The "Physician Assistant Competencies for Genomic Medicine: Where We Are Today and How to Prepare for the Future" meeting was held at the Natcher Conference Center of the National Institutes of Health (NIH) in Bethesda, Md. on March 29-30, 2007. The conference was organized and supported by the National Human Genome Research Institute (NHGRI), with participation of leadership from the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA); the American Academy of Physician Assistants (AAPA); the National Commission on Certification of Physician Assistants (NCCPA); and the Physician Assistant Education Association (PAEA).
The field of genetics and genomics are moving forward rapidly. Within the next few years, we will discover most of the common hereditary factors that play a role in disease, which will lead to the development of many more genetic tests, including ones related to common diseases. The Physician Assistant community is poised to use the power of the human genome to make a difference in public health by bringing genomics into practice. While such developments will soon make genetics increasingly important to the practice of medicine, Physician Assistants are well positioned now, as a vital part of the medical team, to integrate existing genomic tools, such as family history, into current practice.
The goal of this meeting was to develop an outline for how Physician Assistants could utilize current and anticipated knowledge of genetics and genomics as the basis for improving clinical care and make personalized medicine a regular part of patient care.
The NHGRI is pleased to present this summary of the meeting proceedings. We would like to thank all of the presenters, break-out group leaders, and participants for their active participation and for their thoughtful contributions that form the basis for this summary.
The body of this report summarizes each session and concludes with the action plans proposed by each of the four Physician Assistant organizations present at the meeting, as well as other recommendations made by the participants.
Included also are:
The conference opened with welcoming remarks from Acting Surgeon General Kenneth Moritsugu, Dr. Francis Collins, Director of NHGRI, and Mr. Michael Rackover, PA-C of Philadelphia University.
A series of talks were then presented, with interactive discussion periods following each talk. Brief summaries of the talks follow:
Genetic medicine focuses on the impact of single genes on disease, while genomic medicine includes the effect of the entire genome on disease (and health). Genomic medicine is based on the foundation of the Human Genome Project (HGP), which was completed in 2003.
The science and technology related to genetics and genomics are moving forward rapidly. Genomics will change medicine by: creating a fundamental understanding of the biology of many diseases, even many "non-genetic" ones; leading to defining disorders by biology of causation, rather than by symptoms; and providing knowledge of individual genetic predispositions via microarray and other technologies. Genomics will help enable health care providers to treat patients based as the biological individuals they each are.
The family history is a tool we have readily available to personalize medicine now. The U.S. Surgeon General's Family History Initiative encourages individuals and families to talk about their family medical histories and record information to share with their health care providers.
In anticipation of the increased use of genomics in health care, the Genetic Information Non-Discrimination Act (GINA) is currently being considered in Congress, and President Bush has indicated he would sign such legislation if it reached his desk. If enacted, GINA would limit health insurers' and employers' access to, and use of, genetic information.
The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) protects the interest of the public and the Physician Assistant profession by defining the standards for Physician Assistant education and evaluating Physician Assistant educational programs within the territorial United States to ensure their compliance with those standards. ARC-PA became a free standing body in 2001. There are currently 136 accredited programs.
The Standards for Physician Assistant Education outline the requirements for an accreditation of programs. The standards are competency based and have specificity regarding curriculum requirements, but do not prescribe a specific academic degree. The current standards were revised in 2006 and include a requirement for instruction in genetic and molecular mechanisms of health and disease.
The purpose of the Physician Assistant Education Association (PAEA) is to improve quality of healthcare for all patients by fostering excellence in Physician Assistant education. PAEA represents the 136 accredited Physician Assistant educational programs and provides services for the 1,500 faculty and staff who run them.
Physician Assistant programs average 26 months in length with one year of clinical training and one year of didactic training. Advances in genetics, as well as other areas of medicine, are leading to new demands on practicing Physician Assistants. PAEA recently conducted a survey of Physician Assistant programs to gather data that might assist in developing specific genetics competencies, genetics curricula, and curricular delivery methods for Physician Assistants and Physician Assistant educators. The Web-based survey consisted of 18 questions. One-hundred out of the then 134 existing programs responded to the survey (~75 percent).
A sample of the survey results show the following:
The full survey results will be published in the coming months. PAEA sees an opportunity to position Physician Assistant educators as leaders in teaching of genetics in medical education.
The National Commission on Certification of Physician Assistants (NCCPA) is the national certifying agency for Physician Assistants in the United States. Founded in 1975 as an independent not-for-profit organization, NCCPA is dedicated to assuring the public that certified Physician Assistants meet professional standards of knowledge and skills. More than 65,000 Physician Assistants have been certified by NCCPA. All 50 states rely on the NCCPA certification criteria for licensure or regulation of physician assistants. Recertification of Physician Assistants is required in only 23 states; however, about 92 percent of Physician Assistants maintain their certification.
