The Development and Evaluation of Online Podcast Modules as a Toolkit for Teaching Genetics and Genomics Competencies in Post-Graduate Medical Education

Background: The lack of comfort with core genetic and genomic competencies among medical trainees and physicians is a barrier to the implementation of precision medicine. To address this, we developed short online modules to promote genetic competencies for use post-graduate medical education. Methods: The educational toolkit was delivered as short online podcasts accompanied by slides. Each core module is approximately 15-20 minutes, and covered basic genetics, genetic testing, counselling and consenting, and interpreting and delivering results. These were supplemented by case-based modules on cancer genetics, prenatal genetics and cardiogenetics. The modules had pre- and post-test multiple choice questions pertaining to genetic and genomic competencies, attitudes towards precision medicine, and perceived competence. Results: Based on the pre- and post-test data, residents reported a discordance between how often they cared for patients with genetic disorders and their level of condence with core genetic competencies. Post-module evaluations demonstrated a signicant increase in condence in interpreting a microarray, and basic genetics knowledge. Conclusions: Our study demonstrates that podcast modules are an innovative method to promote genetic and genomic competencies to postgraduate medical trainees. Limitations to our study included a small sample size, and further work is needed identify and address barriers to implementation. We suggest that integration at the post-graduate medical education level will be crucial to further promoting the development of precision medicine competencies in medical trainees and physicians.


Introduction
One of the challenges in the implementation of precision medicine is the lack of existing genetic and genomic competencies amongst medical trainees and practicing physicians, which may be due in part to the rapid rate of advances in genomic technology with relatively slower implementation of genomic medicine (1). In order to integrate precision medicine into patient care and to effectively use and interpret genetic technologies for medical management, an understanding of the role and complexity of genetic, and in particular genomic, testing is required (2). Key competencies for physicians and trainees have been identi ed, which include con dence with core genetic and genomic competencies including a basic understanding of genes and inheritance, consent for testing, interpretation of test results, and application of this knowledge to clinical situations (3).
Educating the physician workforce in order to achieve these competencies is di cult due to competing curriculum priorities at the undergraduate medical education level (4). Once trainees have entered independent clinical practice, the opportunities to develop these competencies are limited and there are again many competing priorities (5). Residency offers an ideal time to develop these competencies, as resident trainees may have a better appreciation of their utility as they gain further clinical exposure.
There is a paucity of medical literature pertaining to the teaching of precision medicine to medical residents. Much of the available literature focuses on the importance of preparing medical professionals for the precision medicine era (see systematic review by Talwar et al 2018) (6); however, very few papers present examples of educational programs or approaches to teaching this material. In most cases, the conclusions highlight the need for ensuring an educated work force, including physicians, nurses, bioinformaticians, pharmacists, and other members of the healthcare team. For example, a literature review and modi ed Delphi survey by Tognetto et al (2019) established key foundational components of genetics curricula, but speci c steps for implementation and knowledge translation are typically not addressed (7).
McGrath et al. discuss the importance of medical curriculum reform, including making genetics a core competency in their 2016 article (8). They discuss the need for new continuing medical education (CME) courses, precision medicine certi cation, and proper sta ng. Several groups have approached the teaching of precision medicine using experiential learning (9,10). Medical students and residents were taught about genomic medicine using a hands on approach by analyzing their own genomes; however, the ethics behind this pedagogical method are debatable (11).
There are several online educational modules offered through various associations and organizations (12,13). However, we were unable to nd any examples of online learning modules teaching genetic competencies that have been evaluated to determine their effectiveness as an approach to imparting these skills. We undertook to develop a series of online precision medicine learning modules and to evaluate their effectiveness in teaching key concepts in Genetics and Genomics core competencies to non-genetics medical residents.

