By P. Roland. Bethany Bible College. 2018.
The purpose of the Summary resident s net worth statement is to take a snapshot of their Because of the need to simultaneously manage debt purchase mildronate 250 mg with mastercard pretreatment, create current fnancial position that will provide a starting-point cash fow and prepare for the future order mildronate 500mg fast delivery medications jaundice, professional fnancial for subsequent planning. Ideally, an application for a line of credit or an increase to a line of credit should be Case discussed beforehand with a fnancial planner. A resident who will be completing training in six months and their spouse, who is also in the last year of residency, The interest rate on unsecured loans offered to medical stu- don t have any children yet and live in a condominium dents and residents can be as low as the prime lending rate if owned by the resident s in-laws. Interest rates on secured lated $60,000 in debt (on a personal line of credit) during liabilities such as a car loans are usually higher, ranging from training and has $20,000 in student loans. Here, interest rates can vary from 16 to 24 per cent of the balance, depending on the Introduction client s credit rating. Paying down a credit card balance by using In 2007, the average debt of Canadian medical residents at a personal line of credit can save 11 to 19 per cent of the the end of training was reported as $158,728 (Kondro 2007). Indeed, given rising tuition costs, debt during medical training has become a necessary evil for most residents. However, not Pros and cons of student loan consolidation all debt is the same, and proper debt management can lower All physicians can claim a federal tax credit (15 per cent in overall interest payments and help to speed up repayment. Interest paid are: for any other indebtedness, such as bank loans or lines of Canada and provincial student loans, credit, are not eligible for this credit. However, residents who are carrying with federal and/or provincial student loan authorities. This a signifcant debt load and are faced with a limited cash fow debt tends to be relatively favourable in terms of after-tax rates may wonder about the relative merits of paying down their and repayment options. Several fnal decision may be a matter of personal preference and of Canadian provinces have therefore pioneered programs to risk tolerance. Learning how different fnancial management defer interest on the provincial portion of medical resident practises can best ft a residents personal level of comfort and loans. The interest rates on federal and provincial student loans may be as high as two or three percentage points above the prime Negotiating with fnancial institutions lending rate. However, the interest paid on these loans has been Residents can save precious time and avoid unnecessary frustra- claimable as a federal tax credit since 1998. Most provinces tion by working with a fnancer who is familiar with physicians provide such tax credits as well. In consolidating all debts to the bank, the resi- from terms that are more advantageous than those normally dents will forfeit both federal and provincial tax credits. A fnancial consultant can provide If the student loans stay outside of the loan consolida- their physician clients with some useful advice in preparation tion, the residents will realize an after-tax interest rate of for a meeting with a fnancial institution s account manager. A credit rating is based mainly on an individual s history of debt repayment, The fnancial planner gave three alternatives to the resi- his or her current fnancial position (assets and liabilities) and dents on their debt management process. Because banks often place more emphasis on current credit rating than on future income potential, it is Focus on savings: If they both purchase $13,000 of crucial to maintain an excellent credit rating. Because credit ratings are based on a seven-year cycle, any late interest payments or failures to pay bills will have a negative Focus on reducing debt: After four years of practice impact on an individual s credit rating for some time. A fnancial consultant can provide advice on maintaining a good credit Combine strategies: By combining these strategies, rating. Trainees should be approach their fnancial institutions to consolidate their proactive with their money by negotiating with fnancial loans into a line of credit or term loan. Through appropri- ratings, they can negotiate a line of credit at interest rates ate fnancial planning all residents can secure fnancial as low as the prime lending rate. Tax Tips for the Medical However, caution should be used when considering con- Student, Resident and Fellow. The bank offers the resident and spouse the prime rate of four per cent on a line of credit to consolidate their indebtedness including their student loans, on which they have been paying prime plus three per cent. The bank s offer seems to be attractive, but after a closer look, the actual after-tax savings would be approximately 1. Logan C, Director Disability Services, Homewood Employee Health: personal conversation Canadian Medical Association. In Creating a Healthy Culture in Medicine: a Report From the 2004 Quality Worklife Quality Healthcare Collaborative. College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Rich P. Global Business pdf and Economic Roundtable for Mental health College of Family Physicians of Canada, Canadian Medical 1-E. Promoting healthy partnerships in medical Intelligence: Key Readings on the Mayer and Salovey Model. Leadership in academic psychiatry: the vi- sion, the givens, and the nature of leaders. Balancing family and career: addressing the description of deans and students perceptions. Is that your pager or Stressful incidents, stress and coping strategies in the pre- mine: a survey of women academic family physicians in dual registration house offcer year. Inside/Outside: A Physician s Journey With Reading our way to more culturally appropriate care. Health problems and the use of health services among physicians: a review article with particular emphasis on 4-C. Physical activity and public health: Updated Faugier J, Lancaster J, Pickles D, Dobson K.
