Healthy Rounds With Dr. Anthony Alessi

Bonus Episode: Quality, Patient Safety

This week we revisit the conversation with Dr. Scott Allen, UConn Health’s chief medical officer. Dr. Alessi digs deeper into what we mean by the terms “quality” and “patient safety,” exploring the patient experience as well as how to measure quality and how the increasing complexity of medicine makes safety such a priority. He also differentiates between internists and family medicine practitioners.
Submit questions for Healthy Rounds:healthyrounds@uchc.edu
Dr. Scott Allen:https://facultydirectory.uchc.edu/profile?profileId=Allen-Scott 
UConn Today: Make It 10 Straight A’s for UConn Health’s Hospital Safetyhttps://today.uconn.edu/2025/11/make-it-10-straight-as-for-uconn-healths-hospital-safety/ 
UConn Health Orthopedics and Sports Medicinehttps://www.uconnhealth.org/orthopedics-sports-medicine
UConn Health:https://www.uconnhealth.org
Grant support from Coverys:www.coverys.com
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date, timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery and a grant from Coverys. It is not designed to direct your personal health care, which should only be done by your physician.
I’m your host, Dr. Anthony Alessi, and it’s great to be with you to really dig deep into some of the topics we discussed last week with Dr. Scott Allen. As you’ll recall, Dr. Allen is the chief medical officer here at UConn Health. He is an internist and specializes in primary care internal medicine, and was he went over his personal history, we can see that he’s always had a passion for improving the quality of medical care, and it has really evolved as, that’s almost as a subspecialty of medicine has evolved.
But what was also interesting, and I wanted to clear up some things, is that he is a specialist in primary care internal medicine, and that differs from primary care family physicians. There’s different training involved. So family physicians are primarily people who do general medical care, but includes things like obstetrics and gynecology, different subspecialties may be doing some minor surgeries and other areas, so it’s a more broad field and it’s truly family medicine because they also treat children, so they treat the entire family. And it came about really in people in rural communities as well as now we see more and more this has developed to folks in bigger cities as well, where it’s hard to get access to care. So there’s a difference between primary care family medicine and primary care internal medicine, whereas internists treat adults only, and also a broad range of treatments for those adults.
And among the things he talked about and that I really got out of this was the approach to quality of care and patient safety. These are things that I wasn’t familiar with in terms of how they relate to the patient. And as you’ll recall, he talked about the first of the three phases being the patient experience, followed by the quality of care and followed by safety.
As he explained it, for patients who come to receive medical care, they want to be treated well; they want high quality care, so they want to get better; and more importantly, they don’t want to be hurt. So let’s talk about the patient experience itself. That’s a lot to do with actual having contact with the patient, that initial contact. And there are a lot of things that I’ve learned over the years that help that contact. So even today when I see a patient, I’m asking things like, “Who sent you here?” “What do you like to do?” try to make things conversational. At the same time. I’m trying to identify the patient, speaking to the checklist that we talked about with Dr. Allen. Things like what side is being affected, right versus left, instead of asking again for their date of birth. Now people ask the date of birth a lot ‘cause that’s a big identifier, but I’ll ask the patient’s age. I’ll try to make this part of a conversation. But by the same token, I’m trying to improve their experience as well as identify the proper patient and why we’re there.
One other trick I learned, and it’s not really a trick, it’s actually something that speaks quite well to being in contact with patients, is when I would make rounds with patients and go into their room, often you have all these doctors standing around the bedside, right? So when, when I was the attending, I would primarily be the lead physician. I’ll have residents with me in the whole group. I always made a point of sitting down, whether the patient was in a chair or in bed. I wanted to sit down somewhere so that it wasn’t always this feeling of I’m looking down at them. It also gives the impression that I’m spending more time. I spent enough time to sit down and ask my questions rather than having it seem like I’m on the run, getting ready to get out of this room and get going.
So there are those things that affect the patient experience. When it comes to quality of care, there are a lot of different measures, right? We measure outcomes, frequency of infection rate, how often does a patient have to be readmitted after being discharged from the hospital? So those are the quality issues, but safety is another issue.
And we talked somewhat about why is safety more of a problem now than it was in the past. And I think from my standpoint, it’s clear that medicine has become much more complex. It’s really like the difference between flying a small aircraft and flying some huge jet liner. So there are a lot of things that can go wrong and it’s important to stay on top of those. And that’s where we got into the checklist and that’s why I used the flight analogy, because you always have these checklists. Now obviously when you’re on a huge jet, the checklist becomes much longer. As opposed to flying a small two-seater plane, and I think that’s what has happened now in terms of the evolution of medicine and its complexity with regard to computers and so many other things that are going on with the patient at the time care is being delivered.
One of the things I wanted to mention, we have a grant to do these podcasts from a company called Coverys.  Coverys is an insurance company that provides medical malpractice insurance to physicians, and they’ve been my insurer for many years. What’s interesting is that, you think that, well, it’s insurance, they get the lawyer, and now you go through a process. But at Coverys, they spend a lot of time trying to improve quality by continuing medical education and requiring that continued medical education of the physicians, physician assistants, nurse practitioners who are all their insureds. And some of the courses they take are so important and I’ve learned a great deal from them over the years. So we really appreciate having them on board to support this podcast as we move forward.
With that, I want to thank again Dr. Allen for his time that he spent with us. It was really enlightening overall.
Next week we’re going to be chatting with Dr. Douglas Brugge. Dr. Brugge professor and chair of the Department of Public Health Sciences here at the University of Connecticut, and we spent a lot of time talking about public health initiatives and the effects that these folks out there who are against science have now really impacted public health, and it’s something we all need to be mindful of.
If you have any questions or ideas for future programs, you can reach out to me at Healthy rounds@uchc.edu.
Jennifer Walker is the executive producer for Healthy Rounds. Chris DeFrancesco is our studio producer for the Healthy Rounds Podcast, and Tessa Rickert is in charge of our social media. Until next time, this is Dr. Anthony Alessi. Please stay healthy.

