 All right, I have 301, so I'm going to go ahead and get started. As you can see, you are here for hopefully the right place, the geneticist workforce session entitled Challenges and Opportunities. I'll explain a little bit more for those of you who want to hear a little more explanation about that before we start. I'm also going to go over logistics, but here's the basic agenda. We're going to go, we'll be strict and we'll end it at one hour, no matter how much we've covered or not. I'm going to start with just a quick intro and go over a few logistics for this meeting. Eric Green, the director of NHGRI, will provide the official welcome and some background remarks, and then the main portion of this session will be a moderated discussion with Debra Gehr, who should be up there on your screen, who's the chief of the division of Genetics and Metabolism at Children's National Hospital in DC. That'll take about 30, 35 minutes or so and then at the end, I'll provide either a five or a 10 second wrap up depending on how much time we have left. So let me stop sharing this now. All right, so again, I'm Ben Salman. I'm the clinical director of NHGRI. Thank you so much for joining. The only, I guess, overall remark I wanted to provide other than some tedious logistics is just to mention to set the stage a little bit about the scope of these sessions. So these sessions started from some discussions that a number of us had, including some leaders of groups like ACMG, ABMGG, NSGC, APHMG, ASHG, I'm sure I'm leaving out some others, but lots of folks who have been dedicated to this challenge for many years. In terms of the scope, and Eric's going to define this a little further, but we're really interested in folks who are, I guess, ABMGG or similarly certified as physician genesis, or you might call them clinical laboratory genesis, those two groups. We don't mean to exclude other groups who are involved in this field, such as a cardiologist who works in genetics areas or genetic counselors. We wanna learn about a lot from those groups, but we don't wanna boil the ocean. In a nutshell, my overarching question, or our overarching question is, how do we bring more people into the field? And how do we ensure that the field is vibrant and diverse going forward? So we'll leave it at that for now. I just wanna go over just a handful of quick logistics. First, this meeting will be recorded and will be available on the NHGRI YouTube and website. The first session from a couple of weeks ago is already available there if you wanna go back and listen to it. If you rejoined, thank you for coming to the second session. We're gonna ask some polling questions about that. And hopefully we go into some new areas, but also I'm sure are gonna repeat some really important themes. If you can, as mentioned, you don't have to. If you wanna list your name in addition to your affiliation, that'd be great. If you do, raise your hand and have a comment. Please mention, again, your name and where you're from just so we can learn about each other a little more. We'd love, I know this isn't always possible, but if possible, if you could keep your cameras on, that'd be great. But we understand sometimes dogs, kids, et cetera, genomes are running across the screen so it might not be possible. Please do try to keep on mute. If you can, we have a great group of folks that are helping that will try to put you on mute. If again, your dog or genome is barking in the background, but try to keep on mute unless you're making a point. I will ask if we could try to focus on the discussion that we're gonna have here on the Zoom screen versus in the chat. You're welcome to use the chat. We have actually folks from Extramural NHRI that are gonna help monitor the chat and are gonna help respond to, for example, questions about funding opportunities. But we want to have maybe not two totally separate parallel discussions here, one in chat, one on the screen. Try to direct your attention to the screen if you could. We've outlined a set of questions that we'll show you after Dr. Green presents the introduction or the welcome. If we stick with those questions, great. If we go quote unquote off script, that's great too. We just want to take this in whatever direction you feel is most valuable to you and to the field. I do want to mention that we'll have one more, our third in this set of sessions on August 29th that's gonna be co-moderated. I'll be with Shamita Dasgupta from Boston University in a couple of weeks. So again, you're welcome to come to that, but we're hoping people will have attended only at least one. And then last but not least, I do hope these sessions run smoothly. I think we're all used to lots of Zoom and virtual type glitches. So my preemptive apologies, if we have some technical difficulties, we'll do our best to avoid those or deal with them if they come. So with that, I am delighted to turn to Dr. Eric Green, the director of NHGRI for his welcome and opening remarks. Thanks Eric. Thanks Ben. So welcome all of you. Some of you I know, some of you I don't know as well. We think this is a really important set of discussions that I actually asked Ben and others at the Institute to convene so that the Institute could learn more about the current circumstance with the clinical genetics and genomics workforce as Ben defined. And that includes laboratory clinical geneticists as well as classic medical geneticists. I will say now having been the director of NHGRI for almost 14 years, I'm always profoundly grateful and flattered that when we invite people and ask them to donate some of their time to us as an Institute, people come. And I think it's a testament to the field. I'd like to think it's also a testament to the Institute that people are willing to give their time and help us brainstorm and hoping that if we get good ideas we will improve the field by the work that we do. So why are we here today? Well, I don't need to tell this audience that the field of genetics and genomics is changing quickly. There's unprecedented opportunities for genomic medicine implementation. We've seen rapid areas of accelerated growth when it comes to technologies for sequencing genomes, analytical tools for analyzing such data, better and better technologies including longer DNA sequencing technologies and on the horizon are new opportunities for genome editing and hopefully gene therapy. And all of these have great potential for clinical implementation. And I can't tell you how profoundly honored NHGRI is to be able to help facilitate these areas reaching their full potential. But at the same time, while there seems to be this incredible opportunity for clinical laboratory geneticists and medical geneticists, there's just a lot going on. I think some of it relates to industry consolidation, artificial intelligent approaches and various things going on that might influence how people are making decisions about their career. And so to be honest with you, we need to recognize that we have a lot of challenges. For