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2022 Association of Professors of Human and Medical Genetics A - 2022 - Genetic
2022 Association of Professors of Human and Medical Genetics A - 2022 - Genetic
www.journals.elsevier.com/genetics-in-medicine
EDUCATION REPORT
2022 Association of Professors of Human and Medical
Genetics (APHMG) consensus–based update of the
core competencies for undergraduate medical
education in genetics and genomics
Lauren J. Massingham1,2 , Sabrina Nuñez3, Jonathan A. Bernstein4, David P. Gardner5,
Aditi Shah Parikh6, Erin T. Strovel7, Fabiola Quintero-Rivera8,*; on behalf of the Association
of Professors of Human and Medical Genetics Course Directors Special Interest Group Medical
Education Core Curriculum Workgroup
Article history: Purpose: The field of genetics and genomics continues to expand at an unprecedented pace. As
Received 14 April 2022 scientific knowledge is translated to clinical practice, genomic information is routinely being
Received in revised form used in preventive, diagnostic, and therapeutic decision-making across a variety of clinical
13 July 2022 practice areas. As adoption of genomic medicine further evolves, health professionals will be
Accepted 17 July 2022 required to stay abreast of new genetic discoveries and technologies and implementation of
Available online 31 August 2022 these advances within their scope of practice will be indicated.
Methods: The Association of Professors of Human and Medical Genetics previously developed
Keywords: medical school genetics core competencies, last updated in 2013. The competencies were
Competencies reviewed and updated through a structured approach incorporating a modified Delphi method.
Curriculum Results: The updated Association of Professors of Human and Medical Genetics core compe-
Education tencies are presented. Current revisions include competencies that are concise, specific, and
Medical School assessable. In addition, they incorporate recent advances in clinical practice and promote equity
Medical Genetics and inclusion in clinical care.
Conclusion: The 2022 competencies will serve as a guide for medical school leadership and
educators involved in curriculum development, implementation, and assessment. Use of these
competencies across the undergraduate medical curricula will foster knowledge, skills, and
behaviors required in medical practice across a wide range of specialties.
© 2022 American College of Medical Genetics and Genomics.
Published by Elsevier Inc. All rights reserved.
*
Correspondence and request for materials should be addressed to Fabiola Quintero-Rivera, UCI Medical Center, 101 The City Dr S, Building 54, Suite
1200, Orange, CA 92868. E-mail address: fabiolaq@hs.uci.edu
Affiliations are at the end of the document.
doi: https://doi.org/10.1016/j.gim.2022.07.014
1098-3600/© 2022 American College of Medical Genetics and Genomics. Published by Elsevier Inc. All rights reserved.
2168 L.J. Massingham et al.
elements, but with the advancements in the field of genetics CD-SIG committee drafted a revised competency, to be
and genetic testing, updates are indicated. A delete vote submitted for a second review. The second review was also
indicated that the previous competency was deemed obso- conducted through a Qualtrics survey that was designed
lete and no longer a core component of genetics education. similarly to the first. Itincluded the competency wording of
Groups had the option to provide narrative comments to the first Delphi review, the proposed updated wording for
explain their rationale. the second review, and the rationale for the change. Par-
After the 2019 meeting, the APHMG CD-SIG MECCW ticipants were asked to vote for either the first-review
was formed from volunteer CD-SIG members. All work- wording or the second-review wording and were given the
group members are involved in teaching genetics at their opportunity to make further comments if desired. Agree-
respective medical schools. The 25 members of the CD-SIG ment was reached after the second round of review and the
MECCW were divided into 4 subgroups of 6 to 7 partici- CD-SIG committee incorporated comments to produce an
pants. Groups were assigned portions of the competencies updated set of competencies.
and were provided the recommended changes collected After the modified Delphi method, the updated compe-
during the 2019 workshop. Each group conducted an in- tencies were submitted to the APHMG Council for approval.
depth review of their assigned competencies and the feed- The APHMG Council reviewed the document and submitted
back gathered during the workshop to produce their pro- their comments. Subsequently, an email invitation was sent
posed updates. to the full APHMG membership (225 members), inviting
The CD-SIG Executive Committee (L.J.M., S.N., J.A.B., them to provide feedback. Members received an email,
D.P.G., A.S.P., E.T.S., F.Q.-R.) compiled and reviewed the including a brief description of the project, access to the
CD-SIG MECCW recommendations and developed a draft updated competencies, and instructions for submitting com-
of all updated competencies, which was used to initiate the ments via Qualtrics survey. The survey remained open for 3
modified Delphi rounds. The modified Delphi was used as a weeks. The CD-SIG committee reviewed the collected
method to garner balanced, anonymized opinions in an feedback and drafted an additional competency. This addi-
efficient manner from the members. The Delphi method was tional competency was sent to the APHMG membership for
developed in the 1950s by the Rand Corporation.32 It is a comment via a Qualtrics survey that was open for 1 week.
