Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.
Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. We have an exciting interview coming up with Dr. Alan Friedman of Yale New Haven Hospital and Yale School of Medicine.
But first, in keeping with a podcast that is sponsored by a school of management and a school of public health, I wanted to talk about a paper by three colleagues from those schools: Jacob Wallace and Jason Schwartz from our Yale School of Public Health along with Paul Goldsmith Pinkham from our School of Management had this fascinating study in this week’s JAMA Internal Medicine. We had previously seen investigators finding that counties more highly identified as Republican, including I think a paper by you, Harlan, were having higher death rates than counties more highly identified as Democrat. There was also strong evidence that Republican-leaning counties had differing vaccination uptake as well as other public health behaviors.
But here our colleagues go one step further. They linked the individual-level party affiliation, either Democrat or Republican, to death certificates in two states, Ohio and Florida. Through the first year of the pandemic, there was relatively minimal differences between excess death rates for Republicans or Democrats. But by May 1st, 2021, when there was open availability to vaccinations and that were clearly established, a divergence occurs. Republicans begin dying at rates that are statistically and substantially and unambiguously above those of Democrats, ultimately 43% higher excess death rates among Republicans than Democrats. They then go a further step and look at county-level vaccination rates and death rates by party and found higher excess death rates for Republicans in counties with lower overall vaccination rates.
Now, the authors are careful to explain that many confounding factors could be at play here, and they’re also clear that changing your party affiliation is not going to change your risk. But this study does add to the evidence that politicization of the pandemic and our response to it has real-world consequences. And whether you’re a Democrat, Republican, or independent, you should want better health for all. And I personally would like to see us go back to a time when public health’s not political, where evidence, truth, and facts are embraced, and where elected officials don’t need to look at their party identity to know what words they can or cannot say.
Harlan Krumholz: Howie, I’m glad you identified this article. It’s interesting in so many, many different ways. And you’re right. We did post a preprint, which is now under peer review, where we looked at excess mortality among the various states in the country. We were just looking geographically at those states, and, I don’t know, you and I have talked about this before, but you may remember that the top states in the country for excess mortality during the pandemic ending about the end of September 2022, so through most of the pandemic, were in this order: West Virginia, Mississippi, Oklahoma, then New Mexico sneaks in there. But that may be because of the great excess that occurred in the American Indian population in the U.S. Kentucky, Alaska, Tennessee, Alabama, Arkansas—do those sound like Republican states to you? I mean, we have seen this. And I think that, as you know, there were policies that were implemented in those states.
This study interests me because it wasn’t like a traditional cohort study where they had a bunch of people who identified as either Republican or Democrat and then they followed them over time. This is one of those big data studies where they went to a private company and they bought a bunch of data, but interestingly, the data didn’t even say what state people were from and it didn’t have individual identifiers of who these people were. So they took this study, this mortality study, and they linked it probabilistically to the Florida and Ohio voter registration files, which they could get ahold of.
And it’s an interesting approach. Let me just give you an example about this. So this algorithm they use, this AI algorithm, makes a pairwise determination about whether two records represent the same individual. So here they have these large-scale death records which aren’t identified, and they’ve got this large-scale voter registration, and then they’re using this advanced way to match. So in their approach, you know what the probability that the match is made correctly is?
Howard Forman: Eighty-five percent, I don’t know.
Harlan Krumholz: Fifty-seven percent. So you know that this is an issue. I mean, can we start using these big data sources? And those who have criticized this study have said, “Wow. You didn’t even know what any individual was. You’re using all these algorithms for matching. How do you know that this really works?” So you and I both know these authors and we know them to be terrific, outstanding investigators; these are brilliant scientists. They’re taking it from the point of view of economists. This is more like the kind of research economists do.
And I think, like I said, it matches the work that we’ve done previously. I’m not doubting the finding, but I’m fascinated by whether or not we’re going to start using these large de-identified databases in this way to make inferences, and the debates that will go on about the validity of this in contrast to more traditional research where we have more confidence about each of the data points. In this one, the idea is we may be uncertain, it may put things a little bit out of focus, but in the end it could still tell us important things. I don’t know. What do you think about that?
Howard Forman: I don’t know. I mean, I tend to believe that the thing about a lot of economic research is it relies on natural experiments as opposed to uncontrolled trials, which we’re more accustomed to in medicine. It almost becomes more accustomed to epidemiology rather than the clinical trials or observational trials that we do in medicine where we can do a deep dive into a chart. I think that we learn a lot from it. And if there was anything in it that suggested that they went in with an ex-ante bias, I would be more concerned. But it does seem like they went into this with a null hypothesis that was refuted. And I think we learned a lot from this type of thing. We’re not making a medical decision based on it, but it does add to the evidence that we’ve seen in multiple other studies that there are differences in behaviors and it seems outcomes between the parties in these two states, if not others.