Inquiring About Quality and Patient Safety

We hear a lot in health care about patient safety and quality. While those terms would seem like a given, when it comes to patient care, they in fact are very strategic and measured. As Dr. Scott Allen, UConn Health’s chief medical officer, explains, much has to do with acknowledging the possibility of human error and how to mitigate its impacts, with practices such as daily safety huddles, checklists, empowerment to “stop the line,” and even use of artificial intelligence that can lead to an earlier diagnosis or assist with documentation in real time and enable physicians to focus more on the patient. It’s part of why UConn John Dempsey Hospital is in the running for an 11th consecutive “A” grade from Leapfrog for patient safety.
Submit questions for Healthy Rounds:healthyrounds@uchc.edu
Dr. Scott Allen:https://facultydirectory.uchc.edu/profile?profileId=Allen-Scott 
UConn Today: Make It 10 Straight A’s for UConn Health’s Hospital Safetyhttps://today.uconn.edu/2025/11/make-it-10-straight-as-for-uconn-healths-hospital-safety/ 
UConn Health Orthopedics and Sports Medicinehttps://www.uconnhealth.org/orthopedics-sports-medicine
UConn Health:https://www.uconnhealth.org
Grant support from Coverys:www.coverys.com
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up to date and timely information that’s brought to you by national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopedic Surgery, in addition to a grant from Coverys.
This podcast is not designed to direct your own personal medical care, and that should only be done by your physician. I’m your host, Dr. Anthony Alessi, and it gives me great pleasure to have as my guest today, Dr. Scott Allen. Dr. Allen is the Chief Medical Officer for the University of Connecticut here at UConn Health.
He’s also a specialist in internal medicine and specifically in primary care internal medicine. Scott, welcome to the show.
Dr. Allen: Thank you for having me.
Dr. Alessi: Scott, can you tell our listeners a little bit about your background and how you got here?
Dr. Allen: I’m a general internist by training. I actually trained at the University of Massachusetts Medical Center, came down here in 1994, mainly as a medical educator, also functioning as a primary care physician.
And over time, I took on responsibilities within residency programs, became a residency program director for eight years, and then really had the opportunity about 15 years ago to kind of morph into the quality world. Became a medical director for our quality department when it was first initiated, and then became the first chief quality officer, now as first chief medical officer.
Dr. Alessi: Now, we hear a lot of these terms as physicians here in practice. We hear about quality, we hear about risk management, we hear about patient safety. Can you address those terms and what they all mean to us? Especially patient safety. I find that to be an odd term, right?
Because it gives the impression - do you mean it’s not safe? So, can you talk a little bit about those programs and those terms and what they mean to the public as well as physicians?
Dr. Allen: So, when patients come to see a physician or a practitioner or come to the hospital, they really are looking for three things.
First, “be nice to me”, which really is the patient experience piece of health care.
Dr. Alessi: Sure.
Dr. Allen:, The second is “heal me”. Maintain my health or restore my health. And that’s really the quality component of health care. And then the last is, “don’t harm me in that process”. So that’s really sort of the patient’s safety.
So, all three are really connected to one another. So, the safety piece is really keeping people from harm. And so designing systems of care to allow that. Health care is a very complicated world. It’s high risk. And so, as humans, we’re always subject to making human mistakes, errors. And so, part of our job is to create systems that reduce making those human errors.
Dr. Alessi: Very interesting because back about 26 years ago, as I went back and got a master’s degree in medical management, and one of the things that struck me was much of what we were studying were industrial engineering principles, and back then it was all about Toyota and their industrial engineering and how we could take that and apply it to medicine.
And it was funny ’cause my father was an industrial engineer. And I never had any idea what he did until I went back to school. Can you talk a little bit about that movement of taking industrial engineering principles and how they kind of cover medical care?
Dr. Allen: So, the Toyota model was the ability to quote unquote, “stop the line.”
So, anybody on the production line could basically, in essence, push a button and stop production any time they had a concern. And that empowered those individuals to be invested in the quality and, if you will, the safety of their product. Carry forward to health care. We now empower everybody to be able to voice their concern.
So, if you have a concern about somebody’s safety or quality, you should be able to quote unquote, “stop the line” and be able to say, “I have a concern.” People stop, listen and address those concerns. So, what we’ve learned from Toyota is that empowerment piece to allow people to raise their voices of concern.
Dr. Alessi: Now, that works pretty well, I guess, in the operating room, right? Because now it’s pretty standard. We take a timeout and make sure everybody knows what we’re doing. But how does that work in clinic? I mean, how do you take that and apply it to something that’s so scattered? Is that what the huddle is for and things like that?
Can you explain that to me?
Dr. Allen: So, the timeout for those that are listening is when you go in the operating room, there’s a formal checklist that we will go down. You know, we’re doing the right procedure, the right side of the body, if you will. All those things, all the equipment is ready.
And that’s the checklist. And that’s just making sure that we are in fact prepared to do what we’re supposed to be doing. And so, what we’ve learned from, in this case, the airline industry, when the pilot goes into the cockpit, every single time they go down the checklist. Whether they just flew the plane and they knew it was flying safely, they’re going to go through the checklist.
And so, it’s the same mentality now in health care. We go down those checklists because we have to make sure everything is correct, every single time. So, no matter what’s really going on, you actually go through that checklist. That’s in sort of an OR, very sort of structured environment. In a clinic where it’s unstructured, it’s one of those sort of behaviors, safety behaviors that we promote called attention to detail. And it’s really stopping and taking that sort of mini mental timeout. So if I’m in the medical record and I can actually have four charts open, four different patients, and I’m going to put an order in, I have to sort of take that mini mental timeout to say, “am I in the right patient’s chart?” before I hit that send button. So, teaching people to take that, what we call STAR moment: stop, think, act, review. Mini mental timeout, and so that we’re not rushing. We’re all very busy in medicine, but it’s when we rush is when we create those errors.
Dr. Alessi: Is that the biggest fault? I mean, is it the rushing, like we’re trying like in the OR was it always “let’s rush ’cause we gotta turn over the room” and things such as that? Is that what we’ve found to be the biggest harm?
Dr. Allen: Rushing certainly contributes. And that’s why we actually promote not doing the rushing and actually taking the timeout so that again, we’re prepared every single time that we go in.
And so, we do have to sort of take that sort of momentary stop, that pause if you will, so that we are not rushing, and we’re keeping patients safe.
Dr. Alessi: Have we applied checklists? I mean, we talked a little bit before this interview about The Checklist Manifesto and Atul Gawande’s efforts in that regard.
Do we use checklists in other areas of medicine other than the OR now?
Dr. Allen: So anytime patients, let’s say, get admitted to the hospital, there will be checklists that nurses go through in terms of their initial assessment. You do a history and a physical on the part of the practitioners, there are certain elements of that template, if you will.
So, there’s a lot of elements of those checklists. We build templates into our electronic medical records so that we don’t forget to add a certain element, if you will. There are questionnaires that have, again, a checklist of items. You go in to have an MRI, that MRI tech is going to ask you a series of questions, probably 15 to 20, and they’re going to go through that checklist every single time to make sure that in this case, you don’t have, let’s say, a ferro metallic object that could be a risk for you when you go into the MRI.
Dr. Alessi: How about, let’s talk a little bit about, and you know, now that I’m removed and only in the clinic, I remember we used to have morning huddles, right? Is that still a practice?
Dr. Allen: Absolutely.
Dr. Alessi: Yeah, can you explain that to our listeners what the morning huddle is?
Dr. Allen: Yep. So, we have actually two huddles in the hospital. The first one, we do every morning at 8:30, and it’s about 100, 120 actual middle level, middle management, if you will, folks that are joining that, including senior leadership from the hospital. And we go through the previous 24 hours, all the new safety events that were submitted within our electronic system.
A brief review. We will spend time if we feel that there’s a critical need to, to understand why that happened, initiate some plans, if you will, to mitigate those things from happening again, or deciding when we need to do a deeper dive in terms of an analysis. All those events are reviewed, and then we also then follow up on previous events to make sure that those corrective action plans were in fact completed.
And we go through every single clinical area in the hospital, all our ancillaries, lab radiology, facilities. All those different aspects of care. Every part of the hospital is actually on our safety huddle. Nursing has its own separate huddle after that, which includes all of our nursing units. They go through more sort of the throughput issues.
Dr. Alessi: Sure.
Dr. Allen: And our outpatient clinics also have huddles, again, at the sort of middle management level.
Dr. Alessi: What’s the biggest challenge you think, in terms of your job, in terms of quality and safety? What do you find the hardest -  what keeps you up at night? How’s that?
Dr. Allen: The hardest thing is establishing really a culture of safety.
I think we’ve made great strides. Establishing a culture starts really with leadership.
Dr. Alessi: Yep.
Dr. Allen: And we have great leadership even at our board of directors, which then carries down through Dr. Agwunobi, our CEO and hospital leaders to establish the accountability. The expectation is high quality and high, you know, safety.
So, starts with leadership, and then it’s that culture of reporting. We want people to report safety events. We want them to be able to speak their concerns, if you will. So, establishing reporting, so having an electronic system that makes it easy to report, you can report anonymously or you can have your name attached to it.
And then the last piece really from a culture perspective is what we call fair and just culture. And that’s sort of the middle ground between patient safety and sort of the safety culture. So, we do have accountability in health care, you have to be accountable for all of your actions. So, if you have somebody that is willfully not following policy and procedure, then they should be held accountable and appropriately disciplined.
But as we’ve said before, patient safety is also about human error. And if people create a mistake, they have a human error - they shouldn’t be disciplined for that, they should actually be more consoled. So, establishing this culture where people feel, what we call psychologically safe, to be able to report safety events and not be disciplined for those if it was truly just a human error.
So that’s what we continue to work on, is establishing this fair and just culture.
Dr. Alessi: You know, one of the other terms I guess we mentioned is risk management and Coverys gave us a grant to sponsor this program, and as a medical malpractice carrier, they are very forthright in requiring their insureds to do courses and things for risk management.
Is that the same here in terms of, does this all come under the umbrella of risk management?
Dr. Allen: So, quality and safety, interdigitates with risk management. It interdigitates with regulatory. We all work very closely together. So, if we have a patient safety event, somebody was harmed. Risk will be involved. Is this going to be a malpractice issue or not?
But if it’s a patient safety event, we think it was preventable, we want to be actually upfront and transparent. Days of old, we would sort of circle the wagons. We wouldn’t say anything we would sort of defend, right. Now it’s be transparent, be open. Those lines of communication, that trust, if you will, that you build with your patients, really goes a long way in terms of preventing malpractice and litigation.
So, we have a model here called candor and that that’s basically C-A-N-D-O-R. Communication and optimal resolution. Be upfront, be transparent, and that actually helps resolve things on the back end.
Dr. Alessi: Scott, what do you think has been the biggest success? I mean, you’ve been doing, you’ve been at this for 15 years.
What do you think the biggest success has been in terms of managing patient safety and quality?
Dr. Allen: One of the things that people will look at are external scorecards. Things like the Leapfrog Hospital Safety Grade.
Dr. Alessi: Sure.
Dr. Allen: We’re pretty proud that, you know, we have a letter grade A for 10 times in a row, and that’s one of the longest running in the state of Connecticut.
So, you can look at those external scorecards, you can look at other awards like Health Grades being in the top 15% in the nation for patient experience. So, as I’ve said before, patient experience is one aspect of quality. You have quality and sort of the outcomes of care and then patient safety, and they all kind of interdigitate.
So, I look at the Leapfrog Hospital Safety Grade as just one marker of that success. I think establishing high reliability training is really a marker of success. So, we train everybody, and this was initially through a collaborative with the Connecticut Hospital Association back in about 2011, where we train every staff member in techniques of high reliability.
And that really then carries forward to preventing errors. And so, training everybody, establishing that safety culture really is what I look at in terms of whether we’re successful or not. And yes, we’ve been very successful in improving our safety culture, but it’s one of those things that it’s a never ending journey.
Dr. Alessi: My next question, I guess, is it working? And I don’t mean this to be facetious, but if we look back 50 years ago, right? Do we have these programs now because it’s become so complex? Because there are so many other avenues for error as opposed to the way medicine was practiced before?
Dr. Allen: Yes, health care, I think, has become more complex.
Dr. Alessi: Right.
Dr. Allen: Especially with the electronic medical record, the need to document because of all the regulatory requirements. And so, we spend a lot more time documenting and sort of checking the boxes now. But I think yes, health care has become more complicated.
There’s more sophisticated techniques, tools, people are living longer, so their, if you will, their comorbidities are more complex. So, when people come into the hospital, they are technically sicker than they were in the past.
Dr. Alessi: Thus the risk?
Dr. Allen: Hence the risk.
Dr. Alessi: Okay. Very important. Well, tell us about the future.
Take out your crystal ball for me. What do future programs look like in quality and safety?
Dr. Allen: Well, obviously the buzz term is “artificial intelligence”, and so we are using artificial intelligence now. And then I’ll give you a couple of examples and maybe this will speak to patient safety. So, in our ambulatory clinics, you can just pull out your cell phone and turn it on and it will record the entire encounter. We’ll actually create the encounter note for you. It’s designed to be able to recognize who the patient is, who the physician is, and so that allows more time for the physician or the practitioner to spend time with the patient as opposed to spending time on the computer, typing in notes, if you will.
So, the focus is in now, on the patient interaction as opposed to the documentation. So it allows the physician or practitioner, again, to spend more time focused on what’s important to the patient. Patient experience improves. Again, the focus on health care improves. Second example is, we use artificial intelligence in radiology.
So, we have the ability to pull out all of the reports that have what are called pulmonary nodules, so things that are growing, if you will, in the lungs and shouldn’t be there, and all those reports then get pulled into a database. And the specific software associated with this AI then can actually look at each individual chest x-ray or CAT scan and grade the likelihood of malignancy of that nodule.
What does that do? It actually catches lung cancer earlier. So, if we need to, because of the higher risk, get somebody in for a lung biopsy sooner than somebody who’s low risk, let’s repeat a CAT scan in three or six months, the artificial intelligence is helping us actually catch lung cancers earlier.
Dr. Alessi: Wow. I find that fascinating. I guess one other question is, are patients generally receptive when a doctor goes in the room and explains they’re using the DAC system or the AI system as we know it, are patients generally receptive?
Dr. Allen: They are, I think they’re also in tune to AI and what’s coming down the road.
Everybody knows what cell phones are, so it’s sort of a comfortable environment for them. It’s on the cloud, it’s not something that’s kept in the computer. So, in terms of the risk of a HIPAA breach seems pretty darn low in that sense. So, I think patients are quite comfortable with it.
Dr. Alessi: Scott, thank you.
Thank you for your time today and especially thank you for all you do for keeping quality at the highest here at the University of Connecticut. Thanks again for your time.
Dr. Allen: Thank you for having me.
Dr. Alessi: Many thanks to our guest today, Dr. Scott Allen. If you have questions or ideas for future programs, you could reach out to me at healthyrounds@uchc.edu.
Jennifer Walker is executive producer for the Healthy Rounds podcast. Chris DeFrancesco is our studio producer here at the Healthy Rounds Podcast, and Tessa Rickart is in charge of social media for our podcast. Until next time, this is Dr. Anthony Alessi. Please stay healthy.

Bonus Episode: Dementia Deep Dive

Dr. Alessi goes more in-depth on the topic of dementia in follow-up to his earlier conversation with Dr. Kristina Zdanys, geriatric psychiatrist at UConn Health and co-director of the James E. C. Walker Memory Assessment Program in the UConn Center on Aging.
He takes a closer look at the multifaceted nature of an effective memory assessment program, the role of imaging and monoclonal antibodies in slowing dementia’s progression, reducing dementia risk with lifestyle choices such as the “MIND diet,” misleading medication marketing, and the challenges of decisions around continuing to drive.
Submit questions for Healthy Rounds:healthyrounds@uchc.edu
March 24, 2026, Episode: “Dealing With Dementia” with Dr. Kristina Zdanys:https://healthyrounds.podbean.com/e/dealing-with-dementia/ 
Dr. Kristina Zdanys:https://www.uconnhealth.org/providers/profiles/zdanys-kristina
UConn Center on Aging:https://www.uconnhealth.org/geriatrics-healthy-aging
UConn Center on Aging’s Memory Assessment Program:https://www.uconnhealth.org/geriatrics-healthy-aging/services-specialties/memory-assessment-program
Geriatric Psychiatry at UConn Health:https://www.uconnhealth.org/behavioral-mental-health/services-specialties/geriatric-psychiatry 
UConn Health Orthopedics and Sports Medicinehttps://www.uconnhealth.org/orthopedics-sports-medicine
UConn Health:https://www.uconnhealth.org
Grant support from Coverys:www.coverys.com
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date and timely information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery and a grant from Coverys. This podcast is not designed to direct your personal health care, which should only be done by your physician. 
And today we’re doing what we call the deep dive where we look back at, in this case the interview we did with Dr. Kristina Zdanys. Dr. Zdanys is a geriatric psychiatrist and she’s associate professor of psychiatry at the University of Connecticut. She’s also the director of the James E.C. Walker Memory Assessment Program at the UConn Center on Aging. 
It was great to chat with her and I think there were several points worth discussing. First of all, her directorship in a memory assessment program. I think this goes back to things that we’ve discussed before, and the fact that approaching a problem now is not the purview of one single specialty. And the fact that these programs are multidisciplinary and involve a variety of specialists, typically they will have a geriatric psychiatrist. 
You can have neurologists as well as support staff, nurse practitioners, nurse navigators, as well as neuropsychologists as being part of the team. Radiologists who specialize in various imaging studies of the brain, as she discussed, are all part of a program and a multifaceted approach to a problem, in this case, the problem being dementia. 
And dementia, as she mentioned, affecting currently 7 million Americans, with the thoughts that that’s going to go up to 14 million Americans over the course of the next several decades, so again, that multidisciplinary approach and making funds available for more research in the field of memory disorders, including Alzheimer’s disease and other dementias. 
She also talked a lot about imaging, and it’s something I just mentioned with neuroradiologists, because now we can get images due to PET scanning that look for amyloid, which is one of the main culprits that we find in the brains of people who have dementia and Alzheimer’s disease. So the fact that we can do a scan and look at these deposits and where they’re located helps us a lot in terms of planning for treatment. 
Now we do have some new treatments, and those are in the form of the monoclonal antibodies. In this case, and we hear that term a lot, monoclonal antibodies are used for a variety of problems, typically autoimmune problems, but in this case, these monoclonal antibodies are directed against the amyloid in the brain. 
So essentially it goes in and cleans up the amyloid that’s been deposited. Now, is that a cure? It’s not. It will slow the progression of dementia, a neurodegenerative disease like dementia, and it does involve going for very expensive infusions every two weeks. So there is a real time commitment, but there has been really good data to show that it slows the progression of the process. So I think that that’s a very important finding and something that’s available to us at UConn Health.  
Also, we talked with her somewhat about how to avoid. Dementia. And it was interesting because we’ve talked in the past about stroke and heart disease, and it seems like it also pertains to heart health and brain health overall, and that’s why when we think of ways to avoid dementia. 
We think of things that are just basic, right? Adequate sleep, exercise, diet. It’s not rocket science. And naturally you have to control those risk factors. Blood pressure, smoking, drinking alcohol, all work against you in the long run. So it’s important for us to realize that. And she brought up the idea of what’s called the MIND diet, M-I-N-D, and basically it’s called that because it’s the Mediterranean-DASH intervention for neurodegenerative delay. So it’s a diet that’s designed to help avoid progression of a neurodegenerative process, not just dementia. And it consists a lot of the Mediterranean things, lean meats, fish nuts using olive oil, things such as that. So really changing the diet overall, because we also want to control blood pressure and salt intake, and that’s where the DASH [dietary approaches to stop hypertension] part of it comes in. So again, it’s a combination diet to affect heart disease as well as changes in the brain.  
We also brought up the topic of some misleading ads. You know, we’re seeing a lot of these ads now. I know we mentioned a product called Prevagen and making false claims. There’s so many of these and they seem to target broadcasts where older people are more likely to be tuned in, like news broadcasts and things such as that. So it’s important to really discuss, before you start taking any of these supplements, really talk to your physician and find out what is a legitimate thing to be taking and what you need. 
The other topic we mentioned toward the end of the interview is operating a motor vehicle. And this is a tough one because obviously when someone has dementia, they’re going to be slow to react, slow to pick up the signs of potential accidents and what we call defensive driving. And it’s a problem as we all get older, but specifically in people who have dementia. 
Unfortunately, we’ve created a society where we rely so much on operating a motor vehicle. People who live in big cities don’t have the same problem because there’s plenty of public transportation, things within walking distance. If you live in the suburbs, it becomes much more difficult. It’s also a problem because people feel so much like they’re giving up their freedom, their independence, having to rely on others.  
Now, what has helped is the fact that we have services like Lyft and Uber, and I think promising technology is going to be these vehicles that are self-operating. But the important thing is to realize your loved one is not safe operating a motor vehicle. And they may not have that same insight. Now, it’ll cause some distress, and actually the best thing is to have them go for a driving test. In our area, Easterseals provides that and they will tell you if it’s safe or not to operate a vehicle. But again, it’s a very difficult decision point for families. 
So we learned quite a bit about dementia and the things that are going on at UConn Health in this regard with Dr. Zdanys and her fine work. I want to thank her for her time, and I really want to thank Jennifer Walker, who’s our executive producer here at Healthy Rounds.  
If you have any questions or ideas for future programs, you can reach out to me at healthyrounds@uchc.edu.  

