Improving Genetics Education in Graduate and Continuing Health Professional Education: Workshop Summary (2015)

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

5 Continuing Medical Education Important Points Highlighted by the Individual Speakers • A needs-driven, learner-centric, evidence-based, outcomes- oriented, and practice-embedded continuing medical educa- tion system can contribute to improved quality of care and pa- tient outcomes. • The accreditation system is designed to recognize and promote institutional and personal attributes that are effective in main- taining competencies, performance, and patient outcomes. • Innovative methods in continuing medical education, such as simulations for workplace learning, massive online open clas- ses, and Web-based learning portfolios, can help produce the changes that are needed as the effects of genetics on clinical practice continue to grow. • Partnerships among professional societies can guide the devel- opment of educational initiatives and improve genetic literacy. More than 2 million people each month interact with the continuing medical education system (ACCME, 2014). These interactions involve not just physicians but nurses, pharmacists, nurse practitioners, physician assistants, and other allied health professionals. While the current system has great potential for enhancing genetics knowledge among clinicians, doing so may require innovative educational approaches to ensure that 45 

46 IMPROVING GENETICS EDUCATION practicing health professionals know how to apply emerging genomic information to clinical practice. MAJOR FEATURES OF CONTINUING MEDICAL EDUCATION Continuing education contributes to lifelong learning in any career, said Ann Karty, the medical director in the Continuing Medical Educa- tion Division at AAFP and chair of the Council of Medical Specialty So- cieties’ Conjoint Committee on Continuing Education, which consists of continuing medical education directors from 25 member societies. Con- tinuing medical education introduces learners to new technologies, inno- vative advances, and research. It serves to maintain, develop, and increase the knowledge, skills, and professional performance and rela- tionships that a physician needs to provide services for patients, the pub- lic, or the profession. In this way, it contributes to improved quality of care and patient outcomes. Credit is the “currency” that physicians and other health profession- als earn by taking part in continuing education activities, Karty said. Physicians and health professionals use these credits to maintain licen- sure, specialty board certification, credentialing, membership in profes- sional societies, and other professional privileges, with the requirements for earning a particular credit being determined by the organization re- sponsible for certifying that credit. As continuing medical education is currently set up, a curriculum is designed to lead teacher and learner to reach toward desired objectives. The components of a typical curriculum include aims and goals, content or subject matter, experiences, and evaluation, Karty said. The curricu- lum, when implemented, results in new knowledge, skills, and attitudes or abilities, sometimes known collectively as KSAs. Ideally, the curricu- lum should be needs-driven, learner-centric, evidence-based, outcomes- oriented, and practice-embedded. It should be designed to bridge the gap between actual practice and ideal practice. Box 5-1 describes the per- spectives of various specialists on education about and the use of genet- ics and genomics; these perspectives point to some needs within the community that genetics education could fill. 

CONTINUING MEDICAL EDUCATION 47 BOX 5-1 Perspectives on Genetics Education Before the workshop, Ann Karty asked members of the Council of Medical Specialty Societies to comment on educational re- quirements in genetics and genomics. Here are some of the re- sponses she received: • “When we’ve done programming on genomics, it’s been foundational, didactic activities because it’s primarily new in- formation that our members aren’t familiar with. And be- cause much of it in our field is new, there’s not much clinical application yet. For that reason, the whole issue of just-in- time isn’t relevant for us now because we don’t have imme- diate clinical applications yet.” • “From a general sense, we make more use of point-of-care tools. We haven’t made point-of-care education part of our program, and our certifying board is big on providing tools as part of the MOC [maintenance of certification] self- assessment/performance improvement process.” • “We’re in the process of analyzing our annual meeting pro- gramming process, and one of the issues we’re looking at it is strengthening the basic science education we offer. I think if this gains traction, we might start seeing more.” • “Genomic data cannot be used to improve health if it cannot be accurately communicated and correctly understood. . . . [There is] tremendous variability in the representation of ge- netic test results [and in] the efficient exchange and use of this information by clinicians and researchers.” • “Credit could be an incentive, but point of care tends to be such small amounts that tracking and claiming might actually be a barrier.” • “How can we incorporate genomics into clinical decision support systems [even as it relates to] the goal of phar- macogenomics . . . and using the right drug, the right dose, at the right time.” • “[Our] mission . . . is to facilitate communication, collabora- tion, training, and networking for researchers working at the interfaces between biomolecular and clinical data, . . . to ad- vance the clinical use of genomics data and the fields of ge- nomics and translational bioinformatics, . . . furthering the practice of precision medicine. Our members are highly in- volved in the development of software tools, methods, and standards that are necessary for the clinical application and 

