 All right, thank you to both of our debaters. Now that the debate is over, we'll go back to Fox Studios for our discussions to break down the debate. And so I'm going to turn it over to Laura Rodriguez for her first comments. You didn't, ah-ha, ah-ha, someone wasn't paying attention. Ah-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha-ha. So the people that I have for the discussions are Mary and Howard and Laura. So I am not. I have an email that talks about that the genomic medicine working group folks that are not, that we're not involved in otherwise will actually be acting as discussant. They were on the email. All right, so since there may have been a break in communication for which I am not going to take responsibility for, I will offer you the opportunity. But if you don't want to take it, then we'll open it up for open discussion. So, OK, go for it, Eric. First of all, it was very entertaining. I thought it was very interesting. I guess the question, I mean, it is a bit of a false dichotomy. We should have media appreciated. It was theatrical, and that was the purpose, and that's fine. One of the things that strikes me, and I did like the analogy you were making with HIV, is you're arguing this as if it's a frozen point in time. But in reality, aren't we dealing with the circumstance that the sands are shifting? And so trying to be too strident in a position is a little absurd. Because, or maybe it's not absurd, but you're arguing specific cases, but the base is changing, the foundation is changing. So if you try to argue too much in specifics, it'll be irrelevant at some period of time. If you try to make generalizations. So, I mean, maybe the question's more for Gail in some ways, because she took a more, I mean, I think the lesson we heard first by HIV sort of illustrated the point that with time, more and more will go to primary care. You took a strident position almost as if, and again, to be theatrical, that wasn't going to be the case. But don't you admit that over time, more will shift their way? And that you may argue will be a residual that will always be in the hands of specialists or? Yeah, and if you look at the HIV example, those patients were only seen by specialists in the early days, right? And then as it became understood, as the information became more standardized, and frankly, as the population grew, then it moved into the primary care setting. And many of those patients still get referred to specialists, depending on if they're not responding to usual treatment, et cetera. So, certainly, right now, HIV has one test. We have 75,000. That's an obvious difference. And who orders the right test is a big concern to me. But yeah, I absolutely think that as genetic information becomes more and more common in medical care, the primary care providers will have to and will pick it up and they will do more of it. Are they going to be ordering appropriate tests on appropriate people in the future, I hope so? In the future, I hope so. And it seems to me that the other component is that, which we always can't totally get our heads around, so we don't even know what the life's going to be. The whole data science, I mean, the numbers are just so out of control. At some point, it's going to be not the specialist to me. It's going to be the specialists who have developed the computational tools, the data science tools that the primary care physician will simply rely on for some of the things, whatever they read or whatever they quickly can find. Because even the specialists would do the same thing because they're going to be overwhelmed with the sheer volume of information. Sure. The question is, are those tools being developed? Are they out there? Do they know how to find them? For me, I prep almost an hour per patient for a clinic. And I don't think most primary care providers are going to have the time to do that, right? And what is happening in the field is changing so fast. And frankly, which lab to send the test to and the financial implications of sending those tests and self-pay versus insurance pay, you know, those are very complicated parts of genetics. But the key to me is, do you honestly believe that it's going to be the same situation five years from now? No, of course not. Of course it'll keep evolving. It'll keep evolving. So as that part of it gets better for you, will some of that then be more readily shiftable to a primary care physician? You'll still be stuck with the grungy stuff that has to be solved then and still be complicated. It'll be worse for you. Yeah. Well, yeah. Well, I think if not for a diagnostic component, that a lot of it should shift to actually genetic counselors. And so I think we should be honestly training up for that. Because in the long term, that's going to be cost effective. You know, nurse practitioners are used extensively for many things. This is a very similar thing. You don't need a physician to do some of this care, and the genetic counselors may actually be better at it. So I actually think that that model is going to be important. But genetics is hopefully going to be everywhere in every disease. And so every part of medicine will need to understand it. And I think Robert made a really good point earlier about this fractionalization, you know, there's information going into your OB and your pediatrician and your nephrologist and all these different specialties. But it's going to be in every part, and all of these people are going to have to learn it over time. And the boundary of what requires a medical geneticist is going to move. I genuinely hope so, right? But it's going to move more slowly than we want it to, I think. Howard. I just wanted to say quickly. I agree with my wise adversaries that it is a boundary issue. And like you're saying, Eric, the