 13:17thoughtful place than where I started.
• 13:18So my first inclination is always
• 13:20something that is more judgmental
• 13:22than I would like it to be.
• 13:23It's less, it's more simplistic
• 13:26than I think it needs to be.
• 13:28There's a lot of sloganeering that we
• 13:31hear and and and infuse my thinking.
• 13:33And then over the course of weeks or months,
• 13:35when you're putting together a a piece,
• 13:37you're talking to people that
• 13:38are affected by the issue.
• 13:39You try to understand both sides of it.
• 13:42I always feel like I I end up,
• 13:44you know,
• 13:44whatever version ends up on paper
• 13:46is much smarter than than than
• 13:48whatever version starts in my mind.
• 13:50And so that's,
• 13:50that's one of the reasons that I love it.
• 13:53You know, the idea around
• 13:54misinformation I think
• 13:54is both old and and new.
• 13:56I mean this information yellow journalism,
• 13:58these things have been around forever.
• 14:00And in a way we're better suited to
• 14:03address these things because the ease
• 14:06with which we can access true information.
• 14:08Now the question of like how do you
• 14:10determine what is true and what is
• 14:12not true in a world where motivated
• 14:14actors want to spread mistruths
• 14:15is a really challenging one.
• 14:17And I think it's going to get more
• 14:19challenging in a world where large
• 14:21language models like chat GB T are able
• 14:24to drop the cost of misinformation to zero.
• 14:27You know if in the past a, you know,
• 14:30non state actor or an adversary
• 14:31wanted to meddle with a US election,
• 14:34we actually had to have people coming up
• 14:37with misinformation and putting it out
• 14:39there now you know the cost of doing that.
• 14:42It requires no people essentially
• 14:44and it requires no money.
• 14:45The other thing that I want to point
• 14:48out is I think we we think a lot about
• 14:50misinformation as a function of social media.
• 14:53But there are traditional media
• 14:55organizations that are on cable news
• 14:57that do much more and have broader
• 15:00viewership that also contribute
• 15:02to the spread of misinformation.
• 15:05I don't think anyone has,
• 15:06you know, a real solution to this.
• 15:08I think the surgeon general has put out,
• 15:10you know,
• 15:11reports on the effects of social media
• 15:14as well as calling misinformation
• 15:16a public health issue.
• 15:18I think some of it has to do with media
• 15:20literacy and starting early with that,
• 15:22you know, in elementary school,
• 15:24in middle school,
• 15:25helping people understand the sources
• 15:27that are that are trustworthy and
• 15:29those are that are less trustworthy.
• 15:31I think having you know,
• 15:33one of the reasons I like doing what
• 15:35I'm doing is because I think it is
• 15:37important for people have voices that
• 15:39they trust and that they can go to
• 15:41and that help them tune out and and
• 15:43and sift through all the information
• 15:45that exists because there's more
• 15:46than any one person can go through.
• 15:48But if you,
• 15:49if you feel like you trust a few
• 15:51institutions and a few individuals,
• 15:52maybe you can get get get kind of
• 15:54most of the way there in terms of
• 15:56putting together a coherent picture
• 15:57of the world. So
• 15:59you're also a new father and that
• 16:03changes the way you look at the world.
• 16:05I mean, for anybody who's been a parent,
• 16:08it changes how you look at the
• 16:09world and how you think about and
• 16:11even the questions that you ask.
• 16:12And you mentioned the certain generals
• 16:14report on the impact of social
• 16:17media on youth and adolescents.
• 16:18And I'm wondering,
• 16:19does that start to inform what
• 16:21you want to write on?
• 16:23Have you already started to formulate
• 16:25your own thesis on what your children
• 16:27should and should not be exposed to?
• 16:30How is that change your world?
• 16:31But most of the
• 16:32way that's changed,
• 16:32the way I see the world is,
• 16:34is through kind of bloodshot
• 16:36eyes after sleepless nights.
• 16:38So that's the first thing I think,
• 16:40but the, you know, I think
• 16:45so in one way.
• 16:46I'm I'm grateful for the time my my
• 16:49children are at one and almost three now.
• 16:51And so I I feel badly for the half
• 16:54generation before for before mine,
• 16:57because we really did not understand
• 17:00how problematic the always onlineness
• 17:02of growing up in an environment
• 17:04where all your information
• 17:06comes from the digital world.
• 17:08You're always comparing yourself
• 17:09to people not in your immediate,
• 17:12you know, school or environment,
• 17:13but people who are glamorous somewhere else.
• 17:16The expectations that we put on people
• 17:19have taken it an enormous toll on
• 17:22the mental health of of teenagers.
• 17:24I think because of the good
• 17:26research and the journalism,
• 17:28the advocacy of people,
• 17:29people are starting to understand
• 17:31that this is an enormous problem
• 17:33and starting to take steps.
• 17:34I think you know,
• 17:35at least the way that I approach
• 17:37or will approach my, you know,
• 17:39when my children are of the age
• 17:40where they're using social media,
• 17:42I think it'll be a much different
• 17:44approach than people took in the past.
• 17:47You know, I think we,
• 17:48you know what we're trying to do at least is,
• 17:50is make seeing people in person cool again.
• 17:53I mean that that feels like
• 17:54the the most important thing.
• 17:56I mean I've never met anyone.
• 17:58Maybe you aside, how we that I've
• 18:00liked more online than than in person.
• 18:02Everyone is a less good
• 18:05version of themselves online.
• 18:07They're snarkier.
• 18:07They put people down.
• 18:09They are less thoughtful in
• 18:10the way that they engage.
• 18:12And so I think, you know,
• 18:13it's not like you can wave a
• 18:15wand and and make this happen,
• 18:16but I think the more we
• 18:18spend time with one another,
• 18:20the better.
• 18:21And that also gets back to
• 18:22the misinformation point,
• 18:23which is the reason that
• 18:25misinformation can thrive is
• 18:26because people are mistrustful of
• 18:29institutions and people around them.
• 18:31And so the more you are able to engage
• 18:34with people in a 1 to 1 interaction or
• 18:36A1 to several interaction the better.
• 18:38I mean Mass General where I where
• 18:40I trained during the pandemic,
• 18:41they started doing virtual town
• 18:43halls for vaccine misinformation
• 18:45and they would have,
• 18:46you know 50,
• 18:47maybe 100 patients who were patients
• 18:49of the of the Mass General and
• 18:51they would host these town halls
• 18:53and you know they didn't do some
• 18:54type of evaluation of that program.
