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October 12, 2012

PA CME Contributes to Taking Better Family Histories and Thorough Genetic Analysis

Patient History
A recent study published in the Journal of American Academy of Physicians Assistants found that a Web-based continuing medical education (CME) can produce objectively measured changes in clinically relevant behavior.  Specifically, PAs who took the Web course elicited more complete family histories and more detailed cancer histories.

The results came from a randomized trial that enrolled 50 PAs; 40 PAs completed the trial (18 in the intervention group and 22 in the control group).  Participants conducted simulated visits that were coded for completeness of family history, referral for genetic services, and overall interviewing style using the Roter Interaction Analysis System (RIAS).


Despite the transformational contribution of genomics to advances in biomedical research, the benefits have been slow to penetrate medical practice and patient care. Considering the rapid development of the field, the fact that only a minority of primary care providers (PCPs) report being sufficiently knowledgeable and confident to address genetic issues in the clinical setting should come as no surprise.  These deficits presented a pressing need for easily accessible CME in this area of health care.

The advantages of Web-based medical education with unrestricted access in terms of time, place, and space, as well as its potential for both cost savings and individual tailoring to learning styles, make it an attractive vehicle for meeting genetics education needs.  Moreover, results of a recent meta-analysis support both the efficacy of online CME programs and their equivalence with traditional methods of teaching with regard to program effects.

The research was designed to contribute to this literature by conducting a randomized study of a Web-based program developed by the National Coalition for Health Professional Education in Genetics (NCHPEG).  The program targeted PAs and emphasized core concepts related to family history collection and interpretation; collaboration with genetics professionals; and recognition of the ethical, legal, and social issues associated with genetic disease in both pediatric and adult primary-care settings.

The authors hypothesized that compared with those in the control group, PAs who were randomly assigned to the NCHPEG program would incorporate the targeted skills into their routine practice style. Using these newly acquired skills, PAs would improve their overall clinical performance by eliciting more detailed family histories as they relate to a potential genetically linked condition and make more referrals for genetic testing or counseling during a simulated patient encounter. 


The web-group compared with control-group PAs engaged in more targeted data gathering and thereby elicited a more complete family history and identified more family cancer links.  Although information about referring to and collaborating with genetics professionals was presented in the case study modules of the Web program, the impact of this part of the program was weak.  While disappointing, low referral rates are not unusual; for instance, an analysis of 72 obstetrical visit transcripts of women at high risk for a genetic abnormality found that only 10% were referred to genetic counseling.6

Analysis of the SP sessions suggests that the group differences in communication go beyond the markers of family history and referral to represent distinct patient management approaches.  In short, the Web-group PAs were more proficient at family history, as the authors hoped they would be, but they were also substantially less patient-centered than their counterparts.  There appears to have been something of a trade-off; the greater the focus on family history and potential genetic risk, the less attention was paid to lifestyle and psychosocial issues.  

The unanticipated negative effect of lower patient-centeredness provides an important lesson for designers of CME programs targeting clinical behavior:  Attempts to alter one aspect of clinical practice style may very well affect another.  The trade-off effect may fade as clinicians become more comfortable with integrating history-taking into a patient-centered interviewing style over time.

The study design combined several novel approaches to Web-based CME evaluation, including targeting national conference attendees, with random assignment to the intervention prior to the meeting.  This approach made possible the use of standardized patients as the evaluative tool in a time- and resource-efficient manner while accruing a nationally representative sample of PAs. 

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