 All right, I think everybody can see the flashing lights and I know I assume that people are still likely signing on, but we have a very robust set of folks here. All right. Already we have a healthy participation. So I'm going to go ahead and get started. If that's okay with everybody and even if it's not okay. Okay. I know everybody is very busy. Welcome. Thank you so much for joining us. Dr Eric Green, the director after I briefly go over some logistics is going to give you the full welcome. But thanks for joining. Can you please go to the next slide William. This is, I just wanted to give you a quick overview of what we're going to go over. As you saw from the invite the bulk of the discussion is going to be this moderated portion that Wendy Chung and I will moderate and that'll come after Dr greens welcome and opening remarks. You can put the slides away now I'm just going to go over some logistics. So for those of you who don't know me I'm Ben Solomon I'm the clinical director of NHGRI and a pediatric geneticist myself. As you saw from the agenda side, I'm going to start then Dr Eric Green will again offer his formal welcome and set the stage for us. Before we do that I want to offer just a bit of introduction and a bit of discussion about the scope that I've gotten lots of questions when I've sent out emails about that particular topic. These meetings arose through some discussions about the state of clinical genetics and the genomics field. So, within that we want to focus primarily on physicians and what we're calling clinical laboratory geneticists who are board certified, or eligible through ABM GG type programs. This doesn't mean other areas aren't important it doesn't mean other areas don't have other similar or dissimilar issues but we don't want to try to boil the ocean. However, we would love to learn for example from our genetic counselor colleagues successes that they've had in, you know, in growing their workforce and adapting to changes in technology, and so on and so forth. And our overarching question if I could put it in a nutshell is how do we bring more people into the field, and how can we ensure that the field is vibrant and successful and diverse. So I'm going to leave it at that for now we'll go more into these topics and Dr Green will as well but I'm going to go over a few just logistics right now. As you can probably see this meeting is going to be recorded and will be made publicly available. If you can I know it's zoom can be tricky and sometimes annoying but if you can if you wouldn't mind putting your affiliation by your name if possible, or at least if you're making a point during the during the discussion. I want to mention where you're from it just so we can keep track of that we would love you guys have already done a great job with this but we'd love for folks to keep their cameras on, if at all possible. As you can see the end thank you I see people lighting up there. As you can see the chat is enabled so you'll be able to to chat. I'm hoping that we can encourage folks to have the primary discussion be on the in the verbal part. And if you really need to make a point in chat you can but we are going to attempt not to have to totally separate I guess meetings going in place one in chat, and one in the verbal discussion. And we do have we're happy to be joined by Lucia hindorf that can specifically if for example those questions saying hey NHGRI should fund this or that or something she can say actually you know there is an NHGRI opportunity and here's the name of it so she's our expertise in that area. Thank you. When we get to the moderate discussion section is those four questions that myself and Deb and Shamita and Wendy are the co moderators put together is kind of a set of questions to talk about, but this is not meant to be a prescriptive script you know we can take this in other directions if you think it's if it's important, we can cover one item but not all that's totally fine this is this is a meeting for everybody, not just for what we want to hear or talk about. We have a great group of people we have a lot of people here so there are two other sessions that will cover the exact same topics later in the summer so we have one August 2 and one August 29 if you want to join those you don't have to you know we're very happy you're here at the first one, but there'll be two others that you can join if you would like, or if for example you haven't been able to get a point across in this in this meeting. I guess the last thing I'll say is that this is the first of what hopefully will be a process and an ongoing set of discussions. Hopefully the zoom gods and goddesses will bless us and won't give us any it glitches but you know we may have those so please be patient and bear with us if they're technical or other challenges. And with that I want to turn it over to Dr Eric Green the the director of NHGRI for his welcome and opening remarks thank you. Thanks Ben and welcome all of you to this important discussion has been described focusing on the clinical genetics and genomics workforce. NHGRI always appreciate it we always appreciate when we try to convene brainstorming sessions and remarkably people come in force and we, we respect that convening ability but we also we appreciate it we have respected and we want to take full advantage of it so. So why are we here today. It's pretty clear on all of you appreciate the field of genetics and genomics is quickly changing. It's moving in the more clinical direction in very productive ways giving unprecedented opportunities in genomic medicine. You know we've seen rapid growth of genome sequencing capabilities in the clinical setting the analytical tools are getting better all the time new technologies are arriving including long read sequencing. Not to mention on the therapeutic side opportunities for genome editing and perhaps gene therapy. But all of these, of course, have great potential for implementation and we're obviously incredibly enthusiastic to see them reach their full potential. But at the same time, we recognize there's another challenges, including making sure we have a robust workforce and this is at a time. In the case of clinical laboratory genetics, for example, the industry consolidation is taking place in a breathtaking way artificial intelligence approaches are arriving and are going to have big effects. So we need to also consider the changing landscape in those areas as well. So, you know, we need to be honest and this is what started all of this is there just probably