Dealing With Dementia

There are many disorders that can cause memory problems, which fall under the category of “dementia” when those memory problems interfere with daily living. The most common dementia is Alzheimer’s disease, which afflicts more than seven million people in the U.S. As Dr. Kristina Zdanys, geriatric psychiatrist at UConn Health, explains, we can’t cure dementia; our best bet is to try to slow its progression, or even delay its onset with healthy habits in our younger years. Dr. Zdanys, who co-directs the James E. C. Walker Memory Assessment Program in the UConn Center on Aging, also discusses with Dr. Alessi how genetics factor into dementia, the “mind diet,” the challenge of taking away a loved one’s car keys, and what drew her into the field of geriatric psychiatry.
Submit questions for Healthy Rounds:
HealthyRounds@uchc.edu
Dr. Kristina Zdanys:https://www.uconnhealth.org/providers/profiles/zdanys-kristina
UConn Center on Aging:https://www.uconnhealth.org/geriatrics-healthy-aging
UConn Center on Aging’s Memory Assessment Program:https://www.uconnhealth.org/geriatrics-healthy-aging/services-specialties/memory-assessment-program
Geriatric Psychiatry at UConn Health:https://www.uconnhealth.org/behavioral-mental-health/services-specialties/geriatric-psychiatry 
UConn Health Orthopedics and Sports Medicinehttps://www.uconnhealth.org/orthopedics-sports-medicine
UConn Health:https://www.uconnhealth.org
Grant support from Coverys:www.coverys.com
Transcript
Dr Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up to date timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery in addition to a grant from Coverys. It is not designed to direct your personal healthcare, which should only be done by your physician.
I’m your host, Dr. Anthony Alessi, and it gives me great pleasure to welcome today, Dr. Kristina Zdanys. Dr. Zdanys is a geriatric psychiatrist here at the University of Connecticut where she serves as an associate professor of psychiatry. Kristina, welcome to the show.
Dr. Zdanys: Good morning. Thanks for having me.
Dr Alessi: Let’s talk. Can you describe your background and what it takes to become a geriatric psychiatrist?
Dr. Zdanys: Absolutely. So, after medical school, I completed four years of a general adult psychiatric residency down at NYU. And treating adults, you also treat older adults, but I wanted to really enhance my understanding of working with the older adult population, so I went to Yale for a fellowship in geriatric psychiatry, which focuses on the mental health of folks who are 65 and over generally. And that may be a primary psychiatric problem like depression or anxiety or a sleep disorder, but it can also be dementia, which I think we’ll talk about quite a bit today.
Dr Alessi: Why did you choose that field?
Dr. Zdanys: Well, I think going back a long way, I’ve always been very connected to older adults in my family and my community, and have really enjoyed listening to their stories from when they were growing up and when they were younger adults and raising their kids, and there just seemed to be just this, you know, beautiful tapestry that every individual can present to you that I just found so enticing. So that’s how I initially got that interest. But at the same time, I also was really interested in the idea of memory problems because when you think about illnesses that affect older adults, you can kind of wrap your head around, okay, somebody’s heart’s not working the way it’s supposed to be, or somebody’s kidneys aren’t working the way they’re supposed to be, and you can kind of point to what that is.
But a memory problem seems much more abstract. And, not just abstract, but I also think it affects the individual in a way that’s so unlike any other illness because in a way it robs them of their core identity and I just felt very compelled to try to work with them. And even if I don’t have a cure for their problem, just to try to help improve their quality of life.
Dr Alessi: You know, just thinking of the field of geriatric psychiatry and geriatrics in general, it’s gotta be interesting because it’s such a growing field. We’re living longer.
Dr. Zdanys: Mm-hmm.
Dr Alessi: Right. And I think the statistics regarding memory loss and dementia are outstanding.
Can you talk a little bit about that? It’s tremendous growth.
Dr. Zdanys: That’s very true. So, the number one risk factor for developing dementia is age. So, the older you get, the higher your risk of developing dementia. And I should also clarify what we mean by the term dementia,
Dr Alessi: Please.
Dr. Zdanys: So, dementia is a cluster of different illnesses that presents with memory problems that interfere with somebody being able to do what they need to do day to day.
And in most cases, those dementias are progressive. So just like there’s the term cancer, we know there’s all different kinds of cancers. There’s the term dementia, which means there’s all different kinds of disorders that can cause memory problems. So, in the United States, Alzheimer’s is the most common.
It probably makes up about three quarters of our patients who present with memory problems, and that makes up about 7.2 million people in the United States who are currently living with Alzheimer’s disease.
Dr Alessi: The projections are something like, what 30 million people by 2050 or something of that nature?
Dr. Zdanys: Yeah, I don’t think it’s quite that high, but probably around 14 million by 2050, 2060, so
Dr Alessi: Wow.
Dr. Zdanys: Yeah, and the problem is without a cure, we don’t really have the infrastructure in our society to take care of these patients. Right? So most of the care burden is falling on family members who are often juggling jobs and their own children and trying to navigate the difficult course of the disease.
Dr Alessi: Kristina, what’s your practice look like when someone comes to see you? Are there tests you do? Is it mostly talking to them? Kind of walk me through what a typical visit would be for one of our listeners.
Dr. Zdanys: Sure. So as a geriatric psychiatrist specifically, my primary job is to listen, right? So, I want to hear what’s going on with somebody in their life, what’s important to them, and what is the reason they’re coming to see me in the first place?
So, we might say broadly as our chief complaint, “oh, somebody is coming in because they have problems with their memory.”  But what does that mean for them? Is it that they are now relying on their family for transportation because they’ve been getting lost when they’ve been driving? Or does it mean that their hypertension is poorly controlled because they keep forgetting to take their medication? So, I want to hear what the patient’s experience is, first of all, so I can understand how it’s impacting their life. And I think that might be a way in which a geriatric psychiatry approach might be a little bit different than some other specialties.
But, at the same time, we do perform the same type of blood work that we would do for somebody coming into an internal medicine office or a neurology office. We typically do recommend head imaging. Brain imaging has come a long way in the past decade that I’ve been here at UConn Health. Previously, we were only able, typically to get an MRI.
Now we have special MRIs called NeuroQuant analysis where you can actually measure out the size of different parts of the brain, and that helps us get a better idea of what the patient might be suffering from that’s causing their memory problems. We do more advanced scans, like PET scans that can actually show us whether or not somebody has amyloid in their brain, which is the protein that we see in people who have Alzheimer’s.
So, when I started here, we were making general clinical impressions. To make our best guess about what might be causing somebody’s memory problems. But now we’re using specific biomarkers to have very specific diagnoses available for our patients and inform our treatment plans going forward.
Dr Alessi: How big a factor do you find genetics to play in dementia?
I mean, old people are always asking me that in respect to their father and mother who may have Alzheimer’s disease. How big a factor do you find genetics and the APOE4 studies and things like that?
Dr. Zdanys: Yeah, that’s a really good question. So there’s different types of Alzheimer’s too, and I won’t get into too much of the details about that, but there’s earlier onset Alzheimer’s that tends to have more of a familial component where people have something called an autosomal dominant inheritance, where if they have a parent who has an early onset Alzheimer’s, they may have a 50% chance of developing it themselves.
That’s a very small portion of our population, probably under 5%, if not under 1% of our population. The gene you mentioned, the APOE4 gene. This gene is a risk factor for developing Alzheimer’s disease, but doesn’t mean necessarily that people are going to get Alzheimer’s. So it wasn’t necessarily something that we would typically test for prior to the advent of these new treatments that we have available now.
But what’s interesting about the APOE gene is that based on the version of the gene that somebody has, we can actually predict their risk factor for side effects from some of our new medications. So now we are routinely screening for the APOE gene as opposed to even five years ago when we were maybe considering it, but it wasn’t standard of practice.
Dr Alessi: It’s interesting ‘cause with my practice in sports, there was a period of time where people were advocating to test for the APOE gene in boxers before they got into the sport. And obviously that met with tremendous resistance on the part of promoters and athletes.
And as you describe it, I don’t know that it would’ve been very predictable from that standpoint. Let’s talk a little, let’s get into the drugs, right? I think this has been one of the exciting fields in memory disorders and dementia is the new drugs to kind of clean up the brain. Can you describe a little bit about them and what they do?
Dr. Zdanys: Sure. So, since 2021, we have had a new class of medications available for the treatment of Alzheimer’s disease. This is not a pill that you take. These are actually infusion medications. So our patients are coming into our infusion center once every two weeks and getting the medication through an IV.
What these medications do as a class, they’re called monoclonal antibodies, and essentially what they’re doing is what you described. They’re vacuuming up the amyloid plaque that I mentioned earlier and really exquisitely clearing it out of the brain so that the brains of people with Alzheimer’s no longer have this burden.
Now, the tricky part is that doesn’t mean it’s a cure for Alzheimer’s disease because there’s multiple different factors that play into a person’s development and progression of Alzheimer’s. So, they very well slow down the progression of the disease. They help improve people’s independence, so they’re able to stay more independent longer, in terms of those activities of daily living that they need to do, whether it’s driving, or managing their medications, or doing their finances, or doing their shopping.
But there’s other factors that the medications don’t address. So, one of those is another protein in the brain called tau, which we see in something called the development of tangles in Alzheimer’s disease, which is a marker of neural degeneration. And then also there’s an inflammatory process that happens in the brain of people with Alzheimer’s disease.
And these monoclonal antibodies don’t address that either. So, what I tell patients is it’s not a cure, but it’s really currently the best tool we have for slowing down the progression. But I will say that not every individual who has Alzheimer’s disease is necessarily a candidate for these medications, and there are other medications that have been around for decades that we continue to use for all our patients to slow the progression.
Dr Alessi: Let’s switch gears a little bit in terms of treatment. What should people do? ‘Cause what a lot of people are thinking who are listening to this is, “I don’t have dementia, but I want to avoid it.”
Dr. Zdanys: Mm-hmm.
Dr Alessi: What should people be doing in order to avoid, and there are so many studies about this and people have mid-forties, this is what you should start doing, and a variety of things. Can you talk about what you recommend to patients?
Dr. Zdanys: Absolutely. So I think the general theme that encompasses all those recommendations is that your heart health is your brain health.
So, what keeps your heart healthy is going to keep the blood vessels in your brain healthy, and is going to keep your memory working better longer. Now, just because you have a perfect adherence to all of those recommendations doesn’t mean that you will prevent the development of Alzheimer’s disease, but we know that you can potentially stave off the onset by doing a few things. So, one is cardiovascular exercise and the recommendation for cardiovascular exercise is a half hour of moderate cardio. You don’t have to be running, you can be doing a brisk walk. Half an hour, five days a week is shown to reduce risk of development of Alzheimer’s disease.
Dietary modifications. You don’t have to do a crazy diet, but we generally recommend something called the Mind Diet, which is a combination of a traditional Mediterranean diet, lean protein, fish, chicken, leafy greens, nuts, olive oil, those sorts of things in combination with a low sodium diet called the Dash Diet. So that’s going to help keep your blood vessels healthy, keep your cholesterol in check, keep your blood pressure in check.
I also want to emphasize blood pressure maintenance is really critical. There was a study called the Sprint Mine Study, where folks who kept their systolic blood pressures below 120 during the duration of this monitoring period actually reduced their risk of developing Alzheimer’s by about 20%.
So, blood pressure maintenance is important, not smoking - critical, and also moderation of alcohol use is important as well.
Dr Alessi: So everybody wants a magic pill, right?
Dr. Zdanys: Yes, of course.
Dr Alessi: And their supplements and things like that, most commonly, Prevagen.
Dr. Zdanys: Mm-hmm.
Dr Alessi: Does it work?
Dr. Zdanys: No.
Dr Alessi: Okay.
Dr. Zdanys: So, the FDA is actually after them for misleading advertising.
Dr Alessi: Okay. Because if you follow the ads and it’s all out there. Let me ask you a question. How hard is it for you, and I know it’s hard in my practice to tell people they can’t drive anymore?
Dr. Zdanys: Mm-hmm.
Dr Alessi: You must have to do that a lot.
Dr. Zdanys: Yeah, so, and it’s tricky because I’m not sitting in the car as a passenger with them.
So, I don’t know each individual kind of where they are and what they’re doing. But what I know is that when people have forms of dementia, like Alzheimer’s disease, one of the most majorly impacted aspects of their cognition is actually, it’s not just memory, but also their reaction time. And what I tell people is, listen, if you’re driving down the street, and a kid or a dog runs in front of your car, if you can hit the brake in half a second, that kid might be okay. But if you hit that brake in a second and a half, then we could have a completely terrible outcome. So looking at it from that perspective of safety of an individual, I think can sometimes be very compelling for folks to actually go and get a professional driving assessment where things like reaction time can be measured.
So it’s not a, you know, punitive measure. And I know symbolically taking away someone’s license is horrible in terms of their kind of self-concept and their independence.
Dr Alessi: Only because we don’t have good public transportation.
Dr. Zdanys: Well, this is a whole nother category that we could talk about.
Dr Alessi: I mean, if you lived in a city with public transportation, it’d be fine.
Dr. Zdanys: That’d be totally different.
Dr Alessi: But I think that’s it.
Dr. Zdanys: Yeah, no, here, you know, if you’re living in Farmington or Avon or somewhere, you may feel extremely isolated.
Dr Alessi: Yeah. So along that lines, when you’re thinking of in your field, what’s something our listeners need to know?
What are some of the things that are happening in your field that folks need to know about?
Dr. Zdanys: Yeah, so I think historically talking about mental health and cognitive health has been taboo, especially in the generation of adults who are older now, but number one, we do have effective treatments for many of our mental health conditions like depression and anxiety, and for folks who are experiencing memory changes, it’s worth mentioning to your doctor as soon as you are concerned.
Because the treatments that we have are most effective in the very earliest stages of our disease. Once the Alzheimer’s progresses to a more moderate stage, somebody might no longer be a candidate for things like our infusion medications. So, I think the earlier you can bring it up with your doctor and start that process of working it up, the better. And if your result is, “hey, you don’t have Alzheimer’s”, then wonderful, you know that. But if it is, “hey, yeah, it looks like your brain has the changes consistent with Alzheimer’s disease”, well, let’s talk about that and what we can do to get started on treatment as soon as possible.
Dr Alessi: Kristina, thank you.
Thank you for your time today. Thank you for everything you do for our patients here at the University of Connecticut.
Dr. Zdanys: It’s my pleasure. Thank you for doing this.
Dr Alessi: Many thanks to our guest today, Dr. Kristina Zdanys. If you have any questions or ideas for future programming, you can reach out at healthyrounds@uchc.edu.
Jennifer Walker is executive producer of the Healthy Rounds podcast. Chris DeFrancesco is the studio producer of the Healthy Rounds podcast. This is Dr. Anthony Alessi. Until next time, please stay healthy.