Harlan Krumholz: And one of the things they did I thought that was clever was that they basically said you could look at this period of time before the pandemic and there were no differences between the people they were attributing to the parties. And then when the pandemic comes, the lines separate when you expect them to, with the vaccine and so forth.
Howard Forman: Well, now we have a great guest. Harlan, you do the honors.
Harlan Krumholz: Howie, it’s my pleasure to introduce Alan Friedman, who serves as our chief medical officer at Yale New Haven Hospital. He’s been in so many roles at our place. He was most recently the chief medical experience officer, and he’s as a terrific clinician, a wonderful teacher. He’s led the fellowship program for pediatrics. He’s taught so many cardiology fellows over the years. He’s beloved by patients. He was a medical director for medical affairs and has spent a lot of time thinking about the culture of medicine and how we can put people in a position to do their very best work.
He’s from the University of Michigan, then to Wayne State University. He completed his residency at Children’s Memorial Hospital in Northwestern University. And then we were fortunate in 1991 to have him come here for a cardiology fellowship and he’s never left. I also know him as a terrific father, son, and for me and my family has just been such a wonderful friend, has made our lives so much better just to know him. When we asked Al what he wanted to talk about today, he said, “Why don’t we focus on keeping our hospitals safe for patients and staff?” And I thought that was a really great topic, and let me just set it up for everyone.
So adverse events during hospitalization are major cause of patient harm. These events that you didn’t have when you came in the hospital but came upon you while you were hospitalized. Hospitalization itself can be a cause of harm. In the 1980s and early 1990s, there began to be a lot of attention focused on this, and it started with this Harvard Medical Practice Study. And their key findings were that almost about 4 out of every 100 admissions, that is about one for every 25 admissions, there was an adverse event and about a quarter of them were judged to have been caused by negligence and 16% of them, one in six, led to death or permanent disability.
Our group has done a series of studies looking at trends in safety. We did one about a decade ago, we just finished one about a year ago, and we were finding gradual improvement as the medical world began to focus more on quality. There was a report that came out of the Institute of Medicine called “To Err is Human” that began this in the 1990s, but maybe around the 2000s. But then this improvement we’ve seen is still not enough, and there still is way too much harm that’s inflicted upon people through, I think “negligence” sounds strong, but just some errors that occur in the hospital could be preventable. I like to think about them that way.
So then there was a recent study in The New England Journal of Medicine by David Bates and his group at the Brigham that looked at 11 Massachusetts hospitals. And again, they found that there were a very large number of preventable adverse events. In fact, they found them in 7% of all admissions. And they found that many of them cause serious life-threatening or fatal events. So these are consequential, preventable, they’re part of our medical care system. And it’s good to know that this is something that our chief medical officer, Alan Friedman, is focusing on.
So Al, tell us a little bit about how you’re thinking about how can we make progress in this area? How can we make the hospital a lot safer for our patients? And by the way, also for our medical staff who sometimes are also affected by adverse events, and sometimes it’s psychological, the burnout’s part of this. So how are you thinking about this?
Alan Friedman: So how do we help our patients? How do we care for them and what are we doing to minimize and in fact attempt to eliminate any likelihood that we might harm them? And I think of that in two major domains. One is the process and procedures and policies that we put in place, the nuts and bolts of what we do. And the other every bit if not more important is the culture that we create, the way we communicate clearly and fairly and transparently with each other as a care team and the way we commit to open and honest, transparent communication with our patients. And that communication, in addition to being honest and equitable and transparent, needs to be delivered with compassion and kindness. And I think when we do that for our patients and when we communicate that way with each other, we put ourselves in the best position to provide the best and safest care for our patients in an environment that is safe and comfortable for our staff.
Howard Forman: So first of all, thanks very much for joining us, and you and I have known each other for about 25 years now. And we go back to a common student who I remember very well being inspired by Don Berwick around the time as Harlan points out of the 1998 “To Err is Human” report. And we have made a lot of progress. In fact, when you start to actually look at the areas hospital acquired infections, our changes around a lot of procedures that we do, we do much better. But as Harlan points out, we’ve not done nearly enough.
And from the top-down setting, the culture is so important. And I’m wondering, how do you make the tradeoff between trying to impose your will about how do we change our culture quickly versus helping people along to understand how systems work and how they can be part of the solution. And specifically, if you can—second part of the question—I’d love to hear you talk about how you got involved in the “Cup of Coffee with Al” program, which I think was very important and very well carried out.
