Training for the future of the genetic counseling profession: Exploring the assessment and adaptation of graduate programs' didactic curriculum

Abstract

Since the first genetic counseling program (GCP) was established in 1969, there has been a proliferation of growth and demand for genetic counselors. Advances in technology, affordable access to genetic testing, public genomic health initiatives, and diversifying clinical and non‐clinical roles comprise a dynamic environment that GCPs must respond to. While there is extensive literature regarding how other health professions adapt their curricula to changing environments, this has yet to be documented and explored for genetic counseling. This study aimed to understand how GCPs evolve their didactic curricula to keep up with the rapidly changing professional landscape. An online survey was used to recruit program leadership of fully accredited GCPs for semi‐structured interviews. These interviews explored four critical factors of didactic curricular change, including drivers, implementation, barriers, and mechanisms for evaluation after a change has been made. Interview transcripts were analyzed using reflexive thematic analysis based on iterative discussions with prioritization of excerpts from the codes that had been most commonly applied across multiple transcripts. Multiple factors were identified that program leadership must appropriately weigh when making curricular change decisions. The factors that were considered major influences by all participants included national accreditation standards, program stakeholders, sponsoring institutions and local genetic counseling communities, and the genetic counseling profession as a whole. Our data also demonstrated the extensive role program leadership plays in the adaptation of didactic curricula. With GCP leadership constantly identifying, implementing, and evaluating complex didactic curricular change, there is a need for further exploration of this topic and development of genetic counseling specific resources and tools.

What is known about this topic

There is extensive literature regarding how other health professions adapt their didactic curricula to changing environments, which is yet to be documented and explored for genetic counseling.

What this paper adds to the topic

This paper documents how genetic counseling program leadership identify the need to make didactic changes to program curricula, as well as implement and evaluate these changes to keep up with the rapidly changing professional landscape. This paper also documents what factors influence these decisions, specifically in the genetic counseling profession.

1. INTRODUCTION

Navigating the shifting landscape of healthcare services is challenging for both the professionals who provide these services and for the educational programs that train the next generation of practitioners. For the genetic counseling profession, key variables include innovation in genetic technologies, growing demands for genetic counseling services, economic pressures within healthcare, and the expansion of opportunities for genetic counselors both in and out of the clinic (Baty, 2018; Gordon et al., 2018; Rashkin et al., 2019; Riconda et al., 2018; Sanborn & Patterson, 2014; Shelton & Whitcomb, 2015; Stoll et al., 2018). As the profession advances, the curricula of master's degree programs in genetic counseling (GCPs) must adjust to accommodate these changes.

The Accreditation Council of Genetic Counseling (ACGC) defines the required curricular components of genetic counseling graduate training. They state that the curriculum must support student development of the ACGC Practice Based Competencies through instructional content, fieldwork training and supplemental fieldwork experiences, student teaching experiences, and research and scholarly endeavors (ACGC, 2023b Standards). The ACGC allows program flexibility and states “each program will develop and maintain its own curriculum and unique methods for developing these competencies,” with attention to both core knowledge and skills “while always emphasizing the importance of remaining current with the dynamic field of genetic counseling” (ACGC, 2023b Standards).

The ACGC standards set a baseline from which GCPs can make a variety of adjustments to their curricula. Most existing studies of adjustments to instructional content have examined the didactic curriculum and focused on discussion of a single topic, such as delivering difficult news (Andoni et al., 2018), insurance coverage (Wagner et al., 2021), religion and spirituality (Murray, 2020), and disability training (Sanborn & Patterson, 2014). Other studies have examined changes in fieldwork training, including experiential learning based on the use of standardized patients (Kessler, 2021). However, data is lacking regarding how GCPs make, implement, and assess decisions related to changes to the didactic curriculum.

There is extensive literature describing curricular change within other healthcare professions, including medical, dental, and midwifery education, and how these educational programs resolve competing demands on curricular content (Lucey, 2013; McCourt, 2001; Murphy, 2018; Pyle, 2012; Reis, 2018; Skochelak & Stack, 2017). Like GCPs, these programs must be attentive to several variables that can influence and drive change; these can include accrediting bodies, institutional values and norms, and emerging issues within their respective professions. For instance, large‐scale reviews of North American undergraduate medical education (UME) have led to incremental changes in curricula across programs (Pock et al., 2019). In July 2015, the accrediting body of UME, the Liaison Committee on Medical Education, shifted to requiring a formal continuous quality improvement process for UME curricula, demonstrating the influence regulatory bodies can have on other health professions didactic curricula change processes (Hedrick et al., 2019). Curricular changes can also be driven by shifting educational trends and philosophies. Recent approaches have included competence‐based education (Holmboe, 2018), team‐based learning (Dearnley et al., 2018), and interprofessional learning (McKimm & Jones, 2018). Common tools that are used include curricular redesign tools, such as the 3P‐6Cs curricular toolkit (Khanna et al., 2021), and evaluative change models to outline metrics and monitor the success of didactic curricular changes (Kern et al., 2009; Langley et al., 2009; McKimm & Jones, 2018; Pyle, 2012).

