Imagining genomic medicine futures in primary care: General practitioners' views on mainstreaming genomics in the National Health Service

A qualitative study to evaluate the preparedness of community paediatricians for genomic medicine in England - ready for take-off?

Genomic medicine (GM) was mainstreamed across the National Health Service (NHS) in England in 2018. Non-genetics healthcare professionals can now incorporate genomic testing including whole genome sequencing (WGS) into their clinical practice. This study was conducted to evaluate the preparedness of community paediatricians (CPs) for GM. Semi-structured interviews, using a topic guide informed by the Consolidated Framework for Implementation Research, were conducted with 17 CPs working in the NHS to explore issues related to preparedness and confidence. Data were analysed using thematic template analysis. The codebook included both inductive and deductive codes informed by the Capability, Opportunity and Motivation Behaviour model (COM-B), an implementation theory to explain behaviour change. The majority of participants perceived a net benefit from GM in terms of improving clinical management and information provision for patients and families and were receptive to using GM in their clinical practice. However, there was wide variation across trusts in CP preparedness for genomic medicine for reasons including lack of time and resources, notably workforce support. Many also lacked confidence in the skills required to deliver GM, and did not see GM as a priority. Most participants felt that they had access to GM education, but the main challenge was finding the time to engage with it. Strategies related to fiscal measures, enablement, training and education could help to address these early obstacles. Our findings may be relevant to clinicians in other non-genetic specialties integrating GM into their clinical practice not only in the UK NHS but more globally.

Ethical preparedness and developments in genomic healthcare

Considerations of the notion of preparedness have come to the fore in the recent pandemic, highlighting a need to be better prepared to deal with sudden, unexpected and unwanted events. However, the concept of preparedness is also important in relation to planned for and desired interventions resulting from healthcare innovations. We describe ethical preparedness as a necessary component for the successful delivery of novel healthcare innovations, and use recent advances in genomic healthcare as an example. We suggest that practitioners and organisations charged with delivering innovative and ambitious healthcare programmes can only succeed if they are able to exhibit the attribute of ethical preparedness.

Caring around and through medical tests in primary care: On the role of care in the diagnostic process

Primary care is characterised by a broad understanding of health and illness. Due to the high degree of diagnostic uncertainty in primary care, medical tests play a lesser role in this domain than in specialist medicine. However, medical testing is also becoming increasingly important in primary care, raising questions about how these technologies are integrated into everyday practice. Drawing on qualitative interviews with Austrian doctors, this article shows that the use of medical tests in primary care is often interwoven with practices of care. Doctors engage in care around the use of medical tests by assessing the impact of diagnostic knowledge and addressing patients' needs before and after testing. They also demonstrate care through the use of medical tests, such as administering them to comfort patients rather than for strictly clinical reasons. Situating these findings within the sociology of diagnosis, I argue that diagnostic processes not only guide medical care provision but are also closely intertwined with practices of care.

Boundary-work in genomic medicine: Safeguarding the future of diagnostic next-generation sequencing in the clinic

Next-generation sequencing (NGS) technologies - which allow to look at large parts or even the whole genome at once - are making their way into diagnostic clinical care. With trends towards 'mainstreaming' genetic services into general medicine, significant ethical challenges, and a disputed clinical utility and cost-benefit ratio, genomic medicine's autonomy and dominance in defining and offering NGS care may come under increased pressure from the outside (e.g., regulators, other healthcare providers and facilities, ethicists, and patients). In this paper, we show how the field of genomic medicine engages in substantial boundary-work in reaction to these circumstances. Building on multi-sited fieldwork in two centers for human genetics in Belgium and the Netherlands, we show how acts of demarcation serve to uphold an image of expertise and authority which helps maintain the field's autonomy and dominance. Through examining the delineations put forward in interviews, practice (based on observations in multidisciplinary meetings and consultations), and grey and academic literature, we show the politics involved in moving NGS forward fairly seamlessly in a way that suits the field. First, we show how genetic healthcare professionals have redefined what makes a genetic test 'valuable' so that it underlines its current value. Secondly, we examine how a genetic imaginary is put forward that both emphasizes the extraordinary character of genomic medicine and the normalcy of NGS testing. By underlining the need for their expertise whilst simultaneously normalizing the ethical challenges and positioning themselves as most capable of reflecting on these, the field minimized external regulation and kept a close grip on defining ethical issues and policy. Despite their current dominance in shaping the future of genomic care, we argue that the closedness of the field hinders it from benefiting from external expertise, reflection, and monitoring to ensure enduring and broad support for this future.

