Genetic Counseling (How to Approach the Unknown)

Preston: [00:00:00] Okay. So welcome Julia. Before we formally introduce you, you have, you've been invited to our icebreaker conversations. You'll be joining us for this. Okay. So the question is, if you could find out what year you 

Margaret: were going to die, would you want to know and why? That's a good question. I'll go. I'll go first to save you from going first.

Um, I would not want to know. I think I feel like I would have just anxiety leading up to it and I already have enough existential anxiety, but I think I reminds me to live in my purpose that knowing would just make me be in grief all the time. So I wouldn't buy myself. I want to be taken from the mortal plane.

Unbeknownst to myself. So 

Preston: that's 

Margaret: my answer. 

Preston: So you don't think you'd be able to overcome that grief. 

Margaret: I think that I already live in an existentially informed way. I think any further knowledge won't help me. [00:01:00] 

Preston: Yeah, like death comes for us all. So yeah, like it's also not like a date to it doesn't make a difference for you.

Margaret: No, and it's not a preventable death. I presume so. 

Preston: No, it's not. It's inevitable. Yeah. So I, I'm, 

Margaret: I'm good. 

Preston: Like any attempt to shirk your fate will just bring you closer to it. Right. And I think I would try to shi my fate an ending, 

Margaret: right? Nope. Nope. , I don't know that edible is used correctly in that term, 

Preston: but edible.

I know. Yeah. 'cause like EDUs tried really hard to avoid his fate and then ended up meeting it. Oh, 

Margaret: I thought you were saying edible in the psychiatric psychoanalytic. Oh 

Preston: no. Yeah. I was like, not that way in the, like, , I'm gonna try super hard and like, you know. Not kill anyone, you 

Margaret: know, 

Preston: all that, all that, like, not having sex with your mom and killing your dad kind of stuff.

And then, whoopsie. 

Julia Castro: Is it vodka? Is this, is this why you keep people out of the icebreakers normally? Yeah, this is weird. 

Preston: So I, I would want to know, I think. 

Margaret: You would? Explain. [00:02:00] Because I'm, 

Preston: I'm a planner and, 

Margaret: but how would you, what I, okay, continue. So, 

Preston: so let's say, let's say we ask this Oracle when I'm going to die and it says 2026, bro, I'm not finishing residency.

You know what I mean? Like I am taking out a loan and I'm going to spend my money. Like I, I think that like, as I plan a lot of things in my life, even whether it's next year is the next 10 years or the rest of the life, I want to adjust that to the timeline I have left. And, and as of right now, I'm anticipating living till I'm like, Mid eighties, early nineties.

And so everything I'm doing is kind of based off of that. 

Margaret: But if I found out average man, 

Preston: I am greater than the average. Oh, 

Margaret: okay. 

Preston: It's because I have 20 years 

Margaret: greater. It's because I 

Preston: have these cats and I read feminist literature. That's that's how I know I got a couple extra years. Name one book 

Margaret: of feminist literature you've read.

Preston: Um, stre. 

Margaret: You haven't read that ? I haven't read that. . You hear that listeners? 

Preston: Okay. Um, oh, Nancy Drew. [00:03:00] 

Margaret: That's not fa okay. It is, but that's not, it's not, it's a joke. Magic. Have you be house? Have you read bell hooks? 

Preston: What's that? 

Margaret: And there you, why? Why did 

Preston: you do an office stare at the. 

Margaret: That was for the ladies.

Okay, you should read I'll make you a reading list. We'll put it on the behind the paywall. We'll do a book club. You can have me read things I truly know nothing about. Any other facet of your life besides psychiatry? So 

Preston: okay We're gonna make 

Margaret: your feminist literature dreams come true 

Preston: I'll finish my answer and let you two go back to passing the bechdel test for this podcast.

Yeah, 

Margaret: we will we deserve that So you wouldn't you would want to know 

Preston: yeah because whether it's like if i'm gonna die when i'm 40 or i'm 50 or 60 like I Can adjust my timeline to that and I think at the end of the day like it's about making what time I have left in my life The best quality it is. So there's a benefit to me knowing how much time I have left.[00:04:00] 

So I see it. 

Margaret: Yeah. 

Preston: Okay. Julia, what do you think? 

Julia Castro: I, I think I fall on the same campus Preston to be honest. Oh, 

Preston: the right, the right camp, 

Julia Castro: the right camp. Sure. Well, I don't know if I'd be that bold. Um, I don't know. I also like the idea of like having control over whatever amount of time is left. Um, I was trying to think.

Okay. Would it be worse to like learn I'm gonna die in two years or like that I'm gonna die at 80? Right, right. I don't know. I almost think I'd be more anxious being like, all right. I have like 57 and a half years left. What am I gonna do? That's like meaningful versus like I have one year screw it Quitting my job.

Middle fingers to the sky. Yeah. So 

Margaret: I mean, I, I feel like what you're both saying makes sense to me and like, certainly [00:05:00] like I don't love every single day of my life, but I feel like I really like the ordinary way that I live. And so would it change maybe where I'm living or how I spend time with like family or whatever, like yes.

But I feel like it puts such a cast over. The rest of the time you have that pulls you away out of the present because you know, it's ending. It's like when you have like a final couple therapy sessions with someone and you're like aware it's ending and there's almost a sense of like, well, should we even talk about things that in a real way?

Should we do ordinary things or should I mean, this is ending? So. 

Preston: You should always be where it's ending like, 

Margaret: yeah, but that's different. It's like, there's a, there's a nuance there between like, it's ending and finality. Like, we can abstractly know that like, we're going to probably die. We are going to die, but like, once you once you put that on there, I mean, again, think about doing therapy with someone like if their next session is their last session with you [00:06:00] versus you have like another like year and some change and to work with them.

Yeah. Doesn't it change it? 

Preston: Yeah. So my therapist yesterday says fired you. I'm too stable. She's like, 

Margaret: I don't feel that way. She's like, 

Preston: Preston, I want to make sure that you're getting something. So you've been out of these sessions. Hey, they were her. She said. Quote, I think you're pretty stable Preston. So we can start talking about termination or just make sure that we're where you want to be with your treatment plan.

So 

Margaret: I feel like that's interesting. We won't get into this, but I feel like that's I feel you have, as any of us do many emotions that you are working on processing right now. It's funny 

Preston: because we're saying this after I shaved my head. 

Margaret: Right. Oh, 

Preston: that's really funny. Um, okay. I do have something I do have something thoughtful to say if let's say, so instead of knowing exactly when you're going to die, [00:07:00] what if it was a 50 percent chance you would die in that year or 30 percent as you tried in the year, what does that change your answer?

Margaret: No, that's worse. Yeah, it's way worse. I feel like it depends on how you are as a person. Like, I've had existential dread trying to transform that into meaningful day to day life. Like, my favorite movie, if either of you have seen it, is, um, About Time. Uh, so I feel like I wouldn't my answer would still be the same.

