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Alex Cummings, Andrea Stoddard, Pat McCarthy Veach, Bonnie LeRoy and Heather Zierhut

Keywords

genetics, genetic counseling, case-based learning, on-line learning, flipping the classroom, teaching modules

Introduction

Genetic counseling professionals are in high demand in the United States and that demand is growing. Given the current number of graduates matriculating annually, the increased need for genetic counselors likely will not be met. Recent studies show there are more than twice as many jobs available as there are graduates to fill them. Yet, it is difficult to increase class sizes within genetic counseling graduate programs given the limited resources available to fulfill intensive educational requirements in the clinical setting. As with most human services professions, training involves several supervised clinical rotations. These rotations represent different genetic counseling specialties in which students actively participate in patient care under the direct supervision of certified genetic counselors. Students typically begin their clinical rotations towards the end of the first year in their genetic counseling program and their initial rotation is observational in nature. In subsequent rotations, students assume increasing responsibility for patient care, resulting in the need for even more intensive supervision by certified genetic counselors. In addition to the intensive supervision needed, there are a limited number of clinical rotation sites available for genetic counseling students. These factors limit the numbers of students that can be admitted to genetic counseling programs.

One way to address these issues is by introducing simulated clinic situations into the class, in essence, providing some supplemental observational experiences that occur during initial clinical rotations. Accordingly, we created a series of online modules consisting of genetic counseling cases accompanied by stimulus questions for use in genetic counseling curricula. These modules effectively provide an opportunity for first year students to gain exposure to prenatal, cancer, and pediatric clinical scenarios without taking up valuable clinic supervision spots. To best recreate clinical situations, we chose a case-based learning approach. Case-based learning involves the use of cases representative of real life situations to elicit appropriate learning and understanding of desired curricular points. Unlike problem-based learning, case-based learning allows for preparation prior to discussion and is a more guided inquiry process, with said direction provided by facilitators/instructors.¹ Case-based learning has been implemented within all levels of education and has been shown to be especially effective within the sciences.^2-4 Studies suggest case-based learning increases student motivation and engagement, as well as short-term retention of knowledge.^4,5

Activities involving virtual viewing of and reflection about cases are intended to reduce the amount of time students spend in physical clinical observation. We developed three modules comprised of video recordings of simulated genetic counseling sessions that represent the primary clinical genetic counseling specialties – prenatal, pediatric, and cancer genetic counseling. The modules will initially be introduced into two genetic counseling courses at the University of Minnesota (GCD 8911, GCD 8912) that are designed to prepare students for learning in the clinical setting.

Module Description

Each module contains segments of genetic counseling sessions (scenarios) representing major components (e.g., taking an efficient family history, contracting [mutual agenda setting], discussing testing options, decision making, and providing results). All modules consist of at least two genetic counseling appointments (pre- and post- test). Table 1 shows the structure and major components of the modules.

Students are instructed to watch full length clips of the major components of the genetic counseling sessions (~15 to 40 minutes) and then answer a series of questions associated with segments of the videos (~30 seconds to 2 minutes). Accompanying questions include multiple choice items, short answer, and essay questions addressing both genetics knowledge and psychosocial counseling issues and skills. Progression through the scenarios within each module is comparable to that of an entire genetic counseling session.

The modules and corresponding assignments can be used within the classroom and/or they can be completed outside of class. Students are able to watch, re-watch, and progress through each case at their own pace. By introducing three different cases based upon genetic counseling specialties within the classroom setting, we aim to better prepare students for seeing similar types of patients in subsequent clinical rotations.

Table 1. Genetic Counseling Sessions Structure

Pediatric Module

1 Pediatric Counseling 1: Genetic Counseling: What to Expect?
2 Pediatric Counseling 2: Discussing Duchenne Muscular Dystrophy and Inheritance
3 Pediatric Counseling 3: Considerations for Carrier Testing
4 Pediatric Counseling 4: Carrier Test Results-1
5 Pediatric Counseling 5: Carrier Test Results-2

Cancer Module

6 Cancer Counseling 1: Pretest Counseling Session
7 Cancer Counseling 2 – Return Appointment
8 Cancer Counseling 3: Results Appointment

