Assessment of practice of pedigree drawing and application of standardized patient in medical faculty students

Drawing a pedigree is a useful and effective tool in medicine and has an important place in medical education. The aim of this study is to share our feedbacks on the pedigree drawing practice of 3rd year medical faculty students with a standardized patient applied in professional training skills program between 2012–2017. Materials and methods. A total of 583 medical faculty students asked appropriate questions to a standardized patient and drew a family tree. At the end of the practice, students were asked to fill an evaluation form. Propositions on the form were rated according to the 5 Likert scales. A chi-square was used to assess the differences in scoring. Results. 566 students (97.08 %) rated strongly agreed or agreed that appropriate tools and equipment were used in the practice. The attitude of the instructor was evaluated as appropriate, representing 98.11 % of the participants. About 97.09 % of the respondents reported that the time of practice was enough. These skills were reported to be necessary and might be used in their professional life, representing 82.19 % and 78.35 % respectively. No correlation was found between the scoring of propositions and the application of standardized patients. However, we have observed that the use of standardized patients in practice significantly increases the general assessment scores of family tree drawing practice (P < 0.032). Conclusions. Our data demonstrated that pedigree drawing training was evaluated positively by the students and standardized patient use did not make any differences in student evaluations.

Medical education is a complex and long education period including various types of education and training experiences [10]. Pedigree (family tree) is an important tool in medical genetics, representing the genetic relationship among the fami ly members, the transmission of genetic information from generation to generation and family history diagrammatically [2]. A family tree is used to identify individuals with an elevated risk of inherited disorders/diseases and the inheritance pattern of the disease [6] (Carver, Cunningham, et al. 2018). Pedigree also helps to choose the best genetic testing strategies and establish an early diagnosis, and clinical management of genetic disorders [1,5].
Until the early 1990s, the use of pedigree symbols by researchers and genetic professionals was showing inconsistencies in recording the genetic nature of family history and in genetic publications [1,2]. In 1995, Pedigree Standardization Task Force (PSTF or PSWG), which is the professional issues committee of the National Society of Genetic Counsellors Pedigree Standardization Task Force (NSGC), has made recommendations to reduce the inconsistencies in drawing pedigrees [2].
Simulation is a useful and effective tool in medical education, pretending patient care scenarios for the purposes of assessment and feedback [9] (Okuda, Bryson, et al., 2009). Giving feedback either in oral or written format is known to be essential for the learning process [12].

Aim
The aim of this study is to share our pedigree drawing practice with a simulated patient and feedbacks applied in the professional training skills program at Ondokuz Mayis University, Faculty of Medicine (OMUFM).

Material and methods
A Pedigree Drawing Education Guide has been included in the Clinical and Professional Skills Learning Program. Drawing pedigree training has been applied to 3rd year Turkish and English Medical Education students between 2012-2017 academic years. Pedigree Drawing Education Guide was prepared and distributed to all students (Fig. 1).
Students who participated in this practice session were first taught how to draw a family tree according to the guidance provided and then an illustrative pedigree was drawn using a sample of the family story. Finally, two different practice methods were applied to students. During the 2012-2014 academic years students were divided into pairs and asked appropriate questions to each other to draw up their family tree. After 2014, students asked similar questions to a standardized patient portrayed Huntington's disease. All students participating in the practice drew up at least three-generation family tree of their class fellow or standardized patient using standard symbols and nomenclature in accordance with the learning guide. At the end of the practice, students were asked to fill an evaluation form about the practice of family pedigree drawing. An Objectively Structured Clinical Examination (OSCE) was applied at the end of the semester to evaluate their learning outcome.
A total of 583 third year medical faculty students participated in the survey after the practice. The forms were filled out anonymously and all forms were given the instructor at the end of the practice. Two different evaluation forms were filled by students. During the first two academic years (2012-2014) the students completed an evaluation form including 5 propositions and 9 proposition forms in the last four years. Four propositions were added to the evaluation forms after starting to use the standardized patient after 2014.
All propositions of the evaluation form are listed in Table 1. The students rated these propositions using a 5 point Likert scale from 5 (strongly agree) to 1 (strongly disagree). The first five propositions were common and the rest were prepared for the evaluation of practice after starting to use standardized patent.
Statistical analysis. Correlation between scoring and before and after use of standardized patient was investigated with χ 2 test. P < 0.05 was considered significant.

