 So welcome to our third session on the Genesis workforce challenges and opportunities. Thank you so much for joining. I'm going to briefly go into just some introductory introductory remarks and logistics. As you can see from the agenda which I'll show next, our director of NHGRI Dr. Eric Green will give you the formal welcome. After that, we'll spend the bulk of the time with a moderated discussion that will be co-moderated by myself and more importantly, Shamita Descupta, who among very many titles and accolades is a professor of genetics at Boston University. And then we'll wrap up just in the last couple minutes if we have time at the very end. So let me go ahead and stop sharing my screen. And I just want to go over some logistics again. Thanks so much for joining. I'm Ben Solomon. I'm the clinical director of NHGRI. I know some of you, maybe many of you attended the first or second or both first and second sessions. So my apologies that this is repetitive, but we wanted to give everybody an opportunity to attend as many sessions as they would like. As just a very bit of background, this discussion sprung from some smaller group discussions that we had with leadership of folks like ACMG, APHMG, ASHG, ABMGG, NSGC and other such organizations. To define the scope what we're interested in is how do we A, make our workforce as robust and diverse and exciting and vibrant as possible? How do we continue to grow the workforce? But I wanted to find what I mean a little bit by the workforce here. What we're focused on now are clinical geneticists like physician geneticists and what we call clinical laboratory geneticists. So some of the folks that are affiliated with ABMGG and related type programs. I know there are many other people that can and shouldn't do wonderful things in genetics. We don't mean to exclude them. We'd love to learn from them and get their input, but we're not also trying to boil the ocean and do everything having to do with genetics. I'll leave it at that for now because I know Dr. Green's going to talk some more about this and then you all have the opportunity to talk more about this as well. But I just want to mention a few logistics. Number one, as you can probably already see the meetings can be recorded and will be made publicly available after this is done. The previous sessions, the last two sessions are already available on our YouTube. If you can, please list your name if it's not already listed and perhaps your affiliation after your name on your Zoom screen. We would very much love for you to keep your cameras on if at all possible. Recognize that's often not possible because you have kids, patients, pets running around behind you. But if possible, we'd love for cameras to be on. You are welcome to use the chat function that we're going to try a little bit to make sure that the discussion mostly happens on the Zoom screens versus having two parallel meetings, kind of one in the chat, one on the screens. But please do feel very free to add things to the chat. We'll get the transcript later. And honestly, it is very, very helpful to look at key things that folks may want to point out. After Dr. Green talks, we'll outline, we'll show you the set of questions that Shamita and the other co-moderators who did the other sessions, Wendy Chung and Deborah Gehr, what we designed, but I want to be very blunt to say we don't need to stick to that script if you guys want to take it in different directions. If Shamita says, oh, let's follow up more about this and not so much about that, that's great too. That's just kind of a set of ideas, not necessarily a prescriptive script that we have to follow. I do hope that this session, like the other sessions, will run relatively smoothly, but we all know, I think in this virtual or semi-virtual world, that there can be IT hiccups. So I'm very grateful to our IT team, Gerald, Brandon, and our admin folks like Saray for making this hopefully work as smoothly as possible. But, you know, gremlins can get in the system no matter what. So we apologize if there are some technical issues. And with that, I'd like to turn it to Dr. Eric Green for his welcoming remarks. Thank you so much. Well, thanks, Ben. I wanted to also extend my own welcome to all of you for this important discussion about the Clinical Genetics and Genomics Workforce. I always point out how grateful I am as the Institute Director to be positioned to put out a request for people to give us some time to brainstorm with us. And people just always seem to come. And I think that's because of respect that they have for NHGRI and its history of doing important things. And more importantly, of really listening to the community and trying to hear all voices and then do our best to move the field forward. So I'm always grateful when we're able to get people to donate some of their time for brainstorming with us. So why are we here today? Ben started to set it up. I'll put my own spin on it. Needless to say, we are so excited at NHGRI because the fields of genomics and genetics, they're rapidly changing. Unprecedented opportunities for genomic medicine. We've seen this massive acceleration and capabilities of genome sequencing, better analytic tools, longer and longer DNA sequencing reads, also coupled with gene editing and gene therapy becoming a reality in ways it hasn't previously. So there's all this remarkable opportunity for clinical implementation. And obviously, as an institute, we're motivated to do everything we can to see all these areas reach their full potential. And similarly, there's many opportunities for clinical laboratory geneticists. And there's also a lot of complexity there. A lot of industry consolidation, a lot of questions about how AI is going to have effects on all this. And so we're also thinking about that workforce. However, we also need to be honest. I mean, we are puzzled like many people that there aren't enough physicians going into medical genetics training programs. And many hospitals and clinics are having a hard time recruiting experts in these areas. And that could create real issues around equity and access, especially if you think sort of nationwide or eventually worldwide. And so just like all aspects of the genomics workforce, we care deeply about seeing a properly sized, trained clinical workforce in genetics, laboratory and patient or a facing genetics and genomics expertise. So we've had lots of discussions in an HRI. We, as you know, have a medical genetics training program here we do jointly with Hopkins and but I we've had a lot of discussion about what can we do to stimulate growth of this workforce area. What can any chair I do as a funder and it as a leader. And so we've decided to convene experts for a series of conversations in summer has been said this is the third of three. We're just seeking better ways of identifying what the barriers are, and we want to explore among those barriers, which are the ones in any chair I could do something about or influence. And we know there's a lot of other organizations working on this. And