Download Continuous Professional Development plan for clinical and

Continuous Professional Development plan for clinical
and pre-clinical medical doctors
CASyM training concept
June 2014
CASyM | Implementation of Systems Medicine across Europe
IMPRINT
Publisher
CASyM administrative office
Project Management Jülich, Forschungszentrum Jülich GmbH
[email protected]
Authors
Jure Acimovic, Charles Auffray, Gerold Baier, Mikael Benson, Elliot Crooke, Howard Federoff, Mika Gustafsson,
David Harrison, Colm Nestor, Damjana Rozman, Jesper Tegnér, Sona Vasudevan, Hans Westerhoff, Huan Zhang
Date
June 2014
Contact information
Mikael Benson
Linköping University, Sweden
[email protected]
Please take note that the content of this document is property of the CASyM consortium. If you wish to use
some of its written content, make reference to: CASyM training concept: Continuous Professional
Development plan for clinical and pre-clinical medical doctors, June 2014.
CASyM training concept: Continuous Professional Development plan for clinical and pre-clinical medical doctors | June 2014
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CASyM | Implementation of Systems Medicine across Europe
TABLE OF CONTENT
Summary…………………………………………………………………………………………………………………………………………………………..4
Background………………………………………………………………………………………………………………………………………………………5
Experiences from teaching systems medicine to medical students, clinical and pre-clinical MDs,
As well as other categories ............................................................................................................................. 5
Medical students .................................................................................................................................... 5
Preclinical and clinical MDs..................................................................................................................... 6
How to teach systems medicine? ............................................................................................................................ 8
Implementation of training and education in Systems Medicine ................................................................... 8
Central questions and short answers extracted from the open discussion .................................................... 9
Should we learn Systems Medicine as a tool or knowledge? ................................................................. 9
Should we set different aims and methods for different groups of people
(medical students, research doctors, general practitioners, etc.)? ........................................................ 9
How to make the students and doctors feel interested in this? ............................................................ 9
EACCME accreditation for European CME credits .......................................................................................... 9
Future plan………………………………………………………………………………………………………………………………………………………10
2014 .............................................................................................................................................................. 10
2015 .............................................................................................................................................................. 10
Acknowledgements…………………………………………………………………………………………………………………………………………11
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CASyM | Implementation of Systems Medicine across Europe
SUMMARY
An important problem in health care today is that many patients do not respond to medication. The estimated
cost of ineffective medication in the US alone is estimated at $350 billion per year. Variable treatment
response is also an important reason for the enormous costs of drug development.
Reasons include that common diseases involved altered interactions between thousands of genes and
environmental factors, in combinations that may vary between patients that do or do not respond to
treatment. It would be very difficult to gain understanding of such alterations by studying individual genes or
factors one by one. Systems medicine offers solutions to understanding such complex alterations. However,
currently most medical students and clinicians are unaware of systems medicine. There is therefore a great
need for training both categories in systems medicine, and preparing them for the changes in healthcare that
are likely to result from systems medical research within the next decade. Developing a Continuing
Professional Education (CPD) plan in systems medicine for medical students and clinicians is complicated by
the need to integrate multidisciplinary expertise in fields such as genomics and bioinformatics, which are
currently not well represented in medical curricula. Here, we propose a CPD plan, which is based on
integrating multidisciplinary expertise for both training of medical students and clinicians. However, it is
possible that training of medical students may also benefit by integrating it with student categories that
represent other disciplines. Because few universities offer systems medical training for medical students and
MDs, a major challenge is how to scale existing training efforts and how to provide appropriate accreditation.
We believe that training goals can be realized by combination of classical teaching, project based works and
workshops / tutorials, together with e-learning approaches. The accreditation goals can be achieved through
the ECTS system for medical students and by EACCME system for medical doctors who would aim to specialize
in systems medicine during their continuous professional education. The ECTS credit exchange is in use in a
large number of Universities in Europe. It would allow medical students to take systems medicine courses at
another University, i. e. within the Erasmus exchange, and use these credits for the formal requirements at
their home Universities.
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CASyM | Implementation of Systems Medicine across Europe
BACKGROUND
Despite impressive advances during the last century, modern health care is faced with enormous challenges.
One important problem is that currently available drugs show highly variable clinical efficacy, which results not
only in suffering, but also contributes to increasing costs. The annual cost of ineffective drugs in the US alone is
estimated at 350 billion dollars. Variable efficacy is also adding to the huge costs associated with drug
discovery, development and clinical trials (on average one billion dollars per drug), which further impacts the
financing of health care. One reason for variable treatment response may relate to disease heterogeneity.
