education and counseling and current deficiencies in public understanding, the committee believes that testing at nonmedical sites is inappropriate at this time.

There are not now, nor in the future are there likely to be, sufficient numbers of medical geneticists and individuals trained primarily as genetic counselors to explain genetic tests and test results to all who might want them. Thus, it seems likely that much of genetic testing will be incorporated into the mainstream of medical care and provided particularly by primary care practitioners (family physicians, internists, obstetrician-gynecologists, and pediatricians). More problematic is the lack of time and inclination to provide counseling among primary care practitioners. The committee notes that, in many instances, primary care physicians, by virtue of having continuing contact with their patients, are better suited in several respects to provide counseling than specialists who are likely to first encounter patients only after positive test results have been obtained. Physicians' knowledge of genetics currently has serious deficiencies, and more attention to genetics and genetic testing is needed in medical education (see Chapter 6). Genetic counselors can help in the training of physicians, and in the training of nurses and social workers, who in turn can assist primary care physicians in genetic education and counseling (see Chapters 4 and 6).

Standards of Care

If testing is to be provided primarily by primary care physicians, how will these providers know when to adopt genetic tests? One protection will be afforded by ensuring that new tests and the laboratories performing them have been rigorously examined before they are approved by the appropriate federal agencies (see pilot studies above, Chapters 3 and 9). The committee believes, moreover, that in considering genetic tests, agencies must also consider problems of test interpretation, so that physicians receiving the results have a thorough and understandable explanation of their major implications and limitations. In addition, those providing reimbursement for testing should also require evidence of their safety and validity before reimbursement is provided (see Chapter 7). Of paramount importance is the role of professional organizations, such as the American Society of Human Genetics, American College of Medical Genetics, the American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists, that can establish expert review panels to collect and review the evidence for deciding whether or not specific genetic tests should be designated "standard of care" and under what conditions. These panels should be guided by the principles enumerated in this chapter and by the criteria for specific types of testing outlined in Chapter 2. Objective, professional input is particularly important as physicians are increasingly bombarded by advertisements and other promotional material from laboratories providing tests or from companies selling various products.

The committee recognizes that successful litigation against physicians for failing to provide prenatal tests (Holtzman, 1989; Andrews, 1992) probably accel-



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