And I think the 50 percent would be worse. It would just make me more aware of my mortality without actually a clear direction on how to use the excess time, right? You guys. 

Preston: Yeah, I agree. It makes it worse. And I don't think I'd want to know at that point. If I had certainty, I think that would give me some comfort in how to manage my time.

But if it just added probability with more uncertainty, I think I'd rather just know nothing. 

Margaret: Would you want to know when the cats were going to die? 

Preston: No, dude, I was like literally sitting last night I was like sitting with Maggie on my [00:08:00] chest and I just started crying Imagining what would be like if I have to put her down 

Margaret: yours therapist is so right you're 

Preston: So good No, I've already planned it out Like I'm I'm gonna go back in the room with her because I don't want to be one of those like pet owners that doesn't Like I'm gonna put down 

Margaret: with her 

Preston: Yeah, like I'm I'm her whole life like I'm her whole world outside that yellow chair and like yeah in lilac I don't know.

I just I don't want her, like, final moments to be alone, even though it's going to be 

Margaret: maybe you'll die first, and she'll be the one. Yeah, yeah, 

Preston: maybe you'll get put down by the government. 

Margaret: Uh, oh! 

Julia Castro: What? Anyway. Wait, so that's interesting. So you would, you'd rather know when you were going to die, but you wouldn't want to know when, like Because I 

Preston: think I would treat the cat a lot differently in in in a negative way.

Whereas I was treat my own way positively. I think I think I would call the cats and I would [00:09:00] not play with them in the ways that would be big beneficial. I guess. I don't know. I think, like, I would, I think I'd like to try and to grasp that control over the cats. Whereas, like, it would be easier for me to let control go.

Margaret: You'd be trying to skirt for the cats, but not in your own life. Exactly. Interesting. 

Preston: So I'd be like, like, you're living in a bubble now. So, 

Margaret: thank you for doing that icebreaker with us, 

Preston: Julia. I 

Margaret: think that went awesome. 

Preston: Yeah, now, now we can go into the. The meat of the conversation, which is actually what Julia does, and that's genetic counseling.

So to introduce Julia formally, she is a genetic counselor that works in San Antonio at the Biggs Institute, and you did your genetic counseling at Johns Hopkins in Baltimore. And I do not know where you did your undergrad. 

Julia Castro: I did my undergrad at UC Davis in California. So I have been, you know, deciding where I want to be in [00:10:00] the U.

1. by just trial running different states. 

Preston: Okay. Coast to coast. Wonderful. So, I, being in medicine, should know a lot more about genetic counseling than I do. And, like Margaret, I kind of know nothing about it. So, Can you tell us like what your journey was or your decision to go into genetic counseling? And then actually, what, what is your role in the clinic?

Julia Castro: Yeah, absolutely. I, um, cannot tell you the number of jokes that I got when I tell people I'm a genetic counselor and they have no idea what it is. And they're like, so designer babies or like Do you tell their genes how to feel? And I just have these like really trite responses that I've come up with.

Preston: What are your responses? What are your trite responses? 

Julia Castro: Well, I, they're more in my head because I feel bad saying them out loud. Now's the time to say them out loud. 

Preston: Yeah, this is inside thoughts. I 

Julia Castro: don't know. We should 

Margaret: have 

Julia Castro: made the 

Margaret: podcast that.[00:11:00] 

Counseling genes bothers 

Julia Castro: me. Yeah. Um, but no, so anyways, um, genetic counseling, for the most part, it does revolve a lot around genetic testing, um, to try and understand, does someone's health condition have a genetic basis? Um, that being said, there are a lot of implications to that, uh, psychological and for family members and, uh, sometimes you learn things that you were never anticipating you were going to learn.

Um, so it kind of like, it starts out. Really simple with this kind of basic conversation around, we're going to do some genetic testing, it might find something, but I think the door is really open when the results come back. Um, and there's a lot of different emotions and thoughts and like sheer information that people don't know that somehow needs to be managed and processed and incorporated into someone's life.

Preston: I feel [00:12:00] it's a field where. A little bit of information leads to way more questions very very 

Julia Castro: much. So 

Margaret: yeah, so so question I would ask you is. This the concept, I think, in like testing broadly and what tests are indicated and maybe that people I think a complicated complex thing in health care in general, and I'm sure this is true in genetic counseling is like the idea that the best care is the most tests or kind of looking at the most things, but then it get to answers that are may or may or may not be significant, may or may not indicate something in the future and can cause a lot of anxiety.

Um, so I would be curious as well. I'm sure that could be answered a million ways in your field, but how you think about that, or if that's something you have to deal with every day. 

Julia Castro: Yeah. Um, no, definitely a relevant question. Um, I think. The way that that plays out most commonly for me is that let's say that someone comes in and they have a [00:13:00] diagnosis.

Uh, the reality is there are going to be some genes that are really closely linked to that diagnosis, and there are going to be some genes that maybe like one to 2 percent of the time could cause that. Um, 

Preston: what's an example of a disorder like that? 

Julia Castro: I would honestly say probably dementia is not like a bad example of that.

Um, so. For Alzheimer's disease, there are three genes, maybe four, that are really strongly associated with it. And then there's lots of different conditions that can cause, I would say, cognitive impairment that could easily be misdiagnosed as Alzheimer's. And so how broadly you want to be testing is, is kind of the question, like, do I stick with the core or do I expand it?

Preston: So like, I know, I know ApoE is a really common one, where like, if you're homozygous for ApoE, you have. It's an 80 percent chance of developing Alzheimer's dementia later in life. This is my non genetic [00:14:00] counselor information. So knowing whether I'm like heterozygous or homozygous or APOE can make a big difference, but then do people want to, like you said, expand the panel and be like, test me for every single gene related to dementia?

As soon as I find out my mom has Alzheimer's. 

Julia Castro: I think, I think people tend to lean towards the stance of like information is helpful. Tell me and I, and I want to know, um, I don't know if they always, I don't know if they always know what they're asking for when they say that, which is a huge part. I think of what genetic counseling is.

It's also kind of reframing expectations and helping people understand what information they'll actually be able to learn or not. Okay. So, 

Preston: so let's say I'm in that scenario and like, Okay. I want to not only get APOE tested, what would the other genetic tests I would get be? And like, how helpful would they be?

Just, just kind of to go through like, one example of one disorder of how muddled this could be. 

Julia Castro: Yeah. So this is, this is a whole nother [00:15:00] factor that kind of like complicates things. Um, Genetic testing and, and what you're going to order might be a little more clear cut for someone who has symptoms and a diagnosis of something than somebody who comes in and says, I don't have any concerns, but my mom at age whatever, like had XYZ.