aren't enough clinically trained individuals going into, for example, medical genetics training programs. And meanwhile, many hospitals and clinics are having a hard time recruiting experts in those areas. This can also have secondary effects related to access and to equity. And at a time where certainly all of us and certainly NHGRI we want to see a broad distribution of this genomics expertise. So this prompted a number of discussions internally at first, in part because we have significant footprint in our training arena with respect to medical genetics and also laboratory genetics and genomics. And we're just trying to get a better handle on the barriers to having a stronger recruitment of individuals into these areas. And we want to specifically find out can NHGRI do anything to help. We know other organizations are working hard at this and we've invited those people and from representing the various professional societies that exist in this space to join these discussions. And I would like some of them are far ahead of us in some of these discussions and we don't want to step on any toes. All we want to know is are there things NHGRI can do going forward in partnership with other groups and others that we missed having a conversation with that would make some forward progress. And all of this of course has to have an eye not just on numbers, but it also it's going to be truly critical to think about diversity as well. And, and something that lines incredibly everything I just said aligns incredibly well with the current strategic vision the Institute is operating under that we published back in 2020 in nature. And like many parts of the strategic vision we are checking in to see with the community what they think are barriers, strategies, concrete actions that NHGRI could take to move the needle on these incredibly important areas. So that's the, that's the foundation I would also point out I see a lot of people on we only have an hour I'm going to get out of your way in one second. You know if you don't get a chance to speak we would also tell you please either join a future such session will have two more or email us and we'll have a lot of people up to hear from you. So I want to turn this back over to Ben and Wendy I will who are going to moderate the discussion I think all of you for joining. I think profoundly Ben and Wendy you're doing today I know there's a couple others who are joining to help co moderate in the future. But a special thanks to Wendy because I know she's in the midst of a major professional transition and has a lot on her plate in her new chair role and so thank you Wendy I know you're very passionate about this topic, which is one of the reasons why I had been contact you to have you help us. So I'll turn it over to the two of you. Great thank you so much Eric. Wendy what I thought we could do is just show the questions really quick and then we can moderate I can take notes or whatever and you can leave the discussion but William would you mind would you mind just refreshing everybody's memory by showing those slides real quick. There we go. Hopefully everybody can see this it's a little fuzzy for me but I can see it. But these are the questions that Wendy and Deb and I came up with after discussions with folks for example from the ABM GG and ACMG and ASHG and APHMG and other initials that I'm probably forgetting after some of those discussions but again I want to emphasize we don't have to stick with these we could go in other directions that you feel would be most valuable to this we can probably Wendy is it okay to pull these down you should have these in your email just in case. Yep. And then what we're going to do is use the raise hand feature so for those of you if you go under reactions there's a raise hand feature that'll allow us it'll put you up in queue in order and that just allows us to see who's got questions or it's hard to see everyone across the panel. So it's been said so. Thanks Eric by the way I think it's important to for a field that is changing so rapidly to continue checking in even though the strategic plan was well thought out. I think it's always helpful to be able to get real time feedback so in thinking about this if no one else has any comments I'll start the discussion but what are the key barriers to growth and evolution of the genetics workforce and how can we overcome them and I guess when I think to myself about areas of medicine that are under evolution. I actually can't think of an area that's under more growth or more evolution than our field is and I have to say it's somewhat sad to me that there aren't more people that are excited about coming into the field given these what I think of as opportunities and so in thinking about this I'd be curious to think about what people think why that is and you know in identifying what those barriers are how what solutions can we come up with. Robert do you want to go first. So I have asked a lot of people about this and about what drives them to come in. I also have my personal experience that I think illustrates it. I've been a geneticist for a long time but when I chose to go into genetics, I got an offer to for a job in pediatrics at the same time that I applied for my fellowship and I opted to take the fellowship, and that cost me a lot of money. And it took 10 years for me to get the salary to the salary level that I had been offered as a general pediatrician. And that gap still exists. We make less money than a primary care physician, but we do an extra two years of training. There's nothing about that if we want people to opt for our field. There are lots of residents and and medical students with an interest in genetics, but you have to be able to compete financially for it to make sense for people to make that commitment. So I'm going to summarize Robert, it's money and the way to overcome that is to pay more. Is that is that what you're suggesting. Yes. Well, and part of that is that geneticists lose money because of the way the billing regulations are structured. We can't break even or we rarely break even. Okay, that also is a barrier. Okay, great suggestion. I'm going to move on Natalie. Thank you. My name is Natalie Glant. I'm a clinician educator geneticist and metabolic geneticist out of UC Irvine have been in practice about 10 years. And I also think of what it boils down to is money, but I think about it in several different ways. And this is something I've thought about for a very long time. In Southern California, we probably need three fold the number