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U of M's Brian Van Ness: PGx Can Advance Genetic Counseling to 'Genetics R Us' Status


Name: Brian Van Ness

Position: Head of the department of genetics, cell biology, and development, University of Minnesota in Minneapolis, 2001 to the present

Background: Faculty of the department of genetics, cell biology, and development, University of Minnesota in Minneapolis, 1988 to the present

Post-doctoral training in molecular immunology at the Institute for Cancer Research, Philadelphia, 1979 to 1982

Education: PhD in biochemistry, University of Minnesota in Minneapolis, 1979

As Pharmacogenomics Reporter has reported in the past, physician education is one of the major obstacles to the adoption of pharmacogenomics in the clinic. But can doctors realistically be expected to keep up with developments in genetics and pharmacogenomics, as well as their own fields?

Brian Van Ness, head of the department of genetics, cell biology, and development at the University of Minnesota spoke last month about these issues at the Beyond Genome meeting in San Francisco. Pharmacogenomics Reporter caught up with him this week to discuss the role that genetic counselors might be able to play in bringing personalized healthcare into the clinic, and whether they might take some of the burden off of clinicians.

You mentioned at the Beyond Genome conference in San Francisco last month that genetic counselors would play a growing role in pharmacogenomics. What did you mean?

I think genetic counselors right now have been focusing on the high-prevalence, high-penetration genetic variations that impact metabolic diseases. So, they spend a lot of time in counseling families that have a cystic fibrosis history, or have a muscular dystrophy history, or Huntington's, or in some cases certain genetic predispositions to cancers in family cancer clinics.

And what's happened is that, [according to] my discussion with the head of our genetic counseling division here, [it seems that] genetic counselors see the SNP-pharmacogenomic link as a huge opportunity for them.

They will be able to provide advice not only to the patients, but also to the physicians, and they — more than anybody — I think have a real keen sense of genetic variation and probability. You tell a physician, "This is what this allele means," but if you tell a patient, "This variation gives you an 83 percent chance of having this deficiency," what does that really mean? They [genetic counselors] are very good at associating risk factors and probabilities to clinical probabilities.

Two things, I think, are going to happen. One is that as the genetic tests become more validated and associated, there's going to be more interest in applying them. The second thing that's got to happen is, currently — at least in our state [Minnesota], and I think it's true nationally — genetic counselors don't have their own billing code.

So, if you're a physical therapist and a physician refers a patient to you, you can bill insurance with your own insurance code. Genetic counselors, at the moment, only bill through physicians or hospitals. They are lobbying very hard to develop their own billing code.

In my read — or at least people are telling me — they're probably within a year, or at the most, two, of getting the lobbying efforts through to have their own billing codes.

Once that happens, I could see that Genetics 'R' Us shops are going to be able to open, where now a genetic counselor isn't solely linked to a clinical practice group. They now have an independent status and can contract out for all of the interest that people are going to have in genetic associations, and I see SNPs and pharmacogenomics as the big place where genetic counselors are going to have an impact.

Will genetic counselors take the place of clinicians in any cases, when it comes to interpreting pharmacogenomic data?

No … nowadays, my understanding is that if you're a pharmacist, and you've been given a prescription, when you go back to the patient chart, and you realize that the patient is taking four different drugs that might have interactions that could have adverse effects, you have the capability now to advise [the patient] on potential drug interactions — and bill the insurance company. And there are certain rules and regulations on that.

I think the same is going to be true of genetic counselors. I think they're going to take some of the burden from physicians of having to keep up with this stuff, because what I know now isn't going to be what I know in a year or two years. The field is moving very, very rapidly. And I think it's unreasonable to expect that clinical practice physicians are going to keep up with all of the interpretations of the genetics.

So I still see the genetic counselor as the go-between to advise the physician and the patients. And in fact, I said to the head of genetic counseling [at U of M], "When you bill, you bill through the physician, who [then] bills the patient's insurance company for the interpretation of these genetic tests — cystic fibrosis, muscular dystrophy — [but] do you bill the physician?"

And she looked at me and said, "Come to think of it, no."

I said, "Well, you're providing as much advice to the physician as you are to the patient." I think genetic counselors are going to develop a little bit more of an independent enterprise and probably have a lot of impact on how pharmacogenomics is interpreted, in terms of application to the clinic.

Now, my read on genetic counselors — those that I've met — they're really picky people. They really are. If you say, "There's a 70-percent probability of having this adverse effect" — they don't like that. They want definitive answers.

They want to be able to advise people, and they want to be able to advise people accurately, and not simply say that, "You have a higher risk for developing this adverse event."

No — "You have a 70 percent risk, and I can't tell you whether to take the drug or not, but I can tell you precisely what a population study will tell you that your risk might be." They're very good at that, and I think [that quality is] going to be a huge boon to the genetic counseling industry.

At Minnesota, most genetic counselors are in programs where they get a Master's degree. I think Pittsburgh might have a PhD [program], but there are very few. What we're now launching is a graduate program in which a student can come into our normal genetics and development program, and get a PhD, but instead of doing a teaching assistantship, they'll go intern at the clinics for the genetic counseling program so that they become board eligible.

At the end of their PhD period, they then take the board certification in genetic counseling, so they'll have a PhD and understand the genetics from the laboratory and science standpoint, but they'll have the board eligibility through all of the clinic internships they have to do to get a genetic counseling associate degree, so that they'll have a science PhD and a genetic counseling certification. I think that's going to be a real marketable crowd of people.

I read recently that genetic counseling recruitment is slowing. Why might that be?

I think it's a lull. I think there's going to be a big catch-up. I'm saying, in three to five years, there's going to be a big push.

It's just like [the situation] with nurses. There are these ebbs and flows in our system. Nurses are now given lots more responsibility and authority to do things, and so nursing has become a bigger enterprise in itself.

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