we've had discussions and we'll continue to discuss with leaders of those organizations been named some of them a BMGG ACMG APHMG ASHG EIO I mean there's a lot of other organizations. I can tell you any char is no desire to step on any of their toes and so we just want to make sure that any char is contributing to all of these collective efforts going forward and we're happy to do it in partnership with these other groups. Another aspect that of all these discussions that intersect with anytime we talk about workforce development is that we also need to be thinking about it not only being a strong workforce but a diverse workforce. And so this is saying that I think the conversation should also think a little bit about are we doing enough to make sure that our clinical genomics workforce is sufficiently diverse for all the needs that there's going to be going forward. Well, we've delved into some of these areas and our 2020 strategic plan, which hopefully our strategic vision that I hope all of you have read published in nature. And like almost all parts of that strategic vision where an ongoing efforts to implement them and when we're uncertain exactly how to implement the goals to engage with the community to learn about the barriers and strategies and concrete actions that we can take. That's the context. And I just wanted you to know you heard here and from me and how committed the institutes and we really hope from these three sessions we've had this summer will synthesize the input and maybe we can come up with some absolute actions that any share I could take to maybe try to move the needle working in partnership with others. So with that, let me turn it back over to Ben and also to welcome Shameda and also thank her for co-moderating today's discussion. I thank all of you for joining and back to Ben and Shameda. Thank you. Great. Thank you so much, Eric. I truly appreciate your remarks and and joining us for all these all these sessions. I'm going to flash up on the screen just for about 30 seconds or so. The questions that we developed in planning these sessions. Again, I want to emphasize that we could go through these or we could go in a very different route. This is the third session. So if there's certain areas that we should cover that we haven't yet, that's great. Or if we should just stick with maybe points, I don't know, making up two and four. That's great too, but we'll leave it to all of you and to Shameda to decide that I'm going to stop sharing this now. And I think Shameda is going to lead some of this moderated discussion and I'll be hovering both in the chat and just kind of helping monitor and and prod things along as well. Again, thanks so much and Shameda over to you for the start of the moderated discussion. Thank you so much, Ben and Eric for your investment in these sessions and thank you as well to the NIH team for helping make this possible. What I would really like to do in our time today, one of our goals really in having three separate listening sessions is to try to capture as many voices as possible, but I also want to make sure we capture all the topics. I think in the first couple of sessions we've tended towards thinking more about barriers and perhaps a little bit around the role of the future geneticist, but I also want to be starting to think in a solutions oriented way today as much as we possibly can as a group. But let us begin, as we said with the ideas about key barriers to the growth and evolution of the genesis workforce, and how we can overcome them. And again, this is a moderated discussion so really, I don't want to be talking the whole time I want to hear from you. And hear your thoughts so if you would like to contribute please feel free to raise your hand using the raise hand function, or to ask to be called on in the chat. So key barriers to the growth and evolution of the genesis workforce. Maybe I'll go ahead and call on Fuki because I know that Fuki submitted some questions ahead of time and one of the things that you mentioned was lack of visibility or knowledge of the specialties among those advising medical students and one thing I probably should have said is that one thing that's slightly more general about this listening session compared to prior ones is that I'm coming from a more educational point of view. I'm not a clinician. So I'm thinking about some of these elements as well like who is advising the medical students are they even aware that genetics is a specialty so Fuki, kind of turn it over to you. Sure. Thank you, Shamita. Fuki Hisama from the University of Washington for those of you who don't know me. So I actually met with our medical student advisory office recently to talk about the path to medical genetics. So I basically educated them because they had some misinformation about the tracks and the pathways to a career in medical genetics. So I think that's a start because we have something like 300 medical students per year here across whammy. I think another so just basic exposure and knowledge is sort of like the first gate. And then another one is that no at no medical school that I'm aware of in the United States or Canada is medical genetics a required clinical rotation. So they also unlike, you know, the core clinical rotations of surgery, medicine, pediatrics and OB. No one is required to do a genetics rotation by the time that we get them in the fourth year medical school they've often already chosen what they're going to do. And then later on in residency, oftentimes they have decided somewhere in the beginning of the second year what fellowship they're going to go into. And so I think the model of residency followed by genetics training, we're losing a lot of people that way. So I think a lot of people who are program directors have noted the success of the combined programs like pediatric medical genetics residencies where it medical we recruit medical students to apply for combined training, their dual board eligible. I think it's difficult sometimes to find the funding at the individual institutions from the GME office to expand those programs and have more positions but they're they're a very successful model if you're talking about thinking about solutions for recruitment. And certainly we could have more of that in terms of internal medicine medical genetics combined residency neurology genetics pediatric neurology genetics combined training and so on. Thank you. Thanks for that introduction and I'm so glad to hear you've been working with the folks who are advising medical students at your institution. I will also say that we noticed this past year that amc careers in medicine. Had they sponsored a whole career fair type of event and genetics was not represented there. So luckily Susan Clugman immediately got on board with that and she's the president of ECMG, and she is in touch with the right people to be included next year. But you know this is one of the areas in which we see a gap in terms of awareness about the career and also all the confusion as spooky said around is it a residency