social science technique used in qualitative research to con- The finalized version was approved by the APHMG Council.
sult experts on a specific subject via serial rounds of ques-
tionnaires. After each round of data collection, a new set of
questions is generated and a new report is created. This Results
process is performed until a consensus is reached.32 This
approach is often used in health care research and education Participants in the consensus process
to identify competencies that professionals should acquire on
the basis of expert judgment.6,33-35 Invitations to participate
A total of 25 professionals involved with medical genetics
in this process were sent to the APHMG CD-SIG MECCW
education and members of APHMG CD-SIG MECCW
for review rounds 1 and 2 via email. This invitation included
participated in the small group sessions to update an
a description of the study and a survey (Qualtrics). Responses
assigned set of competencies. These individuals were then
were collected anonymously. APHMG CD-SIG MECCW
invited to participate in the modified Delphi review process.
participants could suggest edits or additions and propose new
In total, 18 (72%) individuals participated in the first and
competencies. To maximize the response rate, 3 reminders
second rounds. Most of these professionals were female
were sent by email during the 3-week period the survey was
(83%) and the mean age of participants was between 50 and
open. The survey was divided into 2 main sections. The first
60 years. Most participants hold doctoral degrees (MD/DO
section had demographic information, including age, self-
33% or PhD 56%). Typically, the professional’s primary job
reported gender, professional qualifications (highest de-
was medical education with a mean of 14 years teaching
gree), years of work, and teaching experience in genetics.
experience. Individuals whose primary job was clinical ge-
The second section required the participants to provide
netics (genetic counselors and medical geneticists) also
feedback regarding each of the proposed competencies,
participated. Many of the medical genetics educators who
which included both the updated and the previous 2013
participated in this effort have also held other roles in
versions and the rationale for the change. Each participant
medical education such as other discipline (biochemistry)
was asked to “agree,” “agree with minor edits,” or “disagree”
teachers, curriculum committee chairs and members, and
each competency and was given the opportunity to add edits
Dean of curriculum appointments. Full details of MECCW
or comments.
demographic information are provided in Table 1.
The survey responses were reviewed by the CD-SIG
committee. If there were no changes or minor changes
(such as simple wording changes in which the overall Quantitative and qualitative analysis
meaning remained the same), the competency was approved
and was not further reviewed. If significant changes, clari- The genetics competencies were organized according to the 6
fications, or suggestions for changes were proposed, the ACGME core competencies framework. Two of the
L.J. Massingham et al. 2171
Table 1 Demographic information of first modified Delphi review competencies and 16 section goals for a total of 99 elements.
MECCW respondents (n = 18) There was a high acceptance rate across all the new core
Demographics n (%) competency elements (mean 82%, range 61%-100%).
Age range, y Disagreement with the newly suggested competency was low
30-39 2 (11) (mean 2%, range 0%-17%). In 16% of the elements, minor
40-49 7 (39) edits were suggested (range 0%-39%). Table 2 depicts the
50-59 5 (28) mean acceptance rate for the first Delphi review round (the
60-69 4 (22) APHMG CD-SIG MECCW members selected “approve” or
Gender “approve with minor edits”) for each of the categories and the
Male 3 (17) subcategories.
Female 15 (83) After the first Delphi review, the CD-SIG committee
Nonbinary 0 (0) reviewed the edits/suggestions. Most of the competencies
Highest degree
were accepted. The competencies that were reworded
Masters 1 (6)
significantly, to the extent that it had a different meaning or
MD/DO 6 (33)
PhD 12 (56) other significant clarifications, were sent back for a second
Other (including dual degree) 1 (6) Delphi review. Two new competencies and 12 modified
Years involved in teaching genetics, 14 (6-35) competencies were introduced in the second review. The
mean (range) acceptance rate of the second review of edited elements was
Primary job role (17 answers) high (mean 95%, range 83%-100%).
