 Great. Thank you, Dan, for being so timely. I appreciate it. Is there a... Yeah, there's a clicker. Thanks. Okay. So I was going to talk just briefly on the, what grew out of the Genomic Medicine 4 meeting that we had in Dallas in terms of this inter-society coordinating committee, just to remind you that the goals of the meeting that we had in January, which grew, you know, grew out of the meeting that we had in May, I think, in Chicago. So each of these meetings really builds on the previous one, and that's why it's so important to get your input as to what our next steps should be. And at the end of the third meeting, people said, you know, we really need to address education, particularly of physicians. And so, you know, we felt it would be wise to try to bring together professional societies and other relevant organizations that are involved in both setting clinical practice guidelines and also developing educational materials for physicians, learn their perspectives on Genomic Medicine, understand their processes for establishing guidelines, and kind of explore how to facilitate the integration of Genomic Medicine into clinical best practices and physician education. And we did kind of, I think, evolve from focusing more on guidelines into more on education, and as we interacted with the societies who basically, you know, are those, the ones that are responsible for making guidelines, but they need to have an educated workforce to be able to implement them. So what we did was to try to identify the largest and seemingly to us most relevant groups in professional societies in that, that we might bring together in a room like this, and we didn't try to capture all of them, or even a representative sample, but basically kind of started with those who were willing to, you know, come to Dallas and meet with us in January. And that's the list that's shown here, about 10 groups or so. We were asked and have been asked why only doctors, this says he was different from other doctors for one thing, he refused to play God, and it doesn't look good here. And so one of the reasons that we did that is as you've heard, I think, throughout this meeting, Nichepeg and other groups have been pretty effective at capturing physician's assistance and reaching out to pharmacists and to a wide variety of nurses and other groups as has NHGRI. We haven't really until now begun to sort of crack the nut of dealing with physicians. And part of the reasoning for that, we think, is that there wasn't anything that really was kind of ready for primetime for physicians to implement until fairly recently. But now we think we have a real opportunity to do that. So we asked the professional societies that were coming, that within their specialties were among your members, can you describe for us sort of the state of the science regarding genomics and practice of genomics within your field? What short and long-term pace of change do you see in the use of genomics? What gaps are there in across leading academic centers, well-informed specialty practices or small practice MDs? Thinking in our minds, at least, there was sort of a hierarchy that presumably the academic centers might be at the cutting edge of this, whether they were evidence-based or not, at least they might be the furthest along, where the small practices might not be. Any needs assessments that they had done, whether patient access to high-quality care they feel is going to be impaired by the lack of physician genomic literacy, whether plans they had to address any perceived shortfalls, specialty board activity that might include genomics in their certification or maintenance of certification processes, and how they go about reviewing literature and fashion guidelines for using genomics in diagnosis and treatment. So each of them was given a list of these questions, much like we gave the federal agencies yesterday, and they all had not enough time to try to address them, but they did a really nice job in approaching that. And all of the materials for these presentations are up on our website, as well, all the materials from this meeting. But areas of general consensus were that one of the major stumbling blocks that at least has been perceived is that physicians have been sort of taught that this is a major revolution in medical care, it's going to turn everything on its head, and that is very intimidating to people. And it's also been a bit of a letdown, because it hasn't turned everything on its head, but it certainly is having an impact. So we were strongly urged to present this as an evolution in knowledge, rather than a major revolution, and I think that was a really important message to get across to us. And that we should embed genomics education at the point of care when it's needed, and only when it's needed, with appropriate clinical decision support, again, when it's needed without overwhelming people, and without really getting in the way to the degree possible of their clinical workflow. We are also urged to utilize other resources in addition to things like lectures and seminars and conferences, such as simple check lists or fact sheets or ethical guidelines, case studies, that sort of thing. And there was considerable agreement that we could incorporate genomics into certification and licensing procedures. We should identify and emphasize appropriate competencies, and there was interest among the societies for doing this, and that we should allow so-specialty tailored training, actually this was more a message, I think, to the genetics community, that insisting that geneticists be sort of certified in the large range of rare Mendelian conditions and dysmorphologies and that sort of thing has acted against getting physicians engaged in genetics. So the oncologists were saying, can't we have sort of an oncologist genomicist track where we learn just what's important for oncology, or just what's important for cardiology, and not necessarily have to learn everything about pediatrics or whatever. And so an interesting thing that I believe the college may be looking into, and I might note that there were several people involved in that meeting there at this meeting, and so I'll give a heads-up to Deborah and Bruce and a couple of others to maybe comment. And Mike Murray, I think I see you back there. So I'll ask you to comment in a bit. Areas of concern that were identified included many of the very things we've heard today about standards for data storage and sharing, not only sharing among physicians, groups, but also even getting results back from a lab and being able to interpret them. Liability risks, we've heard that today as well, from extensive genomic testing and getting back results that you really don't know what to do with. Conflict and guidelines