is a fellowship is it both. Now next let's go to not Robin. Hey, sorry, I was muted and I'm sitting in my basement literally so that's why the cameras off nobody needs to see my basement. So, I think it's an important question to look at and ask. Why. When you say what are the barriers. If you ask medical students or talk to medical students about what they're, you know, don't ask them why they're not going to check ask them why they're going into what they're going into. And there's really a combination of two things, one of which works very strongly for genetics and one of work, one of which works strongly against genetics or work strongly against genetics is salary. You know, students have incredible debt that everyone knows that what works for genetics is lifestyle students are extremely focused now on lifestyle. So I think there is a lot to be said where I think we have advantages but the biggest thing and Jenny Cassidy one of my old residents presented this last year and we're about to publish it. We actually asked people why they chose genetics current residents and young faculty members. And the overwhelming answer that was consistent among almost everybody was they identified somebody early on as a mentor or at least were exposed to it. Not personally speaking Bob Marion for me when I was a pediatric resident. So, getting clinical geneticists into the medical school curriculum early. I used to teach 20 somewhat hours in the beginning of the first year and for many students. It was the first time that ever heard of clinical genetics. And unfortunately my hours have been dropped primal some some which because my interest some which because lecture hours being dropped but I think, you know and I've talked to you about this since way back when when I know the apHMG. Getting us clinical geneticists early into the curriculum and just getting so I know so every year I would have like eight people get really excited by genetics and if I was lucky one or two of them would end up going into genetics. By the time they're fourth years, I actually think it's exact same story for the people who do PhD clinical laboratory work. So I think early exposure early in their PhD curriculum to say yeah you can study biochemistry and try and fight for our ones or how about this really cool field where you get to interact with patients and do some really neat diagnostic work. So I think early exposure is the key. And that's institution dependent and the only real way to get it done is by changing the step one exam that more genetics content but that's that's kind of another discussion and I'll stop other people want to talk. Thanks so much and that you really touched on a lot of important trends that are happening in undergraduate medical education and how that impacts exposure to potential mentors. And of course there's the inherent conflicts between the mentors being oversubscribed in their clinical responsibilities and then also still wanting to give back to the men, you know the next generation of trainees. Let's hand it over to Judith Bankendorf. You're muted you know I know thank you. All right, so I am actually retired but I've worked in the space for 40 plus years at Georgetown University through a CMG and initially at the University of Miami, and just want to say a couple of things. At the University of Miami in the 80s we had a very interesting program in the behavioral science class for medical students, and it was 125 hours interdisciplinary most medical schools have them. And everybody got assigned a patient with a chronic illness to follow for the year, and I immediately said well genetic disease patients teach all sorts of things. I'd like to contribute a dozen patients with genetic diagnoses, and we took them from the hemophilia center, and those medical students who are following the patients that I knew clinically also met with me as well as in their small groups and this work was presented at a double AMC meeting in 1984. And when I went to the double AMC I couldn't figure out why there were no geneticists there. I then wrote a letter to Ash Egg saying, where are all the medical geneticists at the genetics education meetings, because you can teach all of medicine through genetics. We're womb to tomb, we're every organ system, and there isn't a problem that a family doesn't encounter that you're going to find in other facets of medicine. About 20 years later APHMG was formed, and in the 80s I just want to say that the ASHG had a task force looking at medical school education. There were four medical geneticists in the dean's office at that time, and we looked to see if having a medical geneticist in the dean's office made a difference in the curriculum. Overall it did not. We looked to see if it was taught as a clinical science versus a basic science and who taught it, and those data were all published in the 80s. There's also a task force report that came out in 89 that talks about the vertical integration of medical genetics into the curriculum and sadly, we're still having that same conversation. So, I would love to be able to leave medical genetics completely knowing that we've handed this problem over to people who finally have figured out a solution and maybe the medical school curriculum as it stands as form a curriculum isn't the place that after 40 years of having the same conversation. We're still having it. Thank you so much for that historical perspective Judith. I think you raise a lot of interesting points that are very important. And I also will point out that the chief educational officer of the emcee right now is a medical geneticist so perhaps we have a little bit of an in there. I noticed that Neil's hand went down Neil. Did you still want to add anything. Are you still here. I thank you first of all so yeah I wanted to add something that's probably more relevant to some of the later questions but I'll throw it out here now anyway which is that one of the things that you know has been discussed I know in ASG and and other organizations, particularly as it pertains to sort of diversifying the workforce is the idea that genetics in many undergraduate curriculums is is just sort of biology it doesn't involve very much human genetics. And that sometimes the lack of that human genetics. People don't, you know, sort of get that stimulation or imagination that comes with sort of understanding how much you can gain from patient interactions and how much you can learn about human biology from from genetics. And so, particularly in, you know, some of the HPC use and other places, you know, human genetics is just and just doesn't, you know, have a real, it doesn't really exist. And that may be one way, both to increase the diversity, but also to sort of engage people early on as they come in, it's not such a foreign thing when they hit medical school. Well, I think there are incredible points. We tend to focus on the medical school to residency transition but it happens before that too. And HPC use are great. And other minority serving institutions are great places that we