 So this is a conversation with some opinionated people about what disruptive innovation in translational science and translational research might look like. So they're opinionated. I'm expecting more opinions from the audience. I heard some opinions earlier that have not filtered up through comments. Please bring them on. If ever there were a time to push and to question, this is it. And that's what we prepared ourselves. So hopefully you'll hear some provocative ideas here. And your questions will get them to say some even more interesting things. So they've given me some ideas of what I should ask them. I'll play by their rules a little bit, but maybe not as well. And I'll begin actually with Jeff. So Jeff, I want to start by asking you to help us think about what the lab of the future looks like. We were just, Joe actually just talked about the challenge, the remaining challenge even for CTSI and for UCSF of really connecting our basic biologists to this goal of improving health. So 10 years from now, 15 years from now, what does that lab look like? I love being asked big questions. So first of all, I want to follow Joe. I think Joe is right on what he's saying. I think one of the challenges that we have right now is we're stuck in terminology and we've got to get, and to me the future is changing terminology. The word clinical, the word lab, the word basic science, the word clinical research, we've got to change the language because in fact we all are fundamentally studying the same thing. We're studying the human condition, human health, human disease and we're doing it from different places and until we can have a vocabulary that allows us to talk to each other, we're going to always have these barriers. And so to me, the lab of the future or science in the future is going to be a different way to conceive of doing research in humans, with humans, about humans, for humans and it's going to be doing it in a very different way. 30 years ago, UCSF became great and it became great in being able to tap into a innovative approach to understanding biology. But all you needed then was a centrifuge, a bench, a desk and you could invent recombinant DNA technology. Today, we have MRIs and deep sequencing and clinical research and 100,000 patients with Kaiser and a number of big things that we need to do the kind of innovative research. We need to be thinking differently. The lab of the future may not have benches and desks. It may be large spaces where people congregate around cores, cores that are doing the kind of technology. It may be the bedside where teams which include PhDs and include nurses and include pharmacists sit around the bedside and talk about the patient, with the patient, about the patient maybe bringing their own data to the conversation like never before where they hand a chip and say, here's my DNA sequence, what does it mean? So to me, the lab of the future is really nothing like the lab presently. The lab of the future is the ecosystem that we live in and that ecosystem has got to go way beyond what we've classically thought about a lab to be. And again, I would just reiterate, to accomplish that is going to take a very different reward system, incentive system to do that. It's going to require teamwork, it's going to require partnering, it's going to require big things that we've never really been that involved in before. And it's going to involve for CTSI, who is right in the middle of all of this, building the connectors that are necessary, whether it's with the students, whether it's with the scientists, whether it's with the clinicians, the patients, the community. It's going to be groups like CTSI that makes that connection. Great. Thanks, Jeff. So I'm going to move right on to Deborah to say, well, so Jeff's talked about the lab of the future. Let's think about clinical research sort of near term. So we're talking about near term science fiction not 50 years ahead. What have you seen recently that's really gotten you excited sort of with the next stage of clinical research? So we at CTSI talked to a lot of people here, a lot of folks pitch us their activity. And a few of them stand out for me with what we've seen over the past year. And these are actually real activities going on right now. And I think the thing that holds them together is the digital, our digital age and huge computing capacity which we have now that I think is the mechanisms by which we're going to break down all these silos and bring clinical care and research together. So I'll give you just a couple of these examples. One is Intel, Intel inside, you all know about Intel. Intel believes that 50% of all clinical care should take place in the home by 2020. And in fact, they are partnering with the country of China to develop three cities of two million people each where there will be a network grid broadband specifically set up to provide health and health care. So you will have audio, you'll get advice on demand, you'll get video, you'll have telemedicine, you'll have the visit with your doctor in your home. And in addition, data will be collected right from your home. If you think about this, this is almost like creating an electronic medical record for people in their houses. Those electronic medical records will have to be interoperable. So while Intel I don't think is really thinking about it, this could be a huge opportunity for using clinical care for research, just the kinds of things that Sue and Jeff have been talking about. So that's Intel. They've partnered with GE to come up with all sorts of remote monitoring devices, telehealth and so on and so forth. These are ongoing real, you know, real efforts. A second good example is there's