key: cord-0689907-u8renjii
authors: Regier, Debra S.; Smith, Wendy E.; Byers, Heather M.
title: Medical genetics education in the midst of the COVID‐19 pandemic: Shared resources
date: 2020-04-23
journal: Am J Med Genet A
DOI: 10.1002/ajmg.a.61595
sha: f1a8c889c5a05d4394c590f3af53e5f76ebcd41d
doc_id: 689907
cord_uid: u8renjii

In the midst of the COVID‐19 pandemic, it is appropriate that our focus is on patient care and preparation. However, the genetics community is well poised to fill in the educational gap created by medical students transitioning to limiting patient contact, creation of telemedicine patient care, and online learning modules. Our history of agility in learning and teaching is now only inhibited by the time constraints of current clinical demands on the genetics community. This publication is designed to offer ideas and resources for quickly transitioning our education to meet the current demands in the time of a pandemic. Not only will this allow us to continue our strong history of education, it will enhance our strong commitment to using modern educational techniques and tools to address the genetics workforce issues that have defined the recent past. We have the opportunity to aggressively educate for trainees that now have the capacity to learn, and to lead the way in showing how the genetics community rallies together no matter the challenge.

In the midst of the COVID-19 pandemic, the role of agile medical education has become increasingly important. For the genetics community, there has been a growing passion to increase educational opportunities to increase our workforce (Bennett, Waggoner, & Blitzer, 2017) . In this time of unprecedented changes in medical care and education, we must work as a community to create genetic education that is agile, caring, approachable, and innovative.

In this new educational environment, the importance of strong educational theory to guide our decision-making is paramount. Lave and Wenger described the Communities of Practice theory of education where direct interaction with a community of experts and mentorship is the basis of training (Wenger, 1998) . Thus, the design of all of our educational endeavors needs to continue to bring trainees into our community. Malcolm Knowles created andragogy, a learning theory that describes adult learners. This theory includes six major themes (Knowles, 1970; Knowles, 1985; Manning et al., 1987) . First, selfconcept describes that adults choose what they want to learn, when they want to learn it and how they want to learn. The second characteristic is experience, which explores the importance of the adult's past learning to share and grow in the active learning environment.

Next, the adult learner needs to recognize and educational need. This is the one area that is most difficult for traditional genetics to lead to long term learning. Thus, we need to actively apply the educational content to current and important local and national events (i.e., genetic sequencing affecting COVID-19 outcomes, unique needs of rare disease patients, etc.). The fourth important concept of adult learning theory is to create problem centered learning. This style of problem-solving is innately a part of the diagnostic odyssey, which is a common finding in medical genetics. The role of internal motivation in adult learning creates an unknown variant. It is the common reason the most invested learners have personal experience with rare diseases. For this reason, the use of stories is important to increase internal motivation. Finally, the most successful adult learners realize the importance of the knowledge and how it will be applied to problems that they will or are encountering.

Genetics education has historically been ahead of its time with the creation of online resources, modules, and even YouTube videos. As summarized in Table 1 , the available online resources are vast. For example, by including patient interviews available on the National Organization of Rare Disorders web site to an online lecture could be an optional substitution for a patient panel session. Or the creation of a problem-based session with "real" newborn screen results and the Baby's First Test, ACMG ACT sheets, National Newborn Screening and Resource Center, and state lab resources take a dry lecture to an interactive case-based online session. Thus, the opportunity to learn while not in the hospital setting is available and robust. It is not a lack of educational resources, but instead a need to leverage the resources that exist to create a new generation of teaching materials that meet the unique needs of adult learners. In the current environment, where trainees are sequestered at home and tasked with independent learning, online modules, while potentially effective at educating, may lack the interactive quality trainee's desire. As described above, the opportunity to interact with the material, apply it to new and important situations, and bring in past knowledge in new ways, ensure optimal learning. Thus, in place of creating additional online modules, a group of genetics educators have worked to identify ways to create webbased AND interactive learning activities. Here we describe some ideas for how we have converted to a fully socially distanced learning system. In a pediatric residency program with over 100 residents, we transitioned in-person problem-based sessions to webbased problem sessions. The original lecture included having groups use a case as a basis for learning how to use online genetics resources (i.e., OMIM, PubMed, Genetics Home Reference, ACT sheets for Newborn screen, GeneReviews, summarized in Table 1 ) and create a picturebased memory mnemonic. Using the break-out room ability of Zoom (Zoom, 2020), we were able to transition this lecture to digital "break-out rooms." Participants had discussions with a guide (genetic counselors, genetics trainees, senior residents on a genetics rotation) to review the unknown case, "make the diagnosis," and create a memory mnemonic tool to share with the other participants. In one such lecture, residents were split into 5 groups and given a "common" rare disease including the following:

• Cystinosis: diagnosis made using OMIM. Required GeneReview and Clinicaltrials.gov for questions.