Alan Friedman: I think the first and most important element in changing the culture is to model the behaviors that make us proud. And when someone raises a concern that perhaps we haven’t, we have to be open enough to recognize that even if we thought we used the right words at the right time and we demonstrated the right actions. If that’s not what was perceived, we own that too. We own the way we’re perceived. And I think when we are able to navigate through our hospitals and clinics with that insight and that level of accountability, then we slowly begin to change the culture. I think you may be familiar with the hidden curriculum, which was a educational model put forward more than 25 years ago, we know that those who learn from us and learn with us pay less attention to the words we say than they do to the actions that we demonstrate.
So as a pediatrician, a pediatric cardiologist, I can say all the right things about what our culture should be and how we should be behave with our patients and our colleagues and our staff. But if in clinic I demonstrate a dismissive attitude or when someone is asking me a question clarifying a dose of medication that I’ve prescribed and I put my hand up because I’m too busy to listen, that is the behavior that will be modeled by our students, by those who are learning with us. And in fact, as leaders, that’s the behavior that our colleagues will model, the hidden curriculum. And we have to be aware of it in order to be accountable for it.
Howard Forman: Yeah. I wanted to just hear you talk about the cup of coffee talks and why that was so important and why you began that.
Alan Friedman: Yeah. So I will say that we have, much to my happiness, we have changed the name from “A Cup of Coffee with Al” to a now 10-year-old process steeped in peer review of how we hold each other accountable to a set of expectations. I, along with one of my colleagues in legal risk recognized that about 10% of the cases that were brought forward by our staff. We’re less about the technical skill demonstrated by our medical staff, but we’re actually about the way we behaved and interacted. And these concerns were addressed by the quality of care committee. And to be clear, they absolutely impact or have the potential to impact the quality of care, but they were really around the behaviors of our medical staff. And while they occupied maybe 10% of the total cases in any given year, it certainly felt like they took about half of our time.
They were very time- and labor-intensive to address. And my colleague from legal risk, Theresa Conciatori, turned to me one day and said, “Would you be interested in thinking about a peer review process to address the behaviors of our medical staff?” And I’ve learned over the years never to say no to Theresa, and I said yes. And together we began to construct what a peer review process for professional behavior would look like. We developed a charter, we created a committee of clinical experts from our medical staff both in our community and from our full-time faculty at the school, medicine. And we put into place a process to help raise awareness and insight and self-reflection for members of our medical staff about whom a concern was raised.
We refer to this as our Medical Staff Professionalism Committee, or MSPC. It is a non-punitive process, it’s a collaborative process. And members of the MSPC meet with, individually, members of our medical staff who have had a concern raised about words used, actions demonstrated, or the way they’ve come across. And we’ve empowered and engaged our entire staff, no matter the role that you have in our hospital. And we address every concern that comes our way in a non-accusatory manner, a conversation. It may be with a cup of coffee, just to allow one to hear how they were perceived and to remind each of us, and I’m using first person plural here because I still see patients, and I am absolutely vulnerable to using the wrong words or demonstrating actions that don’t make me proud or being perceived that way. And each of us is vulnerable to this and deserves the opportunity to receive the lightest touch necessary to change our behaviors.
Harlan Krumholz: You’ve prepared yourself so well for this. I mean, you started off through this traditional training but then acquired a lot more skills. The professionalism is so important, but I’m also interested in the actual events. How do we hold ourselves accountable, forever continuously improving and making it safer? And when people hear about adverse events, just for those who are listening aren’t familiar, I mean, this can be anything from wrong-sided surgery to leaving a sponge in a patient to a wrong dose of a medication.
I mean, when I’m talking about these preventable adverse events, and by the way, the reason that piece out of the IOM, the Institute of Medicine said “to err is human,” it’s not that we expect perfection, but we’re working towards systems that ensure the people working in medicine can perform at the highest levels. And if there is something that is an oversight, there’s a redundancy of systems so that we save each other so that it’s hard to do the wrong thing. But I fear that as a nation, we’re not making the progress that we should. So when you think about this in terms of tangible events at Yale New Haven, can we set a target for what we want to achieve in this way? And then in addition to the very important professionalism, ensure that we’re actually reducing the number of these adverse events?
Alan Friedman: Yeah. It’s the right question to ask. And I think as the Bates article outlines, adverse events continue to plague hospitals, including hospitals that have put into place very detailed and thorough safety processes and procedures. Our hospital 10 years ago embarked on a process to become a high-reliability organization. We took the model from other industries, the airline industry, where a single error can be catastrophic. Other industries include the nuclear energy industry, the long-distance trucking industry, and healthcare is no different. A single error, while it may not take down a plane of people, it can be catastrophic to a patient and their family.