While GCPs may share common curricular change influences with other health professions' training, unique aspects of genetic counseling training likely mean that significant differences may also exist. GCPs are generally typified by small student cohort sizes, time constraints related to the length of the curriculum, resource availability, and the degree of autonomy granted to program leadership (Hoskovec et al., 2018; Pan et al., 2016; Wagner et al., 2021). While changes in the ACGC Standards drive some aspects of curricular adaptation, the process by which programs respond and implement didactic curricular changes has not been explored. The purpose of this study is to describe how GCPs evolve their didactic curricula to keep up with the dynamic environments in which they exist. By collecting information about curricular change across GCPs, our goal is to identify drivers of change, promote creativity and sharing of best practices, and build a vocabulary around curricular change, implementation, and evaluation specific to our profession.

2. METHODS

2.1. Study team

The committee facilitating this study included four members, all of whom were affiliated with the University of Michigan and had experience with graduate education in the health professions. The project lead (AV) was a genetic counseling student at the University of Michigan Genetic Counseling Program (UMGCP) and had previously worked as an administrator for a family medicine residency program. One member (BMY) was the program director of the UMGCP, with significant experience in that role. One member (CS) is a general obstetrics and gynecology practitioner with academic and research interests in the pedagogy of teaching, training others to teach, curriculum development, and clinical skills assessment across the continuum of undergraduate and graduate medical training. One member (MM) was the associate program director of the UMGCP, with significant experience in that role.

2.2. Study participants and recruitment

Participants were recruited from the Association of Genetic Counseling Program Directors (AGCPD; now known as the Genetic Counseling Education Association) between August and November 2019 via a survey email invitation sent through the AGCPD listserv and flyers with a link to the survey distributed at the November 2019 annual AGCPD meeting. At the time of participant recruitment (August 2019), there were 32 genetic counseling training programs designated as Accredited by the Accreditation Council for Genetic Counseling (ACGC) and eligible for participation (https://www.gceducation.org/).

Eligible interview participants included individuals holding a leadership position (including program directors, co‐directors, associate program directors, and assistant program directors) in a genetic counseling program (GCP) designated as Accredited by the Accreditation Council for Genetic Counseling (ACGC; https://www.gceducation.org). Those holding leadership positions in programs designated as Accredited New Program, Probationary Accreditation, Candidate Program, or those at the first author's graduate program were excluded from participation. Only one member of a program's leadership team was allowed to participate in the interview portion of this study. Otherwise, all eligible individuals were invited to participate in an interview. An anonymous donation on behalf of each participant was made to the Genetic Counseling Foundation as payment for study participation.

2.3. Procedures

Perspectives related to curricular change were gathered through a mixed‐methods study design. A novel survey was designed to gather baseline information and recruit participants for semi‐structured interviews that provided more details about curricular change in GCPs.

The 11‐item survey (Supplement 1: Data S1) was used to confirm eligibility and gather information about participants' leadership position, program demographics, and sponsoring institution, self‐identified recent changes to their program's curriculum, including the scope of such changes (using a 4‐point Likert scale, see Supplement 1: Data S1) and specific examples, and willingness to participate in an interview. The survey was administered via the Qualtrics platform (Qualtrics, Provo, UT). Individuals who did not complete the survey were not invited to participate in an interview. Everybody who indicated a willingness to participate in an interview was invited to schedule and complete an interview. Only one representative from each eligible program was allowed to participate.

Following the survey, a semi‐structured interview guide (Supplement 2: Data S1) was created, consisting of 29 questions exploring factors that influence didactic curricular change decisions. The interview guide was informed by the survey data, themes from literature regarding didactic change in other health professions (McKimm & Jones, 2018), and the expertise of the authors (BMY and MM). Two pilot interviews were conducted with GCP directors not eligible for this study by a single study team member (AV) to refine the guide. The questions were organized within four domains: program structure, drivers of curricular change, barriers to change, and evaluation of changes.

To prepare participants for the interview, they were provided example questions and prompts that previewed the content in the interview guide prior to their interviews. During the interview, participants were asked to discuss a major didactic curricular change made within the last 5 years, as well as discuss curricular changes more broadly. All interviews were conducted by a single study team member (AV) who was a graduate student at the time of the interviews and had no relationship with any of the interview participants. Interviews were conducted between October and December 2019, and recorded through BlueJeans video conferencing software (https://www.bluejeans.com/). Due to challenges related to the COVID‐19 pandemic, this manuscript was delayed to publishing. The recordings were transcribed verbatim using Rev. transcription services (https://www.rev.com/), reviewed for accuracy, and de‐identified with regards to location and program leadership members. In order to maintain participant confidentiality, survey and interview data that could identify participating programs is not shared in this manuscript. Interview times ranged from 33 min to 1 h.

2.4. Data analysis

Survey data, including open‐ended responses, were aggregated into a table for review and comparison. In analyzing responses to the open‐ended questions in which survey participants were asked to describe types of curricular change (Supplement 1: Data S1), we focused on responses pertaining to didactic curricular change. These responses were evaluated by three of the authors (AV, BMY, and MM) and categorized into higher order areas of focus that informed the subsequent interview guide.