• 18:56But I have to assume that that
• 18:58type of trust building in one's
• 19:01community goes a long way to to
• 19:04making sure that you have the trust
• 19:05you need to address the next crisis.
• 19:08And and Speaking of that,
• 19:09so we're at a point right now
• 19:11where as I mentioned Mandy Cohen or
• 19:13graduate of just about 20 years ago,
• 19:15now maybe 18 years ago is nominated
• 19:18to be the head of the CDC.
• 19:20And you know that is one of the
• 19:24hardest jobs in the country right now,
• 19:26despite the fact that it was led by
• 19:29an evidence based infectious disease
• 19:30physician who is deeply committed to the job.
• 19:33Trust in the CDC is lower than it's been.
• 19:36Trust in our institutions are really lower.
• 19:40When you're writing your pieces,
• 19:43do you, do you think about what
• 19:46advice can you give us as citizens,
• 19:49as people who work in medicine,
• 19:51about how do we specifically rebuild
• 19:53trust in the institutions themselves,
• 19:55in Yale, in Yale, New Haven Hospital,
• 19:58in Cornell and so on?
• 20:00Yeah. I mean, I think, you know,
• 20:02we often ask, you know,
• 20:03how do we rebuild trust?
• 20:04And I think that the first kind of
• 20:07thing I always think about is is,
• 20:08you know, gaining trust requires being
• 20:10trustworthy and being a trustworthy actor.
• 20:12And and so, you know,
• 20:15focusing on that is kind of the first thing.
• 20:18And I think one of the.
• 20:19You know, there were a number of
• 20:22stumbles obviously early in the
• 20:23pandemic from the administration
• 20:24and the CDC and other public health
• 20:27leaders that that were challenging.
• 20:28I think throughout the pandemic.
• 20:29I mean communication was a really,
• 20:32you know,
• 20:33difficult thing to do and I'm not
• 20:36saying that that that it's easy.
• 20:39I mean anytime there's a fast moving
• 20:42public health crisis where the data change
• 20:44from day-to-day and from week to week and
• 20:47what was right before is not right now,
• 20:49that is an incredibly difficult
• 20:51period in which to to communicate.
• 20:54I think acknowledging the
• 20:56uncertainty is really important.
• 20:57I think acknowledging that
• 20:58this is the first draft,
• 20:59this is our best effort at at
• 21:02putting out what we understand
• 21:03to be where the evidence is,
• 21:05I think is really important.
• 21:08But, but you're right,
• 21:09I mean trust in institutions and
• 21:11in public health agencies has has
• 21:13kind of cratered over the past,
• 21:14I guess 50 years,
• 21:16but particularly during the pandemic.
• 21:17And so it's a,
• 21:19it's a really challenging thing
• 21:21to try to reverse.
• 21:22I know Rochelle Wilensky,
• 21:24the previous director put in place I
• 21:26think four or five principles to try
• 21:28to regain the trust of the public.
• 21:31They're all things that sound really
• 21:33good in theory that you can't argue with.
• 21:35But whether or not they translate
• 21:37into concrete change, I think,
• 21:39you know Mandy and others will.
• 21:40We'll have to see through.
• 21:42When you look back at what you've written,
• 21:44actually quite a lot.
• 21:45I mean, if people go and look at
• 21:47all the publications you've had,
• 21:48you've written a lot for somebody
• 21:50who's effectively 9 years out of of our
• 21:53school and six years out of residency.
• 21:55Are there any pieces that you look back
• 21:57on with any level of regret or are there
• 22:00any specific pieces that you're so
• 22:01proud of because you wrote it patiently?
• 22:03Because I can point to pieces
• 22:05that were patient,
• 22:06but I'm just curious what you think of
• 22:10you know there I mean regret I I think
• 22:14I probably did the same things that a
• 22:16lot of other folks did was was more sure
• 22:18about things that I should have been.
• 22:21I mean one example that comes to
• 22:22mind is breakthrough infections.
• 22:23And I think early on was quite confident
• 22:26that we would not have the level of
• 22:29breakthrough and disease that would come
• 22:31after full vaccination and had written
• 22:33pieces to that effect and that was,
• 22:35you know, turned out to be incorrect.
• 22:37So I think that that that's something
• 22:38that very clearly comes to mind.
• 22:39I think, you know,
• 22:40the pieces that I'm proud of are kind of
• 22:44deeply reported pieces about what people,
• 22:46individual people were going through.
• 22:48I think that is where I felt like some
• 22:49of the writing was distinguished.
• 22:51And so I I did a profile of a trauma
• 22:55surgeon who had been through kind of
• 22:57months of intense ICU care during the
• 23:00the midst of the pandemic and developed
• 23:04PTSD and had a really challenging time.
• 23:06And I think it's not that all clinicians
• 23:08who went through that experience
• 23:10had the level of PTSD that she did,
• 23:13but I think it resonated and it gave
• 23:15some voice that leads to the fact that
• 23:18a lot of clinicians put themselves in,
• 23:20in challenging situations or were
• 23:21put in in challenging situations,
• 23:23not always with the level of
• 23:25institutional support that they deserved.
• 23:27And so.
• 23:27So that's that's one that kind of
• 23:29comes to mind in terms of something
• 23:30that that I was proud of.
• 23:32I want to open it up for questions
• 23:34and just put your hand up.
• 23:35If you have a question,
• 23:36I'll go and just tell us
• 23:39your name so that we it was
• 23:51well accepted by the
• 23:52community and by my parents.
• 23:54And in questioning how did
• 23:55we did we have more trust?
• 23:57If so how did we lose the
• 23:59trust from years ago?
• 24:01Yeah. You know, I always thought
• 24:03that vaccine hesitancy had to do
• 24:05the fact that we didn't have,
• 24:06like younger people today didn't
• 24:09have to contend with polio.
• 24:11And so it's very easy to talk about a
• 24:14disease that seems abstract and and
• 24:15not want to take the vaccine for it.
• 24:17That also turned out to be very wrong.
• 24:19You know, you could see your
• 24:21neighbors dying and and still
• 24:22have a level of vaccine hesitancy
• 24:24that that kind of appalled me.
• 24:27So the first part of the answer is that yes,
• 24:30I mean trust.
