Does indirect speech promote nondirective genetic counseling? Results of a sociolinguistic investigation

Defining orienting language in the genetic counseling process

We defined orienting language in genetic counseling sessions as 'language intended to direct focus to a particular aspect of the counseling process; a physical, emotional, or cognitive space; or an outcome'. This is a concept expanding on the idea of 'orientation' statements in the genetic counseling literature. We propose that orienting language is an important component of effective communication in the genetic counseling process. Our goals were to document the presence of orienting language in genetic counseling sessions with practicing genetic counselors and simulated clients, categorize types of orienting language, and evaluate the purpose of this language. A sample of Genetic Counseling Video Project videotape transcripts was evaluated through consensus coding for orienting language. Orienting language was found to be abundant in the dataset evaluated. Each excerpt was coded for orienting language Strategies and Purpose. The six categories of Strategy codes identified were Logical Consistency, Providing Context, Guidance, Structuring the Session, Anchoring, and Procedural. The six categories of Purpose codes were Counselee Understanding, Guidance, Engagement, Promoting Effective Counselor/Counselee Interactions, Counselee Adaptation, and Relationship Building. Results support our expanded definition of orienting language, which was similar in both cancer and prenatal specialties and across years of counselor experience. Orienting language acts as a series of signposts to help clients navigate the sometimes complex and unfamiliar territory of a genetic counseling session. The introduction of this term into the genetic counseling literature allows its use by genetic counselors to be further evaluated and potentially incorporated into genetic counselor training.

Supporting Patient Autonomy and Informed Decision-Making in Prenatal Genetic Testing

Genetic counselors have both the burden and the privilege of supporting patients who are faced with making difficult decisions. In the prenatal setting, genetic counselors are responsible for reviewing a growing list of prenatal testing options for patients with the goal of helping people to anticipate the potential consequences of their decision. Prenatal genetic counselors also support patients in making decisions about the next steps after clinical evaluation has indicated a genetic condition, birth defect, or information of uncertain clinical significance in the fetus. The information provided and choices patients face in the context of prenatal and reproductive genetics can be life-altering, and decisions often must be made within a short window of time. It is imperative that the needs and preferences of each patient are considered and that individuals are empowered to make active decisions that are consistent with their needs and values. Here we will review the history of the role of the genetic counselor in the prenatal setting and will provide strategies and tools for supporting informed patient decision-making in the face of an increasingly complex reproductive genetic testing landscape.

"There is a chance for me" - Risk communication in advanced maternal age genetic counseling sessions in South Africa

Providing risk information is central to genetic counseling. Many studies have examined risk communication, but the focus has been on professional and patient perspectives. Less information is available on risk communication in interactions. This study aimed to examine genetic counselors' (GCs) risks communication in multicultural genetic counseling sessions with women of advanced maternal age (AMA). Six GCs (2-20 years' experience) conducted AMA sessions in English (women's second language). The sessions were video and voice recorded and transcribed verbatim. Data were analysed using conversation analysis (CA). CA examines discourse as a topic, i.e. describing the turns, its functions and how these functions are accomplished. Analysis revealed that the GCs presented the risk of having a baby with a chromosome abnormality in several ways and that they invite the women to reflect on the risk information. This discussion was found to be a five step process and showed that the women responded to the invitation to reflect rather than the risk information itself by providing additional information. The counselors in the majority of the sessions responded to this additional information the women provided. It therefore seems that the way in which risks are presented are less important than the meaning of the risks for the women. The research showed the power of interactional research such as CA methodology to gain new insights into old problems. Importantly, the study revealed some on the nuances of risk communication in genetic counseling and has implications for practice.