Analysis of the interview data was conducted by study team members AV, BMY and MM. BMY, and MM were blinded to the identities of the participants.

A codebook was developed by three study team members (AV, BMY, and MM) based on review of three transcripts. Following this first round of coding, the codebook was refined and finalized by applying the codes to two additional transcripts. The final version of the codebook contained a total of 16 codes and 34 subcodes. After finalizing the codebook, each transcript was coded independently by at least two study team members. Discordant codes were reviewed and resolved by three study team members (AV, BMY, and MM). All coding was performed using Dedoose data analysis software v.8.3.17 (www.dedoose.com).

Discussion between the three coders was used to identify relevant cross cutting themes. These conversations relied on deductive thematic analysis exploring factors known to impact curricular change in medical education and inductive thematic analysis evaluating the data for curricular changes specific to genetic counseling training (Macfarlane et al., 2014). Authors AV, BMY, and MM identified cross‐cutting themes based on iterative discussions with prioritization of excerpts from the codes that had been most commonly applied across multiple transcripts.

3. RESULTS

3.1. Study participant demographics

The survey was completed by 20 individuals, including 14 program directors, five assistant program directors, and one associate program director. To maintain anonymity, the survey did not ask which programs were represented. Survey participants had between 6 months and 31 years of experience in program leadership positions (mean = 11.9 years, SD = 9.2 years).

Interviews were completed by 15 representatives from 15 unique programs, representing 47% of the genetic counseling graduate programs with Accredited status. The interview participants included 14 program directors and one assistant program director. Interview participants had between 2 and 31 years of experience in their current program leadership role (mean = 13.8 years, SD = 7.6 years; Table 1).

TABLE 1.

Interview participant demographics.

	Interview participants (n = 15)
Geographic zone (Supplement 3: Data S1)	(# interviewed out of # of fully accredited programs in the region)
Region 1 (CT, MA, ME, NH, RI, VT)	0 out of 2
Region 2 (DC, DE, MD, NJ, NY, PA, VA WV, Puerto Rico, Virgin Islands)	5 out of 8
Region 3 (AL, FL, GA, KY, LA, MS, NC, SC, TN)	2 out 4
Region 4 (AR, IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, OK, SD, WI)	6 out of 11
Region 5 (AZ, CO, MT, NM, TX, UT, WY)	1 out of 3
Region 6 (AK, CA, HI, ID, NV, OR, WA)	1 out of 4
Years since program established
5–9	1
10–14	1
15–19	2
20+	11
Program size (# students per program)
Range	5–30
Median	10
Size of program leadership team (# members)
Range (# members)	1–6
Median (# members)	4
Program leadership member years in current role (# years)
Range	2–31
Median	13

Note: Demographics for participating program leadership and their respective programs.

3.2. Scope of curricular change from survey responses

When asked to describe the scope of didactic curricular changes (4‐point scale) and types of didactic curricular changes (open‐ended responses) that had occurred in the last 5 years (between 2014 and 2019), the majority of survey respondents (55%, n = 11) reported a moderate amount of change, 30% (n = 6) reported a great deal of change, and 15% (n = 3) reported little change to their curriculum. The spectrum of types of changes made within the didactic curriculum included the addition of new courses or new topics or content within an existing course. The most common self‐identified examples of topics added in the curriculum were variant interpretation and expanded roles for genetic counselors. Less commonly noted changes included the redistribution of content between courses, dissolution of courses, and changes to pedagogy. Participants generally described curricular change as incremental: small “tweaks” were made to the curriculum over an extended timeframe.

The data that follow is all drawn from the semi‐structured interviews completed with 15 of the survey participants who expressed interest in an interview.

3.3. Influences of change

Interviews provided an opportunity to explore didactic curricular changes in more depth. When asked to describe drivers of curricular change, participants described a wide variety of influences with four themes identified: (1) stakeholder feedback, (2) professional trends, (3) genetic counseling regulatory bodies, and (4) sponsoring and affiliated institutions.

3.3.1. Stakeholder feedback

All participants highlighted several stakeholders as valuable assets in keeping a pulse on the program and the profession. These groups included clinical supervisors, faculty, students, and alumni, all of whom were seen as having a vested interest in the health of the program itself. Stakeholder influences included identifying a need for change, informing change decisions, and evaluating the outcomes of change. A variety of methods were used to solicit input from these stakeholders (Table 2).

TABLE 2.

Methods for eliciting stakeholder input.

Clinical supervisors

Evaluations of students during clinical rotations

Ad hoc discussion of student performance

Direct requests for feedback

Supervisor meetings

Participation in/on advisory board

Faculty

Participation on advisory board

Direct feedback about student performance and/or classroom interactions

Students

Course evaluations

Rotation evaluations

Board Scores

Job placements

Anecdotal/Ad Hoc conversations

Check‐in meetings

Journal entries

Alumni

Alumni surveys

Alumni having roles within the program (advisory boards, course instructor, course director, etc.)

Note: Methods genetic counseling program leadership use to gather input from stakeholder groups.

