Conclusion

Genomics, as we now understand it, has, and will continue to have, a major role in health care as each of us carries roughly five to six mutations capable of causing significant disease. The major causes of death in the United States are now known to involve genetic influences. The full extent of those influences, including the interactions between genes and genes, and genes and environments, is not yet known. Increasingly, we are learning that genetic mutations influence both the development and expression of disease. We expect that as these influences and interactions become better known we will be able to more precisely understand disease development and expression and so better able to target and manage root causes and effects. Furthermore, as our knowledge increases, we are likely to learn that some traits, which cause disease in certain environments, confer protection against disease development in other environments. Such traits are likely to be similar to sickle cell trait in contributing to sickle cell disease in particular contexts but affording immunity to malaria in other contexts.

Identifying genetic influences and understanding what they mean in the context of a patient's other risk factors is further complicated by features of genetics and heritability that complicate clinicians' usual approaches to categorizing symptoms into candidate diagnoses. Unless or until clinicians' medical decision-making processes trigger suspicion that a genetics factor may be present and pursue a thorough testing of that genetics hypothesis, ''learning'' about advances in human genetics will not be fully integrated into daily practice, and patients will not realize the benefits of genomic medicine.

Medical education research shows that knowledge, skill, and motivation, while necessary to physician acceptance, are, nonetheless, insufficient to bring about performance change.[25] This is largely because the practice of medicine, while anchored in the basic sciences, is itself an applied science but importantly also a normative activity. In other words, it is not so much what the physician knows, can do, or wants to do as much as what the physician actually does to (and for) patients that is of primary importance. What physicians do in practice has implications for their ability to incorporate innovation into daily activities; those daily activities, and habits, give rise to experience that in turn is a powerful determinant of behavior. Medical problem-solving literature, for example, supports this contention, indicating that what physicians actually do in practice is more related to their previous clinical experience than to their fund of medical knowledge.[26] Further, experts have shown that by understanding what needs to be done, how it is to be done, with awareness of potential barriers to successful implementation, physician learners are primed to apply new knowledge (or technological innovation) to a particular problem. Integrating innovation into practice gives rise to a new experience and, ultimately, it is the new experience that gives rise to the potential for learning.

The nature of genetics poses particularly difficult challenges to integration into daily medical practice. Continuing medical education courses, as well as strategies for adopting innovation, often fail to attend to key elements of clinical experience, and in so doing fail to address key parts of an individual's learning process and the relationship between those parts. The end result is the failure of education to effect the desired performance change. In regard to adoption of genetics innovation, unless or until educators know more about clinicians' thinking habits, which are used to assimilate new knowledge, much new knowledge may go underutilized, and potential patient benefits go unrealized. Identifying features of clinical reasoning that promote and thwart accurate and efficient medical decision making about potential genetic involvement can inform the development of future genetics education as well as specific strategies for changing physician behavior. Acceptance can then keep pace with genomic innovation.

Getting Started With Dumbbells

Getting Started With Dumbbells

The use of dumbbells gives you a much more comprehensive strengthening effect because the workout engages your stabilizer muscles, in addition to the muscle you may be pin-pointing. Without all of the belts and artificial stabilizers of a machine, you also engage your core muscles, which are your body's natural stabilizers.

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