Preston: Yeah. So let's say my, um, let's say I'm like 35 and I'm coming to you taking care of my mom, who is, was just recently diagnosed with Alzheimer's dementia via spinal tap and they confirm the protein. So now they say, I want to get tested for everything. How would you like approach that? 

Julia Castro: So my number one rule is testing is gonna be most helpful in the person who actually does have the symptoms.

Um, thought process is, let's say there's something running in the family that causes this condition. Who's going to be the most likely to have it? Someone who has the condition. Okay. 

Preston: So you'd already redirect them towards focusing on the patient. 

Julia Castro: Yep. Absolutely. If you, you can [00:16:00] start there because if there is a genetic factor that's causing this condition and you can identify it in someone who has that.

Then testing for family members doesn't have to include this broad search for all the genes that could possibly be related. You know exactly what you're looking for. 

Preston: Okay, that makes sense. 

Margaret: Well, we came in and I kind of am guilty for this. Like I have a question and then theoretically and ethics Preston had mentioned this but like your story of how you Ended up doing this work.

Um, and and what led you to kind of choose it. Um, before we maybe get into other of our questions be really curious about that. 

Julia Castro: Yeah, so I'm, I feel like I'm a little bit of an anomaly in the genetic counseling world. Um, a lot of genetic counselors are like, I just liked science and I was in college and I'd never heard of this.

And then my professor randomly mentioned it. Um, It's not me. I was 14 when I learned about genetic counseling. 

Margaret: Nice. [00:17:00] That was me with psychiatry, so I get it. 

Julia Castro: Yeah. Goal directed, I guess. I was like, it's time. We've gone on long enough with the questions. I'm ready to commit to a career. No? Um Yeah, I was, like, really fortunate to go to a high school where they had some classes that were targeted towards people who are interested in science, um, and so I got to do some really, like, cool things in those classes, including break open, um, cancer cells and it.

Like, one of the cool, I don't know, cool things about cancer cells is the, the number of chromosomes is like totally out of whack. Um, so you break it open and there's like this mess and it looks nothing like what it's supposed to, um, it was just like a little glimpse into genetics and just like kind of sparked something.

And I was like, yeah, this is, this is awesome. This is really cool. 

Preston: Yeah. It's like the code for life. So [00:18:00] fascinating. 

Julia Castro: It is. 

Preston: I was talking about in biochem, like this is a series of ones and zeros essentially, but like nucleotides that can code for consciousness. You know, it's 

Julia Castro: insane. 

Preston: It's yeah, it's just like, it's like unbelievable to think about.

Sorry, I interjected. Please continue. 

Julia Castro: No, I mean, this is like the same fascination I had because then you start to think about it and you realize that of all the thousands and thousands of nucleotides that make up our genetic code, it takes one difference. to radically reshape someone's life. So I thought that was super interesting, but one of the things I really appreciated about that class was they were like, all right, we have a bunch of 14 year olds who say they like science, like they know nothing about the world.

We're going to force them to actually look up careers and things that they could do. Not just like, I want to be a scientist, but like, what are actual paths you could take? What do you actually like? Um, and so in some [00:19:00] sort of random Google search that was done when I was 14 years old, I learned about genetic counseling, um, and it kind of, I don't know, captured, uh, my fancy, I guess, in that it was this mix of genetics and science, which I found really interesting, but also these really meaningful interpersonal, uh, kind of interactions and, um, relationships.

I always tell people I have a made up job because I really feel like it kind of is, but it's like this magical blend of these things. Well, if you have a made up job. 

Preston: I mean, all jobs are made up, really. 

Julia Castro: This is true. 

Preston: But it's beautiful that it, that neatly fit both your philosophical, sounds like ethical, and then as well as scientific interests.

Which I think is a very common path to medicine. 

Julia Castro: Yeah, no, so it's, It was something that I was like, man, I love both of those things, uh, like rich and deep conversations with [00:20:00] people, but also the, I don't know, the world of science. It's like fascinating to me and genetics in particular. And so I figured, well, You have to study something.

You have to major in something. You kind of have to set your path for something. It might as well be this. And if I like it, great. And if I don't, I'll just change it. And, uh, here I am years later, still on the same path. 

Preston: So you're at UC Davis and You're trying to pick where to go for genetic counseling school.

How did you, um, end up all the way in baltimore? And how did your is his master's in genetic counseling? How's your master's in genetic counseling compared to like what you thought it would be like? 

Julia Castro: Good question. Um, Baltimore is like a fun part of my story in that I was this close to going there for undergrad and decided against it.

Um, so Hopkins re entered my life [00:21:00] later, um, but I had absolutely no control over it. Um, it works like medical residency does where there's a match system. For master's for master's in genetic counseling. Yeah. 

Margaret: Oh, really? 

Julia Castro: Mm hmm. 

Margaret: Why I mean why at residency? But like I say as I'm kind of playing my rank list, but like what like I had no idea 

Preston: enter the match for fellowship right?

Oh, yeah 

Julia Castro: Yeah, 

Margaret: fellowship and child is is better so but yeah, but yes, I had no idea there was a match I didn't know that scourge was present outside of, I knew my friend who's a psychologist, like, had something like a match too. So it was like for going from undergrad to grad school. That's stressful. 

Julia Castro: It's fun to like describe to your friends.

Oh, you know, like, what are you going to choose? Where are you going? You're like, no, no, no. I'm waiting for this Friday where I get an email. No, I was thinking of fate. The fates are going to hold a string and put two 

Margaret: clocks between it. [00:22:00] Um, Well, I guess a question I have for you is obviously both Preston and I are psychiatrists.

Is there something like, what do you think you, what do you wish psychiatrists knew about genetic counselors or like, how do you interface with mental health? I think there's like, obviously there's a level of grief, anxiety people might experience broadly, but you mentioned dementia. I'm just wondering other things that might overlay.

In terms of what the work we do and some of the people that listen to us, because I've never interacted professionally with a genetic counselor, the psychiatrist Preston. I also haven't. Do you think there's a role for it? Or do you think there's something and we're going to talk specifically later about something a different question in terms of like pharmacokinetics and genetics.

But yeah, I guess what's your experience been in working with? Mental health concerns. I think a couple that come to mind is like Huntington's or some of the other genetic conditions and things that have like a developmental level often do. Um, but [00:23:00] yeah, I'm curious. What your experiences with that or what you wish that there would be a more of an overlap.

Julia Castro: Yeah Um, I would say broadly speaking in a way that a lot of genetic counselors might be able to speak to and agree with I think one of the things the genetic counseling is not necessarily built for but introduces the need for is kind of Long term support. Um, so I get to meet with patients and their families at this kind of like critical turning point of hey, like, especially if we do identify a genetic cause, like there is an understanding of why this happened for the person who's affected.

And now there are these really significant implications for family members. Um, and we do have a lot of I don't know, conversations around the psychology and emotions of that. It's not just like an information session at all. And not just like, deal with it. Bye guys. [00:24:00] 

Preston: I am your Gen edX results robot. You will die of dementia later in life.