Clinical laboratory 3 (18) After the second modified Delphi review, the CD-SIG
Clinical genetics 5 (29) committee completed another review and made edits
Medical education 8 (47) based on the comments. The APHMG Council reviewed the
Research 1 (6) draft and provided comments. The document was then
MECCW, Medical Education Core Curriculum Workgroup. circulated to the entire APHMG membership for a 3-week
comment period. Membership comments included 35 mi-
categories were subdivided further for ease of reference. The nor comments and 3 major comments from 6 members. An
medical knowledge category comprises 7 subcategories and additional competency was subsequently developed based
the patient care category comprises 5 subcategories (Table 2). on the feedback. The newly drafted competency was sub-
Each category (or each subcategory for medical knowledge mitted to the entire APHMG membership (N = 225) via a
and patient care) includes a section goal and individual third Delphi review. A total of 74 individuals of the
competencies. For the first Delphi review, there were 83 APHMG membership participated in the third round with an
Table 2 Comparison between the number of section goals and competencies in 2013 vs 2022 core competencies
First Round Modified Delphi:
Core Competenciesa 2013 Version 2022 Version Acceptance Rate by Category/Subcategoryb
Medical knowledge 55 43
Genome organization/gene regulation 8 5 96%
Genetic variation 14 8 97%
Population genetics 5 5 99%
Inheritance 8 7 99%
Cytogenetics and molecular genetics 8 7 98%
Biochemical genetics 5 4 99%
Cancer genetics 7 7 97%
Patient care 38 30
Medical genetics/inheritance 9 5 97%
Genetics and genomic testing 12 9 98%
Cancer genetics 4 4 100%
Reproductive and prenatal 7 6 99%
Treatment and management 6 6 99%
Practice-based learning and improvement 3 2 98%
Interpersonal and communication skills 5 8 97%
Professionalism 7 4 96%
Systems-based practice 6 4 100%
Total 114 (16 section goals, 91 (16 section goals,
98 competencies) 75 competencies)
a
ACGME core competencies are in bold. Genetics-specific categories can be found as subheadings under the appropriate ACGME core competency heading.
b
These acceptance rates do not include competencies added in the second or third review rounds.
2172 L.J. Massingham et al.
Box 1. Continued
4. Describe the underlying genetic mechanisms of non-Mendelian inheritance patterns: mitochondrial, somatic and germline
mosaicism, uniparental disomy, parent of origin (epigenetic and genomic imprinting), and repeat expansion disorders.
Explain how these phenomena affect phenotype and recurrence risk.
5. Describe the concepts of mitochondrial inheritance (mitochondrial DNA), heteroplasmy, and the threshold effect in
mitochondrial disorders.
6. Explain the principles of multifactorial inheritance of normal human traits and polygenic disorders.
Cytogenetics and molecular genetics
Section goal: Apply knowledge of cytogenetics and molecular genetics to recognize uses and limitations of genetic testing technologies.
1. Describe the structure and function of chromosomes. Compare and contrast their segregation in mitosis and meiosis.
2. Describe the basic principles of molecular and cytogenetic nomenclature used to report G-banded karyotype, fluorescence
in situ hybridization (FISH), chromosomal microarray analysis (CMA), and sequencing results.
3. Describe the types of structural variation seen in chromosomes (eg, translocations, inversions, deletions, duplications,
copy number variants, etc). Use the presence of a structural variant to explain an individual’s risk for a syndrome, reduced
fertility, or spontaneous abortion.
4. Contrast the uses and limitations of cytogenetic techniques that detect aneuploidy and structural variation including G-
banded karyotype, CMA, and FISH.
5. Contrast the uses and limitations of molecular techniques that detect nucleotide variants, including Sanger sequencing for
single genes, next-generation sequencing for multigene, exome, and genome analyses.
6. Contrast the uses and limitations of molecular techniques that detect nucleotide repeat expansions or alternative
methylation patterns affecting the epigenome. Examples include polymerase chain reaction (PCR) of repetitive sequences,
Southern blot, array-based methylation, methylation-sensitive PCR, and bisulfite sequencing.
Biochemical genetics
Section goal: Apply knowledge of biochemical pathways and genetic principles to explain the etiology, pathogenesis, diagnostic
modalities, and rationale for management of metabolic disorders.
1. Explain how an inborn error of metabolism (error of enzyme or transport pathway) can result in toxic accumulation of
substrates and/or deficiencies of products. Recognize that these are typically recessive conditions where heterozygotes
have sufficient function and do not manifest disease.
2. Describe the genetic etiology, pathophysiology, and common clinical presentation of inborn errors of metabolism
including amino acid disorders, urea cycle defects, lysosomal storage disorders, fatty acid oxidation defects, organic
acidurias, carbohydrate metabolism and storage disorders, and nucleotide metabolism disorders.