should think about expanding the footprint for human genetics. And that's a perfect segue if we could jump from question one to question three is how can we strategically promote a diverse and growing workforce in this area. So Neil's given us our first task. Others. I guess well folks are thinking if I would ask Neil or anybody else a follow up question you mentioned it sounds like Neil you were describing that it could be beneficial to build some of the bridges if I'm understanding between you know some of the basic science and genetics to what happens in the clinic and the impact on patients. So do folks have ideas about how that could happen or you know what what what would create that link, especially in a school whether it's an HBCU or other school where there's not that link already there. Or maybe I just totally misunderstood what you're driving at Neil. No that's what I'm getting at for instance you know so you know been to like the abracams meeting which is, you know, so for my minor high students, and they have a section on genetics but in that section on genetics there's no human genetics as any part of that it's all sort of biology it's based on thing which is not sort of trying to belittle that but I'm thinking about that as a secondary to be able to engage people. And understanding that hey genetics does payroll in human biology, and therefore you know it's something you can think about even if you're going into medicine because I think it tends to get divorced between the two, particularly in some of those areas and groups. Yes, thank you and also for those of you who aren't aware about abracams and also SACNIS is another partner organization. They are undergraduate groups that allow students of venue students of various minoritized backgrounds of venue to present the research that they've been engaged with. And as Neil noted a lot of it is very basic science oriented and the goal for those organizations have mainly focused on transitioning undergraduates to PhD granting programs. But it is potentially, you know, another community with which to connect that can also help us get folks into the clinical sciences as well. So, Nguyen, I think you were next. In response to your most recent question. I'm not sure how many on the call are aware of the recent entry level modules that will no see or no follow that was just put out in regards to the population of genetic workers basically who are not necessarily getting bachelor's degrees. They may be in high school, they may be in community colleges, and they're probably working. And I feel like that no full. I mean, unfortunately, the way that we had to write it had to be very circumspect about the language, but the aim was, you know, for looking at that population. We're able to get more diversity and exposure to people who perhaps hadn't had exposure to previously or who didn't see or who might not see how relevant it could be and those are frequently our frontline workers people who are, you know, at the offices and in research work who are talking to patients and are going to be asked questions that they may not know the answers to and that that just helps to improve genetic literacy across the board. But hopefully then we'll, you know, trickle up as they say to be able to have more people entering the genetic workforce, because they have more familiarity with it but I think that it has to start much earlier than targeting PhDs or postdocs and people who are, you know, maybe already in undergraduate education or who are already like oh I'm definitely going to go to medical school I mean at that for a lot of people who are in that space for entry level modules. The thought of that kind of advanced education feels out of reach a lot of times and so making it accessible at that stage I think is key. I really appreciate your comments thank you for sharing that you know I think a lot of us are not just by default in those kind of educational spaces which means we have to make a concerted effort to get out there and connect with those communities. And that also has to do with the point that you made in the chat which was, we have a lot of interprofessional partners that we need to connect with and so if we wait until medical school we're going to entirely miss that group of people. And I know I see some of our interprofessional partners here on this call so I would invite you if you have any follow up comments to contribute at this time. And that did you have anything more to add or is your hand up from before. You know real quick. One of the things I've learned is almost nobody says no if you offer to give a lecture or talk. I have done. I don't do it anymore but I used to do a lecture on genetics for an AP bio class at local high schools. And we've talked about that, like about just getting out in the community and exposing people to genetics earlier. And the thing is, most of it, you know people are very hesitant about putting themselves out there. And I'm not sure why because I almost never had somebody say to me no we don't want you to come talk, because genetics is cool with sex everyone loves to hear about this stuff. And I think if you're just aggressive and literally pick up the phone and call your local high school and say, could I come speak to the AP bio class, you'd be amazed how almost always they're going to say yes. Same thing with the undergraduate, you know, there's almost never a time where people don't want you to come talk to them they really love this stuff. Yeah, and to build on your comments that just to give you an anecdotal story from what we did at the most recent APHMG meeting. We connected with title one school in the area, and to send a pilot group of educators out to run some sessions with the middle school age students. And those sessions were based on curricula created for that age group by the personal genetics education project at Harvard Medical School. They partnered with us to give us a lot of super practical advice because it's not the group of learners we normally work with. It's incredibly fun and being a title one school we are reaching out to a lot of different minoritized communities. And, and that's a pretty easy thing to do if you're out at a certain location for your meeting you can get a group of, of educators or clinicians or scientists to connect with schools in the local area. I'm happy to talk to anybody who's interested in doing an activity like that and connecting with the folks that helped sort of nurture this interest for us. Just if I could ask you and that and every couple other folks who commented on this a follow up question and I guess two quick comments one is nobody's ever called me cool. Number two, my daughter specifically said I was not to talk to her AP bio class, despite my, my many requests, but what is the sweet spot you know we've talked about these different you know everything from middle and perhaps even below that to, you know, residents who are about to choose fellowships and you know everywhere in between. What is there a particular area or is it just do