example, we all know that there aren't enough physicians going into medical genetics training programs and that many hospitals and clinics have a hard time recruiting experts in these areas. And this has many consequences, not the least of which is that it creates issues related to access and equity, something the Institute passionately is concerned about. So we've had a lot of discussions at NHGRI related to the workforce, various aspects of the genetics and genomics workforce, including scientists and other career opportunities and genomics. But that's not what we're gonna focus on here. These discussions, as you heard from Ben, we're gonna have three of them this summer. They just seek to get a better handle on the barriers that seem to exist why more people aren't going into medical genetics and laboratory genetics as a career option. And to see whether there's something that NHGRI could do, unlikely we would do it alone because we know there's a number of organizations working hard on this. Some of them are joining us today and our staff is having discussions with leaders of the full set of letters that Ben went through, A-B-M-G-G, A-C-M-G, A-P-H-M-G, A-S-H-G, E-I-E-I-O and so forth. And those conversations are terrific. And we absolutely don't want to, we'll aim not to step on anybody's toes here, but we just wanna know, can we be helpful? We wanna make sure that NHGRI can partner with anybody else in this universe that will help us understand these workforce issues and work with us to see if we can improve them. And we also know there's another aspect of this as we know it's really critical to recruit and train a more diverse workforce to serve the country and the world. And so in addition to just the size of workforce, we wanna be thinking a lot about its diversity. Now we delved into many of these issues in the 2020 NHGRI Strategic Vision, which is our latest strategic vision. And like many parts of that strategic vision, we are involved in ongoing efforts to hear what the community has to say that our barriers or desired strategies or concrete actions that we can take. Sometimes that involves money, sometimes that involves leadership, sometimes that involves arm twisting, sometimes it involves convening. So tell us what we can do. And so that's the charge. And with, I don't wanna take it any more time, I'm gonna turn this over to Ben and Deb, who will co-moderate the discussion with you today. Thanks to Deb and Ben for doing that and for helping organize this. And thanks to all of you again for joining. I look forward to the discussion. Great, Ben. Thanks so much, Eric. That was great. And again, thanks to everybody for joining. I can see our numbers still ticking up. I'm always shocked and surprised when anybody shows up. But obviously this is very important to the whole community. Deb, do you wanna start? I don't know if you're fancy and technologically savvy enough, unlike me, perhaps to do the poll part. If not, we have lots of other folks that can help. But can you guys, can everybody see the poll? So it's only two questions where we're easy people. First, did you attend our prior geneticist's workforce session on July 17th? And do you plan to attend the next one? We're trying to figure out if this is a one-time deal. So we'll do more breadth or if a lot of people were here the first one or doing the third one, we might do more depth today. So we're trying to figure out how to focus the discussion. I'll give it, I'm gonna count to five because I can't. One, two, three, four, five. Okay, so I always, I love seeing my results. Do you guys love seeing the results too, like me probably? So most of you were not here last time. So welcome, we're glad you decided to come join us. Ben and I love to have you together with us. And it's about 50-50 if people will be joining next time. So great. So I think we're gonna kind of start at the basics, Ben. So for the few of you who were here last time, the fourth of you, don't worry. You might have thought about some things or might wanna bring up some things that were brought up last time too. So I'll let you go ahead and put out the questions, Ben. Good, so I'm gonna share, thanks so much. Very interesting to see who had been here or not. We weren't sure how it was gonna turn out. I'm just gonna briefly flash the agenda screen, not the agenda screen, I'm sorry, the question screen now up here. These are the questions that you should have received in the invite emails. And thank you for bearing with me as I sent you lots of invite emails to make sure nobody missed them. These are the four main topics that Wendy Chung, Deb, who's obviously with us today and then Shamita Dasgupta, that we came up that we thought might be interesting to address. And so Deb's gonna go through them with you. In turn, I'll be acting more as a behind the scenes but I'm kind of figuring out if there's stuff in the chat to bring to the forefront. Again, I wanna emphasize if we stick with these and devote equal time to them, that's great. If we only go through one of them because that's where you wanna spend your time, that's great too. This was just more of a set of menu options versus a required script. Okay, so I'm gonna stop sharing these that I haven't written down in front of me. And Deb, do you wanna take us into the questions, if that's all? Yeah, so I feel like sometimes, I know we're supposed to keep it on the screen but there'll be some things that if you can't talk where you are, if you wanna put in the chat, we're gonna capture the information in the chat as well. Let's start and spend about five minutes on the first question. I know that there's more than five minutes worth of barriers to kind of, what are the barriers to helping our field grow? But I'm gonna start with about five minutes of that discussion and we could talk a hundred hours on that, I know. But we're gonna try to focus because I'd love us to get to some strategies and some brainstorming also today. So what do we think are some of our leading barriers? You get to take yourself off mute, you can raise your hand, you can put it in the chat. I can even tell Ben to give us one or two from last time. I see Peter, you took yourself off mute, so I bet you have something to say. So barriers are several. One is salaries for clinicians. The second is the definition of what the specialty is. We have to find ourselves into a corner, which is basically a specialty of rare disorders and that's how we've taught it for years. I think we've made genetically subspecialty in medicine. I think that medicine is a subspecialty in genetics and the sooner we can get to that point, the better off we're going to be and it means changing the way education works in our medical schools and others. And the last is inclusion of other specialties as opposed to making it a, trying to make it a subspecialty, that cardiology and others would be within genetics or related to genetics rather than really touching and include everybody. Can you explain that last one to me