3. Discuss the rationale for current approaches to manage metabolic disorders including dietary therapy, enzyme replacement
therapy, substrate reduction therapy, alternative pathway excretion, avoidance of fasting, and gene therapy.
Cancer genetics
Section goal: Apply knowledge of genetics/genomics to explain the etiology, pathogenesis, diagnostic modalities, and rationale for
treatment of cancer.
1. Describe the multistep model of cancer pathogenesis and the role that DNA repair, proto-oncogenic, and tumor suppressor
genes play in this model.
2. Recognize the types of genetic and epigenetic changes that can result in gain-of-function of proto-oncogenes or loss-of-
function of tumor suppressor genes (eg, Knudson two-hit hypothesis).
3. Explain how cancer is multifactorial in nature and describe the role of different risk factors in cancer development,
including germline (high, moderate, and low penetrance) pathogenic variants, familial predisposition, environmental
factors (smoking, alcohol, diet, estrogen exposure, radiation/UV light), and chance (ie, sporadic).
4. Explain why germline pathogenic variants associated with hereditary cancer predisposition syndromes are often
characterized by earlier onset of cancer, increased risk of multiple cancers in a single individual, and patterns of specific
cancers in a family.
5. Describe the application of current somatic/tumor and germline testing (cytogenetic, molecular, and epigenetic
technologies) to clarify the mechanism of tumorigenesis, evolution, diagnosis, and prognosis of cancer.
6. Describe how genetic testing of the tumor and/or germline can lead to individualized and targeted cancer therapies
(precision medicine), and/or long term follow up. Explain the mechanisms of action of these therapies (eg, inhibitors of
PARP, PD-1/PD-L1, IDH1/2, tyrosine kinases).
acceptance rate of 92% (“agree” or “agree with minor section goals for each core category in 2013 and 2022. The
edits”). complete list of the medical knowledge and patient care
Overall, the completed project includes 91 elements (16 updated competencies is included in Box 1 and Box 2,
section goals and 75 competencies). Table 2 shows a respectively. Updated competencies for interpersonal and
comparison between the number of competencies and communications skills, practice-based learning and
2174 L.J. Massingham et al.
Box 2. Continued
3. Discuss risks, benefits, and limitations of invasive prenatal diagnostic techniques including chorionic villi sampling,
amniocentesis, and cordocentesis.
4. Discuss indications for preimplantation genetic testing.
5. Recognize the impact of teratogens (eg, alcohol, drugs, infectious agents, hyperglycemia secondary to maternal diabetes)
on embryonic development, including the effect of dosage, timing, and duration of exposure.
Treatment and management
Section goal: Apply knowledge of the genetic disease etiology to the selection of treatment options and management.
1. Outline the principles for management of genetic diseases and describe their appropriate application based on disease
pathogenesis. Examples include correction, enhancement, or replacement of a defective structural protein or enzyme,
dietary treatment, modulation of RNA expression or function, alteration of DNA sequence to modulate gene expression
using techniques such as genome editing for somatic and germline therapies, organ transplantation, and stem cell therapy.
2. Define gene therapy and explain the current techniques. Outline scientific, ethical, and clinical obstacles to widespread
implementation of gene therapy.
3. Recognize how identification of a specific pathogenic variant in an individual could lead to targeted treatment and/or
management of disease. Some examples include BCR-ABL1 fusion (tyrosine kinase inhibitors such as imatinib),
PML-RARA fusion (all-trans retinoic acid [ATRA]), exon amenable skipping for Duchenne muscular dystrophy (DMD,
exon 51- eteplirsen), cystic fibrosis (CFTR, G551D- ivacaftor).
4. Explain how the presence of specific genetic variants that affect drug transport or metabolism in an individual patient
(pharmacogenetics) may predict physiological response or adverse reactions to medications and influence medical
management. Some examples include CYP2C19 (clopidogrel), CYP2C9 (warfarin), HLA-B*1502 (carbamazepine). Refer
to PharmGKB.org as a good resource for drug specific information.
Recognize the emerging role of polygenic risk scores in complex conditions and describe how modifications of lifestyle and environment
can prevent or mitigate disease in genetically predisposed individuals. Recognize that there may be limited portability of polygenic risk
scores developed using data from individuals of one ancestry to individuals of other ancestries.
improvement, professionalism, and systems-based practice each competency to minimize redundancies and revise the
categories can be found in Box 3. competency placement within each category or subcategory.