Julia Castro: Girl. 

Preston: Logging off. For empathy, press 1. 

Julia Castro: This is why I'm hoping that, uh, my job won't be too threatened by A. I. 

Preston: By Chad G. Yeah.

Don't worry, it'll go down fast, too. You're like, what do you mean? And the robot's like, 

Margaret: There is no meaning. 

Preston: For assessment of risk, upgrade to our premium plan. Oh 

Julia Castro: my gosh. All you 

Preston: get is the gene. 

Julia Castro: He's so bad. Oh, no, but. I mean, I can do my best to like check in with patients and family members when they come back in, but it's not a practice that's built for this long term follow up.

Um, but there are some, I don't know, I think sometimes people They need that, like, long term support. Now they're grappling with a lot of this, like, uncertainty. Um, [00:25:00] and sometimes they need to try and decide, like, do I want to get tested? Do I not? Like, things like that. Um, but a lot of their providers or mental health providers don't know a lot about the questions that they're grappling with specifically.

They don't know a lot about the condition in question. And so I think that's kind of tough, that I wish there were more providers who had, like, a little more insight or at least ability to To have medical literacy and like learn right about the conditions so that the conversations are targeted 

Preston: Like, from our icebreaker question, it gets complicated really fast as to like, am I going to die in this year?

Is there a certain percent chance I'll acquire a condition on this year? What is what is the severity of that condition mean? 

Margaret: And 

Preston: I think a lot of therapists or psychiatrists are kind of in the dark trying to answer those questions along with them. 

Margaret: I think also, like, if you were, I can think of, like, I'm in Boston and I can think of psychiatry, like, neuropsychiatrists who are hyper specialized here.

And so they can have [00:26:00] this conversation. But there's like, what, like, 20 of those people in the country who are like, I specialize in Huntington psychiatry. Um, so there's that. But then there's also the fact that most of mental health counseling and therapy and support outside of medication is done by non M.

1. therapists. So, I think even having the background sometimes of being able to read the literature around a disease or being trained for at least the five years of like the four years of med school in the year of intern year as a psychiatrist offers you a different sort of lens in, um, but like I can imagine, like my friend is a therapist and we talk about things and she'll ask me mad questions and it's just, it's just a different set of skills in the same way that therapists or psychiatrists.

Yeah. Don't have as many reps as being good at like counseling and therapy as therapists often And so yeah It would be hard to know how to support and to to understand some of this and at the same time While every person's grief [00:27:00] or anxiety is unique That being able to hold that emotion should be in theory done well in therapy, but they're not going to see a psychiatrist often because they're and if they are, they're going to see him for like a sadly a 20 minute med check, which offers not as much of maybe the like interdisciplinary overlay unless there's a therapist specialized in that population, which sometimes there is.

Preston: I think it's really interesting because I almost like Maybe incorrectly put genetics in the same scheme as I put nutrition within my like medical education where it's like you basically have a drive by when it comes to learning about it and Don't go in depth into nutrition or diet as much as we should get we counsel patients on all the time Same with genetics as far as like my USMLE Testing went and the things I learned in my curriculum, it really just kind of felt like a drive by and I think that, like, we have these clinics where we'll have embedded registered dietitians or embedded physical therapist or occupational therapist, but I've, like, never seen an embedded genetic counselor within, [00:28:00] I think, like, all these, like, very relevant clinics where people do have these, like, genetic disorders.

Julia Castro: Yeah, I will say too. I think it's interesting. Um, so I, I work in neurology specifically and, um, Yeah, you really want to find a rear career. Go try and find neurology genetic counselors. Really? You're like few and far between. Why is that? Um, the world of neurogenetics is growing. It's growing quickly, but honestly, its roots aren't that deep.

Um, and so I think Like the ability to even know what genes to be looking for for different conditions is something that within the past like 10 or 20 years we've started to be able to do and so the need for genetic counselors, specifically in neurology, is growing, but like this is new. This is really new.

Preston: Yeah, I think one of the things that blows my mind is the disconnect between the demand for like neurology and genetics and how much supply there is. So there's like four or five [00:29:00] behavioral neurologists that do this type of work in south texas. And I'm pretty sure that like these neurodegenerative disorders will affect about like one in 10 people.

So, so the for your like, Um, information, Margaret, the wait lists they have are like 12 to 14 months. 

Margaret: That's how our ours are. Yeah, it's 

Preston: unbelievable. So it's just like fascinating to me how strong of a demand this is. Like these are ubiquitous in society, these like neurodegenerative genetic disorders, yet clinical counselor in neurology or genetic counselor in neurology is such a rare career.

It's like fascinating to me. 

Julia Castro: Yeah, it depends on the condition, right? So things like things like Alzheimer's, it's Honestly, your hands are still a little tight. So the four genes that I mentioned, one of those is common. The other three, I've never seen. Like, I've never seen them come up in a clinic where I see people with dementia day after day.

Um, and so, [00:30:00] I think the demand, or I guess I should say that the supply of genetic counselors in, in those kinds of spheres, I think will grow again as our ability to actually give relevant genetic information to people grows 

Margaret: to do something that's something that's sort of, you're not actionable, but you can be used to change disease course or how they use their life course or medication management.

Yeah. 

Preston: Okay, so, um, now going forward, there's there is one spot in psychiatry where we do interact with genetics a little bit, and that's something called gene site testing. Have you ever heard of that? 

Julia Castro: Give me a little bit more of a description. Okay. 

Preston: Oh, I get to teach, um, Julia something. So, gene site testing is, it's basically this Way to look at the enzymatic panel of, um, catabolic enzymes in someone's liver.

So, for example, we have our sip for 50 enzymes. We have like our [00:31:00] our 2 d 6 subset 3 2 things like that. And so we get this panel and it tells us whether or not some of those enzymes are hyperactive or hypoactive. And then people use that to make clinical judgements about what SSRI someone should try. So for example, fluoxetine is metabolized by 2D six.

Mm-hmm . So learning which C four 50 enzyme is hyper or hypoactive may inform your clinical decision. In theory. This is con this is in theory. Yeah. So, so this is actually controversial in psychiatry. Hmm. , before I share my opinions, I want to hear what Margaret thinks about like, applying C four 50 testing and, and what the role of that counseling is.

Margaret: Yeah, I think, I think it's controversial. I think that there are instances, like, I think it's an interesting tool and If there becomes more of a database, like on the research setting, like that there becomes more information that would be, I can foresee it being a helpful tool on the other hand, like, I feel like one of the primary things we learned in [00:32:00] med school or that internal medicine people intern year that you think about and I was raised by a primary care father.

So is what does the lab tell us? Like, does this change management is the question always. And so I can see a future where that would maybe be able to change management. But right now. Yeah. You know, if someone let's say someone you get like a like, well, no, that's there's some meds. We even like there's some meds.