Bonus Episode: Remarkable Advances in Spine Surgery

A glimpse into the future of surgery came last year, when a surgeon in Orlando operated on a patient 7,000 miles away! Yet diagnosing a painful disc still comes with a number of challenges. Could figuring that out lead to better decisions on surgery versus conservative management? Dr. Alessi revisits his conversation with Dr. Moss, chair of UConn Health’s Department of Orthopaedic Surgery, particularly in the area of advances in spine surgery, including robotic and augmented reality procedures.
Submit questions for Healthy Rounds:
HealthyRounds@uchc.edu
Dr. Isaac Moss:https://www.uconnhealth.org/providers/profiles/moss-isaac
UConn Health Comprehensive Spine Center:https://www.uconnhealth.org/spine
The Brain and Spine Institute at UConn Health:https://www.uconnhealth.org/brain-spine
UConn Health Orthopedics and Sports Medicinehttps://www.uconnhealth.org/orthopedics-sports-medicine
UConn Health:https://www.uconnhealth.org
Grant support from Coverys:www.coverys.com
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date, timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery and a grant from Coverys. This podcast is not designed to direct your personal health care, which should only be done by your physician.
I’m your host, Dr. Anthony Alessi, and today what we’re doing is what has come to be known as our deep dive, where we talk a little bit about the previous week’s interview. And in this case, it was done with Dr. Isaac Moss, who is professor and chairman of the Department of Orthopaedic Surgery at the University of Connecticut. He’s also a fellowship-trained spine surgeon. And there were several issues that he brought up that I feel need further attention and I went back and dug out a little bit more information on that I’d like to share with all of you.
I think one of the things he talked about is comparing our system with that in Canada, where we have so many spine surgeons in Hartford as opposed to Montreal, and he talks about increased access here in the United States to surgery. And I think that that’s important because, and it’s not necessarily a bad thing, but nevertheless, it has us shy away from conservative management. In many cases, when he discusses diagnostics, it appears that over a period of time where you may be waiting for surgery, your symptoms resolve.
What I found also interesting was that from a diagnostic standpoint, we really can’t diagnose a painful disc, and I see that in electrodiagnostics all the time in EMG, which is what I do, in the sense that I’m going to see someone who has a painful disc and you would think that would have neurologic impairment and does not. By the same token, you’ll see somebody who has a horrible MRI and has no pain at all, but clearly has neurologic deficit on their exam and on the electrodiagnostic studies. So he raises such a good point with respect to how we are lacking in the field of diagnostics. We haven’t really figured that out yet.
And as he points out, as you get to over the age of 50, you’ve got a 50% chance of having an abnormal MRI. So is it an imaging issue? Is it a clinical issue? And I think we really have to resolve that if we’re going to be treating the right patients with surgery or conservative management in order to make that decision.
The other thing, the two other things actually I wanted to talk about: First, he talked about these enabling technologies, and I thought that was a good way to put it. You know, we’re dealing a lot with robotics now and how much that has really changed the practice of surgery, and medicine in general. But in terms of surgery, with these enabling technologies that we are fortunate to have here at the University of Connecticut through UConn Health, it really gives you a totally different image. Now, he brought up something I didn’t know about, and that is using robotics through augmented reality. And with this augmented reality, he’s able to make a smaller incision, right, so really a limited surgery from the standpoint of it being invasive and at the same time really making it more accessible to him. So he can see the same things that he would if he did a much broader surgery, with a bigger incision and being more invasive, with this new technology. And with these robotics, it’s really eliminated a lot of complication and longer recovery times.
Let’s just think about that. I mean, smaller incision with augmented reality, less recovery time, and people are enabled, a good word for it, to get back to work sooner, get back to their life, get back to their sports, rather than being more sedentary.
So these enabling technologies were interesting, but he also mentioned the idea of telesurgery, and I wanted to really discuss that a little bit. In May of last year, 2025, they performed the first long-distance surgery from the standpoint that a patient in Angola had prostate surgery by a physician in Orlando, Florida.
So how does that happen? Well, you have to understand this telesurgery is really where the patient is in an operating room, in this case, in Angola, with a surgeon, with a nurse and a full operating room. But when it comes to the particular part of the surgery that requires more skill, someone who is fellowship trained, as in this case, Dr. Patel in Orlando, he can take over the surgery. And it’s an interesting device. I mean, his head goes into, I mean, it’s a computer with a kind of virtual reality kind of thing here, and he’s able to do surgery. Now, the biggest obstacle has been, whenever you do something online, there’s a lag time, right? So there’s a time where there’s a lag between when you do something and when it gets done, when that motion happens. And that’s been the biggest difficulty. We’ve now, thanks to technology, been able to get that down to six milliseconds, so six thousandths of a second. And that allows enough surgical accuracy and precision to do the surgery. And again, it’s done in three dimensions. The vision of the surgeon in Orlando was three dimensional.
That is also going to be the case with complicated spine surgeries, as Dr. Moss mentioned. And this opens up really a tremendous opportunity for patients who live in isolated areas, in the United States and throughout the world. Again, you need technology on the other end as well. So there is a mobile 3D unit operating in Africa, in Angola in this case, so that it can go from hospital to hospital. So not every hospital has to invest millions of dollars in this technology.
Just thinking about this in terms of brain surgery, in terms of cancer, removing complex tumors of people who can’t get to huge medical centers, I believe is fascinating and really, for me, just so hopeful of the future of medicine. So I’m so happy Dr. Moss brought that up so we have some time to really delve into it, and I recommend you read more about it. There’s a lot of it online, a lot of articles, about telesurgery.
With that, I want to once again thank Dr. Moss for his time in doing this podcast.
If you have any questions or ideas for future programs, you can reach out to me at healthyrounds@uchc.edu. Jennifer Walker is the executive producer of the Healthy Rounds podcast. Chris DeFrancesco is the studio producer of Healthy Rounds, and really the guy who puts all this together. Tessa Rickart is in charge of all our social media and does a phenomenal job of getting the word out, and you could always get this podcast on Apple, or you’ll see it on Instagram and other outlets.
I look forward to next week, when we will have as our guest, Dr. Kristina Zdanys. Dr. Kristina is going to talk to us about dementia and potential treatments for dementia.
Until next time, this is Dr. Anthony Alessi. Please stay healthy.