everything or where would you where would one marshal their energies in in if the idea is to expose people, learners to genetics more. I have no idea what the right answer is or I'm just curious about everybody's thoughts on that. I don't think there's a wrong answer. I don't think there's a wrong answer I don't think, you know, one is mutually exclusive to the other. You know I did these lectures when I was residency program director and I was teaching 20 someone hours to medical school. You know, you can teach anyone who's interested in, you know, who's willing to have you come so I don't think there is a wrong one. It's hours it's time. Some people have more time than others but you know it's a great activity. I'd also love to see a service component to different training programs, you know sending out residents to engage with local communities could be another way and give them, you know academic credit for doing those kind of activities. Did you have more to add. I want to say I really love the service component idea of it, and in relation to that, and building off of what Nat said, I feel like, you know, it can be organizations that you're associated with, you know I did it for the Girl Scouts and for the Boy Scouts and, and, you know, church groups and anybody who had some kind of stem component to whatever conferences that are or get together so they're doing for festivals and that kind of thing. There are mentor programs out there all over the place and, and that's right I mean, if I wanted to I could lecture at every single PA program across the entire country and nobody would turn down a lecture on genetics and in fact, I mean, I get people asking all the time can you come and give this lecture. And with the advent of, you know, zoom, it makes it super easy it's not like you're, you're having to travel really far to do it so I think there's a huge component of being able to to just get out there. I think the main thing though is to make sure that you have a connection. So it's somebody in your community that you know and trust and, and you know you can talk to them about, you know how do we spread the word about genetics. And I would agree with that that genetics is cool. I don't know about sexy but definitely cool. And so, and then we think you're cool. One thing I want to add is whenever I've given these talks. I definitely obviously cover basic science and, and, and, you know, medical stuff but I always talk about genetics is a career, even the high school juniors. And I'm not sure I put that in there and about the good we do, and how much we benefit people because, you know, the students, young people see this every day on TV about what the surgeon does or what, you know, Dr. House does or whoever's whatever. But they obviously have no idea the good we would do and I really make sure I emphasize that. I think we need a television program. Right. To advertise genetics, it would probably have the biggest impact went so to get back to diversity, diversifying the workforce though in the past couple of years I think the genetic counselors have had a lot of success in this area. So, you know, our genetic counseling pro entering classes something like 50% you are in. But what you have to remember is that for physician geneticists. It is such a much longer path to get there that there are so many more other opportunities for people to be drawn away and into other careers because you start out with a genetic counseling student. And two years later, you're going to have a genetic counselor, right, but you start with a first year medical student who's super excited about genetics, but then they go through four years and do all these other rotations and decide oh I want to do pediatric urology or ophthalmology or, you know, something like that. So, I don't know what we can do about that particularly, but in terms of solutions that each the ASHG human genetics scholars initiative. They're the advisory committee, and they have been very successful at creating a cohort group of scholars who meet regularly with each other they have mentorship through the organization they have funding to attend the ASHG annual meeting. And that is doing really well and some of the scholars are really incredible people. Absolutely, the group of ASHG scholars is incredible and maybe that's another cohort that we could tap into to help spread the word. Yeah, but something for like physicians or, you know, clinical geneticists that would be parallel to that. Judith, did you have another comment. Just a quick comment I've been on all three of these sessions and I think what's so exciting about this session is there have been so many stories shared about experiential learning. I think experiential learning really brings things home at any level and anything that we can do in the classroom. From, you know, middle school, all the way through to get people to have a hands on experience, a ha moment, something transforming is going to be extremely valuable. I also think that we need to think about writing up some of the things that we're doing and taking them to the double AMC meeting. We actually were able able to get pre and post data from the dozen students in Miami that followed people with hemophilia, just simply the first day I said, give me some words that come to mind with hemophilia, and they were all terrible bleed to death, but not and at the end, they were talking about qualities of the patient as the primary caregiver, being able to administer their own treatment, people with strength, people with courage, people at risk for orthopedic issues from bleed so you do see attitudinal changes with experiential learning, and that part of the discussion has been tremendously exciting. So thank you to all. I don't know if it's the natural progression by feeling like this is in a nice way people are have some solutions where we're focusing a little more on the opportunities, for example, and the obstacles for folks like you to have attended all three. I don't I don't know if it's okay. David Rosenblatt to put you on the spot but I've just monitoring the chat and there's a number of interesting comments in there. I don't know if you want to pick one but two of the things I was just curious about if you could explain to the group. You mentioned something about the way departments are organized, you know that can help with exposure to genetics or integration of genetics that was one area. And then the other more recent comment I'm curious about is your the genetic researcher of the week experience that you mentioned that seemed to be a neat thing in Canada. So first of all in the other words something I've thought about an awful lot because genetic seem to be sequestered either in pediatrics or medicine they're not like a department in a hospital. And I even look at the training programs like usually if you have internal medicine or Peds, there'd be a courier to and then they'd subspecialize and we really do have some specialties of genetics, but we haven't really organized ourselves that way organizationally. For example, I