We get levels that it makes sense for that. We have a database like a bank of data. What's like the normal levels? So, like, lithium, for example, that we get that's not a genetic set, but just like a blood level, right? And then there's like lamotrigine that you can get levels for, but you really only get levels for really specific settings because you don't really need them from a clinical perspective in a lot of situations, just because, like, you can titrate safely.

He doesn't know that. With genetic testing, with like these like site testings, I think that there's, what do you do with it? Like, because it's, because I, and I think one of the reasons I like have questions about it is because people [00:33:00] will get these and they're sort of divorced from their clinical care and they're like private pay and they're not covered by insurance, which Lord knows the psychiatrist doesn't mean that just because insurance isn't government doesn't mean it's a good treatment, but.

I think with these, it ends up confusing patients, and they bring it back, um, into like their outpatient or inpatient, and sometimes I, like, I try to read it and use it to be helpful, but ultimately, it's like Well, is the, you know, is the Venlafaxine helping you? I think actually Venlafaxine is the one where it can be helpful because there's a secondary one, Desvenlafaxine, that you can prescribe if it misses a certain site of metabolism.

But like, if someone's not experiencing side effects and we learned that they may be like a slow metabolizer of Prozac, if there's no side effects and the med is helping them, knowing that is not going to change anything. Even with people who've tried like 20 meds and then they get one of these, which is the most common thing I see.

I still don't know how to use it in a way that is going to change management. 

Preston: Yeah, sometimes I think 

Margaret: it just limits things. 

Preston: People have this idea that it's [00:34:00] going to be a road map to their perfect SSRI. Yeah, I guess the analogy I use when I think about it is like, I'm trying to find out what soap is best for me in the bath and whether or not I slow the drain on the bathtub, which is essentially what you're doing with these for 50 enzymes doesn't have any input on whether or not the soap works on my skin.

Okay. You know what I mean? So it's like, we're like, Hey, it turns out the bathtub drains a lot faster and use the soap. Like, okay, does this work or not? You know what I mean? And so you're well, you have this cute tests in a lot of ways. You're asking the wrong question, I think, and I think that's interesting to me because it's something we have to push back.

A lot in, um, psychiatry and then same with these, um, getting drug levels. So often, um, I had a friend like message me the other day and say, like, hey, we have this patient, they're inpatient and, um, we want to get a lithium level on them. And I was like, Oh, are they like manic or like, are they having toxicity?

[00:35:00] Like, no, they're just on lithium. We just want to check their level. Like, is that good or should we like consult psych for that? And, and kinda like take a moment and say like, well what's the goal in checking the level? Usually the only reason you check a lithium level if someone is not like manic is if you're worried about toxicity.

And so I think for like a lot of these objective tests we have in psychiatry, we, we mistake the convenience of a number that we get on a report for relevant clinical data. 

Margaret: We love we, you're like a psychiatry. It's like, dude, I wish we had better tools and numbers. I wish we had that, 

Preston: but they're like some number better than no number 

Margaret: and it's like, no, we're going to think false thing.

I feel like the other thing, something I've seen have been helpful for some people that can be validating this if there's some really like market thing of like, oh, you are quote unquote, slow metabolizer across the board. In theory, there can be people who really have much more like. Somatic [00:36:00] and like higher side effect burden from medications and sometimes I think that can almost therapeutically be validating, but I don't think we need the number to validate that.

I think ideally, we should be like, the side effects are experiencing are real. These meds have side effects. 

Preston: The one time that I saw it be relevant for someone else's care is that same scenario. They're metabolizer. They're having side effects on all these medications, and they, they ended up prescribing very low doses, like 2.

5 of Lexapro or like 15 of, of searching, like, unheard of low doses. But because they're a slow metabolizer, they were able to tolerate them at those low doses without having insane side effects. Like they were generally starting doses. But I think that, like, when you see someone continuously having side effects and those issues and Signs of toxicity that leads you to start looking at what's what's causing the bathtub to 

Margaret: overflow.

Preston: Rather than starting with, let's just look at the drainage of the bathtub. So my question to you, Julia, is, and [00:37:00] this is kind of something we come across, which is convenient tests that maybe ask the wrong questions. What do you see in genetics that may be these similar tests that ask the wrong questions?

And as you have to redirect from, 

Julia Castro: well, this is super interesting. I think like so many of the things that you guys have touched on, are there things that are really relevant to genetic counseling? Um, so kind of this question of like, what is the actual utility of this genetic test? How are we going to interpret the results?

Are they meaningful? Are they not like that is in my domain as a genetic counselor, very much so. Um. And I think, kind of as you guys had mentioned before, like I don't know that a lot of medical education for other providers hits on genetics a lot, and so like as a genetic counselor a lot of times I am informing healthcare providers about the relevance and utility [00:38:00] of learning about genetics.

Um, and I don't know if this is the same testing or not, but I mean pharmacogenetics. Testing and this idea right of that is, yes, that is, yeah, so it's really metabolic testing. Yeah, and I mean, and so I've had these results come back for my patients because side note, when you order a really broad genetic test, like full exome or whole genome sequencing, it's an optional add on analysis.

Oh, interesting. Patients can be like, yeah, add that on. I'd love to learn what a 

Preston: car wash. You can just add on like a wax or a leather treatment and just add on my metabolic test. 

Margaret: Let's check in on what the sip girls are doing today. Let's find out. 

Julia Castro: And it's weird because This was not something that, like, in my training, we really focused on at all.

Um, and so, I, I'm curious, honestly, to, like, see where the future will take us, because the [00:39:00] reality is, psychiatry and genetic counseling have really had very little overlap, but I think this is an area In which they possibly could in the future, um, 

Margaret: do you know what I think? I know why that is. So one of the problem is that once it becomes genetic in some ways, like firmly genetic, then it becomes organic and it goes to neurology, like, so neurology, a lot of times, at least in the U.

1. And in Europe is sometimes different. But so once someone's psychosis is like, Thought to be an autoimmune encephalitis derived one, 

Preston: or neurology or something. Yeah, neurology manages 

Margaret: it. So I I feel like it's partially Psychiatry is like we don't know but something's not right. Uh, I mean, obviously there are studies on like genetic likelihood and like schizophrenia bipolar All sorts of things, but I think where there's a concrete clinical role with it.

We haven't existed there together yet 

Preston: and I think that this is a place where psychiatry needs to change going forward because [00:40:00] I firmly believe that all psychosis is organic. There's just what we have identified what we have yet to identify and so if our role in that is just if we find an ideology deferred deferred deferred like 200 years from now as we like elucidate more ideologies psychiatry is going to functionally shrink and see 

Margaret: I feel like this is like this is our programs might differ on this because I'm like we do ICU psychiatry here.