a little bit more? So the idea that kind of within cardiology or neurology, they would have more genetic training and be able to do the work or do you mean that there'd be more like neurogeneticists who would be trained in neuro and then become a geneticist? Well, I think that the training should start in medical schools and begin with it. And we for example, the University of Washington have eliminated genetics as a standalone course as we get small groups with the expectation that the clinicians who are helping with small groups will have enough genetic background to integrate the discussion. They don't. The only people who do as far as I can tell are people who are either actively working in genetics or who are geneticists themselves. And so really going back to models where we think about genetics in all contexts as we're teaching in medical schools and that that then gets incorporated into the further training. And I think, I really think that the idea that medicine is subspecial to genetics is an idea worth considering. And I know it's hard to implement, but I think that if we make it a more major part of training, then we don't have to deal with cardiologists having to take genetic specialties and do that sort of stuff, but really make it integrated in Ireland. Yeah, thanks, Peter. I'm gonna go to David and then Catherine. Go ahead, David. This is probably a long list. I think one of the things that comes to mind though is that there's just not that much exposure of medical learners to geneticists. You just don't see, you get a lot of, you see a lot of cardiology consultants and neurology consultants and et cetera, as you go along, and you don't have somebody modeling the profession to you. So you don't really think of it even as an option or see what they do to get excited about it during the course of training. Yeah, and I would say, Adam, that's being, some of the chat is exposure, right? Like you don't, you don't know you can be something you've never seen. Yeah, that's great. Go ahead, Catherine, thanks. Yeah, I think one of the things that I think could be really helpful is somehow advocating for more GME funding for genetics residencies. So most people on this call know that we have a categorical genetics residency program and then combined programs that also include pediatrics or internal medicine training. And the pool of applicants, I'm program director for both of those at University of Michigan. The pool of applicants is actually really strong for the combined programs. And I think that potentially there are more, more applicants that would consider it as a field if there were more training positions available. I think right now maybe they're like 27, I'm guessing. Actually, Mimi would probably know this positions available. So if we were able to advocate for more GME funding at various institutions, I think that that could be something that would really help out. Go ahead, Mimi, do you wanna comment on what you've got? I'll just comment that there are right now 27 combined piece genetics programs. There aren't enough, it's my bias, and internal medicine genetics. And part of that has been the challenge with the integration with the internal medicine departments in funding. So I agree. I think there are more funded positions. There's that many programs. We're all hearing those that the applicant was strong. I do think that that's one way. I do think that for some prior comments that were made about exposure in med school and a light may increase even our cataclysm as well, but it's not there right now. Yeah, yeah. Go ahead, Mustafa. So I completely agree with the discussion points. I think that it's no longer limited to just internal medicine or pediatrics. I mean, a lot of other specialties are very strongly involved in genetics either. It's genetic testing, sometimes with genetic counselors or without. And then also developing some, these novel treatments in patients. I mean, you can think of like ophthalmology here in very advanced stage doing gene therapy in a lot of inherited diseases. So I think the way to do it will be to increase the spectrum of these combined programs, not just limit them to certain like traditional specialties and others. So then it will be attractive to medical students knowing that they're gonna be in that specialty, but also in genetics. The other point we noticed during the interview, some there are very strong applicants for the residency programs. And some of them are very research oriented. And I think we should find ways of having dedicated year or years for the training during genetics so they can become like physician scientists. And those people can really contribute to developing novel treatments in these conditions that we deal with. Yeah. So I have a lot of, I guess, follow up questions for the last couple of speakers, but let me limit it to a couple just to make sure I understand. So Mustafa and Catherine, it sounds like what you were advocating for are more an emphasis on more creating or expanding more combined spots and programs versus putting more emphasis on the traditional categorical one. Is that where the quote unquote money is or where the opportunity is? Absolutely, in my opinion. Yeah. Yeah, yeah, I agree. And that's been the conversation at APHMG the last several years that's come up too. Let's go ahead, Maria. Can I? I have two thoughts. One is because I came from internal medicine to genetics, salary is a big thing because genetics is a fellowship. It's a second residency. We already have to have some previous training before. I did three years of internal medicine and then did genetics and my potential income was caught in half. I did four years more of fellowship to make half the money that I could have been making if I stayed in internal medicine. So that is a hard sell for a lot of people that have a lot of student loans that have a lot of things and many of our friends who have come and done an specialty before like OBGYN, neuro, whatever, they are practicing that primary specialty with a focus in genetics. They are not practicing genetics because that is just not realistic. And my experience also as an IMG is these combined programs are out of reach for anybody who has not graduated from the United States. I was lucky to find an opportunity at the NIH because the NIH was one of the few fellowship programs when I applied this was 12 years ago. So maybe things are different now that accepted visas and that could sponsor me to come to do a fellowship like that when I was just coming out of internal medicine. So you keep increasing these combined spots but those are highly selected only given in a few universities not all of them sponsor visas and then you're limiting your pool. You're not gonna have a more diverse pool because you're excluding a huge chunk of us. Great, thanks, Maria. Other comments, so I feel like a lot of what we've talked about is now you make a comment. Yeah, of course you decide. I just wanted to comment that Dr. Takin commented that we need more