Abstract
BackgroundScreening and counseling for genetic conditions is an increasingly important part of primary care practice, particularly given the paucity of genetic counselors in the United States. However, primary care physicians (PCPs) often have an inadequate understanding of evidence-based screening; communication approaches that encourage shared decision-making; ethical, legal, and social implication (ELSI) issues related to screening for genetic mutations; and the basics of clinical genetics. This study explored whether an interactive, web-based genetics curriculum directed at PCPs in non-academic primary care settings was superior at changing practice knowledge, attitudes, and behaviors when compared to a traditional educational approach, particularly when discussing common genetic conditions.MethodsOne hundred twenty one PCPs in California and Pennsylvania physician practices were randomized to either an Intervention Group (IG) or Control Group (CG). IG physicians completed a 6 h interactive web-based curriculum covering communication skills, basics of genetic testing, risk assessment, ELSI issues and practice behaviors. CG physicians were provided with a traditional approach to Continuing Medical Education (CME) (clinical review articles) offering equivalent information.ResultsPCPs in the Intervention Group showed greater increases in knowledge compared to the Control Group. Intervention PCPs were also more satisfied with the educational materials, and more confident in their genetics knowledge and skills compared to those receiving traditional CME materials. Intervention PCPs felt that the web-based curriculum covered medical management, genetics, and ELSI issues significantly better than did the Control Group, and in comparison with traditional curricula. The Intervention Group felt the online tools offered several advantages, and engaged in better shared decision making with standardized patients, however, there was no difference in behavior change between groups with regard to increases in ELSI discussions between PCPs and patients.ConclusionWhile our intervention was deemed more enjoyable, demonstrated significant factual learning and retention, and increased shared decision making practices, there were few differences in behavior changes around ELSI discussions. Unfortunately, barriers to implementing behavior change in clinical genetics is not unique to our intervention. Perhaps the missing element is that busy physicians need systems-level support to engage in meaningful discussions around genetics issues. The next step in promoting active engagement between doctors and patients may be to put into place the tools needed for PCPs to easily access the materials they need at the point-of-care to engage in joint discussions around clinical genetics.
Highlights
Screening and counseling for genetic conditions is an increasingly important part of primary care practice, given the paucity of genetic counselors in the United States
Primary care physicians often have an inadequate understanding with regard to evidence-based screening for genetic issues, and a lack of confidence in communicating about shared decisionmaking, and about legal, ethical, and social issues related to screening for genetic mutations and the basics of clinical genetics [3,4,5,6,7]
We found that compared to standard curricular materials, an interactive web-based Continuing Medical Education (CME) curriculum was more effective at increasing physician knowledge around genetic testing, and improving shared decision making behaviors, though it had a small effect on attitudes and minimally impacted clinical behaviors around ethical, legal, and social discussions around genetic testing
Summary
Screening and counseling for genetic conditions is an increasingly important part of primary care practice, given the paucity of genetic counselors in the United States [1] Discussions about genetic risk-assessment increase patients’ knowledge of genetics, improve the accuracy of their perceived personal risk, and reduce their psychological distress [2]. When there is poor physician communication and knowledge, or when the primary care physician (PCP) is unprepared to engage in shared decision-making, the result can be poor medical care – either unnecessary and expensive over testing or inappropriate and potentially dangerous under testing The result is both an underutilization of genetic counseling, failure to test patients most at risk [4, 8] and an overutilization of testing for those at low risk [9]. There is a clear need for interventions that teach risk assessment [12] and improve provider confidence and adherence to evidence-based genetic counseling and testing recommendations [9, 13]
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