Like we do, and we have a lot of large neuropsych department here, and so I feel like there's more joint holding these patients and like the patients who are coming in for like cognitive concerns to like the emergency department, half the time it goes to psych and half the time it goes to neuro. 

Preston: Yeah, maybe it's like a cultural thing, but I found that the attitudes of a lot of people has been if we find.

An ideology or for concern about NMD encephalitis or something? 

Margaret: Sure. I don't need to 

Preston: know anything about encephalitis from autoimmune disorders, [00:41:00] except that a neurologist should treat. It has been kind of the opinion of a lot of people. And so I've I've just. Then I think I like unsettled by that and I think just in general the idea that like psychiatry needs to treat the mind like A black box and that we only target the things that don't have organic sources 

Margaret: interesting Well, my my med school was at Wash U shout out st Louis shut out wash you and we wash you is a super super super neuro bio program And so I feel like that I was my first part of training was under the opposite idea Of like, not that we have the answers yet, but that this is knowable and let's figure that like, let's understand the neurobiology of this.

And this is psychiatry. So they had your view in a lot of ways. Preston 

Preston: because I think you can, you can pivot to have psychiatry approach psychiatric conditions in a way that assumes they're noble rather than kind of the way the DSM set up right now. And I think if you did that, 

Margaret: I don't know about that.

I don't know 

Preston: about that. What do you [00:42:00] mean? 

Margaret: I just feel like I feel like there's still so much that we do not know. I think as individuals, we should continually be reading a psychiatrist as you and I have talked about, but I do actually think in a lot of ways. The DSM is what we know so far. It just sucks because that's not very much.

I 

Preston: think I think what I'm getting at is that we understand the mechanisms with which someone acquires. A like generalize anxiety disorder rather than I'm saying that this is noble in the future. I'm not saying we know. 

Margaret: Yeah. 

Preston: So, but if we operate that that that is a possibility rather than we just identify these symptoms traveling in space together, then it allows us to kind of adapt to a future where we start to unlock some of those mechanisms because the way we operate as this kind of like rule out.

Um, specialty, I think, like, puts us behind. So, like, for example, nephrologists, I would say, like, are in charge of the organ, the kidney. So anything that affects the kidney, they're experts on. And [00:43:00] I kind of wish psychiatry was the same with the mind. Anything that affects the mind, we should be experts on, but we're probably not.

We're experts on things that affect the mind as long as you don't know the organic etiology of 

Margaret: them. I think my experience of psychiatry has been very different than yours. I actually, I'm at a program that is also super, super consult liaison psych, which is, um, I know Preston knows, but which is like the psychiatrist who see people in there in the emergency department or the hospital or the ICU and also have something psychiatric going on while they're medically ill often, which is a very particular way to practice psychiatry.

Okay. And so I feel like one of the core parts of my residency is like, you better have read 20 papers about delirium in an ICU setting coming off a Prussidex or you're, you're dumb. That sounds mean. They don't say or you're dumb, but like the expectation. I'm not that good at reading MRIs, but the expectation in my program is That you are thinking in the org, [00:44:00] like in the non black box way, and I think it's because we're a very CL heavy program.

Like, we have a really good CL fellowship that is like a very competitive one. And so I think that there's a lot of that that is like trickled into the residency, but I agree with you press. I think that's one of the first things we talked about, like psychiatry is like, what does it mean? To work in a field where there's like a lot known and a lot unknown, which is true in genetics, too.

Julia Castro: Yeah, it's interesting to hear you guys talk, and I mean, I feel like this contributes to my thoughts of why genetics and psychiatry have not overlapped a lot, because I think a lot of genetics that has to do with the brain, to be honest, is not changing a lot of clinical management at this point. Like a core function of it is answering the question, why?

Like, why did this happen? 

Preston: Um, 

Julia Castro: and so, but 

Preston: not how can we change it? 

Julia Castro: Well, I mean, I think that's a goal, right? Like if you understand that there's this molecular basis to something, then that [00:45:00] targets the way that we think about how we should treat it. But it's not directly connected right now. Like the vast, vast majority of genetic testing that I do, and I'm describing like the benefits and limitations to people.

It's like, by the way, this probably won't change the medications that you're being prescribed, but it can tell us why this happened. And it can tell us if other family members should kind of have their. Like heads up in terms of, do they want to know what this be useful information for them to think about?

Um, so if psychiatry, or at least in particular places in the U S is less concerned with this, why question genetics has little to do with it, I think at this point in time, or there's not like a great marriage there. 

Preston: It's really interesting. And I think as our career. And like the, the ecosystem, our career evolves, we'll see how much, to what extent that why ends up being incorporated within our clinical management because it, because in a lot of ways, it is almost like a didactic [00:46:00] exercise.

And I think the other camp, I would say that argue with me and you would say, learning all of these mechanisms doesn't change the person in front of you and may end up like, Having you look up a bunch of stuff that's ultimately nonconsequential, just like how we talked about what is this gene site testing matter?

If it's really does the medicine work or not? I think some people have that approach to psychiatry as well. And I think in some ways, like rightfully so, because if if they can find the medicine that works best for the patient helps them live their life in the way they want to, you can make a good argument against going down all these rabbit holes that don't necessarily help.

And I think it's we'll kind of see how those two Camps negotiate the future. So thank you for this first part. I want to go into a break now and when we come back we are going to do some gene trivia and it'll be Margaret versus Julia. I've prepared a couple questions 

Julia Castro: and then [00:47:00] we'll 

Preston: finish up with some closing thoughts.

Julia Castro: I hope this isn't embarrassing for me. Who knows? It will certainly not be.

Preston: And welcome back to gene trivia. I'm your host, Preston Roche. And I'm 

Margaret: joined today by the doo doo 

Preston: doo doo. Welcome to gene trivia. I'm your host, Preston joined by Margaret and Julia. So we're going to do jeopardy style for this. So you can get just, just buzz in, just, just say like buzz. And then I'll call on you.

And if it's quiet, then I'm just going to like, kind of like awkwardly, let the answer trial, and then I'll announce it to you, which is actually what I'm anticipating happening with all of these. So it's really just gonna be me telling you the answers. That's how much mansplain genetics to a genetic counselor?

No, I'm just, I'm just kidding. I think that you guys are both really smart, but I'm worried about 

Margaret: He's like, hold on, 

Julia Castro: hold on, hold on. Well, 

Preston: I'm kind of like, I'm like looking at the questions now and I'm like, I think I may have made these a [00:48:00] little too much. 

Julia Castro: I'm 

Margaret: like, I don't know if these are like reasonable for anyone to get.

They're just like super boring. They're like, what is the exact abbreviation for this gene set? I don't know. 

Preston: Okay, that is one of them. 

Margaret: Oh, oh my gosh. 

Preston: So first question ready 

Margaret: Hey listeners, let us know if you liked this or you can bully Preston. 

Preston: Levi Strauss and Jacob Davis obtained a patent for this invention in 1873.