48 IMPROVING GENETICS EDUCATION interoperability of genomics data, [and] our members also participate in the development, integration, and delivery of knowledge content to clinicians.” • “Due to both rapid changes in knowledge and the size of the genomics domain, we strongly believe that it will be necessary to provide context-dependent, just-in-time genomics educa- tion to clinicians (e.g., through clinical decision support sys- tems, including alerts and curated knowledge bases). Given the complexity of genome biology, however, we believe clini- cians must also have a solid base of knowledge about ge- nomics in order to effectively understand and utilize the just- in-time material.” • “While there may be some instances where offering continu- ing medical education credit for informatics-based courses would have direct impact on patient care, there are probably many more opportunities to offer continuing medical educa- tion credit for courses that provide general knowledge about genomics or specialized (gene- or phenotype-specific) inter- actions. Therefore, the majority of continuing medical educa- tion credit should likely be directed toward content rather than technology.” • “Actual application to clinical practice will require a culture change as well as a technological one. Some clinicians don’t want to use genetic data in their practice until they have ran- domized clinical trial (RCT) evidence that it helps. However, it is not financially or statistically possible to perform an RCT for every genetic variant and every possible clinical applica- tion of that variant. The application of genetic data to clinical practice will not grow significantly until clinicians are both able and willing to apply the interpretations from certified ge- netic counselors in the absence of RCTs when it might help improve outcomes.” • “[We] don’t have any technology-based point-of-care tools or point-of-care education right now, but have produced pocket cards and ‘analog’ tools in the past. . . . It is possible that [a] registry could eventually track and provide links to (yet to be created) educational activities on genetics, but we are a year-plus away from this capability.” “These comments may be potential pieces to a needs assess- ment to help create more continuing medical products,” Karty observed. 

CONTINUING MEDICAL EDUCATION 49 The content of continuing medical information depends on the knowledge, skills, or attitudes that need to be transmitted to the learner. The way in which one measures outcomes depends on the best format (e.g., live activities, self-study, journal reading, manuscript review for journals, point-of-care learning, online learning, performance improve- ment in practice, and translation to practice) for addressing the gap that has been identified and also on the learning objectives that have been designed to address that gap. Karty described a framework for the as- sessment of continuing medical education that ranges from “does” (per- formance) to “shows how” (competence), “knows how” (procedural knowledge), and “knows” (declarative knowledge) and that ensures that education is free from commercial conflicts of interest. Requirements for continuing education can vary greatly between states, Karty said. Requirements also can be highly specific to subspecial- ties. For example, the American Board of Medical Specialties has 24 spe- cialty boards and more than 145 specialties and subspecialties. Despite this variation, however, particular themes appear across requirements, includ- ing patient care, interpersonal and communication skill, professionalism, medical knowledge, practice-based learning, and systems-based learning. Within these themes, AAFP includes genetic and genomic content such as family history taking, red flags, cultural competency, evidence-based medicine, health information technology, and specific content related to certain cancers, cardiovascular disease, congenital hearing loss, devel- opmental delays, and ethical, legal, and social issues. Finally, Karty said, not all practitioners need to know the same thing, despite continuing medical education requirements that force all clini- cians to learn about subjects that they may or may not use. A better ap- proach might be individualized learning portfolios for practitioners, which reveal both what an individual practitioner knows and what he or she does not know. In this way, a testing mechanism could point out what a particular individual needs to learn. “Mandatory continuing medi- cal education is not what I would necessarily move toward,” Karty said. “I would love to have individualized portfolios telling me where my de- ficiencies are so that I could educate myself.” EVIDENCE-BASED CONTINUING MEDICAL EDUCATION With appropriate formats, continuing medical education can create desirable physician attributes and competencies and contribute to organi- 