Another reason is that medical treatment is provided generally in a reactive rather than a proactive approach.
In some diseases, for example rheumatoid arthritis or cancer, delayed treatment resulting from a reactive
approach may cause irreversible damage or death. These problems have led to defining new goals for health
care, namely that it should be predictive, preventative, personalised and participatory – P4 medicine.2 In other
words, patients should ideally be treated before they become symptomatic, and in a way that is tailored to
their individual disease mechanisms.
Systems medicine is likely to contribute to P4 medicine within the next decade. However, despite this
potential many medical students, clinicians and teachers in medical schools are unaware of systems medicine.
In general, systems medicine is not integrated in medical curricula or in CPD courses. Such an integration is a
considerable challenge because of the complexity of common diseases, and because systems medicine
requires the integration of different disciplines. In this report, we 1) describe our experiences from teaching
systems medicine to medical students, clinicians as well as other categories, 2) summarise discussions about
how to teach systems medicine, and 3) propose a CPD plan for clinical and preclinical MDs. Ideally, the training
of systems approaches should be generally incorporated in medical school curricula. We therefore also
propose a plan for this.
Experiences from teaching systems medicine to medical students, clinical and
pre-clinical MDs, as well as other categories
Medical students
Currently the most comprehensive program is offered at Georgetown University, Washington D.C., wherein a
medical student’s fifth year may be devoted to learning genomics, proteomics, translational bioinformatics,
metabolomics, systems biology, pharmacogenomics, epigenomics and biomedical informatics, all in the
context of clinical decision making. In addition to course curriculum the students also experience a year-long
practicum wherein they apply informatics methodologies to clinical data. While the experience is still nascent
it appears that graduates are selecting careers in which these new SM skills will be relevant. Further
information is available here.
The medical curriculum of Linkoping University currently includes a one hour introductory lecture in systems
medicine during the fourth semester. The lecture is available as a PDF file on request.
Briefly it is structured as follows:
1.
An introduction to the problems discussed in the background, such as reactive rather than proactive
medicine and the problems in individualising medication.
2.
The ideal of predictive, preventative, personalised and participatory (P4) medicine is introduced.
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CASyM | Implementation of Systems Medicine across Europe
3.
The reasons for why we do not have P4 medicine are discussed, such as the involvement of thousands of
genes and environmental factors.
4.
A brief summary of high throughput technologies and principles to analyse such data is given.
5.
Successful examples of systems medical studies, which have led to candidate diagnostic markers or
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therapeutic targets are given .
6.
A discussion about how systems medicine will be integrated into clinical practice within the next decade.
The medical curriculum at University of Ljubljana is composed of obligatory and elective courses that represent
up to 10% per each study year (1 – 6). Several systems medicine topics are already offered within the elective
courses, each of 3 ECTS. Biophysics is offered in year 1 as obligatory course (5 ECTS), while students are not
offered mathematics. Students can choose research projects as 3 ECTS elective courses, which includes also
systems medicine projects (not necessarily at University of Ljubljana).
Below is a listed of new systems medicine relevant elective courses that will be available from 2015 and on.
1.
Application of physics and biophysics in diagnostics and treatment.
2.
Mathematical principles in biochemistry.
3.
Basics of computer based imaging methods in medicine,
4.
E-learning and e-materials in medicine.
5.
Health information practicum.
6.
(Molecular) Modelling in biochemistry.
7.
Computer simulations of dynamical processes in biochemistry (3.sem)
8.
Application of bioinformatics tools in medicine.
9.
Contemporary informatics in biomedicine.
10. Functional genomics in medicine.
11. Research projects.
It is envisioned that medical students at University of Ljubljana will be offered a “systems medicine elective
course module”. They will be advised which elective courses to take through years 1 – 6 to maximize their
insights into mathematical concepts in medicine.
