From one size fits all to a tailored approach: integrating precision medicine into medical education | BMC Medical Education

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From one size fits all to a tailored approach: integrating precision medicine into medical education | BMC Medical Education

Precision Medicine (PM) is a rapidly advancing field that challenges the traditionally taught clinical approach and encourages a multi-disciplinary approach to patient care. While the pace of genomic discovery is at an all-time high, the adoption and application of these advances has been slow. Therefore, it is crucial to assess the knowledge and attitude of both medical students and practitioners towards precision medicine, as well as identify the barriers to its implementation. The results of this study can help inform medical education curriculums and improve patient outcomes through the incorporation of PM into clinical practice [12]. The present study included 607 respondents of which 312 were medical students and 295 were physicians of varying levels of expertise.

Understanding the current state of knowledge of both students and practitioners is essential to the implementation of PM. A baseline allows for providing adequate training and emphasizes the urgency of doing so. It was highlighted by Mason-Suares, H. et al. (2016) that a new spectrum of skills is required from healthcare providers, to implement precision medicine; these skills include but are not limited to managing diagnostics facilities, gauging the relevance of tests, and implementing cost-effective procedures [13]. The present study showed that medical students and physicians had a moderate knowledge level about genetic testing and PM, indicating a need for further training and education. Studies conducted in various countries have consistently established the gap in knowledge about precision medicine among healthcare workers of all levels of seniority [14,15,16,17].

A systematic review by Tajik et al., explored the application of various trial designs to achieve personalized oncology treatments, with a notable focus on ‘biomarker strategy designs’ as a frequently utilized treatment strategy [18].

This further emphasizes the use of a ‘tailored approach’ and the effectiveness of targeted therapy in a critical speciality, such as oncology, to ensure optimal patient outcomes. A recent scoping review by Superchi et al., identified 21 trial designs, 10 subtypes, and 30 variations used in personalized medicine, categorizing them into four core types: Master protocol, Randomise-all, Biomarker strategy, and Enrichment. It highlighted the predominance of master protocols in oncology and introduced a new classification system to better navigate the complexities of PM clinical trials [19].

At the time of writing this paper, Precision Medicine remains conspicuously absent from the educational framework of any university in Jordan, encompassing both the core curriculum and the training modules designed for physicians [7]. While sporadic instances exist where certain modules briefly discuss genomic and precision medicine concepts, these engagements lack a systematic and purposeful approach. Moreover, the disseminated information tends to be portrayed to medical students as a futuristic abstraction rather than an imminent and integral aspect of medical practice. This observation aligns with the findings of a study conducted by Al-Zoubi et al. within a similar demographic context in Jordan [7]. In Jordan, the absence of precision medicine education underscores a broader issue in the region. Unlike countries with more advanced frameworks, Jordan faces challenges related to integrating PM due to limited resources and infrastructural support. The enthusiasm for PM among medical students and physicians, despite the current gaps, suggests a readiness for implementation. To bridge this gap, targeted strategies are necessary to foster the effective implementation of PM in Jordan’s healthcare system.

To effectively incorporate Precision Medicine into medical education, a systematic approach is essential. Implementation into Jordan’s medical education system and healthcare infrastructure must encompass various aspects, including curriculum integration, faculty development, encouraging hands-on experience, and innovative teaching methods.

The process begins by identifying successful implementations that can provide valuable guidance for developing comprehensive educational programs [20, 21]. The initial step involves addressing clinician knowledge gaps. Subsequently, engaging faculty members in specialized workshops focused on practical genomic applications and effective lecture techniques becomes vital [22]. Collaborating with genetics educators facilitates the seamless integration of Precision Medicine into the official medical school curriculum. Hands-on experiences, such as DNA extraction and exome sequencing, enrich genetics courses, enabling a deeper understanding of the subject matter [22]. The implementation of ‘flipped classrooms,’ where students engage independently with course materials and participate in interactive in-person sessions, has proven to be an effective pedagogical approach [21]. These strategic initiatives collectively equip healthcare professionals with essential knowledge and skills in the realm of Precision Medicine, fostering a more coherent and comprehensive educational experience.

