Genetic Counseling Sessions Research Articles

Negotiating parental/familial responsibility in genetic counselling

The notion of responsibility is central in healthcare encounters, especially when it involves decisions about others, e.g., parents making decisions for children’s wellbeing. In the context of genetic counselling, given the familial basis of genetic disorders, decisions surrounding offer/uptake of genetic testing to determine the risk status of children become salient. Previous studies have shown that both genetic counsellors and parents routinely orient to others’ perspectives. Extending Pilnick’s (2001) finding that genetic counsellors allude to ‘what other people do’, Sarangi’s (2010) proposal which distinguishes between ‘family-others’ and ‘general-others’ vis-à-vis role-responsibility offers a useful framework to examine how parental/familial responsibility is contingently negotiated between genetic counsellors and parents. Our data consist of 20 genetic counselling sessions within a hospital department of medical genetics in Norway. The parents are either affected by cancer or at a high risk of inheriting cancer because of family history. Using discourse analysis we demonstrate how parental responsibility is framed and responded to differentially to cover genetic risk assessment, the testing process and the dissemination of test results. Our findings indicate that counsellors tend to be more directive about the process of decision making, which may amount to shifting attention from at-risk children to the parents themselves. We link our findings to the professional ethos of (non)directives in genetic counselling.

Genetics and Personal Insurance: the Perspectives of Canadian Cancer Genetic Counselors.

Genetic discrimination in the context of genetic testing has been identified as a concern for symptomatic and asymptomatic individuals for more than three decades. Genetic counselors are often the health care professionals who discuss risks and benefits of genetic testing with patients, thereby making them most appropriate to address patient concerns about genetics and personal insurance (i.e., life, life as related to mortgage or group insurance, disability, critical illness and travel). A pilot study was conducted to ascertain the current practices of Canadian cancer genetic counselors in regard to their discussions with patients about genetic testing and access to personal insurance. Among the 36 counselors surveyed, 100 % reported discussing the issue of genetic testing and personal insurance with their patients. Several factors influenced the content, depth and length of these discussions including age, cancer status, family members, and patients’ current and future insurance needs. Counselors reported discussing with patients the possible impact of genetic test results on access to personal insurance, possible access and use of patient genetic information by insurance companies, and whom patients should contact if they have additional questions. The most commonly reported inquiries from patients included questions about the possible impact of genetic testing on their ability to obtain insurance, and the insurability of family members. While 28 % of counselors reported having been contacted by an insurer requesting access to patient information, only one counselor was aware of or could recall the outcome of such a request. This pilot study revealed that issues concerning genetics and personal insurance are commonly discussed in Canadian cancer genetic counseling sessions. Counselors furthermore expressed a need for additional educational resources on the topic of genetics and personal insurance for themselves and their patients.

Thinking Differently About Genetic Counseling Service Delivery

With the increasing integration of genomic testing into medical care, there is a need to evaluate how genetic counseling services are provided, identify barriers to obtaining services, and establish ways to improve service delivery to ensure adequate patient access to high quality services. This article reviews the current status of genetic counseling service delivery including recent innovations. We describe some key factors that affect access and delivery including the time-intensiveness of genetic counseling sessions, the labor intensiveness of case preparation and follow-up services, and geographic barriers. Current remedies for improving access to genetic counseling services and their effectiveness are reviewed. Factors that potentially pose barriers for increasing access, such as reimbursement for services, are discussed. Finally, we propose ways for genetic and non-genetic professionals to work together to develop targeted strategies for enhancing access to genetic counseling services in their own practice areas.

Hoping Someday Never Comes: Deferring Ethical Thinking About Noninvasive Prenatal Testing