research spots and I actually think that that's a deterrent for some medical students. Medical students a lot want to be practicing medicine and they think of genetics as a very heavily research based lab based field and I'm not sure that's not a deterrent. I was gonna make the same comment or a similar comment that I think a lot of folks think that if you're going to genetics you have to have like a PhD background or you have to have a bench research background or you have to want to be a physician scientist or have that in your future. And I think it's really important for us to make students aware that there are other paths. And of course, Genesis is an academic specialty for the foreseeable future but there are ways to be a geneticist that don't involve doing clinical trials or doing a lot of research that may be a better fit for certain people and I think that might be a deterrent. And I would piggyback that with there are many university settings where you can be a clinical educator and so that would solve our issue of having geneticists who are involved with residents and with students and having an example for people to model to then want to go into genetics. Thanks, Edith and Chair, I agree with both of you, yeah. Go ahead, Peter, are you having a hand up? Well, the reality points that we have to deal with is that we train about 60 medical geneticists, MDs, DOs, et cetera, in a year and we're training 550 genetic counselors in a year. But the total number of genetic counselors that's out there now is closing in on 10,000. The number of medical geneticists hasn't changed since we developed the board, it's about between 1,300 people. So there's been no rise, there's been no uptake of genetics as a profession among medical students and a tremendous rise among people in genetic counseling. So, we've seen genetic counselors come into play in the large companies, at least for a while until they got a little bit stressed in terms of their finances. They're very active in all the academic programs around the country. They are, in many cases, at least as knowledgeable as our trainees coming in because they've been there for longer. There are real resources in terms of practicing medicine but we have to change a number of things that has to do with that. So the bill that's been lagging in Congress about making geneticists eligible for compensation through Medicare really needs to be pushed despite opposition like the other from the ACMG, it seems irrational. But I think that we're still at the point of, I think, I agree, we get much better candidates in the combined programs, they do well, they have insight into what's going on. Can we create combined programs throughout or make something combined with all the other training programs as we're going along and make genetics a significant part of training? We've had remarkable success with an unusual group of people like vascular surgeons and cardiac surgeons in terms of realizing the benefit of genetics and what they do. And I think we need to be really thinking more directly about who's going to be part of it and assuming that everybody will be, not assuming that we can't make ourselves an insular specialty. We have to be part of the DEI and inclusion part of the I as part of that. And it doesn't mean welcoming them to our table, it means going to their table. I'm gonna go to Matthew next and then we're gonna move on to a little bit more delving, a tiny bit more into the role of the future geneticist. We've kind of touched on that but I wanna go there after Matthew's comment. Thanks, Matt Taylor from University of Colorado internal medicine genetics. I agree with your comments there, Peter and was sort of gonna raise and lower my hand because I'm a little hesitant to sort of say this out loud, I'll say it anyway. I think I don't know if it's a barrier or a challenge or how we wanna face it, but at least in the medicine world, it really seems to be that we're losing the battle around what a geneticist is because what I'm hearing from my colleagues is it's just someone who orders genetic testing by the way that's really easy to do. And by the way, most of those genes that are gonna be looked at for gene therapy are just gonna require a test, someone to hopefully somewhat correctly interpret it some of the time and then someone who's not a geneticist will order the gene therapy. I don't know how we address that necessarily because obviously testing is expanding to your comments about counselors expanding and likely at some point being able to bill for services and probably order genetic tests and in many cases, they have to be tied to a provider. But I don't know how we collectively address that issue that the thing that we do that no one else could do which was like, remember what was in those textbooks is now gone because essentially what we do and what is perceived we do is we just drag our feet and take a long time to see somebody and then order a test. And so I don't know how we kind of address that. And again, this is not a comment against the NIH or anything, but we are a little bit of a victim of the successes with what's happened to all this sequencing technology that has been generated and driven out there. And so if we're only training 60, 65 of us a year, guess what? We're not ordering the lion's share genetic testing. We never will be ordering that lion's share. And somehow we've got to figure out how to pull some of that back potentially because we really at the moment are just the people who take longer than everybody else to order the damn test. Matt, I think I'm gonna steal that line. I think it was something like we drag our feet and then order some tests for future talks. It's a different app. You can put it on a T-shirt, something shorter, something like that. I don't know, doddering around and then getting around to working with, sorry. Look for the boot that ASHG, I guess, sorry. I'm gonna go to Melissa because she had her hand up and it came up in the middle of that. So I think that might have spiked something in you. So go ahead. Thank you, thank you. I'm Melissa Dempsey and I'm a genetic counselor. However, I work at Illumina, so I haven't done genetic counseling in some time but I used to work in clinic and actually I work in the marketing department at Illumina. So through what the last couple of people were saying, I feel like maybe the geneticist needs a new branding exercise to kind of rebrand what a geneticist is. And I do think some has gotten lost in this battle between the genetic counselor and the geneticist that I feel like's been going on since I was trained 20 years ago. And instead of focusing on what you both do, which I think there is overlap, focus on what is unique. And I think, I mean, as geneticists, you go to school for a long time to be physicians and you can manage and prescribe and treat patients and now we're at such an exciting time where there's treatments. So it's like, wow, if I go back to medical school, like being geneticists is super fun