OB/GYN residents’ training, attitudes, and comfort level regarding genetics

Abstract

Purpose

While the availability, utility, and complexity of genetic testing expands, limited information exists regarding obstetrician-gynecologist (OB/GYN) residents’ knowledge of genetics and confidence in providing genetic services. This study examined OB/GYN residents’ educational and clinical experiences with genetics during residency, personal attitudes regarding the value of genetics and its role in their practice, level of comfort with genetic counseling, and potential motivators for learning about genetics.

Methods

Eligible participants included residents currently enrolled in a CREOG-associated OB/GYN training program in the USA or Canada. A link to an anonymous 49-question RedCap survey was emailed to program coordinators in October 2017 to be forwarded to all OB/GYN residents.

Results

Eighty-two OB/GYN residents representing all postgraduate years of training completed the survey. Residents indicated learning about genetics through discussions with attending physicians, lectures/courses, and publications. While residents felt their attendings valued (81%) and were knowledgeable about (85%) genetics, 28% felt their attendings did not reinforce concepts that were learned in coursework. Residents valued staying informed about the field of genetics and felt providing genetic services was within their scope of practice; however, there were deficiencies in self-reported comfort level, particularly regarding hereditary cancer counseling. Residents cited accessibility of information as a top motivator to stay informed.

Conclusions

Clinically relevant, accessible didactic information about genetics reinforced in the clinical setting may increase residents’ level of comfort with providing genetic services.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10815-021-02310-1.

Introduction

As the availability and complexity of genetic testing and risk assessment expands [1, 2], obstetricians and gynecologists (OB/GYNs) play a vital role in educating and counseling patients about genetics. As primary care providers (PCPs) for women, they are often a patient’s first point of contact when learning about prenatal screening, instrumental in facilitating carrier screening, and have a responsibility to be familiar with hereditary cancer risk assessment [1–5]. As the American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 693 highlights: it is imperative that the practicing obstetrician–gynecologist or other healthcare provider has a firm comprehension of the benefits, limitations, and risks of offering a specific genetic test, as well as the importance of appropriate pretest and posttest counseling [3]. However, limited data exists about OB/GYN residents’ comfort, understanding, and preparation for handling this evolving genetics landscape.

Although fundamental to the genetic testing process, current literature suggests that PCPs, including OB/GYNs, are not always comfortable integrating genetics into their practice. When asked to identify barriers to the integration of genetic services in the primary care setting, PCPs frequently cite a lack of knowledge, training, and confidence about genetics [6–9], as well as a lack of confidence in their ability to make appropriate referrals to genetics professionals [10]. The few studies focused specifically on OB/GYNs’ have found similar results. In the hereditary cancer setting, over one-fourth of OB/GYNs report that they feel “not qualified” (as opposed to partially qualified or completely qualified) to manage general genetic counseling, breast cancer genetic screening, and gynecologic cancer screening [11]. In the prenatal setting, evidence suggests that most pre-test counseling conversations about genetic screening are incomplete and that clinicians’ conversations are missing many elements of pre-test counseling recommended by ACOG [12].

Though studies illustrate a lack of genetic knowledge and confidence among physicians, limited research exists about residents, particularly OB/GYN residents. Residency is the ideal time to learn about genetics as it relates specifically to each specialty of medicine. It is crucial that residents learn this information before they independently practice and become the only source of information for their patients. Despite guidelines from the Council of Resident Education in Obstetrics and Gynecology (CREOG) which recommends the inclusion of a genetics curriculum in resident education, studies suggest that current genetics education in residency is insufficient. In a survey of practicing OB/GYNs, one-third of respondents’ report that their residency training in cancer screening was inadequate [11]. A separate study also demonstrated deficits in cancer genetics knowledge among OB/GYN residents, as well as a desire for more education [13, 14].

Limited information currently existing regarding OB/GYN residents’ attitudes, training, or comfort with genetics-related concepts and competencies is contrasted by the growing need for OB/GYNs to be providers of genetic services in a landscape that continually evolves and expands. This study aims to address four objectives, which are to understand (1) educational and clinical experiences with genetics during residency, (2) residents’ personal attitudes regarding the value of genetics and its role in their practice, (3) residents’ level of comfort with genetic counseling, and (4) potential motivators for learning about genetics.