Offering a choice between NIPT and invasive PND in prenatal genetic counseling: the impact of clinician characteristics on patients' test uptake

Testing options for pregnant women at increased risk of common aneuploidies are non-invasive prenatal testing (NIPT) and invasive prenatal diagnosis (PND). Clinicians are challenged to comprehensively discuss the complex information in a patient-centered and non-directive manner, to allow for patients' informed decision-making. This study explored the information-centeredness, patient-centeredness, and level of non-directivity of different clinicians and examined group differences between their patients. First, semi-structured interviews with four senior obstetricians and one senior nurse were held regarding their information provision, their adaptation of a patient-centered attitude, and their practice of non-directivity. Interviews were transcribed verbatim and rated by four independent researchers. Secondly, 181 pregnant women were included in the study, of whom 82% opted for NIPT and 18% chose PND. Between clinicians, we assessed the distribution of choice ratios, patients' impression of clinicians' test preferences, and patients' knowledge scores. The results indicate that clinicians do not differ in their information-centeredness, but do differ in their patient-centeredness and their level of non-directivity. Significant differences in patients' NIPT/PND ratios were observed between clinicians, with the largest difference being 35 vs. 4% opting for invasive PND. Between 9 and 22% of the patients had an impression of their clinician's preference and chose in accordance with this preference. Patients' overall knowledge scores did not differ across clinicians. In conclusion, the differences in NIPT/PND ratios between clinicians indicate that clinicians' differing counseling approaches affect the choices their patients make. The interviews indicate a possible framing effect which may unintentionally steer the decision-making process.

Provider's Perceptions of Barriers and Facilitators for Latinas to Participate in Genetic Cancer Risk Assessment for Hereditary Breast and Ovarian Cancer

The Comprehensive Cancer Network (NCCN) recommends genetic cancer risk assessment (GCRA) referral to women at high risk of hereditary breast and ovarian cancer. Latinas affected by breast cancer have the second highest prevalence of BRCA1/2 mutations after Ashkenazi Jews. Compared to non-Hispanic Whites, Latinas have lower GCRA uptake. While some studies have identified barriers for GCRA use in this population, few studies have focused on health care providers' perspectives. The purpose of the study was to examine providers' perceptions of barriers and facilitators for at-risk Latina women to participate in GCRA and their experiences providing services to this population. We conducted semi-structured interviews with 20 healthcare providers (e.g., genetic counselors, patient navigators) recruited nationally through snowballing. Interviews were transcribed. Two coders independently coded each interview and then met to reconcile the codes using Consensual Qualitative Research guidelines. Providers identified several facilitators for GCRA uptake (e.g., family, treatment/prevention decisions) and barriers (e.g., cost, referrals, awareness, stigma). Genetic counselors described important aspects to consider when working with at-risk Latina including language barriers, obtaining accurate family histories, family communication, and testing relatives who live outside the US. Findings from this study can inform future interventions to enhance uptake and quality of GCRA in at-risk Latina women to reduce disparities.

Elaboration of the Reciprocal-Engagement Model of Genetic Counseling Practice: a Qualitative Investigation of Goals and Strategies

As the genetic counseling field evolves, a comprehensive model of practice is critical. The Reciprocal-Engagement Model (REM) consists of 5 tenets and 17 goals. Lacking in the REM, however, are well-articulated counselor strategies and behaviors. The purpose of the present study was to further elaborate and provide supporting evidence for the REM by identifying and mapping genetic counseling strategies to the REM goals. A secondary, qualitative analysis was conducted on data from two prior studies: 1) focus group results of genetic counseling outcomes (Redlinger-Grosse et al., Journal of Genetic Counseling, 2015); and 2) genetic counselors' examples of successful and unsuccessful genetic counseling sessions (Geiser et al. 2009). Using directed content analysis, 337 unique strategies were extracted from focus group data. A Q-sort of the 337 strategies yielded 15 broader strategy domains that were then mapped to the successful and unsuccessful session examples. Differing prevalence of strategy domains identified in successful sessions versus the prevalence of domains identified as lacking in unsuccessful sessions provide further support for the REM goals. The most prevalent domains for successful sessions were Information Giving and Use Psychosocial Skills and Strategies; and for unsuccessful sessions, Information Giving and Establish Working Alliance. Identified strategies support the REM's reciprocal nature, especially with regard to addressing patients' informational and psychosocial needs. Patients' contributions to success (or lack thereof) of sessions was also noted, supporting a REM tenet that individual characteristics and the counselor-patient relationship are central to processes and outcomes. The elaborated REM could be used as a framework for certain graduate curricular objectives, and REM components could also inform process and outcomes research studies to document and further characterize genetic counselor strategies.

'And then you can decide'--antenatal foetal diagnosis decision making in South Africa

BACKGROUND

Decision making is integral to genetic counselling and the premise is that autonomous decisions emerge if patients are provided with information in a non-directive manner. The pivotal activity in antenatal diagnosis counselling with at-risk pregnant women is decision making regarding invasive procedures. This process is not well understood in multicultural settings.

OBJECTIVE

This study examined multicultural genetic counselling interactions with women of advanced maternal age (AMA). It aimed to investigate the participants' orientation towards the amniocentesis decision.

DESIGN

Data were collected during 14 video-recorded consultations between six genetic counsellors and 14 women of AMA in a genetic counselling clinic in South Africa. The design was qualitative and conversation analysis was used for analysis.

RESULTS

Analysis revealed that counsellors used several strategies to facilitate discussions and decision making. However, the invitation to make a decision regarding amniocentesis was not perceived as being neutral. Both the counsellors and the women appeared to treat the offer as one which should be accepted. This resulted in a paradox, as strategies intended to allow neutral discussion seem to achieve the opposite. It is suggested that these results may be linked to the local health-care setting.

CONCLUSION

The results suggest that the understanding of decision-making processes and enhancing autonomy may require a more detailed investigation into psychosocial, political and historical factors in the local health-care setting. Models of practice as well as the training of genetic counsellors need to be sensitive to these influences. A closer examination of interactional variables may yield new and relevant insights for the profession.

Analyzing communication in genetic consultations--a systematic review

OBJECTIVE

To systematically review studies that have analyzed communication within medical consultations involving genetic specialists and report on their findings and design.

METHODS

Drawing from PRISMA and appropriate guidelines for reviewing qualitative research, a systematic search of seven databases was conducted, followed by selection of studies for inclusion based on a set of criteria. Three authors conducted data extraction and narrative synthesis.

RESULTS

Twenty-two studies were identified and were heterogeneous in setting, design, and methods, with many including limited descriptions of health professionals involved. Despite this variability, studies generally pursued the following three main objectives: searching for structural patterns within consultations, investigating communication and genetic counseling concepts, and linking process with input- and outcome-measures. Structural patterns identified included clinician dialog dominating consultations, and talk being mostly biomedical. Counseling and communication concepts investigated were: risk communication, the negotiation of power and knowledge, and adherence to genetic counseling ideals. Attempts to link consultation data to input- or outcome-measures were often unsuccessful.

CONCLUSION

More interdisciplinary research, grounded in appropriate theoretical frameworks, is needed to explore inherent complexities in this setting.

PRACTICE IMPLICATIONS

Findings from this review can be used to guide the design of future research into the process of genetic consultations.

An exploration of the communication patterns and language used between clinical geneticists and parents of children with dysmorphic features

The present study aims to provide insight into the interactions between clinical geneticists and parents of children with dysmorphic features during syndrome assessment. Seven families attending a dysmorphology clinic for syndrome assessment consented to have their consultation recorded and transcribed verbatim. Content and discourse analyses were used to study the language and communication patterns of problematic and challenging sections of the consultations, primarily sections concerning the child's appearance and diagnosis which were marked by dysfluency and hesitation, indicators of problematic communication. Findings revealed that the clinical geneticists used a range of communicative strategies when discussing a child's appearance, such as comparing the child's features with those of parents or other individuals and minimizing differences. In doing so they displayed an orientation to the "face-threatening" nature of this communicative task. While geneticists discussed the child's appearance in an extremely sensitive manner, parents tended to describe their child's appearance using direct and objective language. These findings provide novel insight into the complexity of syndrome assessment consultations in a dysmorphology clinic. We suggest that parents may be seeking a more open discussion of their child's appearance, and clinician engagement with this may prove a more effective communication strategy than those currently employed, while remaining sensitive to parents' responses to such a discussion. At the start of the consultation it is important to give parents the opportunity to voice their concerns and expectations, and to explain to parents that a diagnosis may not be reached.

Hedging, knowledge and interaction: Doctors' and clients' talk about medical information and client experiences in genetic counseling

OBJECTIVES

The article starts from the observation that professionals in genetic counseling deploy the strategy of 'hedging'. It shows how hedging is used in a particular sequential position: doctors' responses to clients' presentations of personal information during information delivery sequences.

METHODS

The data consist of video-recorded sessions of genetic counseling. The methodology is based on ethnomethodological conversation analysis. The analysis identifies interactional patterns in the counseling sessions.

RESULTS

In their responses doctors display an orientation to different access to different kinds of knowledge. In particular, the doctors tread carefully when commenting on the situation of a particular client vis-á-vis the symptoms and prognosis of genetic conditions. Furthermore, the article shows that the doctors' responses and hedging devices in them are fitted to the form and function of the clients' presentations of personal experience.

CONCLUSION

While the focus of the article is narrow in that it concentrates on one type of an interactional sequence, its strength is that it shows how the doctor's talk can be intertwined with the client's contributions.

PRACTICE IMPLICATIONS

The results make it possible for genetic counselors to identify an interactional task they recurrently face and reflect on alternative ways of responding to it.

Bridging the Communication Divide: A Role for Health Psychology in the Genomic Era

The application of genomics to population health has the potential to revolutionize the practice of medicine. Indeed, discoveries into the genomic basis of cancer and other common chronic diseases have resulted in new and improved predictive tests for identifying individuals at increased risk for these conditions and long before their onset occurs. When used properly, information gained from predictive genomic tests can be combined with other leading indicators (e.g., environmental and behavioral risk factors) to inform medical management decisions, preventive health practices, and risk-reducing strategies. However, genomics remains an emerging science and the translation of genomic discoveries into improved population health management remains elusive. There are divides in the translational science continuum at several junctures, and many of these divides could be narrowed or closed with additional data. For example, we know relatively little about how to effectively communicate with the public about the complex interplay among genomics, behavior, and health. Moreover, there is a need to develop better methods of counseling and educating the public in light of newly emerging knowledge about the genomic basis of health and disease. We assert that the discipline of psychology, and health psychology in particular, is well-poised to continue to make significant contributions to this growing area of science and practice. Through a focus on health-related social and behavioral research, psychology can lead the way in overcoming divides in communication, understanding, and action about genomics for the betterment of both individual and public health practices.

A study of politeness strategies adopted in pediatric clinics in Taiwan

Drawing on Brown and Levinson's (1987) politeness theory, this study investigates the communicative interaction behaviors of physicians, patients, and patients' parents in pediatrics in Taiwan. Thirty outpatients and six senior physicians from three different levels of hospital participated in the study. The analysis results indicate that most of the communicative politeness strategies used in pediatrics are bald-on-record, direct, and non-redressed. In addition, physicians adopt a higher percentage of bald-on-record and negative politeness strategies than patients. In contrast, patients' parents use more positive politeness and off-record strategies. These results indicate that while physicians display lower levels of politeness and often communicate directly, patients' parents express more supportive opinions and adopt more indirect communication strategies. The results reveal a preference for efficiency in pediatric clinics, with physicians adopting a dominant role in the communication process. These results also demonstrate an inherently asymmetric power balance between physician and patient. Our findings indicate the presence of several commonly seen politeness strategies and dialogue patterns that encourage greater self-awareness and self-observation for physicians and patients, leading to more effective communication in the clinical context. Finally, also discussed are the possible influences of Chinese culture such as face work, harmony, and power.

A sociolinguistic exploration of genetic counseling discourse involving a child with a new genetic diagnosis

OBJECTIVES

To examine the process of genetic counseling with the aim of observing how participants negotiate a common understanding in light of the inherent power asymmetry of a genetics health care encounter.

METHODS

Data from ten sessions between genetic counselors and parents of children with a genetic diagnosis were taped. Transcripts were examined using a qualitative discourse analysis approach focusing on communication features such as question design, topic initiation and control, and lexical or discourse features which could give insights into rapport building strategies.

RESULTS

Counselors tightly controlled the medical history phase in all sessions and verbally dominated the scientific information phase. More symmetric communication occurred when: (i) counselors showed flexibility with their agenda and gave parents the opportunity to share their health experience; (ii) counselors showed signs of involvement through the use of 'rapport building' strategies; (iii) counselors used a syllogistic approach and information was delivered at a slower pace.