boundaries are going to change. So you've given me PGX. I will give you collagen and all the rare disorders. We're done. We have a boundary. We have boundaries of certain people are going to stay mostly in your wheelhouse. Some are going to stay mostly in our wheelhouse. And again, it's knowing who should go where. And I think as things get clear, it'll be easier for primary care providers to handle. The one thing I'm not positive about is where genetic counselors should fit in. And I'm not convinced genetic counselors should fit into things like PGX and chronic disease testing because I'm not sure, like I said, with our patients with chronic disease testing, they were a little grumbly about how much pre-testing information genetic counselors gave them. They felt like if the test is negative, I didn't need all that. If it's positive, I'll ask you if I want to. But if it's really like a creatinine, let me ask if I'm interested and don't bother me if I'm not. If it's just going to change my drug or change a dose, let me ask the question. So I think in certain areas, they'll be more necessary than others. I think it's going to fall more into a primary camp or specialty, a non-genetic specialty camp. All right. So, sad, it was very upset. No. I think the one thing that really came up... Dot, dot, dot. Yeah. I'm sorry. Couldn't feifei. So one of the things that really struck me from both presentations or both discussions was genetic medicine needs to be as much medicine as genetic. And we have examples in the room here where there really is medicine practiced by a genetic transposition. We have other examples, and I won't name names while I'm live, but where it's really more of a diagnostic visit and very little is conveyed on how to manage the patient. And I think that's what needs to be tightened up a bit is when the release happens, the catch needs to be improved, that's weird, but when the release happens, that it's not just they have this bad thing when you literally could say sad, but rather here's what you do. And there's too little of that going on, at least in where I live, in terms of actually helping a primary care physician manage that person internally, but they require that. Institutionally, we set up these special clinics because we think it's cool, it's good for marketing, it might make us some money, but really that handoff throughout all of medicine, not just genetics, is really getting harder and harder, and no one's really taking ownership of it. As a specialty cancer center, we're not investing what we should in terms of making sure the hand back is truly a hand back, or whether it's a drop off and sprint away. And so there's a lot for the field to do to make sure that there really is that sort of engagement two way or preferably to go forward. I agree with you and I also think, I was just looking to see if David was here, he was saying in his study that one of the areas where patients, the one area where patients were most unhappy with genetic testing was when they found out that there was no explanation for their child's illness that was genetic. So when genetic testing is done, and it's a negative or an uncertain, it's sort of a negative unless we find something out later, then we have really said people coming back to us. And not only do we need what is positive, but we also are going to need to do what's next. Great. So we'll open it up for discussion. Before I take the people who have their cards standing, I did want to just mention one thing that I think the genomic NHGRI is working on that does address some of the issues, which is how do we do this, because I think a lot of times, and again, this was part of the artifice of the debate, was we always think about things as physicians, you know. So when I hear about pharmacogenomics, I think it shouldn't be primary care physicians, it shouldn't be genetic counselors, it shouldn't be geneticists, it should be pharmacists. Pharmacists do this every day. You know, I don't calculate zero order kinetics. My pharmacologists do that, I think. So it doesn't always have to default to physicians. And so there's a working group of ClinGen called CADRE, the Consent and Disclosure Recommendations, that actually has been doing some formative research looking at how do we take different types of genetic information and convey that back. In some cases, it's really as simple as giving information to these two patients. The information is so banal, like for a negative test result, that you don't really have to see anybody, that it can be clearly done that way. There are other situations where genetic counselors are more appropriate, others were medical geneticists, primary care. So they're working on a rubric by which we can begin to more rationally think about how we right size who is actually involved in the process, which will hopefully enable more scaling. And so I just wanted the group to be aware of the funded efforts that are taking place in that space as well. So with that as the brief intro, I'll go Heidi first. So, Gail, this is one very specific question. A lot of the studies you showed, it was interesting to me that they never tested medical geneticists on all of these questions. And, you know, I've been involved in two lawsuits that were supposed to sue the lab and it turned out that it was actually the medical geneticists who made egregious errors. And, you know, the number of medical geneticists might think that hemochromatosis is a dominant disorder, actually maybe staggeringly high. And so, you know, you are an exception. There are a lot of exceptions in this room also. But I think it's, there's a huge range and knowledge even amongst genetic colleagues, right? So that's one thing. The other thing, and not to say that there aren't plenty of situations where a