• 24:31If you look at trust in medical leaders,
• 24:33for instance,
• 24:34in the 1970s around the time of Watergate,
• 24:37I mean 75% of the public said
• 24:39that they had very high levels of
• 24:41trust in healthcare institutions.
• 24:42That number today is in the 20s or 30s.
• 24:45So that is true of the media.
• 24:47That is true of government.
• 24:49You know,
• 24:50I think there's a lot of factors
• 24:51that are involved in that.
• 24:53One is simply the fact that we have
• 24:55access to many other sources of
• 24:57information than doctors or healthcare
• 24:59institutions about our health.
• 25:01And so in the past if you wanted
• 25:02to know something,
• 25:03most people would would have a
• 25:05provider of some sort that would
• 25:07give them that information.
• 25:08Now you look online, you,
• 25:09you know talk to your your friends,
• 25:11you have social media,
• 25:12all sorts of things contribute to
• 25:14the way that you, you, you, you,
• 25:17you understand your own healthcare.
• 25:19I think another part of it is
• 25:21back in the 70s and 80s things
• 25:23like conflicts of interest weren't
• 25:25weren't as widely recognized.
• 25:26I mean, I think in the 90s and early 2000s,
• 25:28people started to think about
• 25:30healthcare leaders differently,
• 25:31in part because they felt that
• 25:35at least some proportion of them,
• 25:37but their care was dictated by
• 25:39the incentives.
• 25:40I think there's been a tremendous
• 25:42amount of corporatization of medicine.
• 25:43And so in the past, you know,
• 25:46there was, I mean now private equity
• 25:48institutions are buying nursing homes.
• 25:50You can imagine how well that
• 25:52that's going to go.
• 25:53But, but more broadly,
• 25:54there's been a tremendous
• 25:55amount of consolidation,
• 25:57massive healthcare systems.
• 25:58You don't have your local,
• 26:00you know mom and pop doctor
• 26:02that that you go and see.
• 26:05And then I think that the final thing
• 26:07I'm there's many other things probably,
• 26:08but the big one that comes to
• 26:10mind is the rising of healthcare
• 26:11costs and the the burden,
• 26:13the financial burden that
• 26:14it places on people.
• 26:15It's very hard to trust the system
• 26:17that with one illness will put you
• 26:19into bankruptcy and you don't have,
• 26:22you don't feel like you have
• 26:23protection against that.
• 26:24Is that the fault of insurers?
• 26:25Is that the fault of the the providers,
• 26:27Is that the fault?
• 26:27I mean people don't really care,
• 26:28right?
• 26:29I mean the fact is most Americans
• 26:31can't pay a an unexpected medical
• 26:34bill and if they have to go
• 26:35fill a drug at
• 26:36the pharmacy that the doctor prescribes,
• 26:37it's going to put them out for a while.
• 26:39So some some some contributors I think
• 26:46plus 63 for the medicine when
• 26:48I trained, all reasons why
• 26:56I did. But right now there's so few
• 27:00people seem to have the primary care
• 27:02doctor and we are doing nothing as
• 27:06the profession really to increase the
• 27:09number of primary care doctors and
• 27:20the intern medicine doing the
• 27:29best we could do for them for a long time.
• 27:31Now each number of people are going to
• 27:35urgent care to be a doc and I I see
• 27:38even though back in 2020 they tried to
• 27:41increase salaries a little bit the gap
• 27:48gets wider and wider between primary
• 27:50care and the sub specialists and
• 27:52no matter what you tell medical
• 27:54students and they can figure out
• 27:56where the money is better than I did.
• 28:08Yeah,
• 28:12I would love to hear your thoughts
• 28:14how we I mean I I myself am
• 28:17a general internist so I also
• 28:19made the mistake that you did.
• 28:21But a couple things,
• 28:24I mean one is the the large and
• 28:26increasing gap between the pay for
• 28:28subspecialties and for general internists.
• 28:30Two is the the status that is afforded,
• 28:34you know different specialties.
• 28:35I mean if you're if you're you
• 28:38know a star subspecialist often
• 28:39you are viewed with higher status
• 28:41than if you're not don't have that
• 28:43level of training or you you are a
• 28:47general insurance like like myself.
• 28:49I think I see things potentially
• 28:52starting to change in some ways.
• 28:54I mean one you know in in my class there
• 28:56were a number of people who ended up
• 28:58going into general internal medicine
• 29:00and in part because they wanted to
• 29:01do other things in addition to it.
• 29:03And so that that that is that
• 29:05is one challenge that a lot of
• 29:08people who now go into general
• 29:10internal medicine are also doing,
• 29:11you know mostly academics or startups
• 29:13or or whatever whatever it might be.
• 29:18You know, I don't know
• 29:19how to reverse the trend.
• 29:21I mean the administrative burden is,
• 29:23is astronomical on on on
• 29:25primary care doctors that the
• 29:28pay is not super high, right.
• 29:30I don't know how how would you? I
• 29:32mean I think the incentives don't align.
• 29:34I mean right now we've set up a system
• 29:37that incentivizes doing volume and doing
• 29:41procedures and unless we really fix that,
• 29:43we're not going to fix everything else.
• 29:45Having said that, there is 10s of
• 29:48billions of dollars being invested
• 29:50in startups including Devoted Health,
• 29:53City Block Health.
• 29:54Amazon just made their acquisition
• 29:55and Aetna made their acquisition.
• 29:58So we're seeing billions being
• 30:00invested in primary care in an
• 30:03effort to disrupt the system.
• 30:05But the underlying economics
• 30:06of it haven't really changed.
• 30:08So I'm not sure that we're any
• 30:11closer than we were ten years ago.
• 30:13But I'm definitely, you know,
• 30:14when reporters ask me about what
• 30:16Amazon's doing, what CVS is doing,
• 30:18what City Block, Alidate and so on are doing,
• 30:21I always say I'm rooting for all of them.
• 30:23Like I I want them to succeed,
• 30:26but there's not been the evidence yet.
• 30:27As you pointed out,
• 30:29with the value based healthcare,
• 30:31you have to squint to see the
• 30:34successes for the moment.
• 30:36There was a question there.
• 30:36And then you Yep,
• 30:39Can you comment on the fact that we all
• 30:45have our desired and trusted sources
• 30:47of information and how do we reach
• 30:50people who have different sources?
• 30:52I had, for example,
• 30:53a friend during the pandemic,
• 30:55the only one who would not get vaccinated.
