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OSU Medical School Adds Personalized Medicine Curriculum with P4 Program for New Doctors

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This story has been corrected from a previous version to correctly identify the P4 program director, Kandamurugu Manickam.

By Molika Ashford

Twenty students from the Ohio State University College of Medicine's class of 2014 are spending the summer in a pilot program with an emphasis on genomics as well as lower-tech methods to individualize care.

Led by Kandamurugu Manickam, a geneticist at OSU's Center for Personalized Health Care, the inaugural class takes place this summer as a pilot project to determine how to integrate P4 — short for predictive, preventive, personalized, and participatory medicine — material into the medical school's new curriculum beginning in 2012.

Manickam told PGx Reporter this week that many universities are interested in adding programs in personalized medicine, but that OSU's P4 approach sets the program apart. "Places have talked about doing [this], but [they have placed] most of the emphasis on genetics, which is why we are really unique, in looking at all these factors," he said.

P4 medicine is the brainchild of Leroy Hood, president of the Institute for Systems Biology, which partnered with OSU in 2009 to form the P4 Medical Institute (PGx Reporter 10/7/2009). The program's goal is to transform healthcare "from a reactive system to one that predicts and prevents disease, and tailors diagnosis and therapy to the individual consumer."

P4 encapsulates a broad approach that includes an emphasis on low-tech and low-cost preventative measures in addition to 'omics based personalization, according to Manickam. " I'm a geneticist, but one of the things we've kind of recognized is that genetics is expensive to do, but there are less expensive ways to get good outcomes," he said. However, genomics is still a large part of P4, he explained, and will become more and more so, as pharmacogenomics and genetic testing develop further.

OSU plans to explore P4 through a variety of clinical programs and the pilot course is a separate push by the university to integrate P4 principles into its educational programs. "We've been trying a lot of clinical ideas at Ohio State in this area," Manickam said. "But we wanted to [provide] a little more education [on the P4 paradigm] for medical students."

The summer course is intended as a testing ground for P4 principles that Manickam plans to work into a scheduled overhaul of OSU's MD curriculum in 2012.

"We started with… two weeks of kind of didactic lectures, just to get everybody on the same page," he said. "And now were doing more small, group exercises as well as doing some interactive [lessons]."

With initial lectures out of the way, Manickam said he plans to use the rest of the seven-week course to work on some of the complex decision-making scenarios that are required when delivering individualized care, especially when dealing with genetic testing and making pharmacogenomically guided treatment decisions.

"Some of it is emphasizing things we should be emphasizing anyway, like evidence-based medicine," he said. "That's one of the big things with pharmacogenomics, is that there's not a lot of evidence-based medicine out there."

Manickam said he plans to teach students how to evaluate the available evidence for genomic tests and treatments, particularly when the data are not conclusive as to whether a genetically guided intervention improves patient outcomes. "How," he posited, "do you judge the evidence that is out there when you don't have the perfect randomized-controlled trial? ... How do you compare two treatment plans, which one is less costly, which one has fewer side effects?"

Manickam plans to administer an exercise in which his students survey the literature on various genetic tests and try to convince each other whether there is enough evidence for them to use this information in patient care. Some hypothetical examples that will feature in this exercise are PGx testing to pick out best responders to the breast cancer treatment tamoxifen and to certain statins.

In addition, a major focus of the course will be the practice of shared decision-making, which is a cornerstone of the P4 concept, but also has specific relevance for genomics practices. "I'm used to working with genetics counselors, and that idea of shared decision-making is pretty important and is definitely one of the changing themes in medicine right now," he said.

The summer course will also focus on providing genetic counseling for patients in the context of direct-to-consumer genetic testing.

With lessons learned from this pilot class, the university plans to incorporate P4 medicine into its general curriculum next year. According to Manickam, most of the material from the course should pass muster with the faculty team in charge of designing the new curriculum, of which he is one. Feedback from students has been positive so far, though some have said that the course is a little lecture-heavy. Manickam said he hopes to be able to incorporate more hands-on activity.

While OSU moves forward with P4 education, it also has plans with ISB and the P4 initiative to test P4 medicine clinically. But Manickam said the school does not yet have a sense of how a broad P4 approach actually affects patient health.

OSU's Center for Personalized Health Care is engaged in other work to evaluate the clinical effects of incorporating genomics into health care. The center recently partnered with the Coriell Institute for Medical Research to study how incorporating genetic risk data into patients' electronic medical record affects their care (PGx Reporter 02/09/2011).

As the university explores P4 further in its partnership with the ISB, the impact on patients should also become more apparent. "The institute has only been established for a year or two," Manickam said. "Clinically we're still just trying out ideas to see what's going to be effective."

Other universities have also begun adding genomics-focused lectures and piloting personalized medicine educational programs to try to figure out the best way to educate students about this emerging discipline.

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UC Berkeley planned a program in 2010 that would test students for three genes involved in the metabolization of alcohol, lactose, and folates, but was kept from disseminating genomic data to individual students by the California Department of Public Health due to the program's genetic analysis procedures. The university ended up limiting the program to analysis of aggregated group results and hosting lectures on the ethical, legal, and societal issues associated with increased public access to genetic data (PGx Reporter 08/18/2010).

Stanford University also announced last year that it would offer MD/PhD students the chance to be genetically tested either by Navigenics or 23andMe at an "educational rate" as part of an elective course being offered in the summer quarter (PGx Reporter 06/09/10).

The University of Pennsylvania School of Medicine offered fourth-year medical students a similar course in personalized medicine one year prior to Stanford, giving students the chance to have their genomes scanned by the Coriell Personalized Medicine Collaborative, which OSU has also joined.

SUNY Upstate Medical University has also offered a course on personalized medicine with genetic testing opportunities for students.

According to Manickam, OSU is, as of yet, the only institution to try to incorporate the specific principles of P4 medicine.


Have topics you'd like to see covered in Pharmacogenomics Reporter? Contact the editor at mashford [at] genomeweb [.] com.

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