In this patient the diagnosis of asthma was confirmed with an exercise test which was associated with a 25 per cent drop in peak flow after completion of 6 min vigorous exer- cise buy discount mildronate 250mg line treatment 360. Alternatives would have been another non-specific challenge such as methacholine or histamine generic mildronate 500mg online medicine 257, or a therapeutic trial of inhaled steroids. After the exercise test, an inhaled steroid was given and the cough settled after 1 week. The inhaled steroid was discontinued after 4 weeks and replaced by a $2-agonist to use before exercise. However, the cough recurred with more evident wheeze and shortness of breath, and treatment was changed back to an inhaled steroid with a $2-agonist as needed. If control was not established, the next step would be to check inhaler technique and treatment adherence and to consider adding a long-acting $2-agonist. In some cases, the persistent dry cough associated with asthma may require more vigorous treatment than this. Inhaled steroids for a month or more, or even a 2-week course of oral steroids may be needed to relieve the cough. The successful management of dry cough relies on establishing the correct diagnosis and treating it vigorously. Twenty-four hours previously she developed a continuous pain in the upper abdomen which has become progressively more severe. Her past medical history is notable for a duodenal ulcer which was successfully treated with Helicobacter eradication therapy 5 years earlier. She smokes 15 cigarettes a day, and shares a bottle of wine each evening with her husband. She is tender in the right upper quadrant and epigastrium, with guarding and rebound tenderness. Cholecystitis is most common in obese, middle-aged women, and classically is triggered by eating a fatty meal. Continued secretion by the gallbladder leads to increased pressure and inflammation of the gallbladder wall. Ischaemia in the distended gallbladder can lead to perforation causing either generalized peritonitis or formation of a localized abscess. Alternatively the stone can spontaneously disimpact and the symptoms spontan- eously improve. Gallstones can get stuck in the common bile duct leading to cholangitis or pancreatitis. Rarely, gallstones can perforate through the inflamed gallbladder wall into the small intestine and cause intestinal obstruction (gallstone ileus). The typical symptom is of sudden-onset right upper quadrant abdominal pain which radiates into the back. There is usually guarding and rebound tenderness in the right upper quadrant (Murphy s sign). If the serum bilirubin and liver enzymes are very deranged, acute cholangitis due to a stone in the common bile duct should be suspected. The abdominal X-ray is normal; the major- ity of gallstones are radiolucent and do not show on plain films. Chest X-ray should be per- formed to exclude pneumonia, and erect abdominal X-ray to rule out air under the diaphragm which occurs with a perforated peptic ulcer. The patient should be kept nil by mouth, given intravenous fluids and commenced on intravenous cephalosporins and metronidazole. The patient should be examined regularly for signs of generalized peritonitis or cholangi- tis. If the symptoms settle down the patient is normally discharged to be readmitted in a few weeks once the inflammation has settled down to have a cholecystectomy. Her appetite is unchanged and normal, she has no nausea or vomiting, but over the last 2 months she has had an altered bowel habit with constipation alternating with her usual and normal pattern. She has smoked 20 cigarettes daily for 48 years and drinks 20 28 units of alcohol a week. A barium enema revealed a neoplasm in the sigmoid colon, con- firmed by colonoscopy and biopsy. Chest X-ray and abdominal ultrasound showed no pul- monary metastases and no intra-abdominal lymphadenopathy or hepatic metastases respectively. She proceeded to a sigmoid colectomy and end-to-end anastamosis, and was regularly followed-up for any evidence of recurrence. Rectal bleeding, alteration in bowel habit for longer than 1 month at any age, or iron-deficient anaemia in men or postmenopausal women are indi- cations for investigation of the gastrointestinal tract. During the last 3 months he has had intermit- tent nausea, especially in the mornings, and in the last 3 months the morning nausea has been accompanied by vomiting on several occasions. From the age of 18 he has smoked 5 6 cigarettes daily and drunk 15 20 units of alcohol per week. He has been a chef all his working life, without exception in fashionable restaurants. The cause is likely to be alcohol as it is a common cause of this problem, he is at increased risk through his work in the catering business. However his alcohol intake is too low to be consistent with the diagnosis of alcoholic liver disease. When the provisional diagnosis is discussed with him though, he eventually admits that his alcohol intake has been at least 40 50 units per week for the last 20 years and has increased further during the last year after his marriage had ended, the reason for this being his drinking.