of geneticists that we have, particularly metabolic. But although we have the clinical demand. We have the funding in place as a whole community to be able to create those positions. One barrier I think of with zero solutions offered is as long as we're in this state where the more patients we see the more money is lost for an organization. And we need to expand the way that other specialties do. And because we don't have many jobs in many geographical areas. Very talented students who might be fascinated by our field they see that there are these online forums student doctor network others that not only the salary itself but when it comes to how many jobs are available and how many areas what are people doing. That's one barrier. Another is absolutely salary. I've encountered some, you know, most recruitable trainees in the past who had to make a decision where they went because they needed to know if they could buy a house for their family in the future. So, you know, salary weighs in, but a major development in the past 1020 years plus is medical student debt. And I would say that that speaks to especially barriers to recruiting a diverse workforce because that affects different communities differently. And that's a lower hanging fruit that I see if there were groups that could get together to increase the number of opportunities for debt repayment or debt forgiveness. Okay, so loan repayment from to NIH. Lucia may want to put something in the chat about that those are great points. Natalie. So, I understand now thinking about the administration of care especially your point in terms of more patients seeing more money lost. I'm going to keep things moving Nina. Do you want to go next. Yeah, great. Hi everybody. I'm Nina gold. I work at Mass General Hospital in Boston and I do pediatric genetics and metabolism. And so one interesting thing I've encountered when doing our interviews is that when I ask our, you know, medical students interviewing in the combined program or pediatrics applicants in the categorical program. They often say that they love genetics since they were in high school or college this very long term interest that's a consistent theme. But when I talked to other friends who I did pediatrics residencies with or some of our OB residents, they found genetics or they found, you know, they were in Nina maybe it's just me but I'm losing you. We'll come back to you Nina price. Yeah, thank you so much I will I will be brief. My name is Bryce Mendelsohn I'm a medical geneticist at Kaiser Permanente Oakland Medical Center I tell people I do everything but cancer. So I just wanted to add just another thought I totally agree with what's been said already. I'm still most pediatric specialties other than I think NICU and cardiology earn less than pediatric primary care. So I think a lot of those problems apply to any pediatric specialty. What I wanted to add is, you know, there might be a way to kind of have a two for one, there may be ways to kind of allow current practicing geneticists to do more and get more done with with their day. And I know working at Kaiser, which has been a blessing for me. You know, there are many things in my private prior position. Things have slowed me down a lot like not having access to people's records due to limitations of the health record. You know, prior authorizations for genetic testing. You know, referrals that could have been answered in a short paragraph, but if they're only were a better way to communicate with the referring doctor. And those are challenges that we've been able to address in our closed medical system. And so I think that having being able to do more with the people you have not only helps with the current workforce, but it also makes it more attractive to enter the workforce because you can just be more effective. And some of the frustrations are can be reduced so easier said than done, but a thought. Okay, so Bryce, what I'm hearing is improving efficiencies in some way. I've also heard people say using other, whether they're scribes or chat GPT with our notes or but things that improve efficiency. Yeah, or even just as easy as educating people who refer to you a lot about common questions. You know, things like that can go a long way towards reducing the workload and letting you get more done for the people who need to be seen. Okay, great. Thank you. Maureen. Wendy. Sorry. Just once. Mimi Blitzer mentioned that she can't raise her hand. Zoom is not being nice to her, but at some point, well, we should just put her in our queue. Okay. After Maureen your next maybe go ahead Maureen. We can hear you now go ahead. Okay, I'm sorry. It's an issue with medical students not knowing that this is a patient care specialty. For those who have had a decent genetics course that that hopefully includes some clinical relatively relativity in their first year. There's nothing that carries it through in the next three years. The attendings on the wards have probably not had very much genetics and they certainly don't bring it into the discussion of patient care either inpatient or outpatient. And I think that's a major problem with people understanding what we do and how attractive a specialty it can be. Great point Maureen. I think Nina's endorsing this in the chat saying that oftentimes people aren't exposed to us until later in their careers later in their medical education as an elective if at all. And so not seeing that front and center maybe they don't even realize it's a possibility. I'll say that when I was teaching at Columbia I had the pleasure of being in the first year and the first semester actually and so we got it right in front of the students right away. The great points and to see what we actually do not that it's just not just a basic science Mimi wherever you are. I'm here so thank you. Good to see everybody agree with all the points that have been said so far and been involved with this for quite a while. I'm going to reiterate a couple I think one of them is the point that you were both just raising about losing that recruitment we need in medical school itself such that even for those of us who have strong genetics and genomics curriculum in the first year. It doesn't necessarily by the time they do the required rotations in their clinical years they don't have the role models necessary to move forward and their other attendings and other specialties certainly aren't giving that exposure unless we push very hard. So I think that's important. I think this is an opportunity to push the double AMC more about the