 Thank you. I looked at who was speaking ahead of me, and so I tried to cut to some of the things that were specific to oncology, because there's some lessons learned there. And also, some emphasis on the practical instruction to practitioners, which Kristen and others have already talked on a little bit, but I'm going to try to bring out a little bit more, because there's a lot of impractical teaching to practitioners, and I think there's an opportunity to have some practical teaching to practitioners, just to be able to say that word a couple more times. One of the unique things about oncology, and it's not unique to oncology, but it's unique, what do you ask about oncology, is there's multiple genomes you have to think about. We've got, of course, the tumor genome, and we've got the normal genome, and there's different people, even in this room, that migrate to one of those as their favorite. Actually, they don't migrate. They desperately sprint to one of those as their favorite. There tends to be a religious divide where either you're one of these or the other. You certainly don't, if you're a somatic person, don't want your daughter marrying a germline person and don't want to exaggerate. And so there's a, from an education standpoint, you see a real uneven bit of education happening across the world. It's not just a US issue, where there's some people coming out of programs where they really know one of these well, and may not even give much credence to the other. But patients have both, and in terms of trying to manage care, have both. And frankly, you've got risk, and you've got benefit in your oncology sense, in terms of trying to put that together to manage patients. And then, of course, you have a bunch of other genomes, whether they're viral, or bacterial, or fungal, or whatever else, that also have to be implemented. And so in terms of instructing practitioners, one of the barriers is just getting you to think about more than one genome. And the way we've found to be the easiest is just stop thinking about the genome, think about the patients, the problems that they encounter, and focus on how to use genetics as a tactic to achieve those goals, as opposed to genetics or genomics as an end in itself. The other thing is that we have all these great pharmacogenomic examples, and I'm sure I left off your favorite one, and please let me know. I'll add it to the list. But some of these are somatic examples of tumor variations that are usually associated with some sort of drug that has come to the market. A lot of germline, different variables. And so if you're in an oncology sense, really there's been a lot of focus with the hematology oncology fellows in particular around the tumor markers. It's hard to prescribe a drug if you don't know what test to order, and it's hard to get paid for if you don't have an order to test, et cetera. But then there's all these other elements that are part of the non-oncology space that are very relevant. We've heard from Laurie and others about some of these already, but pain control, anti-antimethics, anti-depressants, et cetera, also are relevant to how you can manage patients in. And I throw this in there for a couple reasons. One, this is a reminder. But secondly, I have yet to meet a medical oncologist who did all of their training in order to be really good at prescribing anti-depressants to patients. A third of cancer patients get an anti-depressant, either for hot flashes or for depression, funny that, or for pain control or from other areas. And yet, medical oncologists choose to not do psychiatry, but rather to do medical oncology. And yet, are faced with having to end with the new kinesin inhibitors. Peter could probably speak to this. He's had to become really good at endocrinology, because he's causing hypothyroidism in some patients. With the immune therapies, you know, causing hypophysitis and these other problems, cardiac disease, all these other issues that have to be managed. And medical oncologists in general would prefer to have things narrowed down, not to know 20 anti-depressants, but to have some guidance on maybe some that aren't going to work, focus in on some that are, and have those decisions to be a little simpler. So there's some opportunity from an education standpoint on a practical level to look at what is costing people time and can you save time? And people are really willing to learn about something that might save them some time. Now, there's three different areas that the bulk of cancer testing is being done. Most of it is still on the tumor, but it's in disease classification and prognosis, mainly in hematologic malignancies. You have a lot of differentiation of who needs to go straight to bone marrow transplant versus who needs to get some sort of a chemo-based, predominant chemo-based drug, some kind of inhibitors, based on these prognostic factors. There's the FDA approved therapies in terms of if you have a BRAF mutation in a melanoma, you get a BRAF inhibitor or can get a BRAF inhibitor. That kind of directs one test, one drug type relationship. And then you have situations where there's either no FDA approved drugs or where all of the FDA approved guideline-based type therapies have been used. The patients fit, they want additional therapy and one can try to decide which clinical trial or which off-label use can be applied. And in that case, it's really trying to select from this large numbers of mainly kinase inhibitors. Some immunotherapies are also relevant here that one can choose from using a broad panel. And it's really coming down to this change that we're seeing in cancer, starting to see it a little bit in some other diseases, where what used to be a really simple disease is just no longer there. Used to be yet a tumor in the colon. It was a colon cancer. Maybe it was glandular formation. It was adenocarcinoma of the colon, KRAS mutation. So it's KRAS mutant. Adenocarcinoma of the colon. Nice linear process. Now with sequencing, you might have a colon cancer that looks more like a thyroid cancer and is treated with a drug approved for thyroid cancer rather than the sum of the colon cancer. So the whole idea of how education was based and really is still based is really starting to change with the advent of molecular testing. And just as a caveat, the molecular testing, both in the community and the academic centers, is not something that may happen someday. Right now at our center, it's 120 patients a week getting their tumor sequenced. And it's not that unusual proportionally to what we're seeing out in the community as well. So it's something that is already happening rightly or wrongly. And so as we think about ways forward, both education and trial-wise, we need to account for that. And then of course, really the focus is not on