Capacity building of health professionals on omics sciences: evaluation of the effectiveness of a distance learning training course for Italian physicians.

Background. The rapid adoption of personalized medicine approaches in healthcare requires professionals to be able to manage the “omics revolution”. In this context, the genetics/genomics literacy of healthcare professionals should be in line with the continuous advances in this field, in order to implement its potential implications for the diagnosis, control and treatment of diseases. The present study investigates the effectiveness of a distance learning course on genetics and genomics targeted at medical doctors. Methods. In the context of a project funded by the Italian Ministry of Health in 2017, we had set up a distance learning course, entitled Genetics and Genomics practice . The contents of the course were identified from a core curriculum in genetics directed mainly to general practitioners, for physicians and healthcare professionals, previously published. The course focused on genetic/genomic testing in clinical practice, pharmacogenomics and oncogenomic and it was developed according to the main models of andragogical training (Problem-based Learning and Case-based Learning). We used a pre-test versus post-test study design to assess knowledge improvement on a set of 10 Multiple Choice Questions (MCQs). We analysed the proportion of correct answers for each question pre and post-test, as well as the mean score difference stratified by gender, age, professional status and medical discipline. Moreover, the same test was submitted to the participants eight months after the conclusion of the course, in order to assess the retained knowledge. Results. An important number of Italian physicians (N= 1637) completed the course, most of which were primary care physicians (20.8%), public health professionals (11.5%) and specialist paediatricians (10.6%). We reported an improvement in the proportion of correct answers for all of the 10 MCQs set at the post-test. The overall mean score to the questions significantly increased in the post-test, from 59.46 in the pre-test to 71.42 in the post-test (p-value < 0.0001). Conclusions. Genomic literacy among healthcare professionals is essential to ensure optimal translation to healthcare delivery of research. The results of this course suggest that distance-learning training in genetic/genomic practices represents an effective method to improve physicians’ knowledge in the immediate and mid-term time scale.


Background
The last two decades were characterized by a "genetic revolution" that has given rise to the "omics sciences era" as a consequence of the spread of high-throughput investigation techniques, capable of generating enormous amounts of data related to the different hierarchical levels of biological complexity (DNA, mRNA, proteins, metabolites, etc. ...) [1].
The rapid spread of this new knowledge requires healthcare professionals to manage the possible application of the omics sciences, ranging from medical research advances to use in screening, diagnosis and prognosis of different pathologies [2,3].
While several European countries implemented dedicated health policies in this area [4], few countries have integrated Public Health Genomics into the health system offer [5], such as Italy where personalized medicine was included in the National Prevention Plans since 2010 [6,7].
More recently, the Italian National Plan for innovation of the Health System based on omics sciences, identified educational efforts towards professionals, citizens and decision makers as a cornerstone for a proper implementation of omics sciences in healthcare [8]. In this context, the Italian Ministry of Health has supported a distance learning course entitled "Genetics and Genomics practice", aimed to train medical professionals and in particular at primary care physicians, in the responsible use of omics technologies [9]. The course included audio-video lectures and interactive clinical cases and it was structured according to the main models of andragogic 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 [10]. This methodology has been successfully used in other distance learning courses targeted at medical doctors and developed by the same working group [11,12]. The Case-based Learning (CBL) is a teaching methodology used in medical education field, as an aid in connecting theory to practice [13].
Our study presents the project aimed at developing a distance learning course in genetics and genomics, and to evaluate its effectiveness in terms of knowledge improvement of participants after the course, and eight months after its closing.

Elaboration of the scientific contents of the course
The content of the course and the delivery model were identified according to previously two 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" context [15]. Subsequently 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.

Course characteristic, learning methodology and participants
The distance course "Genetics and Genomics practice" was accessible free of charge by the Italian The passing mark was set at 75% of the scored questions answered correctly. Three passing attempts were allowed.
The course methodology integrated the PBL [11,12] and the CBL [13], in order to satisfy the strong clinical orientation of the 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 the participants' results tracking.
The case studies were realized through interactive exercises, consisting in clinical case audio-video presentations, animated slides, clinical notes and a final assessment test 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 was performed in order to gain insight on the knowledge and skills competencies, at course registration (T0). The same test was repeated after the course only for those who completed the entire course and passed the CME certification test (T1). The post-test was repeated also at eight months after the closure of the course (T2).

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 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 that reached a number greater than 3% of the total, while those for which a lower number was recorded were grouped as "other specializations". The results of the follow-up test were analyzed through descriptive analysis, given the reduced number of respondents.

Effectiveness of the course
The preliminary question on a previous attendance to similar training courses indicates that 79.4% of participants had not attended other courses on the same topic. The results of the pre-test versus post-test comparison are reported in Table 3. A significant improvement was registered in 100% of the questions.  Table 5 and Table 6 report the results of the Responders at follow up (T2) test.
Regarding the knowledge, with the exception of the question 4 and 5, improvement was recorded when comparing the correct answers to the post test (T1) and to the follow up questionnaire (T2) with respect to the pre-test (T0) ( Table 5).

Satisfaction questionnaire results
The majority of participants was satisfied from the learning method, the adequacy of the contents and the e-learning platform functioning. It emerges a high overall liking on the course, considering that the values are always between 4 and 5, where 5 express the highest degree of satisfaction.

