Pharmacogenomics courses in pharmacy school curricula

Abstract

Aim: The appropriate use and integration of pharmacogenetic (PGx) testing will pivot on provider preparation and training. Pharmacists have been recognized as one of the key providers in the delivery of PGx testing and as such, professional organizations have recommended inclusion of PGx content in pharmacy curricula. Methods: We reviewed the curriculum of 132 US pharmacy schools for information about PGx courses. Results: A total of 70 core curriculum courses were identified. 55 (42%) pharmacy schools included at least one PGx course as part of the core curriculum, and ten (8%) schools that offered a PGx course elective. Conclusion: While many pharmacy schools have responded to the accreditation standards to include PGx, less than half of the schools have developed a standalone course.

Pharmacogenomics has been at the forefront of the precision medicine movement. Through pharmacogenetic (PGx) testing, information about a patient’s genetic make-up can be applied to decisions regarding drug selection and dosing. PGx testing can be used preemptively with the expectation that all patients will eventually require medication and test results will be available when that need arises [1,2]. Testing may also be ordered at the point of care, when a specific medication is needed that is known to be impacted by genetic polymorphisms. More than 100 medications include some type of PGx information in the drug label (or package insert) [3].

Whenever testing is ordered, multiple health providers are likely involved in the delivery of care, including nurses, prescribers, pharmacists and laboratory medicine specialists. As with any new health application, workforce preparation is essential to the appropriate test utilization. While the field of PGx is not new, studies indicate many types of providers’ are not prepared to deliver PGx testing [4–10] despite calls for enhancing provider education and awareness [11]. The pharmacy profession; however, has recognized its role in the delivery of PGx testing [12–15] and the need to educate their members – pharmacists. Dating back almost two decades, the American Association of Colleges of Pharmacy Academic Affairs Committee recognized the importance of PGx [16] and supported the efforts to increase pharmacists’ competencies [17]. Currently, pharmacy education in the US is guided by the Center for the Advancement of Pharmacy Education (CAPE) Outcomes and Accreditation Council for Pharmacy Education (ACPE) curricular standards [18]. PGx competencies for pharmacists have also been established and updated several times [19].

A 2010 survey study reported that 69 colleges included PGx in the pharmacy curricula, 15 of which taught PGx as a required standalone course [20]. In that survey, PGx content was primarily taught in the first and second years [20]. Another study reported widespread exposure to PGx in medical schools, though fewer hours of instruction compared with pharmacy schools [21].

There are many approaches that can be taken to present PGx content in pharmacy courses. One approach would be the development of a course focused on the science, and another a continuous integration of PGx throughout the curriculum within the content topic of pharmacotherapy. A comprehensive PGx course may provide skills-based training (obtaining sample, communicating results), and an overview of ethical issues, coverage and reimbursement, and clinical practice guidelines and regulations [22]. Alternatively, the material can be divided into two courses – a basic science course followed by an applied PGx course. In addition, personal testing [23–25], simulation [26] activities and laboratory activities [27] can be added or incorporated into courses to provide students with more interactive learning experiences and expanding the traditional didactic learning experience [28]. Several factors can impact which strategy will be appropriate for a given school including availability of expert instructors, faculty development/experience and competing teaching priorities.

Almost a decade has passed since the last published evaluation of the extent of PGx courses in pharmacy curricula [20]. With continuing advances in the understanding of PGx mechanisms and impact of genetic variation in drug response, the availability of an array of clinical PGx tests [29], and continuing calls for provider awareness [15], the need for pharmacist training in this field remains the key. Thus, in this paper, we explored the extent of PGx courses in pharmacy curricula currently offered in US schools in 2019.

Methods

Currently, there are 142 pharmacy schools with full accreditation status by the ACPE (as of 4 February 2019) offering Doctorate of Pharmacy degrees in the US. We reviewed each school’s PharmD curriculum on their website, specifically searching for course titles or descriptions with the terms ‘pharmacogenetics,’ ‘genomics’ and ‘pharmacogenomics’. We did not include the term ‘genetics’ to avoid courses that were more general with respect to molecular biology, molecular genetics, cell biology or human genetics. We recorded the following information: school name and if it was affiliated with a medical or osteopathic school (a 4-year program offering a doctorate of osteopathic medicine or DO); if a course was offered and if so, the title of the course; if it is a required or elective course; and if required, the curricula year the course is to be taken. Also, if multiple PGx courses were included in the curricula, we recorded the earliest year a required PGx course was offered. The curricula year refers to the professional years of pharmacy school (P1, P2, P3, P4). We classified a course as a ‘standalone’ course if it focused primarily on pharmacogenomics and the content was not combined with other topics.

For our analysis, we removed multiple locations/branch campuses of schools if the curriculum was the same in each location (e.g., distance learning was provided and students were able to take the same classes at both locations). We also removed one school that did not post their curriculum on the website, yielding a total of 132 schools. The search was conducted in January–April 2019. Frequency and descriptive statistics were calculated. χ² testing was performed to assess relationship between PGx courses offered at pharmacy schools with or without a medical or osteopathic school (significance level 0.05). Thematic analysis of course titles and/or descriptions were performed in which common phrases were first identified in the text and then coded into themes or patterns.