right now because there's some treatments coming up and genetic counselors can't do that at all. And so I think I would love to see more collaboration between the two and figuring out how to work. I was part of a working group recently and there was a quote that somebody said, figuring out how to work at the top of our scope and not just side by side next to each other in clinic, each person doing the thing they do best at their point by themselves in the room. And I can speak just quickly of my history. I started out as a pediatric genetic counselor and a lot of genetic counselors say there's 550 a year. I would wonder how many work in pediatrics. They've moved into areas like OB, cancer, oncology and industry because they get a little more autonomy and like one-on-one time and independence. So I think if there's a role for them in pediatrics that does give them that autonomy and then give you the chance to be treating the patients and interpreting the tests and the things that I think the genetic counselors aren't is, don't have that medical background would be great. Thanks, Melissa. We're gonna go to Susan next. Hi everyone, I'm sorry I came in late. I was actually seeing patients with genetic counselors. I work in a large reproductive and cancer group and I work with eight genetic counselors. My life would be a lot easier if they were paid independently. The problem with the bill is that the genetic counselors right out of school wanna be paid 85% of what a physician gets paid for without working in a team. And as many of you know, most of this is team-based care now and multidisciplinary care. The bill, if you read the wording has genetic counselors practicing as physicians. And AMA is not supportive and we're members of the AMA as part of ACMG. I agree with, I'm sorry, I think it was Melissa Dempsey with what she said. We should both be practicing at the top of our scope and I agree with what a lot of people said and I think this has been repeated at the ACMG, APHMG at a lot of different things about working. The combined programs clearly have the best applicants and it would be wonderful if we could have more. I'm doing my own part and starting the application. I just have to wait until I have a pediatric colleague to help. I just wanted to make sure that everyone understands ACMG is not against genetic counselors getting paid, but they have to, the bill, the way it's worded now is not gonna get supportive AMA and most medical bills without the support of AMA do not pass. So there's a lot of issues because licensure in multiple states is different, et cetera. I'm happy to discuss it with anyone. I am trying to work with many of my genetic counselor colleagues to get something passed so we can all work together. There are only 56, 5,629 certified genetic counselors now. We may get up to 10,000 soon, but as someone who trains the genetic counselors right out of school from Sarah Lawrence, one of the top programs in the country, the genetic counselors right out of school should not be practicing independently. Maybe after a few years, the genetic counselors who see cancer patients can be practicing independently, but they're not really practicing independently because an oncologist sent the patient to them. And same thing mostly with prenatal. So I think that a lot of the issues came from the worry of genetic counselors ordering exome in the Peds world. Dr. Byers just said, can you send the text of the bill to all of us? I'm gonna have to, I'm on my phone, but if you, I think it's 14, 15, I'll look for it and I'll, if you just Google it, you can see it. By the way, it was put up for adoption or promote, I forgot what the word is in the Congress by someone who didn't know what a genetic counselor is. So it was the ACMG folks who advised this person about the value of a genetic counselor. So I'm, I'm, I've spoken to people in NSGC. It definitely is, would be valuable for all of us. Oh, thank you, Matt. Thank you, Matt. I want to put it up. Thank you, Matt. Yeah. So let's talk for a minute more. Oh, Joan, I see your hand up, and then I'm gonna talk a little bit more about it. What should be the- Has her hand up as well? Or maybe it's a legacy hand. Sorry. My comment goes back a little bit earlier, but I'll be quick about it. Yeah, I think it was Melissa. I'm brought to introduce myself. I'm a pediatric geneticist at Baylor. I think Melissa had said, you know, or somebody had said, we need kind of a rebranding of geneticists that we also treat and we can do gene therapies. I think one of the challenges that a lot of the departments are not set up for that structure, with that infrastructure and that support yet. So that would require a lot of changes at the institutional level as well. I don't practice metabolism. And I know in metabolism, there's usually more of a robust kind of support structure. But if I were to start having to treat lysosomal patients or whatever it might be in my clinic, we would need a lot more infrastructural support. And I think that would be something that needs to change across the board. Great point, Tanya. Thanks. Go ahead, Joan. Sorry, I can't get my video to work. I don't know why. That's okay. I was, there's a lot of stuff in the chat about, you know, what do the residency programs? And I was going to say, I trained in PEEDS and then I went into genetics. So I think a big problem with going right into genetics is if you end up at a small institution like I am in Syracuse, you need a medical home. And it's, you know, I'm in PEEDS. The other geneticist who's with me is trained in internal medicine, but we're in the department of PEEDS. And sometimes our, I mean, we have such a huge backlog that we've just now stopped seeing adults, period. You know, and it could have been a similar problem if I was in an OB department, when I first came out and there were certain patients I couldn't see because OB said, well, why should I pay you to see them? So, you know, it's tough because if you come right out of genetics and you don't go into a department of genetics, you have to find a home in some other department. Well, I think from the conversation today, our home being internal medicine might help the salary structure. Part of it is that our homes are in pediatrics and the expectation of salaries are different in things than they are internal medicine. Susan, I see your hand still up. I don't know if you meant it to be up or not, though. Okay, well, she knows how to, I mean, interrupt me. Okay, role of the geneticists. We haven't gone there much and then we're going to move to strategy. Anything else about what you envision there? Like, how am I supposed to be spending my time in 10 years? And as part of that, I've heard, I guess, I just mentioned that in monitoring the chat, lots of discussions and several of you mentioned more about management, kind of echoing things that biochemical justice do. Is that the main future, one of the main future roles? And I was wondering if people could expand on some of those points about, is