Educating military primary health-care providers in genomic medicine: lessons learned from the MilSeq Project



With few trained genetics professionals, the Military Health System is ill-equipped to manage the rapid expansion of genomic medicine. The MilSeq Project introduces an alternative service delivery model (ASDM) in which primary health-care providers (HCPs) provide post-test counseling (PTC) to healthy Airmen who have undergone exome sequencing. We describe HCP performance after a prerequisite educational intervention (EI).


After a brief EI and pre-/posteducation surveys, HCPs were eligible to provide PTC with a genetic counselor available for consult. PTC was recorded, transcribed, and reviewed. Opportunities for improvement were organized into four error adjustment categories: (1) knowledge limitation, (2) minor, (3) moderate, and (4) critical. Thematic analysis was also performed.


Pre-/posteducation survey responses revealed statistically significant improvements in all domains. Minor error adjustments were most represented (n = 93), followed by knowledge limitation (n = 39) and moderate (n = 19). No critical errors were identified, and 17 transcripts required no adjustment. Thematic analysis revealed four themes that would benefit from more focused education: (1) family-centered care, (2) conveying risk, (3) disease knowledge, and (4) assay knowledge.


HCPs demonstrated competence in basic PTC after a brief EI. This ASDM may be a viable interim response to the shortage of genetics professionals in some systems.

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Fig. 1


  1. 1.

    American College of Medical Genetics and Genomics. ACMG applauds increase in funding for newborn screening and medical genetics workforce study in FY 2019 LHHS appropriations. Accessed 6 July 2019.

  2. 2.

    Hoskovec JM, Bennett RL, Carey ME, et al. Projecting the supply and demand for certified genetic counselors: a workforce study. J Genet Couns. 2018;27:16–20.

    Article  Google Scholar 

  3. 3.

    De Castro MJ, Turner CE. Military genomics: a perspective on the successes and challenges of genomic medicine in the armed services. Mol Genet Genomic Med. 2017;5:617–620.

    Article  Google Scholar 

  4. 4.

    Hellwig LD, Turner C, Manolio TA, et al. Return of secondary findings in genomic sequencing: military implications. Mol Genet Genomic Med. 2019;7:e00483.

    Article  Google Scholar 

  5. 5.

    Smith DJ, Bono RC, Slinger BJ. Transforming the Military Health System. JAMA. 2017;318:2427–2428.

    Article  Google Scholar 

  6. 6.

    Vassy JL, Lautenbach DM, McLaughlin HM, et al. The MedSeq Project: a randomized trial of integrating whole genome sequencing into clinical medicine. Trials. 2014;15:85.

    Article  Google Scholar 

  7. 7.

    Vassy JL, McLaughlin HL, MacRae CA, et al. A one-page summary report of genome sequencing for the healthy adult. Public Health Genomics. 2015;18:123–129.

    Article  Google Scholar 

  8. 8.

    Vassy JL, Christensen KD, Schonman EF, et al. The impact of whole genome sequencing on the primary care and outcomes of health adult patients: a pilot randomized trial. Ann Int Med. 2017;167:159–169.

    Article  Google Scholar 

  9. 9.

    Christensen KD, Vassy JL, Jamal L, et al. Are physicians prepared for whole genome sequencing? A qualitative analysis. Clin Genet. 2016;89:228–234.

    CAS  Article  Google Scholar 

  10. 10.

    Brothers KB, East KM, Kelley WV, et al. Eliciting preferences on secondary findings: the Preferences Instrument for Genomic Secondary Results. Genet Med. 2017;19:337–344.

    Article  Google Scholar 

  11. 11.

    Jorde L, Varey J, Bamshad M, White R. Medical genetics. St Louis: Mosby; 2006.

    Google Scholar 

  12. 12.

    Baron RJ. What’s keeping us so busy in primary care? A snapshot from one practice. N Engl J Med. 2010;362:1632–1663.

    CAS  Article  Google Scholar 

  13. 13.

    Gray SW, Hicks-courant K, Cronin A, Rollins BJ, Weeks JC. Physicians’ attitudes about multiplex tumor genomic testing. J Clin Oncol. 2014;32:1317–1323.