a group called SAGE, BioNetworks. And SAGE's big problem is that we've got all these data, which we do. We have data here, we have data there, you know, 23andMe and so on and so forth, but it doesn't, none of these data can talk to each other. So SAGE's idea is to provide public infrastructure to make this happen and to sort of market this direct to people, to patients, so that as a person you could provide, you could provide SAGE with your laboratory results that you got at UCSF, you could provide them with your genome that you had done on 23andMe, you could provide them with your electronic health records from UCSF or from Kaiser and these would be created into a data set that would then be de-identified and available to researchers essentially for free and would allow the people, the participants to provide whatever data they think is correct and also let them give permission to be contacted. And a really key part of this undertaking is right now we give consent for research for specific research, usually, and that's a really big hand to cap. So what they've been working hard on is what they call portable informed consent and this informed consent would be, you put your data into the system, it can be used for anything, anytime, anywhere for the foreseeable future. That is actually, I think, an important change that could really promote research. And then the final one that is actually active right now is a company called Mitris, which was started by one of our own faculty members, Steve Cummings, which conducts trials without walls. So patients are contacted using social media and so forth, they provide their own data using web or various applications, their telephone, they are found to be eligible, they are randomized, they're sent drugs or other things in the mail. If measurements need to be made, they can be done at the local lab down the street, they can send home nurses to make other measurements. So this creates the ability to do a multi-center trial where each center is a person at home. All the data are collected in real time, you get high quality data and this can be done anywhere, anytime. And they've actually completed three trials using the system. Great. Katherine, I'm going to come to you in a second, but I want to talk to you about how we're going to get to some of these places that Jeff and Deborah are taking us. But first, I just want to go back to Jeff because you're going to help us understand where we're coming from. So in a particularly candid moment, apparently it was a bad day for Jeff, you use the analogy of the flea market to describe UCSF today. So I want you to speak to that a little bit. Just describe where it is today, it's okay, we're going to then talk about how we get to these great places, but if you could start by just telling us where that comment came from. I'm in a great mood today, so let's use a farmer's market instead of a flea market. By the way, before advertisement tomorrow, we invited Stephen Friend, who's a founder of SAGE, who's going to be here giving a seminar, I'm not sure exactly what time, but you can look it up on UCSF website. So if anyone's interested in SAGE and what they're doing, which is really interesting, there's a seminar down here. And I should just say that John Wilbanks, who has done a lot of the work at SAGE, may be here. Is John here? He was going to come and may not have been able to. So what do I mean when I talk about the farmer's market? So there's this continuum, right, between an organization that's well-defined, well-focused, well-targeted on singular mission where everybody is targeted to do the same thing. And then there are places like UCSF and academic medical centers in general, where what we do as an institution is that we provide you a limited amount of resource. In a flea market might be a table, in a farmer's market it might be a little cubby in which we say to you, look, here's your table, here's some electricity if you're lucky. And now go out and sell whatever you want. If you can find the best fruit or the best vegetables or you can grow them and sell them all the better. And whatever you can sell, then you can use that to buy more fruit. Maybe you'll even be able to buy the table next to you if you're lucky. And we created an environment of entrepreneurism and innovation and creativity, which has worked extraordinarily well for us over decades. And having grown up in New Jersey at the English town farmer flea market, it's an incredibly successful operation. But what we don't worry about as much as we may need to going forward is we don't worry about if the guy in row three is selling the same thing that the guy in row one is and asking them to make sure that they're working together to sell the best possible fruit or vegetables. We don't worry so much if, in fact, we can't afford to have as many tables because of the stresses they're under that Sam mentioned. Because we always think that if you bring in more tables, you're going to inevitably then just be selling more stuff. And I think the way we have to think about the future as a university is we, first of all, number one, we have to give more than just a table and electricity. We have to provide enough added value to the vendors, to you, the people doing the work, that you get added value in being a part of the university. That there is a enterprise-wide value in being part of what we call UCSF. That we give you an opportunity not just to sell your own goods, but to work more effectively with the guy in row three who's selling something similar. But maybe also, if you're going to be selling the crackers, work with the guy that's selling the cheese, because cheese and crackers work better than