geneticist is actually at an outstanding level of knowledge, but that's one thing that... Exactly. Well, exactly. Everybody screws up. And it would be really, have been really interesting if they actually had included geneticists in those surveys. The other really critical thing, and this sort of speaks to some of the Howard's comments, but it can take, you know, often six months to get in to see a medical geneticist. And if we really want in this evolving world of use of genetics for those genetic, genetic information to actually be dictating care and management and which tests are ordered and perhaps prevent ordering a lot of, you know, tests to save costs because you get the diagnosis immediately. We can't wait six months to get in to see the medical geneticist. So I think figuring out ways to improve the turnaround time is also going to be critical. So let me respond on the testing issue. We do take tests. They're called boards. And we're required to keep taking them. And I'm taking tests every six months. I get a whole new set of questions that I have to answer correctly. And I'm sure there are other people in this room. And so this is an ongoing evaluation process for people's capability to do medical genetics. That's not to say people don't make mistakes. They certainly do. And I think they do in all areas of medicine. But we actually are trained and credentialed to do this care and other specialties are not. Are incorporating genetics into their curricula. So, you know, you look at the medical school curricula and genetics is only a two-week thing. Well, actually, if you look at all the systems being addressed, every one of those systems should have genetics, cancer, cardiology, et cetera, incorporated into the training. And the physicians will actually learn better. It's in the context of specialties, right? So I think we just have to think about especially for nonsyndromic conditions, you know, having specialists be able to contextualize that for cardiomyopathy or, you know, very kidney disorders or whatever. Whereas the syndromes are where a geneticist really has a much better toolkit, I think, than complex disorders. Anyway, thoughts? Yeah, I mean, as an adult geneticist, I'll say that, you know, I have not found that my colleagues, even oncologists, even want to take over the genetic testing. I have one colleague who does order testing. Everyone else refers because they don't want to spend the time, energy, or deal with billing. You know, honestly, there's reasons why people don't do it. I do agree. Every specialty should be better trained in genetics. But, you know, until they are, then we have a gap. As far as wait list, we don't have a wait list to get into our clinic. If we have all your documentation, you can be seen within a couple weeks. I mean, a couple weeks, we don't call a wait list. The Children's Hospital does have a longer list. They're working hard to do that. We have emergency spots at both ends. But you can wait, you know, I mean, I've waited that long to see a dermatologist. So, you know, I mean, waits in medicine is not unique to medical genetics. That's why we're called patients. OK, I'm going to go with Peter next. I found this debate really interesting because this is what, when I go out to my primary care sites for my educational tour, I call it, I see this debate play out for, you know, in real time with my clinicians. And so my role in my position is, well, how do I take these two different perspectives that are real perspectives in my institution and build a system that can handle that? Because I have some clinicians that, matter what we do right now, they're going to refer everything versus I do have champions who say, you know, I want to take this song. This is an exciting new era of medicine. But I want to be assured of that safety net. And I think that's part of, you know, the solution building is working on, well, how can we leverage things like in the EMR so that we can at least start to assess, well, who are our BRCA carers in our system? Because that's a fundamentally difficult question for most hospital systems to answer. And know that, OK, they're getting the right care sort of by monitoring, well, what are they getting from their screening, et cetera, just like we do for other public health initiatives as well. And provide that reassurance that if someone is veering, whether it's a clinician, you know, a patient-centric or just patient-centric, fill in the gaps there. But part of that realization is, you know, getting sort of the content, the educational content, the knowledge base that we're having to build to know when I imagine other institutions are struggling with this. So as, you know, NHGRI, how can we get more of that resource where it's more shareable into the EMR so not every institution has to build it? And the comment on the GCs with the pharma genomics, they don't get any training in drugs. So we actually started with our pharma genomics clinic model as a GC paired with a pharma genomicist, but then switched to an APN, who we had some internal training to a model with our pharma genomicist. So, you know, this is how things have evolved over time. I hope that genomics can learn from other specialties that have gone before it. You know, there are, I have colleagues who refer hypertensives to cardiologists and people with diabetes, type two diabetes to endocrinologists. I don't. And what happens over time is we try to figure out what system do we have to maximize appropriate and minimize inappropriate referrals, right? So now we have like, I don't know, four sugar that we can call if we want to quit consult so we don't refer inappropriate people and we can curbside. And I assume genomics is gonna go the same way for some of the simpler stuff. I still don't understand, even as