And I would add to our staff as we moved forward with that high-reliability mission, first and foremost was our commitment to speak transparently and safely whenever we had a concern about a patient’s safe care or their wellbeing. And again, no matter our role, a nursing or medical student on their very first day or their very first month in July of their training is empowered to stop the line of patient care in the name of patient safety. And we have to accept that question, and we have to thank the question-asker for raising it.
The other thing that we did starting about 10 years ago is we committed to a seven-day-a-week, 52-week-a-year, a process of talking about safety events from the prior 24 hours, trying to anticipate what safety events might occur in the next 24 hours. And then sharing that learning across all of our service areas. When we started this journey, our hospital averaged between 80 and 100 serious safety events in that 12-month period. And when we rolled out high-reliability, we changed our communication style. We welcomed those questions of clarity and arcing up, and we talked about safety every single day. And our rolling 12-month average of serious safety events continued to hover for a year or two in that 80 or so range.
It wasn’t—and this speaks to your question, Howie—about how to change culture quickly. It took several years of living this high-reliability commitment, living a safety culture before we started to see our serious safety events begin to decrease. And we went from an average of about 80 down to an average of about 20. Now, I will share with you that our goal along the way was to get to zero. And our goal today is to get to zero because a single serious safety event that occurs because of a medical error is one too many. And we remain somewhere in that 15 to 24 average right around 20 per year. That last 20 has proven to be very, very stubborn despite all of this work. But this safety culture represents a marked change from the decades prior.
Howard Forman: Well, look, the institution and the community owe you an incredible debt of service. You are a true servant to the people, and I’m thankful to work with you. I talked to two people this morning who were so excited to see you. One of them said that, “I effing love Al,” and I obviously it’s a PG-rated podcast. I don’t go further than that.
Harlan Krumholz: Well, let me just tell you, I effing love Al. I effing love Al.
Howard Forman: Exactly. And the one last question I’ll ask you before we go. How is it that after 30-plus years here that you’re still a Detroit Tigers fan?
Alan Friedman: Well, some things are in the DNA, and it’s very hard to alter those. I do want to correct one thing that you said, Howie. I view myself as a product of this environment and this culture. I’ve been privileged to help lead it. But the work that I’ve referenced today was really led by our friend Tom Balcezak and others. And like all of us here, we are the beneficiaries of this work, and we’ve taken the baton and we are moving it forward.
Howard Forman: Well, you’re a mensch, and thank you very much for joining us today.
Alan Friedman: Thank you.
Harlan Krumholz: Yeah. Thanks, Al.
Alan Friedman: Pleasure.
Harlan Krumholz: I really appreciate it.
Alan Friedman: Thank you.
Howard Forman: That was really awesome. I love listening to him. He is such a good person, and I really mean it when I say he’s a mensch. But Harlan, since we’ve completely flipped the script today. Tell me what’s on your mind and what got your attention this week.
Harlan Krumholz: Yeah. I wanted to talk about one major thing, and then I have a hot take here at the end if you don’t mind. But the first thing I want to engage you about, which is really about this issue of out-of-pocket costs and healthcare. I know we keep coming back to this stuff, but gosh, Howie, just drives me nuts. And I think I told you one time about a story of a patient I was taking care of. This is a guy who had gotten drunk, hit his head, somebody in the ER at some point heard him say he had chest pain. It was a young guy in his thirties. And that led to a rule out for myocardial infarction. I mean, the guy—chance this guy was having a heart attack was so small. But anyway, they made a decision they were going to admit him, and I was the admitting attending and there were no beds on the regular hospital floor.
So they put him into the ICU just because they needed a bed, and the guy comes out of it, and of course he doesn’t have a heart attack and he’s fine. And we discharge him. The next day and on rounds, I just happened to say, “So tell me a little bit about this guy.” And somebody pipes up at some point and said, “By the way, he’s uninsured.” And I said, “Well, let’s look into this. What’s this going to cost him?” And it was like $25,000 because it was a night in the ICU and it was all the stuff around it. And I was just thinking the complication for this guy wasn’t that he had a day of sickness and maybe had to sleep off a hangover, but that he was going to have a heck of a financial hangover as a result of this.
And our group has written about this before, and with Khurram Nasir doing a lot of work, Rohan Khera, and others in our group. And we’ve looked at, for example, for people with heart failure and found that a remarkable number of these people are experiencing catastrophic out-of-pocket costs that’s related to their medical condition even when they have insurance. So what that’s meaning is that oftentimes even up to 20% of their disposable income is going to servicing their medical obligations. And this just can’t continue. I’ll just say one final thing.
