Characterizing standardized patients and genetic counseling graduate education

Status of abortion curriculum in genetic counseling: Survey of graduate programs and recent graduates in the United States

Genetic counselors (GCs) are trained to help individuals navigate the medical and psychological implications of genetic test results, familial conditions, and ultrasound anomalies. Therefore, familiarity with reproductive options, including abortion, is vital. However, previous studies have found gaps in GCs' knowledge regarding abortion care and there are currently no recommendations regarding abortion curriculum. This study aimed to assess the state of abortion curriculum in genetic counseling graduate programs in the United States and to examine and compare the satisfaction levels of program representatives and recent graduates. Program representatives and recent graduates were invited to complete an anonymous survey evaluating the abortion curriculum, satisfaction with said curriculum, and perceived preparedness to counsel on abortion. Quantitative data from 46 program representatives and 123 recent graduates were analyzed using descriptive statistics and appropriate statistical analyses, including the Mann-Whitney U-test and the Kruskal-Wallis test. Large variability existed in the amount and types of abortion training. Results showed greater satisfaction and feelings of preparation to counsel on abortion in graduates whose program provided a dedicated abortion curriculum (p < 0.001, p = 0.005). In addition, graduates with abortion counseling experience felt less prepared to counsel on abortion than their programs believed them to be (p = 0.04). Graduates perceived procedural timing, facilitation of genetic testing, and resources/support desired by patients before, during, or after an abortion, to be the most important topics, although these were not included in all programs' curriculum. Program representatives and recent graduates alike noted that variability in clinical training is a barrier to abortion education. Our results demonstrate a need for curricular reform to reduce variability in training and ensure that all graduates receive the same foundational abortion education. Further research is needed to determine the scope of GCs in abortion care, as well as which topics and education formats are most helpful in graduate education.

Creation and beta testing of a "choose your own adventure" digital simulation to reinforce motivational interviewing skills in genetic counseling

Standardized patients and/or role-playing are commonly used for practicing genetic counseling (GC) skills. Use of digital simulation, incorporating gamification elements, would require fewer resources to sustain than standardized patients. This manuscript reports steps taken and the lessons learned from creating a digital "Choose your own adventure" simulation in which students select preferred dialog for a genetic counselor who is seeing an adult patient to discuss genetic testing for the known pathogenic variant that caused familial adenomatous polyposis (FAP) in their father. The case has three endings, one of which is attained by selecting options that are mostly consistent with motivational interviewing counseling techniques. We conducted a preliminary evaluation of our beta version among nine GC students and one educator using a survey to assess acceptability and appropriateness as well as to elicit open-ended feedback. All participants agreed or strongly agreed with statements indicating the case was acceptable, appropriate, and fun. Users particularly appreciated the immediate feedback given throughout the case simulation. Many users wanted more options to select from and listed various other recommendations, including several which would require substantial resources to implement.

Beyond multiple choice: Clinical simulation as a rigorous and inclusive method for assessing genetic counseling competencies

Educational use of clinical simulation is a way for students to immerse themselves within a realistic yet safe and structured environment as they practice clinical skills. It is widely used in healthcare training and evaluation, and there are best practices for design, implementation, debriefing, and assessment. An increasing number of genetic counseling graduate programs use simulation in various ways, ranging from role-plays to working with professional simulated/standardized patient (SP) actors. At this time, there is very little consistency across programs, research on the approaches, and standards by which simulation is incorporated into training. Simulation is an understudied but promising approach for genetic counselor (GC) education and assessment. After graduation, GCs demonstrate their competence as entry-level providers through American Board of Genetic Counseling (ABGC) multiple-choice examination (MCE), along with their participatory clinical encounters from graduate training. Data from genetic counseling and other professions highlight the limitations and biases of MCEs, suggesting they not only fail to accurately capture competency, but also that they disadvantage underrepresented individuals from entering the field. In addition, MCEs are limited as a tool for assessing nuanced counseling and communication skills, as compared to more quantitative scientific knowledge. We propose that innovative, evidence-based approaches such as simulation have the potential to not only enhance learning, but also to allow GCs to better demonstrate competency during training and in relation to the board examination. Collaborative approaches, research, and funding are needed to further explore the viability of routinely incorporating simulation into GC training and assessment.