either one alone. We have to provide that infrastructure to do it. And so, it's not that I'm in a bad mood, but I do believe that fundamentally we need to be successful at building an enterprise-wide effort that brings these various enterprises that have been now siloized for decades together to do it. Now, what's the risk? The risk that what many call disruptive innovation turns into creative destruction. And what we don't want to do is destroy the things that have been so important to make UCSF great, which has been that individual entrepreneurism and that individual effectiveness that comes from having to work every day to bring the goods to market. And so, the challenge as in the administration from my perspective is how to keep that fire, how to keep that great innovation while providing an infrastructure that allows for teamwork, collaboration, interaction, and a business that doesn't just depend on people coming or going in their individual stalls, but depends on working together more effectively. Great. Thanks. So, now that's a great setup for Catherine who's going to really help us think about how do we get from what is still a farmer's market, a productive and interesting farmer's market, to this complex system that both Jeff and Deborah described. A system where behavior is so very different to the various players, research is being done in homes, care is being given in homes. So, Catherine, what are the tools you use to think about how one might actually change such a complex system? So, Midi asked us to think about what would be a disruptive approach to clinical and translational research. And I'm going to give a somewhat disruptive approach because I'm going to suggest that we'd be less disruptive. When you think about CTSI, we are extraordinarily future-focused and it is very appropriate. We're looking for the cures of tomorrow. We're looking for optimum care that's going to be the result of all of our translational efforts. But we have to not only be future-focused, we have to be committed to the present. We have patients who need great care now in addition to patients who will need cures in the future. And we're not doing so well as a national community. We know that despite years of effective clinical and translational research that tells us what the best treatments are for people, we still don't reliably get those treatments into the patients that we serve. We certainly do at times, but not consistently and not reliably. And I think a really disruptive approach to the CTSI efforts is to look at the other end of the translational spectrum. And that is the science of implementation in the real world and the assessment of implementation in the real world. We need to commit to optimizing our patients' health today in addition to providing the cures for tomorrow. And that doesn't mean we distract our attention from the basic and translational science we're doing now. It means that we actually add a commitment to implementation science and we also change the way we look at scientists. Scientists have to be present across this spectrum and that clinicians have to be engaged in this very complex system of research, not just people who have committed their lives to understanding molecular mechanisms and caring for clinical research to see what patients benefit both from those mechanistic innovations. So I think actually one way we can innovate around this is to actually think about a much more integrated network to set of scientists. So scientists will range from the molecular to the very practical. There will be basic sciences and there will be behavioral scientists. And they'll work not in sort of a linear technical approach that is sort of illustrated by our use of the term pipeline and our very linear description of T1, T2, T3 and T4, but a much more integrated community of people who are committed to advancing human health today as well as in the future. And Sue spoke, it was kind of interesting because I didn't know what she was going to say, she spoke about the importance of aligning the clinical mission with clinical research and I think that is truly the disruption that needs to happen. Right now we're in a tremendous timeframe, a tremendous time of innovative growth around care delivery models. We've all heard about the Accountable Care Organizations and we have the Accountable Care Organization over here and we have the Translational Science Institute over here and they need to come together so that care that is delivered is scientifically designed to be optimal, not just in the science that we use but in the care delivery mechanisms that we use. So I think actually if we can figure out at UCSF how to do this and I think we're the campus that can do this to create a clinical and research accountable innovations network then we'll actually have the ability to really jump start over and above our colleagues across the country and actually serve our community well. Now that means different things in terms of education. It means that the idea of scientific training shouldn't be just relegated to those who've chosen basic science or translational science as a career or even clinical studies. It means that every clinician has to understand a scientific approach to not only doing the work but to continuously improving the work that they do in the offices in which they work. And it means that we need to extend our research network so that the clinicians aren't just the recipients of the good ideas from higher up in the pathway or upstream in the pathway but actually influence that upstream pathway in a constant and continuous manner. Great. I actually would like to, and this is really for any of you, but let's focus on that