Spine Surgery’s Advances and Promising Future

More than eight in 10 of us have had or will have back pain, but far fewer will have surgery for it. Those who do have surgery enter a realm of innovation like few other areas of medicine. That’s what drew Dr. Isaac Moss into the specialty, yet he says there’s still so much we don’t know. Dr. Moss, renowned spine surgeon and the chair of UConn Health’s Department of Orthopaedic Surgery, discusses the advances in spine surgery, its promising future, and the importance of academic medicine, and offers his first-hand perspective on the health care systems in the U.S. and Canada.
Submit questions for Healthy Rounds:HealthyRounds@uchc.edu
Dr. Isaac Moss:https://www.uconnhealth.org/providers/profiles/moss-isaac
UConn Health Comprehensive Spine Center:https://www.uconnhealth.org/spine
The Brain and Spine Institute at UConn Health:https://www.uconnhealth.org/brain-spine
UConn Health Orthopedics and Sports Medicinehttps://www.uconnhealth.org/orthopedics-sports-medicine
UConn Health:https://www.uconnhealth.org
Grant support from Coverys:www.coverys.com
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up to date and timely information that’s brought to you by national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopedic Surgery, in addition to a grant from Coverys.
This podcast is not designed to direct your own personal medical care, and that should only be done by your physician. I’m your host, Dr. Anthony Alessi, and it’s great to have as my guest today, Dr. Isaac Moss. Dr. Moss is professor and chairman of the Department of Orthopedic Surgery here at the University of Connecticut.
He is also a fellowship trained spine surgeon. Welcome to the show, Isaac.
Dr. Moss: Thank you, Tony. Great to be here.
Dr. Alessi: First of all, let me thank you for your support of this podcast, which we’re looking forward to really furthering medical information coming from our institution. To begin, I want to go back a little bit, back to 2019.
Here you are at the University of Connecticut. You’re a very successful, well-known spine surgeon. You have grant support and suddenly you are thrust into the limelight of being chairman of one of the largest departments at the University of Connecticut, certainly one of the busiest. Walk me through that.
I mean, did you want to become a chairman because you were fairly young at the time? And when I think of chairs, I mean, they’re usually older folks.
Dr. Moss: So, I appreciate first of all that shout out and calling me young. I’ll let my kids know. But yeah, I think I was a little, I was typically a little bit younger than the average person who takes this kind of job on, but, you know, sometimes kind of opportunities come your way and they’re hard to say no to. And this particular opportunity, you know, we’re lucky. We have a tremendous, tremendous orthopedic department, all specialties, great people, great education, great research. And at the time there was a transition at the health center and the leadership came to me and said, “Hey, you know, we need some leadership in the department at this time, we think you’re well suited to do it.” And that was flattering, first of all, and somewhat hard to say no to, especially if you ask my mom.
But, you know, so I took a step back and said, okay, is this something, well, you go from a sort of your own practice to leadership, you have to change your focus from what’s good for you and what’s good for your patients is obviously your main focus, to what can you do for everybody else? And, you have to be at a certain point in life where you can do that, first of all, and a certain attitude to do it. And, so actually the first thing I did was I sat down with a group of orthopedic surgeons. I said, “Hey guys, is this something you want me to do?”
Right? Because one of the great things we have in a department is we have a tremendous team, right? So even though we’re individual surgeons, we all have our subspecialties, we really work as a team together. And I think that’s one of the strengths of our department because we get that whether it comes to patient care, right, so in fact, yourself, Dr. Alessi, you’re part of our department. And so how often do I send you a patient saying, I’m not sure what to do with this person. They have some particular neurologic problem. Can you help me define it so that I can give them the right care?
That also happens sometimes somebody comes in, we think is a neck problem, maybe it’s a shoulder problem. I have great colleagues that can do that too, so that is a tremendous asset to our department. And so, which is one of the reasons I said, “Hey team, if we can do this together and we can make ourselves better, I’ll take this on as a responsibility.” And it was, you know, a tremendous privilege to be able to do it. Certainly, I’m not sure that it made my life any easier, but it’s been an education and a privilege to do so for the past six or seven years.
Dr. Alessi: You know, and I think that’s a rarity. Having lived through that, those events with you, I mean, to have the unanimous support of your department, makes a big difference when becoming chair.
But let’s talk about now. I mean, so now you’re chair of the department the last six years. What’s the biggest challenge? I mean, there are a lot of challenges. I mean, you have to coordinate clinical care, right? We have research to deal with, funding, teaching. What’s the biggest headache?
Dr. Moss: That’s a tough question.
I’ll start off with saying what’s the, you know what’s interesting is, and one of the nicest things about this job is I certainly don’t need to motivate my employees, right? So, like, orthopedic surgeons are intrinsically motivated to work hard. And so in a way, while it’s a blessing certainly, but you know, we also work in a large institution and there’s a lot of moving parts to this institution.
So really what I lose sleep over is how do I set things up or how can I work with the rest of the institution to almost allow our surgeons to be as productive as they want to be, right? And not only surgeons, we have, as you know, surgeons, neurologists, non-operative doctors, physiatrists and all these, there’s all these providers who want to provide care for their patients and sometimes their pace may exceed the pace of the rest institution for certain cases.
And that’s again, it’s not to the fault of the institution. It is a big place and there’s a lot of priorities, so how do I make sure that our providers can almost work to their capacity. And again, everybody wins that way. We’re getting them, the institution’s getting the most out of their providers.
Our patients are getting the most of their providers and the department. That’s one challenge. But we also have to balance clinical care is one of our pillars. But there’s three pillars in an academic environment. There’s patient care, there’s research, there’s education. And trying to balance all those things, especially in an environment where one of them is financially is driving, some are less so.
But again, we don’t want to lose our mission, which is again, to make sure we’re educating the rest of the next generation of orthopedic surgeons to develop the new knowledge through research that’s making everybody’s care better and at the same time treating our patients in Connecticut and making sure they have excellent orthopedic care.
Dr. Alessi: So, I think you may have answered the next question, but what do you think are the goals for the department now that you look at the future of orthopedic care? I mean, you must go to meetings, you must meet with other chairs, and what are the trends towards departments? Are most people facing the same challenges? Is funding an issue?
Dr. Moss: Sure. Yeah, I mean, actually one of the, it is nice to go to some of these meetings sometimes because you realize that regardless of an institution, we all have the same problems to a certain extent, and they may be highlighted more in one than the other, and there may be particular nuances, but really if you look at it in general as orthopedics, we’re very lucky because we can generate significant revenue, but we also need to get that reinvested in our business, right? Which means to provide care, which is whether that’s expansion, whether that’s new technology and equipment which we’ll talk about later, whether that’s just ensuring that, again, we have the infrastructure to provide the care we want. The second part though, is how do we balance that with some of the non-revenue generating activities, right?
Like research, which can, but not always, or like education, which again, without that why we’re really here. I mean, our doctors are here because A, they love to provide care, but B, they want to be teaching. That’s exciting. That actually just makes our job interesting, and in fact, I think it actually improves the quality of care because we have a young doctor asking us, “Hey, why are you doing that today?”
Right? I’m not just sitting there doing whatever I want. I’ve got to justify my decisions to a very smart orthopedic resident or spine surgery fellow every day, which actually makes me a better doctor I think, and makes me give better care to our patients.
Dr. Alessi: Absolutely. I agree wholeheartedly. You came here from Canada and trained in Chicago at Rush in spine.
How does your experience here compare to medical care in Canada? And I use it as a general term, you know, delivery of care, quality of care, access to care, how do we compare? Because people are always saying, “well, the Canadian system, everything’s paid for”, and things like that. Give us some insight since you’ve worked on both sides of the water.
Dr. Moss: Yeah, so it’s interesting. I think first the easy part is I think quality of care is the same once you get down to, once you get the healthcare that you’re getting in Canada, and again, being part of that system, having relatives and colleagues that work in the Canadian healthcare system, once you are there, once you get to the doctor, you’re getting very high quality care.
I think the issue that the system has is access, right? And if I compare to here, we almost have too much access, right? So I grew up and I went to medical school in Montreal, which is the city of, I don’t know, four and a half million people or something like that, at this point. I think there are more spine surgeons in Hartford, for instance, than there are in Montreal.
Dr. Alessi: Really? Wow
Dr. Moss: Right, which is probably a quarter of the population. And again, so, the issue we have here is it’s, in certain respects, access is almost too easy, right? You have an itch in your nose, you’re going to go see an ENT surgeon. That’s not necessary, right? Probably you should wait it out or go to your doctor, right? Or for instance, I remember when I started my training when I was in Chicago and somebody came to our spine surgeon’s office with like two days of back pain. Now, back pain is ubiquitous. 85% of people have it and most of it goes away.
So you know the idea that you’re in a spine surgeon’s office within a couple of days. To me, this was in Canada that would never happen. By the time you get to the surgeon, you need the surgeon. Whereas here, because of access, because of market forces, it is just different, right. And so to me, I think some of the, now granted there’s extremes to all of this, and there are people that are probably waiting too long for their care in the Canadian healthcare system.
And that’s been the subject of some debates, that’s been the subject of some healthcare changes that are happening up there. But the flip side is, it is a bit of a barrier and probably does in a way regulate some of the care, which may not be entirely necessary that happens in this country.
Dr. Alessi: It’s interesting, but I guess it leads into my next question. Do we operate too much here in America? When you look at the literature, right? I remember the early Swedish studies done at the Volvo plant, and they were really seminal articles about how, you know, conservative management really help these people stay on the line.
And that must be, what, 30 years ago or more. Do we operate too much?
Dr. Moss: As a surgeon, I would say I think to a certain extent we do, right? And I think there’s a lot of things, though. I don’t know that it’s necessarily driven by physicians, driven by patients, driven by marketing. But again, when you have access to something and people are, I mean, again, people are in pain, right?
And part of it is you can see as a patient, and you’ve seen these patients yourself as a neurologist, you know, if you have a really bad sciatica and I’m telling you, "Hey man. Most likely you waited out six weeks, this will go away.” Not everybody wants that.
Dr. Alessi: No.
Dr. Moss: Right. And I’m a very conservative surgeon in general, and I will really sit there and in fact, it’ll take me more time to talk a patient out of surgery than I would just say, “Hey, have your discectomy. It's a quick operation,” but I know that if it was me or if it was my family member, which is how I always try to treat my patients, I would say, wait. In fact, I had a hernia disc in my neck a couple years ago. I waited. It was a miserable three months. But it went away. I never ended up with surgery. So for the not wrong reasons, right?
Patients are there, they have issues that we can help. But this idea, and then part of it is we just live in a quick fix society. Everybody wants everything now. And if I say, wait six weeks, you’ll get better versus have surgery next week and you’ll get better next week, a lot of people would sign up for that.
Right or wrong, it may not be necessary.
Dr. Alessi: Good point. Let’s talk about some of the advances. I mean, spine surgery is one of the fields that we look at where we’ve seen so many advances in how things are done. I mean, the operating room looks nothing like when I was a medical student and when I was in training and certainly over the last 30 years.
Dr. Moss: That was candlelight then, right?
Dr. Alessi: It was candlelight. And, you know, you just had to wash your hands. No gloves. But just looking at that, what are some of the biggest advances you’ve seen since you’ve been practicing spine surgery?
Dr. Moss: It’s funny you should ask that because that is actually the reason, one of the reasons I went into spine, so I remember my first rotation of residency, two amazing things happened.
So number one, I showed up and turned out the attending was actually my hockey coach when I was six years old. So Stephen Lewis, who’s a tremendous spine surgeon in Toronto, taught me how to skate as well. Which again is funny from a very stereotypical Canadian story I think. But, so I showed up, I said Coach Steve, and he was doing these amazing things and, him and this other guy, Raj Rampersaud, who this was 2003, so it was the beginning of some of this navigation technology, minimally invasive surgery.
And I walked into this OR, things I had never seen before in my life as a medical student. And I said, wow, there is opportunity in this field to innovate. And that was actually one of the things that really drove me towards spine surgery, I ended up learning from them. I took two years in the middle of residency, I did a master’s of bioengineering looking at how to regenerate, some of the, because there was just such a need, right?
We didn’t know what we were doing to a certain extent. We could do certain things, but really when you look at the larger picture, there was so much we didn’t know about spine surgery. And to me that was the most exciting thing and which is honestly what pushed me to choose that as a specialty.
There are things in my practice I do now I never even heard of in residency, which is pretty cool, right? I mean, that’s over 15 years ago. But it’s procedures that I do routinely that did not exist. There’s technology that I use routinely that did not exist. And when I think of what’s coming next, I mean, it’s a super exciting field, right?
And there’s so much we don’t know. So, I’ll hit on two things. So, number one is diagnostics. So, if you think about it, and again, you see this in your practice. We have no idea how to diagnose a painful disc in your spine, as crazy as that is, right? So again, back pain is ubiquitous. Everybody has it to a certain extent. But the problem is if you take an MRI, if you do an MRI of everybody, whatever decade you’re in, more or less, that’s the chance you’ll have an abnormal MRI. So if you’re 50 years old, there’s a 50% chance you’ll have an abnormal MRI regardless of symptoms.
So, I see patients with terrible MRIs and basically no pain, patients with beautiful MRIs and tons of pain. So, there’s something we’re missing, right? And there are studies, there are things being done on this front. So, there’s different MRI sequences that people have been experimenting on. There’s a group in San Francisco that’s been doing this and trying to commercialize how to say what is painful.
We’re looking at some different kinds of nuclear medicine studies, but again, that whole world, we can’t even diagnose. Imagine this, we have this whole treatment. We can treat, we can do all these things, but we don’t even say, “Hey, this is the disc that hurts.” So, I think that’s a huge opportunity for the future and we’re going to see a lot of investment, I would say, in making that, because if we could narrow that down, the reason spine surgery gets a bad wrap is a diagnosis problem. It’s not a surgery problem, right? The surgery generally works, but are you doing it on the right person at the right place? So that’s one side of things.
The other side is what we call enabling technology. So, enabling technology allows us to do surgery that we were doing before, but in an easier way. So, this robotics was one thing. So, we were actually one of the first in New England to have robotic-assisted spine surgery where that helps us, almost guides us. And it used, it’s actually an Israeli company that used missile-tracking technology to allow us to then track and put screws in the spine.
And, very, very cool technology. So we had that for a while, and now over the past several years, been using Augmented Reality. And so what this is, it’s actually x-ray vision, more or less. It’s like a really awesome thing. So it will project the spine through your body. So now through tiny incisions, I can see exactly where I am, do exactly what I was doing in open surgery, but without the morbidity of that kind of a procedure.
Dr. Alessi: So, it sounds like these enabling technologies are things we’re going to be seeing. So, when you’re sitting back here 10, 20 years from now, do you think these enabling technologies are going to be the thing that we’re talking about? 
Dr. Moss: Hopefully we’re not talking about them ’cause they’ll be so commonplace, right? It’s like we don’t talk about FaceTime anymore. I mean, we think about the iPhone in our pockets, right? Like when that came out in 2000 and whatever, nine, that blew our minds, right? We had Blackberries and all of a sudden we’re like, you know? So I don’t think we’ll be, we probably won’t be talking about it. I think it would be cool ’cause we probably won’t be talking about it, but what would be awesome would be, and again, not necessarily good for our business here, but this should commoditize surgery. It should make no difference if Tony Alessi is having a spine surgery at the University of Connecticut or in the middle of a cornfield somewhere, right?
So as long as you have a spine surgeon, this technology should level the playing field and allow us to that everyone’s care, to deliver the same care no matter where you are. And I think then society will be better on a whole.
Dr. Alessi: Boy, you’ve certainly given all of us something to really think about. Isaac, thank you for your time today.
It’s been great to have you. And, thank you for all you do for our patients here at the University of Connecticut.
Dr. Moss: Thank you, Tony. Pleasure.
Dr. Alessi: Many thanks to our guest today, Dr. Isaac Moss, who is professor and chairman of the Department of Orthopedic Surgery here at the University of Connecticut. If you have any questions or ideas for future programming, you could reach out to healthyrounds@uchc.edu.
Jennifer Walker is our executive producer here.
Chris DeFrancesco is our studio producer for the Healthy Rounds podcast.
Until next time, this is Dr. Anthony Alessi. Please stay healthy.

