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PAs and the practice of genetic medicine

Joseph D. McInerney, MA, MS and W. Andrew Faucett, MS, CGC

Joseph D. McInerney, MA, MS, is executive director, National Coalition for Health Professional Education in Genetics, Lutherville, Maryland. W. Andrew Faucett, MS, CGC, is an instructor at Emory University School of Medicine, Atlanta, Georgia.

Concerted, visionary efforts by the PA profession’s formal leadership and its rank-and-file members have placed physician assistants in a position of prominence with respect to the integration of genetics into education and practice. Those efforts—sustained during the past half-dozen years by individual PAs and by the entities responsible for education, accreditation, and certification—have begun to address the systemic challenges inherent in the rapid growth of human genetics and genomics. Among those challenges are the dearth of formally trained special-ists in genetics and the need for all health professionals to assume shared responsibility for providing care that increasingly is informed by genetic perspectives and emerging genetic technology.

The Clinical Watch piece in this issue (page 18) from the AAPA’s Clinical and Scientific Affairs Council (CSAC) addresses those challenges with advice to PAs for managing patients with hereditary breast and ovarian cancers. The article is at once a concise summary of the important clinical issues and a demonstration of the inherent tension between the need for nongeneticists to practice genetic medicine and their ability to do so competently.

Nowhere is this tension more evident than in CSAC’s injunction that PAs be more heavily involved in “identifying, educating, counseling, managing, and referring to other specialists to minimize cancer risks.” That list of tasks assumes the ability to take and interpret a genetic family history; knowledge of multiple cancer syndromes and the clues to the rarer ones; knowledge of genetics concepts such as penetrance; the ability to order appropriate genetic tests; the ability to interpret and communicate genetic test results, including difficult concepts such as variants of unknown clinical significance; the skill to convey genetic risks accurately and effectively; an understanding of the ethical legal, social, and economic implications of genetic testing; and knowledge of when and how to refer to specialists in genetics. None of those skills is beyond the capabilities of the average PA, but neither is any of them part of the average PA’s standard skill set.

It is, therefore, essential that PAs recognize their limitations in the provision of genetically based health care, and it is incumbent upon PAs who wish to play a role in genetic medicine to seek specialized and ongoing training in genetics to ensure that they are competent to do so. Furthermore, it falls to the leadership of the PA profession to ensure that training programs and CME offerings help to make that possible. The National Coalition for Health Professional Education in Genetics has developed a set of core competencies in genetics for health professionals (see www.nchpeg.org/core/corecomps-3rd_ed_aug07.pdf) and has collaborated with AAPA on the development of a Web-based CME program on genetics in the PA’s practice (see http://pa.nchpeg.org/). Those PAs who wish to provide genetic counseling services to their patients should be able to perform all components of the process, as defined by the American Board of Genetic Counseling (see http://abgc.iamonline.com/english/View.asp?x=1529).

PAs should develop relationships with board-certified genetic counselors and clinical geneticists (physicians board certified in clinical genetics) for case discussion, medical support, and referral. Those who wish to refer patients for genetic counseling can find board-certified counselors at www.nsgc.org/resourcelink.cfm and clinical geneticists at www.acmg.net. The relative paucity of genetic counselors and their concentration in urban areas mean that some PAs will not be able to find a counselor in close proximity for referral. Most genetic counselors and clinical geneticists will, however, be happy to consult by phone.

PAs have assumed an influential leadership role in bringing genetics into mainstream health care. As members of the genetics community, we welcome well-prepared PAs to this new era in medicine. JAAPA