Training physicians to care for urban populations: a win-win for health systems

Background: Aurora Health Care and University of Wisconsin School of Medicine and Public Health (UWSMPH) created TRIUMPH to prepare medical students to promote equity and reduce health disparities for urban, disadvantaged populations. TRIUMPH integrates clinical training during the last two years of medical school with the development of leadership and community health skills. Purpose: TRIUMPH students are more likely to choose career paths needed to care for urban populations and to select residencies in Milwaukee and Wisconsin. Methods: Since 2009, TRIUMPH students have relocated to Milwaukee for 15 months. They develop community health improvement projects and participate in a core curriculum focused on skills needed by community-responsive physicians. A student database and program evaluation track student characteristics and self-assessment of knowledge, skills and attitudes related to working with disadvantaged urban populations. In 2014, interviews were conducted with six alumni completing primary care residencies in Milwaukee to better understand the impact of TRIUMPH on specialty choice, residency and practice selection. Results: To date, there are 23 graduates who are predominantly female (67%), Wisconsin residents (74%) and all with prior experience working with disadvantaged populations. A comparatively high number entered primary care residencies (78%) vs. UWSMPH non-TRIUMPH graduates (45.5%). All graduates are serving urban, underserved populations. Ten graduates (43.5%) have remained in the state to train, with two at UWSMPH, three at Milwaukee College of Wisconsin and five at Aurora Health Care’s Family Medicine Department. Interview themes revealed a motivation to serve diverse, urban populations in clinical and community health modes. TRIUMPH clarified specialty choice and led many to consider Milwaukee for residency. Students identified increased skills and confidence related to community engagement activities and an inclination to consider practicing in Milwaukee. Conclusion: TRIUMPH students self-select with a common motivation for urban underserved service. They are more likely to be female, from out-of-state, and from disadvantaged backgrounds than their UWSMPH peers. While the study is limited by enrollment selection bias and small sample size, the percentage of students going into primary care and staying in Milwaukee and Wisconsin for training is remarkable and bodes well for practice selection and addressing physician workforce needs. TRIUMPH is meeting the personal and professional needs of the learners. And TRIUMPH is a win-win for all partners – state, medical school, Milwaukee and Aurora

Personalized Medicine in the Oncology Clinic: Implementation and Outcomes of the Johns Hopkins Molecular Tumor Board

Tumor genomic profiling for personalized oncology therapy is being widely applied in clinical practice even as it is being evaluated more formally in clinical trials. Given the complexities of genomic data and its application to clinical use, molecular tumor boards with diverse expertise can provide guidance to oncologists and patients seeking to implement personalized genetically targeted therapy in practice. A multidisciplinary molecular tumor board reviewed tumor molecular profiling reports from consecutive referrals at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins over a 3-year period. The tumor board weighed evidence for actionability of genomic alterations identified by molecular profiling and provided recommendations including US Food and Drug Administration-approved drug therapy, clinical trials of matched targeted therapy, off-label use of such therapy, and additional tumor or germline genetic testing. One hundred fifty-five patients were reviewed. Actionable genomic alterations were identified in 132 patients (85%). Off-label therapies were recommended in 37 patients (24%). Eleven patients were treated off-label, and 13 patients were enrolled onto clinical trials of matched targeted therapies. Median progression-free survival of patients treated with matched therapies was 5 months (95% CI, 2.9 months to not reached), and the progression-free survival probability at 6 months was 43%(95% CI, 26% to 71%). Lack of locally available clinical trials was the major limitation on clinical actionability of tumor profiling reports. The molecular tumor board recommended off-label targeted therapies for a quarter of all patients reviewed. Outcomes were heterogeneous, although 43% of patients receiving genomically matched therapy derived clinical benefit lasting at least 6 months. Until more data become available from precision oncology trials, molecular tumor boards can help guide appropriate use of tumor molecular testing to direct therapy

Personalized Medicine in the Oncology Clinic: Implementation and Outcomes of the Johns Hopkins Molecular Tumor Board

Tumor genomic profiling for personalized oncology therapy is being widely applied in clinical practice even as it is being evaluated more formally in clinical trials. Given the complexities of genomic data and its application to clinical use, molecular tumor boards with diverse expertise can provide guidance to oncologists and patients seeking to implement personalized genetically targeted therapy in practice. A multidisciplinary molecular tumor board reviewed tumor molecular profiling reports from consecutive referrals at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins over a 3-year period. The tumor board weighed evidence for actionability of genomic alterations identified by molecular profiling and provided recommendations including US Food and Drug Administration-approved drug therapy, clinical trials of matched targeted therapy, off-label use of such therapy, and additional tumor or germline genetic testing. One hundred fifty-five patients were reviewed. Actionable genomic alterations were identified in 132 patients (85%). Off-label therapies were recommended in 37 patients (24%). Eleven patients were treated off-label, and 13 patients were enrolled onto clinical trials of matched targeted therapies. Median progression-free survival of patients treated with matched therapies was 5 months (95% CI, 2.9 months to not reached), and the progression-free survival probability at 6 months was 43%(95% CI, 26% to 71%). Lack of locally available clinical trials was the major limitation on clinical actionability of tumor profiling reports. The molecular tumor board recommended off-label targeted therapies for a quarter of all patients reviewed. Outcomes were heterogeneous, although 43% of patients receiving genomically matched therapy derived clinical benefit lasting at least 6 months. Until more data become available from precision oncology trials, molecular tumor boards can help guide appropriate use of tumor molecular testing to direct therapy