relevance of this and integration and requirements in medical schools to do this. So I think that attending exposure is a challenge in the clinical years. And we have a recruitment loss there. The debt issue is already brought up and I thought I wanted to bring up one other point. ABMGG has data and we're looking and we're trying to get some support to do a deep dive into our data. We do have it over time. We do know that there are actually more residents going into the programs in the last six years. I wanted to have these kinds of data. I wanted to just comment on some discussions I've had with the medical school dean at one of the HVCU universities who said that their students don't have models of clinical geneticists. And that's one problem. The other is going back to salary. They come out with a significant amount of medical school debt. And one of the questions is, what are they going to earn in this career? Will they be able to survive and pay off their debts? And I think that's an issue we have to think of if we want to appropriately recruit more underrepresented individuals in Madison careers. I'm just going to make thanks, Mimi. Those are great points. I'll also, Stephen's got a point that in Europe we don't seem to have this problem, which is interesting. I didn't realize that. And then Catherine Highland is making the point that, and I have seen this with the foundational sciences getting cut back in the preclinical time. Even if we do get any FaceTime, it's getting cut back and which I actually find interesting. I get criticized in my course that I teach more than just the boards asks about. And so that that's the exciting stuff is the new stuff that hasn't hit the boards yet. So April, your next up, April Adams. So I, you know, this is, I think, a really, really important topic and I am a maternal fetal medicine and medical genetics and so kind of, I think reiterating some of the things about when people talk about salary discrepancy. Obviously that's a big deal in pediatric specialties, but that also applies to people who do maternal fetal medicine, REI, all the things that they want to be able to see genetics patients. Many departments will say you can do that, but we're not going to pay you to do it or we're going to pay you less or we won't offer you a position if that's what you want to do. That's what trainees are hearing right now. So we're having a hard time even saying to people, come do this specialty. I know you want to do reproductive genetics, but I don't know if you're going to get a job or you're not going to get the job that you want. And so I think including that those combined specialties and people who are doing other, you know, non-pediatric specialties in that picture because we don't have salary baselines. We don't really have an idea of what other people are doing or what their clinical mix is. And so a lot of that information is lacking and we don't have anything to come to our departments with. Can I just ask, so are you taking a price salary cut then to be more specialized? Is that what I'm hearing? So you either would have to take a salary cut or you will just, you know, have to do those kinds of things in your spare time. You have to kind of come up with time to see genetics patients. It's a very tricky thing to navigate in some of these combined situations. Even though it is a huge part of what we do, like for maternal fetal medicine, you know, we see a huge volume of genetics patients, maternal versus fetal versus, you know, family history, all of these things. It's a resource that people need, but because there's no numbers to show them, they don't realize they need to pay for it or include it as a line item in their budget, which is a big issue. And then the other thing I was going to add is just to add to the disparity issue. There is a really big, so academic medicine promotion. There's a lot of promotion disparities in academic departments. There's funding disparities is who gets funded for grants. And so a lot of those things when you're looking at genetics careers, which are very highly academic, a lot of the times of people who are from underrepresented groups oftentimes steer away from those jobs because of the environment and also that depth burden. So big pieces to consider. Great points. Thanks for making that. We're going to take two more comments and then we're going to go to the next question. Catherine. Hi, I'm a genetic counselor from UC Irvine. And I don't know how to do this, but if a pathway existed for me to become a medical geneticist in less than the what nine years that it would take to do all of that, I'd be interested. At this point in my career, it's too late to go and invest another decade in training, but I think I'm probably not alone. And if there's some way to build some kind of pathway towards that from people who already have clinical experience in genetics, obviously not trained as a medical geneticist but are interested in getting that training in some way. I had for a moment considered like nurse practitioner, but then I'd have to go to nursing school and go through all of that. So if there was some way to have a bridge. There would be others who would be interested and truly would understand the field and know what they're getting into and wouldn't then want to jump ship. Interesting point Catherine I have seen people go that career career route but not many so I understand the barriers. Hi, I'm from UNC Chapel Hill of being in genetics for 35 years. I agree with most of the things people have said three comments I want to make the first one is currently most institutions will only accept residents who are US citizens. I'm a great example of a foreign graduate who has done wonders with my own career and contributed to the society. I had a fellow who we took as a foreign graduate at VCU many many years ago he is an amazing department chair at Miami now so I think we really need and we want diversity is what I hear. So making some way to have these people accredited so the institutes pay for them, because if you take a foreign graduate the institutes do not get the dollars to pay for them. So that is number one. The second thing I think Mimi already alluded to but we all know that the combined peace genetics program is much more successful in recruiting candidates my own Institute lost four candidates in four years in a row. We have two other institutes because we have the approval but we don't have the funding to fund our combined peace genetics residency. So, you know they will come back to me as faculty