Preclinical and clinical MDs
Training of preclinical and clinical MDs can be given in several different settings. One is through the doctoral
school that would lead students to the MD PhD title. University of Ljubljana offers doctoral training to MDs
within doctoral studies of Biomedicine, where MDs can choose courses for PhD in Basic Medicine or Clinical
Medicine. This 3.5 year doctoral study will in autumn 2014 offer also a 10 ECTS module of Systems medicine. It
is envisioned that 10 – 20 doctoral students per year will chose this module that will include lectures, hands-on
computation tutorials and systems medicine project works that will be graded. The syllabus is appended to this
report (in Slovenian language with English translation). According to the national higher education
accreditation rules, only professors with habilitation at University of Ljubljana are listed. However, it is
envisioned that professors from CASyM, UCL and Georgetown University will be invited to participate as
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S. Bruhn, Y. Fang, F.Barrenäs, M. Gustafsson, H. Zhang, A Konstantinell, A. Krönke, B. Sönnichsen, A. Bresnick, N. Dulyaninova, H. Wang,
Y. Zhao, J. Klingelhöfer, N Ambartsumian, MK .Beck, C. Nestor, E Bona, Z. Xiang, M. Benson. A generally, applicable module-based
translational strategy identifies a key diagnostic and therapeutic candidate gene in allergy. Science Translational Medicine 2014:8;6(218)
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Mapstone M, Cheema AK Fiandaca MS, Zhong X, Mhyre TR, Macarthur LH, Hall WJ, Fisher SG, Peterson DR, Haley JM, Nazar MD, Rich SA,
Berlau DJ, Peltz CB, Tan MT, Kawas CH, Federoff HJ. Plasma phospholipids identify antecedent memory impairment in older adults. Nat
Med. 2014;20(4):415-8.
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CASyM | Implementation of Systems Medicine across Europe
teachers and tutors in formation of the first systems medicine doctoral course in Europe. In is also envisioned
that in the future students from other Universities will take the doctoral systems medicine module at
University of Ljubljana. In such case all courses will be given in English as is already a common practice with
international students.
The second challenging possibility is doctoral training of systems medicine through e-learning. Here the
University College of London took the lead and is already offering a Systems biology course SysMyc to UK
students of different Universities. It is interesting to note that students funded by BBRSC in the field of life
sciences are obliged to take this e-course. Several topics of the SysMic course are relevant for systems
medicine, especially all introduced mathematical concepts. What is missing is the disease oriented problem
work, that could be introduced with the aid of CASyM personnel. With this in mind, professors and tutors from
University of Ljubljana asked UCL for the permission to enter the SysMic course and evaluate its contents and
training approaches. This has been just realized on May 1st 2014. Seven teachers and tutors form UL entered
the course and will evaluate it tentatively until September 30, 2014. The next goal is to add medical topics and
data examples to the course to channel it from systems biology to systems medicine. It is envisioned that one
of the Universities within CASyM (possibly University of Ljubljana) will aim in signing a contract with UCL, to
formalize collaboration on development of the systems medicine e-course and set the rules for international
student participation.
Other manners of systems medicine education and training for preclinical and clinical MDs:
1.
International conferences for different medical disciplines, such as the European Academy of Allergy and
Clinical Immunology (EAACI). The advantages of such conferences are that they reach many clinical
colleagues as well as researchers in a context that is directly related to there are professional activities.
One of the authors of this report (MB) has given an allergy oriented one-hour lecture at an annual
EAACI a conference. The structure was similar to the one for medical students, except for its orientation
towards allergology. During 2014 MB, CA and other collaborators will also give talks at other
conferences, such as those organised by the European Respiratory Society in Munich and Dublin.
2.
Workshops for preclinical and clinical MDs, as well as medical students, and students or researchers from
other disciplines. A successful example of this was the CASyM workshop in Ljubljana 2013 [more] that was
accredited by 5 ECTS credits at Unversity of Ljubljana and National Institute of Biology, and by 20 CME
credits from the Medical Chamber of Slovena. Similar workshops are planned in various European
locations during coming years.
3.
Web-based training which offers multimedia content with guides for self-study and self-assessment. E.g.
the UK-based SysMIC course on Systems Training for the Biosciences runs since October 2013 and already
has more than 700 bioresearchers inscribed. This shows the growing awareness of life scientists of the
need of systems skills. A cohort of medical researchers from Slovenian institutions will be given access to
the course from April 2014 to find out which elements will be useful for Systems Medicine training.
4.
Interactive sessions with experts guiding through real-world problems – either face-to-face or via multiuser websession. The latter is currently being tested at the University College London, with a professional
web-training licence for up to 200 participants. One of the authors of this report (MB) has positive
experiences Skype-based tutoring and discussions with medical students at Georgetown University who
studied systems medicine.
5.
Exchange of medical students involved in research projects in systems medicine between different
medical schools. Such an exchange is currently discussed between Georgetown University and Linkoping
University. This will serve as a scalable model for similar exchanges between other universities.
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HOW TO TEACH SYSTEMS MEDICINE?
CPD training is typically mainly given by clinicians or clinical researchers. To some degree, this also
characteristic of medical schools. However, because of the complex, multidisciplinary nature of systems
medicine, the ideal training setting would be if both teachers and students form multidisciplinary teams.