that feasible? What would it take? And so on and so forth. Yeah, Catherine. Yeah, so I'm really lucky. And so I also, another role that I have is I'm the division director of pediatrics genetics at University of Michigan. And I have, I'm fortunate to have several incredible faculty members who are super enthusiastic about bringing treatment into medical genetic or pediatric or medical genetics as a specialty. And so implementing not just treatment for biochemical disorders, but for things like the psoratide for echondroplasia. And I can't remember the name of the treatment, but the new one for RET syndrome and bringing all those treatments in and having genetics as the home for those patients. Another thing that we're trying to do is start a gene therapy service line that would be, you know, at our institution. So we're trying to actually work with the business school to develop a business plan for this with the hope that we can bring this in and have geneticists as the sort of point people for delivering gene therapy services here. And so I think that, you know, we've always been the diagnosticians, right? And I think that that is a role that we will always serve. But as we get more into the cardiologists ordering the genetic testing, the neurologists ordering their genetic testing, et cetera, I think that in order for genetics to survive, we need to move into treatment and own that as a specialty. How are you doing it with the business model? So I've heard from some places, that's the hard part is, you know- Yeah, I'll let you know in about a year in the months where we've actually got a proposal for a team of executive MBA students to bid on a project to help us develop that model. So I'll let you know how it turns out. Yeah, Cynthia, your thoughts? Yeah, I totally agree with the idea that we need to emphasize the role of geneticists and treatment of patients. And I think that's something where the training programs need to, you know, expand. And, you know, part of that will be some of the requirements that come from ACGME to do that, you know, it's nowhere really in the milestones that I'm aware of to really say that, you know, students, trainees have had experience in clinical trials or gene therapy. And I think that, you know, we shouldn't give all those away to other providers, you know, possibly, you know, we're not gonna be doing gene therapy for eye diseases, but although we can train those ophthalmologists to be geneticists also. But yeah, I think, you know, we need to find a way to emphasize that part of our scope of practice. Yeah, go ahead, David. Sorry, unmuting. So I'm a little bit of two minds about the whole treatment thing, because often the, what you're treating is some falls well within somebody else's specialty, you know, do you expect vision to get better, epilepsy to get better, renal function to get better. And I think although I can imagine it's being part of a team, it's taking it over entirely. I guess I'd have to think a little bit more about how that might work. I guess one thing that I haven't seen coming up much, and I realize the laboratories have taken this over to a large extent, but is the use of genomics data as a lifelong resource for healthcare, including reanalyzing data. You know, the radiologists interpret MRIs, which are orders of magnitude less complex than the genome. I mean, I think that there should be a role for us to engage with that data set and connect it to the patient's healthcare in a way that we haven't pursued as a field. And we've seeded it to a large extent to testing laboratories that are very sort of, in many cases, narrow in their approach to how they use it. Yeah, Matt? To your comment, David, I have the same struggle with where this sort of fits in terms of what we can do. And I agree that it's gonna be difficult for me to walk into pulmonary clinic and say, hey, newsflash, CF is genetic. Step aside, I'm gonna manage all this. I completely agree with that. On the other hand, I think we have to acknowledge that we're not doing a very good job training our trainees to do gene therapies and enzyme-based therapies and some of these novel therapies, RNA-based, in our own sort of ultra rare specialty field. And I think that we should lay claim to that, even though we probably won't necessarily lay claim to CF for sure, probably a lot of the eye diseases, understandably, based on the mode of injection. But I think we could do a better job. And unfortunately, that's gonna be training some of us on this call, many of whom I suppose have had some exposure to gene therapy, others, myself, nearly, but not quite dosed anybody yet. So we'd have to train our sort of discipline and then help move that in a direction. That'd be pretty exciting to medical students to be able to probably do some of this stuff. But I think traditionally, we as geneticists outside of metabolic disease, I've really been sort of the stand back at the back of the room and say, here's a diagnosis from 50 feet. That's pretty impressive. And we have to shift a little bit to where we actually get more involved in those trials as we're involved in a trial right now, but it's a cardiomyopathy trial. And it's pretty clear that the sponsor is really looking for cardiologists. We've done some of the seminal research in this space, but they're looking for cardiologists to run that trial and we need to figure out a way of flipping the script for these rare diseases that ultimately do fit with what we do. So Matt, I want to bring up, I guess something that I'll, I can't take any credit for Wendy Chung who is the previous co-moderator just in some discussions behind the scenes, mentioned this. And I'm just curious if the group agrees with this or not, but I think there's a lot of neat things here is there's obviously lots of genetics to go around, meaning there are many different people affected by genetic conditions, whether they're managed by a pulmonologist or a cardiologist. Her thought, which I personally agree with, but I'm curious again about what the group thinks is that the niche for geneticists could be these multi-system disorders that a renal doctor isn't going to take on because they love the kidney but they don't want the other pieces or a pulmonologist is going to take the lung. Does that, is there enough to go around with that? Are there, are the treatments promising enough for that? Or will that not work for other reasons that folks can think of? I will just say since you, I was just the last one speaking, that'll work in some circumstances. In other circumstances, things may get seeded away. And so, who's taking care of Pompeii disease these days? It's mostly neurologic, so a lot of neurologists are involved. Fabric disease, which is multi-system is kind of across the board. There are some places where it's genetic, some places it's more nephrology. I think we're gonna have to pick and choose to some degree for the more common disorders that have sort of got their own clinics, got their own space, even if they're