think prenatal diagnosis is very different expertise from cancer genetics very interesting neurogenetics great different from psychiatric genetics various from, you know, so from laboratory genetics. And we, and the way we've evolved we haven't moved to the thing where we're like we're on a par at the Dean's chair with the head of pediatrics and the head of medicine is equal, making the case, either at the universities or in the hospitals and we don't have that in Canada either so it's very hard at at McGill but never really been able to do it after like more than 40 years of trying. And we have a situation where most of at least in Quebec all our trainees go into a five year medical genetics training program, but they still do like two years of medicine medicine and piece rather than like a year rotating and then get into two years of genetics and then to your subspecialties and people like an endocrinology or neurology are actually better trained say tend to go up after their fellowships and then do something more deep. And our guys come out more generalists, after the five years and really haven't picked a subspecialty of genetics because we matured so much that we're going to compete with endocrinologists and pediatric neurologists, and the other people who was special narrow area and then learn the genetics, like all the psychologists are doing a ton of genetics. And they're other and now we're mainstreaming the cancer genetics with oncologists are in their own tests so I just don't know what the niche is but I haven't really found that we're competitive with some of the other areas that are more mature. Yeah, the Canadian but so I don't know if this was actually done by a foundation but I'm sure they're equal things in the states and this was like 10 years ago a student by the Canadian gene care foundation doesn't exist anymore, had a competition for high school and then placed them in labs across the country for a week, and then now 10 years later one replied and does a master's now down to failure doing a PhD in genetics so you know it's a way of getting them early and putting human genetics into the high school curriculum don't teach mental speeds, start with human genetics in high school biology. Thank you so much, these are all really important points and I'm glad also that we're having some conversations across international borders as well. I just call on Jonathan Berg with the comment of our hearts go out to you at UNC we're thinking about you all. Oh, yeah thanks everyone yeah that was a disturbing time most people weren't close to it but obviously whenever it happens on your own campus it's. Yeah, it's it's home so you know I really appreciate all of the comments, I mean, I think this is great that the NHGRI is doing this. So one thing that has occurred to me and you know and. Our specialty kind of spent a lot of time waiting for therapies to come, and we haven't prepared ourselves to be ready to be the people who deliver the therapies. Right, so I don't know how quickly we can catch up, but you know if instead of handing off all of the gene therapy to the individual specialists who already do infusions. And so forth. If we could capture some of that that might be an opportunity for us to kind of be the leaders in delivering these types of gene therapies but of course, you know for for some conditions there's already a specialist that owns that condition right so for example at UNC, historically the cystic fibrosis center has been run by pulmonologists they don't really need geneticists over there they don't think they do. And, you know, and so we don't really do much with cystic fibrosis so if there were ever targeted therapies for that condition they would own it that they would run it and so we've sort of. I feel like we've a bit lost that that opportunity, to some extent, I guess another thing that we can be doing though is trying to get on top of precision medicine whatever that means to people. You know, and often precision medicine is about rare disease diagnosis and genetic testing and management of people with rare disease but could also mean that we need to really be at the forefront of each of our institutions in governing and how to use other forms of precision medicine whether it's predictive testing population screening and those types of things so these are the areas that I'm trying to focus on more more so here at UNC as sort of how can we kind of get at the front of some of those other novel areas before they get taken up by the other specialties. Thank you that's such a critical point we need the students to understand that it's not just a diagnostic specialty but that there are therapies down the road. And it really changes I think they're all whole outlook about what their practice might look like and what their career might look like. So, I want to go to Mimi I don't know if your point is related or eventually I want to transition to talk about the role of future geneticists. Yeah, I just want to add first that totally agree with what Jonathan said about. Not that we've necessarily let it go the management and therapy and treatment but it's something that we actually have to claim. And and be proactive about like you man. I think that's one. I think the other thing that I've been hearing and at our institution is and and others when I get calls is that geneticists or genetics and general clinical geneticists are very research oriented which is true and that's positive but those that want to do much more clinical medicine and not the research side as much or don't want that are the MD PhDs we happen to have more MD PhDs and other specialties percentage wise. That we need to encourage and welcome them into our specialty and really recognize that we're going to attract individuals by being such an important and exciting clinical specialty. I just want to bring that up. Thanks so much Mimi so as I mentioned I would like for us to talk a bit about what the role of the future geneticists geneticists should be and what we can imagine the directions of future practice. And I also want to put a special call out I see some trainees and recent trainees out here on the call. If you have your perspectives from your own recent training periods that would be wonderful to hear as well. So thoughts about the future of the practice. You know I'm saying I guess one thing I would ask as a follow up and I was I was going to do this but Jonathan if I could ask you again so maybe picking on that first thing you said about management which has come up in some of the previous sessions. So what would you do to get ready to to to prepare geneticists at least for some chunk of that business, or I always say business some chunk of that part of medical care sorry. I mean I think it's a good question so I mean, it probably depends very much on the institution we happen to have folks at our institution who have been on the forefront of that with enzyme therapy and Joe Monser and the, you know, work that he's been doing and now have a junior faculty that's sort of following in his