The dawning era of personalized medicine exposes a gap in medical education
Guest blog by Keyan Salari, PhD Candidate at Department of Genetics, Stanford University School of Medicine and MD Candidate at Stanford Medical School
“It’s far more important to know what person the disease has than what disease the person has.”
The importance of personalized medicine has long been understood in the medical profession. Physicians routinely take into account a patient’s environmental, behavioral, and genetic factors of disease and drug response in their clinical practice, but until recently the granularity at which genetic risk has typically been assessed has been the family history and ethnicity. However, in the near future high-throughput genotyping and DNA sequencing technologies may dramatically change the way physicians assess genetic risk, and give personalized medicine a new meaning.
In an article published this month in Nature Biotechnology, Stanford engineering professor Stephen R. Quake described the decoding of his own genome for less than $50,000 using a machine built by a company he founded, Helicos Biosciences. Dr. Quake noted that steadily declining costs of DNA sequencing “will democratize access to the fruits of the genome revolution” by enabling many labs and hospitals to decode whole human genomes. Similarly, in June of this year, genomics technology company Illumina announced the launch of a $48,000 genome sequencing service at the Consumer Genetics Conference in Boston. However, unlike most consumer genomics companies, Illumina’s service will require a physician’s prescription. While the price tag is still out of reach for most consumers or healthcare payers, the cost of DNA sequencing is falling faster than that of computing power. This means that the much-discussed goal of the $1,000 genome could be attained within two or three years. Provided the cheaper and better technologies translate to new clinically relevant findings, physicians may soon see a new array of gene-based tests, or perhaps even whole genome sequencing, become reimbursable clinical tests.
Today, companies like 23andMe, among others, are offering direct-to-consumer testing for common genetic variants. The advent of consumer genomics will certainly increase the demand for genomics-savvy physicians. But more importantly, clinicians stand to greatly benefit from the incorporation of genomics and pharmacogenomics into their own clinical practice. Already, studies showing how specific genetic variants can alter a patient’s response to drugs have led the US Food and Drug Administration to change the label of warfarin and clopidogrel (Plavix). The labels now suggest that a patient’s genetic variants should be taken into account when dosing the drugs for optimal safety and efficacy. While the potential for genomics to influence clinical practice is huge, the benefits will only be realized if physicians are poised to take advantage of them. To that end, medical education needs to be revamped.
For three years, I have served as a teaching assistant for the human genetics course required of all first-year students at Stanford Medical School. Birthplace to the DNA microarray, among other genomic technologies, I imagined Stanford would be an ideal place for medical students to learn about such paradigm-shifting technologies and their impact on clinical medicine. But despite their juxtaposition just two floors below the Department of Genetics, medical students have been lectured on basic principles of genetics with little mention of advances made over the past two decades. Hearing similar anecdotes from colleagues at several other US medical schools led me to the medical education literature, where I learned that this gap in medical education is widespread and must be addressed.
Several organizations have begun to develop learning objectives and competencies in genetics for all health professionals, as highlighted in the article I just wrote for PLoS Medicine. I argue further that physicians should have several additional competencies to fully realize the potential of genetic information in advancing personalized medicine. To in part address this need, I have been working with several faculty members across the School of Medicine to design and implement a new course for medical students on personalized medicine. The course will focus on recent advances in genomics and pharmacogenomics, and how to incorporate genetics into clinical practice. We hope the course, among the first of its kind in US medical schools, will encourage other medical schools around the world to follow suit and help close this gap in medical education.
[…] The dawning era of personalized medicine exposes a gap in medical education […]
Timely, well-written, and well-placed in the public domain. Kudos to Salari for challenging the conventional wisdom of traditional medical education and pushing the boundaries of progress in our profession.
As a medical student myself, personalized medicine seems to be the great new frontier. However, I think the excitement and interest we have in this developing field should be tempered by realistic expectations about discovering its proper place in the practice of medicine. The use of genetic information is not by any means simple, practical, or widespread at this stage. While it is necessary to address the opportunities personalized medicine affords all of us, its role in medical education may be more appropriate as a few lectures within a larger genetics course, or a separate elective course.
Medical education should allow students a preview of the future, but it is also about establishing basics and standards of care. Placing undue emphasis on things that might be would be premature, and probably not the most effective use of students’ time and a school’s resources.
Thanks for your comment, LS.
You raise a good point, which I think speaks to a broader philosophical issue related to medical education. That is, what kind of balance do we strike between teaching medical trainees the fundamentals of medicine versus the start of the art, cutting edge material, some of which may not yet even exist in the clinical realm?
I think there are different schools of thought that address this question, and each medical school forms its educational mission and curriculum accordingly. Some medical schools teach, as they say, ‘to the boards’, while others spend significant classroom hours discussing areas of biomedical research that have promise to impact clinical medicine (e.g. the Stanford curriculum, or the Harvard HST curriculum). The latter approach at the least provides a preview of the future, as you mention, but at best facilitates and encourages physicians-in-training to become pioneering leaders of these emerging technologies and their applications to clinical medicine.
While I agree that significant classroom time spent on genetics/genomics and personalized medicine might be premature for all medical schools across the board, I think the time is right for the ‘early adopters’. Indeed, a couple of US medical schools are implementing some of this material into their curricula.
[…] El concepto de medicina personalizada, se explica a los estudiantes de medicina en su primer año., al parecer en casi todo el munto porque en la revista PLoS Medicine, en la parte dedicada a los estudiantes de medicina (Student perspective), encontramos esta entrada ” The dawning era of personalized medicine exposes a gap in medical education https://speakingofmedicine.plos.org/2009/08/24/the-dawning-era-of-personalized-medicine-exposes-a-gap… […]
Perhaps the biggest challenge in education is not to teach knowledge, but to engender a desire and ability to acquire knowledge. Clearly it has always been the case that a medical student would graduate with a steep learning curve ahead before becoming an independent medical practitioner. With the advent of more health technology and more research available the goal of medical school surely must be to enable people to go on to constantly be learning about the state of the art as and when it is changing?
Aw, this was a really good post. In concept I would like to jot down like this too – taking time and actual effort to make a superb article… but what can I say… I procrastinate alot and by no means appear to get something carried out
Personal genome – DNA card?
We need to establish in future clinical practice the use of BIOCHEMICAL MARKERS (in couple of years by the goal of 1000$ genome)
and at the same time evaluate enviromental and familar factors impacting on a disease.
It is crucial to guide further steps in a diagnostic process (lab work up, immaging…) to reduce a big number of potential affections in a concrete testing of the highest risk for a disease.
In this way it will be our medical generation outcome revolution!