If the D-dimer is normal no further investigation is r Secondary varicose veins develop after valve function required discount mildronate 500mg online treatment bulging disc. The valves in the perforating Management veins are disrupted generic 250mg mildronate fast delivery symptoms of ebola, so that blood reuxes from the Bedrestandcompressionstockings;patientswithabove- deep veins to the supercial veins. These changes are referred to as lipodermatoscle- patients with a large iliofemoral thrombosis. There may be a family history or his- on examination there may be one or more visible cord- tory of previous deep vein thrombosis. The supercial veins are prone Complications to thrombus formation due to stasis, causing tender, If there is a portal of entry, e. Investigations The site of the incompetent valve can be identied by the Investigations TrendelenbergtourniquettestorbyDopplerultrasound. No investigations are necessary, except to diagnose un- derlying deep venous insufciency. Management Elderly patients are managed conservatively with weight reduction, regular exercise and avoidance of constricting Management garments. Sclerotherapy and laser therapy can be used The condition usually responds to symptomatic treat- for small varices, but only surgery is effective if there ment with rest, elevation of the limb and non-steroidal is deeper valve incompetence. After the acute attack, treatment of underlying r To interrupt incompetent connections between deep chronic venous insufciency may be necessary, scle- and supercial veins. The sapheno-femoral junction rotherapy or laser therapy may be used as treatment for is visualised and the saphenous vein is ligated and varicose veins. Denition Ulceration of the gaiter area (lower leg and ankle) due to venous disease. Supercial thrombophlebitis Denition Incidence Inammation of veins combined with clot formation. Aetiology/pathophysiology r Thrombophlebitis arising in a previously normal vein Age may result from trauma, irritation from intravenous Increases with age. Aggravating factors include old age, obesity, re- current trauma, immobility and joint problems. Aetiology The aetiology of most congenital heart disease is un- Pathophysiology known, and associations are as follows: r Genetic factors: Down, Turner, Marfan syndromes. Chronic venous ulceration is the last stage of lipo- r Environmental factors: Teratogenic effects of drugs dermatosclerosis(the skin changes of oedema, brosis around veins and eczema, which occurs in venous sta- and alcohol. Pathophysiology Clinical features Normally in postnatal life the right ventricle pumps de- Distinguishable from arterial ulcers by clinical features oxygenated blood to lungs and the left ventricle pumps and a history of chronic venous insufciency (see Table oxygenatedbloodatsystemicbloodpressuretotheaorta, 2. Investigations Congenital heart lesions can be considered according Phlebography is performed to assess the underlying state to one or more of of the veins. Blood from the left side of the heart is re- Management turned to the lungs instead of going to the systemic Healing often takes weeks, possibly months. Skin grafts may speed healing, but only if venous pres- Clinically lesions can be divided into two categories: sure is reduced, e. Surgery to remove r Acyanotic heart disease, which include the left to right incompetent veins before ulceration occurs. Denition Prevalence Abnormal defect in the ventricular septum allowing pas- Up to 1% of live born infants are affected by some form sage of blood ow between the ventricles. Eventually M = F these changes become irreversible and pulmonary hy- pertension develops, usually during childhood. The re- sultant high pressure in the right side of the heart causes Aetiology areductionand eventual reversal of the shunt with as- In most cases the aetiology is unknown but may include sociated development of cyanosis termed Eisenmenger maternal alcohol abuse. On ex- r Small defects result in little blood crossing to the right amination there is usually a pulmonary ejection mur- sideoftheheartandnohaemodynamiccompromise mur and there may be tachypnoea and tachycardia if maladie de Roger. The murmur is, however, causes a loud pulmonary component to the