 So, the next talk is from Gene Passamani, who is a long history of doing lots of stuff at NHLBI, NHGRI, physician education, and I'm just going to talk about physician education programs. Well, good morning. And for those of you who I haven't met, I spent two decades at NHLBI mostly designing and running clinical trials and trying to keep an extramural division together, a place where we could barely agree where to go to lunch together, much less anything else. So, Eric, I feel your pain. The second two decades I spent in a community hospital as an executive, a director of cardiology initially and as a chief medical officer later, so I know the enemy, which is the practice community who are very, very different from Fruit Street in Boston or Monument Street in Baltimore. I've dealt with a thousand of them and they are a different bunch. I think it's appropriate that I come at the end of this meeting. Physician education is way, way down on Eric's strategic plan. It's way, way to the right. Lots of things have to happen before that can be done very well, although it seems like that's where we want to end up. That's where the rubber meets the road, where patients derive benefit from all your hard work. There are a couple of light motifs in this presentation I'm going to make and my hope is that I can stimulate some discussion because we're going to have to grapple with this sooner or later and sooner is better. One is that specialties march through that strategic plan at different tempos. Infectious disease is really into this business now, I'm told. In fact, I have it from an expert in infectious disease that infectious disease fellows no longer do Gramstans. They do genomes of bacteria to identify the organism and then treat it appropriately. So the ID folks are really into this in a big way and further along than I think most oncology seems like another one that's out in front as well. So all doctors are not equal in terms of physician education. You've got to sort of temper your approach by where they are. The other part of that is professional associations are really the way to get at practicing docs and they have an ability to do both general literacy which I think is really important to kind of at least have the sense of what's going on in genomics and also they carefully draft guidelines which Paul quite appropriately criticized but some of them work pretty well and I would assert that they're the best or the worst except for all the rest and sometimes they really work. I just recently rotated off a professional education committee for the American Heart Association and I have some data from them. They have a professional education center and for the fourth quarter of 2011 50,000 doctors went to that site. Half of them cardiologists, another bunch of neurologists for stroke, family practitioners and emergency doctors. So they're doing something right and they have access to doctors. So I think we really have to think hard about professional associations in trying to support physician education. Also timing for professional associations is really important. If they put something together for education of physicians and it's too early, they irritate their physicians and nothing happens. If they put it up too late, you've got an access problem because you've got something that works that doctors aren't using and so they really try hard to time that just right. I actually pitched the notion of education in genomics with this group and that was their one concern. They didn't want to get into the game too early but they also didn't want to get in too late. So anyway, that one I think is very important in terms of interacting with these professional folks. I'm not going to touch on training of students, residents or fellows today. You know more about that than I do certainly and I think our speaker who didn't make it today was going to talk about that and probably knows a lot about it. I hope when we finish that we'll have good discussion about opportunities because I think we have to start this now because of what Eric said yesterday. This thing is really beginning to move and move very rapidly. So just a few comments on the opportunity and you all know their stuff. Their rapid advances in your science, astonishing reductions in cost and turnaround time and increased public interest and I think as Pearl said expectations are high and I think they're probably way too high. This is a long-term slog for us I think and patients aren't going to see this immediately. Seems like pharmacogenomics is approaching the clinical horizon. You've got good work going on in clinical decision support and medical leadership is very good particularly at your centers. I think there's a genuine interest and apprehension in practicing doctors and I'll tell you an anecdote we put together with NHGRI lecture series at Suburban Hospital for Clinicians and at the start, the initial lecture in that David Valley gave a wonderful talk and the clinician sitting next to me at the end of it looked at me and said, I don't understand anything. What's a SNP? Get that recommendation on your LinkedIn site there. I think it had to do with the reception rather than the delivery. I guess the other thing you're all aware of is a successful and really informative New England Journal of Medicine series on genomics. Those who read it probably know more than this clinician but in fairness to clinicians they knock it out hard every day and they're not reading everything in the medical literature that's for sure and yet they're the folks that are passing out this care to people that matter. The barriers, largely innocent of genetics and genomics, multiple categories of physicians with different interest and needs. I think we really need to keep that in mind and genomics transcends specialty areas so it stretches across a whole different bunch of folks, some who are really interested in this and sophisticated, others who aren't and it seems to me it's really important that we keep that in mind. As I mentioned, professional associations worry about getting ahead of their members and this can cause an executive director his job if he's not too careful about that. We've got lots of people interested in education, no means of fund it and it's difficult to monitor advances over so broad a piece of science and it seems to me that's a really big problem and one that we have to deal with. A minute on physician statistics, there are 850,000 physicians licensed to practice in this country. 