Once medical graduates are equipped with the necessary knowledge, it is imperative to ensure that Jordan can implement this knowledge in real-world settings. Policy, governmental support, and institutional backing are crucial for driving this change, providing funding, policy adjustments, and incentives to all involved parties.

Knowing how receptive future and current practitioners are to the practice of PM is important to gauge the true application of such innovations in clinical practice. The present study demonstrated positive attitudes despite limited current knowledge, with 80.9% of respondents willing to use a patient’s genetic information to guide decisions in clinical practice. This value is comparable to a study from Adelaide Medical School in Australia, where 73% (85/116) showed willingness to implement PM [3]. This similarity was also found when measuring the willingness to use genome-guided prescribing tools even if more senior physicians were not, which was 78.4% in the selected Jordanian sample, and 72% (83/116) at Adelaide Medical School [3]. This indicates the potential for widespread implementation of PM in Jordan.

A great majority of the participants were willing to expand their knowledge of the topic. However, they were hesitant to take up learning on their own, regardless of their level of expertise. This implies that practitioners are largely unfamiliar with the field of PM. Students preferred to see PM integrated within the curriculum, while physicians showed interest in workshops, external to core learning. Webinars and courses were also popular choices, but reading material was not. This indicates the need for external assistance from professionals in the field and highlights the importance of adapting teaching methods to the level of expertise of the learners. As expected, younger participants were more malleable to adapting to change, and showed greater eagerness to learn. Integrating PM into the medical curriculum will require overcoming limited funding, relevant expertise, foundation, and framework. Medical education is reliant on the presence of good examples for students to emulate, which in the case of PM, is lacking [23].

However, while PM has been received in a positive light from both medical students and physicians, concerns arose with regards to its application. Concerns regarding patients’ anxiety about test results (77.8%) and a breach of confidentiality (75.3%) were reported by most participants. Additionally, participants, regardless of their level of expertise, were uncomfortable with interpreting genomic test results and recommending them to patients. To ensure the preparedness of practitioners for the application of PM, it is important to not only provide them with the necessary knowledge but to also supplement them with the confidence to apply this knowledge gained. Innovative teaching methods may be helpful in doing so. A study at Stanford School of Medicine found that students that analyzed their own genotyping data had increased knowledge and confidence in the results of personal genome testing [24] .

Interestingly, there was a stark difference in the perceived barriers towards integrating PM. Most (80.2%) of medical students identified cost to be the main hurdle, while physicians almost unanimously agreed (92.9%) believed it was limited accessibility. A study in the UAE concluded that cost, lack of training and insurance coverage, (62%, 57.8% and 57.2% respectively) were the 3 major barriers perceived amongst healthcare workers [4]. Concerted efforts must be made to address these hurdles and broaden the application of precision medicine.

The present study had several strengths, including being the first of its kind in Jordan. The sample included medical students from all medical schools and physicians with different seniority levels across the country. By using a simple random sampling strategy, we aimed to ensure that each individual within the population had an equal chance of being selected, thus enhancing the generalizability of our findings. The calculated sample size, adjusted for a 70.7% response rate, provided sufficient statistical power to draw meaningful conclusions. However, it is important to recognize that non-response bias could affect the generalizability of our results. Although we made efforts to increase participation through follow-up reminders, some subgroups might still be underrepresented.

One strength was that we explored the interests of medical students and physicians in learning more about PM, and their preferred teaching tools, which can inform effective teaching strategies in the future.

However, there were some limitations. One limitation was the use of Likert scales which are susceptible to central tendency bias due to selection of neutral answers. However, the low percentage of neutral answers helped decrease the potential impact of this bias on the results.

This cross-sectional study was based on self-reported information provided by students and physicians. Therefore, there is potential for reporting bias which may have occurred because of the respondents’ interpretation of the questions or simply because of inaccuracies of responses. To mitigate potential bias, definitions for ‘precision medicine’ and ‘pharmacogenomics’ were provided prior to the attitude section, along with an example of precision medicine in oncology. This ensured that all respondents had a clear understanding of these terms, reducing the risk of misinterpretation.