second quieter as there is less turbulent ow. Initially increased pulmonary blood ow does not cause arise in pressures within the pulmonary circulation Investigations due to the vascular compliance. If, however, there is a r Chest X-ray: Abnormalities are only seen with large defects when cardiomegaly and prominent pul- monary vasculature may be seen. Measurement of the size of the defect and the blood ow allows prediction of the outcome. The shunting of blood from left to right increases the volume of blood passing through the right side of the Incidence heart leading to right ventricular volume overload and 10% of congenital heart defects. Prolongedhigh volume blood ow through lungs can occasionally lead Sex to pulmonary hypertension due to changes in the pul- F > M monary vasculature similar to ventricular septal defects (see page 84). Aetiology Defects in the ostium primum occur in patients with Clinical features Down syndrome often as part of an atrioventricular sep- Atrialseptaldefectsareoftenasymptomaticinchildhood tal defect. On examination Pathophysiology there is a xed widely split second heart sound due to the The atrial septum is embryologically made up of two high volumes owing through the right side of the heart parts: the ostium primum and the ostium secundum, and the equalisation of right and left pressures during which forms a ap over the defect in the ostium pri- respiration. A diastolic murmur may through the fossa ovalis and hence shunts blood away also occur due to ow across the tricuspid valve. In normal individuals Rarely patients may present with paradoxical emboli at birth the vasculature within the lungs dilate at birth (where thrombus from a deep vein thrombosis crosses and hence the right heart pressures fall. Once the left the atrial septal defect and causes stroke or peripheral atrial pressure exceeds the right, the ostium secundum arterial occlusion). Eighty per cent of cases occur in association with a Management bicuspid aortic valve. The defect may be closed using an umbrella-shaped Clinical features occluder placed at cardiac catheterisation. Traditional Proximal hypertension may cause headache and dizzi- open surgical repair requires cardiopulmonary bypass ness, distal hypotension results in weakness and poor pe- and may use a pericardial or Dacron patch to close the ripheral circulation. Surgicalinterventioninostiumprimumdefectsis are weak or absent and there is radiofemoral delay. Four- morecomplexduetoinvolvementoftheatrioventricular limb blood pressure measurement will demonstrate the valves.
The condition does not often cause and chordal rupture may require emergency valve re- signicant regurgitation mildronate 500mg on line treatment with cold medical term. Mitral valve prolase Denition Complications Prolapsing mitral valve is a condition in which the valve Rupture of one of the chordae may occur leading to se- cusps prolapse into the left atrium during systole discount mildronate 250 mg with amex medications education plans. A particular form of supraventricular tachycardia and complex ventricular prolapse may result from myxomatous degeneration of ectopy may occur. Echocardiography reveals prolapsing mitral valve in 5% r Echocardiography shows the mid-systolic bulging of of the normal population; however, not all are clinically signicant, especially in the absence of any mitral in- the valve leaets. There is an Denition opening snap after S2 caused by the stiff mitral valve, An abnormal narrowing of the mitral valve. If the Incidence patient is in sinus rhythm there is a pre-systolic increase Declining in the Western world due to the decline of in the volume of the murmur due to increased ow dur- rheumatic fever. Pulmonary hypertension may re- sult in pulmonary regurgitation with an early-diastolic Sex murmur (Graham Steell murmur). The pathological process of rheumatic fever results in brous scarring and fusion of the valve cusps with cal- Investigations cium deposition. The valve becomes stiff, failing to open r Chest X-ray shows selective enlargement of the left fully. When the normal opening of 5 cm2 is reduced to1 atrium (bulge on the left heart border). The pressure within the within the mitral valve may be visible and there may left