multi-system, we may be already, that may be already cast out of the bag, so to speak, but there are thousands of rare disorders, many of them that, I haven't heard of all of them, of course, so many of them that are cresting the horizon with possible therapies, we're probably best suited to take those ultra rare things, especially if they're polysystem diseases as well. We might need help from colleagues in managing some of this for sure, but we should, I think, step up and be more on that therapeutic front line for the, at least the rare and ultra rare stuff, I think, but maybe others disagree. I'm gonna comment back to you, Matt. Now I'm commenting as a comment or not as anything else, that the reason we all do this job is because we want every patient to have access to the right tests, the right treatment, and not to be lost in the shuffle, right? That's the point. So if the CF clinic is doing a better job than I am, take it, that's fine. I have a 13 month wait list. Let me go take care of someone who needs me. So on one hand, yeah, I don't wanna, you know, give away what brings us money in our bottom line. I'm a chief, I have to get the bottom line, but I also am not gonna fight with CF. I'm gonna choose my battles. I'm gonna go for the ultra rare. Great, let me be ultra rare. Can I bring a different perspective here? There are like, I'm sorry, I forgot to introduce myself at the beginning too. I am a clinical and molecular geneticist and I work at GDX now. One of the things that we see when different outside collaborators approach us looking for patients for their trials, like the people driving the trials that develop the drugs are rarely geneticists. We are not involved in industry where the initial steps of the clinical development is happening. And when the medical directors in pharmaceutical companies have other specialties, their relationships are with those specialties. Eva cardiology is helping develop a new therapy for cardiomyopathy. They, their network is gonna be with cardiologists who is gonna talk to direct to drive those clinical trials in the different institutions. So it's probably gonna be cardiologists. If we wanna be involved in treatments, we also need to get in industry. We need to be in those roles and we need training to do that. We need training on regulatory compliance and FDA regulations and all those things that could be part of our group to be as medical directors in industry and then bring it back. Let me go back. Susan and Julie have both noted that we need to take back genetics at the level of the medical school level. And I think that that's really true. I think fiddling at the, once you get to the fingertip, which is something of what we're talking about, that is that we're looking at the very end of the process about where we're gonna get changes without bringing, coming back and making genetics a requisite part and an integral part. And in fact, I think the part of medical education, we're gonna be stuck and we're gonna be stuck trying to change the things that have already been put in place. And we need to introduce the language of genetics and the thinking process of genetics. I mean, I think you know, when you talk to your colleagues about things that you think differently than they do about disease mechanisms and about how to understand diseases. It is a different process being a geneticist than it is being an internist or being any of theologists. And it's a very, very integrative language. It's applicable to every ology out there. And it really should become a very strong basis of how medical learning is done. And I think we need to really get it back and recapture. I'm not sure how to do it. I think we've seen some people at Rochester has done a good job at getting it to very much part of the curriculum. Hopkins or Dave Valley really tried to make it happen there. There's always been a lot of pushback. But I think that if we can get that operational thing going a lot of the rest of it will flow and will work more easily. But without that, I think we're sort of dealing at the end of the process. And that's very difficult to change. I think to have cardiology, to have cardiac surgeons talk about as this happened here, that we should be testing everybody who comes in the door is a remarkable transformation of that specialty from somebody that we think of as plumbers as opposed to thinking about how genetics fits into their specialty. And we should be seeing that in every single specialty. And we provide the language for doing it, I think. Thank you, Tracy. We're gonna go next to you. And then I don't know if, Maryanne, if you're in a place where you can unmute yourself after Tracy speaks but I was wondering if you might mind, wouldn't mind expanding on this medical home idea which I think is interesting in addition to some of the direct treatments like gene therapy. But please Tracy, please go ahead. So I'm a medical educator at Florida International University. I do not have a clinical practice. FIU does not have a genetics residency. And so our students are really left with nothing unless I'm really pushing super duper hard. And I push really hard. But what about all of those other medical schools? We have 150 plus medical schools in this country and we don't have near that many residencies. And so what are we doing to get attention to genetics in those places where there is no clinical genesis and there is no genetics residency? We've got to be paying attention to them as well. So for the last, I know we only have a few minutes left. I don't know if Maryanne's able to talk a little bit about the medical home comment that she put in which I thought was very interesting. The thing that I want to have us spend at least a little bit of time and I'm going to conflate a couple of questions into one are, and I've seen a lot of this in chat so folks can just mention this verbally to make sure we don't miss key points. So what do we do now? And I'm going to ask this in two ways. This is what I'm conflating. One is what do we do to concretely get more of genetics into medical education or to steal Peter's phrase, take back. I think Peter is what you said, take back genetics education. Are there concrete things that we should be thinking about doing and ways to address that? That's number one. And then much more proroquially and boringly, what should the next steps after this third session on August 29th be? How should we continue this conversation? How do we get the group to keep working on this issue instead of just leaving the Zoom issues with a lot of these Zoom meetings with a lot of ideas but not necessarily next steps. And so I would love for folks to just talk about what our next step should be both to improve things and just to keep the conversation going in the last couple of minutes. So I'm gonna start because no one put their hand up. And I saw a comment saying, we're getting this pressure. We can't even get into the first two years of med school. I'm gonna be blunt with all of you. I have