624,000 of them do mostly clinical care and of those 209,000 are really primary care physicians. That is they deal with the general run of what wanders into a doctor's office. I also wanted to mention there's an estimated shortage coming up in the next 15 years, 150,000 by some experts. So we've got a real problem there as well. The other piece about the general practitioners is you all know that they slug it out in the office every day and it's really tough. Every 15 minutes a patient with three systems down, that's really very difficult. So a few thoughts on the way forward. I guess we could do nothing and let the traditional means of education sort of do their bit. It seems to me that's not very satisfying and I think it's really irresponsible. I think the first thing is I think this has already been said in place is to set up a process for review and consensus development. What matters, what doesn't, how big a deal is it, how accurate is it? And it seems to me that we ought to try for genomics literacy across the whole spectrum of practicing physicians. They ought to know what a SNP is and they ought to have some sense of what's important, what's not important. They don't need to get into all the details but they really ought to have a sense of what's important in this field. Seems like pharmacogenomics is going to be pretty close to what most physicians deal with since all of them use drugs. And I mentioned to some of you, it seems to me that doctors who are in practice respond to cases, that's where they live. And so I wondered whether it would be useful for us to collect a vignette, a series of vignettes about where genomics matters today in patients. And I think you all probably have some examples of that and I would hope we could collect that and use it. I think we also have to rank order physician specialties and associations by the proximity of the science to the clinical horizon and the likely number of patients involved. That is, we ought to really focus on those where we have something really good to sell and that it involves a lot of people. I think we have to interact with these professional societies such that when a clinical science matures, that guidelines are prepared and delivered just in time. I think physicians are not ready to accept that this is going to be important someday. They need to have something that's important tomorrow. I think public education has to go on in parallel because patients and doctors have to see the same things. And I thought that New England Journal series was very good. I put this up just to sort of show you at least a partial list of these associations and the number of members they have. And they range from the biggest, which is the College of Physicians, a very important part, the Academy of Pediatrics. And then smaller associations, and I'm sure I left one out. I think I did leave out the Infectious Disease Society of America. But these are the folks that I think we're going to have to strike out and form some sort of communication relationship with now so that when we're at the point where we really need to deliver some of this stuff, we've got the relationship. And I threw in these societies, which are big and not necessarily physician societies alone. They're very large organizations which have a different collection of practicing physicians, and I think they're all really important. So that concludes what I had to say. I was hoping that we would get discussion from this, and I'll be happy to answer your questions or listen to your comments. Good. So, comments? I, okay. David, Howard. Can you go back one side? Yeah, so you don't have American College of Medical Genetics and Genomics, which recently renamed itself to reflect its interest in playing a major role and translating all of this into medicine. And it's tiny, and the experience of the American College of Medical Genetics and Genomics is the number of physicians entering our specialty is declining, but the number of master's degree genetic counselors is increasing nicely, although can't possibly meet the need. And the number of PhD laboratory trained people is increasing. So the laboratory component, the genetic counseling component, are growing, but need to grow faster. The physician component is declining in the face of increased need. So I think all of these education discussions need to be much broader in terms of physicians, PhDs, nurses, PAs, PharmDs, all the groups that need more genomic medicine education in order to address these needs, because it's just not gonna come from current physician workforce. Thank you, I didn't include them, I know they're there and I know they're very, very well aware of what's going on here. Other comments? Okay, so Howard, I think was next. So I'm wondering in the context of physician education, I'm wondering whether we're trying too hard because the radiology community didn't try to make generalists into biophysicists and we don't need to make generalists into molecular biologists or geneticists even. And so certainly knowing what a SNP is would be useful. But there are a lot of elements that can remain in the black box and they're just fine with that. It's more the usage part of it that's important. Most generalists don't care how Billy Rubin's measured, they wanna use it. So there are nuances that we get really jumpy about. But at the end of the day, I think if we maybe calibrated the need a little bit better, we might have more inroads, especially with initial stuff. Now, ACMG needs something different from the American Academy of Pediatrics or some of these others. But I think in some ways maybe need to lower our goals to something more achievable. I think that's a good point. It does seem to me that that's a part of the point that all physicians aren't created equal in this. I mean, podiatrists are probably not much interested in it. But internists who deal with subspecialties of medicine