atrium rises and left atrial hypertrophy occurs. Signs of right ventricular hyper- falls with little increase possible on exertion. The condition is asymptomatic until the valve is nar- r Echocardiography is diagnostic showing the narrow- rowedbyaround 50%. Doppler studies can to pulmonary venous hypertension and the resultant assess the degree of stenosis and any concomitant mi- oedema, with dyspnoea, orthopnoea and paroxysmal tral regurgitation. A cough productive of r Cardiac catheterisation is used if Doppler is inconclu- frothy,blood-tingedsputummayoccur(frankhaemopt- sive and to assess for coronary artery disease if valve ysisisrare). On examination the patient may have mitral facies (bi- Management lateral, dusky cyanotic discoloration of the face). In se- The course of mitral stenosis is gradual with interven- vere mitral stenosis atrial brillation is very common. Associatedatrialbrilla- The apex beat is tapping in nature due to a palpable rst tion is treated with digoxin and anticoagulation. Patients with refrac- On auscultation there is a high pitched early diastolic tory pulmonary venous congestion or pulmonary hy- murmur running from the aortic component of the sec- pertension are treated surgically by conservative surgery ond heart sound. This is a mid- diastolic rumbling murmur due to back ow of blood Aortic regurgitation during diastole causing a partial closure of the mitral valve. Denition Retrograde blood ow through the aortic valve from the aorta into the left ventricle during diastole. Investigations r Chest X-ray shows an enlarged left ventricle and pos- Aetiology/pathophysiology sibly dilation of the ascending aorta. This may result from: r Inability of the valve cusps to close properly due to mal valve movement. Doppler studies demonstrate thickening, shrinkage, perforation or a tear in the and quantify the regurgitation. Causes include rheumatic heart disease (now itor the clinical effect of the valve lesion is to measure rare in the United Kingdom), infective endocarditis the left ventricular dimension. An end systolic dimen- occurring on a previously damaged or bicuspid aor- sion of over 5 cm indicates decompensation. Causes include se- infective endocarditis should be administered when vere hypertension, dissecting aneurysm and Marfan s appropriate. It is only when volume overload is heart size or diminishing left ventricular function are excessive and chronic that the left ventricle fails. The indications for surgical intervention usually by valve rst sign of this decompensation is a reduction in the replacement. There is also reduced coronary artery perfusion with associated increased risk of myocardial ischaemia. Prognosis Mild or moderate aortic regurgitation has a relatively good prognosis and thus surgical intervention is not Clinical features required. However, it is important to perform surgical Aortic regurgitation is asymptomatic until left ventricu- correction before irreversible left ventricular failure lar failure develops. Onexamination there is a large volume pulse, which is collapsing in char- acter (see page 27). The blood pressure has a wide pulse Aortic stenosis pressure (high systolic and low diastolic pressure). Various signs of the high-velocity blood ow Aortic stenosis is a pathological narrowing of the aortic have been described but are rare. There is however turbulent r Echocardiography is diagnostic, often showing cusp ow across these valves, which become thickened and thickening and calcication. Severe stenosis may develop over a period of the degree of stenosis and can measure left ventricular 20 30 years. It may lead to thicken- r Treatment includes management of angina and car- ing and calcication of the aortic valve, which is often diac failure. This pres- r Severe stenosis (pressure gradient over 60 mmHg) or sure overload results in left ventricular hypertrophy and symptomatic stenosis are indications for surgery (see arelative ischaemia of the myocardium with associ- page 30). As the stenosis becomes more severe, re- but this is increased if coronary artery bypass is also duced coronary artery perfusion exacerbates myocardial required. Balloon valvuloplasty may be used in pa- ischaemia even if the coronary arteries are normal.
