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'Yes, And': Genetic Counselors Share Strategies for Embedding Services Into Primary Care

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CHICAGO – Genetic counselors at this year's annual National Society of Genetic Counselors conference suggested their peers take a principle from the improv theater playbook and apply it when pitching their services to primary care physicians.

At a panel discussion Wednesday, genetic counselors discussed models for integrating their services into primary care and shared tips for how to start that discussion with primary care providers. Panelists noted that many primary care clinicians might have misconceptions about what genetic counselors do or concerns that patients would find referrals to something called "genetic counseling" off-putting, so it's imperative to refine that pitch.

With "physicians, you have to determine what they are interested in getting out of a partnership with genetic counseling," Sasha Bauer, a genetic counselor at UW Health's SwedishAmerican Hospital in Rockford, Illinois, said during the session. "You're taking what they want, and saying 'yes, I can provide that as a genetic counselor — but I can provide so much more.'"

"It's taking whatever they're interested in getting out of this collaboration with you, and saying, 'Yes, and …'" Bauer added.

There are many points of alignment between primary care and genetics, said Mylynda Massart, a family medicine physician at University of Pittsburgh Medical Center and an associate professor at University of Pittsburgh. For example, risk assessment and genetic testing can be critical components of preventive care, and pharmacogenomics can inform prescription management.

"When you really start to think about it, almost all the scope of practice in primary care aligns with genetics," Massart said, arguing that genetic counselors should be part of multidisciplinary teams within primary care, especially as knowledge about genetics grows and is integrated into routine medical care. "There's a real match."

She added that genetics as a clinical specialty will also be important separate from primary care, such as for patients with classic genetic syndromes or rare diseases, though genetic counselors embedded in primary care could help to make those referrals.

There are multiple approaches a partnership between genetic counselors and primary care physicians could take. UPMC, for example, uses an approach that can be characterized as a "hub and spoke" model, said Natasha Robin Berman, a genetic counselor within family medicine at the health system. Genetic counselors at UPMC serve multiple primary care clinics throughout the region, with genetic counselors as the "hub" and various primary care clinics as the "spokes" surrounding them.

That might be a scalable model for others to pursue, since it enables a limited number of genetic experts — who are already in short supply in North America — to work with numerous primary care centers. However, it means patients might be expected to go to an additional separate visit after a primary care appointment, which could delay access.

"It also relies on the primary care clinician to be knowledgeable enough to make that referral in the first place, so we still might be missing people," Berman said.

Another approach, which Berman referred to as the distributive model, involves embedding genetic counselors into primary care clinics, where they could answer genetic needs of patients in person. That setup could even allow physicians to offload pre- and post-test counseling to the genetic counselors, as well as test selection and results interpretation.

The GenomeCanada-funded GenCOUNSEL Project, for example, aimed to identify avenues to provide genetic counseling to patients who received genome sequencing, including by integrating such services directly into primary care clinics, said Prescilla Carrion, a genetic counselor and clinical associate professor at the University of British Columbia.

As part of this project, she saw patients at the Cool Aid Community Health Centre in Victoria, where she was part of a team including primary care doctors, nurses, and dieticians. They tried multiple referral methods, ultimately landing on a process in which Carrion was able to review patient records and reach out to patients she thought could benefit from counseling.

Some of the common reasons she saw patients was for psychiatric genetic counseling or to discuss family history of cancer, cardiovascular disease, and other conditions.

The distributive model can decrease some logistical barriers for patients since they will be going to a clinic that they are already used to as part of primary care. However, with only about 6,500 genetic counselors and fewer than 1,300 medical geneticists in North America, there likely isn't a large enough workforce to achieve this model throughout the healthcare industry.

An answer to the genetic expert shortage could be an avenue in which genetic counselors act as clinical proctors, providing support and consulting with multiple primary care clinicians to provide genetic education, Berman said. In this model, genetic counselors themselves would only see patients who need their specialized services the most, while those with more general needs would get information from their primary care doctor.

Regardless of what model genetic counselors take, it will require pitching the specialty's services to primary care providers, who are not all familiar with what genetic counselors do, said Jehannine Austin, a professor in the psychiatry and medical genetics departments at the University of British Columbia.

Genetic counselors will have to explain how they can support primary care as part of a team, taking family histories, conducting risk assessments, and facilitating cascade testing for family members. Genetic counselors can pitch themselves as "physician extenders," enabling primary care physicians to take on more patients, Austin suggested.

"If we're going to deliver on the promise of genomic medicine, then really, we need to do this," they said. "Family physicians can't do it on their own."