on sort of Sue's comment which does tie to your comments that you know part of what we might need to do is to become a seamless part of the clinical delivery system. Okay. How and can we think through what that really means? How do we get there from here? Because you know even when it comes to something nitty gritty like the electronic medical record and stuff that's really seems really obvious. You need that data to do research. We know it's been it's very hard to move that kind of initiative ahead and that feels much more tangible than the big picture integrating research into clinical delivery. So what would we need to do and I don't mean you know in the next year but what in five years and ten years what do we need to do to make research part of clinical delivery? What might that look like? Anyone? Well I'll say actually it has to you have to start with the focus of our goal is to improve human health today and that means that the clinical encounter doesn't just become a source of data for us to study and improve the care of the next patient. It means that the clinical encounter itself is the source of research in terms of how that encounter can go better, can be more effectively delivered and how populations can actually benefit from as I said advances that have already been made but aren't fully being implemented and we've somehow sort of left that out of the equation when we look at innovations and if we as clinicians know that all of the smart minds in the arena are helping us improve the work that we do in a scholarly fashion using the science of implementation, using the science of communication, using the science of systems then we're also going to be willing to partner with you to help the next set of patients who are coming through but I think our disconnect is that we know a lot, we have a lot of advances that have been made, we just haven't gotten them into our patients and some of the things that Deb was talking about in terms of home monitoring and home treatment will get us part way there but we still need to make sure that we can reach out to the entire population and that the people who need the care that we've already sort of discovered is best are actually getting that. Great, thanks. I'm going to change the text just a little bit and ask you to think back to the past because that all often has lessons for the future so again any of you, is there something that you've seen in the last 20 years some kind of change that you could never have imagined would happen and you've seen it happen that has lessons in it for our future? So a relatively small thing I think that we heard recently at our external advisory board meeting was from the CEO of the Integrated Healthcare Association who talked about how their pay for performance systems had created a culture where physicians were now used to getting reports on how well they'd done and that transition from never getting them and responding to them to a place where they were more used to seeing such reports and responding to them was quite a cultural shift and doesn't allow for some additional opportunities so that's a relatively recent change. So maybe this doesn't quite address the question but something that struck me and I've talked to a number of people, Keith Yamamoto and Sue and others about this, is that if in 2000 when the first genome was sequenced and so many of the enterprises from pharmaceutical industry to academic medical centers to NIH said we've now solved the problem because we can now get the data. The biggest problem up to 2000 was how do we get the data we need to understand human biology and disease and what's amazing is what's happened in the last 12 years is the question of how useless that's been as an exercise. Okay, the postage stamp collecting has been useless. Pharmaceutical industry who devoted billions of dollars in thinking that they wouldn't need academia anymore because all they needed to figure out what the genes were and then they'd have drugs coming out the other end. So to me I think the biggest awakening that's happened over the last few years is the fact that data is not the problem. We can even conceive of using. There'll be 10,000 genome sequenced by the end of this year and probably 100,000 by the end of the decade or more. So that puts us in a very different position than I think we thought we would be in 2012. Now all of a sudden we're important again. The pharmaceutical industry realizes they still need to understand what's the questions is not just the data. We're going to be thinking about how to redefine diseases, how to redefine biology given the data that's out there if we can figure out how to have the tools to do that. So for me that has been just a dramatic change in the last few years is the realization that just having the information wasn't going to be enough. I mean I will just echo that. I think we're in a period where we can collect data until the cows come home and we can store it in the cloud and we can manipulate it. But a basic premise of epidemiology is that if you need 100,000 participants in a study then the effect of whatever intervention or association you're studying is so small as to be clinically useless. So we do not need huge amounts of data. We need to focus on how to intelligently gather specific data, not just all data. That's what we're doing right now. It's like data, let's get more genomes, let's get some proteomes, let's get some metabolomes and all kinds of ohms. But we're not thinking about what we might eventually be able to do with that that's going to improve human health. And that I think is our big lesion right now. And I would say one example that has really impacted the way I've thought