Half of these episodes result from complications of drug therapy; amazingly generic 250mg mildronate mastercard medications names, one in ten comes from diagnostic procedures order mildronate 500 mg visa medicine 018. No wonder that the health industry tries to shift the blame for the damage caused onto the victim, and that the dope-sheet of a multinational pharmaceutical concern tells its readers that "iatrogenic disease is almost always of neurotic origin. Such attempts to avoid litigation and prosecution may now do more damage than any other iatrogenic stimulus. On the one hand defectives survive in increasing numbers and are fit only for life under institutional care, while on the other hand, medically certified symptoms exempt people from industrial work and thereby remove them from the scene of political struggle to reshape the society that has made them sick. Second-level iatrogenesis finds its expression in various symptoms of social overmedicalization that amount to what I shall call the expropriation of health. The patient in the grip of contemporary medicine is but one instance of mankind in the grip of its pernicious techniques. It occurs when people accept health management designed on the engineering model, when they conspire in an attempt to produce, as if it were a commodity, something called "better health. This ultimate evil of medical "progress" must be clearly distinguished from both clinical and social iatrogenesis. I hope to show that on each of its three levels iatrogenesis has become medically irreversible: a feature built right into the medical endeavor. The unwanted physiological, social, and psychological by-products of diagnostic and therapeutic progress have become resistant to medical remedies. Technical and managerial measures taken on any level to avoid damaging the patient by his treatment tend to engender a self-reinforcing iatrogenic loop analogous to the escalating destruction generated by the polluting procedures used as antipollution devices. For them, nemesis represented divine vengeance visited upon mortals who infringe on those prerogatives the gods enviously guard for themselves. Nemesis was the inevitable punishment for attempts to be a hero rather than a human being. I believe that the reversal of nemesis can come only from within man and not from yet another managed (heteronomous) source depending once again on presumptious expertise and subsequent mystification. My final chapter proposes guidelines for stemming medical nemesis and provides criteria by which the medical enterprise can be kept within healthy bounds. I do not suggest any specific forms of health care or sick-care, and I do not advocate any new medical philosophy any more than I recommend remedies for medical technique, doctrine, or organization. However, I do propose an alternative approach to the use of medical organization and technology together with the allied bureaucracies and illusions. It fostered the tendency of wounds to heal, of blood to clot, and of bacteria to be overcome by natural immunity. Grafts involve the outright obliteration of genetically programmed immunological defenses. Social Iatrogenesis Medicine undermines health not only through direct aggression against individuals but also through the impact of its social organization on the total milieu. Social iatrogenesis designates a category of etiology that encompasses many forms. Medical Monopoly Like its clinical counterpart, social iatrogenesis can escalate from an adventitious feature into an inherent characteristic of the medical system. When the intensity7 of biomedical intervention crosses a critical threshold, clinical iatrogenesis turns from error, accident, or fault into an incurable perversion of medical practice. In the same way, when professional autonomy degenerates into a radical monopoly8 and people are rendered impotent to cope with their milieu, social iatrogenesis becomes the main product of the medical organization. A radical monopoly goes deeper than that of any one corporation or any one government. When cities are built around vehicles, they devalue human feet; when schools pre-empt learning, they devalue the autodidact; when hospitals draft all those who are in critical condition, they impose on society a new form of dying. Ordinary monopolies corner the market;9 radical monopolies disable people from doing or making things on their own. They impose a society-wide substitution of commodities for use-values by reshaping the milieu and by "appropriating" those of its general characteristics which have enabled people so far to cope on their own. The malignant spread of medicine has comparable results: it turns mutual care and self-medication into misdemeanors or felonies. Just as clinical iatrogenesis becomes medically incurable when it reaches a critical intensity and then can be reversed only by a decline of the enterprise, so can social iatrogenesis be reversed only by political action that retrenches professional dominance. Iatrogenic medicine reinforces a morbid society in which social control of the population by the medical system turns into a principal economic activity. People who are angered, sickened, and impaired by their industrial labor and leisure can escape only into a life under medical supervision and are thereby seduced or disqualified from political struggle for a healthier world. If it were recognized that diagnosis often serves as a means of turning political complaints against the stress of growth into demands for more therapies that are just more of its costly and stressful outputs, the industrial system would lose one of its major defenses. The issue of social iatrogenesis is often confused with the diagnostic authority of the healer. To defuse the issue and to protect their reputation, some physicians insist on the obvious: namely, that medicine cannot be practiced without the iatrogenic creation of disease. He is a moral entrepreneur,27 charged with inquisitorial powers to discover certain wrongs to be righted. In primitive societies it is obvious that in the exercise of medical skill, the recognition of moral power is implied. Nobody would summon the medicine man unless he conceded to him the skill of discerning evil spirits from good ones. Here medicine is exercised by full-time specialists who control large populations by means of bureaucratic institutions. Unlike guilds, which determine only who shall work and how, they determine also what work shall be done. In the United States the medical profession owes this supreme authority to a reform of the medical schools just before World War I.