Results

We identified 55 (42%) pharmacy schools that included at least one PGx course as part of the core curriculum and ten (8%) schools that offered a PGx course elective (Table 1). A total of 70 core curriculum courses and 12 elective courses were identified. 21 PGx courses (38%) that were part of the core curriculum were offered in the second year of the curriculum. One school included PGx content in its specialty pharmacotherapy courses in its core curriculum and also offered elective courses. Another school included four PGx courses in its core curriculum. We hypothesized that pharmacy schools located on a campus with a medical or osteopathy school may be more likely to offer a PGx course due to the larger group of biomedical research faculty that may be working in PGx. However, of the 55 total schools that included a PGx course in their core curriculum, almost half (44%) were based at a campus without a medical or osteopathic school (p = 0.28).

Table 1. . Summary of pharmacy schools’ availability of pharmacogenetic courses.

PGx course	Number
Place in program (per school): – Core curriculum – Elective	55 10
Curriculum year for schools requiring PGx course (excludes schools that offer PGx course only as elective): – First year – Second – Third	17 21 17
Type of school/campus: – Pharmacy (no medical or osteopathic school) – +Medical School – +Osteopathic School	24 24 7
Total number of schools that have a PGx course	65/132

PGx: Pharmacogenetic.

Of the 72 required PGx courses, the most common course title was ‘Pharmacogenomics’ or ‘Pharmacogenetics’ (a total of 15 courses) (Box 1). Among the most common course titles, eight courses combined PGx with ‘pharmacokinetics’, seven courses combined PGx with ‘genetics’, six courses combined it with ‘personalized medicine’ or ‘precision medicine’ and three courses combined it with ‘molecular biology.’ Based on a review of 48 course descriptions we collected (the remainder could not be accessed online), we coded 40 of courses as general or a basic overview of PGx, that included the principles of (human) genetics, molecular biology and/or PGx; the remainder were considered as applied/clinical courses about PGx, describing the applications of PGx, biotechnology, personalized or precision medicine. 11 courses ‘introduced’ concepts, and the most common terms included were ‘metabolism’ (15 courses), ‘pharmacokinetics’ (12 courses), and ‘variation’ and ‘ethical’ (nine courses each).

Box 1. Pharmacogenetic course titles.

Core curriculum courses (70)

• Advanced Pharmacogenomics

• Applied Biomedical Sciences Workshop

• Applied Pharmacogenetics and Precision Medicine

• Applied Pharmacokinetics & Pharmacogenomics (x2)

• Applied Pharmacokinetics and Pharmacogenomics I

• Applied Pharmacokinetics and Pharmacogenomics II

• Applied Pharmacokinetics and Pharmacogenomics III

• Biopharmaceutics and Pharmacogenomics

• Biopharm & Pharmacogenetics

• Clinical Pharmaceutics

• Clinical Pharmacokinetics and Pharmacogenomics

• Essentials of Pharmacogenomics

• Foundations of Pharmaceutical Chemistry & Pharmacogenomics I

• Foundations of Pharmaceutical Chemistry & Pharmacogenomics II

• Fundamentals of Molecular Biology and Pharmacogenomics

• Genetic Control of Cell Structure and Function, Genes, and Pharmacogenomics

• Genetics and Pharmacogenomics

• Immunology, Biotechnology, and Pharmacogenomics

• Immunology, Immunotherapy, and Pharmacogenomics

• Integrated Pharmacotherapy (IPT blocks): Introduction, Nervous System I/II, Cardiovascular I/II, Gastrointestinal/Endocrine & Reproductive, Renal & Urologic, Pulmonary & Critical Care, Hematology/Oncology, Immune/Musculoskeletal/Integumentary

• Introduction to Pharmacogenomics and Molecular Biology

• Personalized Therapeutics: Clinical Pharmacokinetics/Pharmacogenomics/Pharmaceutics

• Pharmaceutical Biochemistry II – Molecular Biology and Pharmacogenetics

• Pharmaceutical Biotechnology & Pharmacogenomics

• Pharmaceutics/Pharmacogenomics

• Pharmacogenetics

• Pharmacogenetics and Pharmacogenomics

• Pharmacogenetics, Genomics and Personalized Medicine

• Pharmacogenomics (x14)

• Pharmacogenomics I

• Pharmacogenomics II

• Pharmacogenomics and Contemporary Biotechnology

• Pharmacogenomics and Drug Metabolism

• Pharmacogenomics & Med Genetics

• Pharmacogenomics & Personalized Medicine (x3)

• Pharmacogenomics: Personalized Medicine

• Pharmacogenomic Therapies

• Pharmacokinetics and Pharmacogenomics (x2)

• Pharmacology and Pharmacogenetics

• Pharmacotherapy: Pharmacogenetics

• Pharmchem & Pharmacogenomics I

• Principles in Human Genetics & Pharmacogenomics

• Principles of Pharmacogenomics (x2)

