A 6-month genetics educational initiative significantly improved the confidence and competence of family physicians, according to the findings of a small study.
“Primary care providers are going to be increasingly involved in the delivery [of genetics services]. There's a huge literature out there that we're deficient in. We have to be able to assess risk. We have to know when to refer. We have to provide counseling and follow-up after test results. And we are probably increasingly going to be asked to tailor our preventive care, medication choice, and treatments to people's individual genetic profiles,” said Dr. June Carroll, the Sydney G. Frankfort Chair in Family Medicine at Mount Sinai Hospital and the University of Toronto.
The study randomized 125 primary care physicians to an educational intervention (61 physicians) aimed at improving primary care genetics skills, or to a control arm (64 physicians), that received the educational material at the end of the study.
Participating physicians came from both rural and urban practices in the province of Ontario.
The intervention involved a 1-hour workshop conducted by a genetics counselor and a family physician, and a portfolio of primary care–appropriate genetics “tools,” such as genetics pearls, red flags, risk-triage cards, and tables outlining possible consequences of genetic test results.
The most exciting aspect was access to an information service called “Gene Messenger,” according to Dr. Carroll. “Our team scanned the newspapers every day during the time of the trial, and we looked for any big headlines or articles about a new genetic test or a genetic disorder. We then very rapidly developed a critical review of that disorder or test, and came up with bottom-line recommendations for primary care,” she explained.
The one- to two-page reports were written by a genetics counselor, with input from geneticists and family physicians, and were e-mailed or faxed to study participants every 2 weeks during the 6 months of the study.
“We produced 16 of these reviews over the course of the project. They were as evidence based as possible, although sometimes we did have to use expert opinion. And they were fully referenced,” she said.
Study participants were assessed 1 month before and 6 months after the intervention for the primary outcome of the study, which was the appropriate intention to refer a patient for genetic counseling. Secondary outcomes looked at the participants' perception of the difficulty in making a decision and their self-rated confidence in a set of 11 core genetics competencies, as defined by the National Coalition for Health Professional Education in Genetics.
All participating physicians also answered the following three questions about hereditary breast and colorectal cancer:
▸ Is there paternal inheritance of the BRCA mutations? (Answer: yes)
▸ What percentage of breast cancer patients have a BRCA mutation? (Answer: fewer than 10%)
▸ What percentage of people with the HNPCC (hereditary nonpolyposis colo-rectal cancer) gene will get colorectal cancer? (Answer: more than 50%)
These are the “big ticket items” in genetics that family physicians need to know in order to advise their patients, she said.
Compared with physicians in the control arm, those in the intervention arm showed a statistically significant improvement from baseline in their appropriate intention to refer patients, based on a set of 10 clinical vignettes (7.8 of 10 vs. 6.4 of 10 for controls).
In addition, self-reported confidence was significantly higher among physicians in the intervention group (43 of 55, compared with 34 in the control group).
“We saw an increase across all 11 items of family physician core competencies in genetics,” said Dr. Carroll. For example, physicians were more confident eliciting genetic information from a family history; doing risk assessment and deciding who should be offered referral; discussing risks, benefits, and limitations of genetic testing; knowing where to refer; providing psychosocial support for those who have had genetic test results; providing management and following people who have had genetic test results; and reassuring patients who are at low risk. Handling all of these areas is “going to be a big job for us in the future,” she said.
Yet despite their increased confidence, physicians in the intervention group scored no better than controls on the first two knowledge questions. The percentage of correct answers “was low for two of the questions, and a large percentage said they weren't sure,” said Dr. Carroll.
The group hopes to expand the intervention to include a wider range of conditions, and to distribute the material to more physicians. “It would be ideal to have one center that was developing these reviews and recommendations in response to the media and new discoveries, and having them disseminated widely so that family physicians could get timely information to share with their patients about new genetic information,” she said.