Results
The scores of the first five propositions and the general assessment before and after including standardized patients in the practice are shown in Tables 2 and 3, respectively. No correlation was found between the scoring of the first five propositions before and after the application of standardized patients.
In total, 97.08 % (n = 566) of the students participated in the survey rated strongly agreed or agreed that appropriate tools and equipment were used in the practice. The attitude of the instructor was assessed appropriate by 98.11 % (n = 573) of the participants. This proposition was at the highest level among the students that positively evaluated propositions. The rest of the students responded to this question as neutral or disagree, 1.54 % and two students respectively. The time allocated for this skill was found to be sufficient by 97.09 % (n = 569) of the respondents. Fourteen students preferred to stay neutral and three students disagreed with this proposition. This skill was expressed to be necessary by 82.19 % (n = 480) of the students, whereas 3.76 % of students were disagreeing with this proposition. Four hundred fifty six students (78.35 %) reported that they will be using the knowledge of this practice in their professional life. However, twenty nine students did not agree on this proposition.
We have observed that the use of standardized patients in practice significantly increases the general assessment scores of family tree drawing practice (P < 0.032). Our results showed that students who gave 5 points to the practice before  The equipment and the materials were appropriate. 2 The attitude of the instructor was appropriate.

3
The allocated time for the skill was sufficient.

4
I think learning this skill is essential.

5
I can use this skill in my professional life.

6
I could draw a pedigree based on the knowledge I acquired from the standardized patient.
7 I received appropriate feedback for the pedigree I drew.
8 I could determine the inheritance pattern of the pedigree I drew. 9 Use of a standardized patient made it easier for me to learn the skill. ISSN 2306-8094 Table 2. Score distribution of the first five propositions before and after the use of standardized patient the use of the standardized patient were more than those who gave the same score after using the patient. Likewise, the number of students who evaluated the practice as 6 points increased after the use of standardized patients.

Assessment of Practice of Pedigree Drawing and Application of Standardized Patient in Medical Faculty Students
The scores of the other four propositions added to the evaluation forms after the use of standardized patients are given in Table 4.
Three hundred eleven students who participated in the survey assessed the 9th proposition as strongly agreed or agreed. Therefore 91.74 % of students agreed that the 'use of a standardized patient made it easier to learn the skill'.

Discussion
All clinicians take family histories, but developments in genomics suggesting genetic factors should be considered during taking family histories. According to the World Health Organization, taking family history should be used to identify genetic risk factors within the first step of the content of health care measures. All diseases besides trauma have genetic components. The power of a genetic component in a family can be understood by the number of people affected by a particular condition. A pedigree consists of information about the affinity status of family members and any  medical conditions they have. Drawing a pedigree allows the researchers and the clinicians to discuss the probability of the genetic origin of the disease and risk assessment. A carefully drawn family tree sheds light on the heredity risk of specific diseases, shared environmental factors, and concerns about the individual's health [13]. Drawing a family tree has an important place in genetics. International schematized language is used for drawing of pedigrees and the use of this nomenclature in drawing of pedigrees makes the analysis of patient and disease easier particularly in large families. Hence, the use of standardized language facilitates the communication among health professionals, patients and their families regarding diagnosis and testing and has the potential to decrease the medical inaccuracies and [2]. Likewise, health professionals all over the world enable to share, understand and interpret the pedigree information. Thus, clinicians need to draw and interpret pedigrees using standardized competence. This necessity is overcome by designing a practice session for standardizing pedigree drawing at Medical Faculty. Indeed, a high percentage of our students stated that this skill was necessary and they thought that they were able to use it in their professional life.
During the first two years of our practice, students were asked to draw the family tree by asking appropriate questions to each other, later students asked similar questions to a standardized patient portrayed Huntington's disease at the end of the teaching session. In this way, we wish to analyze the feedbacks made by the students about the family tree practice and evaluate the possible impact of standardized patients using student feedback. Our results demonstrated a general increase in assessment scores of the last four propositions after the use of standardized patients suggest that the application of standardized patient was favorable in medical education.
McGovern et al (2006) stated that the use of standardized patients in pedigree practice increases the confidence of students for their similar future patient assessments. The interaction with standardized patients may influence medical students positively to draw pedigrees, evaluate genetic risks and give genetic counseling [4,8,9] also reported that simulated patients practice and personal drug choice in problem based learning sessions were appreciated by the students. In addition, the instructor applied an examination using a simulated patients after this pharmacotherapy teaching session. About 93.9 % of their students stated that this educational program should be applied all medical faculty students.
At the end of the education, some of the participants demanded more frequent simulated patients in their educations [4]. The use of a standardized patient did not make any differences in the evaluations of the suitability of tools and equipment, the attitude of the instructor, the time of practice, the necessity and the future use of these skills.
Feedback is the constructive and objective evaluation of a practice that develops skills. The goal of feedback which is non-critical and based on direct observations of learners is to increase the learner's ability and improve their behavior and performance in education [3]. We used 5 points Likert scale which is frequently used in medical education and researches of medical education for evaluation [11].
Practicing pedigree drawing may help the students recognize the challenges faced in collecting family history information, particularly in the setting of acute hospitalization [7].

Conclusion
This study has shown that applied family tree drawing training was evaluated positively by the students and the use of standardized patients improves the general assessment evaluation of the student.