across societies, there were a couple of rather telling examples of that listed. Interpretation and counseling on patient-initiated direct to consumer testing, and marketing pressures, which we heard about from the military groups, from genetic evaluation companies. Also in kind of reviewing some of the surveys, there are about four groups that had done surveys among their members. Some of them did them in response to this upcoming meeting, which was very gratifying. And they found that even the physicians who were confident in their genomics knowledge felt really reluctant about ordering and interpreting these tests. So that's something that we really need to address. Even those who thought genomics were important were only willing to commit one to two hours to education. So one to two hours is not a lot of time, and we need to use it very wisely. And it was also interesting, I think, to some of us, that the minority of physicians who really thought that family histories were important, only a minority of them routinely take a complete three-generation family history. And I can tell you, I don't take a complete three-generation family history. I do take a family history. I think it's better than most, but I don't do it in every patient, so maybe I should. OK, so what came out of the meeting in Dallas then at the end was we need some kind of a conglomeration of these societies where we can continue to share materials and coordinate to develop resources in that four-physician education without reinventing the wheel and duplicating what everyone is doing. And I think Deborah, through the College of American Pathologists, had shown us some really nice educational materials that they have that everybody sort of drooled over and said, we'd love to have access to these. And she said, of course, here. And we will. Yeah, no, that's great. No, I need to comment when I get through. So the charge to this group then that they've kind of agreed on pretty much is to improve the genomic literacy of physicians. And we added other practitioners, so again, focusing on physicians at least to start and enhance the practice of genomic medicine through sharing educational approaches and jointly identifying educational needs. And really the purpose of this group is to facilitate interactions among the professional society. So it's not an advisory group. It's not a recommendation group. It really is just a club where people get together and share approaches. And it focuses, again, primarily on physicians. We added dentists because dentists really don't have any other home. And it seemed like a nice thing to do for them. And also, and teeth are important. And then hoping soon to begin to collaborate or expand collaborations with allied practitioners. We recognize that relations to professional societies are very important, that we not overstep any bounds that there may be in recognizing their primacy in defining practice guidelines and certification requirements for their members. So that is not something that we want to do or should be doing to support and stimulate the activities of these societies by offering our partnership and available expectees when they want it and not when they don't want it. And we recognize that we're not intending to assume any primacy in these interactions at all. Dan is a long-term vision guy and encouraged us to come up with a long-term vision. So I think this one may work as well as any. Which is recognizing that the technology continues to advance and it will soon make it possible for lots of patients to have lots of their genome characterized and available in their medical record. And we see this as inevitable. And I think you've heard that during these meetings as well. One can debate what the timeframe will be and what the steps will be to get there, but it's almost indubitable that this is gonna happen. So it seemed to us that if we begin educational efforts now, when the body of knowledge that one can implement is relatively limited so that it's not overwhelming. And then allow the understanding of the genome and its application to grow with the practitioner's knowledge of that understanding and application would be a good thing. So that's why it seemed good to start at this point. And we felt that there were sufficient numbers of clinically relevant findings available currently that would support effective educational efforts so we can get people's attention for the use of these variants without, again, scaring them off. We proposed a structure that would be each professional society would nominate one person. They could send more than one, but we'd like at least one. And many of them have already done this. We've asked them if they'd be willing to support the travel of those members. And for the most part, they have been able to do that, which is great. There's not a lot of travel. We're anticipating meeting face-to-face maybe twice a year at the most. We would invite ad hoc content experts as needed, propose that we have a co-chair who's a professional society representative and one that's an NIH person. Again, meeting at six-month intervals and then kind of design a three- to five-year work plan with the potential if it goes well to extend that. This is a list of proposed specific activities. I won't read them all, because these slides I know are very text dense, but there were a number of them sort of surveying the literature, kind of identifying things that are about ready to be applied, reviewing and disseminating them, having working groups to address a number of things, focusing on physician competencies and listening what those might be. Reviewing professional society guidances on request. I mean, if there were an interest in having another sort of disinterested group look over what professional societies were proposing to put into guidance, we'd be happy to look at that. Disseminate some metrics for assessing educational programs, sharing those, collaborating with those that are working with other allied health providers. And particularly, we had both the accreditation council on graduate medical education and the accreditation council on continuing medical education. So that's, you know, residence fellows and practicing physicians, very, very engaged. And particularly the ACCME is quite interested in engaging with us in developing materials and sharing them throughout physician's careers. And then what we're working on currently is to identify a few activities that we could bring forward in the short term. Again, you wanna have a couple of early successes. And we asked our members to kind of pick among the 10 specific activities we'd identified maybe five or six or so that might be things we could move forward on. And the ones that kind of got the highest votes where there were four