Background: Noninvasive prenatal testing (NIPT) is a new prenatal screening technology that became commercially available in the United States in 2011. NIPT's increased accuracy and low false positive rate compared to previous screening methods enable many women to avoid invasive diagnostic testing and receive much desired reassurance. NIPT has received much attention for both its benefits and drawbacks. Methods: Observation of genetic counseling sessions and qualitative interviews with women offered NIPT at a large academic medical center were conducted. Two ethnographic cases studies derived from the overall data set are used to illustrate the study findings. Results: Many fundamental ethical questions about prenatal screening, such as abortion or the value of disabled children, often do not emerge during clinical sessions, enabling most women to defer thinking about these issues until the future, when and if the need should arise. It may only be in the rare case when a woman receives a positive test result that she may be forced to confront ethical issues that she had up until then been able to avoid. Conclusions: Women want, and are grateful to have, access to NIPT, which offers much desired reassurance. This desire for reassurance may come at the expense of having contemplated the potential negative outcomes and limitations of testing. In the rare circumstance where women do not receive reassuring results, they may be unprepared and shocked by what NIPT can and cannot reveal. The routinization of NIPT as the latest and best available prenatal screening test does not necessarily create new ethical issues, but this study highlights ethical continuities following its arrival. However, the continued expansion of NIPT to include more conditions and women will increase the number of women who receive positive results, including false positives, and who may be shocked and unprepared as a result.

The Long and Short of Genetic Counseling Summary Letters: A Case-control Study.

Genetic counseling summary letters are intended to reinforce information received during genetic counseling, but little information is available on patient/family responses to these letters. We conducted a case-control study to assess the effectiveness of two different letter formats. Parents of children receiving a new diagnosis were enrolled. The control group (n = 85) received a genetic counseling summary letter in a narrative format, 4-5 pages in length. After the control enrollment period, genetic counselors were trained by a professional medical writer to develop a concise letter format. The case group (n = 64) received a concise letter, approximately 1.5 pages in length, utilizing simple sentences, lay terms, and lists/bullet points. Parents completed a survey 4weeks after the visit to rate the letter's format, usefulness, and their emotional reaction. Results show that parents in the case group rated the letter more highly (p = 0.023), particularly in the emotional response dimension (rating changes in anxiety, depression, fear, ability to cope, and confidence in response to the letter). Parents in the case group also rated the genetic counseling session more highly (p = 0.039). In the control group, parents without a college degree were more likely to rate the letter as too long and the level of medical detail as too high. In the case group, no significant differences were seen between parents with or without a college degree. These data suggest that a short genetic counseling summary letter is rated higher by parents, and is particularly associated with a more positive emotional reaction. A short letter format highlighting the basic facts related to the genetic condition may be more useful to parents of diverse educational backgrounds, and may support a positive emotional adaptation at the time of a new diagnosis. Genetic counselors may benefit from specific instruction in medical and educational writing.

Perceptions of Latinas on the Traditional Prenatal Genetic Counseling Model.

The traditional genetic counseling model encompasses an individualized counseling session that includes the presentation of information about genes, chromosomes, personalized risk assessment, and genetic testing and screening options. Counselors are challenged to balance the provision of enough basic genetic information to ensure clients' understanding of the genetic condition in question with a personalized discussion of what this information means to them. This study explored the perceptions Latinas have about prenatal genetic counseling sessions and aimed to determine if they had preferences about the delivery of care. Data were collected through focus groups and one-on-one, semi-structured interviews of 25 Spanish speaking Latinas who received genetic counseling during their current pregnancy. We implemented grounded theory to evaluate participant responses, and were able to identify common emergent themes. Several themes were identified including an overall satisfaction with their prenatal genetic counseling appointment, desire for a healthy baby, peace of mind following their appointment, lack of desire for invasive testing, and faith in God. Several participants stated a preference for group genetic counseling over the traditional individual genetic counseling model. Our data indicate that Latinas value the information presented at prenatal genetic counseling appointments despite disinterest in pursuing genetic testing or screening and suggest that group prenatal genetic counseling may be an effective alternative to the traditional genetic counseling model in the Latina population.

Genetic counselling in parents of children with congenital heart disease significantly improves knowledge about causation and enhances psychosocial functioning

BackgroundOne of the key questions asked by parents of children with congenital heart disease (CHD) is ‘why’ and ‘how did this happen?’. Receiving more information in response to these questions is therefore important to parents. This study sought to assess the efficacy of individualised genetic counselling sessions in improving knowledge of causation and psychosocial functioning in parents of children with CHD. MethodsParents of children undergoing surgery for CHD were offered individualised genetic counselling during their child's hospital admission. Assessments occurred at three time-points (immediately pre-, immediately post-, and two months post-session) using questionnaires comprising a purpose-designed knowledge measure, as well as validated psychological measures. ResultsOf the 94 participants approached, 57 attended the genetic counselling session (participation rate=60.6%). Knowledge scores for the participants who completed all three questionnaires improved significantly from pre- (x¯=7.38/16, SD=3.53) to post-session (x¯=13.33/16, SD=2.82) (p<0.001). Participants retained this knowledge over time, with no changes in scores at two-month follow-up (p=0.11). Perceived personal control also increased post-session, while reported guilt, shame, depression, anxiety and stress decreased. Overall satisfaction was high, with 96.4% of participants indicating they would recommend this service to other parents of children with CHD. ConclusionIndividualised genetic counselling sessions were highly beneficial to parents of children with CHD in regards to improving knowledge about the causes of CHD and enhancing psychosocial functioning, and should be considered as part of ‘best care’ practices.