I think are very interested in it and they really ought to know the pharmacogenomics pretty well it seems to me. But I take your point. Other comments? There's a long speakers list. I'm watching it, don't worry. Okay, couple of quick comments. First having done this kind of education for about 15 years, recently the American College of Physicians has reached out to the American Society of Human Genetics, American College of Medical Genetics and a couple of other groups and said they're interested. And that's the first thing I found that's really, really helpful. It's now on their radar. And John Tuquer, who is their former executive director is actually charged with that. So I think there's a huge opportunity there for us to reach out to them. The second you probably noticed or you may not have in Joanne Armstrong's presentation yesterday that Aetna has a focus on genetics education and actually has a budget for it. And I think we really need to figure out how to partner with them because they can actually require the physicians in their system to do some Aetna education every year. And I believe they reach one in 10 US physicians. So huge thing. And then my last comment is that there was a very successful program that the American College of Medical Genetics did probably 10 years ago with endocrinology. And what they did is they switched the paradigm a little bit in that they made the endocrinologist a patient and took them through genetic testing. So they really saw the power of genetic testing and the effect that it could have on them and then took that back. And a lot of endocrinologists started using genetic testing who hadn't before. So that's a model I think we could replicate in many professions. We could all have 23 and me done on ourselves. Well, yeah, but I mean when they really, what we did is at their meeting we set up where they had had pre-testing and then they had short genetic counseling sessions and it was just eye-opening. I was one of the counselors there and talked to like 10 of these endocrinologists and they didn't know what a genetic test was. But it really became powerful when you made it something that would apply to them and their family and then use that in relation to their patients. Just curious what genetic testing did they have done? Like just a couple of candidate genes? MEN2 and some other things that have an endocrinology basis. So we had a whole work but we picked like six conditions Did any of them have anything? Actually, yes. Oh, okay. Say no more. Yeah, yeah, yeah, yeah, yeah. Physician-client privileges but I do think that's a powerful and you can even do it in an abstract where you set up the whole process but I think that would be something that would be really worth thinking about doing with some of these other groups because they just don't put genetics on their radar and this got it on their radar. Michael, Josh, Pearl, Jeff. Everybody wants to say something. So Michael. Wait, I have to say something. So I just spoke at the American. I know, I know, I just took over the mic. So I just spoke at the American College of Physicians. They invited us back for a second year. It was actually an ethics session but all on genetics, genomics. And I'm invited to speak at the American Geriatric Society later this fall and I still haven't figured out what they want me to say. But so I think we do, I bet there are lots of people in the room who get those types of invitations and there is interest out there. Okay, go ahead, Michael. Oh, and also I just have to say. In response to Dr. Leverett, I was just on the American Board of Medical Genetics and actually the numbers of clinical geneticists and so forth is kind of leveled out. We're no longer declining in our numbers of enrollees in the program. So that's good news for us. I was gonna say that the drivers of physician education are CME credits, board certification or maintenance examination content and patient questions in the room. So until those three things happen, you're gonna find a lot of physicians not interested. And the other comment would be that the new way to deliver physician education is in short 10 to 20 minute interactive, web-based CME credits. So people that are thinking about education and getting out to groups of practitioners, no matter doctors or others, that's one thing to really think about in your design. And those are really good ones for cases, like short cases. Right. Okay. Murray then Josh. At the Marshall Clinic, we've done just exactly that. So we have now mandatory computer-based training in pain management that includes a module on pharmacogenetics and it's really quite nice. And so our physicians, all of them now know about you know, SIP 2D6 and variants of that. So it's really nice. It's worked quite well. I'm not sure if it's proprietary. I don't think it is, but I could ask. Sounds like a nice model. Okay, great. So I was just gonna say, I'll raise our hands again. The, so I think this is a real demonstration of a case where there's going to be, there's a fire hydrant, it's just going to get worse. And it's one of those real opportunities as a representative of the informatics community for I think us to engage as meaningful use comes on board, more and more EMRs are out there that we can deliver that information just in time. And if you could, and this is what we're trying to do with some of our prospective genotyping efforts and trying to test some of that in front of physicians, what kind of language looks good and how do they respond with progressive enabling them to kind of click and learn more just kind of as they need it. But we're never gonna build support and educate around everything if we can support and educate around the concepts they need, then maybe we can do more and more just in time stuff with informatics. I wouldn't sell specialist and some specialist short. Some of them are very smart and very able. And if you put it in front of them and it seems like it's useful and they'll lick it up, that's no, I don't think there's any question about that. And in fact, we actually have a link off of our advisor rounds to 2019 where you can see all 60 articles that we've curated around Clopidogrel if they want to read