Genetic counseling students' use of patient-centered communication skills predicts standardized patient satisfaction during virtual simulated sessions

Communication is essential to effective genetic counseling, but few studies have systematically evaluated methods of assessing communication skills among genetic counseling trainees. The study's objective is to compare the strength of associations between standardized patient (SP) satisfaction with simulated genetic counseling sessions and student skill use during the sessions, as reported by SPs and students. We hypothesized that (1) Both SP- and student-reported skill use will be significantly associated with SP satisfaction ratings during the baseline simulation and (2): SP ratings of student skill use will show a stronger relationship to SP satisfaction than student self-rating of skill use. Sixty genetic counseling students and recent graduates (referred to as "students") from accredited U.S. and Canadian programs participated in the study and completed a baseline virtual-simulated genetic counseling session. Both students and SPs completed post-session questionnaires about communication skill use (a 22-item checklist) and SPs completed a satisfaction questionnaire based on the session (a 14-item Likert scale). Multilevel regression models assessed associations between SP satisfaction during the baseline session and SP- or student-reported skill use. SP satisfaction was significantly associated with skill use reported by both SPs and students, but the model based on SP report explained a higher proportion of the variance in SP satisfaction than student-reported skill use (SP model fixed effects R2  = 27%, adjusted R2  = 21%; vs. student model R2  = 7%, adjusted R2  = -2%). For both the SP and student models, use of more skills from the LISTEN domain (which focused on eliciting the patient's perspective) was associated with higher SP satisfaction, while other skill category domains were not. These findings support the SP satisfaction measure as sensitive to variation in student performance of key communication skills, especially those eliciting the patient's perspective. Moreover, SP assessment of session satisfaction can be a useful assessment of student communication performance and a meaningful proxy for actual patient satisfaction.

Exploring the impact of virtual SPIKES training on genetic counselors' confidence to deliver difficult news

Delivering difficult news is a common occurrence in genetic counseling. This is evidenced by widespread instruction among genetic counseling programs. There is a disconnect in the confidence level of being able to deliver difficult news (DDN) following educational training across healthcare disciplines. Other healthcare professions have addressed this issue with simulation-based training based on the SPIKES protocol, a stepwise process for delivering difficult news. To our knowledge, there is limited research that investigates the impact of simulation-based training in delivering difficult news for genetic counselors. Our aim was to develop simulation-based training in how to deliver difficult news for genetic counselors and analyze the extent to which it increased their confidence to deliver difficult news. Board-certified genetic counselors from all specialties were recruited to participate in a 2-h training session which included the opportunity to practice delivering difficult news. We collected self-reported confidence scores in each of the SPIKES steps from 16 genetic counselors pre- and post-intervention. Participants answered open-ended evaluations about the program's strengths, weaknesses, and gaps in delivering difficult news content. Almost all participants (N = 15) stated that they had gained confidence in delivering difficult news following training completion. Confidence significantly improved in four of seven SPIKES steps. Participants found strengths of the training program to be in their ability to practice with a simulated patient, to reference concrete examples, and to follow the program easily. The results of this study suggest that post-graduate training in how to deliver difficult news using the SPIKES protocol may strengthen genetic counselors' confidence in performing this important skill.

Acceptability of an online communication training intervention for genetic counseling students

Technology provides opportunities to enhance communication skills training for genetic counseling graduate students. We assessed the acceptability of an online communication training program. Graduate student volunteers completed five online training modules on basic communication skills with opportunities to practice the skills within three simulated/standardized patient (SP) sessions. Participants completed online questionnaires reporting on acceptability, perceived usefulness, and realism of the modules and SP sessions. They also reported on the ease of transferring skills from the modules to clinical practice. Out of the 60 students who completed the baseline session, 35 (58%) completed all five training modules. Out of these 35 students, most found the modules to be useful (94%) and agreed that they were relevant to clinical practice (97%). At least 88% of participants found the genetic counselors, patient, and case scenarios to be realistic. Twenty-eight students had participated in clinical rotations since completing the intervention. Of these, 17 (61%) reported that it was at least slightly easy to use the skills in actual clinical cases. Most students also reported being able to transfer the skills they had learned into clinical practice. While the training was well-received, the relatively low completion rate of 58% raises concern that the intervention may need formal integration into the program curriculum to succeed due to the time and effort demands on students.

Efficacy of an online communication skill training intervention on genetic counseling students' performance during standardized patient sessions

OBJECTIVE

To examine the efficacy of a brief, online intervention designed to enhance genetic counseling students' patient-centered communication.

METHODS

Genetic counseling students and recent graduates were randomized to two groups following a baseline standardized patient (SP) session: (1) immediate intervention exposure, which consisted of five modules that taught patient-centered communication skills followed by a second SP session, or (2) delayed intervention exposure following completion of the second session. Sessions were coded using the Roter Interaction Analysis System. Short-term efficacy was assessed by comparing communication during the second session between the delayed and immediate intervention exposure groups. Longer-term efficacy was assessed by comparing communication during a third session approximately five weeks later.