CONCLUSION

Observations from this study suggest that, when counselors focus on building rapport with parents, the human voice of the parent emerges. Examples of rapport building strategies by the counselors included adapting to the parents' variations in knowledge, recognizing the needs of the parents, verifying their understanding, and choosing a more interactive approach to the delivery of information.

PRACTICE IMPLICATIONS

Our findings suggest that for effective communication to occur, parents need to be provided with opportunities to be active participants in the genetic counseling encounter.

Assessment of the content and process of genetic counseling: a critical review of empirical studies

This article reviews studies that assessed the process and content of genetic counseling communication. A systematic search of the literature was undertaken of studies that audio- or videotaped genetic counseling sessions conducted by genetics health care providers and subjected them to communication analyses. A total of 18 studies (published in 34 articles) were identified that met the eligibility criteria. Studies show that providers speak more than clients, that a large proportion of communication is biomedical rather than psychosocial and that the teaching model of genetic counseling is widely implemented. Higher levels of counselor facilitation of understanding and empathic responses, lower levels of verbal dominance (ratio of counselor to client talk) and the provision of a summary letter of the consultation are associated with more positive client outcomes. Findings from these studies should be used as an evidence base for teaching and continuing education of genetic counseling providers.

Are counsellors' attitudes influencing pregnant women's attitudes and decisions on prenatal screening?

OBJECTIVES

It is generally recognised that choices concerning treatment or screening should be people's own, autonomous decisions. However, in the context of genetic counselling, many studies found that counsellors deviate from nondirectiveness, or that subjective norm influences behaviour. The present study aimed to investigate whether prenatal counsellors (midwives, gynaecologists) influence pregnant women's decisions and their attitudes regarding prenatal screening. It was hypothesised that uptake rates and attitudes would be associated with the counsellor's attitude toward prenatal screening.

METHODS

Pregnant women attending their midwifery or gynaecology practice were asked to fill out postal questionnaires before and after they were offered prenatal screening for Down syndrome. Their prenatal counsellors also filled in a questionnaire. These questionnaires assessed attitudes toward prenatal screening and background variables. The study sample consisted of 945 pregnant women, being guided by 97 prenatal counsellors.

RESULTS

Multilevel regression analyses revealed that neither uptake rates, nor attitude toward prenatal screening were significantly predicted by counsellors' attitudes toward prenatal screening.

CONCLUSION

It is suggested that the advice these pregnant women were reported to have received, should rather be interpreted as an indication of shared decision-making and social support than of social pressure and undesired influence.

Coming full circle: a reciprocal-engagement model of genetic counseling practice

As genetic health care and genetic testing expand from primarily addressing conditions that are exclusively genetic in nature to common diseases with both genetic and environmental components, the scope of genetic counseling has grown. Identification and utilization of a normative model of practice defined by members of the profession is critical as genetic services become more commonplace in medical care. The purpose of this paper is to describe the results of a consensus conference convened to define a model of genetic counseling practice based on the guidance of educators and leaders in the profession. Twenty-three program directors or their representatives from 20 genetic counseling graduate programs in North America listened to presentations and participated in group discussions aimed at determining the elements of a model of practice, including tenets, goals, strategies, and behaviors for addressing patients' genetic concerns. Their discussion is summarized, training implications and research recommendations are presented, and a model of practice that extends their ideas is proposed.

Cancer genetic counseling: communication and counselees' post-visit satisfaction, cognitions, anxiety, and needs fulfillment

Little is known about the relation between communication during cancer genetic counseling and outcome. We assessed associations between counselor-counselee communication and counselee satisfaction, cognitions, anxiety, and fulfillment of major needs, corrected for pre-visit levels as appropriate. In total 171 consecutive new counselees, mainly referred for breast or colon cancer, received pre- and post-visit questionnaires assessing needs/fulfillment, knowledge, perceived control (PPC), anxiety (STAI), and satisfaction. Initial visits were videotaped and counselor eye gaze was recorded. Verbal communication was rated by Roter Interaction Analysis System (RIAS). Asking more medical questions was associated with lower satisfaction levels. Receiving more medical information was related to higher correct knowledge scores, higher reported fulfillment of some needs, and unrelated to perceptions of control. Receiving more psychosocial information and longer counselor eye gaze were related to higher anxiety scores. Longer visits were related to higher correct knowledge scores. Providing medical information appears the most powerful communication aspect to increase counselee satisfaction and address needs. More research is needed on how to address adequately (emotional) needs and increase feelings of control.