Bonus Episode: Social Services Deep Dive

Dr. Alessi drills down on a number of topics discussed with Connecticut's Social Services Commissioner Andrea Barton Reeves, including Medicaid truths, social determinants of health, and how the ACEs survey fits into overall health.
Submit questions for Healthy Rounds:HealthyRounds@uchc.edu
DSS Commissioner Andrea Barton Reeves:https://portal.ct.gov/dss/knowledge-base/articles/home/dss-commissioner
UConn Health:https://www.uconnhealth.org
Support from UConn Health Orthopedics and Sports Medicine:https://www.uconnhealth.org/orthopedics-sports-medicine
Grant support from Coverys:www.coverys.com
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date and timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery and a grant from Coverys. It’s not designed to direct your personal health care, which only you should work out directly with your physician.
I’m your host, Dr. Anthony Alessi, and it’s great to be with you for what has come to be known as our deep dive, and that is where we look at the most recent podcast we did and try to drill down on some of the topics that were only able to glance over. This particular podcast was done last week with Commissioner Andrea Barton Reeves.
Ms. Barton Reeves is the commissioner for the Connecticut Department of Social Services. That is the part of our state government that oversees Medicaid, and Medicaid is a pretty general term here in Connecticut. We refer to it as HUSKY, but we always think of it as just being this kind of handout program where it just takes care of one thing, like doctor’s visits.
Medicaid is an all-encompassing program, and it’s done in conjunction with the federal government for people who qualify economically. Now these are people, many of whom work, but they don’t make enough. They are below what is determined as the poverty line, and when you’re below that, you’ll need some assistance in order to provide meals for your family, to provide health insurance or health care, which is the HUSKY program, and some of it is hospitalization. It is used for durable goods, such as crutches and canes. It’s used for home health care, so there are a lot of different facets of it. Among them is also the nutrition program. We call it SNAP, the Supplemental Nutrition Assistance Program here in Connecticut. People refer to it as food stamps in the past, or an EBT card. This also provides free breakfast for children. So it looks at a lot of different aspects, and there are over a million people who’ve received some form of Medicaid in the state of Connecticut.
So that’s a big part of our population and it has a $9 billion budget. But as I mentioned, it’s got a lot to do with a lot of different services. One of the things we talked about is the importance of those services in terms of childhood development and the risk factors going forward. I brought up the idea of childhood separation, which is something we’re hearing a lot about with people who might be undocumented immigrants who came here trying to find a better life for themselves now being separated from their children. And it brought to mind something we mentioned, which is the ACEs score, the Adverse Childhood Experiences score or survey. And this is a survey that was designed to look at experiences in childhood before the age of 18 that may in some way impact the future of children, specifically with respect to health.
There are a lot of variations on the ACEs survey, but particularly what they look at are childhood experiences related to trauma, meaning death in the family, shooting. Was a parent or a close relative put in prison or incarcerated for a long period of time? Was there a lot of divorce or fighting in the family? Was it a broken home in some way, shape, or form? So these are all experiences. Also more violent ones: Were they witness to a crime? Did a close relative die by suicide? And what they have done is really looked at the social outcomes and these scores. And it’s interesting because it has clearly shown that children with a higher adverse score were more prone for increases of injury to themselves, sexually transmitted infections, early pregnancy were among them, but also chronic illnesses like cancer, diabetes, heart disease, and taking their own lives by suicide. So these scores are quite important in terms of how they stress the entire social services system, and it’s important that we look at that.
The other factor that we talked about are the social determinants of health. And the social determinants of health was something I brought up, because it’s a firm belief of mine that unless we address social issues, we’re not going to make progress in terms of improving the health. We all hear about this Make America Healthy Again. Well, we need to take a step back and look at how we got unhealthy. And if you look back at that, a lot of it has to do with how society has changed and how we have to deal with these social determinants. So there are five basic social determinants of health.
We look at education, access to education, and quality of education for an individual.
We look at health care, access to health care. Do you live in a rural community? Do you not have transportation to get to good health care? And what is the quality of the health care where you’re living?
We look at your neighborhood or what we call the built environment. Where are you living in terms of the physical structure? Is it an apartment? Is it a house?
And the next thing that goes with that is kind of the social and community context of where you’re living. Is it truly a community? Is it a supportive community? It could be a church community, it could be a very supportive neighborhood and ethnic community. But again, it’s an important determinant.
And obviously the last one being economic stability, economic stability being so important for these social determinants of health.
What I found interesting is, in looking at some articles on social determinants of health, is how it relates back to a previous podcast we did with Dr. Peter Schulman. Dr. Schulman impressed upon us the fact that heart disease has really changed. It’s been a paradigm shift from ischemic heart disease or heart attacks to now heart failure, where the pump begins to fail, the heart itself, whether it be by infection or primarily old age as we live longer. So with heart failure, we are trying to address that with different medications, a lot of different care. It’s very different from angioplasty and bypass surgery and things such as that.
So a recent article looked at people who were hospitalized for heart failure and they wanted to look at the readmission rate. So this has been a big factor throughout health care and something we monitor, when someone is in the hospital and gets discharged, how long before they are readmitted for the same problem? Right? Because when you’re thinking about it, you start thinking, “Well, maybe we didn’t fix the original problem and that’s why they needed to come back. Why did these people have to come back?” And what they found was in heart failure, one of the biggest reasons for people being readmitted were these social determinants of health, meaning we addressed the problem, but they were going back to an environment which was not supportive. They did not have good access to health care. They did not have the support. They lived alone, for example, didn’t have a support system for them, or it was just basic economic stability. Could they afford these very expensive medications to keep them out of heart failure?
So I think when I came away from the interview we did with Commissioner Barton Reeves, it was awakening for me to see that how much her whole department really impacts everything we do in health care at UConn Health. And I think it’s important for us as people who deliver health care, as those of us who are friends of people who are ill, is that we have in the back of our minds how to keep our patients healthy, and work with them and ask more questions about their social position and what support services they have, after we treat patients.
With that, I look forward to our next encounter. Next week we’re going to be chatting with my boss here at UConn Health, Dr. Isaac Moss. We did a taped interview with him that I know you’re going to enjoy about spine surgery, but also what’s it like being chairman of a department of a very busy, active department here at UConn Health? And I think you’re going to be amazed when I ask him the question of, what does the future look like in spine surgery?
Many thanks for listening today, as always. If you have any questions or ideas for future programs, you could reach out to me at healthyrounds@uchc.edu.
Jennifer Walker is executive producer of the Healthy Rounds podcast. Chris DeFrancesco is our studio producer for the podcast. Tessa Rickart is in charge of social media for Healthy Rounds. Until next week, this is Dr. Anthony Alessi. Please stay healthy.

Medicaid Myths, Keeping CT Families Healthy

Recognizing and addressing social determinants of health can have a great impact on our overall well-being. That also goes for the people who are responsible for the care of others, be it their children or an aging or sick relative. Connecticut has a number of services and programs available to help, and Department of Social Services Commissioner Andrea Barton Reeves joins Dr. Alessi to explain them, clear up misconceptions around some of these programs, and discuss some of the challenges around social services in 2026.
Commissioner Barton Reeves recently joined the UConn Heath Board of Directors.
Submit questions for Healthy Rounds:HealthyRounds@uchc.edu
DSS Commissioner Andrea Barton Reeves:https://portal.ct.gov/dss/knowledge-base/articles/home/dss-commissioner
UConn Health:https://www.uconnhealth.org
Support from UConn Health Orthopedics and Sports Medicine:https://www.uconnhealth.org/orthopedics-sports-medicine
Grant support from Coverys:www.coverys.com
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide up to date, medical and timely information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopedic Surgery and a grant from Coverys. It is not designed to direct your healthcare, which should only be done by your physician.
I’m your host, Dr. Anthony Alessi, and it gives me a great pleasure to have as my guest today, Commissioner Andrea Barton Reeves. Commissioner Reeves is the commissioner for the Department of Social Services here in Connecticut. She’s also a recently appointed member of the Board of Directors of UConn Health.
Welcome to the podcast.
Commissioner Barton Reeves: Thank you for having me.
Dr. Alessi: Let’s start out. You’re an attorney. What drew you to your career in advocacy?
Commissioner Barton Reeves: I would say that my parents were always, they were people that were very clear that we owed more to our community than just being three privileged children. So my father was a physician, he was a board certified child and adolescent psychiatrist, and my mother was a nurse.
She held a master’s degree and she taught at Columbia and worked at a large hospital in New York. But they were immigrants. They came really with nothing and worked very hard to get their own educations and to educate my brothers and I. But in the course of that, they made it clear that they actually had careers and, you know, in the medical profession that gave back to people.
And because so many people had made their lives and the success in their lives possible, that we had a responsibility to do that as well. So I think it’s been ingrained from the time I was very young. It’s my nature and all my brothers and I, we all are in similar fields in the helping professions and do very similar work.
Dr. Alessi: What a great legacy for your parents. You might be wondering why I’m having you on. Most of our guests have been physicians, but I wanna let you know that I firmly believe that the key to better health starts with the social situation of patients, whether they’re homeless, whether they have enough to eat, and now we’re hearing a new term, right? The social determinants of health.
Commissioner Barton Reeves: That’s right.
Dr. Alessi: And with that here in the state of Connecticut, we have a Medicaid program. Can you talk a little bit about the program and somewhat profile the people who are on it because there’s so much misinformation and disinformation out there. I read a recent opinion piece where they touted the fact that the people on Medicaid are here illegally, they are undocumented people.
And I know that for a fact that that is not the case. So can you really talk to us a little bit about who are the people on Medicaid in Connecticut? Are they working? Who are these people?
Commissioner Barton Reeves: Sure. And thank you for this opportunity because there is so much disinformation and really I think negative stereotyping of people who are on Medicaid. People who are on Medicaid can be individuals or families. And your eligibility for Medicaid depends on what percentage of your income places you at or below the federal poverty level.
And it’s a large, complex calculation with lots of charts and we won’t go into that, but in this state, over a million people are on Medicaid. What people also don’t understand is Medicaid is complex in the sense that it’s not just an individual or collective insurance policy for working adults or for children.
Medicaid dollars also pay for care in hospitals, and they pay for long-term services and supports with people who are at home. And Medicaid dollars also pay for federally qualified health centers and places where people get lots of care, and I don’t think people really understand that, and they believe that we’re spending the amount of money that we spend, we have a $9 billion budget for Medicaid in this state, but it also goes to pay for pharmacy.
And as I mentioned, it pays for people to be able to live at home, to stay out of nursing homes. It pays for acute care in nursing homes. It pays for a number of things that aren’t necessarily what people believe is their own belief around Medicaid, which is a person who is deliberately trying to suppress their income so that they can become Medicaid eligible. That is far from the truth of how this works. It also covers so many people who are disabled and can’t work. And so that there is no single profile of people who are on Medicaid, simply put. For every person that’s on Medicaid, it is a different and unique story.
Dr. Alessi: More recently, there have been changes in the regulations, right? Especially with result to the Supplemental Nutritional Assistance Program in terms of work requirements. And when looking at that, I found that interesting because it’s almost like the old HUSKY C we used to have where someone would have to be either working, looking for work, but in this case volunteering is one of the factors.
As I’m sure you are, I’ve been a big advocate for volunteerism, even in people when a patient tells me, “well, I’m retired”. Well, what does that mean? What are you doing? Okay, because there are people who need your help. So, can you talk to me a little bit about how is that gonna work?
How are people supposed to do that? We know, and I think the number is what, 350,000 people, or some ridiculous number. They’re not gonna go out and find a job, so they’re either going to have to claim disability or volunteer.
Commissioner Barton Reeves: Well, let me try to provide some context around the numbers.
The changes that happened in HR1, OBBBA, the One Big Beautiful Bill, all the ways that people refer to it only reference a specific population in Medicaid. It is not the entirety of those who are on Medicaid. So the vast majority of people who are on Medicaid in this state that include all the populations that I just named, they are not impacted by this.
It’s only what we call our HUSKY D because our program here in Connecticut, right, is called HUSKY. That’s Medicaid, right? Lot people don’t know that either, and that’s what we call the expansion population. Those are people who, during the Biden administration, were given an opportunity to join the Medicaid program who normally would not have qualified because they’re just a bit over income and a bit over the assets for what you would normally have, but still not enough to be able to provide themselves private insurance.
As an incentive to have more people enrolled in Medicaid, which are fewer people that are uninsured, right, conversely, we were offered, and all states who agreed to this were offered a very generous federal match of 90% of what we spend, and then the state would have to come up with the 10%.
So now for the expansion states, as we call them. In this state, we have 365,000 people about who are in that expansion population. About a third of them are at risk of being impacted by these newly changed rules for what we call HR1, meaning that if they cannot find a way to fit into the categories of exemption, then they’re gonna have to find a way to provide proof of being involved in community engagement. And, you know, the same thing, it’s called work requirements. Those terms are used interchangeably. But it means that they have to volunteer, they have to work, or for Medicaid, they have to have income that’s equivalent to $580 a month, which is really the federal minimum wage times 80 hours or some combination of those monthly in order to continue to qualify for Medicaid. If they can’t, then they’ll drop off. Then they have to find a way to get back on by complying with the 80 hours.
Conversely, or comparatively, SNAP is completely different. The Supplemental Nutrition Assistance Program has always had work requirements. This is what people don’t know, right, they’ve had it since 1971. But now with HR1, there’s been some changes in the categories of people who were formally exempt from those work requirements that now are, so now it’s up to age 64.
If you’re caring for a child who’s up to the age of 14, you may be exempt. If you’re caring for a child with a disability who’s up to the age of 18, you’re no longer exempt because you or your child is no longer in that exempt category. Kids who were formally in foster care and then they aged out at 24, they were exempt before. They’re not exempt now.
So that new category of people under SNAP now, they also have to find work using the SNAP rules, which have not changed. And then in this state, the Medicaid rules that are now nationwide apply to people on Medicaid, which has never happened in Connecticut before. There are other states that had work requirements, Kentucky, Georgia, a few others. Some were more successful than others, but now every state has them because of the new federal law.
So that’s really how it works.
Dr. Alessi: So will we now have to monitor to make sure people are doing their volunteer hours?
Commissioner Barton Reeves: Well, not necessarily “we”, you know, the royal, “we” state of Connecticut. But there will be, and there have to be reporting requirements.
So that’s part of what every state now has to figure out how to hire a vendor who will adjust our systems and make all the changes so that people will be able to report. Yes, I no longer fit into the categories of exemption, and I have to meet the work requirements for Medicaid and SNAP. Here’s how I’ve been doing that.
I’ve been volunteering 10 hours at the library. I’ve been, you know, 5 hours at the hospital and I’ve got a job where I work 20 hours a week. Or for Medicaid, I’ve done those things or I don’t need to do those things because I do have $580 a month in income, whatever that looks like. Yeah, so we have the responsibility to do that.
That’s built into the statute. We have until January of 2027 when it becomes live for Medicaid. And we are running furiously at this moment to get everything ready so that when people start to be subject to these requirements in January for Medicaid, we will be ready for them. Yeah.
Dr. Alessi: I’m gonna shift gears a little bit.
Commissioner Barton Reeves: Sure.
Dr. Alessi: In your career, you’ve been a particular advocate for children.
Commissioner Barton Reeves: That’s right.
Dr. Alessi: You were the guardian ad litem, and, the past few days, we have all been focused on Liam Ramos. Okay, an undocumented child. One study came out today and said that he’s just one of up to 4,000 children who have been detained because their parents are undocumented.
We’ve not heard those stories here in Connecticut. And, for some reason I think we’re somewhat protected. Are these children safe here in Connecticut and what can we be doing to keep them safe?
Commissioner Barton Reeves: I wish I knew the answer to that question. I think it’s hard to define what safe looks like because the behavior of those that are charged with enforcing our immigration laws appears to be unpredictable.
So we don’t really know what safe looks like. We’ve seen children across the country moved from schools, you know, kind of picked up off the street, at the grocery store, wherever there happens to be. But I would say this, knowing what I know, in the 10 years that I’ve represented children, whatever children are violently and unexpectedly separated from their families, there is significant trauma that they experience.
There is no question about it.
Dr. Alessi: Absolutely.
Commissioner Barton Reeves: And the child’s ability to recover from that resiliency has everything to do with what happened to them during the time that they are away from their families and how well they’re supported when they return. Some children will be deeply affected for a very long time by what has happened, and some children will be affected but not necessarily scarred, and they’ll be able to move on with their lives, but will always have had that experience.
We tend to think that children sometimes are little adults or that they should be expected to get over very traumatic circumstances, but I can tell you that especially within the first five years of their development, traumatic separation from family can shape how they grow up for the rest of their lives.
So, you’re absolutely right and we all are to be very careful and very mindful about the indiscriminate ways in which we’ve seen children separated from their families and detained because the long-term damage from that that we’ll see societally, we haven’t even begun to measure yet.
Dr. Alessi: Yes, and many of us are familiar with the ACEs survey, right?
The Adverse Childhood Experiences survey, in which we have found that these experiences not only lead to psychological issues of PTSD, but diabetes, hypertension, obesity. So, you know, again, we get to the social determinants of health. You know, I take care of a lot of patients who have had brain injuries as a neurologist.
And one of the programs, if you could talk a little bit about, is where in home assistance is given by a family member and, is that only for traumatic brain injury or has it been extended to other people? For example, people with stroke who would otherwise be in a skilled nursing facility?
Commissioner Barton Reeves: That’s right.
Dr. Alessi: Can you bring us up to speed a little bit about that? I think a lot of physicians would be interested in that.
Commissioner Barton Reeves: So the state has a program known as Community First Choice. We refer to it by its initials, CFC as an acronym, and it is a program that is designed to provide individualized support in the home for people that need it.
Not just people with traumatic brain injury or stroke, but people who may have significant physical disabilities who without the support would most likely end up being in a long-term facility or a nursing home. There are two ways in which the state provides this support. One is what we call agency based care, and there are other private agencies that actually hire, excuse me, personal care attendants, PCAs, that go out into the community to a person’s home and provide them with support.
Then there is another population that is known as self-directed care. So, we have people who act as their own employer. And they can hire the personal care attendant that they’d like to care for them in their home, and that can include a family member. And there’s a whole process for that to occur. It does help people be more independent. It does help keep people out of nursing homes, which we know can be very expensive and a congregate care setting, and it can help to contribute to a much better quality of life. It can.
Dr. Alessi: You know, there are so many topics, and we could go on and on. But in closing, I’d like to ask you, if you were to design your own social services system, what would it look like?
Commissioner Barton Reeves: Such a great question. I would love to see social services be more individualized because we serve so many people, many states, not just ours. We’re in a legacy system where people have to go to 1 of 12 offices. They’re out usually in the middle of an industrial park, and people have to find their way to us.
It would be so much better if we had smaller spaces that were more connected to individuals in their communities where they could talk face to face to someone and not be on a line and not be in a building looks like a bus stop. You know, that’s my greatest wish is that we could really deliver services differently so that people could have the dignity that they deserve.
Just because you need Medicaid and SNAP doesn’t mean that you don’t deserve dignity, and I’d really love to see that change.
Dr. Alessi: I think that’s so important, especially the individuality of it because not everybody fits into the same box. And have different situations. So I really appreciate it.
Commissioner, I can’t thank you enough. It’s really been an honor to chat with you. I hope at some point we continue the conversation and thank you. Thank you for your time. But more importantly, thank you for everything you are doing for the people of Connecticut and our patients.
Commissioner Barton Reeves: I appreciate that.
Thank you so much. Thanks for having me. It’s been great.
Dr. Alessi: Thanks.
If you have any questions or ideas for future programs, you can reach out to me at healthyrounds@uchc.edu.
Jennifer Walker is Executive Producer of the Healthy Rounds podcast.
Chris DeFrancesco is the Studio Producer for the Healthy Rounds podcast.
Tessa Rickart is in charge of social media.
Until next time, this is Dr. Anthony Alessi. Please stay healthy.
 