The current competencies for the Physician Assistant profession were approved in 2005. The Content Blueprint for the Physician Assistant National Certifying Exam (PANCE) does not currently have a section on genetics, but genetic diseases are included as examples and some genetics questions are included on the exam.
The American Academy of Physician Assistants (AAPA) represents the interest of Physician Assistants in clinical practice and educational and research settings. Physician Assistants are members of the healthcare team and practice with the supervision of a physician. There are 40,000 Physician Assistant and student members of AAPA. AAPA provides CME services to the community. It also has alliances with several other medical organizations.
Some statistics about the profession:
The fields of genetics and genomics are changing rapidly. A modern day view of the genome looks different from the linear set of sequences of ACTG we usually see. The genome involves a complicated network of interactions, and we are just beginning to unravel the relevant biological pathways and metabolic networks.
Patients are catching up to the practitioner, if not already ahead, in terms of awareness of genetics news. Practicing Physician Assistants and students need to be knowledgeable regarding genetics; however, it's not easy to determine how to fit all of the items needed into the curriculum.
There are different levels of what the Physician Assistant needs to know about genetics. Three basic items that Physician Assistants should know about genetics are:
Advances in technology such as pharmacogenetic testing and the $1,000 genome will enable us to personalize medicine. Use of the Electronic Medical Record will allow results of genetic tests and other medical information to reside in one location for facilitated analysis.
There is a role for all health care providers in genetics. Role models can be useful in getting the rest of the community to "buy into" genetics.
Genomic Medicine offers the next major breakthrough in diagnosis, prevention, and cure of disease. Should race be a part of genomic medicine? How do we use race as a concept in thinking about genetics? Many disciplines are engaged in the conversation about race as a concept, and articles in the scientific literature have expanded from commentaries on race to scientific articles on genetic variants.
Personalized medicine is more effective than medicine based on race. When should we use race and ethnicity to assist with personalized health care decisions? There is limited empirical data on health professionals' understanding and beliefs about race and human genetic variation. Thoughtful use of racial and ethnic categories is required in health services, clinical and genetic research, and clinical care. Developing a deeper understanding of health professionals' knowledge of human genetic variation, attitudes about human genetic variation, and use of race in clinical practice will be instrumental for successfully translating genomics into clinical practice.
We've been promising a revolution in health care driven by the Human Genome Project, but it is hard to get students to learn about genetics based only on promise.
A survey by the Genetic Alliance and the National Coalition for Health Professional Education in Genetics (NCHPEG) asked individuals and family members affected with "genetic disease" about their experiences with a variety of health professionals not trained in genetics. The survey results demonstrate a missed opportunity for health professionals to educate patients and families regarding genetics (In Press for Genetics in Medicine [geneticsinmedicince.org]).
There are challenges and barriers to expanding and improving education in genetics for health professionals who are not genetics specialists. Barriers to genetics education for health professionals include crowded curriculum, misconceptions about genetics, lack of knowledgeable faculty, a disconnect between basic sciences and clinical experiences during training, failure to integrate genetics across the curriculum, and inadequate representation of genetics on certifying exams. Barriers to the integration of genetics into primary care include a dearth of genetics professionals, lack of knowledge about genetics among primary care providers, lack of confidence, inadequate family histories, lack of referral guidelines, and limited payment for genetics-related services. We need to look at the "other side" of the barriers to identify the drivers for adopting genetics into practice.
Providers need to learn to look for the red flags that can be identified through reviewing a patient's family history.
There is no niche for genetics in curricula; it is actually the information on which everything else rests. Case-based approaches, layered content, relevant clinical guidelines, guidelines for referral, and links to resources can all be very useful in teaching genetics to Physician Assistants. NCHPEG and AAPA are working together to develop the "Genetics in PA Practice" program, which is a case based and interactive tool. The tool is going into field testing in April 2007.
On the afternoon of Day 1 (Thursday), each attendee participated in one of two breakout groups. Both of these breakout groups were given the same charge: to focus on the Physician Assistant profession in general (rather than any specific PA organization) and to discuss how to integrate genetics/genomics into Physician Assistant education and practice, as well as to describe obstacles to this integration and ways to surmount these obstacles. Each of these two breakout groups reported back on the morning of March 30:
After discussion of these presentations, the meeting attendees split into new breakout groups - this time, four groups sorted by Physician Assistant organization - to discuss how each organization might implement the recommendations from the first set of break-out groups. Each of these four breakout groups reported back, as follows:
The entire group then discussed these four breakout group reports, as well as other "next steps," as follows.
A lot has been accomplished in this short meeting. The Physician Assistant
community is very cohesive and well suited for the opportunity to be change
agents. NHGRI would like to be partners in this endeavor through the following:
" Visibility of the U.S. Surgeon General's Family History Initiative at the upcoming AAPA Annual Meeting. Consider making laptops and printers available for attendees to view the "My Family Health Portrait" website and complete their own family history at either the 2007 or 2008 annual AAPA meeting.
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Last Reviewed: April 20, 2012