Periodic updates of genetics curricula are necessary
because this is a rapidly evolving specialty and use of genetic
Discussion information is becoming more integral in clinical care across
all medical specialties. As our understanding of the genetic
The updated 2022 APHMG core competencies for medical architecture of disease expanding, medical student educational
student education reflect the systematic collection, collation, objectives need to be adapted to match current genetics and
and synthesis of input from the APHMG medical and hu- medicine practice. As the students learn from the updated
man genetics education community through a structured curriculum, they will be well positioned to take advantage of
process incorporating a modified Delphi method. The advances in genetic testing variant classification and inter-
updated competencies are current, assessable, specific, and pretation as a consequence of improving bioinformatic tools
are designed to promote equity and inclusion in health care. and functional studies. Additions to the competencies included
The professionals involved in this project have signifi- expansions of important new concepts, such as the next-
cant experience in medical genetics education and/or clinical generation sequencing competency to include multigene,
practice or laboratory medicine. A substantial percentage exome, and genome analyses in Box 1 (medical knowledge,
also had broader leadership roles at their respective in- cytogenetics and molecular genetics, competency 5). Poly-
stitutions, including undergraduate medical education asso- genic risk scores are a new concept since the last update that is
ciate Dean(s), chairs, and members of the curriculum now included in Box 2 (patient care, treatment and manage-
committee. This is beneficial because it provides a wider ment, competency 5). These competencies will continue to
breadth of experience in multiple subsections of genetics, benefit from periodic updates as new advances, such as RNA-
and it allows broad input and more accurate inclusion of based studies and population-based genetic screening, enter
topics and phrasing. clinical practice. Competencies focused on less used or older
Revisions were made with 4 main objectives. These methods, such as linkage analysis, were eliminated to give the
include thoughtful inclusion of new concepts and retirement student the opportunity to focus on the more current and
of outdated ones; use of precise language to capture the relevant diagnostic techniques. Some topics were revised for
highest level of competence expected of learners; addition clarification, such as expansion of the biochemical genetics
of new competencies or revision of existing ones to embrace competencies to further highlight the importance of under-
inclusivity, diversity, and strive for equity; and scrutiny of standing of the biochemical pathway to explain the disorder’s
2176 L.J. Massingham et al.
Box 3. Interpersonal and communication skills, practice-based learning and improvement, professionalism, and systems-based
practice
pathogenesis and the rationale for management (Box 1, med- examples of how pharmacogenetic risk variants may influence
ical knowledge, biochemical genetics, competencies 2 and 3). management in Box 2 (patient care, treatment and manage-
In some cases, examples were added to objectives with the goal ment, competency 4). Because more appropriate terminology
of explaining or presenting the objective more clearly, for has evolved, updates were made to reflect more current ter-
instance, examples included in Box 2 (patient care, genetics minology, for example changing errors or mutations to vari-
and genomic testing, competency 1) screening vs diagnostic ants (various competencies).
tests, examples of some targeted therapies in Box 2 (patient There was an emphasis on enabling the independent
care, treatment and management, competency 3), and assessment of learning related to each objective. One way to
L.J. Massingham et al. 2177
accomplish this was optimization of incorporation of American descent and indigenous people represent less
Bloom’s taxonomy framework to clarify the action item for than 4% of participants in genome studies.36 In
medical students for each objective. Bloom’s taxonomy contrast, participants of European ancestry are greatly
follows a hierarchy, which supports the idea that learning is overrepresented (78% in 1 study).37 The GWAS Di-
built on prior knowledge and previously learned skills. It is versity Monitor is a new tool to monitor trends and
typically depicted as a pyramid with the lower-order tasks identify gaps by disease, ancestry, and geography.37
originating at the base (or foundation) and progressing to This inequity has resulted in questions regarding the
more complicated tasks moving up the pyramid (higher- applicability of these results to wider populations.
order tasks). The 2013 competencies were written to use • Disrupting attempts to interrupt the root cause by
Bloom’s action verbs, however in the current version, we disturbing or altering the conditions that contribute to
refined some of the competencies to be higher-order tasks. the inequity. An example of disrupting can be found in
An example of this includes using “compare and contrast,” a Box 2 (patient care, medical genetics/inheritance,
higher-order task, rather than “describe” the organization of competency 3). In this we suggest use of the most
nuclear and mitochondrial genome (Box 1, medical current and inclusive documentation techniques of a
knowledge, genome organization, competency 1). Another pedigree. Traditional pedigree documentation may not
example is updating “recognize” to “discriminate between” accurately convey the identity of transgender and
different tissue testing strategies (Box 2, patient care, ge- gender nonbinary individuals. