Implementation outcomes of a multiinstitutional web-based ethical, legal, and social implications genetics curriculum for primary care residents in three specialties.

PURPOSE: Medical genetics lends itself to disseminated teaching methods because of mismatches between numbers of physicians having patients with genetic disorders and availability of genetic specialists. METHOD: During 3 years, we implemented an interactive, web-based curriculum on ethical, legal, and social implications in medical genetics for primary care residents in three specialties at three institutions. Residents took five (of 10) cases and three (of five) tutorials that varied by specialty. We assessed changes in self-efficacy (primary outcome), knowledge, application, and viewpoints. RESULTS: Overall enrollment was 69% (279/403). One institution did not complete implementation and was dropped from pre-post comparisons. We developed a six-factor ethical, legal, and social implications self-efficacy scale (Cronbach α = 0.95). Baseline self-efficacy was moderate (71/115; range: 23-115) and increased 15% after participation. Pre-post knowledge scores were high and unchanged. Residents reported that this curriculum covered ethical, legal, and social implications/genetics better than their usual curricula. Most (68-91%) identified advantages, especially in providing flexibility and stimulating self-directed learning. After participation, residents reported creating learning goals (66%) and acting on those goals (62%). CONCLUSIONS: Ethical, legal, and social implications genetics curricular participation led to modest self-efficacy gains. Residents reported that the curriculum covered unique content areas, had advantages over traditional curriculum, and that they applied ethical, legal, and social implications content clinically. We share lessons from developing and implementing this complex web-based curriculum across multiple institutions.

Breast cancer risk communication: assessment of primary care physicians by standardized patients.

PURPOSE: To assess primary care providers' communication about breast cancer risk. METHODS: We evaluated 86 primary care providers' communication of risk using unannounced standardized (simulated) patients. Physicians were randomly assigned to receive one of three cases: (1) moderate risk case (n = 25), presenting with a breast lump and mother with postmenopausal breast cancer; (2) high-risk (maternal side) case (n = 28), presenting with concern about breast cancer risk; and (3) high-risk (paternal side) case (n = 33), presenting with an unrelated problem. After the appointment, three qualitative parameters were assessed by standardized patients on a 3-point scale (3 = highest satisfaction, 1 = lowest): whether the physician took adequate time; acknowledged her concerns; and offered reassurance. RESULTS: Mean satisfaction with physician communication was higher for the moderate risk case (2.92) than for the high-risk paternal case (2.25) or high-risk maternal case (2.42) (P < 0.0001). The score was not influenced by session length, medical specialty, or physician gender. CONCLUSION: Physicians more consistently provided a moderate risk standardized patients with reassurance and support compared with the high-risk cases. Primary care physicians may be more unprepared or uneasy addressing the issues raised by more complex scenarios and may benefit from training in the assessment and communication of breast cancer risk.

Genetic assessment of breast cancer risk in primary care practice.

Family history is increasingly important in primary care as a means to detect candidates for genetic testing or tailored prevention programs. We evaluated primary care physicians' skills in assessing family history for breast cancer risk, using unannounced standardized patient (SP) visits to 86 general internists and family medicine practitioners in King County, WA. Transcripts of clinical encounters were coded to determine ascertainment of family history, risk assessment, and clinical follow-up. Physicians in our study collected sufficient family history to assess breast cancer risk in 48% of encounters with an anxious patient at moderate risk, 100% of encounters with a patient who had a strong maternal family history of breast cancer, and 45% of encounters with a patient who had a strong paternal family history of breast and ovarian cancer. Increased risk was usually communicated in terms of recommendations for preventive action. Few physicians referred patients to genetic counseling, few associated ovarian cancer with breast cancer risk, and some incorrectly discounted paternal family history of breast cancer. We conclude that pedigree assessment of breast cancer risk is feasible in primary care, but may occur consistently only when a strong maternal family history is present. Primary care education should focus on the link between inherited breast and ovarian cancer risk and on the significance of paternal family history. Educational efforts may be most successful when they emphasize the value of genetic counseling for individuals at risk for inherited cancer and the connection between genetic risk and specific prevention measures.

Medical case teaching on the web.

BACKGROUND: Little is known about strategies for developing teaching cases and strategies for identifying design features that optimize a learner's interactions with Web-based cases. PURPOSES: We examined design features in Web cases that facilitated interactive and engaging learning. METHODS: Nine collaborators reviewed selected Web cases and documented the presence of features that facilitate interactive learning, including opportunities for information gathering, decision making, and receiving feedback. RESULTS: Eighteen Web sites offered cases. These cases mainly were narrated based on biomedical information without patient voices. The cases were organized in a linear structure from patient presentation to follow-up. Many cases presented only a single case. We found little use of features for augmenting a learner's interaction with cases. Only a handful of cases generated feedback on the basis of the learners' responses. CONCLUSION: Our study suggests ways to improve the development of Web cases. These methods contribute to future research in testing cases for educational effectiveness.

Promoting academic excellence through leadership development at the University of Washington: the Teaching Scholars Program.

The University of Washington Teaching Scholars Program (TSP) was established in 1995 to prepare faculty for local and national leadership and promote academic excellence by fostering a community of educational leaders to innovate, enliven, and enrich the environment for teaching and learning at the University of Washington (UW). Faculty in the Department of Medical Education and Biomedical Informatics designed and continue to implement the program. Qualified individuals from the UW Health Sciences Professional Schools and foreign scholars who are studying at the UW are eligible to apply for acceptance into the program. To date, 109 faculty and fellows have participated in the program, the majority of whom have been physicians. The program is committed to interprofessional education and seeks to diversify its participants. The curriculum is developed collaboratively with each cohort and comprises topics central to medical education and an emergent set of topics related to the specific interests and teaching responsibilities of the participating scholars. Core sessions cover the history of health professions education, learning theories, educational research methods, assessment, curriculum development, instructional methods, professionalism, and leadership. To graduate, scholars must complete a scholarly project in curriculum development, faculty development, or educational research; demonstrate progress towards construction of a teaching portfolio; and participate regularly and actively in program sessions. The TSP has developed and nurtured an active cadre of supportive colleagues who are transforming educational practice, elevating the status of teaching, and increasing the recognition of teachers. Graduates fill key teaching and leadership positions at the UW and in national and international professional organizations.

A conceptual framework for developing teaching cases: a review and synthesis of the literature across disciplines.

Case-based teaching is regarded as a superior instructional method compared with lectures in promoting a learner's critical thinking skills. While much is known about the role a discussion facilitator plays in case-based teaching, the debate on the influence of the format and structure of cases on learning is controversial. We sought to identify strategies for constructing cases based on studies from multiple disciplines, which report the development and use of cases in teaching and learning. The purpose was to offer the medical and other educational communities a conceptual framework that can be examined in future research. Based on a review of 100 studies, we synthesised 17 strategies around 5 core attributes of cases: relevant (level of learner, goals and objectives, setting of case narrative); realistic (authenticity, distractors, gradual disclosure of content); engaging (rich content, multiple perspectives, branching of content); challenging (difficulty, unusual cases, case structure, multiple cases), and instructional (build upon prior knowledge, assessment, feedback, and teaching aids). Despite the wide use of cases in disparate disciplines, there has been no overarching study that synthesises strategies of case development or tests these strategies in research settings. The framework we developed can serve as a menu of case development options that educators and researchers can pilot and evaluate in their local settings.

Family history assessment to detect increased risk for colorectal cancer: conceptual considerations and a preliminary economic analysis.

BACKGROUND: Although the rationale for earlier screening of persons with a family history of colorectal cancer is plausible, there is no direct evidence that earlier assessment is either effective or cost-effective. OBJECTIVE: To estimate the clinical and economic effect of using family history assessment to identify persons for colorectal cancer screening before age 50. METHODS: We developed a decision model to compare costs and outcomes for two scenarios: (a) standard population screening starting at age 50; (b) family history assessment at age 40, followed by screening colonoscopy at age 40 for those with a suggestive family history of colorectal cancer. The analysis was conducted using the health insurer perspective. RESULTS: Using U.S. population estimates, 22 million would be eligible for family history assessment, and one million would be eligible for early colonoscopy; 2,834 invasive cancers would be detected, and 29,331 life years would be gained. The initial program cost would be USD $900 million. The discounted cost per life year gained of family history assessment versus no assessment equals USD $58,228. The results were most sensitive to the life expectancy benefit from earlier screening, the cost of colonoscopy, and the relative risk of colon cancer in those with a family history. CONCLUSIONS: The cost-effectiveness of family history assessment for colorectal cancer approaches that of other widely accepted technologies; yet, the results are sensitive to several assumptions where better data are needed. Because of the relatively high prevalence of family history in the population, careful analysis and empirical data are needed.

'That's like chopping off a finger because you're afraid it might get broken': disease and illness in women's views of prophylactic mastectomy.

While data are accumulating on the efficacy of prophylactic mastectomy as a means to reduce breast cancer risk in high risk women, the effectiveness of the procedure depends on women's interest in undergoing the procedure. We report on women's responses to this surgical option as a prevention tool. Data derive from a multi-method study of women's interest in and understandings about genetic testing for breast cancer susceptibility. The sample comprises 246 women of varying ethnicities and familial breast cancer risk from Seattle, USA. In this paper, quantitative data are presented on the sociodemographic and risk perception correlates of degree of interest in taking a genetic test for breast cancer if prophylactic mastectomy were the only treatment option. In addition, we report results of a content analysis of women's open-ended responses to the question of whether and why they could imagine undergoing prophylactic mastectomy. Our analysis of these data benefits from a central distinction in medical anthropology between the concepts of illness and disease. We suggest that while prophylactic mastectomy may prevent the "disease" of breast cancer, it may be of little interest to women who see this surgery as itself mimicking the "illness" of breast cancer.