This possibility was discussed in a multidisciplinary workshop at the international conference in systems
biology in Copenhagen in 2013. Several of the participants had positive experiences of workshops were both
tutors and students were multidisciplinary. The problem was that some parts of the training, such as
modelling, may require rather intensive efforts from the tutors. The solution for this could be a combination of
training session with prepared web-based materials which are made available to the trainees before the
sessions. Trainees work on the problem beforehand and then get individual guidance and feedback during the
session (flip teaching) Another possibility, is that both training medical student and clinical specialists involve
in periods of research. Such periods could be ideal opportunities to train how to apply systems medical
principles to problems of direct relevance for the students. One of the participants (MB) report a very positive
experiences of integrating both medical students and clinical specialists in ongoing research projects, which
had resulted in publications with those students and specialists as co-authors (a summary of the workshop is
given below).
Implementation of training and education in Systems Medicine
There is a consensus amongst the meeting participants that Systems Medicine needs to be implemented as a
discipline over the next two decades in a multi-layered fashion. We agree that both research MDs and clinical
practitioners involved in the diagnosis and treatment of diseases will have to familiarize themselves more and
more with genomics and data integration, should have a better feeling than at present for statistics,
bioinformatics, and –omics technologies, and should appreciate the use of Systems Biology modelling for
medical purposes.
Combining course modules, e.g. from Georgetown university (Elliott Crooke), with online tools for Systems
Approaches (for example the UK based SysMIC course, www.sysmic.ac.uk), and with bespoke modules from
the University of Manchester and the University of Amsterdam which were already tried out at the Ljubljana
CASyM course, will foster, improve and further strengthen Systems Medicine training concepts relevant for
CASyM. To develop and implement such concepts it is essential that physicians and teachers actually work
together and identify training tools that qualify for Systems Medicine.
On the other hand, some already existing systems-based approaches (such as the modelling of the aetiology
and therapy of disease, network-based drug target identification, model-based biomarker interpretation,
genome sequence-based prediction of inborn metabolism defects) could already be integrated into the
medical curriculum, facilitating a faster implementation. Here, CASyM should find a consensus to replace
current courses such as on anatomy, or biochemistry, by similar but now Systems-Medicine-facilitated courses
to save time and efforts during MD training. Such new courses have the potential to be much more efficient,
since they aim at understanding complex topics with the help of dynamic systems approaches (such as
modelling represented by movies or interactive representations of the disease) as opposed to a classical
“learning by heart” approach. However, it is essential that Systems Medicine training makes sense to students
and that it proves to be superior compared to traditional learning systems.
Simulation based learning tools utilizing mathematical/computational modelling approaches are a very
attractive method for students to develop a deeper understanding for disease-relevant pathways and their disregulation than through classical learning-by-heart approaches do. Such models will make learning of complex
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interactions of physiological settings much more attractive. This can be supported by the use of (visualizationbased) gadgets and devices that use Systems Medicine modelling to help a student/MD to learn and
understand (cells, tissues, organs, organisms and their corresponding –omics) networks, but also to recognize,
diagnose and treat/prevent (disease).
An important added value of systems-based or computational training in general is the following: The
development of the past showed that students who acquired competences in computational modelling,
independent of their actual topic, are more attractive for the job market. This is not only true for European but
also for students from the US. Based on this development, many pharmaceutical companies already started
building up modelling facilities and would welcome students with a strong background in computational
modelling, also medical students because they come with the extra medical motivation and insights. An
example is MedImmune, AstraZeneca’s R&D branch which currently has a cohort of 40 researchers inscribed in
the SysMIC eTraining.
Central questions and short answers extracted from the open discussion
Should we learn Systems Medicine as a tool or knowledge?
Answer: In Ljubljana it became clear in comments after the lectures that the MD students want also to be
taught Systems Medicine as knowledge, in the sense of understanding the deeper meaning of the concept
‘network disease’.
Should we set different aims and methods for different groups of people (medical
students, research doctors, general practitioners, etc.)?
Answer: Yes
How to make the students and doctors feel interested in this?
Answers: (a) By using the Systems Medicine to make the learning of anatomy, biochemistry, etc. easier and
apparently more relevant. (b) By showing that the Systems Medicine helps them both to understand the
disease of their patient and to identify which therapy to use.
Answer: No, the software should be made so user friendly as to make them model without them even realizing
that they are modelling: the ask a question about an image of their patient and the answer is calculated in that
virtual twin; they see the answer as a movie played in that virtual twin.