Chirurgie annexielle prophylactique des femmes à risque héréditaire : vers de nouvelles pistes ?

Hereditary ovarian carcinomas represent 10% of cases of the around 4,500 yearly ovarian cancers in France. They principally consist of high-grade serous carcinomas. They are especially observed in mutation carriers on genes BRCA1 or 2 and, at a lesser degree, on genes of the hereditary non-polyposis colorectal cancer (HNPCC) syndrome. Due to the absence of an effective screening method for this highly lethal disease, laparoscopic prophylactic adnexectomy is strongly recommended as soon as possible, after a genetic counselling session. However, not all women accept the outcomes of an early menopause, especially if a substitutive treatment is contra-indicated. Recent data obtained from the thorough examination of risk-reducing salpingo-oophorectomy (RRSO) specimens highlight the pivotal role of the Fallopian tube in the pathogenesis of most ovarian carcinomas, especially its fimbrial end for the high-grade serous subtype, so frequent with mutation carriers. Thus, for these at-risk women, reluctant to RRSO, the idea of a temporary prophylactic surgery, limited to a bilateral radical fimbriectomy until oophorectomy at menopause, is being assessed in a prospective study. Meanwhile, due to these informations, it is advocated as well to perform salpingectomies in non-at-risk patients, candidates for a conservative hysterectomy or a surgical tubal ligation, as a primary prophylaxis of this dreadful disease.

Influence of anchoring on miscarriage risk perception associated with amniocentesis.

One factor women consider when deciding whether to pursue amniocentesis is the risk of miscarriage. People use mechanisms like anchoring, or the prior belief regarding the magnitude of risk, as a frame of reference for new information. This study aimed to determine a woman's perception of miscarriage risk associated with amniocentesis before and after genetic counseling and to determine what factors anchor a woman's perception of miscarriage risk. One hundred thirteen women being seen for prenatal genetic counseling and possible amniocentesis at six Houston clinics participated in the two-part anonymous survey. While most women (56.7%) perceived the risk as low or average pre-counseling and indicated the numeric risk of amniocentesis as <1%, significantly more patients (73%) correctly identified the numeric risk as <1% post-counseling (p < 0.0001). However, the majority of patients' qualitative risk perception did not change after the genetic counseling session (60%). Those who changed their feeling about the risk after counseling showed a decreased perception of the risk (p < 0.0001). Participants who elected amniocentesis had a significantly lower perception of the risk (p = 0.017) whereas those who declined amniocentesis were more likely to view the risk as high (p = 0.004). The only two anchoring factors that had an effect were having a friend or relative with a personal or family history of a genetic disorder (p = 0.001) and having a child already (p = 0.038); both were associated with a lower risk perception. The lack of significant factors may reflect the uniqueness of each patient's risk assessment framework and reinforces the importance of genetic counseling to elucidate individual concerns, particularly as non-invasive prenatal testing becomes more widely available and further complicates the prenatal testing landscape.

An assessment of genetic counseling services for individuals with multiple sclerosis.

Multiple sclerosis (MS) affects up to 1/500 Canadians. The University of British Columbia MS Clinic (UBC Clinic) is the only MS clinic in Canada (and likely internationally) that routinely offers genetic counseling to patients and their families. A typical session includes the collection of family history and demographic data, discussion of the inheritance of MS, interpretation of family-specific recurrence risks and psychosocial counseling. The aims of this study were to explore patients': 1) expectations of the genetic counseling session; 2) understanding of the etiology of MS (both pre and post-session); and 3) post-session perceptions of genetic counseling. A two-part questionnaire to assess genetic counseling services was distributed before and after sessions to all consenting patients seen during the period October 1, 2008 to February 28, 2009 inclusive. Sixty-two completed questionnaires were analysed. Genetic counseling was found to significantly increase the number of individuals who were able to correctly identify the etiology of MS (p < 0.001). Patient satisfaction with genetic counseling was high, with an average satisfaction score of 32.4/35 (92.6%). Of those who provided comments (n = 42/60) regarding the usefulness of the genetic counseling session, 95.2% reported it useful (n = 40/42). Findings suggest that genetic counseling is effective in increasing patients' knowledge of the etiology of MS and is viewed by patients as a useful service. Based on the high level of positive feedback regarding genetic counseling by the study sample, this study suggests that the services provided by genetic counselors may be beneficial for patients with MS seen in other centers.