That was blue jeans. 

Margaret: Oh, that, shut up. I was like, I was like, well, he has the jeans, but like, I don't, what 

Julia Castro: else? 

Preston: Okay, next question. 

Julia Castro: These are the kind of jokes I get when I tell people I'm a 

Preston: So, um, 

Margaret: it's just, this is just Preston's type 5 around genetics. He's like, I'm trying to workshop this for a conference.

Preston: This superhero from the mutant subspecies goes by the names Marvel Girl, [00:49:00] Phoenix, and Dark Phoenix. What's her name? 

Margaret: This who now? 

Preston: This superhero from the X Men franchise, or from the mutant subspecies, also goes by the name Marvel Girl, Phoenix, and Dark Phoenix. 

Margaret: That was, 

Preston: that was Jean Grey.

I feel like there's a theme we could pick up on here. 

Margaret: I didn't know that. That's never been a thought. That name has never been in my brain. Levi's. I was like, okay, I get it. And then you're like this, and I'm like, I don't know. Sorry. Sorry I was outside. Not reading. 

Preston: Have you seen those TikTok comments where it's like, Um, hey, can anyone explain sorry I'm employed?

Margaret: Hey, sorry I have friends. Okay. 

Preston: Alright. 

Margaret: Sorry, it was cool. We're over two. Let's make it 

Preston: over three. 

Margaret: Oh boy. 

Preston: This Swiss psychologist, known for his work with child development, started the [00:50:00] International Center for Genetic Epistemology in Geneva in 1955.

Margaret: Is it Carl Young Margaret? Who is Carl Young? No, think 

Preston: Swiss. Wow. 

Margaret: 1935. 

Preston: That was Jean Piaget. 

Margaret: Oh, . Oh, I didn't know it was Swiss. That really threw me, I guess Carl Young wasn't either, but 

Preston: it felt more like it might be, you could just say for all these, you could just answer it and said, Jean. And you would have been right.

Now I'm having more fun getting them wrong. Now I'm having more fun getting them wrong. I'm like, I gave it to you guys, like, Women, they never get it. I know, like you just had, all you had to do was just buzz it and yell Gene. And we would get all these trivia questions. Now 

Margaret: I'm in protest and not gonna.

Preston: Okay, this trinucleotide repeat disorders increase in severity within the progeny of carriers of the disease. Julia buzzed in first. [00:51:00] 

Julia Castro: I'm going to assume what you're referring to is anticipation. 

Preston: Yeah, it was anticipation. Because I didn't want you to anticipate that the fourth question was going to be genes again.

So we had to switch it up. Good 

Margaret: thing we didn't catch on the first three. We weren't anticipating shit. No risk of that. 

Preston: Okay, and the final question. Which you, which you did anticipate this gene known for its relationship to achondroplasia, a disorder that affects the growth of long bones is, um, goes by what name or what is the, what are the letters associated with it?

You can say either. 

Julia Castro: I should know this. And I think I know it, but I don't. 

Preston: That was FGFR3, Fiber Blast Growth Factor. 

Margaret: That sounds like something I knew one time. 

Preston: So yeah, so this has been Gene Trivia with Preston. [00:52:00] We are contested and got zero answers right. Oh, sorry, what? I am so sorry. Julia has won Gene Therapy.

With your excellent question about anticipation and this increased severity of trinucleotide repeat disorders for, um, final gene trivia, I want you to write down on your, uh, whatever paper next to you. What are, what are the three, um, trinucleotides in the repeat associated with Huntington's? 

Margaret: Oh, I don't remember.

Preston: Yeah, this is just solely to embarrass Margaret. So I'm not doing so. 

Margaret: Did you hear any of those first questions you asked?

I know it's just a vibe. Reveal your 

Preston: final trivia answers. 

Margaret: I didn't write anything down. 

Preston: Oh, okay. I literally 

Margaret: don't remember. I [00:53:00] remember like fried rick fried, Rick's ataxia sort of. 

Preston: Okay. What, what is that answer? Julia? 

Margaret: Should be CAG. 

Preston: Yeah. Cag. 

Margaret: Cag. 

Preston: Cag. Cag. Cag. I always remember from the sketchy, like the, the CAG pants.

Cargo pants with Huntington's. Oh, so 

Margaret: I remember like the big guy like falling over, isn't it for Friedrich's ataxia? 

Preston: Mm-hmm . What 

Margaret: does Friedrich's Ataxias repeat? 

Julia Castro: I know the number that you need, but I look into the actual nucleotides, you need 66 or more, but. Oh, 

Preston: the number of nucleotides, that's interesting.

So, now, if you wanted to talk to someone who is thinking about genetic counseling, what would you counsel them about? 

Margaret: Ga is the Friedrich's taxia, sorry. Oh, yeah, yeah, yeah. That's because he's like, Ga, and he's falling over his feet in the sketchy. Anyway, yeah, real question. Okay, wait, repeat that. 

Preston: So let's say there's a 14 year old who [00:54:00] just took a science class where they got to crack open some cancer cells and their interest in genetic counseling.

What would you tell them about this career field? 

Julia Castro: Um, I mean, I think that they just wanted to, to know about it. I'd probably give a pretty similar overview to what I gave you guys earlier. Um, but I think one of the things, one of the things that's cool about genetic counseling is that again, it's a really new field.

Um, and so that means a couple different things. It means you're on the forefront of the knowledge that's growing. Um, and so like. I, I work with patients all the time where I'm telling them about the gene therapy trials that are happening and like we are like right at that intersection and this is like an exciting place to be where we are constantly learning new things.

And so it, I don't know, it is exciting and also like it's fun to have a career where you're. You're kind of needing to always learn more, um, 

Margaret: because 

Julia Castro: it's not like a settled, Oh yes, we've known [00:55:00] this forever and I'm just here to kind of like disseminate information. Um, so what would you 

Preston: caution them on? 

Margaret: Or who would not?

Who do you think should not would like be a bad fit, but maybe this job would not be because I presume that you have a lot of hard conversations. Um, and so I wonder if there's anything that you didn't know before going in. That's like, this does kind of weigh on you in this job. There certainly are those things in psychiatry.

Julia Castro: Yeah. Um, I almost feel like that's advice that I'd give to people who are already kind of on that path, because I think different specialties in genetic counseling, like depending on what health care field you're situated in, feel really different in terms of the conversations you're having. So one of the reasons I really liked neurology is because sitting down and talking with someone about whether or not they want to learn if they're going to develop Huntington's is not a conversation about What screening then you'll be able to do or what treatments you're going to take [00:56:00] like it is a personal tell me what your life tell me about what you would do if you knew and what you would do if it's positive or negative and like let's just Talk about life and what this information means to you.

Preston: So like really putting the counseling in genetic counseling 

Julia Castro: And there are other places where those conversations for predictive testing for somebody symptomatic, but they just want to learn like what will happen. It's much more information focused or targeted to like, these are what your next steps would be the 

Margaret: screenings.