Study Design
Our group developed a series of online video podcasts to be used as an online toolkit to promote genetic The toolkit is delivered as short online podcasts accompanied by slides, which provide a collection of clear, concise educational modules available to learners for their ongoing reference. Each core module is approximately 15-20 minutes, and covers basic concepts in genetics, genetic testing, counselling and consenting, and interpreting and delivering results. These are supplemented by shorter case-based modules. Development of the curriculum was based on genetic and genomic competencies deemed to be important for a general practitioner and which ful lled various aspects of the CanMEDS framework of essential physician abilities, outlined by the Royal College of Physicians and Surgeons of Canada (14) (Figure 1).
Participants were recruited through email or by attending the resident academic half days. The toolkit and evaluations are password-restricted to postgraduate medical trainees at the Cumming School of Medicine. The website was designed in a manner which did not force participants to complete the questions and participants could advance to the next module without completing the questionnaire. The responses were collected anonymously using Google forms.
We then evaluated the effectiveness of the online podcast modules as a technique to teach these competencies. Each module has pre-and post-module questions pertaining to genetic and genomic competencies, attitudes towards precision medicine and perceived competence. Questions were primarily multiple choice (for knowledge-based questions) or modi ed Likert scale (for con dence-based questions) (

Demographics
A total of 166 pre-tests and 110 post-tests for Modules 1-4 were completed by residents in at least 8 disciplines ( Figure 3). The majority of residents were from family medicine, pediatrics, and pediatric neurology, and most were in their rst or second year of residency. Due to the website structure, residents who completed more than one module were counted independently for each module.

Level of Exposure to Genetics in a Clinical Setting
Participants were asked two questions to gauge their level of exposure to genetics in a clinical setting: "How often do you care for patients with genetic disorders?" and "How often do you see the results of genetic tests?" for each pre-test. Responses were graded on a 5-point Likert scale. Due to an error, this information was not available for participants who completed Module 1. There were three individuals who answered the question "How often do you see the results of genetic tests?" but not "How often do you care for patients with genetic disorders?".

Level of Con dence with Medical Genetics and Genomics Competencies
Participants were asked two questions to gauge their level of con dence with genetic competencies commonly encountered in clinical settings: "How con dent are you in interpreting the results of a microarray?" and "How con dent are you in discussing speci c genetic concerns with patients and families?" in each pre-and post-test. Responses were graded on a 4-point Likert scale. Due to an error, this information was not available for participants who completed Module 1.
We then compared responses pre-and post-test, to determine whether con dence levels improved with the modules. A 2-sample proportion test was applied to those who reported "Not at all con dent" and those who reported "Not very, Somewhat and Very con dent". A p value of <0.05 was considered statistically signi cant.
Con dence levels improved signi cantly for interpreting the results of a microarray (z=3.33, p=0.00086). While there was a trend to improvement, the change in con dence in discussing genetic concerns with patients and families was not signi cant (z=1.84, p=0.066).

Knowledge of Genetics and Genomics Core Competencies
Participants were asked a short series of multiple choice questions examining knowledge of the core competencies and application in clinical scenarios for each pre-and post-test. For each module, more participants completed the pre-test than the post-test (116 pre-tests and 110 post-tests completed), and Module 1 had the largest number of respondents (59 pre-tests and 35 post-tests).
We compared mean scores for each pre-and post-test for all modules separately, and for the 4 modules combined ( Figure 5). An independent two-tailed t-test was applied for each scenario. A p value of <0.05 was considered statistically signi cant.