Diving for PERLS: working and performance portfolios for evaluation and reflection on learning.

Professional competence requires a commitment to lifelong learning, self-assessment, and excellence. Complex skills such as these require flexible and comprehensive teaching and assessment measures. We describe a combination of working and performance portfolios that both foster and evaluate the development of professional competence. We explain the conceptual and practical underpinnings that maximize the effectiveness of these tools. Drawing on experience with University of Washington residents, we identify 5 criteria that can help promote successful use of portfolios: separate working and performance functions of portfolios, developing a supportive climate, developing skills in faculty and residents, observing progress over time, and fostering mentorship opportunities.

Reconsidering the family history in primary care.

OBJECTIVE: The purpose of this paper is to review the role of the family history in predictive genetic testing, describe how family history taking is practiced in adult primary care, identify the current barriers to appropriate application of the family history, and outline the requirements for a new family history tool for primary care. DESIGN: We reviewed current perspectives on the family history, identifying key references in the medical literature and web-based family history tools through discussions with multiple content experts in clinical genetics, family medicine, and internal medicine. We conducted a Medline query using the search terms family history and primary care to identify references from the past 10 years. To illustrate the usefulness of family history information, we calculated the predictive value of family history and genetic information for familial adenomatous polyposis using current references and standard formulas. We identified paper and web-based family history tools through discussions with content experts. We also conducted a search on the World Wide Web to identify resources for electronic medical record and family history. RESULTS: The family history is the most important tool for diagnosis and risk assessment in medical genetics, and promises to serve as a critical element in the use of predictive genetic testing in primary care. Traditional medical education about family history has often been unsophisticated and use of family history in adult primary care has been limited, compounded by multiple substantive barriers. Although there are numerous paper and computer-based aides for taking the family history, none currently meets all the needs of adult primary care. CONCLUSIONS: The patient's family history remains a critical element in risk assessment for many conditions, but substantive barriers impede application in primary care practice, and evidence for its contribution to improved health outcomes is limited in this setting. Short of radical changes in reimbursement, new tools will be required to aid primary care physicians in the efficient collection and application of patient family history in the era of genetic testing.

Educational effects of international health electives on U.S. and Canadian medical students and residents: a literature review.

PURPOSE: To evaluate the educational effects of international health electives (IHEs) on participants. IHEs are a popular component of many medical school and residency program curricula, and are reported to provide benefits in knowledge, skills, and attitudes. METHOD: The authors reviewed all studies reported in Medline and ERIC databases that have assessed the educational effects of IHEs on U.S. and Canadian medical students and residents. Data extracted from eligible studies included type and duration of IHE, details of survey instrument, response rate, comparison group, and outcomes. Seven of the eight eligible studies assessed educational effects on participants using self-reported questionnaires; a single study used an objective measurement of knowledge. RESULTS: Eight studies involving 522 medical students and 166 residents met inclusion criteria. IHEs appear to be associated with career choices in underserved or primary care settings and recruitment to residency programs. They also appear to have positive effects on participants' clinical skills, certain attitudes, and knowledge of tropical medicine. CONCLUSION: IHEs appear to have positive educational influences on participants' knowledge, skills, and attitudes. Furthermore, IHEs may play some role both in recruiting residents and in their choices of careers in primary care and underserved settings. Future directions for research in this field are discussed.

Hereditary hemochromatosis: perspectives of public health, medical genetics, and primary care.

Hereditary hemochromatosis (HHC) is a condition characterized by excess iron in body tissues, resulting in complications such as cirrhosis, cardiomyopathy, diabetes, and arthritis. These complications usually manifest during adulthood. Two methods of screening for the detection of early stage of HHC are available: serum iron measures and molecular testing to detect mutations in the gene. These phenotypic and genotypic screening tests are of particular interest because a simple treatment-periodic phlebotomy-can be used to prevent iron accumulation and clinical complications. HHC might represent the first adult-onset genetic disorder for which universal population-based screening would be appropriate. Therefore, HHC has been proposed as a paradigm for the introduction of adult genetic diseases into clinical and public health practice. However, universal screening for HHC has not been recommended because of the uncertainty about the natural history of the iron overload or HHC and, in particular, uncertainty about the prevalence of asymptomatic iron overload and the likelihood that it will progress to clinical complications. If universal screening is not appropriate based on current data, what other measures might reduce the disease burden of iron overload? New studies provide more systematic information about the penetrance of the C282Y mutation and shed further light on the natural history of the disorder. The authors review these data and consider their implications for public health, medical genetics, and primary care.