Scoping review of enablers and challenges of implementing pharmacogenomics testing in the primary care settings

INTRODUCTION

Pharmacogenomic testing (PGx) plays a crucial role in improving patient medication safety, yet ethical concerns and limitations impede its clinical implementation in the primary care settings.

AIMS

To systematically review the current state of PGx in the primary care settings and determine the enablers and challenges of its implementation.

DESIGN

A scoping review was carried out by adhering to Arksey and O'Malley's 6-stage methodological framework and the 2020 Joanna Briggs Institute and Levac et al. DATA SOURCES: Cochrane Library, EMBASE, Global Health, MEDLINE and PubMed were searched up to 17 July 2023.

ELIGIBILITY CRITERIA

All peer-reviewed studies in English, reporting the enablers and the challenges of implementing PGx in the primary care settings were included.

DATE EXTRACTION AND SYNTHESIS

Two independent reviewers extracted the data. Information was synthesised based on the reported enablers and the challenges of implementing PGx testing in the primary care settings. Information was then presented to stakeholders for their inputs.

RESULTS

78 studies discussing the implementation of PGx testing are included, of which 57% were published between 2019 and 2023. 68% of the studies discussed PGx testing in the primary care setting as a disease-specific themes. Healthcare professionals were the major stakeholders, with primary care physicians (55%) being the most represented. Enablers encompassed various advantages such as diagnostic and therapeutic benefits, cost reduction and the empowerment of healthcare professionals. Challenges included the absence of sufficient scientific evidence, insufficient training for healthcare professionals, ethical and legal aspects of PGx data, low patient awareness and acceptance and the high costs linked to PGx testing.

CONCLUSION

PGx testing integration in primary care requires increased consumer awareness, comprehensive healthcare provider training on legal and ethical aspects and global feasibility studies to better understand its implementation challenges. Managing high costs entails streamlining processes, advocating for reimbursement policies and investing in research on innovation and affordability research to improve life expectancy.

Precision medicine in primary care: How GPs envision "old" and "new" forms of personalization

Visions of precision or personalized medicine (PM) are gaining currency around the globe. While the potential of PM in specialist medicine has been in focus, primary care is also considered to be a fruitful area for the application of PM. "Low-tech" forms of personalization and attention to individual patients are already central features of primary care practice, and primary care thus constitutes an area in which "old" and "new" forms of personalization (may) come together. Against this backdrop, we explore general practitioners' (GPs) views on PM and how they envision the future of personalization in primary care. We draw on 45 qualitative interviews with GPs from Austria, Denmark, and the United States. Along the lines of major "promises" of PM-tailoring treatment decisions, improving disease prevention, empowering patients-we show that in some areas GPs consider PM to be a continuation or extension of existing practices of personalization, while in other cases, GPs envision that PM may negatively disrupt current forms of personalization in primary care. We suggest that this ambivalent stance towards PM can be understood through the lens of GPs' views on core values and practices of primary care.

Writing the worlds of genomic medicine: experiences of using participatory-writing to understand life with rare conditions

The diagnostic and treatment possibilities made possible by the development and subsequent mainstreaming of clinical genomics services have the potential to profoundly change the experiences of families affected by rare genetic conditions. Understanding the potentials of genomic medicine requires that we consider the perspectives of those who engage with such services; there are substantial social implications involved. There are increasing calls to think more creatively, and draw on more participatory approaches, in evoking rich accounts of lived experience. In this article, we discuss our rationale for, and experiences of, using 'participatory-writing' to understand the diverse, variable and multilayered everyday lives of families and how these correspond with the emerging, rapidly changing and complex field of genomic medicine. Participatory-writing has many benefits as a method for social inquiry. Writing can be expressive and self-revelatory, providing insight into personal and sensitive topics. Writing together produces new conversations and relationships. Pieces written by participants have the potential to affect readers, evoking and enlivening research and prompting professional change. Working with a writing tutor, we organised a participatory-writing programme for families touched by genetic conditions. This involved a series of workshops with an emphasis on building confidence in expressing lived experience through experimenting with different writing techniques. Afterwards we arranged reflective interviews with participants. We drew on dialogical narrative analysis to engage with participants' written pieces, and highlight what everyday life is like for the people who live with, and care for, those with genetic conditions. The stories produced through our writing-groups unfold the implications of new genomic technologies, illuminating how genomics acts to (and likewise, fails to) reconfigure aspects of people's lives outside of the clinic, while simultaneously existing as a sociotechnical frame that can eclipse the wider contexts, challenges and liveliness of life with rare genetic conditions.