I'm hoping but it's a great loss to my Institute. So that would be something, you know, kind of going to CMS and seeing how we can create these positions due to the need based issue. And a lot of my colleagues echoed. Yes, we need to make ourselves more seen by the medical students unfortunately most institutes are going to a new curriculum with barely any time for us to go in front of them. I mean we did first year for years and it was way too early, but it was still okay. One of the things we have done and I know a lot of schools do is have the special interest group of students where we take the time and you know give them lunches and talk to them. But that is not enough because it's not backed up with the compensation we need for these kids to say yes I love so so most of us in genetics are there because of passion not because of compensation, but the new millennial states cannot deal with that and so we need to work on that but thanks for having this it's great. Great points. So let's think about the future state. So if we think about what genetics is genetics genomics is going to be in the future. What is that and what are geneticists what are we going to be doing and I'll say within this that to put some other context. What I often see is that there are cardiologists that are doing some amount of genetics or oncologists that are doing some amount of genetics or when it comes to gene therapy. Hematologists are doing some for sickle cell disease so what is the future going to be and what is our role going to be in that Stephen did you have your hand up for this one. I wanted to be a little provocative to start this off and relay some conversations I've had with local genetic counselors. There is certainly a strain of argument that I have heard that what is the need for geneticists when you have counselors and you have genomic testing. And to quote hon Brenner and other sister good genomes are better. But this has been advocated by some of our counselors particularly coming in from cancer genetics. I with the idea that counselors are better equipped and Genesis handle a face to face interactions with patients and they don't need the geneticist because now they can order molecular tests. And so they don't see why we are persevering on the lack of geneticists and our manpower issues. So I think we need to think carefully about what the scope of our practice is going forward when we are pressured from one side by counselors and we're pressured on the other side by molecular testing and by AI. Do we have any answers Stephen. What are we going to do for getting squeezed. Is there something is there something some other value added we can bring I hope so. I hope so I think that I that this to me again it's a personal bias. I think that we need to. Even though we are trained clinically we also need to make sure that we are adept and up to date on on like our interpretation and genomics that's going to be key to our survival. Another thing I would say just to close out my comments are healthcare system likes what they heard from the counselors when they say this because they see this is a way to save me they are very much a you eat what you kill institution and they see that the counselors are making money and the geneticists who are toiling away and rare disease are losing money. So there that's another issue we have to address which both speaks to what our scope should be going for if it also how do we attract more people into genetics and how do we survive. Okay, Maria I'm going to call on you next you haven't said anything yet. Okay, are you able to hear me. Yeah, go ahead. So the future of genetics practice. I'm with Baylor Scott and white in Texas, and have been doing this almost 20 years and from a family practice background so I took kind of a roundabout route into clinical genetics, and we have very unique practice that is comprehensive. But it has evolved in the future of genetics is going to require that there are focused clinic clinicians and specialty and to what was said previously we need to really evolve a collaborative approach with other clinicians be that our maternal fetal medicine colleagues, cardiology neurology, pediatrics, historically has been the bulk of it, and those collaborative clinical models work and are self sustaining, only if institutions would incorporate downstream revenue, whether that's a genetic counselor that sees a cancer patient, or a clinician treating a Fabre patient and preventing readmissions from renal complications or whatever example you want to use a collaborative approach that's integrated throughout all the the medicine medical practices needs to be, I think part of our future as sustainable genetics practices are we are cognitive specialty primarily we're not going to make money on our own with procedures. But definitely the downstream revenue is substantial and we haven't got a handle on how to capture that, at least not in Texas. Okay, so what I'm hearing is this is core infrastructure to an organization effectively and so this is really adding value in total and so you should bear the cost across the organization is what I'm hearing. So I won't disagree with that. Phillip, I think you've got your hand up for the first time go ahead. Yeah, thank you for organizing this I think it's very helpful. I just wanted to comment on the comment that was made about testing and why do we need, you know, physicians if we can just test and everything and I, you know, I'm primarily a clinician and I think, you know, when you get excellent reports back you get panel reports back and you get tons of the US is and trying to sift through that. I think it's. I think medical geneticists this is what we're really trained for it's really, you know phenotyping and it's really looking at the patient, seeing what patient has and what testing we can do to help make a diagnosis for families and reports these days are better than you know genetic counselors are great, but you know also, you know, they're not, and I'm not being biased or anything in any way but you know there's a difference and you know physicians also have the medical background and can really, you know, think through, you know, malformation syndromes and things like that which is what we're trying to do so. I don't know I, I know that we're short, but I think there is a need for us to despite genetic testing. Then I'm going to let you be go ahead as a moderator. Yeah, no thanks I just want to call out as promised monitoring some of the comments I just want to call out I don't know Peter if