footsteps and I think that's you have to build that kind of program be known for having those types of therapies. But you know it requires a lot of specialized infrastructure right you have to have the right facilities you have to have the right trained staff to be able to do the infusions. And so, you know I think that that to some extent also hinges on the institution being willing to invest in that. And being, you know, wanting to be seen as a place where people go for those therapies, assuming that they're not going to quite yet be that every medical center right there's always going to be that sort of specialized center that's doing it so it is a little bit challenging even though, you know, even though UNC has done a lot of work in vector development for gene therapies, they're not doing a lot of clinical trials for gene therapies, and it's just the infrastructure is not quite there. So it's a challenge. So if you're not building the infrastructure to do the gene therapy trials, you also don't have infrastructure naturally there for delivery of the care once those therapies are approved. Absolutely. And Annie, I see your hand up. Yeah, I think maybe you're calling me out for the training perspective. I missed the first part of this unfortunately I was late from clinic but I think that one of so I'm not sure how much this was already touched on I feel like one of the more common questions that I get is trying to be a more vocal current about how to get through this pathway is even the logistics of doing the training pathway I heard people talk about the, there's a longer training process going through medical school in the residency and then there gets to be a sense that we're a subspecialty field and I think part of that is inherent within the training pathways that exists that for the combined program you're pairing it with Peds which then people assume it's a subspecialty of Peds the majority of practitioners have had some background in Peds and they're under these Peds departments at their institutions and so I think that's harder for others that don't commit from that specialty. I also think that there's inconsistencies from the various programs even for the categorical programs at those institutions that say you need to have finished one year some you say you need to have finished three years in a residency and I think that just leads to confusion over what do you have to do before you do genetics. Do you want me to do one year, do you want me to do three years there's not, you know, to be board eligible it's one year, but some that's not the same as an institutional preference so that's one of the questions that I feel like I've encountered a lot is how do I even do this, even though the programs are published online the frequently asked questions I feel like are less publicized. And then even just familiarity within Dean's offices about how to about these programs that exist I think everyone on this call I'm sure tries to be as proactive as possible at their own institutions sharing the fact that clinical genetics is a specialty but I think realistically when medical students have questions about applying their meeting with their Dean's office their particular mentor and advisor. They're the ones writing the supervisory letter and you know my Dean's office told me don't apply to these combined programs will never get it. So like, and they just weren't aware of that these programs existed and so I think the more we can get integrated into the actual medical school advising structure would help a lot and kind of paving the way and constructing on the pathway to get through the programs. Thank you so much any these are really incredibly important points and I also think it's it's important for us to consider that there are a lot of medical schools both allopathic and osteopathic that don't have access to clinical geneticists of any sort so those students are definitely not getting this detailed advice about how to apply for the next level. I also saw that Judith had brought up an issue around geography and I just wanted to also put out there just to return to our conversation about promoting a diverse and growing workforce. Thinking about the impact of dobs on recruitment to the specialty since a lot of our medical genetics training programs are in states that have now abortion restrictions, and how that's impacted folks if there are any anecdotal stories out there that we can learn from. I will say I guess just to start my wife who's an OBGYN and this is not that was that is not especially that I would have. I take that's point very well about differences and specialties and fits. But she's described differences and where folks are going for residency afterwards because of that decision you know and I really worry it's going to cause even worse problems with access to geneticists and other subspecialists and you know treatment options and so on so forth. In my very limited experience. I've heard people say they would not do residency not because of the training issue because of personal issues. You know it's not that they're scared you're not going to get the proper training because of dobs. It's just that they wouldn't want to be put in a position where they could die with that topic and that's literally the quote I heard recently. Absolutely they're not only trainees but they're actual real people who happen to be a reproductive age to. So I see we're getting close to the end of our time so I want to open it up more generally if there's any final comments particularly with respect to solutions oriented ideas and also to put it out there that. This is not the end of the conversation even though it's the third listening session of three. We don't plan to just end here so thinking about like what we should do as a community. Post these sessions. We just something real real quick and this has been discussed off and on by a lot of people but a way to create almost like a speakers Bureau that Nord is doing that this summer with a focus on. You know medical students and residents and medical students I think primarily but you know we're talking about like reaching out to high schools and places that don't have access to any kind of clinical genetics. And you know NIH might have the biggest trumpet to be able to you know broadcast this far and wide but getting a speakers Bureau people are willing to do zoom talks on topics because they could literally be anywhere around the country. That would just be one suggestion. Now can I ask you or just for anybody else and I've asked this before and I'm ambivalent about it I admit the zoom work does it have to be in person is some of each of the above or you know where would you again put your chips for for for that for a speakers Bureau type idea which I love the idea of figuring out ways to expose more folks. I would just just convenience wise I would say you'd have to do by zoom because if you want me to speak to, you know, more house universities undergraduate campus. It's a lot more convenient do by zoom they get in the car for five hours