Clinical supervisors and teaching faculty, who often had overlapping roles in the program, were highly valued by all participants as sources of information about what students need to know in order to be successful in practice. Clinical supervisors were valued for their ability to understand trends in clinical practice. Furthermore, clinical supervisors' perspectives of students' clinical performance were used to provide real‐time feedback about the effectiveness of content being taught in the classroom. Because clinical supervisors understand both the program's curriculum and the skills necessary for those entering the workforce, participants felt these stakeholders were able to identify both general concepts and specific content areas that were either missing from the didactic curriculum or needed to be explored in more depth.

I have lots of really excellent practicing genetic counselors in the area. … coming from all over. And we do a lot of yearly, yearly input from them to say, Okay, what aren't we covering? What do you see on a clinical side, working with students that you think they need, that they might not be coming with as strongly as they should at this stage? (Participant 123)

Student input was also valued by all programs, though to differing degrees. While all programs gathered student feedback and input, close to two thirds of the represented programs expressed the sentiment that they relied more heavily on learner input to elucidate areas of the curriculum that needed evaluation or to inform change. Input from current students was seen as valuable in providing immediate feedback on their most recent learning experiences, including actual curricular content, pedagogy, and the learning environment.

And there are, of course, course evaluations and that kind of thing. And we do meet with each student at the end of each semester. I meet with each student individually; we call it mid‐year review and first year review. We do exit interviews of all the students as they graduate. So we get feedback on the whole program and stuff. But that's again, student‐driven or student feedback. Which we do take pretty seriously, I would have to say. (Participant 121)

A majority of participants mentioned incorporating feedback from alumni, who had already transitioned to the workforce and could comment on how well the curriculum prepared them for their roles as genetic counselors. Alumni feedback was gathered through alumni surveys and conversations with alumni who served as clinical supervisors for current students. Alumni were particularly valued for their deep understanding of the program, including the intricacies of how well the curriculum prepares learners to take on genetic counseling roles over the course of their career.

One of the things that I think is super challenging with student feedback is what students think about a class when it's happening and what they think about it two years later is very different… So, student feedback is… often helpful and sometimes more helpful later, when they actually have a job and they can tell you what they used and what they didn't. (Participant 117)

3.3.2. Professional trends

Another critical driver in electing to make didactic curricular changes was the genetic counseling profession as a whole. Participants described the value of understanding current genetic counseling practice and being able to forecast trends in the profession. Trends in the genetic counseling profession, such as improved testing technology, increased access to testing, changes in service delivery, or the growth of knowledge in a particular specialty of genetic counseling, were considered drivers behind much of the curricular change that occurred.

Usually when we make curriculum changes, … we're changing lectures here and there, it's due to things that we're observing in the field… we recently made a lot of significant changes within our laboratory rotation course that includes things like variant interpretation, direct to consumer, raw data interpretation, meeting with counselors in industry and kind of exploring those additional roles that we see genetic counselors taking on more and more things like utilization management. So typically, we're changing things because of the changes in the field. (Participant 113)

Clinical supervisors and alumni were particularly helpful in garnering information about trends in the profession.

I think it mainly comes from what the supervisors think the students need to be successful in their clinical rotations and consequently, in the field as practicing genetic counselors. … So, they will identify that's a need and they'll bring that back into their courses. Or they'll all realize, geez, we're having to do more and more variant interpretation. And we're having a lot of trouble ourselves as clinicians knowing how to use ClinVar and how to use online databases, these open access databases to do variant interpretation for their patient's exome results.… I think it's driven by the needs of the genetic counselors in practice, and hence for the students in their clinical rotations, and then we bring it back into the didactic work also. (Participant 115)

Additional resources used to forecast the profession included: educational conferences, professional organizations (e.g., National Society of Genetic Counselors, American College of Medical Genetics and Genomics, American Society of Human Genetics, Association of Genetic Counseling Program Directors), regional genetic counseling and genetic organizations (i.e., state chapters of NSGC), literature reviews, holding leadership positions in professional organizations, practicing genetic counselors (particularly what they need education in and/or where they think their practice is headed), and professional colleagues (i.e., leadership at other genetic counseling programs (GCPs), leadership team within the program, clinical supervisors, colleagues within the institution).

3.3.3. Genetic counseling regulatory bodies: ACGC and ABGC

Guidance provided by the ACGC, including the Standards of Accreditation and the Practice Based Competencies (PBCs), was noted as drivers of change. They were utilized by all participants as important didactic curricular benchmarks against which the curriculum was regularly evaluated. All participants mentioned that when change occurred in the Standards or the PBCs, they would consider whether their curriculum was compliant and then adapt accordingly.

We always look at things like the ACGC standards and the practice‐based competencies, the practice analysis. So, we look at those published documents as well, and we want to make sure that our curriculum is in line, especially with the practice analysis with what's going on out there… as we make curriculum changes, we have to make sure that we're not losing a competency. (Participant 113)

Participants noted curricular reviews occurred quite regularly, including ACGC‐mandated reviews. These periods of evaluation provided an opportunity to reassess programmatic goals and whether the current didactic curriculum was successful in achieving them. It was also an opportunity to evaluate if and how the ACGC competencies were addressed within the didactic curriculum.

