A recent set of comments came to me from a Genetic Counselor. They were well thought out, but I think she may have misinterpreted me...
I pray that your attitude changes before you have a practice of your own and I pray for the genetic counselors at Yale who have to work with now, knowing that you think they are unnecessary and undeserving of respect.
This was said in response to my asking that if someone is billed a code 99245 that a person should be seen by a physician or at least someone who could perform a physical exam. Billing without the physical exam is more disrespectful and illegal than I was in the prior post... Unfortunately, that post was taken as if I think genetic counselors don't matter. In fact the reader further went on to feel as if I wanted to replace the whole field.
"What you are proposing will actually hurt patients, the medical system and the personalized medicine effort altogether."
I actually am not proposing to replace genetic counselors. The 2000 or so are an absolutely needed resource for counseling. The problem is that most counselors are specialized in the classical fields of genetics: Prenatal, Cancer predisposition, Metabolic and Clinical Genetics (Syndromes and Autism)......there are several hurdles for personalized medicine to be implemented, including manpower, and the already busy with long wait list genetic counseling services would be swamped with personalized medicine issues if we were to use them.....The same could be said for the 100 Internal Medicine Geneticists or the 700 or so other MD Geneticists......I see the experts of classical genetics as instrumental...but not as trying to churn through 1000s of patients evaluating drug metabolism. This is especially true in the underserved.
Their expertise really lies in expert systems that busy clinicians.....over 800k doctors in the country.......could consult in real time.....Yes, the classically trained counselors and geneticists will always be needed to see NF, Metabolic Disease, cardiogenetics, Prenatal issues, developmental delay, etc.......but the dual trained Internists Geneticist could be suited seeing pharmacogenomics, adult onset multifactorial disease, etc.......Even if they do, that is 100 or so doctors versus 800,000......
What should be done in the case of counselors and geneticists is in the realm of expert systems and teaching.....rather than take a year or 2 out of your schedule to learn internal medicine, neurology, etc. you could.....
1. Work hand in hand with a provider in a specialty and providing your expertise. This model was shown in Scotland to be very effective, until the CGC left the practice. Then things kinda fell off.
2. Create expert networks that busy clinicians can consult with in real time....thus leveraging your capabilities.....Just like the pioneer Heather Shappell has done.....
3. Go back to school and learn internal medicine, neurology, etc, which you could be doing in option one in real time......
4. Beg that the code for genetic counseling gets paid more, complain when it doesn't, and don't do anything to advance the personalized medicine ball. Which is a silly thing because 2000 genetic counselors will be overwhelmed doing the day to day counseling for Factor V Leiden, Hemochromatosis, and pharmacogenomics for 300 million people....I agree, you should get paid by the hour, just like physicians should, but we have been begging for increased reimbursement and look where that has gotten us...
It is not a viable strategy for long term success....Increased pay is needed for sure, but that is not a solution for the manpower issue. 2 years to be a CGC, 9 years to be an MD geneticist....neither is that attractive right now....You could teach a man how to fish and feed millions in the matter of a few months...Why not do that rather than keep it amongst the "Special Interest Group"?
Like DTC I do see that the small part of the medical field holding this information, even away from other practitioners.....which is dead wrong....
Oh and the last thing from the email I received
"Therefore, please use your time and energy wisely, advocate for genetic counselors. They are the gatekeepers to responsible genetic information."
The Sherpa Says:
Genetic counselors are very much needed. However, so are NPs and PAs and PMDs......We are all part of the solution and trying to maintain gatekeeper status when there is a tsunami of applicable genomic healthcare information is coming down the pike is not smart for such a small group of healtcare providers. The ecosystem needs to change and it can, but Geneticists and Counselors need to get out there and TEACH the NP, PA and MD without fear of not having a job after they do the teaching.......If you don't do the teaching......Slick Marketers with huge budgets will.....and that would be a loss to the entire healthcare system....
4 comments:
How dare you misquote me! I never said in my email the genetic counselors "are the gatekeepers to responsible genetic information". I also never said “What you are proposing will actually hurt patients, the medical system and the personalized medicine effort all together”. I did however, ask you to spend your time advocating for genetic counselors instead of consistantly cutting them down!
I've been saying this for a couple of years already. We need genetic counselors, we need clinical geneticists, and we need people who can see patients in just about every clinical department there is. For instance, a large sized clinic like the University of Wisconsin Hospitals and Clinics should try to have at least one person trained in taking a detailed family history in every department. This will help catch cases where their is a family history of the condition but it isn't cought because of the way things are done these days. This is why we need PA's, NP's, MD's, DO's, nutritionists, and GC's to work TOGETHER.
P.S. Thanks for the links today. I really liked them.
@ Lisa,
I never used your comments. I get emails from many counselors. Those quotes are actually from another counselor. I am sorry that I made you assume that my post was about you.....Ever heard of Carly Simon????
I don't ever want to cut down counselors. EVER. I do want to remind them that they are PART (to be read as NOT ALL) of the solution......Teaching NPs, PMDs and PAs, rather than laughing at how poorly they understand genetics is the solution.....
Don't say you haven't made an MD joke where they decide to test and made a complete hash of it.....
I have heard these jokes and even laughed too.....But I went about teaching them.....you should too...
2-3000 CGCs, 117,000 NPs.....you figure out who is going to be doing the heavy lifting for 300 million people..
Not cut on you, but NPs and PAs can do physical exams, that is what makes them physician extenders, not their advanced degrees, although that is a plus as well.
-Steve
I agree with your opinions on the use of genetic counselors in this new area of "personal genetics" - there are not enough and they have more important cases to counsel. I have worked with several and the tendency is to be oriented to counseling about risks of serious disease which is often not appropriate. I am involved in a European funded project to incorporate personal genetics into the clinic - starting with nutrigenetics. So far the pilot clinics have seen nearly 200 patients, counseling is available if requested but has not been. There have been few worries and those have been addressed by the trained medics / nurses. One thing we have learned so far is that a lot of time is needed with the patient during the first visit to explain what it's all about. The healthcare professionals involved have been very receptive and keen to learn. All fairly positive so far - details are on the website, and we will be writing up on the project next year: http://eurogene.biomed.ntua.gr/
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