Some in the life sciences community are calling for the launch of a wide-ranging new program to use molecular and systems approaches to build a new taxonomy of human diseases 500mg mildronate with amex administering medications 6th edition. Embarking on such a program would require that existing data linking molecular cheap 250mg mildronate with amex treatment variance, environmental, and experiential factors to disease states be surveyed and compiled, and that gaps in these data be identified and priorities set and acted upon to fill these gaps. Criteria must also be established for providing or denying access to and interpretation of data. And the many ethical considerations surrounding such a program would need to be addressed. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease Each of these areas is technically complex. Undertaking such a program would clearly require the participation and collaboration of many government and private entities over a considerable period of time. To ensure that progress is being made, goals and milestones against which program success can be measured would need to be developed. The Committee would leverage the expertise of additional scientists, clinicians, and others by holding a large (approximately 100 participants) workshop to obtain ideas from the broader scientific and medical communities. Desmond-Hellmann previously served as president of product development at Genentech, a position she held from March 2004 through April 30, 2009. In this role, she was responsible for Genentech s pre-clinical and clinical development, process research and development, business development and product portfolio management. She also served as a member of Genentech s executive Committee, beginning in 1996. She joined Genentech in 1995 as a clinical scientist, and she was named chief medical officer in 1996. In 1999, she was named executive vice president of development and product operations. She holds a bachelor of science degree in pre-medicine and a medical degree from the University of Nevada, Reno, and a master s degree in public health from the University of California, Berkeley. Prior to joining Genentech, Desmond-Hellmann was associate director of clinical cancer research at Bristol-Myers Squibb Pharmaceutical Research Institute. While at Bristol-Myers Squibb, she was the project team leader for the cancer-fighting drug Taxol. She also spent two years in private practice as a medical oncologist before returning to clinical research. In January 2009, Desmond-Hellmann joined the Federal Reserve Bank of San Francisco s Economic Advisory Council for a three-year term. In July 2008, she was appointed to the California Academy of Sciences board of trustees. Desmond-Hellmann was named to the Biotech Hall of Fame in 2007 and as the Healthcare Businesswomen s Association Woman of the Year for 2006. She was listed among Fortune magazine s top 50 most powerful women in business in 2001 and from 2003 to 2008. In 2005 and 2006, the Wall Street Journal listed Desmond-Hellmann as one of its women to watch. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 84 served a three-year term as a member of the American Association for Cancer Research board of directors, and from 2001 to 2009, she served on the executive Committee of the board of directors of the Biotechnology Industry Organization. Sawyers laboratory is currently focused on characterizing signal transduction pathway abnormalities in prostate cancer, with an eye toward translational implications. Sawyers work in prostate cancer has defined critical signaling pathways for disease initiation and progression through studies in mouse models and humane tissues. Sawyers is past President of the American Society of Clinical Investigation and served on the National Cancer Institute s Board of Scientific Councilors. He has won numerous honors and awards, including: the Richard and Hinda Rosenthal Foundation Award; the Dorothy Landon Prize from the American Association of Cancer Research and the David A. Karnofsky Award from the American Society of Clinical Oncology; and the 2009 Lasker DeBakey Clinical Medical Research Award. He is a member of the Institute of Medicine and in 2010 was elected to the National Academy of Sciences. David is a co-founder of Perlegen, and was most recently Chief Scientific Officer of the company since its formation in 2000. David was Professor of Genetics and Pediatrics at the Stanford University School of Medicine as well as the co-director of the Stanford Genome Center. He completed a Pediatric Residency at the Yale-New Haven Hospital in New Haven, Connecticut and was a Fellow in both genetics and pediatrics at the University of California, San Francisco. David is certified by the American Board of Pediatrics and the American Board of Medical Genetics. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease of the Human Genome Project while carrying out research involving the molecular basis of human genetic disease. He has authored over 100 peer- reviewed scientific publications and has served on numerous editorial boards. Cox s honors include election to the Institute of Medicine of the National Academy of Sciences. Fraser-Liggett is Director of the Institute for Genome Sciences and a Professor of Medicine at the University Of Maryland School Of Medicine in Baltimore, Maryland. Previously she was the President and Director of The Institute for Genomic Research in Rockville, Maryland. She led the teams that sequenced the genomes of several microbial organisms, including important human and animal pathogens, and as a consequence helped to initiate the era of comparative genomics. She has served on a number of National Research Council Committees on counter-bioterrorism, domestic animal genomics, polar biology, and metagenomics. Fraser-Liggett has more than 220 scientific publications, and has served on Committees of the National Science Foundation, Department of Energy and National Institutes of Health.