The other is through the accreditation and re‐accreditation process and the yearly… reports that we send in where we say, ‘This is how we're doing what we're doing.’ And we look at how we're mapping things out, and so that we're meeting better what we're able to meet. Rather than just squeezing one lecture in here, do we actually have this across many different areas? (Participant 117)

Program leadership also utilized student performance on the American Board of Genetic Counseling (ABGC) national certification exam to determine areas that needed improvement in the didactic curriculum.

So, the board exams, … you can see as a class, how did your students perform compared to the national average, … Are there areas where we could be improving that are consistently low? Typically, there you'll find that one year this class may do a little bit higher in this area and then the next year it might be completely different area, and so there's not necessarily a trend, but if a trend is identified, then certainly that's something that we'd look at. (Participant 112)

3.3.4. Sponsoring and affiliated institutions

Changes that occurred within the sponsoring institution, home department, and local genetic counseling community were commonly cited as disruptors of the didactic curriculum. Examples included programs that were forced to make changes when affiliated departments, programs, or partners altered their curriculum or pedagogy. Other forces that led to didactic curricular changes included loss of instructors from the teaching community, shifts in requirements at the departmental, school, or institutional level, and changes in resource availability.

Occasionally a change will be caused from an external factor. So, for example, a few years ago, our medical school went from having designated courses to doing systems‐based and they did away with both the Genetics block and with Embryology. And so, we had to react to that. We knew it was coming so it wasn't a surprise, but that wouldn't have been our choice if we could have left things the way they were, we would have. (Participant 125)

3.4. Execution and evaluation of change

When asked about the execution of didactic curricular changes, program leadership—including program directors, co‐directors, associate program directors, and assistant program directors—sat at the center of this process. In collaboration with relevant stakeholders, they decided what, when, and how changes were made.

3.4.1. Program leadership agency

A majority of interview participants discussed that program leadership had a great deal of autonomy when making decisions about changes to the didactic curriculum. Most changes did not require institutional or departmental approval in order to be implemented. Consequently, program leadership could independently finalize decisions and take action to make changes.

We have a lot of flexibility and… we change stuff every year, and I feel like we're supported by our deans to make those changes. So, I don't feel like we're lacking for ability to be responsive to the field in most aspects. (Participant 125)

Notable exceptions to program leadership autonomy included large didactic curricular changes, such as adding or removing a course or administrative changes (changing a course number or course credit hours), which often required institutional approval. These bureaucratic hurdles were variable and typically institution‐ and program‐specific.

I think there are institutional barriers to making big changes. And it's just the bureaucracy, I guess. It has to go through a lot of different panels and committees even to change a course name, that kind of thing. (Participant 121)

While this agency was critical, participants reported that they also relied on assistance from individuals within their professional networks. These individuals could be found within their institution, their department, among their leadership peers at other programs, and their genetic counselor contacts. These relationships were described as helpful in identifying and accessing resources and expertise.

It's networking and just keeping an eye on what's happening outside of our microcosm to see what's new and exciting, and then how we can access that or leverage it to make our program better… I have a good network of people who I think are leaders in the field who will from time to time see me or send me an email and suggest new opportunities or they heard a good lecture, they think it would be good for the students, so it's just working that network as well. (Participant 119)

However, the utility of these resources relied heavily on the initiative and motivation of program leadership to seek out and access them.

So, I performed research, I queried other genetic counseling programs, I looked in the literature quite extensively. I worked with my genetic counseling colleagues as I developed the syllabus and the goals and objectives for each lecture. And then we're able at our institution to implement a change. (Participant 122)

3.4.2. Prioritization of core skill development

Every participant highlighted the need to be attentive and responsive to the fact that the genetic counseling profession is rapidly evolving. Program leaders discussed maintaining a focus on teaching genetic counseling skills and relying on the mindset that building core skills takes precedence over expanding factual knowledge. Interview participants expressed that constant change in the profession and the short time frame to develop competent clinicians prompts prioritization of essential skill development, such as those outlined by the PBCs, over teaching specific content (ACGC, 2023a Practice). A majority of participants expressed the sentiment that it was difficult to predict what knowledge would be needed in the future, therefore focusing on fundamental genetic counseling skills was critical in enabling their learners to keep pace with changes in the profession. Participants also highlighted the need for trainees to develop critical thinking skills to remain lifelong learners.

And then the question …… we always end up asking is the change that we want to make really necessary? Because sometimes it's easy to confuse new information with new skills. They're not the same thing. If it means that students need a different skill or a more enhanced skill, that's one thing. If it's just information, you can look it up… Do we really need to tell students every piece of information that we now know or can we tell them that there's new information and this is what it encompasses, and they need to go find it because the information will always change. The information is not necessarily the best reason to make any changes. Skills are the best reasons to make changes. (Participant 117)

I’ don't think we can teach everything, so my hope is that we are teaching enough in the way of critical thinking skills, and how to use resources so that when the newest thing on the block comes around, that students will be able to know where to go and find the information and how to teach themselves, I.E. lifelong learners, I'm really hopefully… our grads are considering themselves to be lifelong learners. (Participant 123)

Many participants noted the essential nature of teaching communication and counseling skills and discussed how these skills are adaptable to a wide variety of professional environments.