• 22q11 deletion syndrome: diagnosis made using OMIM. Required Genetics home reference, GeneReview to answer question.

• Tuberous sclerosis: diagnosis made using OMIM. Required GeneReview to answer question.

• Noonan syndrome: diagnosis made with Pubmed or OMIM.

Required Genetics home reference, NORD, or GeneReview to answer questions.

• Phenylketonuria: required use of newborn screening and genetics guideline resources.

Following the disorder identification and answering the basic clinical questions, each group was assigned to make a "drawing" to help them remember the disorder. They were encouraged to be creative, use any tools they liked (i.e., one person drawing for the group, PowerPoint together, etc.). Following this, each group presented their case to the larger group. To manage the groups and time, the leader used the Zoom texting function to give time warnings and "dropped in" to each of the breakout rooms early in the time period when working through the case and later when working on the image to ensure each group was moving forward with the project. Table 2 ). By creating a curriculum that directly relates to patient care (e.g., metabolic emergencies), offers education on expanding their examination skill knowledge (e.g., dysmorphology), and teaching counseling techniques have been well received.

For medical students, we created a picture-based Zoom lecture of dysmorphology cases using the chat function to "compete" for identifying abnormal features in the pictures. The anonymity of the chat function was even more effective than previous live lectures as it allowed for more inclusive participation. Thus, this method proved to be incredibly effective. A second institution created an in-depth casebased learning (CBL) curriculum that allowed for learners to have discussions with faculty over time (Table 3) . By creating interactions with the faculty in the short and longer time period these programs allowed for interactions with medical genetics providers and expanded the understanding of our field to trainees at all levels. Consider checking the web site for any pharmaceutical and product sites for education content. We have found these to be very helpful in modeling effective curriculum.

Note: This table contains organization names, a short description of their resources, and their website for readers to use as a reference.

At the request of the fellowship faculty from multiple other divisions, we have offered our faculty as a learning resource during this time. For example, neonatology asked if we could do a virtual "review" session with fellows on the carbohydrate metabolism disorders, based on a chapter in their review textbook. I am certain that many reading this article are similarly cringing as the author did with this request. What could have been a very dry lecture was actually very interactive and fun when each person was given a case to "present" to the group after taking a few minutes to research what they thought the child had (based on pictures or a single people of additional information to a low glucose level). By giving them a 

At the request of medical students, pediatric residents, and medical genetics residents sequestered in their homes, but wanting to continue to be involved in patient care, we expanded our rotation size to allow each attending to have a "learner" dedicated to their telemedicine visit day. By assigning each learner to a mentor, they were able to "join" the telemedicine visits with the attending physician. This allowed them to not only learn about genetics or metabolism, but also about the intricacies of telemedicine. From learning how to help a family log-on to the telehealth portal, to eliciting an exam over a camera, to determining what you can tell about a child from their running around their home, to building rapport over an internet line, these interactions were useful to both the learner and the mentor. The technical requirement was only that the telehealth portal was able to allow entry to more than one individual to the visit. On our review of the available telehealth platforms, this was a common ability and in the future, this should be a requirement for any platform to be used in the genetics setting. Initially, it was though that this would be a "better than nothing" experience. Instead, it became a "this could be an amazing resource that I have learned to use for the rest of my career."

Due to the remote learning functions of the learners on our rotation, we were concerned that their experiences would not be consistent between different providers. To help address this issue, we began a seminar series for all learners on any of our rotations. From dysmorphology cases to metabolic 101 to identifying the case management needs of a family, the short educational series allowed the whole team to come together, share joys, share hurdles, and created a subcommunity within the greater community. The participation in each of these sessions varied based on the subject content and the number of faculty and staff joining in for the educational session. For session only for earlier learners, they were often with the attending and only a few learners (i.e., six participants) and

for the larger activities of dysmorphology cases available to all clinicians, staff, and learners about 40 individuals joined to learn from each other.

We realize that every community, hospital, genetics program, and care team will have unique abilities to educate and expand the genetics community during this time period. It is our hope that this article will serve as a source of ideas, resources, and encouragement to find ways to expand the Genetics Community of Practice in the middle of the COVID-19 pandemic.

Data sharing is not applicable to this article as no new data were created or analyzed in this study. 

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