Genetic counseling communication with an African American BRCA1 kindred

We studied communication in genetic counseling sessions conducted with an African American, Breast Cancer 1, Early Onset (BRCA1) kindred in the USA. The Roter Interaction Analysis System (RIAS) was used to code and compare two sessions of 46 participants (26 females and 20 males) before and after they underwent genetic testing. Three certified genetic counselors and one medical geneticist conducted the sessions. When compared to pre-test communication, most of the providers' post-test communication was devoted to the provision of biomedical information (including screening recommendations) with fewer questions and psychosocial statements. Clients contributed a similar proportion to the total session dialogue in pre- and post-test sessions (40%). A larger proportion of their post-test session was devoted to indicating receptiveness to provider information than in the pre-test session. We found when providers were informing clients that they were BRCA1 mutation carriers, they provided more biomedical and psychosocial information and asked more psychosocial questions than when talking with non-carriers. This study provides the first description of genetic counseling communication for pre- and post-test BRCA1 sessions with African American individuals.

Do Notions of Risk Inform Patient Choice? Lessons from a Study of Prenatal Genetic Counseling

Risk modeling is an increasingly important part of clinical medicine; however, "risk status" is a complex notion, understood differently by patients and clinicians. Patients' ability to make informed choices about clinical procedures often requires that they interpret risk statistics, which may be difficult to understand and apply. In this article, which is based on a study of prenatal care in South Texas, we consider how notions of risk affect patient decisions about prenatal genetic testing. The term "risk" carries multiple meanings for clinicians and patients. These meanings may conflate concepts of danger and probability as well as muddle population risk and individual risk. We propose that failure to articulate the varied and contrasting meanings of risk held by clinicians and patients can undermine clinical communication and, thereby, hamper patients' ability to make autonomous, informed choices. Attending to these differences may prove useful in empowering patients to make truly informed decisions.

Communication analysis of BRCA1 genetic counseling

In this study, we apply an existing medical communication coding system to BRCA1 genetic counseling sessions, describe the session dynamics, and explore variation in session communication. The sample was comprised of 167 members of an identified BRCA1 kindred whose pretest counseling session was audiotaped and coded using Roter's Interaction Analysis System (RIAS). Three certified genetic counselors followed a research protocol that dictated areas to be covered in the counseling session. We found that it was feasible to code long, protocol driven BRCA1 sessions in a quantitative manner without the use of transcripts and capture the dialogue of all session participants. These findings support the use of RIAS in genetic counseling research. Our results indicate that these BRCA1 sessions were predominantly educational in nature with minimal dialogue devoted to psychosocial issues. We found that participant gender, presence of a client companion, and counselor identity influence session communication.

“SLANG”—Sensitive Language and the New Genetics—an Exploratory Study

SLANG-Sensitive Language and the New Genetics--is a concept that arose out of informal discussions between a number of interested parties, both consumers and professionals, who were becoming increasingly uneasy with some of the language commonly used in medical genetics. Some language choices were felt by the authors to be inappropriate for a variety of reasons. Poor language choice may impede an individual's understanding of a genetic condition or important medical information and the chosen words themselves may simply be perceived as discriminatory and even offensive. SLANG is an important concept to explore partly because literature in this area confirms that language choices in medical settings can be of great significance to both patients and families. Studies have shown how language choices impact on professional practice by, as one example, changing the intended meaning of medical information and affecting individual perception of risk and choice which, in turn, may affect individual or familial well-being. In addition language choice has the power to affect how individuals perceive themselves and are viewed by others. This paper presents the results from our pilot study and discusses the implications for health professionals with particular reference to medical genetics settings.