which frankly probably I wouldn't do. And things like that, where, you know, if we had a zoom based, like 15 or 20 or 30 I don't know how many people. And you could just put it out there and say if you want a speaker on topic x, here's five people reach out to them. Somebody will jump on it and I'll speak to you know, you know, Boise States undergraduate biology class. Yep. I'm not a Skype a scientist but specifically for genetics right right and for educational stuff, this specific thing. Amy, I think your hand was up next. Hi, hi all I'm at OHS you organ health science university. So actually I'm, I'm pretty unique in that I am in the Department of genetics and I also trained in New York at Mount Sinai which was also not under pediatrics or internal medicine, but within a department of genetics and so I have a different view of things and, and I wear both hats even though I'm a clinical geneticist I also do metabolic because that's I'm comfortable with that my training program has allowed me to see the breath and with of both dysmorphology as well as metabolic and so actually that's how I practice today I have one metabolic genetics clinic and I have one clinical genetics clinic, a week. And I think if we want to encourage people to come into our field, these are people who want to treat and help, you know, families and patients and and be rare disease advocates, and I do agree that we need to be more in the line of treatment, because that's what attracts people coming out of medical school and and going into a resident they want to do something about these conditions they want to help these families, they want to do an intervention. And I've seen actually more interest in the in these past couple of years in terms of interviewing in our program asking about that additional year track in in the medical biochemical because there's that dry there's that desire and we're actually trying to shape our program so that we have that additional one year fellowship, but I want to pose to the group if we want to take the bulls by the horn sort of speak and become, you know, treatment providers, then we really should not separate the two we should really put it all into one clinical training experience, which we do in a two year program in the various shapes and forms and, but we should do better about making sure that they come out with a good comfort level how to do ends and treatment therapy how to treat and manage acute metabolic conditions even though they're not metabolic geneticists they have to be comfortable in how to put in an IRB for extended access or, you know, emergency, you know, compassionate care use we should have that skill set so that we can continue to treat our families the best that we can. And I think that we should put more emphasis on treatment and clinical trials and, and, and I think that will help attract more trainees because that's that's really where we thrive at is in engagement with the rare diseases and we need to be able that's where parents and patients are now they're trying to push that envelope and that's where we need to be. Amy for your comments and I think also maybe part of the intersecting space with your comments and Jonathan's comments are maybe the end of one genetic treatments are an area where the geneticists can add particular value, because that's not necessarily totally by infusion centers alone, they need a little bit more help with those. When I know we're right at the end of our session but I wanted to put out there that I did a survey in 2022 PAs and PAs students, I had almost 800 PAs students who were interested in rotation in medical genetics. So, there is an entire subset of the population of people who are, you know, getting ready to get into the medical field and who really would like more exposure to working with medical geneticists not understand we don't have enough medical geneticists but an interim you could take a student for four weeks and train them in the way that you want them trained and then you get to, you know, use their services for free for those four weeks basically while you're training them and figure out okay is this person a good fit for my clinic for my department and then, and in the, you know, you're training somebody to actually learn how to do things in the way that you want them to. And to net's point about the Speaker's Bureau switching topics. The foundation did something like this we had one of our national priorities was nutrition. And so they created nutritional outreach fellows and those fellows were educated in terms of how to give about nutrition and receive training from, you know, in nutrition, and then we're tasked with going out and giving lectures to as many people as they could and so, and they do this every year now and so it's getting more providers educated. There's a minimum investment, it was like $1,000 that each fellow got and then, then there's their each spreading the word. And so that's one way to get that Speaker's Bureau going and they give you a set of slides to start off with and you can modify them for your audience as needed. So that's one way to get that Speaker's Bureau started. And in that model just one quick follow up question, were the fellows trainees or were they established professionals or something. They're all PAs because it was the PA foundation so they're all working PAs. Okay. Excellent. Now I'm going to turn it over to Ben. So I think we're right at the hour so I want to thank everybody who attended one, two or three of these sessions, especially Shamita for co moderating this. If I can make one promise is that we're not just going to leave it with these three one hour sessions of chatting as we've already talked Shamita and I and others about kind of what our next follow step follow up steps could be not to pick favorites but just as some examples I heard today, especially today as well as the other sessions that set the stage I think a little bit kind of some short medium and long term possibilities you know in the shorter term. It seems to me maybe figuring out ways to expose different learners to great people like us and others, you know in the medium term how do we do things like target and increase the number of combined programs. How do we prep for management and the role of the Genesis in the future so we're doing kind of cool exciting things not that they were doing isn't exciting now but how do we continue to evolve for the future. And in the long terms I think something that wasn't mentioned as much this session but was really a big and important point previously are things like reimbursement and ways that we can advocate for really important areas like that that affects salaries and effect. You know the ability of people to get the proper treatments. Thank you so much to all of you. Keep an eye out because you registered we have your email address for perhaps some follow up surveys as we try to gather more data to help us inform NHGRI and NIH is next steps and the next steps with all of you again thank you so much for taking your time have a great day.