• 30:58And I felt as a Yale Medical school graduate,
• 31:01perhaps she was not a physician
• 31:03to listen to me. And she did not.
• 31:05And explain to me that she had
• 31:07her quote UN quote own sources and
• 31:10concerns about the history of the
• 31:13autism and vaccines which has been
• 31:17you know you know compudiated and
• 31:19yet you go to the correct sources.
• 31:22And I will not say what they are
• 31:24but I think we all do and I think
• 31:26we all know the people remote them.
• 31:28So there are people I feel like
• 31:30we live in a in a country.
• 31:33I live in a different world than the
• 31:35world that this person does because
• 31:37the information they receive and and
• 31:40don't in my and and critically assess
• 31:42and I was and then she is not the only one.
• 31:45I've had patients say this to me and
• 31:46where I finally have to interrupt
• 31:47them and say
• 31:51need to agree to disagree
• 31:55on with my being able to take care of you.
• 31:56Yeah. I mean I think you know one one
• 32:03part of this is the fact that people
• 32:07don't make decisions based on careful
• 32:09analyses of the risks and benefits.
• 32:11Most of the time most of our
• 32:13decisions are socially determined.
• 32:15You know the people,
• 32:15what the people around us are doing,
• 32:17how our community feels about an issue,
• 32:19what our family and friends have done.
• 32:21And so a big part of this,
• 32:22I mean one thing to note to to the
• 32:24earlier question is that trust in
• 32:26medical leaders broadly has fallen,
• 32:28but people actually have very high
• 32:30levels and trust of their own physician.
• 32:31So if you have your own physician
• 32:33off and that's that's that's
• 32:34a really important part of it.
• 32:35But even in this case,
• 32:36when people have different types of
• 32:38information sources that you feel like
• 32:40you're not able to to get around,
• 32:41I mean part of that,
• 32:42the reason is that they're not analyzing,
• 32:45you know,
• 32:45the number needed to treat in the
• 32:47way that that that we might be 1
• 32:49concept that I found very helpful
• 32:50is this idea of trusted messengers.
• 32:52So every community has people who
• 32:54they look to and they may look
• 32:57to different different sources
• 32:58than than we look to.
• 33:00I wrote an article recently
• 33:01about Francis Collins,
• 33:02the outgoing NIH director,
• 33:04and he's an evangelical Christian.
• 33:06And so a lot of what he wants to
• 33:08do in his post directorship life
• 33:10is focused on this very issue.
• 33:12So he's doing a lot of work
• 33:14with church groups and pastors
• 33:15and going into communities.
• 33:17He's he said he wants to spend
• 33:19whatever you know credibility and
• 33:21capital he has gained over this
• 33:23long career as the scientific mind
• 33:25trying to go into the communities
• 33:27that he feels are his own communities
• 33:30evangelical Christians and trying
• 33:32to increase trust in public health
• 33:35and vaccinations And so are there
• 33:37a lot of trusted messengers in some
• 33:38of these communities probably not.
• 33:39But I think that is the most
• 33:41effective intervention that I've
• 33:43that I've ever come across.
• 33:45David. Yeah I'm David Greene class three.
• 33:49I want to get your thoughts on the
• 33:51disturbing trend that we're seeing
• 33:56largest most eligible population.
• 33:59Of course, we're seeing the
• 34:04hugest number of primary cares
• 34:06going to falls fears medicine,
• 34:08while the population of patients and that
• 34:20looks like increasingly that's
• 34:21becoming the shape of the future.
• 34:24So I want to see what
• 34:25your thoughts are on that.
• 34:26The shape of the future.
• 34:28Yeah. I mean, in a way when
• 34:29I've talked to people who
• 34:31do concierge medicine,
• 34:31I mean some of it is financial.
• 34:33Some of it is at least they say this
• 34:35idea that they're able to practice
• 34:36the type of medicine that they want
• 34:38to practice that they don't feel the
• 34:39same pressures to see as many patients
• 34:42as they as they as they did before.
• 34:45You know I think we to
• 34:46our earlier conversation,
• 34:46I think having a practitioner whether
• 34:49it's a nurse practitioner or a
• 34:51Doctor Who is your primary point
• 34:53person into the healthcare system is,
• 34:55is incredibly it is one of the
• 34:57most important things that that
• 34:58one can have for their health.
• 35:00You probably know the space
• 35:01better than I do in terms of
• 35:03concierge medicine And and
• 35:05yeah, I mean concierge medicine
• 35:06had like a peak very early on and
• 35:08then it's sort of modified itself.
• 35:10That the example of concierge medicine
• 35:12that worries me the most right now is
• 35:14and maybe I'm going to get it wrong,
• 35:16is 1 medical that was on the West
• 35:18Coast that was acquired by Amazon.
• 35:19But that was a level of of a primary
• 35:24care pay your subscription and
• 35:25you can get access to a doctor.
• 35:28But if you're not a member of that network
• 35:30and you're not paying the subscription,
• 35:32and then you're relegated
• 35:33to fending for yourself.
• 35:34And So what it does is it provides a really
• 35:37good level of care for those that have means.
• 35:39We all have means,
• 35:41but there's a huge swath left behind.
• 35:44And quite frankly, to me,
• 35:46one of the biggest concerns is that we've,
• 35:49you know, we're drowning the frog.
• 35:50We're just acclimating to the idea
• 35:52that we do have two tiers of a
• 35:54system right now and that that's
• 35:56sort of acceptable in most locales.
• 35:58I mean, you're you're in New York,
• 35:59which is a great example where you
• 36:01have a City Hospital system operating
• 36:03in parallel with private hospitals.
• 36:06And if you're a poor or underinsured
• 36:09or Medicaid patient,
• 36:10you go to the city hospitals and
• 36:12if you have commercial insurance,
• 36:14you go to Wild Cornell or you go to
• 36:16Columbia or you go to NYU Langone.
• 36:19Yeah. And and the other thing that I think
• 36:21people don't talk about enough is that
• 36:22the city hospitals and public hospitals,
• 36:24they actually subsidize the the,
• 36:26the more private oriented hospitals,
• 36:27right, Because they,
• 36:28they take patients who otherwise would
• 36:30have to be treated in those institutions.
• 36:32And so I don't think that's
• 36:34something that people have fully,
• 36:35fully grappled with. Yep.
• 36:38I'm Carl Mann C and Gro 73.