Bonus Episode: Heart Month Deep Dive

Dr. Alessi revisits his American Heart Month conversation with UConn Health cardiologist Dr. Peter Schulman, drilling down on advances in prevention, treatment, and management of heart disease, heart attack, and heart failure, how they've changed over the years, and further changes potentially on the horizon.
The Healthy Rounds Podcast at UConn Health:https://www.uconnhealth.org/healthyrounds
Submit questions for Healthy Rounds:HealthyRounds@uchc.edu
Dr. Peter Schulman:https://www.uconnhealth.org/providers/profiles/schulman-peter
Pat and Jim Calhoun Cardiology Center at UConn Health:https://health.uconn.edu/cardiology/
UConn Health:https://www.uconnhealth.org
Support from UConn Health Orthopedics and Sports Medicine:https://www.uconnhealth.org/orthopedics-sports-medicine
Grant support from Coverys:www.coverys.com
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date, timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery and a grant from Coverys. It is not designed to direct your personal health care, which should only be done by your personal physician.
I’m your host, Dr. Anthony Alessi, and it’s great to be with you on what has become known as our deep dive. And this particular episode of our deep dive is dedicated to a show we did with Dr. Peter Schulman last week. As you’ll recall, Dr. Schulman is a cardiologist and professor of medicine here at the University of Connecticut, where he has practiced for 44 years, and he has been a cardiologist for longer than that.
But before we get to Dr. Schulman, I want to go back to something that was discussed in a previous episode with Dr. Juthani, and that was the use of messenger RNA. We’re hearing a lot about that this week, because the Food and Drug Administration refused to review a flu vaccine that is based on messenger RNA, that’s put out by the Moderna company. And they really haven’t given good reason for why they have refused to review this.
Now, let’s take a step back, because we know that the current administration has stopped research to the degree of $500 million cut, just on the topic of messenger RNA. And that’s because there is misinformation out there -- I almost think it’s disinformation, but it’s misinformation -- that messenger RNA, somehow changes a cell structure, and that’s not the case at all. Dr. Juthani used a good example of it, but I’m going to go a step further.
Messenger RNA is just that. It’s a messenger. It brings a message to a cell. Think about it this way: If you were to order food from Uber Eats or DoorDash, right, that food is brought to your door by a messenger, he leaves the food and then leaves your premises.
Think of messenger RNA as just being that messenger. He doesn’t come in your house and start telling you how to rearrange your furniture. He just brings the message about what it is your body needs to be fighting, in this case, the flu.
Now, one of our problems is that we keep coming up a little bit off target when it comes to influenza, and Dr. Juthani explained that it’s because we have to decide in February. So right now in February, we’re deciding what flu we’re going to be fighting in the fall. We base that on information that we get from the southern hemisphere with the flu. That is the flu strain that is most prominent there. It takes a long time because you grow it in eggs and that’s how you produce the vaccine messenger RNA.
And thanks to Operation Warp Speed, we are now able to come up with a vaccine in a much shorter period of time. So let’s think about it. If we could do it in a shorter period of time, we will have a better idea of what our target is. For influenza that year. So now we’re talking about instead of February, possibly doing it in May or June when we have a better idea of the target and a better chance of hitting it. So again, I want to emphasize the fact that messenger RNA is purely a messenger and it’s not changing your cell structure in any way.
But let’s get to our discussion with Dr. Schulman, which we put out on the airwaves on February 9, and that is, we wanted to get him on because this is American Heart Month. That’s something that was started in 1964 by Lyndon Johnson, and they did it to coincide with Valentine’s Day and the heart. And I guess, many of you listeners are probably my age or thereabouts. And remember, the one thing about the heart I remember is, Dr. Christian Barnard, right? Dr. Barnard, on December 3, 1967, he performed the first human heart transplant into a fellow by the name of Louis Washkansky in South Africa. Now it only lasted 18 days and, and that was ostensibly because we didn’t really have immune-suppressant drugs that would avoid this rejection of the heart. But it suddenly really brought to light that great things were possible.
And indeed, great things have developed since 1964. In a recent study -- and this is because I like to know, are we getting our money’s worth out of something, right? So we’ve made changes in our lives, changes in our lifestyle that Dr. Schulman talks about, right? A better diet, stop smoking, exercise regularly, and, and taking newer medications, but has it made a difference? And it’s interesting because a recent study published looked at heart disease mortality, so everybody who died of any heart disease from 1970 to 2022, and those deaths are down by 66%, the biggest drop being in ischemic heart disease, the typical heart attack from a clogged artery. That dropped from 91% of the overall deaths to only 53%. But what we have also seen is an increase in heart failure, where the heart, as Dr. Schulman again explained very clearly, the pump of the heart begins to fail. And a lot of that is because we’re getting older. So there are newer medications to really work on that because heart failure was up 146% since 1970. So again, we really want to emphasize that we’re making great strides, but now we are redirecting our efforts to a large extent.
The other things we talked about that were really most striking, we had a question from Bob about taking aspirin -- and again, if you have questions for me or things you want to address on the show, you can go to healthyrounds@uchc.edu -- and this was a question about aspirin. At first everybody thought everybody should be taking a baby aspirin as you got older. But again, it’s something you need to discuss with your physician because there are certain risks to doing that.
But the other thing we talked about was cardiac arrest. We’ve gone through great efforts to have programs to teach people CPR and how to use these automatic external defibrillators, the AEDs, and these are very important devices if we’re going to save lives. But once again, I asked him, has it been worthwhile?
And what was interesting to me, that 90% of deaths from heart attack occur before getting to the hospital. But when we looked at CPR and AEDs, we looked at the survival being about 25 to 35%. So again, if you have. A cardiac arrest where your heart stops outside the hospital, you still only have a 30% chance of survival. But again, we do know that the quicker you have CPR or use an A ED, your chances of survival are better.
But when you address the issue of, am I having a heart attack? Everybody has come up against this, and we hear about this all the time: I’m not sure if it’s indigestion. I’m not sure if it’s a heart attack. Dr. Schulman made it very clear that cardiologists don’t mind a false alarm here because 90% of the deaths from heart attack -- so everybody who dies from a heart attack, 90% of those -- occur before getting to the hospital. So it’s important, I think if there’s one message to take away from this podcast, it’s that if you believe you are having symptoms of a heart attack, the typical ones crushing chest pain, pain radiating from your chest to your jaw, to your left arm, or both arms. Any of those signs, especially the crushing chest pain, shortness of breath, get to an emergency room, it will certainly in many cases, be lifesaving.
One of the best parts of all our shows I enjoy is when we ask our guests. What will we imagine in the future, 40 years from now? What is the treatment of heart disease going to look like? And it was so interesting hearing from Dr. Schulman, because he talked about rebuilding the heart. Because we talked about that heart failure number having gone up. How do we rebuild the heart? And that’s where he thinks the greatest strides are going to be made, either by using stem cells that can be used for growing new heart muscle, or devices that can be placed in the heart, even just through the groin, that would again help the heart to pump more efficiently.
Well, anyhow, I think that’s about it from my end here. I really enjoyed Dr. Schulman and all the information he was happy to share with us, and I hope you’re enjoying this deep dive as we do them, and the guests as we come up with them.
Next week, I’m excited because we taped an interview with my guest, who will be Commissioner Andrea Barton Reeves. She is the commissioner for the Connecticut Department of Social Services, and we had a lively discussion about Medicaid, the people who are on Medicaid, and a lot of, again, misinformation that’s out there about the Medicaid program and SNAP programs here in the state of Connecticut.
If you have any questions or ideas for future programs, as I always mention, reach out to me at healthyrounds@uchc.edu. Jennifer Walker is executive producer of the Healthy Rounds podcast. Chris DeFrancesco is the studio producer for our podcast, and Tessa Rickart is in charge of social media for the Healthy Rounds podcast.
Until next time, this is Dr. Anthony Alessi. Please stay healthy.