EACCME accreditation for European CME credits
®
UEMS-EACCME - The European Union of Medical Specialists (UEMS) is the oldest medical organisation in
Europe as it celebrated its 50th anniversary in 2008. With a current membership of 34 countries, it is the
representative organisation of the National Associations of Medical Specialists in the European Union and its
associated countries. Its structure consists of a Council responsible for and working through 39 Specialist
Sections and their European Boards, addressing training in their respective Specialty and incorporating
representatives from academia (Societies, Colleges and Universities). An Executive comprising the President,
the Secretary-General, the Liaison Officer, and the Treasurer, is responsible for the routine functioning of the
organisation.
UEMS represents over 1.6 million medical specialists in all the different specialties. It also has strong links and
relations with European Institutions (Commission and Parliament), the other independent European Medical
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Organisations and the European Medical / Scientific Societies. By its agreed documents, UEMS sets standards
for high quality healthcare practice that are transmitted to the Authorities and Institutions of the EU and the
National Medical Associations stimulating and encouraging them to implement its recommendations.
Key activities of the UEMS include:
Political lobbying (Commission, Parliament, support of NMAs)
Standard setting for training and practice in individual medical specialities
®
 The accreditation of CME/CPD through UEMS-EACCME


®
The UEMS-EACCME (http://www.eaccme.eu/) has provided an international accreditation system applicable
throughout Europe for CME meetings for the last 12 years. Over that time, significant developments have
occurred in CME-CPD that have included international mutual recognition agreements with the USA and
Canada, and major changes in the regulatory framework for the support of medical education. Following an
®
extensive set of consultations, the UEMS-EACCME has developed new criteria that reflect this new regulatory
environment and provide a developmental stimulus for the achievement of higher standards for medical
education in Europe.
As a means of enhancing the transparency of its processes and of those expected of Applicants, the UEMS®
EACCME has amended its criteria for the accreditation of Live Educational Events (LEEs). These criteria (UEMS
2012/30) have become applicable for all applications made as of 1st January 2013 and supersede the previous
accreditation criteria (UEMS D 9908 and subsequent revisions) as of that date.
FUTURE PLAN
2014
®
The aforementioned description of UEMS-EACCME shows importance of accreditation of “medical” events
and furthermore helps disseminate systems medicine as all accredited events are listed on-line
(http://www.eaccme.eu/) with MDs as target audience.
On April 16, 2014 a hands-on tutorial entitled “CASyM: Modeling Tools for Pharmacokinetics and Systems
Medicine” (http://www.mdo2014.de/Workshop-01.716.0.html) was granted 6 European CME credits (ECMEC)
by the European Accreditation Council for Continuing Medical Education (EACCME). The one-day tutorial is a
th
satellite event of 20 International Symposium on Microsomes and Drug Oxidations, which will be held from
May 18 to 22, 2014, in Stuttgart, capital of the Southwestern state of Germany, Baden-Württemberg.
The following EACCME applications for two more events are in progress:
Systems Biology and Systems Medicine: Precision Biotechnology and Therapies, Lake Como, Italy,
September 21-27, 2014
 Systems chronobiology and chronotherapeutics: Cells, tissues, whole organisms and patients, 44th Congress
of the Francophone Society of Chronobiology, October 29-31, 2014, Paris, France

2015
In 2015 we plan to attach hands-on tutorials of Systems Medicine to bigger medical meetings/congresses with
focus on clinical research.
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ACKNOWLEDGEMENTS
This event was part of CASyM work package 2 – “Multidisciplinary training in systems approaches for the next
generation of scientists and medical doctors”.
CASyM is funded by the European Union, Seventh Framework Programme under the Health Cooperation
Theme and Grant Agreement # 305033.
STEERING COMMITTEE
The following officials, as part of the Scientific Steering Committee, are involved in the scientific coordination
of CASyM:
Charles Auffray - European Institute for Systems Biology & Medicine - EISBM, France
Mikael Benson (Deputy Speaker) - Linköping University Hospital, Sweden
Rob Diemel - The Netherlands Organisation for Health Research and Development, The Netherlands
David Harrison (Speaker) - University of St. Andrews, United Kingdom
Walter Kolch - University College Dublin, Ireland
Frank Laplace - Federal Ministry of Education and Research, Germany
Francis Lévi - Institut National de la Sante et de la Recherche Medicale, France
Damjana Rozman (Deputy Speaker) - University of Ljubljana, Faculty of Medicine, Slovenia
Johannes Schuchhardt - MicroDiscovery GmbH, Germany
Olaf Wolkenhauer - Dept. of Systems Biology & Bioinformatics University of Rostock, Germany
ADMINISTRATIVE OFFICE (COORDINATION)
Marc Kirschner - Project Management Jülich, Forschungszentrum Jülich GmbH, Germany
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