about what will the physician of the future and the exercises we spend a lot of time on in education is the success of the HIV epidemic management over the past several decades. What started as as you all know a universally fatal disease has now become essentially a chronic disease that people live with and live good lives with and now actually we're struggling with issues that people who are HIV infected never used to struggle with which is my retirement. That's a good problem to have. But that wasn't a success that was purely predicated on biomedical science, conventional biomedical science and molecular mechanisms. That was actually simultaneous activation of multiple scientific and community and clinical care networks. That was the basic scientists working with the translational scientists. It was the behavioral scientists working with the physicians on communications. It was the social scientists working with the communities on how to change the way we approached our population to talk about risk behavior. It was the most perfect example of the importance of having multiple lenses looking at a complex problem simultaneously not sequentially. I think that's has really influenced the way I look at the physician of the future. They have to be able to work in these teams and understand where the different lenses are going to come from to help them solve these disease-based problems. It's not going to be a linear progression from basic science through translational to clinical to epidemiologic and community. It's got to happen simultaneously and it's going to happen in teams where everyone brings a different lens. Okay, so to get us there last question and then we're going to turn it over to the audience. Do you wonder faculty got together to put together the first CTSI grant which is always one of the best statistics in my mind about CTSI. I love it. Not another CTSI grant, but what if we could get another 200 faculty to come together to do the next big thing? Not a writing a grant. What might that be? What would you like if you had 200 fantastic faculty from UCSF to come together and create the next thing? What would it be? I would say it would be creating a structure that everybody would be comfortable, a sandbox let's say, that everybody would be comfortable playing in. I think if we could come up with a way to break down barriers that exist in our organization not for bad reasons for perfectly reasonable reasons but if we could come up with a structure that everybody would be very comfortable playing with that they realize the kind of credit that they deserve for the contributions that they had the kind of educational opportunities that they needed to be successful that the stresses and bureaucracy and challenges that we put every day on their lives would be diminished by the new activities that they would be able to do together. Now I know that's an administrator speaking but from an administrator having been involved in large networks they've been able to break down some of those barriers if we could do that within UCSF to me if you could get 200 people to come out of rooms thinking that they had a place in the organization that they would be rewarded proud of, not feel resented or resentful I think we could achieve amazing things. So sort of a mini incubator within UCSF is a starting point where we try out these ideas of creating a sandbox where basic scientists could play with clinicians and we remove some of the barriers in their way and be very protected and not feel threatened and not feel the same stresses it would be a pilot, it would be small 200 people is very small in an organization of 23,000 but if you get 200 people who could sit in a room and have a common language have a common set and try that out and see how that looked that would be pretty exciting to me. Well I think that's a great point I have some questions from the audience I see a hand back there and then Talmach here I think there's some mics floating around and do share your name with us so everybody knows who you are I'm at the School of Pharmacy Is this? It's on It was on Don Odir on the School of Pharmacy Clinical Pharmacy I actually just like to follow up on what Jeff just said about getting 200 people into the room and having people feel included and protected and being very creative I think we would have a wonderful opportunity to not just include faculty but also get the feedback from staff and from patients and from research subjects to create something that is really innovative new and inclusive Great Talmach had a question here I saw your hand up Talmach I saw it up You know people consult others who they trust When patients go to a doctor it's because someone else recommended that doctor usually or when I as a general internist consult the cardiologist is because I trust that individual and similarly when basic scientists work with another colleague they trust their integrity and I think we have this opportunity as Jeff was saying to develop wider and wider circles of trust and we do that based on how we interact with people what roles we assign them how we support them but I also think there's opportunities for us to create new models of relating to each other using technology and also using different different workplace environments we functionally have the same workplace environment we've had for 30 years we have labs, we have classrooms we have hospital beds and what's happened over the past 30 years has become progressively more segregated so we trust the people in our own sort of environment and don't have as much opportunity to interact across those environments so I love Jeff's idea because I think what would come from that is new models