it. That's great. Knowledge map for genome education. I know that medical school and resident education wasn't part of your talk, but is there any evidence that the younger doctors are trained up adequately and you know, well I know not a chance. I mean, it's a, you look at the curriculum and it is a little scary. And on one side, I mean, there's a lot of concern that they're not being taught physical exams. And what are they being taught instead? And I know just anecdotally, just going into the wards and seeing a person with shock and I thought, oh, I know how to deal with this, volume, volume, volume, impressors. And immediately went off into what calcium channel blocker might be a mutation. And meanwhile, you know, the patient's dying of hypotension. So my concern is, I mean, is there any data that the new wave can potentially educate our geezers or is everybody in the same bad boat? I guess I'll take, I'll say a piece here. I do think we've run the risk of having sort of an intergenerational tussle here, but my goodness, surgery is really suffering today. And the reason is that they're limited to 80 hours in the hospital. And I've seen residents in their second year who I'm told don't know how to tie knots. And so what happens to those residents is they go out and make the mistakes while they're in practice that they should have made while they're in a more controlled setting. Anybody else know about what's going on in medical schools? So a couple comments. First of all, the online tools are great, but just a word of caution that our place, there was a current calculation of the total hours required to be spent on online exams of various things. Responsible conduct of research, HIPAA, blah, blah, blah, blah, blah. And it was estimated to take about one week of eight hours a day to complete the current online requirements. So adding more may not be received favorably. That's not to say there's still not a niche to fill. That we've changed our curriculum. We're trying to infuse a genetic thinking into the education of medical students. It's too early for us to know whether or not we've achieved any kind of success. And if you think about changing the curriculum as an experiment, it's a very hard thing to gauge the success of an experiment because the controls are very difficult to come by. So it may be in the category of an experiment that you just get all the opinions in one room and try to make your best choice and go forth that way. The other thing I'll say though is it's clear that medical education has different challenges at different phases of the career. So you have the medical students, then you have the house staff and the house staff do a lot of educating of the medical students in the third and fourth years. If you don't educate the house officers, anything you do to the medical students is likely to get beaten out of them in years three and four. And then you have to educate the practicing physicians and your academic colleagues. So I think it may be important to think about different strategies for different levels of medical education and in a way, I think they have to be taken on almost simultaneously so that you, because the educational experience goes on for such a long period of time. Thank you, David. It seems to me that this machine is going to deliver wonderful results and we don't know exactly where. And we're gonna be in tough shape if we're not ready to deal with them. Two quick comments. One relative to Andy's anecdote about the endocrinologist, Susanne Haga, who could not be here today, has published a paper that has shown after surveying hundreds of primary care physicians that those that actually had genetic testing on themselves were 10 times more likely to order a genetic test for their patients. So that's a provocative piece of data that could be channeled constructively into some educational programs. We could offer it to our medical students. It's being done. Okay, I have a second comment. Do you wanna? So let me, so for the second year this year, we engaged in an exercise at Vanderbilt, stolen from the Stanford experience. So I make no apologies for that. We managed to get it into the curriculum. They managed to get it as a summer optional course where we offer 23 and me testing to the medical school class. And we go through a long sort of pre-test exercise where we discuss the ethical downsides and what an odds ratio of 1.2 actually means. And then they go and pick up their kits and spit. I don't think anyone's had their dog spit yet, but who knows. And then we have a session where we deliver the results to them and Josh actually organizes a survey that they fill out. And the survey is sort of, what was your odds ratio for developing type two diabetes? What was your odds ratio for this and that? And then a whole session on ancestry and a whole session on rare things that 23 and me looks at. And would you do this again? Do you feel like you're smarter? Those kinds of things. But I think it comes back to the point that you made that when you do this on yourself and you get the results, it's sort of, oh, isn't that, there is sort of a resonance of some kind that I think Suzanne would have told us about. And I've certainly felt when I looked at my own website. So I think that's a tool. And one of the things that I hope I'll be able to do is interrogate the medical students who had it last year and who are now coming into fourth year and say, well, you know, do you remember that session at all? Do you remember anything about it? Does it make you think differently about a patient when you're sitting on the ward? So those are the kinds of things that I'd like to hear. And Josh participates when he's not traveling, which is not a criticism because I travel more in delivering that kind of information to the medical students. It seems like that might also populate our ranks with people who want to do this. So I like the idea of sort of, you know, personalizing it somehow so they remember and they know how it feels, whether it's that way or your way or our way, I don't know what the right way, probably any one of those experiences are right. So your other comment. My other comment is that I think this guidelines