    Article  Google Scholar 

  14. 14.

    Kaphingst KA, Kreuter MW, Casey C, et al. Health Literacy INDEX: development, reliability, and validity of a new tool for evaluating the health literacy demands of health information materials. J Health Commun. 2012;17(Suppl 3):203–221.

    Article  Google Scholar 

  15. 15.

    Ostergren JE, Gornick MC, Carere DA, et al. How well do customers of direct-to-consumer personal genomic testing services comprehend genetic test results? Findings from the Impact of Personal Genomics Study. Public Health Genomics. 2015;18:216–224.

    Article  Google Scholar 

  16. 16.

    Bowling BV, Acra EE, Wang L, et al. Development and evaluation of a genetics literacy assessment instrument for undergraduates. Genetics. 2008;178:15–22.

    Article  Google Scholar 

  17. 17.

    Kaphingst KA, Facio FM, Cheng MR, et al. Effects of informed consent for individual genome sequencing on relevant knowledge. Clin Genet. 2012;82:408–415.

    CAS  Article  Google Scholar 

  18. 18.

    R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2013.

  19. 19.

    McLaughlin HM, Ceyhan-Birsoy O, Christensen KD, et al. A systematic approach to the reporting of medically relevant findings from whole genome sequencing. BMC Med Genet. 2014;15:134–146.

    Article  Google Scholar 

  20. 20.

    US Department of Health and Human Services. Protection of human subjects. 45 CFR §46.

  21. 21.

    NEJM Catalyst. What is patient-centered care? Accessed 29 Nov 2019.

  22. 22.

    American College of Cardiology. Pediatric familial hypercholesterolemia: Expert analysis. Accessed 29 Nov 2019.

  23. 23.

    Tercanli S, Miny P, Siebert MS, Hösli I, Surbek DV, Holzgreve W. Fanconi anemia associated with increased nuchal translucency detected by first-trimester ultrasound. Ultrasound Obstet Gynecol. 2001;17:160–162.

    CAS  Article  Google Scholar 

  24. 24.

    Tandy-Connor S, Guiltinan J, Krempely K, et al. False-positive results released by direct-to-consumer genetic tests highlight the importance of clinical confirmation testing for appropriate patient care. Genet Med. 2018;20:1515–1521.

    Article  Google Scholar 

  25. 25.

    Lent RC. Overcoming textbook fatigue: 21st century tools to revitalize teaching and learning. Alexandria, VA: ASCD; 2012.

    Google Scholar 

  26. 26.

    Miller CE, Krautscheid P, Baldwin EE, et al. Genetic counselor review of genetic test orders in a reference laboratory reduces unnecessary testing. Am J Med Genet A. 2014;164A:1094–1101.

    Article  Google Scholar 

  27. 27.

    Kotzer KE, Riley JD, Conta JH, Anderson CM, Schahl KA, Goodenberger ML. Genetic testing utilization and the role of the laboratory genetic counselor. Clin Chim Acta. 2014;427:193–195.

    CAS  Article  Google Scholar 

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This material is based on research sponsored by Air Force Medical Support Agency, Research and Acquisition Directorate AFMSA/SG5 under cooperative agreement number FA8650-17-2-6704. The US Government is authorized to reproduce and distribute reprints for Governmental purposes notwithstanding any copyright notation thereon. The views and conclusions contained herein are those of the authors and should not be interpreted as necessarily representing the official policies or endorsements, either expressed or implied, of Air Force Medical Support Agency, Research and Acquisition Directorate AFMSA/SG5 or the US Government.

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Correspondence to Megan D. Maxwell MS, LCGC or Megan D. Maxwell MS, LCGC.

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R.C.G. receives advisor compensation from Alzheimer’s Institute of America, Inc., Applied Therapeutics, Inc., Humanity, and Verily Life Sciences, LLC, and is cofounder of Genome Medical, Inc. The other authors declare no conflicts of interest.

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Maxwell, M.D., Hsu, R., Islam, R. et al. Educating military primary health-care providers in genomic medicine: lessons learned from the MilSeq Project. Genet Med (2020).

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  • genetic counseling
  • genetic services
  • education
  • intervention
  • exome sequencing