of working that will engender more trust and will accelerate the types of innovative questions, information sharing and better patient care and so forth I mean if you all think about how your work habits have changed over the past 10 years I'm going from sitting at a desk with a big computer and you know a phone with a cord to moving around to doing your work all over the place I mean we've changed so much but our sort of our clinical and research structures and infrastructures really have not changed very much at all so my thought was I wanted to follow up on Jeff's suggestion because I like it but I was thinking that we needed a specific thing that the 200 people would be working on and the thing that I the thing that flashed the blank response I wanted to blink twice before was personalized medicine so you know one of the things that I the other comment I want to make just put out there one of the problems at UCSF now because it exists throughout the nation is that we're really struggling to figure out how the academic medical center side, the hospital clinical patient side of this thing is going to survive and I'm really worried that we need to figure out because that financially drives so much of what we're able to do with the school of medicine maybe the other school is not as much but the clinical enterprise is really under pressure and I think there's a huge need to do something disruptive that secures the place of the clinical enterprise because it generates so much of the flexible money that we use and so one example is the whole issue of personalized medicine and there's a lot of discussion about what that is and what it should be what are the major issues that will make that work and we've been alluding to it and many things we've said about that people will be getting their care at home and they'll be coming in with information but we don't have any idea how we're going to do that and I think it would actually position us if we got 200 people from across the campus including staff and patients and we really thought about what that really means and come up with a plan for how that would happen and how we would actually effect that and not only here but in the community I think that would be a useful step and would put us in a very different place a lot of people are going to put up a banner that say they do personalized medicine or whatever the term will be but most people nobody knows what that means and I think we could figure that out and probably get ahead of the curve or catch up with it a little so if I could make a comment about that because how much I think you've touched on a really important area that there is an interest here in doing that and some of that interest has been generated by Sue's activity as part of the National Academy report on precision medicine the new taxonomy of disease and out of that really for it's just right in our bread basket because what it says is is that understanding disease is going to be understanding basic understanding of disease etiology it's going to be a scientific approach rather than a symptomology approach and personalized medicine is going to be about understanding connections you know we'll be talking in 20 years about ciliopathies or tauopathies instead of a brain disease and a kidney disease now it's going to be an approach to something that actually UCSF can take advantage of so Keith Yamamoto has been very interested in this whole knowledge network idea is in fact working with right now the memory and aging group to try to come up with a pilot may not be 200 people maybe 50 people who are going to think about how to connect up these various elements sort of like a Google map of precision and data and clinical care and to try to do it across the spectrum as a pilot to see could we do that in that area already there's been interest in the cancer community in working with the memory and aging community to connect up with them so you're going to be seeing a lot of that kind of pilot programs we put some resources into that to try to do that secondarily I would say that next spring we're going to be holding we don't have a title yet 90 summit on precision medicine where we're going to bring in 250 people to talk about this in a way that leads to action actionable projects actual experiments to try to get exactly what you're talking about because what you're mentioning fits so well into what we can do what we're all about here because we do understand from the patient care back down to the basic science back out to the community ways that some institutions don't so if you want to be in on this this would be great because this is I think a great opportunity for us doing this earlier discussion I raised the question that I want to raise for the audience that I've been think a blank 15 times on whether I would do this so the yeah I'm saying it out loud so one of the things that I one of the things I'm struggling with is that when I got this agenda today the future of CTSI sustainability and innovation and then so it seems like that's what we're here to talk about what I'm worried about is that a lot of discussion has been about CTSI doing something but is that what's going to be the key to sustaining CTSI going forward in the way that we want it as we sustain it's going to help it may help identify a project or whatever but will it sustain CTSI and is this conference really aimed at worrying about how we get the next grant from the NIH or not because I guess what I want to say is that the CTSI is our intel inside and the value that it has brought to the organization is that it's allowed us to really make the organization sort of work better together and we already have schools