50 IMPROVING GENETICS EDUCATION zational self-assessment and improvement, said Murray Kopelow of the Accreditation Council for Continuing Medical Education (ACCME). Continuing medical education can be based on evidence-based require- ments with the expected results being changes in competence, perfor- mance, or patient outcomes. It also can be done in a way that manages boundary issues with commercial interests. As an example of the potential impact of continuing medical educa- tion, Kopelow mentioned work that he had done several years earlier in the White House Office of National Drug Control Policy on the misuse of prescription drugs. A continuing medical education program on miti- gating risks for these products was developed that resulted in about 2,000 activities that reached about 60,000 participants. Such success stories could be repeated elsewhere, Kopelow said. Under ACCME, the accreditation system is based on evidence of what is effective for changing competencies, performance, and patient outcomes, Kopelow said. It encourages the right formats for particular educational needs. A recent ACCME report identified 39 systematic re- views that together describe an evidence-based approach to designing continuing medical education (Cervero and Gaines, 2014). The report found that continuing medical education improves both physician per- formance and patient health outcomes, although the more reliable effect was on physician performance, Kopelow said. It also determined that continuing medical education is more effective when interventions are interactive, longer, and reinforced. Kopelow particularly emphasized the importance of predisposing learners to seek out the information they need, because learners often are not aware of how much they are missing or what they cannot do. Most learners are committed to excellence and to lifelong learning, but they do not necessarily know what they do not know. Kopelow also noted that accreditation requires that continuing medi- cal education providers involve undergraduate medical students and graduate medical students in the planning, delivery, and evaluation of continuing medical education. Providers that are not medical schools or residency training programs have been pushing back on this requirement, saying that they do not know how to involve students in the education they offer. But, Kopelow said, such organizations have many ways of engaging students in their work. Since 2007 ACCME has also had a program that covers interprofes- sional education, which is particularly important in genetics. Nursing, pharmacy, and medical institutions can be accredited through one pro- 

CONTINUING MEDICAL EDUCATION 51 cess to do “education for the team, by the team,” Kopelow said. The ac- crediting organization also is changing its criteria for accreditation with commendation to encourage interprofessional practice. Kopelow cautioned that many intervening variables lie between con- tinuing medical education interventions and changing the health of the people of the United States. In general, the greater the number of inter- vening variables there are, the greater the likelihood is that there will be no change as a result of continuing medical education. Furthermore, Kopelow observed, continuing medical education is not necessarily always designed to change behavior. It may be designed to give people ideas about what they can do or how they can overcome bar- riers. “Don’t be constrained by any current structure that you observe in continuing medical education,” he said. “This can be all reimagined and reinvented. The formats of education are only the formats that people have thought of so far.” Even failed experiments in continuing medical education can be useful in revealing something that did not work, he said. Innovative technologies are beginning to be used in health profes- sional education, Kopelow said. (See Chapter 3 for further details.) Young physicians tend to learn through a variety of new methods, in- cluding group activities such as interactions on social media. “What peo- ple need to know is not how to plan a Twitter interaction but how to judge the information,” he said. “When they hear it, they need the tools to judge what they are hearing. How does it fit with the literature that is available? Where do they go for wisdom and judgment about how to ap- ply it in practice?” This educational trend will likely continue to grow. The physicians who will be entering practice in 10 years are now starting college, and those who will be entering practice in 20 years are in the fourth grade, Kopelow observed. “Those are the people that we need to plan for.” DEVELOPING COMPETENCIES THROUGH CONTINUING MEDICAL EDUCATION There is a distinction between continuing education and continuing professional development, said Constance Goldgar, associate director of the University of Utah Physician Assistant Program. The former refers to educational activities that serve to maintain, develop, or increase knowledge, skills, and professional performance, while the latter is a 

52 IMPROVING GENETICS EDUCATION multifaceted approach to the acquisition and application of knowledge during the practice life of a health care professional. In particular, con- tinuing professional development is learner-driven, tailoring instruction to individual needs, and it encompasses lifelong learning across the span of one’s career (IOM, 2010). Educational activities can be both systems-based and competency- based, with the former relying on incentives and programs and the latter involving individual-directed learning. A particularly useful framework, Goldgar said, involves competencies, which she described as the observ- able abilities of health professionals. Such a framework defines the out- comes desired at the end of an educational pathway. These competencies are based on a foundation of evidence, ranging from expert opinion to systematic reviews to computerized decision sup- port. This evidence needs to be clinically meaningful, implementable, and available at the point of care, Goldgar said. The ability to modify competencies, which are different today than they would have been 20 years ago, is essential to adaptive change. Changes in the genetics education environment are being driven by a number of forces, including research, technologies, regulations (such as those governing MOC), funding, quality improvement, health disparities, changes in health care institutions, the genetics workforce, and the clini- cian population. Meanwhile, broader social, technological, economic, environmental, and political changes are occurring that influence these driving forces. Identifying the driving forces can reveal uncertainties or polarizing forces that lie ahead, Goldgar said. Using innovative methods in continuing professional development can help bring about the changes that are needed as genetics increases its impact on clinical practice. Among the interesting innovations that have been discussed are advanced simulations for workplace learning, audits of patient populations using electronic health records, massive open online classes, collective intelligence through networking, and Web- based learning portfolios. “The future is wide open,” Goldgar said. PROFESSIONAL SOCIETIES IN GENETICS EDUCATION The amount of data in a genome sequence is enormous, said Michael Murray, an internist and geneticist at the Geisinger Health System in Pennsylvania and a co-chair of the Inter-Society Coordinating Commit- tee for Practitioner Education in Genomics (ISCC) for the National 