More than ‘information provider’ and ‘counselor’: Constructing and negotiating roles and identities of nurses in genetic counseling sessions

This paper contributes to research on genetic counseling by exploring the complexity of this activity from the angle of identity construction. We argue that an analysis of the processes through which healthcare providers construct and negotiate their roles and identities in these encounters may contribute to a better understanding of the complexities of genetic counseling. Drawing on more than 150 video‐recorded genetic counseling encounters between nurses and clients in Hong Kong, we illustrate that the discursive processes involved in the construction of the nurses' identities are complex, overlapping and at times contradictory as the nurses respond to the (sometimes) competing norms and expectations of their institution, their clients and their own. They manage to solve these tensions by drawing on the roles traditionally assigned to nurses in these encounters such as information provider and counselor, as well as creating the new roles of co‐decision maker and cultural broker/mediator.

Preparing for and communicating uncertainty in cancer genetic counselling sessions in Norway: an interpretative phenomenological analysis

Risk communication is widely recognised as playing an important role in how individuals at risk of familial cancer understand and interpret their genetic status. To date, however, there has been little empirical investigation directed towards understanding how genetic counsellors themselves understand and actually deal with the challenges of communicating uncertainty of being identified with a gene fault in cancer genetic counselling sessions. In this article, we explore this relationship by using interpretative phenomenological analysis of semi-structured interviews with two genetic counsellors, prior to initial sessions with six patients in Norway, to examine whether the communication during consultations reflects what the genetic counsellors say they do. Analysis of the interviews demonstrates that the counsellors approach the patients’ experiences of their uncertain genetic status by drawing on past family history information and clinical experience as much as numerical risk information. Communicating the uncertainty in a manageable manner is described as a balancing act, involving being supportive while presenting realistic outcomes of the gene tests. Furthermore, our findings from the consultations show that although their clinical experience is emphasised, the counsellors do not explicitly invite patients to express how they themselves experience uncertainty in the context of their lives. While the counsellors provide the patients with balanced risk information, they do not explore how this uncertainty is experienced from the patient’s perspective. As such, our findings provide insight into an under-researched area within the field of genetic counselling.

Interdisciplinary education for genetic counselors: developing the concept and assessing the need in australasia.

Interdisciplinary teams are increasingly common in healthcare as a means of improving patient care and there is consensus in the literature that a formalized framework of interdisciplinary education for health professionals is an advantageous means of professional development. To our knowledge no such application to genetic counseling has been reported. Prompted by limited direct exposure to the oncology processes discussed during genetic counseling sessions, two genetic counselors completed an interdisciplinary education exercise by observing various oncology settings. As intended we gained a deeper understanding of the: (1) Roles of other health professionals within the oncology interdisciplinary team, (2) Patient experience of cancer screening and treatment, and (3) Clinical processes relevant to cancer genetic counselors' discussions. In addition, further benefits resulted from (4) Insight into how patients and referring providers utilize the FCC within wider oncology care and (5) Strengthening of relationships between the FCC and other oncology-related teams. The observation experience and resulting learnings are described in this paper. To investigate wider application of this novel initiative, a survey of Australasian genetic counselors was conducted, finding that genetic counselors mostly source knowledge about oncology procedures through indirect means and that, overall, anecdotal descriptions from patients were the most common information source (74 %). Over 95 % of respondents expected that interdisciplinary observations would be a beneficial part of their professional development and almost 90 % expected the program to be potentially feasible in their workplace. These findings indicate there is a role for interdisciplinary education to be considered as a formal continual learning tool for genetic counselors.