and institutes that are doing the things that I hear we were talking about that's why we're here why do I have a department of medicine a lot of what we're talking about is what it does why is CTSI taking on that role as opposed to the role it has successfully done which will not go away I mean if you look at the scorecard for the CTSI on your website it seems to me the things that you've accomplished are incredibly valuable and even if the NIH took the funding away wouldn't we want that to stay here so is that what we're talking about was that the purpose of this meeting as opposed to the sort of pie in the sky idea that we seem to be through you're beyond the pay limit of this group so so yeah Talmage you know now I don't have to give my closing comments at the end but the we don't want to be doing what the department of medicine should be doing we don't want to be doing what the chancellor's office should be doing even or what any of the schools are doing but then what is it that we should be doing so obviously when we existed we were before we existed some of these things were going on they were funded through the clinical research centers we change the sort of scale and scope of those activities we make sure that everything we do across all the schools it's something that doesn't just belong to one school or one department or one division that's always part of our criteria but the other thing that we try to think about is you know how do we transition what it is we're doing to long term sustainability in alignment with existing organizations in the institution so what do I mean by that the example that we give all the time one of the things that we worked on early on is an intramural granting program that was more rational where we had better reviews and the system for soliciting proposals was cleaner and the administration was cleaner and cheaper and more efficient and then once we developed that we handed it over to the chancellor's office to manage that and so more and more we need to be thinking about how do we really provide to campus in that case it was sort of the innovation to say hey this is an important problem not just for one school or one division it's an aggregate problem that was below the radar until we brought these people together let's solve that thing but then let's hand it over and let them sustain it so we can continue to innovate so I think that really the way we're seeing ourselves more and more as within the organization we're listening to more voices looking at more common denominator needs across the training and research community creating the initial structures to address those needs by hearing lots of voices bringing in outside partners thinking about sustainability and then ultimately handing those off to the organization that's best suited to handle them so does that make sense in terms of an overall strategy otherwise we could just grow and we're also bumping against other organizations that can do these things as well or better than us once the innovation part has happened he says we're an enzyme oh no that's not going to happen yeah I mean I get we like catalyst better than enzyme that sounds cleaner somehow although it's not as biologic I guess yeah so that's right so you're right so for us the sustainability model is that the organization itself innovates without us the real sustainability model is that CTSI doesn't need to exist because the organization has embraced that that sort of common let's look at common goals let's look at creative solutions let's hear lots of voices and let's take some risks and then you don't need us if I could disagree with that the sign of any good catalyst is that after one reaction is completed it goes on to the next reaction so to me the sustainability and I don't know how many of you feel about this but to me the sustainability is that the larger community comes to realize that catalyst is essential to what they do and then the whole community is going to want to make sure that it continues to exist because the mitochondria are critical for the cell but the whole cell has got to believe that mitochondria is worth existing so I think sustainability can't count a trustworthy partner as we all know I'm talking as an institution as an individual as the individuals are great rather than being seen as the bacteria outside the organism getting it to do things well that we would become the mitochondria so couldn't you imagine that this would be a function within the chancellor's office or within the schools as a part of the of the fibric of the institution and all I would ask is that and again I get hung up on language because I think the language has not helped CTSI in some ways with the basic science community all I would ask is that we create this catalyst this enzymatic reactivity for the institution and then the whole institution won't want to see it go away because it provides that kind of innovative, creative kind of spark that then a Talmadge or I or David Vlahoff or someone can then take to implement and to expand on and to grow within the confines of its own unit so to me sustainability is to create that it's not to create necessarily a recharge function is to create an essential institution so that the institution wants to feed feed it and keep it alive and not assume that it only stays alive if it can figure out other ways to fund itself. I should clarify too that when I showed that I think it's now what are we up to 35% of our support comes from institutional support and recharge it's a tiny fraction that's recharge so in fact that is the way we've incorporated we've said how do we deliver on institutional goals that others are committed to funding because they