• 36:40Tell me the difference between valuebased
• 36:43medicine and riskbased medicine.
• 36:47There's a lot of overlap between
• 36:49those two things. I mean, so the,
• 36:51the basic idea behind value based
• 36:53medicine is that you tie payment to
• 36:56some measure of of quality and there
• 36:59are different ways to go about that.
• 37:02And so in the kind of initial
• 37:05version of that, you might just tie
• 37:07a regular fee for service payment.
• 37:08So you do it, you do something
• 37:10and we're going to pay you and
• 37:12we're going to adjust that payment
• 37:13slightly based on the quality or
• 37:15the outcome of that procedure.
• 37:17Let's say that's what the the
• 37:20MIPS program for instance,
• 37:21the Medicare MIPS program is focused on.
• 37:23There's a lot of controversy about
• 37:26whether it does anything that is
• 37:28that that is helpful for patients.
• 37:30The on the other end of the
• 37:32spectrum is kind of full risk,
• 37:34meaning you as an organization or provider
• 37:37care for a population of patients upfront.
• 37:42We will give you the, the,
• 37:44the what we expect this population of
• 37:48patients to cost and you get to functionally
• 37:51keep the difference between what we
• 37:53paid you and what you end up spending.
• 37:55And so you're taking the
• 37:57risk for that population.
• 37:58So if you come in over that,
• 37:59if you spend you know $15,000
• 38:01a patient instead of 10,000,
• 38:03you eat that cost.
• 38:04If you spend 8000 and you know and
• 38:07and we gave you 10,000 per patient
• 38:09then you you benefit from that.
• 38:11You can see how this is challenging and
• 38:13in one way in that it may incentivize
• 38:16people to do less for for their patients
• 38:18because they want to save money.
• 38:20So there are some guardrails around that
• 38:22you have to meet certain quality metrics.
• 38:24You know the ideally the outcomes
• 38:27for those patients are are measured
• 38:29very closely and then there's the
• 38:31additional challenge is the amount
• 38:33that you initially get paid for
• 38:35that group of patients depend on
• 38:37how sick those patients are, right.
• 38:38So if you're a young person
• 38:40with one comorbidity,
• 38:41you know you're not going to cost
• 38:42as much in theory as someone who is
• 38:44much older with many comorbidities.
• 38:46So there's the incentive on
• 38:48the part of the providers,
• 38:50people will say or the insurers to
• 38:52make their population look sicker
• 38:54than they actually are or make
• 38:56them look as thick as possible.
• 38:58So you can see why value based
• 39:00care in theory.
• 39:01At the beginning of this,
• 39:02we talked about how we felt it
• 39:03was really the right thing to do
• 39:05and I still think generally it
• 39:06is the right thing to do.
• 39:07But there's all these ways
• 39:09to game programs that make it
• 39:11really challenging in actuality.
• 39:13And and to that point I would just
• 39:16say like they were series of lawsuits
• 39:19including one against Cigna earlier,
• 39:22a late in last year,
• 39:23I think November of 22.
• 39:25And it just highlighted for
• 39:27me how these companies,
• 39:28you know if you want to make them blameless,
• 39:29you can just say that the incentives
• 39:32line up for Cigna to want to elevate the
• 39:34risk rating of their patient population.
• 39:36So they could collect as much money as
• 39:39possible and ideally they want to spend
• 39:41as little as possible on those patients.
• 39:43Ideally, it's not exactly what
• 39:45you would describe if you were
• 39:47talking about building a a value
• 39:49based healthy healthcare system.
• 39:51But the theory
• 39:52is you know you have this population
• 39:53of patients, we're going to give you
• 39:55this much money and you figure out
• 39:56how best to manage these patients.
• 39:58So in the past you know you only get
• 40:00paid if the patient actually comes
• 40:01in for the doctor's visit and then
• 40:03you bill them and then they now
• 40:05let's say you can do telehealth,
• 40:06you can call them,
• 40:07you can send someone out to their home.
• 40:09This is the theory that you can
• 40:10be more creative in the way that
• 40:12you care for these patients.
• 40:23I
• 40:28would just say about Kaiser,
• 40:29which is always I think I
• 40:30agree with you about Kaiser.
• 40:31Everything I've read, I talk about
• 40:33it a lot when I teach my courses.
• 40:35But Kaiser has the luxury of
• 40:37dealing with a commercially insured
• 40:38population and only takes on Medicaid
• 40:41patients to the extent they want to
• 40:43take on Medicaid patients and same
• 40:45for Medicare Advantage. So it is,
• 40:48it is a different entity and animal,
• 40:50it's an integrated system.
• 40:51But I agree with you.
• 40:52Like if you asked me what I would
• 40:54prefer to have anywhere in the
• 40:55country would be a Kaiser model now.
• 40:57And of
• 40:58course up until two years ago,
• 41:00the CEO was Yale 72.
• 41:03That's right. That's right. Let
• 41:04me go over here and then I'm
• 41:06going to come back around.
• 41:07I think him first and then you Ed
• 41:10Weaver, Class 93 probably value based
• 41:17care. What assumptions did you
• 41:19have then that you realize now
• 41:22might not have been correct that
• 41:24altered how things turned out?
• 41:26Yeah, I think, you know,
• 41:27we all were drinking the kool-aid
• 41:30about how successful Kaiser,
• 41:32Geisinger, even Cleveland Clinic,
• 41:33like each place we would talk about being,
• 41:37look how successful they are.
• 41:38They can do it.
• 41:39Why can't we do it anywhere else?
• 41:41And there are a lot of cultural
• 41:43differences between Kaiser in, you know,
• 41:46Southern and Northern California
• 41:48and Kaiser putting it in Texas or
• 41:51Kaiser putting it in Pennsylvania.
• 41:53And I think what we've come to realize
• 41:55is the culture among physicians and
• 41:57the culture on patients has to align
• 41:59with the system we're talking about.
• 42:01So it's a lot easier said than
• 42:03done because I was one of those
• 42:05people who thought like,
• 42:06why can't we just recreate
• 42:08Kaiser in other places?
• 42:09But easier said than done.
• 42:11That was probably my single biggest point.
• 42:13I don't know if you have other thoughts.
• 42:14I was going
• 42:14to ask you why you feel.
• 42:16I mean is it just the cultural
• 42:18exploitation that's really hard.