you're if you want to talk a little more verbally about what you put in there about the scope creep and genomic based therapies I think it's a really interesting one and that's worth maybe discussing a little bit. You know, I think we see look at any pharmaceutical pipeline there are chaperone modules there's all kinds of therapies based on genomics yet. It doesn't feel like we're owning that space for their that conversation and I think that's another point if you think about where we are we have to move, not just being quoted diagnostic field but also one that does therapies and deliver those most of them have implications across disease specialties that they're treating. And you know whether danger being a small specialty is someone's going to feel that void and so how do we make sure that it's not you know cardiology is only just looking at the heart and we're not missing the neuro aspects of a particular disease and so I think that's something huge for a field to tackle head on over the next five 10 years. Now, honestly, Peter, I just want to emphasize that I think it's now I've been surprised at how many of my genetic colleagues for instance I dove in with VHL treatment when we had that available or a contraplasia but I was interested at how reluctant my colleagues have been. And you know to that point I mean I'm calling a spade a spade I have not been in but like the last year trying to look at how I can honestly revisit things that I haven't done since my training I don't know for. I guess I'm considered mid career I don't know I'll leave others to that judgment but like how do you kind of polish up and be that voice in your institution. Can you think about anyone what we can do about that. I mean is it just a matter of we need to do some at continuing education for our own. Practically and this is just what I'm trying to do is there's a huge void of enzyme replacement therapy in the Chicago land for adults no one's really doing it I haven't done it since Boston and I've been trying to work to kind of think about how do we put that play. I mean the financial aspects are you know can present challenges but even just you know helping to bring some of the more operational aspect and you know so that you can go to your organization with an R. That's a that's a big barrier there's a paper. Maybe 10 years ago that I think highlighted Emory and College of Wisconsin I think I was don't hold me to that but you know setting up an infusion center but these kind of practical things that kind of other places are trying to revisit these types of programs and their institutions you know could be potentially helpful. Robert you had a comment in the chat and I know you've been waiting a long time but this is my theme of diagnosis and audios and I think geneticists have to get away from that I think that diagnosis is really just the beginning is that what the point you were making. That is one of the points that I was making we've we dubbed ourselves here in Cincinnati as a interventional genetics a long time ago we're not talking just metabolics or gene therapy, but just syndrome management, you make a diagnosis. And there's a lot of syndromes that we have protocols for we should take responsibility for making sure that those things are done. That will help us one to update the protocols and keep them current and useful to it will make us more visibly useful. Three, it's more fun because you get to know the patients and the patients get to know you and establish relationships. I think it will be more helpful on all levels, and nobody is doing that right now. We actually looked at what do specialists do when we when they order get a genetic test back and have a diagnosis. We tried to use that we specifically tested cardiologists and neurologists. The cardiologists knew a surprising amount about what each gene did to the heart, but they completely ignored that there was a patient attached to that. The cardiologists ordered everything or nothing on each patient, but didn't change practice and didn't really understand what most of it meant other than the genetic counseling for heritability. Yeah, we can do better than that. And I especially think patients with multi systemic disease are the ones that we own so to speak. We're the ones that are willing and able to deal with that complexity. Paul, do you want to go ahead? You may have a unique perspective also thinking about the laboratory side. Yeah, thanks, Wendy. Paul Krushka here. I'm chief medical author at GDX and then I also volunteer at Children's National here in DC. Um, I think right now we are in a crisis just from my, my perspective nationally just looking at talking to all you guys on this call. For example, there's not a geneticist in the state of Mississippi right now that's practicing in, you know, take University of Mississippi. They have 142 beds there and they're NICU. There's no one there to really help out. And I see that in other places in the country. There is these gene deserts for the foreseeable future. I don't see us training enough geneticist to cover these areas. And I would just like to make the point ideas about extending our services. I think are important, whether this is telemedicine training, PAs, nurse practitioners. Working with other specialists, Rob Hopkins mentioned some of the issues with pediatric neurologists, I believe, and cardiologists in their understanding of genomics. I can say from the laboratory side, we are seeing more and more neurologists ordering big tests from from the commercial side. So one part, Dr. Green, one thing Dr. Green asks is what can NHGRI do is certainly helping educate other specialties because they're going to have to, they are picking up the load right now. The reality is they're jumping in because the lines are long to see a geneticist right now throughout the country. So I guess I would just, you know, my closing point is just how do we extend ourselves as clinical geneticists? Again, telemedicine, you know, there's a lot of, you know, creative ideas we could do. Okay, good. Important to address those disparities and access. I'm also seeing some comments in the chat about being able to be part of clinical trials. Part of this is having the infrastructure, the administrative support for these, the training for being able to do this. So again, possibilities for retraining our community, being able to share protocols for some of these rare diseases. And so I do say, see dissemination in terms of that some of this expertise. Maureen, is your hand still up from before? Did you