RESULTS

During the second session, students in the immediate intervention exposure group (n = 18) used more emotionally responsive statements and were more likely to use teach-back than those in the delayed intervention exposure group (n = 23). Students' emotionally responsive statements decreased among the immediate intervention exposure group during the third session.

CONCLUSION

Exposure to the intervention was associated with multiple, positive changes to students' patient-centered communication behavior.

PRACTICE IMPLICATIONS

These time- and resource-efficient modules may be beneficial as an introduction to communication skills training or a supplement to existing training.

Teaching perspectives on the communication of difficult news of genetic conditions to medical students

Informing parents that their child has a diagnosis of Down syndrome (DS) is a common example of the delivery of unexpected or difficult news. Expectations and life planning will change, and if detected prenatally, discussions might include the option of pregnancy termination. Medical school curricula currently include training in breaking unexpected news; however, it is difficult to teach and assess. We use the perspectives of clinicians, educators, and a medical student who is the parent of a child with DS to frame a discussion on teaching, practicing, and assessing communication of difficult news in human genetics during medical school.

Assessing genetic counselor communication in response to virtual, asynchronous simulated video prompts

Online methods of teaching and assessing communication skills meet not only the need for remote education during the COVID-19 pandemic but also future demand for flexible training methods. This study aimed to explore the utility of standardized video prompts intended to elicit samples of genetic counselors' (GCs') interpersonal, psychosocial, and counseling skills by describing variation in GCs' socioemotional communication during their responses to a series of videotaped communication challenges. We analyzed the previously recorded communication of 43 GCs responding to a set of videotaped simulated client prompts related to a cancer or prenatal counseling session. We applied the Roter Interaction Analysis System to the prompts and GCs' responses, focusing on the proportion of socioemotional content as an indicator of interpersonal, psychosocial, and counseling skill use. We analyzed the responses of 21 GCs to the cancer prompts and 22 GCs to the prenatal prompts. Two-sample t tests explored differences in the proportion of socioemotional content in GCs' responses to prompts within and across the two scenarios. Overall, socioemotional statements accounted for 31% (SD = 8%) of all GC statements in response to the prenatal prompts and 36% (SD = 9%) of statements in response to the cancer prompts (Bonferroni-adjusted p=.49). The proportion of socioemotional communication in individual prompt responses varied from 4% (SD = 12%) to 76% (SD = 26%) across the cancer prompt series and 10% (SD = 13%) to 76% (SD = 30%) across the prenatal prompt series. Across the two scenarios, two of 10 matched prompts showed significant differences in the proportion of GCs' socioemotional content of the prompt responses (p's < 0.001). These differences appear related to differences in the socioemotional nature of the prompts. These findings inform online methods of communication assessment that are useful during restrictions to in-person learning due to COVID-19, as well as future hybrid training and research efforts.

Differences in genetic counseling student responses to intense patient affect: A study of students in North American programs

Research indicates genetic counseling patients often experience intense emotions. No studies, however, have investigated how genetic counseling students respond to patient affect. This survey study investigated student responses to patient emotions and select factors affecting their responses. One-hundred fifty-one genetic counseling students in North American programs wrote a response to each of three hypothetical prenatal scenarios, identical except for the patient affect expressed (anger, fear, or sadness). They also completed measures of empathy tendency and tolerance of negative affect and demographic questions. Multivariate analysis of covariance (MANCOVA), used to analyze the effects of major study variables on the types of responses given by participants, was significant. Follow-up univariate ANCOVAs indicated small to moderate effect sizes for student clinical experience, race/ethnicity, and relationship status within and across scenarios. For example, as number of patients counseled increased, participants used more feeling reflections and fewer self-involving statements. There were no significant differences in responses due to empathy tendency or affect tolerance. Most common responses were information provision and feeling reflections for the Anger scenario, information provision for the Fear scenario, and influencing responses for the Sadness scenario. Responses to each scenario typically involved multiple thoughts (range: 1-14; means ranged from 3.25 in the Sadness scenario to 3.62 in the Fear scenario). Most students (82%) reported the Anger scenario was the most difficult. Thematic analysis of reasons a scenario was difficult yielded four themes: Discomfort with situation/emotion, Positive countertransference, Uncertain how to respond, and Negative countertransference. Findings that clinical experience affects how participants responded to patient affect support the essential role of applied experience. Findings also support training and supervision to help genetic counseling students in North America learn ways to respond to strong patient emotions and recognize and manage countertransference.