• 42:19I mean Kaiser's tried to expand,
• 42:21if not done very well,
• 42:23The Mayo Clinic has tried and in some
• 42:25places and still have some institutions.
• 42:28But is it a matter of you can't
• 42:30just stick the name of this
• 42:32amazing institution on some
• 42:33other place somewhere else?
• 42:34And or like, why?
• 42:35Why is it so hard to expand? I
• 42:37think in Kaiser's situation is that the
• 42:40population actually accepts that care is
• 42:42going to be delivered a different way,
• 42:43That you don't deserve an MRI
• 42:45every time you twist your knee,
• 42:47that you don't have to go into an expensive
• 42:51emergency room every time that you have,
• 42:55you know, an ankle pain.
• 42:56I mean, I work in the emergency
• 42:58room as a radiologist and I read
• 43:00histories basically on every single
• 43:01study and then blown away by what
• 43:03we call an emergency right now.
• 43:05Kaiser knows how to triage that.
• 43:06Kaiser knows how to use their own supply
• 43:11side limitations on care to be able to
• 43:14deliver the most important care of the
• 43:16people that most acutely in need and
• 43:18be able to put people on a schedule
• 43:20for care if they're later in New Haven.
• 43:22If you were to tell somebody,
• 43:24come back in in three weeks
• 43:26and if it's not better,
• 43:27then we'll we'll see you again.
• 43:30They would find a different doctor to see,
• 43:32wait till you come to the
• 43:33Upper East Side of New York,
• 43:35right, Right. Yeah. Yeah.
• 43:36There's another question here and then
• 43:38I'm going to go back there. Yep. So
• 43:41as
• 43:48physicians, we basically do two things,
• 43:50right. We use our cognitive abilities
• 43:53and we also comfort patients.
• 43:55And it seems to me that it's quite
• 43:59clear that machines are going
• 44:00to be able to do both of those
• 44:03functions much better than us. As
• 44:15I guess I would question the premise of
• 44:18the question in that do you think that
• 44:21people will feel comforted by machines
• 44:23in the same way they do as humans
• 44:39are going to have more machines
• 44:43as friends
• 44:56as they are going to have. Yeah.
• 44:57It's I mean it's a really I don't
• 44:58think anyone knows the answer to this.
• 44:59I do know that a lot of people who
• 45:02work on a I place the the likelihood
• 45:04that A I will make humans it's extinct
• 45:07somewhere between 10 and 20% and so that.
• 45:09So it's a very scary kind of
• 45:11thing going forward.
• 45:13You know I used to think or I I my my belief
• 45:16still is I I kind of have three jobs.
• 45:17I write and I do research and I and I
• 45:20practice medicine and I do think that
• 45:22my first two jobs are most amenable
• 45:24to being replaced by by an A I like,
• 45:26I there's not.
• 45:26I do think probably in 10 years an A I
• 45:28can write an article for The New Yorker.
• 45:30You know like I I,
• 45:31I I think that's probably true.
• 45:33Before I talked to you I felt like
• 45:36maybe my doctor job was safe but
• 45:38but maybe I'm wrong about that.
• 45:40I don't know.
• 45:41I mean, I, I, I,
• 45:43I hope that there's still not just
• 45:47not just the comforting role,
• 45:49but there are other parts of medicine.
• 45:52I mean I look at a lot of the patients
• 45:54that I care for in the hospital and I
• 45:56think about how what do they often need?
• 45:58I mean do they do they need the
• 46:01diagnostic acumen of an A I or do
• 46:04they need a lot of them need nursing
• 46:07care and support in that way.
• 46:09A lot of them can't use technology.
• 46:11They they you know they're not
• 46:13able to themselves engage with it.
• 46:15I do think medicine at least parts of
• 46:18it are safer than than than maybe we
• 46:21we we were talking about right now.
• 46:23I I wrote an article recently about a
• 46:26I psychiatry and the and the potential
• 46:29for chat bots to deliver psychiatry
• 46:31and explored a lot of these issues.
• 46:33And my sense is that for the kind of
• 46:37routine things that that we do that
• 46:41are protocolized that yes A I will
• 46:44probably replace those functions.
• 46:46But for I think for a lot of the
• 46:48more sophisticated things that we do
• 46:51that require a certain knowledge of
• 46:54the real world that's further off.
• 46:56But if we were talking six months
• 46:58ago before ChatGPT,
• 46:59I would have we were you know I
• 47:01wouldn't have any idea what to to say.
• 47:03So I don't know
• 47:04I was told 10 years ago that
• 47:06radiologists would be replaced
• 47:08by now and they haven't been.
• 47:10So I think things are,
• 47:12even though it feels really fast
• 47:14right now with ChatGPT and the
• 47:16movements in that direction,
• 47:18I still think we're going to play a role.
• 47:21It's just going to be a very different role.
• 47:22I mean it would be ideal if it be
• 47:24if there was a reliable way in
• 47:27which we could harness that power
• 47:29for people to get the answers that
• 47:31they want from us but that aren't
• 47:34really at the top of our license.
• 47:37But get those answers by going
• 47:39online and feeling comforted by
• 47:41that and using us for the top of
• 47:44license intellectual inputs we have.
• 47:46But how is it so pathology
• 47:49and radiology were or you know have been
• 47:51talked about for a decade now, right.
• 47:52I mean you can a I can figure
• 47:55out a cat versus the dog.
• 47:56They can figure out whatever it
• 47:57is that you you try to figure out.
• 47:59But does a I play any
• 48:01role in your world.
• 48:03What role does it play right
• 48:04now in your. So it helps.
• 48:06It helps with triaging of exams.
• 48:08So it will pick up most
• 48:12intracranial hemorrhages.
• 48:13It'll pick up most fractions
• 48:14of the cervical spine.
• 48:16It's now doing a good job
• 48:18picking up pneumothoresis,
• 48:19rib fractures,
• 48:22pulmonary emboli,
• 48:24large vessel occlusion in the brain.
• 48:26You go to work,
• 48:27does it, does it present these,
• 48:29it presents these you and then use
• 48:31triaging those things.
• 48:31For me, it's telling me this
• 48:33is a case we think is positive,
• 48:34so I'll put that case at
• 48:36the top of my cue to read.
• 48:38But then it also is just an extra
• 48:40set of eyes on every single case.
• 48:43So quite honestly,
• 48:43I used to joke with the residents
• 48:45that it's your job to look for rib
• 48:48fractures on a chest CT because
• 48:49I don't want to spend all my
• 48:51time looking at rib fractures.