have a new comment? No, I just had another comment. Yep, go ahead. I disagree with the earlier comment about genetic counselors. We're a large specialty. We have a huge amount of area to cover. Genetic counselors, there's things that they do much better than we do as clinical geneticists. There are things we do better than they do and there are things we do much better when we work together. And I don't see, I don't see ourselves as competing with genetic counselors. I see ourselves as cooperating with them. Also the comment about hospital costs. There were some studies a number of years ago and it may still be true that clinical geneticists cost the hospital some money, but they also contribute to a lot of the money that other departments can gain like radiology and pathology and a number and all of the other subspecialists. To whom we refer. And yet we're the ones who manage the overall who conduct the orchestra so to speak that the individual players play in. And we're really necessary for those hospital services. Yep, 100% I agree Maureen. We're going to keep moving the discussion along the next question is what strategies can we use to promote a diverse and growing workforce. And diversity we've heard a little bit about this in terms of the barriers we need to pay more we've got student loans we need to have exposure to the diverse group of learners anything else we need to do in terms of promoting diverse diversity in our workforce. We're doing anything that's discouraging people. So not to Wendy, not to raise I guess a controversial topic but just to mention something that was discussed at the APHM G meeting which was terrific I'll do an ad for that a couple months ago. But some of the barriers to requirements from other countries which are already mentioned but it is challenging to have a diverse workforce especially diverse workforce we do want to populate the whole world. When for our specialty the barriers are higher and I understand it's complicated with residency versus fellowship and so on and so forth, but it makes it challenging to bring folks from other countries and therefore send them back to other countries to serve the larger community, because of that. It's a repetition what I mentioned before which is specifically more loan repayment opportunities particularly targeted towards the clinical service or clinical geneticists, given that individuals from disadvantaged backgrounds or also diverse backgrounds there's a differential impact of medical debt and extent of it. Yeah, absolutely. All that we all had medical schools like NYU where you could just get a free education. All right, can you hear me okay. I think presence more of a presence again in medical school and other other postgraduate programs whether it's PAs or nurse practitioners as genetics being population health, and I think that needs to be highlighted more so by our specialty. Our patients already recognize that, you know that that. Many of the reference genomes are not the equitable, not equitably representative of many populations throughout the world that medical students also need to be aware that genetics is a preventive health specialty we are a population health specialty, and it's a public health. We're kind of a community hospital setting, not an academic, and I really hope that we get that more in front of the medical student that maybe thought genetics was more of a primary more of an academic specialty. I'm just going to call out John Belmont, you know, is thinking about how can we within rare disease groups basically think about how to standardize care, collect outcome data. John, I'm just going to, I'd love to talk about to you offline, I think as a community with rare diseases we 100% need to double down on that have standards of care and improve the value of what we're doing. And more importantly than that improve patient outcomes so we ought to be able to do that disseminate that make it easier on all of us who are cognitively overloaded. Yes, hi, thank you. One way of improving the knowledge is not only teaching medical students in the first year, but try to incorporate genetics and like, you know, when they're doing cardiology rotation maybe genetics lecture should be embedded in that part of the rotation or each specialty so it makes genetics less of a block at the beginning, but more throughout the curriculum I was talking to at Brown here with the core co director years ago that would be nice if we could do a little bit of a genetic at the end of you know cardiology block at the end of neurology block at you know somewhere along there. And then that way, the residents are the students actually at that time, know that genetics is actually embedded in every field. And that may bring on some who has more interest. Thanks. I'll say, I'll just share from the way I've done the medical curriculum we do it in the first year and fundamentals we have and we've done an inventory of our thread of genetics throughout the other organ systems and then we have a back to the classroom block in fourth year so they've done a little in pediatrics and OB and then they come back to it to learn the basic science and the clinical and putting it back together but I realize most people don't get that much airtime so to speak. Before you call Maria, what have you done to make that successful because I mean other than just being excellent at what you do but are there are there strategies that help medical schools incorporate some of the things you've been talking about into the curriculum. So I'll say 20 years ago someone asked me to redesign the genetics portion of the medical curriculum because it was two lectures on Down syndrome and cited genetics and I said that's great here's what I would do and they were they said okay then go to it and so it's been a lot a labor of love but in doing so was I find actually very reinvigorating and the students really love it I have to say that many of my students love it and go into genetics but they figure out the formula they can make more money as a cardiologist than a geneticist so they become a cardiac geneticist rather than a full time geneticist but. Thank you anyway. And message me again saying that she can't raise her hand but has another comment. Go ahead Mimi. Sorry, can't just can't do it today. So, I just wanted to echo Wendy just for a second that we have done the same thing here about 2022 years ago and same thing happened and one of our geneticists said oh I'll help with that and did it as a labor of love we went with transition to a new curriculum in 