You may have seen this piece in The New York Times recently. That was by a couple of really famous economists who’ve been studying U.S. healthcare for a long time. And I thought what was interesting was, I’m just going to say this quote. They go into about “six in 10 uninsured Americans are eligible for free or heavily discounted care,” but many “remain uninsured.” They go on about the difficulties for applying the administrative friction people encounter. And here’s what they said, Howie: “The only solution is universal coverage that’s automatic, free and basic.” And I agree with this, Howie. We’ve got to find a way. We’re spending so much money; we can’t be torturing people like this. This financial toxicity of care is just unacceptable.
Howard Forman: Yeah. Look, I agree too. I just think that the political obstacles to making it happen are truly insurmountable in the short run. And I think in the long run, what we can do is get Medicaid to be at the same level as Medicare, and we can ensure that the uninsured in this country have access to something that is equivalent to either of those two things. That gets us in a political climate of something that’s feasible. It gets us 90% of the way to what you’re describing, but as of right now, that’s not the case. We have haves and have-nots in this country. We have people about 85 million to 90 million people that are Medicaid-insured, and then we have another 20-plus million people who are uninsured. And then you have some privately insured people who are considered underinsured. So there’s a large number of people that don’t have access to the healthcare system that you and I have on a day-to-day basis. And it’s unacceptable.
Harlan Krumholz: Yeah. I’m reminded of every time I’m in the uninsured clinic too, because there are just life-saving medications we can’t administer. That’s why these people just can’t afford. Hey, I just got one other hot take I thought people might like. Yeah. This week a study came out. There’s so few randomized trials of diet, and yet here we had one. People are recommending what they’re calling neuroprotective diets. Have you heard of those?
Howard Forman: I did because you told me about it, but I only think of people saying the Mediterranean diet, so I that, that’s not as simple as that.
Harlan Krumholz: Yeah. Well, it’s Mediterranean diet. You’re absolutely right. And it’s also a combination of the sort of DASH diet, which is being cognizant of salt and so forth. But this is plant-based foods mostly, green leafy vegetables, nuts and berries, fish and olive oil.
Howard Forman: I’m sure these people live longer and they have better cognitive outcomes. Is that what you’re going to tell me, Harlan?
Harlan Krumholz: Limits the intake of foods with high saturated fats and sugar, limits red and processed meat, butter and margarine, whole fat, cheese, pastries, and sweets and fried foods. All the stuff that we know so many people who love. This is just going to make people healthy. They do the randomized trial, da da, da, da.
Howard Forman: They live longer and they’re smarter.
Harlan Krumholz: No.
Howard Forman: So sad.
Harlan Krumholz: No. This was among cognitively unimpaired people. So this is among people that had a family history of dementia but were currently fine. They looked at brain MRI outcomes. They looked at changes in cognition. It was over three years. You could say it wasn’t long enough, but three years did not differ significantly between those that followed this diet and those who followed a controlled diet that was about mild caloric restriction. But you know how that doesn’t really stick. So this is a major disappointment for many people. Maybe for the people who like fried foods, it’s a major point of excitement. But I just wanted to share that because I thought it was a really interesting finding.
Howard Forman: It’s fascinating, but it just proves exactly why we have this podcast because what seems obvious to people is not always obvious, and we need to actually test the hypothesis.
Harlan Krumholz: Absolutely. 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, you can find this on Twitter, or maybe not, Harlan.
Harlan Krumholz: Yeah. Isn’t it “X” now, Howie? What the heck are we going to do about this?
Howard Forman: It’s X. Yeah.
Harlan Krumholz: My goodness. I don’t know. Every day is stranger and stranger in the social media world. But meanwhile, at X, I’m @hmkyale, that’s H-M-K-Yale.
Howard Forman: And I’m @thehowie. That’s @T-H-E-H-O-W-I-E. You can also email us at health.veritas@yale.edu. Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the Healthcare Track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs or check on our website at som.yale.edu/mba.
Harlan Krumholz: Health & Veritas is produced with the Yale School of Management in the Yale School of Public Health. Thanks to our researchers, Inez Gilles and Sophia Stumpf, and to our producer, Miranda Shafer. Absolutely amazing weekend, week out. Talk to you soon, Howie.
Howard Forman: Thanks very much, Harlan. Talk to you soon. And by the way, for our listeners, this is our last episode until September, but we are going to have a special surprise to drop for you before that time, so stay tuned.
Harlan Krumholz: Yeah, stay tuned.
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