Discussion
The aim of this study was to analyze the effectiveness of a distance learning course on genetics and genomics for Italian physicians. In recent years, a growing interest in promoting courses on genetics/genomics topics is clearly emerging [16,17], due to rapid developments in genomic technologies and to the not sufficient knowledge of healthcare practitioners in this field [18][19][20].
Previous research in learning field suggests that different aspects of an educational intervention may have impacts on its effectiveness, including the type of intervention, and the amount of practicereinforcing strategies it contains [15]. Indeed, it appears that interactive learning, including case studies, is generally more effective at improving medical knowledge than learning based on theoretical principles alone [21].
This course represents the second Italian experience in distance training in genomics [22].
The main innovative aspect of the "Genetics and Genomics practice" course is related to the teaching methodology, oriented to an active training. The PBL methodology encourages the participants to "learn to learn" by solving real-world problems that reflect their work context [11,12]. Schmidt et al. [10] indicated that in PBL the presentation of a problem activates the participants' prior knowledge, enabling more effective learning to take place. Compared to a conventional approach, in PBL learning occurs in a more active way, since participants attempt to solve a problem and to identify their specific learning objectives. This way, learners face a cognitive conflict and construct their learning on their previous knowledge and experience [23]. Although in some studies CBL is contrasted to PBL in terms of structure, being guided learning, we integrated these two approaches, in order to provide a comprehensive andragogic and active orientation to the course [24]. CBL, indeed, encourages participants to integrate their learning in the context of realistic clinical environment and to connect theory to clinical practice. The learning theories applied to CBL derive mainly from adult-learning and inquiry-based learning approaches, relaying also to cognitive and social constructivist models [25].
The results of our "Genetics and Genomics practice" course suggest that distance-learning training in genetic/genomic practices represents an effective and satisfactory method to improve physicians' knowledge across all age groups of participants.
Among the 1637 participants who completed the course, the most represented age class was those of 51-65 years. This result may be related to the educational need of the over-50 age physicians in an innovative field as omics sciences are. In fact, most healthcare professionals did not receive an adequate training on this topic, as demonstrated by a negative correlation between time from medicine degree and omics sciences knowledge [26].
Participants declared their previous training experience on the course issues at the beginning of the course and results reports that the majority of participants had never attended other courses on that topic before.
The effectiveness of the course was measured through a Knowledge test made of a set of 10 MCQs that was repeated before the start and at the end of the course. The overall results suggest that the course improved the general level of knowledge. Nevertheless, as revealed by the stratified analysis, the improvement was not homogeneous for all the medical specialties. For example, the knowledge improvement was greater for Primary Care physicians and Sport Medicine physicians. These results accomplish our expectations regarding the course, since it was intended mainly as directed to GPs and FPs (primary care), that don't receive a specific education in genetics during their specialization, but deal with genetic problems during the daily practice. The low pre-test score of this specialty group confirmed the educational need we hypothesized in planning the course. As for Sport Medicine physicians, the lowest pre-test score they reported could be explained with the fact that they deal with genetics more rarely than other specialties physicians; however, the great improvement obtained in the post-test score could demonstrate the effectiveness of the course in filling the knowledge gap. On the opposite, the Gynecologists and Occupational Medicine physicians reported the lowest difference between the pre and post-test. For the first category, this might be related to the high pre-test score they reported, while for the latest both the pre-test and the post-test scores were low, if compared to the overall scores. The highest pre-test and post-test scores were registered for the Geneticists, demonstrating their pre-existing knowledge on the topic. Our results are consistent with the results reported by Michelazzo et al. [22], that analyzed the effect of a previous course in genetics and genomics for physicians, organized with different educational methodologies.
To our knowledge, this is the first study that attempts to measure the knowledge retain and the educational effects of the course after a follow-up period. This was obtained by inviting all participants to complete the same pre/post-test after a follow-up period of eight months. Although the proportion of respondents was low compared to the high number of participants, the overall scores shows that after eight months the knowledge level decreased if compared to the post-test score, but it was higher than the pre-test score, thus supporting the effectiveness in knowledge retain.
The follow-up data also allows some considerations on the self-perceived sense of competence, before and after the course, in giving information on genetic tests to patients by medical staff. Among the 258 Responders the sense of competence has improved at follow up and there was an increase in the number of doctors who felt more capable of providing information about diagnostic/prognostic utility of predictive genetic test.
Our study presents some limitations. Firstly, the effectiveness of the course could be overestimated, due to the fact that only data of those who completed the entire course were collected. Therefore, it might be possible that the "dropouts" would have reported lower improvements or less satisfaction than the "completers". Secondly, the sample size of those who completed the course was quite heterogeneous in terms of specialties, not allowing a significant representation of all the discipline categories, many of which were grouped into one "other specialties" category.
Despite these limitations, the results of our study confirmed the effectiveness of genetic and genomic courses in improving participants' literacy on omics sciences, not only in terms of knowledge, but also in terms of managing genetic information in daily practice. In particular, our results suggest that especially primary care physicians are those who can have the most important benefit from a course about this topic.

Conclusions
In conclusions, in our experience a distance-learning training in genetic/genomic practices that adopts a PBL and CBL approach was highly effective method to improve physicians' knowledge and skills.

Ethics approval and consent to participate
According to institutional regulation in Italy, ethics committee approval was not required for this study: participants were informed about methods and aims of the study and, by registering for the course on the online platform, agreed to the use of anonymous data in accordance with Italian Data Protection Regulations (Legislative Decree no. 196/2003 amended by the decree adapting the national legal system to the GDPR 2016/679).

Consent for publication
Not applicable

Availability of data and materials
The datasets generated and analysed during the current study are not publicly available, as personal information of the participants of the course are stored, but are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.