• 48:52It's not a particularly top of license issue.
• 48:56But now if the A I app says
• 49:00there's no rib fractures,
• 49:01I'm sort of like there's no rib fractures.
• 49:04So it is slowly giving us the
• 49:06comfort of an extra set of eyes.
• 49:08Now at some point it's going to
• 49:09be better than me and at some
• 49:11point it's going to be able to
• 49:13figure out how to integrate the
• 49:14findings into a diagnosis,
• 49:15which it does nothing of the sort right now.
• 49:19That's when I think we'll
• 49:20see real fast change.
• 49:21Are you as confident that 10 years
• 49:24from now they'll still be as many
• 49:26radiologists as there are today or no,
• 49:27There will be a smaller number
• 49:29of radiologists relative
• 49:30to the number of studies.
• 49:31But that's been going on for a long time
• 49:32and I think it's going to continue happening.
• 49:34Technology has allowed us to read,
• 49:37I read 120 to 150 studies
• 49:39on a shift right now.
• 49:41There was a time, you know,
• 49:4320 years ago where if I was reading 30 or 40,
• 49:46that would have been a lot.
• 49:47So that's been going on for a long time.
• 49:49This is just another
• 49:52technology accelerating that.
• 49:53There were a lot of questions.
• 49:54Yep,
• 50:06the first one, chat GB T3I think failed,
• 50:09but GB T4 can pass with 90%,
• 50:12which is better than nine out of 10 docs.
• 50:17The question in my mind
• 50:18is, is I I think we assume that G,
• 50:20PT5 and six will be either
• 50:23linearly or exponentially better.
• 50:25It's not clear to me.
• 50:27I'm not, I'm not a computer scientist.
• 50:28Whether that's that's true or not.
• 50:29I mean, there are some people,
• 50:31I think who have already
• 50:32indicated like Sam Altman,
• 50:33the the CEO of Open AI,
• 50:35that they may be getting kind of to
• 50:38the limits of what they can achieve
• 50:39by just putting more and more
• 50:40data into these types of models.
• 50:42And so there may be different
• 50:43things that need to happen for it
• 50:45to actually get to the next level.
• 50:47But but I guess you know that
• 50:49that remains to be seen
• 50:51you and then you sorry, I think it's
• 50:52more concerning that Jack GPT lies
• 50:56and makes stuff up for no reason.
• 50:58There's a lawyer that may filed with
• 51:02the court and forget what the issue was,
• 51:04doesn't matter, and decided to use ChatGPT
• 51:14chat. GPT started out
• 51:16with some regional stuff,
• 51:18but then made-up judges and opinions
• 51:21and citations that never existed,
• 51:24and within citations and citations,
• 51:28within citations and citations
• 51:30that we had a thin air,
• 51:32not just trouble for.
• 51:38And then another
• 51:46governors of South Dakota for South
• 51:49Dakota magazine and did a fine thing
• 51:54on the oldest one and then for no
• 51:58reason made-up a youngest governor
• 52:01and completely BS the whole thing.
• 52:04And it also created a very
• 52:08gubernatorial governor,
• 52:09quintessential governor looking governor,
• 52:12two pockets with two
• 52:16pocket
• 52:23squares. So that makes me very
• 52:26concerned if the artificial intelligence
• 52:28is acting a little bit like how
• 52:33from
• 52:362001. One issue is that it doesn't
• 52:38actually think about anything, right.
• 52:39It just it's like people describe
• 52:41it as auto correct on on steroids
• 52:42or auto complete on steroids.
• 52:44It's just predicting what the next
• 52:46word should be in a sequence and it
• 52:48has no idea what it's actually saying.
• 52:51I don't think that's the way that
• 52:52these models are are are used.
• 52:54I mean they there's a model that
• 52:56basically said that Elon Musk died
• 52:58in 2018 in a Tesla car crash and
• 53:01it has tons of information that
• 53:03discounts that prediction but it
• 53:05has no idea what it's saying.
• 53:07I think one question in my mind
• 53:09is is is it going to is in certain
• 53:11highstake fields like medicine is
• 53:13the use of a I going to be like it
• 53:15is in driverless cars where for a
• 53:17decade or more we've been talking
• 53:20about driverless cars and and and
• 53:22the level of accuracy and precision
• 53:24you need to like feel very confident
• 53:27that you're going to let the A I take
• 53:30over is greater than 99.9% probably
• 53:32even even if it's better than
• 53:34a radiologist that reading a scan
• 53:35or better than a driver at driving.
• 53:38The the culpability the blameworthiness
• 53:40that we want to have someone to
• 53:42blame something goes wrong and
• 53:44blaming a machine isn't isn't enough.
• 53:46And so I think that might be one
• 53:48reason that some of our jobs are
• 53:51protected for some period of time is
• 53:52that it's such a high stakes endeavor.
• 53:54Any mistake is potentially catastrophic
• 53:56and and we don't want to hand that
• 53:59over just yet to the machines.
• 54:43Yeah, I'll take the first one,
• 54:45you take the second one.
• 54:46So there was a, there was a a study
• 54:49published in JAMA Internal Medicine I
• 54:51think recently that looked at patients
• 54:53who are asking questions on Reddit and
• 54:55ended up comparing the responses that
• 54:57were automatically generated by chat TBT.
• 54:59And those were that were answered
• 55:01by doctors and the ChatGPT responses
• 55:03were both more empathic and
• 55:04more accurate than the doctors.
• 55:06Now these are doctors that are
• 55:07answering random questions on Reddit.
• 55:09I mean you know,
• 55:10take it for what what you will,
• 55:11but it's at least suggestive that that
• 55:13what you're saying is is correct.
• 55:15Yeah.
• 55:15And your point about Kaiser is, is fair.
• 55:17I mean, I think any supply side
• 55:20integrated delivery system,
• 55:21whether you're talking about the
• 55:23National Health Service of Britain,
• 55:24whether you're talking about Yale
• 55:26University Health Services or whether
• 55:27you're talking about Kaiser on the margin,
• 55:30the people who are vacillating in
• 55:32that Gray zone of can I get the care
• 55:34I think I need or my doctor thinks
• 55:36I need and you're being told no,
• 55:38you're going to be distant,
• 55:39you're going to feel disenchanted by that.