…helping [students] feel empowered to use this skillset in any way that they think they could apply it. And so, while the roles of genetic counselors continue to change and evolve, I think the core skillset, compassion, empathy, kindness, flexibility, great communication skills, those are the things that are going to carry. Being really critical and being objective in your analysis of a situation, those are things that are going to carry you through regardless of where this profession turns… we say we've given you this toolbox, and in the toolbox would be skills, that if used correctly, should be applicable for your career. You might have to figure out how to use the tool a little differently, but that's okay. That's just adaptive learning. (Participant 114)

3.4.3. Evaluation of didactic curricular changes

Programs used various approaches to assess the efficacy of a didactic curricular change. The most common metrics were board scores. Stakeholder feedback was also used as data for assessment of curricular change. Clinical supervisors' evaluations of student performance following a didactic change were used as part of the evaluation process. Feedback from students and alumni was valued as they provided firsthand perspectives on didactic curricular changes. Most participants described gathering student feedback through course evaluations and ad hoc interactions, such as discussions after class or individual student meetings with directors. Alumni feedback was gathered through ACGC‐mandated alumni surveys.

Interviewer Prompt “…evaluating after you guys have made a change. Does your program currently assess how curricular changes impacts the education of your students either formally or informally?” Participant Response “I would say yes by all the same mechanisms that we've already talked about. Informal comments through student advising, course evaluations, student success in courses or success on the boards, alumni evaluations.” (Participant 124)

Participants mentioned challenges when evaluating the impact of a change. Learner feedback, as an evaluation tool, had limitations in that learners could only reflect on one side of a change, since they had nothing to compare their experience(s) to.

So last year students really liked the course. What's hard is they don't have a compare contrast. They can just tell us if they like what they experienced. (Participant 125)

Program leadership also found it difficult to discern whether student performance, both in clinic and on the board exam, was due to didactic curricular changes or individual student variability within a small cohort.

Sometimes because it's really, really hard to know in the long run what's been effective and what really hasn't been effective when you have such small classes. So, one year everybody passes the boards, and the next year everybody passes the boards, and you go, “Wow, look what I did.” And you didn't do anything. It just happened that those two classes are full of people who were really good at taking exams and they studied. And then the next year, three people fail and you're like, “Well, what the hell happened?” (Participant 117)

3.4.4. Challenges to curricular evolution

When asked about limitations to making desired changes in the curriculum, participants described several barriers. The most commonly reported barrier was time, which was mentioned by all participants. Participants noted that a 2‐year training model required them to be very deliberate in making changes. The expanding scope of professional knowledge and responsibility was seen as an additional challenge as participants struggled to find time in an already crowded curriculum to teach newer skills and information. About half of the participants noted that this decision‐ process was impacted by the need to consider both students' mental health and learning capacity.

It's really important, because you could keep adding things but if you don't take away things, then you're going to end up with burned out students. So, you always have to be cognizant of what's need to know versus what would be nice to know. So, we're always having those conversations because you can't teach students everything. You shouldn't try. You should just give them the skills to be able to learn what they need to learn once they leave, too. (Participant 120)

The small size of the student cohort of many GCPs was also viewed as a restriction to didactic changes. Participants noted it was challenging to find experts willing to teach small groups of learners. This factor was particularly impactful when trying to identify experts to teach specific content areas, especially newer content areas where expertise may be more limited and less accessible. Participants also said small program size posed a challenge when assessing the effectiveness of didactic changes, because there were a small number of students taking boards and filling out evaluations.

We don't evaluate the change itself I guess is the short answer. We don't really have a way to evaluate the change itself out of the broader context of the way we always evaluate things. We can't really evaluate the before and after. We can see student satisfaction maybe go up if we add a certain component. But it's tough, in isolation, to evaluate each curricular change in and of itself. (Participant 115)

It's real easy as a program to react to a very small “n” So, you have one class that doesn't do well and then you think the whole program fell apart, but it didn't. And sometimes you can't put your finger on what really happened in that one class or those few people. (Participant 117)

4. DISCUSSION

This is the first study to examine the evaluation and adaptation of the didactic curriculum within genetic counseling programs (GCPs). We provide a snapshot of the ways didactic curricular changes are being made as graduate programs strive to respond to the evolving landscape of professional genetic counseling practice. Interviews with GCP leaders across North America revealed the complex, iterative process employed when making changes to the didactic curriculum. We found that as Accredited GCPs make didactic curricular changes, the main influences include feedback from stakeholders and changes in the profession, awareness of factors within their own institution and local genetic counseling community, and adherence to mandates from governing bodies. We found that GCPs face challenges related to the short length of training and the small size of their cohorts. Our findings also highlight the challenges GCPs face in responding to change and forecasting what is to come in the profession, while retaining curricular content that enables learners to develop the required competencies.