Characterization of a Phenotype-Based Genetic Test Prediction Score for Unrelated Patients With Hypertrophic Cardiomyopathy

ObjectivesTo determine the prevalence and spectrum of mutations and genotype-phenotype relationships in the largest hypertrophic cardiomyopathy (HCM) cohort to date and to provide an easy, clinically applicable phenotype-derived score that provides a pretest probability for a positive HCM genetic test result. Patients and MethodsBetween April 1, 1997, and February 1, 2007, 1053 unrelated patients with the clinical diagnosis of HCM (60% male; mean ± SD age at diagnosis, 44.4±19 years) had HCM genetic testing for the 9 HCM-associated myofilament genes. Phenotyping was performed by review of electronic medical records. ResultsOverall, 359 patients (34%) were genotype positive for a putative HCM-associated mutation in 1 or more HCM-associated genes. Univariate and multivariate analyses identified the echocardiographic reverse curve morphological subtype, an age at diagnosis younger than 45 years, a maximum left ventricular wall thickness of 20 mm or greater, a family history of HCM, and a family history of sudden cardiac death as positive predictors of positive genetic test results, whereas hypertension was a negative predictor. A score, based on the number of predictors of a positive genetic test result, predicted a positive genetic test result ranging from 6% when only hypertension was present to 80% when all 5 positive predictor markers were present. ConclusionIn this largest HCM cohort published to date, the overall yield of genetic testing was 34%. Although all the patients were diagnosed clinically as having HCM, the presence or absence of 6 simple clinical/echocardiographic markers predicted the likelihood of mutation-positive HCM. Phenotype-guided genetic testing using the Mayo HCM Genotype Predictor score provides an easy tool for an effective genetic counseling session.

Personalized Genomic Results: Analysis of Informational Needs

Use of genomic information in healthcare is increasing; however data on the needs of consumers of genomic information is limited. The Coriell Personalized Medicine Collaborative (CPMC) is a longitudinal study investigating the utility of personalized medicine. Participants receive results reflecting risk of common complex conditions and drug-gene pairs deemed actionable by an external review board. To explore the needs of individuals receiving genomic information we reviewed all genetic counseling sessions with CPMC participants. A retrospective qualitative review of notes from 157 genetic counseling inquiries was conducted. Notes were coded for salient themes. Five primary themes; "understanding risk", "basic genetics", "complex disease genetics", "what do I do now?" and "other" were identified. Further review revealed that participants had difficulty with basic genetic concepts, confused relative and absolute risks, and attributed too high a risk burden to individual single nucleotide polymorphisms (SNPs). Despite these hurdles, counseled participants recognized that behavior changes could potentially mitigate risk and there were few comments alluding to an overly deterministic or fatalistic interpretation of results. Participants appeared to recognize the multifactorial nature of the diseases for which results were provided; however education to understand the complexities of genomic risk information was often needed.

Is It Time to Embrace Telephone Genetic Counseling in the Oncology Setting?

Is It Time to Embrace Telephone Genetic Counseling in the Oncology Setting?

The efficacy of a standardized questionnaire in facilitating personalized communication about problems encountered in cancer genetic counseling: design of a randomized controlled trial

BackgroundIndividuals with a personal or family history of cancer, can opt for genetic counseling and DNA-testing. Approximately 25% of these individuals experience clinically relevant levels of psychosocial distress, depression and/or anxiety after counseling. These problems are frequently left undetected by genetic counselors. The aim of this study is to evaluate the efficacy of a cancer genetics-specific screening questionnaire for psychosocial problems, the ‘Psychosocial Aspects of Hereditary Cancer (PAHC) questionnaire’ together with the Distress Thermometer, in: (1) facilitating personalized counselor-counselee communication; (2) increasing counselors’ awareness of their counselees’ psychosocial problems; and (3) facilitating the management of psychosocial problems during and after genetic counseling.MethodsThis multicenter, randomized controlled trial will include 264 individuals undergoing cancer genetic counseling in two family cancer clinics in the Netherlands. Participants will be randomized to either: (1) an intervention group that completes the PAHC questionnaire, the results of which are made available to the genetic counselor prior to the counseling session; or (2) a control group that completes the PAHC questionnaire, but without feedback being given to the genetic counselor. The genetic counseling sessions will be audiotaped for content analysis. Additionally, study participants will be asked to complete questionnaires at baseline, three weeks after the initial counseling session, and four months after a telephone follow-up counseling session. The genetic counselors will be asked to complete questionnaires at the start of and at completion of the study, as well as a checklist directly after each counseling session. The questionnaires/checklists of the study include items on communication during genetic counseling, counselor awareness of their clients’ psychosocial problems, the (perceived) need for professional psychosocial support, cancer worries, general distress, specific psychosocial problems, satisfaction with care received, and experience using the PAHC questionnaire.DiscussionThis study will provide empirical evidence regarding the efficacy of a relatively brief psychosocial screening questionnaire in terms of facilitating personalized communication, increasing counselors’ awareness, and optimizing management of psychosocial problems in the cancer genetic counseling setting.Trial registrationThis study is registered at the Netherlands Trial Register (NTR3205) and ClinicalTrials.gov (NCT01562431).