Methods

Study population and recruitment

The study population consisted of residents enrolled in CREOG-associated obstetrics-gynecology training programs in the USA and Canada. In October 2017, an email with a link to an anonymous RedCap survey was sent by the Northwestern Medicine OBGYN residency program director to program coordinators via a CREOG listserv, with a request to forward the email and survey to their residents. A reminder email was sent after 1 month, and the survey was closed after 8 weeks. We were unable to track how many program directors received and forwarded the email. Consent was implied by participation and completion of survey. Participants were given the option to enter a drawing to win one of ten $50 Visa gift cards by submitting their name and email address separately upon completion.

Survey development

A validated survey tool addressing attitudes, comfort, and educational experiences regarding concepts in genetics was not available. Thus, the survey instrument used in this study (Online Resource 1) was developed by the researchers to assess the objectives.

The survey consisted of 49 questions, including items to assess demographic data. The remaining items aimed to capture information about the main objectives: educational and clinical experiences with genetics during residency; personal attitudes regarding value of genetics and perception of the role of OB/GYNs in providing genetic services; level of comfort performing genetic counseling tasks; and factors that would motivate residents to learn more about genetics. All questions were designed in multiple-response multiple choice, 4-point Likert-scale, or yes/no formats. This study was deemed exempt by the Northwestern University Institutional Review Board (IRB #00,205,939).

Data analysis

Data analysis was conducted with SPSS S25 (IBM Corp; Armonk, NY), and descriptive statistics were used to characterize response frequency. To facilitate data analysis, variables measured by 4-point Likert scales were collapsed to create a dichotomous variable by grouping “agree” and “strongly agree” into one category and “disagree” and “strongly disagree” into a second category. Chi-squared test or Fisher’s exact test were used to carry out statistical comparisons of responses between categorical groups, such as comparisons in responses between residents in different post-graduate years (PGY). P values of < 0.05 were considered statistically significant.

Results

Demographics

Ninety-one OB/GYN residents began the survey. Respondents who solely completed demographic questions were excluded from analysis. Eighty-two residents answered at least one non-demographics question with 76 respondents completing the survey. Due to recruitment methods and uncertainty of how many residents received the study invite, a response rate was not calculated.

Demographic characteristics of the sample population are summarized in Table 1. Mean age of respondents was 29.3 years (± 2.4 years; range 26–41) with residents from all four years of residency (also known as postgraduate year or PGY) represented. Majority of respondents were female (85.3%, n = 69/81), held M.D.s (91.5%, n = 75/82), and completed medical school training within the last 3 years (76.5%, n = 62/81). Most were in programs that were academic- or university-based within urban settings. Approximately half of respondents (n = 42/81) planned to practice general OB/GYN, a third (n = 27/81) planned to pursue a fellowship, while 15% (n = 12/81) did not yet know their post-graduate plans.

Table 1.

Demographics

What is your year in residency?	N = 81	%
PGY1	29	35.8
PGY2	14	17.3
PGY3	23	28.4
PGY4	15	18.5
What is your gender?	N = 81	%
Male	10	12.3
Female	69	85.2
Others	2	2.5
What is your age?	N = 81	%
25–30	59	72.8
30–35	21	25.9
35 +	1	1.2
What year did you complete your medical school training?	N = 81	%
2017	29	35.8
2015–2016	33	40.7
2013–2014	16	19.8
2012 or earlier	3	3.7
What post-graduate degree do you hold?	N = 82	%
M.D	75	91.5
D.O	6	7.3
Others1	4	4.9
Please select your residency program type:	N = 81	%
Urban	67	82.7
Suburban	10	12.3
Rural	4	4.9
What are your post-graduate plans?	N = 81	%
Practice general OB/GYN	42	51.9
Fellow, total	27	33.3
Pelvic medicine reconstructive surgery	4	14.8
Gynecologic oncology	9	33.3
Maternal fetal medicine	4	14.8
Reproductive endocrinology and infertility	5	18.5
Genetics	0	0
Other fellowships2	5	18.5
Do not know	12	14.8

¹Other post-graduate degrees: MPH (n = 1), M.S. (n = 2), Ph.D. (n = 1)

²Other fellowships: clinical research, family planning, minimally invasive gynecologic surgery

Educational and clinical experiences with genetics during residency

Perception of education. Residents were asked if they (strongly) agreed or (strongly) disagreed with the statement “I feel that the genetic education I received was sufficient,” regarding both residency and medical school. Forty-two percent (n = 32/76) of respondents (Fig. 1a) indicated their genetics education in residency was not sufficient. Slightly fewer (33%, n = 25/76) of respondents indicated that their genetics education in medical school was not sufficient. There was no statistically significant difference with regard to sufficiency of genetics education based on residency year (p = 0.291).

Fig. 1.

Educational and clinical experiences with genetics during residency. a Participants were asked whether they felt the genetic education they received in medical school and residency was sufficient and b about their personal clinical experiences with genetics during residency * denotes statistical significance between PGY1/PGY2 and PGY3/PGY4

Clinical experiences with genetics. When asked about personal clinical experiences with genetics during residency (Table 2, Fig. 1b), over 90% of respondents indicated that they were aware of genetic counselors at their institution (n = 76/81); however, only 30% (n = 23/76) had interacted with one in their daily practice. Roughly half of the respondents (n = 40/81) had the opportunity to work with or shadow a genetic counselor, and over 80% had made a referral to a genetic counselor or geneticist. A statistical significance was observed in referral practices between PGY1/2 and PGY3/4 respondents. Nearly all reported that they or their attending have ordered genetic testing (97.5%, n = 79/81) with over one-third (n = 30/81) reporting that only prenatal genetic testing had been ordered and over 50% (n = 46/81) reporting that both prenatal and hereditary cancer genetic testing had been ordered. No respondent reported that they had not ordered genetic testing due to a lack of comfort.

Table 2.

Clinical experience with genetics

	PGY1 or PGY2 (n = 43)	PGY3 or PGY4 (n = 38)	Overall (n = 81)	Overall %	p value
Are there genetic counselors at your institution?					p = 0.05
Yes	38	38	76	93.8
No	1	0	1	1.2
I do not know	4	0	4	4.9
In your day-to-day practice, do you interact with genetic counselors?			n = 76		p = .132
Yes	10	13	23	30.3
No	28	25	53	69.7
Have you had the opportunity to work with or shadow a genetic counselor?			n = 81		p = .402
Yes	20	20	40	49.4
No	23	18	41	50.6
Have you ever made a referral to a genetic counselor(s) or geneticist(s)?			n = 81		p < 0.001
Yes	30	36	66	81.5
No	13	2	15	18.5
Have you or your attending physician ordered genetic testing before?			n = 81		p = .240
Yes, prenatal genetic testing	19	11	30	37.0
Yes, hereditary cancer genetic testing	3	0	3	3.7
Yes, both prenatal and hereditary cancer genetic testing	20	26	46	55.8
No, because there has been no need to order genetic testing	1	1	2	2.5
No, because I did not feel comfortable ordering genetic testing	0	0	0	0

Sources of information. Three most reported sources of learning about genetics during residency (Fig. 2) were discussions with attending physicians (94.9%, n = 74/78), lectures or genetics courses (80.8%, n = 63/78), and publications from professional societies such as ACOG (74.4%, n = 58/78). The least common sources of learning were laboratory representatives, conferences, and genetics rotations.

Fig. 2.

Sources of information. Reported sources of learning about genetics during residency

Residents’ personal attitudes regarding the value of genetics and its role in their practice

Perceived value of genetics. Respondents agreed that it was valuable to be informed about genetic testing and advances in the field (Fig. 3a). Nearly all valued understanding the benefits and limitations of both prenatal and hereditary cancer genetic screening (98.8%, n = 79/80 and 100%, n = 79/79, respectively), while 92% (n = 74/80) also valued staying up to date on new advances in the field of genetics. Seventy-seven percent (n = 62/80) of respondents valued updating patients’ family histories at each appointment.

Fig. 3.

Value of genetic information. a Perceived value of genetics. Residents were asked whether it was valuable to be informed about genetic testing and advances in the field. b Beliefs regarding responsibilities of OB/GYNs. Participants were asked to answer the questions. In general, we feel that the following is a responsibility of OB/GYNs: c Perception of attendings’ knowledge, practices, and values. Residents were asked if they felt that their attendings’ had enough knowledge regarding genetics, reinforced genetic concepts, and valued being able to competently order genetic testing

Beliefs regarding responsibilities of OB/GYNs. Residents’ opinions regarding the responsibilities of OB/GYNs are illustrated in Fig. 3b. Over 85% of respondents indicated that pre- (n = 68/76) and post-test (n = 65/76) counseling for both prenatal diagnostic and screening tests were a responsibility of OB/GYNs. While most (81.6%, n = 62/76) also considered pre-test counseling for hereditary cancer a responsibility of an OB/GYN, slightly fewer individuals (72.4%, n = 55/76) considered post-test counseling for hereditary cancer to be a responsibility of an OB/GYN.

Residents’ perceptions of attendings’ knowledge, practices, and values. Eighty-six percent (n = 68/79) of respondents agreed or strongly agreed that their attendings had enough knowledge about genetics and genetic testing to discuss it with them (Fig. 3c). Respondents who agreed or strongly agreed that their attendings were knowledgeable, valued genetics, and reinforced genetics skills in the clinical setting were significantly more likely to view their education as being sufficient (p = 0.045, p = 0.012, and p < 0.001, respectively).

Residents’ level of comfort with genetic counseling

Residents’ comfort level in performing various tasks related to genetic testing and risk assessment is illustrated in Fig. 4. More respondents felt comfortable with pre-test counseling tasks (discussing benefits and limitations of testing) as opposed to ordering tests and interpreting test results. More respondents reported feeling comfortable with genetic counseling-related tasks in prenatal settings as opposed to hereditary cancer settings. Approximately 40% (n = 33/76) of respondents reported a lack of comfort with assessing a patient’s hereditary cancer risk and providing pre-test cancer counseling, and over half reported a lack of comfort with ordering and interpreting cancer genetic testing results. Differences in comfort level were observed depending on year of training. Residents further along in their training (PGY3/PGY4) were more comfortable (p < 0.05) performing almost all tasks apart from ordering and interpreting carrier screening and hereditary cancer results and assessing a patient’s risk of hereditary cancer syndromes.

Fig. 4.

Self-reported comfort level with genetics by residency year. Participants were asked to respond to the question: Most of the time, we feel comfortable (question in figure) with patients. Prenatal diagnostic testing included amniocentesis and chorionic villus sampling. Cell-free DNA testing referred to non-invasive prenatal screening or NIPS. Genetics professional could mean either a genetic counselor or medical geneticist. * denotes statistical significance between PGY1/PGY2 and PGY3/PGY4

Potential motivators for learning about genetics

Respondents were given a list of incentives for learning about genetics and were asked to select all that they would consider to be motivating factors for learning in the future. Nearly all respondents reported that additional opportunities to easily access information would be motivation for learning more about genetics and genomics (95%, n = 72/76)). Nearly 90% of respondents indicated that patient requests for more information (n = 67/76), board certification requirements (n = 66/76), and opportunities for earning continuing medical education credits (n = 65/76) are motivating factors.

Discussion

OB/GYN residents value genetics and agree that many clinical genetic testing tasks fall within their scope of practice, but almost half of residents feel that their genetics education in residency is insufficient. This study also showed that residents are more confident in their ability to complete key genetics-related tasks successfully as they progress through training. However, gaps remain in residents’ comfort level with offering and interpreting genetic tests and results even in their final years of training. Preparedness to offer genetic services is particularly important given professional standards in the field of obstetrics and gynecology regarding scope of practice. Addressing these gaps is important to ensure that OB/GYNs are fully trained and comfortable providing genetic counseling and testing to their patients.

ACOG emphasizes that providing pre- and post-test counseling for genetic testing is within the scope of OB/GYNs [15]. However, this study highlights significant self-reported deficits in comfort with providing these services, which can impact preparedness of residents in their future practice. Although residents further along in residency were more likely to be comfortable with genetic tasks, there was a lack of comfort with tasks related to hereditary cancer across all years. This was true even among residents in their final years of training where 22% of residents in PGY3 or PGY4 residents did not feel comfortable ordering and interpreting results of hereditary cancer genetic testing. This finding is consistent with previous studies highlighting relative deficiencies in knowledge and comfort that exists among residents, OB/GYNs, and practicing physicians [7–12, 14]. Of note, residents who reported that their attendings reinforced genetics skills in the clinical setting were more likely to feel that their genetics education in residency was sufficient and reported feeling more comfortable with genetic tasks.

The findings from this study highlight the need for more clinically relevant education in residency. Additional studies are needed to determine effective means of education that help reinforce genetic concepts, especially in hereditary cancer, over the course of training. Given competing interests for time, it is important that information be both clinically relevant and succinct. In terms of resident education about genetics, this study recognizes attending physicians and genetic counselors as valued and influential educators during residency. Opportunities to shadow genetic counselors during residency in addition to alternative educational models, such as webinars or videos simulating genetic counseling sessions, can provide additional learning opportunities. Less than a third of the residents in this study reported routine interaction with genetic counselors. The accessibility of such resources would be valuable in terms of its motivational power, as accessibility was the most indicated motivating factor for learning.

Physician learning research suggests that improved knowledge alone does not lead to consistent, lasting changes in physician behaviors nor improved patient outcomes [16]. Multifaceted approaches to teaching, as opposed to solely didactic methods, are most effective [17, 18]. Stone et al. described specific features of teaching interventions associated with greater success in integration of new knowledge into practice. These include social influence, achieved by transmitting information through valued members of a social group; targeting interventions to group interests and motivations; and tailoring information to the specific needs of the group [19]. Data from this study revealed that residents who found their attendings to be more knowledgeable about genetics were themselves more knowledgeable highlighting the importance of faculty members as transmitters of knowledge and leveraging this to improve genetics education for residents.

Although this study utilized an unvalidated survey and had a small sample size that may not be representative of the OB/GYN resident population, the sample population did include a similar percentage of women compared to the number of women who matched into OB/GYN residency programs in 2016 (85.2% vs 82.3%) [20]. And while a response rate was not calculated, there were approximately 5,200 active OB/GYN residents in the USA in 2017 which would result in a less than 2% response rate if everyone resident did receive this survey [21]. Despite these limitations, this study provides a foundation to further study graduate medical education within the field of genetics to ensure that future OBGYNs and other healthcare providers have a firm comprehension regarding the benefits, limitations, and risks of genetic testing and can provide appropriate pre- and post-test counseling. Additional studies specifically looking into how genetics is incorporated into the residency curricula may help identify the most effective means of educating these clinicians.

Conclusion

The results of this study suggest that OB/GYN residents see value in understanding the benefits and limitations of genetic testing, staying abreast of updates, and believe that providing some genetic services falls within their responsibilities. However, the results are indicative of sustained gaps in genetic education and training during residency. Easily accessible, clinically relevant didactic education about genetics continues to be vital to filling these gaps. These results also highlight other factors, such as the reinforcement of this information in clinical settings during residency, which will be fundamental in ensuring that the next generation of obstetricians and gynecologists are successfully prepared to provide these services, especially as genetics and genomics continue to become an integral and indispensable part of healthcare.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contribution

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Anastasia Kathrens-Gallardo. The first draft of the manuscript was written by Anastasia Kathrens-Gallardo, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

The research was conducted as part of a Master’s thesis project for the Northwestern University Graduate Program in Genetic Counseling. Funding for the study was provided by Northwestern University.

Data availability

Access to data is restricted to certain individuals in accordance to IRB protocol.

Code availability

Not applicable.

Declarations

Conflict of interest

AA and LP are or were employed by laboratories that offer genetic testing at the time of study. The other authors declare no competing interests.