CONTINUING MEDICAL EDUCATION 53 Human Genome Research Institute. Figuring out how to interpret the data will be a 100-year project. In a 2012 survey of more than 480 internists conducted by the Amer- ican College of Physicians, half of the internists reported that their vol- ume of genetic testing had increased over the preceding 2 years, while 13 percent reported that they had not ordered a genetic test in the prior 2 years. The overwhelming majority—97 percent—said that they were will- ing to devote time to continuing medical education in genetics. Although this suggests a “ready and willing” audience, Murray said, as discussed previously, education must be relevant to the needs of clinicians in order to retain their interest. If it is not relevant, they will drift away, and it will take time and effort to get them back. “We have to use our opportunities wisely,” he said. “In that effort, we have to engage the people who are doing this work and work with them as we develop continuing medical education opportunities, not just talk to people like me who are genetics professionals.” Launched in 2013, the purpose of ISCC is to facilitate interactions among medical professional societies and the institutes and centers of the National Institutes of Health in order to exchange practices and resources related to genomics education and clinical care. Its goals are to • Promote the sharing of educational approaches and the joint identification of educational needs in order to improve genomic literacy and to enhance the practice of genomic medicine. • Jointly identify the needs of professional societies and clinicians in filling in gaps in evidence and knowledge and in providing ef- fective educational efforts. • Offer partnership and available expertise to member societies to guide the development of educational initiatives. ISCC has divided its activities into four areas: competencies, educa- tional products, engagement of specialty boards, and use cases (Manolio and Murray, 2014). The group reviews existing competencies in genomic medicine education as well as guidelines for the use of genomics, exam- ines surveys and other sources to see what competencies fit into current practice, and interacts with individual professional societies to determine how amenable they are for developing competences in genetics for their profession (Korf et al., 2014). ISCC also collects existing educational products from current members, identifies relevant federally funded re- sources and initiatives that could assist genomics education efforts and 

54 IMPROVING GENETICS EDUCATION clinical practice, works to identify areas of emphasis for educational products (such as the ordering of genetic tests, counseling, or the return of results), and identifies new advances that may require educational ini- tiatives. A major effort within ISCC is to determine the extent to which specialty boards have integrated genomics into their examinations and to engage directly with those boards that may not be doing so at this time, Murray said. The group also acts to link specialty boards with relevant professional societies that are already implementing genomics education or are looking to do so. Finally, ISCC collects existing use cases or develops general and society-specific use cases in genetics across five general topic areas: pharmacogenomics, family history, rare single-gene disorders, common diseases with genetic components, and whole genome/exome sequencing, including incidental findings. These use cases can be identified by specialty end users or based on existing competencies. As Murray pointed out, competencies differ from entrustable profes- sional activities (EPAs), although they may be closely related. While EPAs cannot serve as an alternative to competencies, they do represent a means to translate competencies into clinical practice. Five EPAs have been developed by ISCC so far: • Family history EPA: Elicit, document, and act on relevant family history information pertinent to the patient’s clinical status. • Genomic testing EPA: Use genomic testing appropriately to guide patient management. • Patient treatment based on genomic results EPA: Use genomic information to make treatment decisions. • Somatic genomics EPA: Use genomic information to guide the diagnosis and management of cancer and other disorders involv- ing somatic genetic changes. • Microbial genomic information EPA: Use genomic tests that identify microbial contributors to human health and disease, as well as genomic tests that guide therapeutics in infectious diseas- es. These EPAs are not the final word but rather are a framework for the development of competencies, Murray said. “The hope is that each group would take these, personalize them, and use them in effective ways with- in their specialty or their professional area.” Murray also affirmed the utility of the G2C2 resource (the Genetics/ Genomics Competency Center for Education) referred to in Chapter 4. 

CONTINUING MEDICAL EDUCATION 55 Mapping educational needs to these resources reveals the holes in educa- tional products, Murray said. “When we think about where we are and where we need to get to, this will allow individual practitioners or groups to . . . begin to know what we don’t know, to realize where the holes are and where the good educational products are.” Finally, Murray briefly described ongoing work at Geisinger using whole-exome sequences on 100,000 patients in the organization’s biobank. As part of the educational products associated with the project, physi- cians can sign up along with their patients to receive 5 to 10 whole- genome sequence reports. Through a mixture of lectures and self-study, providers learn about the genome report and then have a resource center from which they can access information. In the first round of sequencing results, more than 1,000 physicians and 800 advanced practitioners are delivering results to patients. In this setting, education is shifted to the moment when the provider is most likely to be interested in learning this information, Murray said.