topic with all the caveats that Paul raised this morning needs to be an agenda item for our next meeting when we engage these professional organizations because my bias is that it's the equivalent of having primary care physicians review a genetics grant. I mean, how are, just in relative, it came up in the eGap discussion yesterday about pharmacogenetics. I mean, the people that are making the guidelines are probably not in this room. It would be my guess, except for the CPIC group, which is sort of an interesting way to approach it. And maybe we should even think about how CPIC could be a resource for the professional organizations instead of having them reinvent the wheel. I'm sure that most of them realize that they need help and we might be able to give it to them. Okay, there are lots of hands still. Can you sit? Behind you. So, okay. Oh, sorry, the Air Force goes first. This Air Force goes first. And then you, sorry. It's just Cecilia. I just had a quick comment about the National Coalition for Health Professional Education and Genetics. They were kind enough to work with us on our symposium last September. And in terms of our enrollment strategy for our study, I made the decision to enroll people who are part of the healthcare team because, although as physicians in theory, we're the leader of that team, I wanted to try to start that genomic literacy effort for all of our providers. So in our system, that's nurse practitioners, physician assistants, nurses, of course, and then our medical technicians as well because they do have increasingly independent roles in terms of the way that they interact with patients. Thanks. And pharmacists, very important. Sorry, if I could just throw one thing in here real quickly. So I surveyed. Okay, go ahead. So in a lot of our life, I created an educational management system and so I pulled up 400 concepts related to genetics and survey, 10 years of our curriculum and it actually has increased. 22 lectures, about hours of the curriculum in 2002 and 147 in 2010. Wow, thank you. Welcome to an informatics rich world. Right, and on the informatics note, so clinical informatics was approved as a board certified subspecialty last September. The first exams will be in 2013. So a few places are designing fellowships and rotations for the residents and so this is your chance to make sure that those rotations and fellowships include exposure to genomics, not just to Microsoft Excel and SQL databases. So the clinical genomics is a subspecialty in? Clinical informatics. In pathology. In clinical informatics. In pathology. And there's also biomedical informatics of specialty in preventive medicine. Yeah, that's right. Okay, other comments? I saw lots of hands, but they all just disappeared. Okay, yes. So two things. One is that one of the other ways to go about this is actually to get the fellows as specialists to take a little bit more interest in genetics. So ACMG has worked on, instead of going through a genetics residency or fellowship is actually have like a one year course of somebody's a cardiologist and wants to specifically look at cardiovascular genetics, have a program like that. And so you don't need to train everybody to be a general geneticist. You just need to train them in a specialty that's applicable to them and then hopefully they'll be the leaders as going out. The other thing that doing student education, one thing that I've started to do is how to teach the students how to look at uncertainty. And so these variants of unknown significance, these are common, we get them all the time, but how do you get the students to think about how do you critically analyze information? And this is Apple to the regular life too. I mean, you get a lab result and you're like, well, what am I supposed to do with this potassium? Do I watch it? Do I repeat it? Do I treat it right away? But this is a good lifelong lesson that if you can teach them how to look at uncertainty, how to evaluate it and how to react to it that it's not just Apple genetics or genomics, but everything else as well. David, one more. Just to put in a plug, this summer will be the 53rd annual short course in experimental and medical genetics at the Jackson Labs and Bar Harbor. It's a two week course, 53 lectures and eight workshops, lots of prominent speakers. It's really pegged at just the right level for fellows, PhD students and young faculty who are in various specialties but want to sort of get a two week intensive experience in genetics, I highly recommend it. Thank you, David. Okay, I think we'll stop this part of the discussion. The next discussion is from me and so you're gonna have to bear with me while I transfer the slides that I've been working on all morning onto a stick. I have to remember where I put them first. No, I don't know. When is it coming? Will you do that? Yes, please do something to take up the dead air. Okay, in terms of sort of an alternate thing, we're constantly looking from the IRB world in terms of how do you present probability, et cetera, and looking at recent literature on how numeracy in the U.S. It was something like 50% of the public cannot tell you if 10 out of 1,000 is 1% or 10%. And then they went to medical students and they were not much better. So I think where we're talking about even beginning to talk about relative versus absolute risk, we're talking just percentages. I mean, so it's really scary that we're gonna end on a positive note here. Yeah, it sounds horrible. The answer is for Eric to fix K through 12 education. We established that yesterday. So rather than watch Dan struggle his way through this, just a quick question for folks. We will be talking about locations for meetings in that, but any thoughts about this particular hotel? Is this a positive? If we come to Chicago, would you rather be here, even though it tends to be a bit more expensive? Or we can go to an outlying hotel, but you have to take a shuttle to get to it in that. Any strong feelings? Okay, so no strong feelings? Yes, the O'Hara Hilton is my favorite place in the whole world for a meeting. Well, there you are. It's my least favorite. I guess. The St. Croix vault is pretty nice too. Thank you, Mary. Thank you, Mary.