We found that genetic counseling graduate programs are able to be nimble, deliberate, and thoughtful in curricular change. All interview participants acknowledged the value of the guiding documents and regulatory structures established by the Accreditation Council of Genetic Counseling (ACGC). Our interview participants viewed the Standards of Accreditation for Genetic Counseling Graduate Programs (ACGC Standards) as important benchmarks for the content of their didactic curriculum, but not necessarily drivers of most change. Previous publications have discussed the challenge the Standards impose when training programs must balance “the desire to respond to rapid changes in technology that have direct implications for genetic counseling practice against the obligation to address the existing required standards” (Riconda et al., 2018). Importantly, our interview participants did not view the ACGC Standards as a hindrance to change, suggesting that these benchmarks still provide enough flexibility for adaptation to changes in the profession. Furthermore, several of the assessment tools described in the ACGC Standards, including course evaluations, alumni surveys, review of ABGC scores, and feedback from supervisors, were deemed valuable (ACGC, 2023b Standards). In addition to the ACGC Standards, our findings underscore the value of the Practice Based Competencies (PBCs) as important guides to assure programs meet established requirements (ACGC, 2019a Practice; ACGC, 2023a Practice).

Due to these factors, we found that program leadership are intentional in the choices they make when adapting their didactic curriculum and prioritizing the teaching of clinical reasoning and critical thinking skills. Although GCP leaders did not refer or name specific, educational frameworks or models, their priorities and behaviors align with those utilized in other health professions, such as the Kirkpatrick Four Levels of Training Evaluation (Anderson & Merkebu, 2024; Kirkpatrick & Kirkpatrick, 2016). Our interview participants described an intention to produce lifelong learners who can leverage the unique skills of genetic counselors to be successful in any future role. A similar focus on lifelong learning, clinical reasoning, and critical thinking is emphasized in the literature on medical education (Al Moteri, 2019; Anzia, 2021; Persky et al., 2019; Richards et al., 2020; Young et al., 2020). While academic medicine has amassed a large body of literature highlighting the value of clinical reasoning and has developed several teaching and learning models, such as the Master Adaptive Learner, similar data regarding model‐based change and evaluation specifically in genetic counseling training is lacking (Cutrer et al., 2017). The vast body of data, research, and literature within other health professions provides an opportunity for GCPs to evaluate and improve their didactic curricula through a different lens and framework.

We found that program leadership is central to didactic curricular evaluation, change, and implementation. While training in other health professions often relies on multiple committees evaluating and updating the curriculum (Cole et al., 2018), in GCPs, the program director typically leads a small, core team responsible for shaping curricular change. GCP leadership uses a holistic approach to inform didactic curricular change, relying on input from multiple stakeholders and various resources. Unlike undergraduate medical education where stakeholders can be seen as a hindrance (Velthuis et al., 2018), stakeholders were viewed as a positive and valued force in didactic curricular change for GCPs. We also found that it often falls to program leadership to identify and adapt the resources required to make didactic curricular changes.

Given the intricacies our interview participants described when making changes to didactic curricula, it is therefore critical that program leadership possess a deep, broad skill set and agency. The current ACGC Standards are important in defining a set of required qualifications and experiences for program directors and other leadership positions (ACGC, 2019b Standards). Over time ACGC qualifications for program directors have become more rigorous (ACGC, 2013 Standards; ACGC, 2019b Standards; ACGC, 2023b Standard Revisions). The value of these increased requirements is supported by our data, which demonstrates the complexity of this role. We found that program leadership must filter a constant flow of information, manage and protect their own limited time, grow and nurture a large network of people and resources, and stay in tune with all of their stakeholders. As part of this process, program leadership must navigate a great deal of uncertainty, as there is often limited data to help them evaluate the efficacy of changes. For new program leaders, our study highlights the importance of not just understanding compliance but also understanding the variables within a sponsoring institution and supporting community. Agency allows program leadership to maintain compliance while remaining creative when making curricular change.

Interview participants expressed limitations in their ability to assess the efficacy of discrete didactic curricular changes. GCPs are currently utilizing board scores, course evaluations, and job placements to indirectly monitor the success of didactic curricular changes. They are also gathering supervisor feedback to assess the impact of these changes, which can be a subjective source for evaluation. While these assessments often lack the “granularity to assess effectiveness at the level of day‐to‐day instructional design,” GCPs are using similar processes to those in other health professions training environments, which also utilize proxy metrics when evaluating curricular changes (Fischer et al., 2023; Goldman et al., 2012). Ongoing curricular evaluation is imperative to demonstrate a training program's effectiveness in meeting its objectives, to ensure program quality is maintained, to decide whether to maintain or adjust curricular components, and to fine tune program improvement efforts (Santen et al., 2019). Much like clinical entities use plan–do–study–act (PDSA) cycles to evaluate the impact of changes in clinical care, similar structured evaluation can be applied to understanding the impact of curricular changes and educational interventions. It is not evident that GCPs are applying direct, evidence‐based frameworks of evaluation at this time. In part, this may be due to GCPs lacking resources, like personnel, tracking technology, and funding. GCP evaluation metrics are also challenged by the small cohort sizes and the short length of these programs. These factors limit the amount of usable data that can be gathered, the ability to make practical comparisons, and the ability to assess overall impact of specific changes. This study highlights assessment of change as an area for growth for GCPs. As GCPs continue to reflect changes in the field within their curriculum, there may be value in creating a consortium of programs, much like other health professions have utilized, to evaluate curricular change on a larger scale (Lomis et al., 2021).