a PCPY and necessarily need a pharmacist, if you're telling me that they shouldn't be on Plavix, they should be on something else, I'll just make the change. But you know, but I think, you know, I hope hopefully genomics can learn from all the other communities, but you're still trying to deal with appropriate referrals. So the comment on the pharmacist, so our PCPs are ordering pharma genomics testing in our system and our clinic is meant as that safety valve now where, you know, maybe there's certain applications where we're not taking level one evidence from CPIC, but there are those elements of the data where for a complex case we, it takes, you know, kind of that level of expertise where we have had some several anecdotal intervention but providing that safety net. Great, so I have Terry and Steven and then Bruce and Dick and Robert and Bob. That's the, and Jeff. That's the order I have. That'll may do us, but we'll see how things go. So Terry? So I wanted to get back to the issue of handoffs and perhaps Steven is going to respond on this, but perhaps he'll respond when I call him, which is that my understanding, Steven, is that you do a fair amount of handoff to the neonatologist, but there is a certain degree of a given specialty feeling like they know how to manage an area and they don't want a specialist telling them, do this, do that, just give me the information and I'll work with it. So maybe you could comment on that. Yeah, thank you. I really appreciate the spirit with what you presented this and for you teeing it up. I think that what we found is a festering wound in modern medicine that is all too real and for which patients routinely suffer. Turf wars between sub-specialists are ubiquitous. I don't actually think there is much of a turf war at all between primary care physicians and medical geneticists, but I do think there is between sub-specialists and particularly in tertiary and quaternary care and these wars can be bitter and patients suffer day in, day out because of egos and the lines drawn in the sand and whether you regard this as your domain and hell, you're not coming in that door and it's tragic and we forget that we are servants, not glorious physicians. So I appreciate the tenor of this and the light-hearted manner, but I think there is an ugly truth beneath this. People have made really good times. I mean, I love my medical genetics colleagues. I love David Demak to death. I couldn't consider how we might pioneer in genomic medicine as an institute without having somebody like him to be our heart, our beating heart in everything that we do, but the fact of life is there's only a couple of hundred folk like David Demak who practice in the United States. There are entire states that have not a single medical geneticist. There are large regions of very populists. I mean, right now we're looking at putting our technology into Arizona. There's one practicing medical geneticist in that state. Can you believe that? He's retired, so he works part-time. They cannot attract another medical geneticist because that person will be on call 24, 7, 365 days a year and we'll cover both dysmorphology and biochemical, every positive newborn screen. So, you know, there are extraordinary things. Patients wait on average in tertiary care and in quaternary care for six months to see a medical geneticist. Clearly we need solutions. Part of this has to fall on the shoulders of the specialty bodies. Something which I think makes eminent sense is to say what is a minimum curriculum whereby good medical geneticists would say I accept that you have a proficiency, a level of skill that I'm comfortable with. You're not going to make the stupid rookie mistakes. You're going to get it right most of the time and we're gonna teach you when you need to hand off a certificate of competency that could be accomplished by really any pediatric specialist in say three months based on case-based learning. I think that's what we desperately need because like it or not, genomes are gonna become ubiquitous in healthcare. Whether we like it or not, it's gonna happen if we're not very careful as with other major recent transformations in healthcare delivery where the entire medical establishment misses the boat entirely and it becomes a direct-to-consumer play. That's my fear. It's not whether it's primary care physicians who are interpreting the results or medical geneticists. It's much more that 23andMe will be the provider of healthcare, excellence and other organizations like it. I also think for medical geneticists, the world is radically changing. Their world is, and I feel for them, is no longer about making a diagnosis. We now know that a good genome with a reasonable history taken by a non-expert will make a genetic disease diagnosis really routinely. And so their world is now changing to be much more about, so therefore what? What can we do to change the trajectory in this patient? And thankfully we have a new arsenal of drugs and interventions that really give hope that we can change the whole specialty from being a descriptive specialty to one which is therapeutic in emphasis. And this resonates with me. I trained as a rheumatologist back when we also were the guys called in to put a label on a disease that we could not treat. Well, we could, we gave everybody steroids and if those didn't work, we gave them cyclophosphamide. So I really feel for them and now I look at my old specialty and they're so interventionist in their approach and the field has changed remarkably. So sorry for taking so long. Thank you. I'm going to go to Bruce because there's been a couple of comments about curriculum and I know that that's something you've spent a tremendous amount of time on so it seems appropriate to let you talk about that and also ask your