The Effect of Genetic Counseling for Adult Offspring of Patients with Type 2 Diabetes on Attitudes Toward Diabetes and its Heredity: A Randomized Controlled Trial

The aim of this study is to investigate the effect of diabetes genetic counseling on attitudes toward diabetes and its heredity in relatives of type 2 diabetes patients. This study was an unmasked, randomized controlled trial at a medical check-up center in Japan. Subjects in this study are healthy adults between 30 and 60 years of age who have a family history of type 2 diabetes in their first degree relatives. Participants in the intervention group received a brief genetic counseling session for approximately 10 min. Genetic counseling was structured based on the Health Belief Model. Both intervention and control groups received a booklet for general diabetes prevention. Risk perception and recognition of diabetes, and attitude towards its prevention were measured at baseline, 1 week and 1 year after genetic counseling. Participants who received genetic counseling showed significantly higher recognition about their sense of control over diabetes onset than control group both at 1 week and 1 year after the session. On the other hand, anxiety about diabetes did not change significantly. The findings show that genetic counseling for diabetes at a medical check center helped adults with diabetes family history understand they are able to exert control over the onset of their disease through lifestyle modification.

Distinct communication patterns during genetic counseling for late-onset Alzheimer's risk assessment

ObjectiveTo identify and characterize patient–provider communication patterns during disclosure of Alzheimer's disease genetic susceptibility test results and to assess whether these patterns reflect differing models of genetic counseling. Methods262 genetic counseling session audio-recordings were coded using the Roter Interactional Analysis System. Cluster analysis was used to distinguish communication patterns. Bivariate analyses were used to identify characteristics associated with the patterns. ResultsThree patterns were identified: Biomedical-Provider-Teaching (40%), Biomedical-Patient-Driven (34.4%), and Psychosocial-Patient-Centered (26%). Psychosocial-Patient-Centered and Biomedical-Provider-Teaching sessions included more female participants while the Biomedical-Patient-Driven sessions included more male participants (p=0.04). ConclusionCommunication patterns observed reflected the teaching model primarily, with genetic counseling models less frequently used. The emphasis on biomedical communication may potentially be at the expense of more patient-centered approaches. Practice implicationsTo deliver more patient-centered care, providers may need to better balance the ratio of verbal exchange with their patients, as well as their educational and psychosocial discussions. The delineation of these patterns provides insights into the genetic counseling process that can be used to improve the delivery of genetic counseling care. These results can also be used in future research designed to study the association between patient-centered genetic counseling communication and improved patient outcomes.

From genetic counseling to “genomic counseling”

Genetic counseling is “the process of helping people understand and adapt to the medical, psychological, and familial implications of genetic contributions to disease.” Traditionally, this process includes collecting and interpreting the family and medical history, risk assessment, a comprehensive educational process for potential genetic testing, informed consent, and psychosocial assessment and support (National Society of Genetic Counselors' Definition Task Force et al. 2006). While genetic counseling falls within the scope of many health care professionals, clinical geneticists (physicians) and masters level genetic counselors have been working in the United States for more than 40 years, providing genetic counseling primarily for single-gene conditions. Debate about what “genomic counseling” will include and who will practice it has been fueled by the transition from single-gene focused genetic counseling and testing to a full genomic medicine approach. The routine incorporation of genomic medicine will likely induce differences in the scope, approach and process of genetic counseling (Table ​(Table1).1). In this commentary, I will discuss the several areas where practice will likely change as we move toward “genomic” counseling, with a focus on the unique skills and roles that genetic counselors and clinical geneticists provide. Table 1 Changes that will impact the transition to “genomic counseling.”