share that vision that that's a great next thing to do and that is going to be the way we're going to most likely effectively grow what we do so I think our visions are actually not that different it's whether it exists as an independent entity or not and I think as an independent entity I think we do have value but how independent do we need to be depends on how the other components of our institution run but the hallmark of a complex adaptive system is that you adapt to the environment and you form and reform and you change the way you work based on the pressures in the environment and the opportunities that exist for you and I think another word for sustainability is relevance and adaptability and I think that's what clay has been really good at in charging us to think about and I think that's what's going to sustain the CTSI going forward is that it will change to meet the needs of the environment and the challenges that are in front of it yeah we hope so we're trying, we are Howard so one of the ways that you generally find out whether an institution or process or a project is of value is you have some metric we can't do the experiment of what would you CSF be like in five years if CTSI wasn't here we can't do that experiment we don't have the metrics I can tell you as a user of CTSI that it's definitely helped us with our translational work and particularly in the area of approval and review of protocols, institutional review board meeting requirements of external regulatory agencies, statistics so there's a lot of value that they add but one thing that you might think about that would be very helpful and I don't know if you could create a metric for it is because you have profiles because you have a pool of consultants would there be a way when a protocol is submitted for example to actually have the research reviewed by local experts to improve the design for example to say well did you know about this can we improve the quality of the research that's going on and the other thing that perhaps you could do is bring the clinicians into the evaluation of basic science proposals to say which ones seem to be the most promising to lead toward improvement in health care do we do that, can we do that how would you propose to do that so here's a comment on this because I'm going to cheat because our idea from our table didn't make it so now I'm going to say it anyway but one of the things that CTSI has been doing is creating this thing called open forum and now the department of medicine is using it and I think others where instead of using the old system of you write an application, you put it in thumbs up, thumbs down, go back and do it again this allows for basically real time critiquing and improvement right throw up the proposal and if someone has a good idea of how to make it better that's great if someone thinks it's great that's great if someone thinks it's lousy at least you want to hear that talk about sort of creative destruction imagine having a password protected website where a month before your R01 is due or your trained grad you could throw it up to the website and people around the university could look at it and give you some ideas and give a read it wouldn't just be relying on one mentor two mentors who you happen to cajole into reading your R01 before you put it in but a community they might say you know I have a mouse that might help you or you know I have a cohort of patients that might do this could we get enough trust and get back to the trust that we would be able to allow each other to look at our deepest ideas and our deepest thoughts with the idea that they would give us things that would help make it better now that would be a bizarre you know there's a new journals now that are like that there's a journal called pure J which has been out of plus the guy from plus that's what they're going to do they're going to throw the papers up early and they're going to say you know we want to publish the best papers give us a critique and then we're going to go back to the author and give them a second chance so I don't know if that's anything that could fly here that was our table not my idea by the way someone else at the tables idea but you know maybe we could try a pilot and something like that I don't know Jeff I wonder I work on open proposal and a piece of it that I do wonder is how do we establish that trust especially among researchers sharing their information because it is a real paradigm shift how do we really start to establish that trust ensuring that kind of information hope that's a rhetorical question I'll come back to you in a couple of months well we probably have an opportunity here more than other places I don't know maybe I just love UCSF and I believe that but we also have shared for example and I haven't heard of other CTSD doing this we've shared successful proposals so not pre-proposals but we have a library of successful range of successful K proposals and that's a step and that's only for UCSF investigators but again I feel like if any place has the seeds to do what you're suggesting and I love the idea we have it and it's exactly the kind of thing I think that CTSI would love to help catalyze I think we need to come up with a way to demonstrate that I think the perception that there's a set size of pie and you know if you don't get if you get your piece somebody else can't get it we need to come up with some way to demonstrate that that's not true that collaboration and partnering can actually make the pie bigger and we should have metrics to show that I don't know exactly how we collect those metrics but I do believe that collaboration particularly across disciplines can make the pie bigger