question. So I actually hadn't planned to say anything about that but since you asked, just let me just make three quick points and then I'll come to that. I agree with Eric that it was a false economy to begin with. Genomic medicine isn't one thing. It covers a broad territory and I think the two of you would agree that there's room for both for lots of different practitioners. I was going to say the same thing Stephen just did so I won't, other than endorse it. I sort of hate to hear that we just diagnose and then release. I really do think geneticists have to take responsibility for management and treatment of the kind of rare complex disorders that we become, I think, somewhat uniquely familiar with. The third thing I was going to point out which I don't think has been said before is that somehow there seems to be an underlying assumption that all this has to be done by human beings and I'm not so sure that's necessarily true. I think there should be room for artificial intelligence and other kinds of novel approaches. For example, to pretest counseling. What would be so bad about pediatricians sending genome sequencing on their patients who have some sort of developmental disability or congenital anomalies? When I think of the diagnoses that we do make by sequencing I'm humbled by the fact that almost never is the answer something I had thought of our priori and I think we do a pretty good job of explaining it after the fact but I have to admit that usually we're at the end of a long line of people who didn't think of it and then the genome reveals it. So what would be so bad? Well one thing that would be so bad is they might not do such a great job or even take the time to do the kind of pretest counseling you wish would happen and maybe genetic counselors can fill that void but maybe there are other innovative ways we could think of to do it realizing that scaling the workforces is a challenge. Finally, to Mark's point about curriculum I've spent a lot of my time over the years trying to help educate people, medical students, genetic counseling students and many others about the kind of fundamental vocabulary of genetics and genomics, things like what does the variant of unknown significance mean? It means it's a variant whose significance is unknown. Something that you would have thought wouldn't be so hard but. And I absolutely agree that we need to focus on that but on the other hand when I think about the kind of things I do in practice I order a lot of MRIs. If you were to crap me and say how does MRI work? I couldn't begin and I'll hypothesize that most of my radiology colleagues couldn't either and because you don't have to. I mean you have to if you want to develop new approaches to it you need to be able to understand the physics for that but not to order it and to interpret it. There are people who are really good at recognizing the patterns and looking over your shoulder helping you but I feel pretty comfortable doing those things. So I absolutely agree that we need to educate but I actually frankly think sometimes we expect too much in the education system and rather I would like to see us do a better job of developing systems. When people make mistakes and interpreting results how much of it is on them and how much of it is on the way the report was written and designed that made it easy for them to misinterpret it and yeah an expert won't make that mistake but would it be better if the lab did a better job of writing the report clearly so that even a non-expert wouldn't make that mistake? So I think there's plenty of room for improved education but I also think there's a lot of room for improved systems. Thank you. Dick. I just want to quickly ask based on what you were just saying and maybe ask Gail would it be appropriate in some situations like what you were saying if there are times that you think like 80 or 90% of the time the test would be negative would there be times where a more primary care person or a non-genetic medicine person could order the test with some prep and then only refer the positives? It used to be that we sent everybody with diabetes for retinal exams to the ophthalmologist now we have retinal cameras we only send the positives to the ophthalmologist so is there a way that the general community could absorb some of the testing and send you the positives or is the pre-testing so important that we can't do it? Yeah, I think it's a good question. I think there are probably areas where that standardized tests if lots of people are gonna get the same test and you know what test it is I think that sending an array on a child with intellectual disability as a first test is something primary care providers do and it's a good first place and if it comes back positive they often refer and if it comes back negative then they refer for the next thing so I think there are individual tests the quest and I think you can explain limitations of the test and frankly I think for arrays you know it's not that challenging and the parents are very motivated so they'll probably sign up you know I think it is harder to know what is the test to send in many circumstances and you know panel testing is helping with that a little but not entirely and so you know I think that's really the challenging if there's a straightforward obvious test or if we get to the point where we're doing like cardiac risk scores you know those may be appropriate things that primary care providers can order and frankly explain even but I think there's gonna be a lot of subtlety in that just the scope of the field is very wide. Yeah I think it's important, you know I agree that I think we could develop guidelines for a lot of scenarios that could facilitate ordering the challenge of course is that there's another educational component