• 55:40So it's a very real concern,
• 55:42but it but it's like weight off
• 55:44of the benefit that flows both
• 55:46financially as well as delivery wise.
• 55:49So Yep,
• 56:02as a surgeon, the surgery is as a
• 56:09legacy. My father and my uncle were surgeons.
• 56:11Both graduated here and I came here.
• 56:13I want to be a surgeon.
• 56:14I wanted me to do the best I
• 56:16could from all perspectives.
• 56:17And I was profoundly
• 56:18impressed by the faculty here,
• 56:20surgical and otherwise, that were
• 56:22pursuing excellence for its own sake.
• 56:24And their their reward for doing that
• 56:27was increased fame and writing papers.
• 56:30But the better they got,
• 56:32the more work they they got to
• 56:34do and the same school deal.
• 56:36But we didn't have any exams.
• 56:38And that
• 56:46was all great. And I came out and I started
• 56:54working in a couple of levels,
• 56:56community hospitals and a major
• 56:59University Hospitals affiliated with
• 57:01Harvard and the surgeons there, all,
• 57:04you know, they all made a good living,
• 57:05but they were busy.
• 57:06And the ones who weren't good
• 57:08didn't make a good living.
• 57:09But the way they functioned,
• 57:11they were aware that they
• 57:12had to do a quality product.
• 57:14And even though we were
• 57:15competing with each other,
• 57:16we regularly talk weekly go over our
• 57:19morbidity and mortality and but that that
• 57:35surgeon has worked that system
• 57:37has worked pretty well.
• 57:38You know surgeons do cases that
• 57:41are indicated and they don't think
• 57:43they get run out of town and good
• 57:45surgeons make a pretty good living.
• 57:46And if people are in a place where every
• 57:51everybody gets paid no matter what they do,
• 57:53surgeons tend to not to want
• 57:55to work that hard.
• 57:56So you know, I I think the surgeons,
• 58:11yeah, I think and what
• 58:12you're saying makes a lot of
• 58:13sense to me. I mean even in in valuebased
• 58:15payment systems, there's room for
• 58:17productivity incentives within those.
• 58:18So you could envision a system that has
• 58:21both some element of risk or capitation
• 58:23and also productivity incentives for for
• 58:25surgeons or other procedures or for anyone.
• 58:28A couple of things.
• 58:29I mean, one is I think Howie once said,
• 58:31you know, in the decades ago, you know,
• 58:35people thought that doctors did the right
• 58:37thing no matter what the incentives.
• 58:39And now people think that doctors
• 58:41only respond to incentives. And.
• 58:43And and I think that's also
• 58:44incorrect in the sense that,
• 58:46you know, any quality measures,
• 58:48I was talking with a colleague earlier,
• 58:50any quality measure in my view
• 58:52only measures a very small part of
• 58:53if a doctor does this much stuff,
• 58:55a quality measure,
• 58:56whether you check the A1C or whether you,
• 58:58you know, did this or that,
• 59:00measures a tiny fraction of what
• 59:01we actually do.
• 59:02And so the idea that we need to
• 59:05instill professionalism and pride
• 59:06in our work and that should be the
• 59:09primary motivator for any doctor, not,
• 59:11you know, this this small incentive,
• 59:14this quality measure here.
• 59:15I think that's that's a really
• 59:17important insight.
• 59:18One question I have for you and for
• 59:21you is the places that you mentioned
• 59:23where I think Yale and a Harvard
• 59:26affiliated institution and I have no
• 59:28doubt in my mind that the Mayo Clinic
• 59:30and the Cleveland Clinic probably
• 59:32don't need these types of incentives.
• 59:34I do wonder if you can standardize
• 59:36quality through the ethos you
• 59:38described across the country and
• 59:41is that true in every pocket of the
• 59:43country or do you need some type of
• 59:45incentive system in those places?
• 59:47I think one of the reasons that
• 59:50valuebased payment took off and quality
• 59:51measurement took off and you should
• 59:53talk about this because you were there is,
• 59:55you know,
• 59:55a lot of the Dartmouth studies,
• 59:57the the studies that came out of
• 59:58Dartmouth which showed that there's
• 60:00tremendous variation in the way that
• 01:00:01people care for people across the country.
• 01:00:03So if you're in one state or one town,
• 01:00:06you might be three times as likely
• 01:00:08to get a cesarean section as
• 01:00:10someone in the town next door.
• 01:00:11If you are in another you know,
• 01:00:13part,
• 01:00:13you get an MRI for this and
• 01:00:15you don't get an MRI for that.
• 01:00:16Some of that might be appropriate.
• 01:00:17Some of it may reflect
• 01:00:19underlying preferences,
• 01:00:20disease prevalence and population.
• 01:00:22But I think a lot of this work towards
• 01:00:25quality measurement and standardization
• 01:00:26grew out of this recognition that.
• 01:00:29There was wide unexplained variation
• 01:00:31in practice across the country.
• 01:00:34Yeah, I mean, I look,
• 01:00:35I happen to believe that incentives
• 01:00:37have to work in both directions.
• 01:00:39We need to be able to meet.
• 01:00:40We do not want to reach a point where
• 01:00:44physicians are paid minimum wage, right?
• 01:00:46We want to be able to put a value
• 01:00:48on what people are able to provide,
• 01:00:50and we want to have the appropriate
• 01:00:52incentives to ensure value to the patient.
• 01:00:54Quality of care,
• 01:00:56of cost should be a consideration.
• 01:00:59It's a very it's it's more than
• 01:01:01an imperfect system we have
• 01:01:02right now that's the problem.
• 01:01:04If we only had an imperfect system,
• 01:01:06we would be striving to make it better.
• 01:01:08We have a very deeply flawed system
• 01:01:10where there are people that are able
• 01:01:13to extract enormous economic rents
• 01:01:15and then we rely on very charitable
• 01:01:17good people to provide care to grossly
• 01:01:21underinsured and uninsured individuals.
• 01:01:23And for those of us that think that
• 01:01:25social justice or equity or anything
• 01:01:27in terms of Healthcare is important,
• 01:01:30it it creates a real challenge for us.
• 01:01:32But I want to,
• 01:01:33I want to wrap it up because we're over
• 01:01:35time and and Michael's looking at me there.
• 01:01:37I just want to thank you
• 01:01:38first of all for doing this.
• 01:01:40It's really generous of you
• 01:01:41to give us your time.
• 01:01:42I want to thank all of you for joining us.