title: Communicating microarray results of uncertain clinical significance in consultation summary letters and implications for practice.
abstract: Letter-writing is an integral practice for genetic health professionals. In Victoria, Australia, patients with a chromosomal variant of uncertain clinical significance (VUS) referred to a clinical geneticist (CG) for evaluation receive consultation summary letters. While communication of uncertainty has been explored in research to some extent, little has focused on how uncertainty is communicated within consultation letters. We aimed to develop a multi-layered understanding of the ways in which CGs communicate diagnostic uncertainty in consultation summary letters. We used theme-oriented discourse analysis of 49 consultation summary letters and thematic analysis of a focus group involving eight CGs. Results showed that CGs have become more confident in their description of VUS as 'contributing factors' to patients' clinical features, but remain hesitant to assign definitive causality. CGs displayed strong epistemic stance when discussing future technological improvements to provide hope and minimise potentially disappointing outcomes for patients and families. CGs reported feeling overwhelmed by their workload associated with increasing numbers of patients with VUS, and this has led to a reduction in the number of review appointments offered over time. This study provides a rich description of the content and process of summary letters discussing VUS. Our findings have implications for letter-writing and workforce management. Furthermore, these findings may be of relevance to VUS identified by genomic sequencing in clinical practice.
authors.affiliation: Murdoch Childrens Research Institute, Melbourne, VIC, Australia.|Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.|School of Languages & Linguistics, The University of Melbourne, Melbourne, VIC, Australia.
authors.forename: Jean Lillian
authors.identifier: http://orcid.org/0000-0003-0891-7035
authors.initials: JL
authors.lastname: Paul
authors.affiliation: Murdoch Childrens Research Institute, Melbourne, VIC, Australia.|Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.|Genetic Health Service NZ (Northern Hub), Auckland, New Zealand.
authors.forename: Rachel
authors.initials: R
authors.lastname: Pope-Couston
authors.affiliation: Murdoch Childrens Research Institute, Melbourne, VIC, Australia.|Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.|Victorian Clinical Genetic Services, Melbourne, VIC, Australia.
authors.forename: Samantha
authors.initials: S
authors.lastname: Wake
authors.affiliation: Murdoch Childrens Research Institute, Melbourne, VIC, Australia.|Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.|Victorian Clinical Genetic Services, Melbourne, VIC, Australia.
authors.forename: Trent
authors.initials: T
authors.lastname: Burgess
authors.affiliation: Murdoch Childrens Research Institute, Melbourne, VIC, Australia. tiong.tan@vcgs.org.au.|Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia. tiong.tan@vcgs.org.au.|Victorian Clinical Genetic Services, Melbourne, VIC, Australia. tiong.tan@vcgs.org.au.
authors.forename: Tiong Yang
authors.initials: TY
authors.lastname: Tan
mesh_terms: D001315:Australia; D002869:Chromosome Aberrations; D003657:Decision Making; D005817:Genetic Counseling / Q000941:ethics* / Q000523:psychology; D030342:Genetic Diseases, Inborn / Q000175:diagnosis* / Q000235:genetics / Q000523:psychology; D015894:Genome, Human; D006282:Health Personnel / Q000941:ethics / Q000523:psychology; D006801:Humans; D017422:Sequence Analysis, DNA; D035501:Uncertainty