that comes in here that we frequently don't acknowledge and that is our friends that are actually are developing the tests and the panels that are coming in and talking to the docs and frequently the competitive argument is well our panel tests for 50 genes whereas our competitors only test for 30 genes well we only understand 10 genes so I really only want those 10 because I know that what happens to the variance of uncertain significance the more we do so you know we have to have some sort of a way to make sure that we can take in information like the Brugata information and just say you've got 30 genes on a Brugata panel you need one gene that's all we have the evidence for right now but that's of course not the way we have tended to compete around that but I think that there are ways to develop systems that would essentially be able to do that in a more automated way and that's been done in other situations certain rheumatologic tests where there'll be an order set that essentially says if this then this then and you can do that kind of decision support in a reasonable way. So that's what we've tried to accomplish with our genetic and mental assessment tool is we know if there's a certain affirmative actions we're gonna start with a certain panel that has NCCN guidelines, genes, et cetera there's certain areas where we can start with and then if it's negative or then we can kind of reflex if we need a broader panel or they can be seen but I would argue that as a geneticist I don't need to see as the first line the breast cancer patient who's a vascular as a Jewish ancestry there's a starting point there that we can definitely build a system around. Dick. So first of all there may be some lessons to be learned even though Gail wants to give it away from pharmacogenomics in that this is the aspect of clinical genomics that is already touching virtually every patient everywhere in terms of large academic medical centers and what we've learned at the Mayo Clinic where for many years now there have been alerts the doctor doesn't order the test there's an alert that says if you order this drug there's enough clinical evidence that you want to consider ordering a test if it's TPMT I hope they order it or DPYD but the fact of the matter is that's all reactive and what we've now done with 10,000 of our local patients who get their care from primary care physicians is to preemptively sequence all the known clinically actionable pharmacogenes and put that information in their electronic health record. Now remember the doctor didn't order that even with our prompting the reactive the physician has to order the test. Now it's all going in their electronic health record and these are virtually entirely primary care physicians so we're running the test and seeing what the results are and it's fascinating to see the sort of outcome. Some of these primary care physicians within a matter of a few months will find 200 of their patients will have sequence based information on all the pharmacogenes in the electronic health record. Much of it dealing with drugs the patients are already on and some of it says that may not be the best drug for this patient and think about how we handle that. Now when we did that immediately and began even moving where we're moving we have 700 pharmacists on our Rochester campus when the time came for them to respond because what did the doctors do when that alert came up? They picked up the phone and called the pharmacist they didn't pick up the phone and call me thank you God they picked up the phone and called the pharmacist and the pharmacist of my age range wouldn't know an intron from an exon from an enhancer from a promoter from a splice variant and they just wanted this to go away. The younger pharmacists saw this as a career path and so now we have young pharmacists who are wrapping their arms around this many of them trained with Mary and some of them trained at Florida you know who's doing this sort of thing they're PGY to pharmacogenomics trained farm deeds and we're hiring those people lots of them not for the routine stuff because what happens in both the specialties and in primary care is the same. Some enthusiastic young physician who doesn't know that they're not supposed to deal in something they don't know anything about becomes the champion and they teach the people of my generation what really it needs to be done. Except in the complex cases then the farm deeds are called in. So it's evolving in a way that both of you were right of course I mean we all understand that but we're running the experiments now that's a microcosm even though you want to give it away that's a microcosm of what I think we heard Eric saying just a few minutes ago this has all evolved very rapidly shockingly to me how rapidly these bright young people both from the pharmacy and from the medical side both in primary care settings and in specialty settings the dynamics the social dynamics are the same in both of them and I think this is what's going to happen broadly in genomics it's just one example of it so like most debates you were both right. Robert. Sure keep it briefed I just think following up on Dick's point what he's saying about pharmacogenomics we found in the MedSeq project which specifically looked at primary care docs who self identified as being interested in this and I think there's going to be whole new cadres of primary care docs who self select and if we can match that up with clear reporting and a safety net like we did in MedSeq for primary care docs in academic setting sure they were in academic setting we're also doing it in mill seek for primary care providers not even all doctors in a military setting and we're transcribing what they say to their patients and reading these and identifying errors and