the genome, but rather on what tools can be used to personalize therapy. And so at least in our training program, we don't ignore non-genomic stuff. We'll include circulating tumor cells or expression arrays or fish or other things in their functional imaging as a way of putting that together. Because out in practice, there are very few people who are doing genome-guided therapy. They're doing genome and proteome and whatever else, ohm-guided therapy. If shoe size works, if shoe size, whatever will allow you to make a better choice for your patient is what's driving the care. And so we need to educate in that way. And so just like we complain about genetic exceptionalism in terms of our data is looked at, whatever, we don't need to train more people to think that genetics is so unusual that it has to be a separate thing that can ever be applied in reality, but rather implement it in the normal curriculum. But in the end, there's a lot of things that a practitioner need to understand in terms of applying personalized medicine, pharmacogenomics, things like that in practice. What is the clinical need? Really defining it well. Because if it's a case of needing permission to use an FDA approved drug, that's quite different than trying to use an off-label drug where there's only a phase two trial that was underpowered and had one responder or something like that. Which test and why? There are new testing companies coming out every couple of minutes, and they all have a really glossy handout. And they bought barbecue. So there must be a test worth doing, because they wouldn't have brought barbecue if it wasn't a good test. So how does one really look at these tests and decide which one's appropriate and go forward that way? Which drug, and more importantly, which drug not to use? Why not? There are times when our tumor board suggests that among all these variations that were found that there are no therapeutic options that stand out as being an obvious choice. And being able to say no is as important as being able to say yes from a credibility standpoint. But also patients want therapies. But if they know that they took a shot, looked at the results, and there wasn't something obvious there, there is a degree of comfort for the patient and the family that they at least tried and can go forward that way. So that's an important part. Clinical trial versus off-label use. How do you get all this deped data into the electronic medical record in a functional way? Up until the time we started doing personalized medicine consults, our tactic, and our tactic still is to upload a PDF of the test results and hide it deep in the EMR so that no one can find it. And we're very, very good at that. But now with these consults, people are able to actually find it. So it's kind of ruined the whole thing. The idea that one can put it there in a functional way, it can stimulate CDS or whatever is a big challenge because there is testing coming from all sorts of different areas, in-house testing, out-house testing, send-outs, and lots of different approaches there. And then how to pay for it. And so there is something that we can't ignore. If you identify an amazing tyrosine kinase inhibitor that's appropriate, could have a probability of working for a given patient, one needs to be able to convince the payer or someone that it's worth using. And so that's something that can't be ignored if we're trying to create practitioners in terms of how does one create that? Often in academics, we want to leave that gap. And really closing that whole gap in terms of going from a test all the way through to a pill that a patient swallows and hopefully beyond is really an important part of it. So this is an older slide, I haven't drawn a prettier one, but it kind of gets the points across. We structured things in a couple of different ways. We have a personalized cancer medicine clinical training program. I'll tell you a little bit about it in a second. We have a personalized medicine clinical service. And the trainees rotate on this service. And so they're doing daily cases. So there's 120 cases a week that come through that service. Not all of them need to have an extensive review. Some of them need 30 seconds because we've already identified they have nothing that needs extra work. Some of them need six hours and a lot of in between. We have a functionally, we have a molecular tumor board at this level, a weekly molecular tumor board. And then we have a monthly molecular tumor board that I'll get to in a second. And then of course, that interacts with the molecular diagnostics program. Our community partners get in through this route, et cetera. We also have had to think about what kind of team do we want. Now, I happen to not be a Cavaliers fan, but I happen to be able to find these slides. So I use them. It's what Gu LeBron is a very effective PR machine. And his pictures come up first. But here's a picture of LeBron James. He's a basketball player for those of you who are interested. And here he is with his team at a cherry event in China. And some lovely fellow team members there. And if it's against a bunch of other people of the same size and ability, then that's probably just fine. But if it's against some real players, you're in trouble. You have a great player, and then some players that I would bet are not quite as good. Or you can have him with his actual team of Cavaliers who are playing now all tonight. And so that type of team needs a bunch of different people at a very high level operating together. Not an amazing person and their minions. And so training someone to be more than a minion is an important part of that. And we're not sponsored by Disney or wherever makes minions, but Universal Studios, I guess it is. But the idea of training people to be a team member is just really appropriate. And so with our Clinical Genomics Action Committee, our bigger board, we have all sorts of different disciplines that are looking at these cases. There's different types of oncologists in terms of specialty, and you see some tumor types here. There's folks that are genetic counselors or medical geneticists. There's pharmacy folks. There's different types of pathology, molecular pathology, heme path, anatomical path. There should be one more somewhere. Usually a lab medicine person in there. Bioinformatics. There's some basic science people that come here to reluctantly add their two cents. They're terrified that someone might mistake them for a doctor. Their PhD, they keep hearing, I'm a PhD, but. But often they'll have some insights that could really add to this. And so having fellows trained in this environment allows them to first of all start respecting other disciplines, but also start thinking about how to go forward. And those of you, because I know you'll