Prenatal Module

9 Prenatal Counseling 1: Family History Part A
10 Prenatal Counseling 2: Family History Part B
11 Prenatal Counseling 3: Gina Declines Testing
12 Prenatal Counseling 4: Gina is Unsure about Testing
13 Prenatal Counseling 5: Gina Wants Testing
14 Prenatal Counseling 6: Gina’s Reaction 1
15 Prenatal Counseling 7: Gina’s Reaction 2
16 Prenatal Counseling 8: Preliminary Test Results
17 Prenatal Counseling 9: Final Test Results

Prenatal Module Implementation

After reviewing several online applications, we decided to initially host the modules within a centralized learning management system. Implementation of the prenatal module began within the genetic counseling curriculum at the University of Minnesota in Fall 2016. The first-year genetic counseling students (N = 10) were required to watch the prenatal module videos over a four-week period and answer the corresponding questions. The prenatal module was divided into four segments:

1. Collecting Family History Information (Family History Part A and B)
2. Discussing Genetic Testing Options (Gina Declines Testing, Gina is Unsure about Testing, Gina Wants Testing)
3. Test Results (Gina’s Reaction 1 and 2)
4. Discussing Results and Next Steps (Preliminary Test Results, Final Test Results)

Each segment contains two or three videos representing the different components of a counseling session. Initially, students watched the videos in their entirety and then watched short clips with corresponding questions.

After the students completed the entire prenatal module, they were given a 13 question online survey to assess their perceptions of this teaching tool. The survey included six closed-ended questions in which students rated the module on a five-point Likert scale (excellent, good, adequate, marginal and poor). This portion of the survey addressed:

• How well the stimulus questions related to the video clips
• The clarity and difficulty level of the questions
• Whether the module helped students apply knowledge gained in clinical observation and classroom instruction
• The overall usefulness of the module

Two additional questions, rated on a four-point scale (very comfortable, comfortable, somewhat comfortable, and little or not at all comfortable) assessed students’ comfort level in addressing patients’ informational and psychosocial needs before and after completing the module. The survey questions align with the course objectives, namely, to provide students with background information and skills needed to begin the clinical training component of their education as well as with an opportunity to practice the skills needed in the clinical training component of their education.

A forced-choice (yes/no) question was included in the survey to determine whether students would recommend this teaching tool for future genetic counseling students. The remaining four questions were open ended, asking about students’ perceptions of the advantages and disadvantages of the prenatal module compared to clinical observations and classroom instruction (lectures, class discussions, and role plays). At the end of the survey, students had the opportunity to provide additional comments about the module.

Student Assessment of Prenatal Module

All ten of the genetic counseling students completed the prenatal module, and nine completed the survey (Table 2). The prenatal module assessments were rated on average as “good” with respect to difficulty level and the ability to apply classroom material and clinical observation experience to completing the on-line clinical scenario questions. Ratings of the module questions’ clarity and extent to which they related to the video clips were on average between adequate-to-good.

Table 2. Student Evaluations of Genetic Counseling Prenatal Module (N = 9)

Prior to module completion, the average student comfort level addressing patients’ psychosocial needs was somewhat comfortable (mean = 2, SD = 0.5, median = somewhat comfortable) (Scale: 4= very comfortable to 1 = little or not at all comfortable). After the module was completed student comfort level increased by 0.67 points to an average of 2.67 (SD= 0.5; median = comfortable).

Students identified several advantages to the online module over clinical observations. Almost everyone mentioned they liked the capability to “pause or re-watch a section that may have been confus[ing]…” and make observations or connections they otherwise would have missed. One student wrote, “[You] catch different aspects of the session, such as the way things are phrased that you might not catch in a clinical observation.” Additional advantages include: the modules presented the opportunity to “really analyze the situation…” and allowed students to “assess their knowledge and understanding by completing the questions.” One student mentioned that a major advantage of the module is the ability to “follow a patient through all of their appointments with the genetic counselor to see the full picture, whereas in clinic you might not get the chance to be there for every appointment.” Several students also mentioned that they liked the ability to think through and consider how they would respond to certain situations without the pressure of being in clinic.