To address self-selection bias, we used several strategies. We distributed the questionnaire through multiple channels, including university email lists, social media, and professional networks, to reach a broad and diverse audience. We also sent follow-up reminders to encourage a higher response rate. Furthermore, we compared the demographics of our sample with those of the broader population of medical students and physicians in Jordan to assess representativeness and identify any significant discrepancies.

Although the sample size was sufficient for our analyses, it may limit the generalizability of our findings. We made every effort to collect data from all medical schools across Jordan, but it wasn’t feasible to reach every area where physicians practice. Additionally, the voluntary nature of participation might have introduced self-selection bias, as those with a particular interest or existing knowledge in precision medicine may have been more inclined to respond. To ensure a broader representation, future studies should aim for larger and more diverse samples, which would help validate and expand upon our findings.

Another limitation was the aggregation of all physicians in one category regardless of their specialty and seniority level. Future studies should focus on physicians in each specialty to inform the proper adaptation of PM into different residency programs.

To enhance the robustness of the regression analysis, a backward stepwise logistic regression was employed. This method automatically selects relevant features while excluding irrelevant or redundant predictors. The stepwise approach facilitates the elimination of independent predictors that do not contribute significantly thus optimizing model performance [25]. Model significance was assessed using the Nagelkerke R² to explain the variance in knowledge scores and the percentage accuracy in classification.

Additionally, the ROC curve was utilized to evaluate the model’s performance and measure its discriminative ability [26].

The model’s discriminative ability, indicated by an AUC of 0.69, was considered satisfactory by Trifonova [27], or modest according to Howell [28] and kumar [29].

Our present research does not aim to design a predictive tool; rather, it utilizes regression modeling to identify the major variables impacting knowledge levels in our sample, as detailed in Table 4.

Potential ethical concerns related to the study’s findings include privacy and consent, equity and access, and genetic discrimination. Protecting patient genetic data requires robust privacy safeguards and clear consent protocols [30, 31] Integrating Precision Medicine into medical education must address disparities in access to genomic technologies, ensuring benefits for all patients regardless of socioeconomic status. Additionally, the risk of genetic discrimination necessitates comprehensive training on ethical standards and legal protections, which must also be included while building the curriculum, to prevent misuse and ensure equitable application in clinical practice. Legislation such as the Genetic Information Nondiscrimination Act (GINA) provides a framework to protect individuals from discrimination based on their genetic information by employers and health insurers​ [32]. The application of precision medicine may bring about a unique set of risks and pitfalls, and without careful consideration, may lead to more harm than good. Concerns regarding overdiagnosis, overtreatment, and unnecessary use of resources, can be tackled by performing rigorous validation, rather than relying on weak correlations, as well as standardization of predictive markers.

Several factors could impact the integration of precision medicine into healthcare, notably the need to address the educational and staffing gaps [33]. Training programs should be expanded upon to include rotations dedicated to precision medicine in genetics labs, research centers, and clinical settings. Continuing medical education (CME) courses and workshops on recent advancements, applications, and the latest research should be provided. Online learning modules and webinars can be utilized to facilitate ongoing education for both students and practicing physicians. Accreditation standards can be revised to include competencies in precision medicine, ensuring that medical schools and residency training programs integrate these principles into their curricula.

Future research in this field should consider several key areas. First, conducting longitudinal studies could significantly improve the integration of precision medicine principles into medical education and healthcare practices. These studies would help identify the long-term impact of educational interventions designed to enhance the understanding and application of precision medicine among medical professionals. Additionally, focusing on specific medical specialties would be beneficial to understand how precision medicine can guide more targeted educational strategies and resources tailored to the unique needs of each specialty. Another important area is interventional studies. Investigating the effectiveness of various educational interventions, such as curriculum enhancements, workshops, and online modules, could provide valuable insights into how best to improve knowledge and attitudes toward precision medicine.

Given that this study explores knowledge, attitudes, and perceived barriers to precision medicine in Jordan, it is crucial to recommend a careful and critical approach when applying precision medicine in clinical settings. Predictive markers, like novel treatments, require rigorous clinical validation to prevent overdiagnosis, overtreatment, and the risk of patients being denied effective therapies. Healthcare professionals must develop the skills to evaluate the validity and relevance of biomarkers, ensuring the responsible and effective integration of precision medicine into practice.

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