• Therapeutic Drug Monitoring Translational Pharmacogenomics

• Principles and Clinical Applications

Electives (12)

• Advanced Topics in Pharmacogenomics

• Clinical Applications in Personalized Medicine

• Genetics and Pharmacogenomics

• Introduction to Pharmacogenomics

• Pharmacogenomic Literature Assessment

• Pharmacogenomics (x4)

• Pharmacogenomics: Genetic Basis for Variability in Drug Response

• Pharmacogenomics Lab Principles of Pharmacogenomics and Personal Medicine

Discussion

Pharmacists are increasingly recognized as leaders and team members in the delivery of PGx testing [12,14]. To prepare pharmacists to play a leading role in the delivery of PGx testing, efforts have been underway to integrate PGx content into pharmacy school curricula and establish core competencies for pharmacists [19,30]. While the importance of PGx education has been noted for a range of health providers [31–33], the pharmacy community appears to have been making the greatest strides to prepare their workforce. To date, we find that more than half of the US pharmacy schools include a course specifically on PGx or pharmacogenomics, and 10% offer elective PGx courses.

Given the complexity and rapid advancements in genetic/genomic technologies and interpretation of the clinical significance of PGx variants, course development may be challenging and require ongoing revisions. Some primary challenges with incorporating PGx content in pharmacy curricula are how to deliver the necessary skills and knowledge to pharmacy students and the availability of expert faculty to do so [34]. Of the pharmacy schools with PGx courses, we found no significant difference in inclusion of PGx courses in pharmacy curricula between schools affiliated with a medical or osteopathic school (where potentially more PGx research is being conducted or testing implemented in academic centers, and thus, more experts available) and pharmacy schools not affiliated with a medical or osteopathic school. At least one school has partnered with an academic medical center and developed PGx courses [35]. In some cases, schools may adapt publicly available curricular material or develop a team-taught course with guest lecturers to incorporate PGx content. Murphy et al. [20] reported in their 2010 study that PGx courses were predominantly team-taught and there was strong interest in shared curricula, such as PharmGenEd, developed by a team at the University of California, San Diego (CA, USA). Some educational resources are available [36], some specific to pharmacists [37], including shared pharmacy curricula [38] and train-the-trainer approaches [39], which can greatly benefit schools lacking an in-house PGx expert. Furthermore, online courses could supplement classroom lectures and can greatly enhance practicing providers’ knowledge [40,41].

In the ACPE 2016 standards, pharmacogenomics is listed as a required element in the section on pharmaceutical sciences and clinical sciences under the subsection on pharmacotherapy [42]. In line with these standards, our review of course titles indicates that schools are divided as to the placement of PGx courses – either as an introductory or general science course or, alternatively, as an advanced course on applications. Our data indicate a large increase in the number of standalone PGx courses since Murphy et al. [20] reported that 15 schools had a standalone PGx. Thus, the number of didactic hours have increased substantially over recent years. It is unclear if pharmacy students are gaining exposure to both the fundamental principles regarding genetics, penetrance and variation as well as appropriate utilization of PGx tests and information about ethical, legal and social issues (ELSI), such as genetic discrimination, familial implications and anxiety about medications related to PGx test results. ELSI is currently included in PGx competencies for pharmacists [19] and we identified nine of the 48 available course descriptions as including the term ‘ethical’, ‘legal’ and/or ‘social’. This disparity in content was noted in 2010 by Murphy et al. [20]

Some limitations of the study should be noted. As data were retrieved from pharmacy curriculum websites and not confirmed by an instructor or administrator, it is possible that the information was outdated and incorrect. In addition, course titles or descriptions may not have explicitly noted PGx or provided a comprehensive description of lecture topics (such as ELSI) covered in the course. Therefore, some courses may not have been identified as a ‘PGx course’ and/or the content analysis was limited without a course syllabi. We speculate that PGx content is offered in an even higher number of schools, as PGx content may be embedded in courses on molecular biology, pharmacotherapy and clinical applications. Future surveys of associate deans of education or curriculum directors may yield further insight regarding the inclusion of PGx in courses and facilitators/barriers to increase PGx content.

During this period of transition, there will likely be uneven levels of knowledge and awareness about PGx between new graduates and practicing pharmacists, preceptors and prescribers [43,44]. As limited provider knowledge can impede integration and utilization of PGx testing in clinical settings [4–10], it is essential to raise the level of awareness about PGx and available tests. With the support of professional and educational organizations, PGx has permeated pharmacy curricula. The continued availability of resources for course instructors and developers will be important to enable new course development and course revisions as data and clinical practices change. Partnerships between the pharmacy community and other health provider educators can further facilitate more development of new courses or integration of PGx content in existing courses to even the level of awareness among providers. As the field continues to advance, it is essential for pharmacy schools to provide course instruction on PGx to prepare the next generation of pharmacists to serve as both leaders in PGx and participate in team-based delivery of PGx testing.