In addition to advantages over the clinical observations, students identified advantages of the module over classroom instruction as follows: Most commented that they enjoyed the ability to work on the module on their own schedule and were not limited by time restraints. A typical classroom challenge concerns the “difficult[y] to review topics multiple times” and “sometimes things go too fast [in the classroom] and a student is unable to take detailed notes.” In contrast, using the module, students could review the material as many times as they wanted. Additional comments included that the module was superior to classroom instruction in regards to practicality and application. Students commented:

• The classroom instruction is not as practical as the module. With the module you can see how the information you learn in class is applied to the profession of genetic counseling
• The module was a more realistic example rather than talking about sessions in class
• With classroom instruction, it is harder to imagine actual sessions and what they would look like or the various ways that patients might respond to information

The students also noted several disadvantages. The main disadvantage noted was the inability to talk to one’s “supervisor or instructor before and after the session.” Introducing the online modules removed students from the physical environment of a clinic. As genetic counseling encompasses more than the actual sessions with patients, removal from the physical setting precludes student observation of the preparation for a genetic counseling session and post-session follow-up. The module only shows the direct contact with the patient in the sessions and does not illustrate the larger scope of a genetic counselor’s responsibilities within the clinic. Being in clinic also “allows you to see other aspects such as working with sonographers and other paperwork…” In the future, additional vignettes could be added to these types of clinic activities and interactions could be added as separate vignettes to show these “behind the scenes” types of activities and interactions. Other disadvantages included the hypothetical nature of the module: the lack of a “real interaction between patients and a counselor,” and “’[actual] patient emotion[s]… are much more intense… in a clinic setting.” In summary, perceived disadvantages are that the online module eliminates immediate communication with supervisors, diminishes collaboration between students, lecturers and supervisors, fails to portray other genetic counselor responsibilities, and is somewhat contrived.

Although the module had its drawbacks, every student indicated it should be used as a teaching tool for future genetic counseling students. To improve its effectiveness, the students suggested completion of the module prior to their clinical observations. Another common suggestion was having students watch the video on their own time and then to review it “… [during] class so we could talk about ideas” and “come up with questions.” Regarding module formatting, students offered a few suggestions. For time management purposes, they recommended adding the number of questions and estimated time for completion to the beginning of each module section, or playing the entire video and having it “pause and pop up a comment box when there is a question” associated with that portion of the video.

Discussion/Future Directions

In summary, students perceived the module as clearly executed and comprehensible. By flipping the clinic and the classroom, we have enabled students to use precious classroom time to review clinical cases aligned with relevant course work. Students regarded stimulus questions associated with the counseling sessions as useful in allowing them to directly apply the knowledge they had gained from their clinical observations and classroom instruction to a clinical scenario. The module appeared to increase students’ comfort level addressing patients’ psychosocial needs, although further research including a control or comparison group is necessary in order to conclude that the differences in comfort level are attributable to the module. Finally, the students perceived more advantages to using the module than disadvantages.

A limitation to the assessment of the prenatal module is the limited number of responses due to small class size. Only ten first year genetic counseling students viewed the module, and of these, only nine completed the survey, resulting in limited generalizability of the findings. A small sample of this type may also be more vulnerable to “demand characteristics” (e.g., giving more favorable ratings as the course instructor is one of the authors of the module).

Improvements to the website will be addressed in future versions of the modules. There were technical difficulties such as one of the video clips not aligning with the question being asked. This could have altered students’ views of the module and resulted in lower ratings for module clarity. In order to improve upon the prenatal module, the video clip will be fixed and the number of questions associated with each section and the approximate time to completion will be added.

The next step in flipping the classroom requires implementation of the pediatric and cancer modules. If these modules prove to effective, like the prenatal module, then all three modules can be used as a prototype for the development of additional cases representing different, more diverse medical indications, as well as cases from more specialized genetic counseling clinics. These modules will aim to obviate some of the observational time needed during initial clinical rotations, thus freeing up clinical sites and supervisors.

Conclusions

By flipping the clinic, we hoped to enhance student engagement and learning, and provide an orientation to clinical practice. While there are advantages and disadvantages to the online prenatal module, overall the module appears to be beneficial and a “value-added” supplement to both in-class and clinical supervision experiences. Module based learning cannot replace clinical observation and classroom instruction. However, the types of genetic counseling modules described herein may reduce the amount of clinical observation time needed and thus help with diminishing the supervision bottleneck. Module based learning is a valuable tool that can be used in conjunction with previously established teaching strategies in order to increase class sizes in genetic counseling graduate programs.

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