Discussion
We developed a series of online video podcasts to be used as a toolkit to promote genetic and genomic competencies for non-genetics residents. While a clear need for teaching of Genetics and Genomics key competencies has previously been demonstrated, prior to our study, evidence regarding the effectiveness of existing online modules as a tool for teaching precision medicine competencies was limited.
Our study identi ed a marked discordance between residents' reported exposure to patients with genetic diseases and their level of con dence in basic genetic competencies, in keeping with the previously identi ed need to prepare physicians-in-training for genomics-based healthcare. While 59% reported seeing patients with genetic diseases "Sometimes, Often, or Very Often" in their practice, prior to our modules, 59% reported they were "Not at all con dent or Not very con dent" in discussing speci c genetic concerns with their patients. Similarly, we noted that exposure to patients with genetic conditions was reported to be higher than exposure to genetic test results; the majority of residents (68%) reported that they "Rarely or Never" see the results of genetic testing. We speculate that this may re ect local reporting practices, as results of genetic testing in our centre are not available on the electronic medical record and are typically sent to the ordering staff physician.
There was a trend towards improvement in genetics and genomics con dence and knowledge with the completion of the modules, with some areas demonstrating statistically signi cant improvements. Prior to participating in the study, 75% reported that they were "Not at all con dent or Not very con dent" in interpreting the results of a microarray. Participants' con dence in interpreting a microarray demonstrated a statistically signi cant improvement (z=3.33, p=0.00086) following completion of our toolkit modules.
Our study showed signi cant improvement in residents' knowledge of basic genetic concepts between Module 1 pre-and post-test responses. Although results for the other modules did not reach statistical signi cance, the scores all trended up between the pre-and post-test modules. Similarly, while there was a trend to improvement, there was no statistically signi cant increase in con dence in discussing speci c genetic concerns following completion of the podcasts. We speculate that this may be in part to due the wide range of genetic disorders seen by participants, not explicitly covered by the four modules.
One of the strengths of our study was the wide range of participants who enrolled. Residents participated from multiple programs, including dermatology, family medicine, internal medicine, neonatology, neurology, pediatrics, pediatric nephrology, pediatric neurology, and other (22 remained unspeci ed). We had participation from residents in their rst year of training, to their 6th year into residency. Comparison by specialty demonstrated that residents in pediatrics and pediatric neurology are most likely to care for patients with genetic disorders and see the results of genetic testing, while patients in family medicine and dermatology report doing so less often.
Another highlight of our study includes some of the important gaps in participants' knowledge of core genetic concepts that were identi ed. For example, in the Module 1 pre-test, 58% of residents failed to identify that mitochondrial diseases can also be inherited in autosomal and X-linked patterns, and 12% incorrectly identi ed the correct number of autosomes and sex chromosomes in a normal human karyotype. We also noted several gaps in knowledge in the pre-test responses in Modules 2-4. For example, 21% of residents incorrectly identi ed the main type of genomic variation detected by a microarray. These knowledge gaps have the potential to seriously impact clinical care for patients with suspected genetic disorders, and again highlight the importance of ongoing genetics and genomics education at the undergraduate medical education and post-graduate medical education level.
Our study had a number of limitations. Since the responses were anonymous, the pre-and postquestionnaire for each participant could not be matched to determine if an individual participant improved their genetic and genomic competencies. Similarly, it could not determine how many modules each participant completed. This impacted our ability to detect and analyze differences in outcomes between pre-and post-module tests. We also had a small sample size, particularly for Modules 2-4. We speculate that this is because most residents were asked to complete the modules on their own time, rather than being provided dedicated time (for example, at an academic half-day). We suggest that integration at the post-graduate medical education level, including protected teaching time, is crucial to promoting the development of competencies in precision medicine.
We identi ed several future areas of development. While the toolkit included clinical case modules in a variety of disciplines (cancer genetics, prenatal genetics, cardiogenetics), these were not evaluated in our study. Addressing barriers to completion of the online modules will be necessary to determine if they are effective in promoting additional genetics and genomics competencies among residents. At our centre, physicians in many non-genetic specialties frequently order genetic tests for their patients and deliver the results. Without effective and innovate educational solutions, the genetics knowledge gap among residents will remain a barrier to successful implementation of precision medicine in healthcare. Finally, while these modules were developed prior to the COVID-19 pandemic, there has been an overwhelming adoption of e-learning techniques during the pandemic, and these modules are easily adapted for use in this context.
In conclusion, podcast modules are an innovative method to promote genetic and genomic competencies to postgraduate medical trainees. Developing con dence with core genetic and genomic competencies is essential for effectively implementing precision medicine into patient care. Teaching these competencies during post-graduate medical training remains a challenge due to competing curriculum priorities as well as limited time. Self-directed learning through online modules and podcasts offers an opportunity to overcome some of these challenges.

Declarations
Ethics approval and consent to participate This study was approved by the Conjoint Health Research Ethics Board at the University of Calgary, REB18-0089. Informed consent was obtained from all participants, and data was de-identi ed.  The curriculum objectives covered by the precision medicine toolkit ful ll key competencies, as outlined by the CanMEDS framework for Canadian physicians.  Reported frequency of seeing the results of genetic tests, and caring for patients with genetic disorders (A, B). Resident con dence with discussing speci c genetic concerns, interpreting results of a microarray (C, D).