ask later, the reason we called the Clinical Genomics Action Committee was not inspired by Dilbert. Rather, we're going to call it a molecular tumor board. But many of the molecular tumor boards that I've seen are academic freak shows, where they'll look and say, wow, that tumor had a Jack 2 amplification. Isn't that crazy? Jack 2. Next. As opposed to what do we do for the patient? So we want to focus it down in that way. Also, there might be people on the same campus, but they're not necessarily on the same page. So you go to a major medical campus, and you've got a pharmacy school and a medical school. And pharmacy school is over here. Medical school is over there. And they may or may not interact. And then within the medical school, we've got the pathologist in the basement. Not as much these days, but used to be. We've got medical oncology up on the fourth floor. And clinical genetics, and who? Clinical genetics. I'm not sure genetics is even in this building. They're not necessarily working together in that way. And so we have to pull people so they're working together. And so the way we designed our program, and this did not come out very well, in terms of an actual, what we call a plus one program, if someone already has done training, medical oncology, pathology, and clinical pharmacy, or the main three, they can do a plus one year, one extra year. It could be up to three extra years with our program. And so that allows them to get that training, both on the clinical side and the research side, and build that up. And it's certainly common in pathology and medical oncology to do a plus one year. You might do an extra year in bone marrow transplant, or you might do an extra year in breast oncology or something like that. Pathologists do a lot of subspecialization training. And so that sort of concept is there. In pharmacy, this is, I guess, the equivalent of a PGY3 or something like that, where you have that third year on top of your existing residency. And we've gone through our actual genetic medical education office, in terms of placing it there, so that it is formally with our institution, and not just something we do on the side in my lab type of format. Also, the leadership, but you can't really see it. I can barely see it from here, you might be led by some pharmities, but also has a hematologist, an anatomical pathologist, and a solitum or medical oncologist, as part of the leading group that are involved every week and go forth from there. We also offer a one month rotation that has now become a mandatory rotation. So every he-monk fellow and every molecular pathology fellow has a required one month rotation during their second year on this service, so they can get this sort of training. And this is what the jolly good fellows look like for there. We have three of them per year. One of them is going to go do additional training of pathology, because these guys don't like to stop. One of them is going to be a assistant professor at University of Kentucky, and then one of them we're hoping to keep at Moppet, so hands off. The other thing is there's a lot of other people to train. So far, we've trained about 120 nurses, and this came up yesterday. I think it might have been Todd that said it, maybe not, but I'll give you credit anyway. The nurses interact with patients time-wise. There's much more surface area in terms of their exposure to nurses for patients than others. And so making sure that our nurses actually knew what personalized medicine was, and what we offered, what we didn't offer has been really important. And we have 900 nurses, so we've trained 120 of them who are now then gone on and are training the others. So every floor, every clinic has some people that are trained and go that forward. You're supposed to go up, not down. The rotation is already mentioned. We also provide these boot camps, which are one to two hour trying to raise people, not to make them become personalized medicine specialists, but to take an existing medical oncologist and give him or her more comfort in which tests order and how to interpret it, partly so we'll have less work to do, but partly so that they can at least do that part, and then we can take it from there. And then I mentioned the fellowship program. So we really have to decide, what do we want out of a precision medicine practitioner? So the ability to guide selection from amongst equal options, we're trained that every week in New England Journal of Medicine, there's a clinical trial with a survival curve and the winner and the loser is there on that curve. Actually, it's usually this way. Sorry, Marilyn, that made a confusion. And so you get the winner. And so really what we're talking about is first line and second line therapy. We might use the winner first, but if that doesn't work, we use the loser. Call it that, but so it's really choosing for amongst almost equals in terms of those options and learning how to do that. Really understanding what multidisciplinary require is required rather than preferred. A medical oncologist tries to do this by himself, is in trouble. A pharmacist that tries to do this by herself is in trouble. They have to learn how to work together much more than just exchanging emails. And so there's work to be done. Learning how to work with a bunch of other people who you don't even speak their language. The folks within different levels of information technology, not just the EMR, but also some of the other aspects, patient safety, the insurance companies, donors, revenue cycle, which is basically what we call a moffat, the people who cause us to be able to get paid from insurance companies or whatever. We need to be able to talk to those people. In some cases it's a Spanish, Portuguese, sort of similar language type thing. In a lot of times it's Hungarian or some language that has no similarity to English. And how does one do that? And then we need to remember why we're doing this and trying to understand. And at least in our rotation, our fellowship, they have to counsel patients. And a pathologist learning how to counsel a patient about a drug is hilarious because they can't pronounce any of them. But the idea that one can go in and learn this, have that competency and not forget why we're doing it is an important part. So I've gone over, I know that Teji will beat me up if I don't stop. So we'll stop right there and we can have I guess the discussion. So just a, are we stopping to get lunch and coming back? That's what's on my program. Okay, so let's do that. Let's take, see how quickly we can get lunch and bring it back to the table here. And then we'll have a discussion. So we'll start at like 12.50, so 15 minutes? Yeah, I think everyone can get back in 15 minutes. All right, so 12.50, we'll pick up again with the discussion.