Our Great Strides in Cardiology Care

Heart disease and heart attack are much more treatable, manageable, and preventable today than they were 40 or 50 years ago. For American Heart Month, Dr. Alessi speaks with Dr. Peter Schulman, UConn Health cardiologist, about the evolution of care for and prevention of cardiovascular disease, from medications to procedures to lifestyle changes.
Still, some things haven’t changed, including the crucial difference early intervention, defibrillation, CPR, and getting to the hospital as soon as possible can make with a suspected heart attack.
They also discussed the evolving recommendations on baby aspirin, the current and future state of statins, the difference between the sexes when it comes to heart disease, and the continued trajectory of cardiology care in the future.
Submit questions for Healthy Rounds:HealthyRounds@uchc.edu
Dr. Peter Schulman:https://www.uconnhealth.org/providers/profiles/schulman-peter
Pat and Jim Calhoun Cardiology Center at UConn Health:https://health.uconn.edu/cardiology/
UConn Health:https://www.uconnhealth.org
Support from UConn Health Orthopedics and Sports Medicine:https://www.uconnhealth.org/orthopedics-sports-medicine
Grant support from Coverys:www.coverys.com
Transcript
Dr. Alessi: Welcome to the Healthy Rounds podcast, where we provide you with up-to-date, timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopedic Surgery and a grant from Coverys. It is not designed to direct your personal health care, which should only be done by your physician.
I’m your host, Dr. Anthony Alessi, and it gives me great pleasure to welcome my guest today, Dr. Peter Schulman. Dr. Schulman is a professor of medicine here at the University of Connecticut, where he is also a cardiologist and has worked in the Department of Cardiology for the past 44 years. Peter, welcome to the show.
Dr. Schulman: Thank you very much. I’m happy to be here.
Dr. Alessi: So, this is American Heart Month and it’s kind of interesting ’cause it’s one of those concepts that’s developed over time where we make people a little bit more aware of heart disease. But I’d like to take a step back a little bit, since you’ve been here 44 years and you and I are relatively of the same generation.
Can you talk a little bit about kind of the evolution of cardiology and the things you’ve found over the past 44 years?
Dr. Schulman: Well, that’s a very good question. I think I would almost call it a revolution, but evolution is pretty good. So, I was just thinking back on this, when I started cardiology practice more than 45 years ago at one other institution, if you had a heart attack and you survived the heart attack, you would probably have your second heart attack within 5 or 10 years, almost for sure. Because there was such a high risk of recurrent heart attacks, we didn’t have ways to prevent the second heart attack once you had one.
Actually, we didn’t even have ways to reduce your risk of your first heart attack. Now, 45 years later, in 2026, we not only have ways to dramatically reduce your risk of your first heart attack, but should you be unfortunate enough to have one, we can substantially reduce your risk of a second heart attack.
So, people who have a heart attack, that may be the end of it. They may have no further heart problems for the rest of their lives, and that’s what we’re striving for. Now, the same thing happened in heart failure. If you had severe heart failure back 50 years ago, if your heart was weak, well, sorry about that, but you probably would not live another 5 or 10 years. Your heart function, it’s like a motor of a car, would just lose horsepower over the years and decades and you’d be possibly gasping for breath in 5 or 7 years. Heart function would decline inexorably, just keep on going down.
Nowadays, we have ways to reduce the risk of heart failure, and we have ways to actually improve heart function if you already have a weakened heart. We have whole host of medications and many are very new within the last 5 years and we have devices that can strengthen the heart. So really, it’s major advances in heart disease prevention, heart disease treatment, and patient wellbeing that I’ve seen over the past 50 years. Those are just two examples.
Dr. Alessi: You know, that’s interesting because you talked about, you know, this revolution in medication as opposed to the more sexy things, right? The angioplasties, bypass surgery, so many of them, replacing valves through a catheter. I mean, those are the things you hear about and yet, I’m impressed that we’re hearing about the medical things, in terms of treating with drugs, as opposed to those. Have those things changed things a lot? I mean, it used to be an angioplasty was a big deal. And now it’s kind of routine, isn’t it?
Dr. Schulman: That’s correct. If you have a blocked artery, let’s say from, you have a heart attack and that’s usually due to a blocked artery, you can have an angioplasty. What that does is they put a little tube in the coronary artery. That’s the artery that supplies the heart with blood and oxygen, like the fuel line to our car. If that gets clogged, you can go in there with a little tiny balloon at the end of this long tube, open up the balloon, open up the blockage, and then put a stent in there, like the spring from a ballpoint pen.
It expands, it stays open, and it keeps the vessel open sometimes permanently. That’s all you’ll need. The stents never come out, they stay in the heart, and the heart tissue grows over the stent so that it almost becomes a new artery again with no blockage whatsoever. So yes, that’s a sexier way of treating heart disease.
But if we can prevent heart disease from the beginning, that would be a better way. Now, you brought up the sort of sexy way to treat heart disease. Now we’re realizing now that you can make lifestyle changes and a lot of them are very helpful, like getting more exercise, keeping an ideal weight, not smoking cigarettes, making sure your diabetes is controlled, keeping your weight controlled, diet, et cetera.
We realize now that that can be helpful. The lifestyle changes are important, but the newer medications really sort of outrun the lifestyle changes, so you should be doing both, in many cases.
Dr. Alessi: And that brings up, I had a listener question to bring in, and Bob had asked me this question, and the question was about a baby aspirin.
Now, you know, we’ve gone through these changes where, you know, when I was in training, we all knew that well, most doctors are taking a baby aspirin every day. We know it reduces heart attack and stroke. And then we start hearing that aspirin can also reduce colon cancer. And then all of a sudden more data says it’s not that useful.
Where are we on the use of a baby aspirin? ’Cause it, it seems like such a benign way of causing such a catastrophe.
Dr. Schulman: So, that’s very interesting, baby aspirin. It has gone both ways about 81 milligrams. Some countries actually use 75 milligrams, some use 100 milligrams. Well, it turns out that aspirin does reduce the risk of heart attack and stroke in just about everybody.
However, in many people, and if your risk is very low, that is taken into consideration. The other side of the coin with aspirin is that it slightly increases your risk of bleeding, so you can have a bleed into your brain. So, every recommendation is based on trying to balance the risk of taking aspirin, causing bleeding, versus the benefit of aspirin reducing the risk of a stroke or a heart attack.
So, in general, the long story short is that for people who’ve never had a heart problem and don’t have a ton of risk factors, we generally do not recommend aspirin because even though it does reduce the risk, your risk is already so low, and your risk of a bleed into the brain is not very big, but it’s a little bit higher with aspirin.
So balancing risk/benefit. Most people with no heart disease, no stroke in the past, we would not recommend aspirin.
Dr. Alessi: Okay. Alright. Thank you for that. Bob, you got your answer now. And in talking about American Heart Month, I wanted to talk a little bit about something probably less sexy than even medication, and that is, we’ve had this revolution of using CPR and defibrillators and making them more available.
How has that impacted cardiac disease and cardiac death in the field? I mean, are we wasting our time or has this been, do we have real data to support putting money behind that and training people?
Dr. Schulman: Well, we do have data to support that. It turns out that the quicker that if someone has a cardiac arrest, out of a hospital, in the hospital it’s different, but if someone has a cardiac arrest outside of the hospital, their recovery, their neurologic recovery, in other words, how well they can function, and their probability of survival depends on how quickly the CPR is given and how quickly the patient is defibrillated, if there is a portable defibrillator on site. It’s called an AED, “automatic external defibrillator”.
So, yes, there are data that shows that the quicker you get those treatments, the greater the survival. Unfortunately, the overall survival in out-of-hospital cardiac arrest is not great.
If you have a cardiac arrest, a true cardiac arrest, it’s probably in the neighborhood of 25, 30, 35%, something like that. So, there’s a pretty high chance you’re not going to make it. But, if someone, if a man has a heart attack and the wife knows CPR and can get EMS to the house, to the patient very quickly, then there’s a much greater chance of survival.
And one thing that brings up, if someone is having a heart attack, the chance of a cardiac arrest is higher. So, it’s important to realize that 90% of deaths from a heart attack occur before the patient reaches the hospital. So, the best thing to do if you’re having a heart attack or you think you even might have a heart attack, is get to the hospital very quickly.
If you end up in the emergency department, you have already jumped over 90% of the risk of dying from that heart attack. So, we cardiologists would rather see a few false alarms. You know, people have crushing chest pain and maybe it’s heartburn, but we don’t know at that time.
Better to get to the hospital, let the ED figure that out, because if you do have a heart attack, we could provide treatment immediately and it’s dramatic in improving the chance of your surviving and improving your long-term health.
Dr. Alessi: Wow, I didn’t realize it was that big a hurdle. That’s so important for us to know. What’s the most common thing you see in your practice? Over the years, has that changed? Is it mostly coronary artery disease? Is it valvular disease? What do you usually see?
Dr. Schulman: So, the most common, basically the most common disease is coronary artery disease, heart attack, and stroke to a lesser extent. But stroke is still important. So, heart attacks and coronary artery disease - that’s blocked arteries that supply the heart muscle with blood and oxygen - that’s still the most common.
But now that people are living longer and healthier, we’re seeing a lot of other conditions. We’re seeing heart failure, and that means that the heart, it’s not failing completely, but it’s failing to do its job properly. Heart failure comes in two different shades, one of which is a weak pumping heart, that’s called systolic heart failure.
And the other is a not-well-relaxing heart. It’s too stiff, and that’s diastolic heart failure. Both of those are becoming more important. And the other condition that’s very common, more in the senior population over the age of 70 and 80 is atrial fibrillation. And that’s a condition where the heart rhythm is, the upper chamber is beating very fast and irregular, and the main issue, the main risk of atrial fibrillation, is you know, is stroke.
Dr. Alessi: Yeah, it’s interesting that you say heart attack and stroke, because I guess the old saying is “if it’s happening in your heart, it’s happening in your brain at the same time” when it comes to cerebral vascular disease and cardiovascular disease.
Dr. Schulman: That’s exactly right.
And we tell patients that coronary artery disease means cholesterol buildup, atherosclerotic cholesterol buildup, sludge in the arteries. That can be arteries in any place in the body. It could be arteries in the heart that cause a heart attack, arteries in the brain cause a stroke, arteries in the leg that cause peripheral vascular disease, and many other places too.
Dr. Alessi: I’m going to shift gears a little bit since we’re moving into that topic a little bit, and something I didn’t anticipate us chatting about is the use of statins. In a neuromuscular practice I see people who try to shun the use of a statin, they’ve heard it makes you weak, things such as this.
Can you talk a little bit about the benefit of being on a statin medication?
Dr. Schulman: Yes, and we get that question every week in our clinic. Statin medication, what it does is it lowers the level of your bad cholesterol. And that is very helpful. Yes, every medicine we take can cause side effects.
Statin side effects that are significant are maybe 5%, and if you stop the statin, the side effects go away. So, it’s basically a very safe drug. Some people think there may be a teeny, very, very small incidence of diabetes that’s triggered by that, but that is infinitesimal. It’s so tiny.
But the benefit of risk reduction for heart attack is dramatic. You can reduce your chance of a heart attack by 25 or 30% or even more by taking a statin. So, patients ask me, “well, what are the side effects of statins?” So I tell ’em, “Yeah, a few percent of muscle aches, is very rare. You stop it, it goes away. What are the side effects from not taking the statin is a heart attack and a stroke. So take your pick.”
Dr. Alessi: Yeah, it’s a good way to put it. And I think about that because, I mean, when we started practice we didn’t have these drugs, really. Lipitor, Crestor, things like that, you know. It has made a big difference.
The other thing in American Heart Month, recently, we’ve emphasized heart disease in women. And is that because they’ve been kind of an ignored population? I think have they thought that in the past that women didn’t get heart attacks. What has happened there? Why the need for more awareness now?
Dr. Schulman: Yes, many of the things you mentioned are correct. So, women were felt initially to have a lower risk of heart attack. Partly in the past, because there were fewer women who were smokers. The women were less likely to have more of the risk factors, hypertension, et cetera. Now we see that men and women are more alike from a physiologic standpoint.
Women are more commonly in the workforce. The instance of smoking is closer to the same, the instance of diabetes. So, all the risk factors for developing heart disease are the same. And then on top of, so women for initially underrepresented or non-represented in major clinical trials. For example, the first major trial of heart disease was the Framingham study that was started in the late 1940s.
And there were no women included. There were about 4, 5,000 men from Framingham, Massachusetts who were studied to see who would develop heart disease and what risk factors they had. So now we recognize that more frequently women are getting heart disease. But, the other side of the coin is their symptoms can be atypical.
So, women in heart disease, it’s in part an effort to assure that physicians and cardiologists and primary care providers are recognizing that A) women can have heart disease just like men, and B) the way that their symptoms could be somewhat atypical. So instead of, for example, a heart attack, instead of chest pain, like an elephant on the chest or a squeezing in the chest, women may have just shortness of breath, or weakness, or fatigue.
So, we have to remember that those could be symptoms of heart problems, and we need to take those seriously.
Dr. Alessi: If we were to have this conversation, I don’t know, 40 years from now, what do you think is developing in the field? What’s the future in terms of heart disease and treating heart disease?
Is it in mechanics? Is it in medication? Is it genetics? What do you think we’re going to be? Or are we going to be dealing with routine heart replacements? What do you think?
Dr. Schulman: That’s a difficult question. You know, I see patients coming into the office every day and I’m just trying to treat them for heart failure or atrial fibrillation.
I think, number one, we will have major strategies to prevent heart attacks. For example, right now, if you don’t get your cholesterol lower enough to prevent a heart attack with a statin, there are now injectable drugs. There are a class of drugs called long name PCSK9 inhibitors. They inject under the skin.
They substantially reduce the cholesterol levels to less than 40, let’s say.
Dr. Alessi: Really?
Dr. Schulman: And these drugs will be available in pill form in the next 2 to 5 years. So, we’ll start to get fewer heart attacks down the road. Heart failure will be treated with even more medication. Now we can, in most people, stabilize the weakened function of the heart. Few people, we can make it stronger. But, down the road we’ll have more medications that will clearly get the heart stronger.
We may be able to infuse cells, stem cells that are targeted for the heart. They implant themselves in the heart muscle and they regenerate normal heart muscle so any weakened heart will be strengthened again.
Dr. Alessi: Wow.
Dr. Schulman: We’ll have devices. There probably won’t be heart transplants, there’ll be little battery powered, AA-powered mechanical hearts that we could just slip in maybe through the leg instead of by open heart surgery. I’m just speculating, I don’t know, but I see things going in that general direction.
Dr. Alessi: Wow. Well, Peter, I want to thank you for your time today. But more importantly, I understand you’re going to be retiring this year, so I really want to thank you for everything you’ve done for our patients over the years and the care you’ve given them. So many patients speak so highly of you and the personalized care they’ve gotten from you, and I want to thank you for that publicly.
Dr. Schulman: Thank you very much.
Dr. Alessi: Many thanks to our guest today, Dr. Peter Schulman. If you have any questions or ideas for future programs, you can reach out to me at healthyrounds@uchc.edu.
Jennifer Walker is Executive Producer of the Healthy Rounds podcast.
Chris DeFrancesco is the Studio Producer for the Healthy Rounds podcast.
Until next time, this is Dr. Anthony Alessi. Please stay healthy.