Doctor's Expertise and Managing Discrepant Information from Other Sources in Genetic Counseling: A Conversation Analytic Perspective

The study examines a recurrent interactional pattern in genetic counseling. It describes clinical geneticists' responses in situations in which clients have presented information from other sources that is potentially discrepant with information given by the doctor. The data consists of 12 video-recorded sessions of genetic counseling in Finland, and the method is conversation analysis. There are two primary ways the doctors respond: either they accept the client's information as such, but show that it is not discrepant with the doctor's information, or they reject the client's information. In the latter case they mitigate the 'wrongness' of the client's information. The clinical geneticists seem to be working with a dilemma: they need to find a balance between ensuring correct understanding of the information and showing respect for the expertise of others. A particularly complex case is also analyzed and reflected on.

Differences in Individual Approaches: Communication in the Familial Breast Cancer Consultation and the Effect on Patient Outcomes

This multicenter study aimed to assess (i) whether individual clinical geneticists and genetic counselors vary in their communication skills and (ii) whether this variation in communication impacts on patient outcomes, such as anxiety, depression, genetics knowledge, and satisfaction. One hundred and fifty women from high-risk breast cancer families attending their first genetic counseling consultation completed pre and post-consultation self-report questionnaires. The consultations were audiotaped and transcribed verbatim. Univariate analyses showed highly significant differences between individual clinical geneticists and genetic counselors in: facilitating understanding (p < or = 0.001); facilitating active involvement (p < or = 0.001); facilitating partnership building (p = 0.003); addressing emotional concerns (p < or = 0.001); and discussing prophylactic mastectomy (p = 0.017). Multivariate linear regressions showed that this variation in communication resulted in a greater change in patient's depression 4 weeks after the counseling session (p = 0.017). These findings suggest clinical geneticists and genetic counselors have achieved some standardization in communicating information, but showed diversity in their facilitation skills. Communication skills may be a useful area to explore further in this field.

Assessment of genetic testing and related counseling services: current research and future directions

With the recent completion of the sequencing of the Human Genome, genetic testing will increasingly become available for a greater number of medical conditions, many of which are those that manifest in adulthood (e.g., various cancers, cardiovascular disease, diabetes) or for which little or no treatments are available (e.g., Alzheimer disease). Genetic services, defined here as those relating to genetic testing and counseling, will be with helping more individuals deal with medical information that affects their health directly, as opposed to affecting primarily the health of their offspring. This paper reviews the existing research in the genetic testing and counseling literature and presents an evaluation framework outlining the intended outcomes of genetic services. The purpose of this framework is to provide an overview of the potential outcomes of these services and highlight constructs for future research in this area. In addition, other issues that will affect the assessment of genetic services are raised, using examples from the existing literature. Ultimately, the goal of this paper is to highlight and suggest directions researchers can take to produce the information needed to guide genetic testing and counseling practice. Moreover, as genetic knowledge is increasingly applied towards the prevention and treatment of various common, chronic disease conditions, genetic information will have implications for providers outside of the traditional medical genetics realm, such as primary care providers and public health practitioners. A better understanding of the outcomes of genetic testing and counseling will provide a basis from which to ensure an appropriate application of genetic information by all those who eventually provide care and "genetic" services.

The genomic revolution and the obstetrician/gynaecologist: from societal trends to patient sessions

A major aspect of reaping the benefits of the genome revolution in women's health relates to questions of how we are going to handle this scientific manna of information and potential treatment options while minimizing social exclusion along the lines of race, class and gender. Four society-level scenarios or patterns of diffusion of genomic access are discussed, each with its own set of assumptions and outcomes in terms of equity. Like it or not, the front-line obstetrician/gynaecologist will play a critical role in whether such new information helps either to reduce or to exacerbate discrepancies in health-care status along the lines of race and socio-economic status. Patients must not be denied access to knowledge and information within the genetic counselling session, or to the opportunity to make an informed autonomous decision because of the use of unfamiliar language and conventions of conversation that support power differentials and discourage rapport and empathy. Aspects of communication that are critical to the outcome of the genetic counselling session, such as the level of directness of counselling, physician interruptions of the patient and the power implications of the rhetorical question, are explored. In addition, the special challenges to counsellor neutrality and patient autonomy offered by the longitudinal primary obstetrician/gynaecologist relationship are discussed. Strategies encouraging more effective collaboration and communication between generalist and patient in the counselling session are offered.