finding that with just three to six hours of orientation to that report they make precious few errors certainly no errors that we would consider egregious so I do think I mean I sympathize with the kind of anecdotes that Gail is reporting and I'm sure that they're going to continue to happen to some extent but I do think with some forward looking thinking over time and we're going to find people who self select and lead this field secondly I think we have to realize that there's inevitability to the integration of genomics and that we have this responsibility to create ways to manage it not just with decision support but with allowing other specialties in primary care to do this if we try to build some artificial wall we're inviting a whole different initiatives from consumerist point of view to reject us, the medical world, the academic world as somehow too slow moving to meet their needs and I think there's a real danger at a sort of pseudo scientific consumer backlash that sort of paints us as unwilling to move quickly enough for these exact reasons in part because we're sort of protecting the excellent from the good enough this is just by the way a preview of things to come because it's going to get worse when we get into multi-omics when we get into integrating if we're talking mostly about sequencing today when we get into integrating multi-omics microbiomics, metabolomics where there's even less of an identified database I think this gets worse and we've finally got to be able to train ourselves to be comfortable saying we don't know so those are some thoughts from Mitzi I always thought that was the most important thing for a geneticist to learn was 50 different ways to say I don't know but still be supportive in some way, shape, or form and for that reason I do really recognize how Carol emphasized that in her side of the debate though I agree they weren't actually totally opposed to each other but she emphasized the responsibility to talk about the limits of our knowledge which is key Good, Bob. Just to get back to the false dichotomy and point out that it's in part driven by our healthcare reimbursement system where you get one choice you get to do it yourself or you get to refer to someone else and either one way or the other somebody's going to bill for it and then I think as we move towards accountable care organizations and others that don't work under the same principles there are opportunities for a much more graded approach to utilizing the expertise of the medical geneticist as you know in doing curbside consults and doing consultations through the EHR that are recorded and maintained as part of the record but where the geneticist doesn't see the actual patient necessarily if that's not needed to answer the question the hole that the primary care provider has in their knowledge. So we have one more question but before I give Terry the last word because I picked on Gail but we know really who always has a last word. I just wanted to come back to something that Bruce has said in an earlier session he said in a different way I think more looking at data visualization and the cool tools and everything but you mentioned the term system engineering and I think that really a lot of what we're talking about here really comes down to how do we actually think about practicing medicine in a systematic way as opposed to the traditional way that we've always done it which is very physician focused. I think high performing healthcare systems have identified the fact that in many cases if not most cases care that is not provided by the physician actually gives better results. If you have diabetic nurse educators who get better results. If you use pharmacists to run chronic disease clinics or medication management you get better results and it's just a matter of having physicians do what they're really good at which is actually synthesizing data in unknowns and not having them to do the routine sort of stuff and so I think there's a lot of what genomic medicine is going to evolve to Eric's point that is gonna become more routine in which case we can build systems around it to really help to keep things organized and so my sense is that everything is on the table in terms of the discussion. We need everybody at the table and we need everybody participating which will be exciting and scary which change always is. So with that Terry you get the last word. Well I would like to raise the issue that Steven raised in terms of certificates of competency so Bruce not to call on you except I'm calling on you. I can recall a discussion among the association of professors of human and molecular genetics where this idea came up and this was several years ago and the feeling was it would take an awful lot of effort to develop such a curriculum and there wouldn't be enough people to use it and that's how I recall the conversation you may want to comment differently but things have changed since then so the NHS England has produced a very nice curriculum that is available to anyone and they are essentially upskilling their primary care practitioners to be able to do this kind of work and probably the demand is increasing and it almost likely will increase dramatically in the next few years. So I guess the question is to those of you who are you know died in the world geneticists is this such a crazy idea and is it something that we could possibly try to implement? So you're referring to creating curricula that? A three month curriculum for your for your dumb internist like me to be able to say yeah I can handle probably half of the sort of routine complex disease pharmacogenetic sorts of topics without killing anybody and know when to refer somebody. I think that's Stephen what you were sort of suggesting. Is that right? Yeah so well you mentioned