Of particular note, social movements and global events were not considered drivers by participants. This highlights the value of repeating this study regularly to address newer drivers in didactic curricular change. Although the 2023 revisions to the ACGC Standards now mandate it, our participants did not mention evaluating GCP curricula through the lens of justice, equity, diversity, and inclusion. Carmichael et al. have called out the need to continuously evaluate curricula through this lens for careful attention to creating an equitable training environment, which has not been specifically addressed in the literature for didactic curricula (Carmichael et al., 2020). Exploring the extent of a “hidden” or “informal” curriculum, as outlined by McKimm and Jones (2018) for medical school education, could be valuable in further understanding the landscape of GC didactic curricula.

As this study is the first to examine didactic curricular change in GCPs, further understanding of the factors that influence change decisions and how these impact the overall didactic curriculum will be necessary to assist in improving this process. Our data highlight opportunities for continued collaboration across programs to create and share tools to better inform and evaluate didactic curricular change. For instance, collecting and sharing data about specific curricular components may help increase the volume of student feedback to make meaningful, informed changes. Additionally, it is important to consider the unique roles that stakeholders, including program leadership, play in the curricular change process and define opportunities to further leverage their expertise.

4.1. Study limitations

While our research was able to capture a snapshot of the ways that the leadership of genetic counseling programs were adapting their didactic training curriculum, it does not provide a comprehensive or longitudinal look at the process of curricular change. As noted above, the data were collected in late 2019, just prior to several additional drivers of curricular change, including the COVID‐19 pandemic (Bergner et al., 2021; Kahn et al., 2021; Stallman et al., 2021) and social justice movements following events like George Floyd's murder (Baty & Davis, 2023; Paysour et al., 2024). As a retrospective study, interview participants may not have been able to recall unique or significant examples or specific details about how change decisions were made. Additionally, there may have been self‐screening during recruitment by directors who were either too busy to participate or who did not believe they were making significant curricular changes. Our response rate of 47% could reflect this bias, including differences based on region and program age, with most interview participants working with older programs in the northeastern and midwestern United States. These possibilities could have limited the diversity of responses. Additionally, racial and ethnic demographics were not collected in our survey or interviews, so we are unable to comment on whether program leaders from underrepresented minorities were among our participants and/or whether their views differed from other participants. Future studies could benefit from attention to the makeup of program leadership and how that might affect change decisions.

5. CONCLUSION

This study revealed the complex process surrounding genetic counseling program (GCP) leadership's decisions to make didactic curricular changes. Overall, participants described a multitude of drivers that are incorporated in these change decisions, the major driver being changes in the genetic counseling profession. Interview participants shared several implementation strategies used to incorporate these changes into the didactic curriculum, such as prioritizing skills over didactic content. Several significant differences in the didactic curricular change processes between other health professions and genetic counseling training emerged, namely the type of changes being made and the role of program leadership. Some of the reasons for these unique findings in genetic counseling didactic curricular change include the fast‐paced evolution in genetics knowledge, the structure of the leadership teams, and the influence of a program's institution and governing bodies. GCPs are constantly identifying need, implementing, and evaluating complex didactic curricular change; however, this highlights the necessity for further exploration in this space and genetic counseling‐specific resources and tools for facilitating this process. Understanding the process by which these curricula evolve in response to these variables is essential in understanding the process by which the competence of emerging providers is defined.

AUTHOR CONTRIBUTIONS

AKV: contributed substantially to the conception and design of the work, acquisition of data, analysis and interpretation of the data, drafted the manuscript, approved the final version and agrees to be accountable for all aspects of the work. BMY: contributed substantially to the design of the work, analysis and interpretation of the data, revised the manuscript for important intellectual content and approved the final version to be published. MM: contributed substantially to the design of the work, analysis and interpretation of the data, revised the manuscript for important intellectual content and approved the final version to be published. CMS: contributed substantially to the design of the work, interpretation of the data, revised the manuscript for important intellectual content and approved the final version to be published.

FUNDING INFORMATION

This study was funded by the University of Michigan Rackham Graduate Student Research Grant (www.rackham.umich.edu).

CONFLICT OF INTEREST STATEMENT

Anna Vercruyssen, Beverly Yashar, Monica Marvin, and Caren Stalburg declare that they have no conflict of interest.

ETHICS STATEMENT

Human studies and informed consent: This study was reviewed and designated exempt by the University of Michigan Institutional Review Board (HUM00165078). All participants gave their informed consent prior to their inclusion in the study.

Animal studies: No non‐human animal studies were carried out by the authors for this article.

Supporting information

Data S1.

Vercruyssen, A. K. , Yashar, B. M. , Stalburg, C. M. , & Marvin, M. (2025). Training for the future of the genetic counseling profession: Exploring the assessment and adaptation of graduate programs' didactic curriculum. Journal of Genetic Counseling, 34, e2023. 10.1002/jgc4.2023

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.