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As PGx Matures, US Medical Schools Struggle to Keep Students Informed

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Drug makers and pharmacogenomics researchers anxious that physicians entering practice today will be ill-equipped to embrace personalized medicine may have reason to worry.

Some medical schools, aware that pharmacogenomics is caught in a limbo between its potential real-world application and hype, are encouraging their students to probe the new discipline delicately. But instead of committing to traditional textbooks and core curricula, most medical schools instead are relying on the age-old tool of learning by osmosis — that is, learning by observing.

Coincidentally, this kind of learning will offer pharmaceutical companies and technology vendors greater latitude to influence the opinions of students. Yet the potential to reach them — according to the American Association of Medical Colleges there are almost 17,000 med-school students nationwide — may not outweigh the concern among some drug makers that learning pharmacogenomics by osmosis may not cut it.

“My concern is that there is a significant lack of knowledge in the physician community in this area,” said Gary Peltz, head of genetics and genomics at Roche Bioscience, whose company is one of the largest supporters of pharmacogenomics technologies. “My impression is that it’s not a large part of the medical curriculum, [and] learning by osmosis doesn’t work very well.”

The resulting ignorance, some say, will shortchange patients and hamper new-technology development.

Educators contend the picture is not that bleak. “We’re not too far behind the curve,” said Stephen Huot, associate professor of medicine at Yale University. “I think people currently in training and in medical school are at least hearing the information.”

Know Too Much Biology

To be sure, few of the 126 accredited medical schools in the United States have made pharmacogenomics a component of the core curriculum. Instead, pharmacogenomics has become “part of the language” to which students become exposed, said Huot. Some educators argue that the learning-by-osmosis method serves pharmacogenomics well for a number of reasons, chief among them its nascency and the fact that most students argue their curricula are bursting at the seems already.

“When you tell people what should be part of their core, everyone gets pretty defensive because there’s so much they already feel they have to have in there, and I’m just not sure enough the [pharmacogenomics] is quite front-line yet,” said Huot. “As the technology gets more user friendly, I think we’re going to have to find ways to get it to people in a usable way.”

Huot said it is important that medical students get “a realistic understanding” of pharmacogenomics. “They should know that this is part of the pharmaceutical industry, and it is not a separate entity, that it has significant regulatory issues that really are going to impact the way many pharmaceuticals in the future come to market.”

He recalled that at a recent medical meeting reviewing new statin drugs, one of his senior residents struck up a conversation with another participant after she overheard him talking about ways in which pharmacogenomics is being applied to this class of drugs. “This was someone who I had done no personal educating with at all,” said Huot. “She at least knows what the language is, and has some broad understating of what [pharmacogenomics’] impact might be.”

Medical-school students “don’t need to know how the FDA does what it does, but they do need to recognize that these new technologies don’t just appear, [but that] there’s a real process, and that regulation is going to have a fair bit to do with the development and implementation of [pharmacogenomics],” said Huot.

He also said he thinks diagnostic labs, those prosaic accoutrements to the health-care process, will evolve to be major drivers in the way med students learn about pharmacogenomics. “I don’t think we’re going to be teaching people what the DNA [sequences] are … but I think we will be teaching them, as the information evolves, how to use laboratory data that shows different responses to different classes of medication,” he said. This concept ties nicely with the widely held belief that molecular diagnostics will reach broad clinical application at least 10 years ahead of genomic-based therapeutics.

However, medical schools face clear challenges to ensure that their graduates begin practicing with some sort of pharmacogenomics literacy. According to Huot, the familiarity within a given medical center about pharmacogenomics by contact faculty — those instructing students as opposed to those conducting research — “probably varies a fair bit.” In other words, he said, it’s “not necessarily that there are not people who have some knowledge in the evolving field of pharmacogenomics — I think there are. But those are not necessarily [the] people who have direct contact with students. What students tend to learn is what a medical school has identified as a core curriculum, and those things are the personal interests of the people who are lecturing in the classrooms.”

Moreover, even though pharmacogenomics will eventually be used nationwide, students who attend medical school in a community in which genomics or pharmacogenomics technology is being developed — say, Boston and Cambridge, Mass., and San Diego and San Francisco, Calif. — will have an advantage. “In these kinds of places, students will see posters for seminars. They’re going to get notices in their e-mail.”

Two weeks ago, in fact, Huot was asked to make introductory remarks at an annual pharmacogenomics symposium sponsored by Yale’s department of internal medicine and paid for by Genaissance Pharmaceuticals. At Yale, where Huot oversees the internal-medicine residency program, pharmacogenomics instruction is done “informally.” There, lecturers “talk about [how] pharmacogenomics information may play a role in therapeutic decision making.”

But this notion is not universal. The medical school of the University of Vermont, not known for genomics, has retooled its curriculum from the ground up recently and now offers a genetics track that runs through all four years of its MD program. (It doesn’t hurt that Alan Guttmacher, deputy director of the National Human Genome Research Institute, was the school’s director for genetics for a time.)

Still, Vermont is an exception. Roche’s Peltz, who is also a physician, said that as more drug makers begin using pharmacogenomics tools, “it is essential that the health-care providers understand and are comfortable with these technologies.” He said schools that do not offer concrete pharmacogenomics-related curricula create “the first gap in what has to happen to bring [pharmacogenomics] to students.”

Peltz knows this issue first hand. As a faculty member at UCSF, he has proposed over the past four years to install genetics as part of the school curriculum. For four years he has been refused. Asked to explain why this is the case, Peltz said it is because genetics — never mind pharmacogenomics — is still outside the mainstream among faculty decision makers.

Some believe medical schools are not the only ones that have a responsibility to keep physicians up to date on new technologies. In fact, most agree that the responsibility also falls on the medical societies. These groups, like the American Medical Association and the American Academy of Family Physicians, are in a unique position to educate a broad swath of practicing physicians — there are slightly more than 836,000 medical doctors in the US, according to the AMA.

“Most people view [the medical societies] as a very important place for disseminating new knowledge,” said Huot.

The AAFP, for its part, believes that pharmacogenomics will play a big role in primary care and family practice and plans to direct an annual “clinical focus” on genomics in 2004, according to Norman Kahn, vice president of science and education at the AAFP. (An AAFP clinical focus hones in on one particular topic that is taught through a variety of media and applications.)

The group has also helped launch a program to teach genetics and genomics to a variety of medical-school faculty. Co-funded by the AAFP, the NHGRI, and the US Health Resources and Services Administration, among others, the program, Genetics in Primary Care, has organized 20 national “teams” to bring genomics curricula to faculty teaching family medicine.

“The idea is to prepare faculty in primary care to incorporate the genetic revolution into the teaching of medical students and residents,” Kahn told GenomeWeb, SNPtech Reporter’s sister publication.

Added Huot “I think that if it’s viewed that it really matters in terms of decision-making as a doctor, and its intellectually exciting, then I think that people will do what they need to do to become aware of it. Things that really matter are the things that people go and learn.”

— KL

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