Elaboration of the scientific contents of the course
The course included audio-video lectures and interactive clinical cases and was structured according to the main models of andragogical training (Problem-based Learning and Case-based Learning). The Problem-based Learning (PBL) is a training methodology that stimulates the participants to "learn to learn" by solving real-world problems that reflect their work context [11, 12]. The Case-based Learning (CBL) is a teaching methodology used in medical education as an aid in connecting theory to practice [13].
The content of the course and the delivery model were identified according to two previous literature reviews: the first systematic and aimed at identifying the core competencies in genetics/genomics for non-genetics healthcare professionals [14], and the second aimed at identifying the most effective educational interventions to improve knowledge of health professionals in the "omics sciences" field [15]. The course topics were validated by a panel of expert geneticists involved as teachers of the course.
The general and specific objectives and the content of the course, including 9 case studies, are reported in Table 1.
Table 1. Objectives and content of the distance learning course "Genetics and Genomics practice".
General objective
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Training of medical professionals (in particular primary care physicians) in the responsible use of "omics" technologies.
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Specific objectives
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- Identify the basic concepts of human genetics
- Describe the main genetic / genomic tests currently available and their application
- Describe the main applications of pharmacogenetic tests
- Describe the main applications of genetic / genomic tests in oncology
- Consciously manage clinical information, family history and genetic test results for optimal patient management (including possible specialist referral).
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Topics
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Case Studies
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Public Health Genomics
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Genetic tests in the clinical practice
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- Pulmonary disease, sinusitis, digital hippocratism (Atypical Cystic Fibrosis)
- Unilateral maculopathy and predictive tests (example of predictive tests aimed directly at consumers)
- Monitoring of pregnancy with "super-villocentesis" or "super-amniocentesis"
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Pharmacogenetics
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- 4. Hypersensitivity to warfarin
- Patient with insufficient response to antiplatelet therapy
- Abacavir hypersensitivity syndrome
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Oncology genomics
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- Hereditary breast cancer
- Family history of multiple cancers
- Hereditary colon cancer
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Integration of genetic tests into cancer screening programs
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Notes: GPs: General Practitioners; FPs: Family Pediatricians
Course characteristic, learning methodology and participants
The distance course "Genetics and Genomics practice" was accessible free of charge on the Italian National Institute of Health e-learning platform (EDUISS - https://www.eduiss.it). The Learning Management System (LMS) used was Totara Learn, that offered the technical resources to reproduce the selected methodological approaches (PBL and CBL).
The course was delivered from February 27th, 2017 to February 1st, 2018. The course, open to all physicians potentially involved in the prescription and/or interpretation of genetic tests, was primarily targeted at General Practitioners (GPs) and Family Pediatricians (FPs). The maximum number of subscribers was 3500. Successful completion of the course included the release of 30 CME credits. Participants were expected to spend 30 hours to complete the course and could access the course at any time.
According to the Italian regulation, ethics approval was not required for this study: by registering for the course on the online platform, the participants gave the consent to the use of their anonymous data.
The course was structured in 4 sections:
- Introductive section: introduction to the course explaining its relevance, general aims and structure; general objectives of the course; participants guide containing all the information needed to attend the course; preliminary self-assessment test to set the initial knowledge (pre-test) consisting in 10 Multiple Choice Questions (MCQs). No minimum score was required to complete the test.
- PBL section (1 entire PBL cycle - 7 steps): problem presentation and analysis, specific learning objectives identification, bibliographical references and list of useful web sites to be consulted, reading materials to deepen the topics of the course, audio-video tutorials by experts and the solution of the problem.
- Case Studies section: exercises on 9 different clinical cases (Table 1).
- Conclusive section: post-test (same 10 MCQs set of the pre-test), final certification test, satisfaction questionnaire. Passing the final certification test, consisting in 90 MCQs (0 points for wrong answers - 1 point for correct answer) was mandatory to complete the course and get the CME credits. Each learning objective has been represented and tested in a set of MCQs. The passing mark was set at 75% of the scored questions answered correctly. Three passing attempts were allowed.
Despite some Authors point out that MCQs couldn’t be fully appropriate to assess the competences acquired through PBL approach, as it should be based upon performance and not only upon giving correct answers [16], however MCQs tests can be considered suitable for self-assessment especially when required to assess a large amount of knowledge, as in the case in study [17]. Using MCQs tests was also appropriate since the assessment was directed to the levels of “understanding” and “remembering” [18], as expected in such an e-learning environment.
The course methodology integrated the PBL [11, 12] and the CBL [13], in order to satisfy the strong clinical orientation of the course. PBL has been successfully used in other distance learning courses targeted at health professionals by the same working group. Over the years PBL has been adapted to the e-learning context and different learning models have been developed, depending on the level of interaction between participants and facilitator [9, 12]. In courses with high turnout the participants follow the steps of the PBL by their own, even if small groups or facilitator are not provided. In this course the entire PBL cycle was set up using platform tools such as feedback, web pages, quizzes. The first steps of the PBL cycle, consisting in problem analysis and learning objectives identification, were provided through an interactive tool that allowed to track the results of the participants.
The case studies were realized through interactive exercises, consisting in clinical case audio-video presentations, animated slides, clinical notes and final questions on the case focal points.
Data collection
When registering for the course in the e-learning platform, the following demographic and professional information about the participants were collected from the system: gender, age, region of residence; CME discipline; professional status (National Health Service - NHS employee, freelancer, private contractors with NHS, unemployed). A preliminary question on the previous learning experience on genetics was proposed only at the beginning of the course. Afterwards, a pre-test of 10 MCQ was performed in order to gain insight on genetic knowledge at course registration (T0). The same set of 10 MCQ was administered after the course (post-test, T1) before the CME certification test and was sent by e-mail to be repeated also eight months after the closure of the course (follow-up, T2) to those who had passed the course.
The test consisted of 10 MCQs related to the different modules of the course. For those completing the test at T2, an additional question on the perceived competence about the capability to meet the patients requests on genetic tests was administered. At the very end of the course, participants who successfully completed the final certification test (consisting in 90 MCQs) were also required to fill in the satisfaction questionnaire (SQ), consisting in 18 closed questions about the perceived quality of the Learning Methodology, the educational Contents and the E-learning platform functioning.
Statistical analysis
We performed a descriptive analysis for demographic and professional information. The results of each question, for the pre-test, post-test and for the follow-up test, were reported as percentages of correct answers. The pre-test and post-test results were compared through the McNemar test. We calculated a score for the ten MCQs by assigning 10 points for each correct answer. The average scores of the pre-test and post-test were compared by t test for paired data for the eligible participants. Data were stratified by gender, age categories, region of residence (North, Center, South and Islands), medical discipline and professional status. The discipline of the course participants was analyzed reporting individually those disciplines with more than 3% participants of the total, while those for which a lower percentage was recorded were grouped as "other specializations". The results of the follow-up test were analyzed by presenting the number and proportion of those who gave the correct answer to the test questions. The pre-test (T0) and follow-up results (T2) were compared through the McNemar test.
Statistical analysis was performed using the Stata software (StataCorp. 2013. Statistical Software: Release 13. College Station, TX: StataCorp. LP).