2020. And sort of front loaded but we have now a person who's actually a genetics thread throughout all four years and got that appointed, which helps but it's a lot of work, it takes time and you need support for the teaching which many of you on this call now. And the other comment I wanted to make was looking out there for some examples of about diversity which I think was the question that then you mentioned or word or Wendy. The American Board of Emergency Medicine, although it's relatively popular specialty until coven is very, very much looking into it and they had the funds, which is when they're talking about opportunities to bring in invite through an application process, a group of about a group of students from who are underrepresented to come and spend two weeks with a sort of an immersion process in the city where their board is but I could see this and I energy or I or somewhere where they come in and they shadow the clinical and the research and the whole opportunity but really targeted in this it's been very, they've done it for two years so far, it's become extremely competitive already but they support them completely to come and do this. And it looks like it's been a very positive. I'm going to be on a panel with them next week so I'll be able to see their more close current data but it seems to me that's something that this group could consider. Thanks. That's great Maryam. Okay, we're going to move on to our final question in the last five minutes. After these virtual sessions you've heard a lot of great ideas. What do we actually do. We need to move this from discussion to action. So if you had one thing you could do. I know that NHGRI is lurking in the background so what would you want NHGRI or us to do as a community. Natalie pool and publish the results in a way that we can bring back to our organizations to help with advocacy to help explain the scope of our practice. The existing ACMG documents and others have been so instrumental in getting the type of support and explain that we do complex multi system management. And making these results generalizable. Okay, so what I'm hearing is administratively have someone really make the argument for what our value is and the economic sort of reasoning for supporting these types of programs. Yes. Okay, Robert. So I think that one way to do that, that would be fairly easy is to start getting groups of disorders and reporting on management outcomes, and the difference it makes, but to get a diagnosis early and manage it prospectively versus finding out as a teenager what you have and seeing how far behind you are. And that could be presented at ACMG or ASHG. And at least the geneticists would start to think in terms of wow I should be doing that. Okay. Robert that's true I'm going to argue that means earlier and earlier diagnosis. That's another. Absolutely. Perinatal diagnosis. Okay, less. I haven't heard from you yet go ahead. Well, I just wanted a pile on Belmont's comment I think that is a key observation the children's oncology group totally changed the specialty and the disease and thinking about a way and that could that's something that can be catalyzed in the course of our research dollars, ways to completely tackle a problem and provide infrastructure and objectives and goals and an organized program that can support and train and generate enthusiasm and results. And that's what we need. We, we live with this legacy of being called stamp collectors, and it's not good for us. We need to make kids better make patients survive longer live better lives and do it in a clear and dramatic way. And that's what COG did and I think it's a really good model. I'm going to step further and say my opinion about how I think we can do this, because I've been thinking a lot about this so we do have experts in domains there are many, many rare diseases but we could split them amongst ourselves figure out and come to consensus about what standards of care could be enough for us are on epic that you could think about pushing out these standards of care and being able to help improve compliance with that and even at the same time collect data to understand what the outcomes are. So maybe just to put a strong man out there's something like that we could do. Catherine, you're up. Thank you so I would say that in addition to these really important clinic changes and finances that we've been discussing I want to also come back to like the education component. And I think what we need to also focus on is educating non geneticist clinicians that was brought up much earlier, and clinical educators so that there is more buy in for genetics in the curriculum early on. Some of us have been pushing Afghan, you know, have been losing time in the curriculum and are not getting buy in from others and so therefore the students are getting the message that genetics is not as important in medicine as other fields. So I think, you know, some if we could do more education and have some keynote talks at, you know, cardiology meetings at neurology meetings that other at double AMC, you know, at lean certain learn serve lead meeting. That actually would be really key to have a key medical education meetings to have some really keynote talks about the importance of genetics and education. Peter, I don't mean to skip over you but I'm going to give the last word to Ben to wrap it up. Thanks and Peter we can email or please come to the next session so I'll be very quick here because I know everyone is busy Wendy thank you so much for doing such a wonderful job moderating. We heard a number of themes I'm died lots and lots of notes and this will be recorded so I'll take more notes themes around money and that ties to things like reimbursement loan repayment, including for clinicians etc etc. Systems improvements was another big theme. Third was how do we expose and educate and do a better job about that. You know, I think one thing we won't, we won't steal and call it the Belmont report but john Belmont gets credit for at least bringing up the idea and then Wendy and less extending on this of doing things like the technology group. It's three o'clock I'm going to leave it at that except mentioned that there will be two more sessions on August 2nd and August 29. We can go into these discussions afresh, or we can start in a new or different direction. Thank you so much for attending everybody and we really appreciate your enthusiasm and your engagement have a wonderful rest of your day. Bye bye. Thanks for doing this this was great. Thank you. Thank you.