APHMG they have developed curricula actually or at least fairly detailed lists of competencies that are intended mostly to inform medical school I don't think they've extended out into continuing medical education for example. I don't think it's at all a crazy idea but I think the challenge has always been one of the sort of marketplace I guess you could call it which is if they build it is anybody actually gonna come and use it? And so it's always been a bit of a question about creating something and putting a lot of time and effort into it and then worrying that now who would actually come to take these courses or to participate in these curricula. So I think that's been one of the bigger challenges is just a concern about sustainability of that sort of thing. But the idea of infiltrating into the educational systems of different specialties and seeding them with not overwhelming amounts but relevant amounts of material in the long run is probably a really important opportunity and it's one that in my judgment the genetics community has been slow to adopt maybe because they're not welcome into some of these other places it's hard to be sure. There is a little bit of a turf protection phenomenon probably taking place but no I don't think it's at all unrealistic particularly if there were incentives put in the path to make it really worth their while. I think it's really more of a Google map problem. I think what we have not figured out how to do is to teach people how to read the map because we don't have street level information in our heads but we've learned how to read a map or in some cases listen to a voice wisely or not that tells us where to go. And I'm a pretty much a nihilist when it comes to traditional medical education because I think the evidence tends to show that our traditional way of delivering content through lectures or certifications of that really doesn't impact because if you could imagine a scenario where you would do your three months you're all ready to go and if it's a year before you see your first relevant patient it's all gone. And so I think what we really need to say is how do we do this on the fly? And we've had some experience now in our program with some of our primary care physicians about 20% of them that really want to take ownership of returning that result. And so we've built for them very short in a directive sort of like the ACMG Act Sheets where it says okay if it's this result this is what it means this is what you do and here's the number to call if you have any additional questions. It's very directive, it's very clear, it's one page and it's accompanied with patient materials that they can hand off. They're getting very good at that and they like it. They enjoy being able to do that and the point that Carol was making earlier they have the relationship with that patient which is where I come in. I have to try and build that up and I don't know all the other contextual factors. So I think that type of point of care just in time with somebody that has at least a basic competence about how to read the map is ultimately where we're gonna end up going and over time that's gonna build a competent workforce. So it's like- I can't resist but to point out the time I went two hours out of my way because it turned out when I put a thing into the GPS it turned out to be two small towns that sounded close enough like and I didn't think that why am I going north when I should be going north? The Google Maps has as an analogy is certainly not perfect and we've all been- By the way, it had a medical outcome which is I finally arrived at my destination hours late. No place was open. I went to a pub for dinner and got food poisoning. Let me just come- Help. Yeah. Let me just come at Mark that I wouldn't expect your average primary care physician to get this certificate and then sit in their office and wait for a genetic patient to come to them. What I was thinking was more on the realm of a consult service which I think a couple of people have mentioned. So what if that person then became the consultant for their hospital when a genomic case came up? That might be a way of sort of addressing both of those needs. So we've had a couple of ABNs now as part of the City of Hope Inherited Cancer Virtual Program as an extender because it's pretty intensive actually when I got under the hood of it but they completed it and so they're helping us bridge some of the demand that we have because while we're still trying to hire genetic counselors it's still taking time to fill in that voice that this is an alternative. I could see this concept because we have our cardiomyopathy director. He, we've had numerous conversations so we've built a systematic relationship where he starts with it because nine times out of 10 the patient's affected when he comes in. So it's a very different conversation so we have this balance level. We have a structured way of ordering so we can know where the result is so that we can help with the FOB so if there's a positive or a VUS he then kicks it to the Genetics Clinic to help whether it's getting under the wheels of why is it a VUS or help initiating that cascade testing, et cetera. So if there's some level that clinicians like him that are physician champions in our system could be demonstrate. I think there's a real potential there. Great, so are you closing the session or am I? Well, I'd like to thank Mark for being such an excellent moderator. Thank you, Mark. And sorry that we went a few minutes over but I think it was worth it. We'll reconvene tomorrow morning at 8.30. There will be breakfast out here. It's starting at eight o'clock, 7.30. So get here early. All right, see you tomorrow. It'll all be gone. Yeah, that's right. If it was graduate students it would be all gone.