Here's prophylactically. I'm thinking of like the bracket. Like, there's like a very, yeah, here's what we're going to do. Here's what we can do. And maybe if you're someone who. Likes focusing on that more and optimizing that, or if it's really, really tough for the gray to be there, then that would be like something that would help the field.

Wait, is that a person or a color? 

Preston: It's a person that immune from the subspecies of X Men, also known as [00:57:00] Marble Girl, Phoenix and Dark Phoenix, Jean Grey. It was it was question number 2 from gene trivia. 

Margaret: I don't sorry. I was making a pun. Okay. Well, that's all the time 

Preston: we have

1. So, Julia, do you have anything, um, any promotions or websites, social media profiles that you would like to promote or shout out 

Margaret: any genes you're selling? 

Preston: Aging testing. 

Julia Castro: I honestly. I don't, um, 

Margaret: super ethical. You guys. 

Preston: Yeah. Any conflicts of interest? 

Julia Castro: Nothing to disclose. 

Margaret: She's working on the X Men comics.

That's 

Preston: fantastic to hear. And then anything that you want to bring the public's attention to then if you don't have anything personal. Yeah, 

Margaret: this is your moment to 

Preston: something. Julie is into baking your chance to. So I'll [00:58:00] tell the story. The other day she brought in zucchini bread nice for the office and yeah.

No, not nice. People like slammed it. And they're like, why would you put a squash in bread? And I, I grew up with zucchini bread and I was like, oh, I love zucchini bread. My mom made all the time, you know? And so they're like, Julie's like pressing. Can you validate me? Like zucchini is normal and bread and I like I would but she was getting blasted in the workroom.

So I was like, I've never heard of putting a squash in a bread. That's weird as hell. 

Margaret: Unfortunately, I'm going to abandon you. And then I secretly went to 

Julia Castro: eat more. Right. Well, this is fun to hear Preston's version of the story. Um, slightly different than mine. In secret, I was 

Preston: like, please bring more zucchini bread.

I love it. 

Julia Castro: Right, right, right. That's why he didn't try any when I brought the zucchini bread in. I ate a lot 

Preston: of zucchini bread. 

Margaret: Preston, do you cook? 

Preston: No, 

Margaret: I'm just 

Preston: [00:59:00] kidding. I'm trying to get better cooking. I went to a class at the culinary institute. I have one in San Antonio, and I learned how to make ratatouille at home the other day.

Yeah, 

Margaret: that's cool. I'm taking a cooking class in January, so I get less depressed during the winter, but I'm taking it the Culinary Institute in Boston, and it's like six weeks, and it's like four hours each time. And so, and apparently they're kind of mean to you. And I'm like, hell, yeah. And you'd like the 

Preston: yes, chef thing.

No, it's so real. 

Margaret: I'm excited. 

Preston: They feel like they feel like attendings, but for cooking. It's so interesting. I love 

Margaret: it. I need more of that. There's not enough energy like that anymore in psychiatry. So I need to get 

Preston: get on it. Like, I was like, cutting the ratatouille in the class and like, The, the, like, resident equivalent, um, like, comes over and he's like, he's like, oh, the, the, like, ratio of eggplant to, like, onion isn't good enough.

And I was like, what do you mean? He's like, you need to cut these eggplants. Yeah. So the ratio matches in the stew and [01:00:00] then, like, chef comes over and she's like, what's with this ratio? And he's like, sorry, chef, we're going to correct it right away. It's like, Oh man, I'm like, he's like, who cut this? I'm like, I point to the, like the 12 year old, like it was Peter.

It was Preston. 

Margaret: Preston's in like a kid's cooking class by himself. Yeah. I 

Preston: have like, it was like gratitude for 

Margaret: kids. Preston's like, I like gratitude too. What? 

Preston: It's so funny. It's a, it's a good dish actually. Like it tastes pretty good. 

Margaret: I believe it. I believe it mostly, you know from the movie, but 

Preston: yeah, did you know that the dish existed before the movie?

Margaret: Now that's that seems now you're saying that's like saying like france existed before epcot 

Preston: Made it.

Margaret: Sorry, friends. I'm kidding. 

Preston: So if you so your your fun facts, I write a few days. It was a peasant dish designed to extend the life of vegetables. So if you had a vegetable that was like kind of like 2 days from going bad, chop it up and throw it in a stew. You [01:01:00] get extra 5 days out of it. So all these French 

Margaret: peasants, they 

Preston: would go through their pantries and be like, oh, shoot.

I got these like peppers, eggplant, squash, zucchini. Let's just cut them up and throw them together, mix some salt in there, and then you got ratatouille. It'll last you a couple more days. So it was born out of necessity, and now it is a delicacy in the world of fine dining, and also a blockbuster film.

Okay, so thank you so much for listening. How was the show? Did we stay on topic? Let us know if we did it. 

Margaret: We certainly did, but I don't think everyone understood. 

Preston: Come chat with us at Our Human Content. Podcast family on IG and TikTok at human content pods, specifically about what she thought of gene trivia.

I want to get your feedback on that because I like gene trivia. I would like to do more gene trivia segments. 

Margaret: Speaking directly to camera. 

Preston: You can contact the team directly at HowToBeA PatientPod. com. Shout out to all of our listeners who left kind feedback. [01:02:00] And the ones who bullied 

Margaret: us positively. We're going to get better.

Bullying 

Preston: works on me specifically. I have a very weak sense of self. If you bully me again, I will probably read it and also only remember it for the rest of my life. On YouTube, full videos are available each week at It's Presro, which is just like my normal YouTube channel. Thanks again for listening.

We're your hosts, Preston Roche and Margaret Duncan. Our executive producers are me, Preston Roche, Will Flannery, Kristen Flannery, Aaron Corny, Rob Goldman, and Chauncey Brooke. Our editor and engineer, Margaret's also a producer. 

Margaret: I'm going to kill you to edit this section. Yikes. It's not his fault. The glass ceiling just 

Preston: gets to me sometimes.

Margaret: There was a tweet today that, never 

Preston: mind, I'm not gonna go with this. Our editor is Tracy Barnett. Our music is by Omer Benzvi. Check out our show notes to see the references and resources we used for this discussion. And to learn more about our program disclaimer and ethics policy, submission verification, and licensing terms, and our HIPAA release [01:03:00] terms, Go to our website, how to be patient pod.

com or reach out to us at how to be patient at human dash content. com with any questions or concerns, how to be patient is a human content production 

Margaret: by Jean.

Preston: Thank you for watching. If you want to see more of us, or if you want to see, this is lilacs. She's my cat. She's going to be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac, point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there.

They probably exist for real. But in the meantime, I'm just going to pet Lilac and then I'm going to go dance in the [01:04:00] background.