of them, one was on competencies. And, you know, one could have a working group on competencies that kind of reviews the sources that are available, see what competencies might fit into current clinical practice, review the existing ones, work with the societies to determine their desires and needs, that sort of thing. Another on educational products where you gather together the educational products that are available, review them, see where the duplications are or the synergies and make them available in a reasonable way. Engaging specialty boards, so a lot of the societies said, you know, what we really need to do is to get the specialty boards from the various, relevant to the various professional societies really engaged in this. Because what physicians will study, given their very limited time available for education, is what they have to know in order to maintain their certification. And so far, the specialty boards have been quite interested, particularly the American Board of Medical Specialties, which is kind of an umbrella group over 18 or not, maybe it's 20, different specialty board groups. And they are quite interested as well, so trying to engage them in the most effective way. And developing use cases, we've heard about use cases here as well. So those seem to be the four working groups that we see as being sort of ripe to bring forward. And we're planning to meet in June for the first time. We've had a couple of conference calls of this group where we develop these materials, produce a white paper, which is kind of deroger of meetings and groups like this. So, and kind of move forward from there. And we've even come up with a few suggestions of how to evaluate and show success, some of which would be process metrics, like we identify some best practices and disseminate them, we generate competencies or estimates of physician use of these materials. But recognizing that the process metrics were sort of less satisfying than actual practice improvements, more substantive things like the educational products actually get used and that there's evidence of improved knowledge and comfort in using genomics. There might be useful papers or even improved clinical practice, which is what we're aiming for. So, I would just close with as of today or perhaps yesterday, in white are kind of the initial groups that we had involved. And I've added in blue those that have kind of approached us and Deborah came up and said, we really need to have the College of American Pathologists and they're interested in joining it, so they're up as well. And I think with that, that's probably all I had. Yeah, so I'll stop there and be happy to take any questions. Oh, yes, Bruce, please comment and I'll call on Mike as well. Yeah, so I'll comment specifically on the issue of subspecialty training that you raised. The American College of Medical Genetics and Genomics has been very interested in creating training tracks for, for example, cardiologists or oncologists and various other specialties who, as you point out, don't need to know all the things that or be competent and all the things that a medical geneticist might in order to focus on the area of their interest. It has not been easy engaging the American Board of Medical Genetics in that discussion or at least in moving them forward largely because of the enormous expense of creating an ABMS sort of blessed subspecialty that involves using the National Board of Medical Examiners to produce an exam and so forth. It's a quite expensive process and we're not quite sure how many people would actually be doing this. So that is an option on the table but a quicker option is probably for a professional society which the college could be to issue some kind of certificate of special competency which honestly has probably as much weight as the paper it's printed on and the organization that stands behind it so take it for what it's worth. But in fact it could be a formal education program on the assumption not everybody who say does cardiology needs to be an expert in genetics. I guess I look at this and I think the college does as sort of concentric circles in a way which the outer ring being, you might say, all physicians who we hope will have more awareness of genetics and genomics in the middle one being specialists in different areas some of whom may be quite expert just in the area relevant to their specialty and at the center people who are the really experts in medical genetics and genomics much more broadly. And for example if you're going to interpret a whole exome sequence done for clinical purposes you may well need to be at that center target because of the breadth of what could potentially come up that needs to be discussed whereas if you're doing a panel of exons for cardiomyopathy you could very well function effectively in that middle tier. I think competencies and defining them is going to be in some ways the key to getting this off the ground. Great, thank you, Bruce. Deborah, did you want to comment as well? Or cover things that you... I think the only reason that CAP fell off the list is because I moved to the University of Vermont kind of right after the meeting and was in a tizzy so I didn't get them connected in with the ISCC but they are very interested in doing that. Fantastic. Mike, please. Yeah, with the American College of Physicians the internal medicine organization we undertook the survey that generated that one to two hours willing to commit but also in that data an overwhelming number of the doctors agreed that they needed further education on this which is remarkable and a good sign I think because they also told us that they're not seeing this in their practice for the most part so physicians are very practical learners usually what gets on their radar are things that patients are asking them or they have to carry out in their daily practice but they're watching this and they're interested I think. Great. I might also note that this is a joint effort between the Division of Genomic Medicine at NHGRI and the Division of Policy Communication and Education that Laura Rodriguez leads and this really is an educational effort and so we're happy to involve you. Did you wanna comment at all Laura? I'm not sure that I have anything to add to the overview that you gave. I mean I think that Gene Jenkins and others have put a lot of effort into our educational outreach and as was mentioned before have had great success with some of the allied disciplines but reaching into the physician pool has been challenging and so we're really excited by all the momentum that we're seeing coming out of this group and looking forward to pursuing the activities that have been identified. Great. Okay. I think with that I'm done. I can't remember who's at 12. Derek.