three med schools in my area and everyone said, we're gonna keep having you come because our students like you. You tell the best stories. They get that biochem is meaningful because of you. We're gonna keep an hour for you. And I was like, cool, keep an hour for me. I'll be there. This idea of can we help our trainees teach better? Can we be the best stories? Can we be the ones that show the application every day? We have the best stories on the planet, right? But I think sometimes unless we get in there and then do an outstanding job, we're not gonna keep the spot in med schools. I just tell stories. I would follow up that question to everybody again. And to you, when I look at the maps, I think it's that Jenkins et al article and Ginex and Medicine from the 2019 survey. It shows as you'd expect the academic quarters, their geneticists there and hiring geneticists, right? But we don't see a lot in certain other parts of the country, let alone other countries. So I guess the other question, I think going back to Tracy's comment, how do we get exposure? How do we get exposure to the places that might not be connected to Children's National or to some of the other places where folks are? So I'll comment that there is a move within National Organization for Rare Disorders to have clubs at med schools. So they're now starting to ask us to come and talk. So they're getting the CF centers and the sickle cell centers, but every once in a while, if they know there's a geneticist out there, you might be asked to call even if you're on a coast. So call in Zoom has changed how we can get into these, like specialty clubs too. I think Tracy's comments about things are really very relevant. And that is if you teach the language of genetics to medical students and you engage as part of that, the faculty, even if you don't have genetics as a specialty in the school, you teach the language. And they bring that on with them and they carry it with them as they're seeing patients, as they're doing medicine. And Tracy may have the ideal situation in which to test the model, that is get it in early and get it in hard. We only have a very few minutes left. So we're gonna go kind of in lightning order. And if you guys could keep your comments maybe to a minute and a half and then I'll sum up in three seconds at the end, but I'll go Julie, Matthew and then Catherine, if that's okay. Julie, please go ahead. So my comment was to state that we have a club for interest for med students, for every single possible potential pathway they can take after med school. And at WashU we have one for medical genetics. And I have a student now who's in the interest group and the thing is though that too many of the med students don't even know what we do and it's not presented to them. So they don't have an attraction for joining this particular club whereas the internal medicine club has a lot of student interest or even general Peds or OB. So I think we have to be there and be in their faces and teach them and be a friend to them and tell them all of our stories. And I think that is a really important thing. Thank you. Catherine and I will say I like the vest or the fleece Catherine. Good a good a good shout out. And I'm probably the only one wearing a sweater here. Ray also I'm sure is very hot. I'm in San Francisco and it's kind of cold and foggy today. So wearing my nice APHMG switcher. But so to kind of follow up on some of these comments I'll just say quickly that to refree some or to restate some of the things that came up in the beginning as well is we're really caught in this vicious cycle of we need clinical geneticists to be in front of the students for them to see about that this is a field that it is a specialty in and of itself. And we need clinical geneticists to be taking a lead role as well as many of us PhDs in medical genetics education. But I can say at our institution the clinical geneticists are totally overwhelmed in clinic. There's a major shortage of geneticists. They don't have time to teach. So it's all put on me to do and I'm happy to do as much as I can but I need to have clinical geneticists involved. You need an MD to talk to MDs. Unfortunately, that's the way it goes. To talk to the deans, they really are gonna hear more from other MDs. And so we just need more clinical geneticists to be out there with time to teach and to be engaged with students. So it's kind of this vicious cycle as I'm saying. Right. Maybe we can start a more of a road show movement or re-engage some of what I heard in the chat. Matthew, you're gonna have the last word and then I'll sum up in about 10 seconds. Go for it. Yeah, so embracing the we're caught in the cycle part. I'll just say that I think that a lot of things that were just mentioned, get in front of med students, more teaching, more clubs and stuff. I argue we've probably been doing that and trying to do it for a long time as best as we can with the resources we have. And if anything, we're in no better possibly worse situation we're before in spite of our field getting much more interesting and excited. So I would just caution us to say that we're a small group with limited bandwidth. I don't know if we've done it long enough to test the question of can we influence change from the grassroots level of the medical school? Cause it's a one potential, you know, explain it or not answer that hypothesis is possibly not. Cause for the last 20, 30 years, although we are sure had some successes, globally as a group, we're flat lined in terms of new geneticists and we're having these conversations of workforce. So I just think that we should be sober about sort of that approach. Cause I would say I'm not sure it's worked before multiple times. Yep. Yeah, thanks. I like that a good way to conclude is to phrase it as a well-designed research trial or the need for that. So very briefly that I wanna thank everybody for your time. I know you're incredibly busy. I really appreciate you taking the time out to attend this session and maybe we'll see you next session. I got four themes from this. I just wanna repeat out loud, but please go back and look at our notes and look at the recorded session or share it with others. So money, money, money, that comes up in all ways, shapes and forms. The need for exposure or I really liked what Melissa said about some perhaps some consider some scientifically based rebranding. A lot of interest very concretely in combined programs and the potential that's there to bring more people and people from other specialties. And then finally a lot of discussion on the move I wanted to say from diagnosis but to include diagnosis as well as a lot of the therapeutic and management areas but that would include institutional requirements. With that, I know it's a poorly organized summary but I wanna thank you all again and please feel free to reach out to me. Thank you so much Deb. Thank you Eric. Thanks to our whole team that made this happen and we'll see you on the road or on Zoom at least. Thanks so much.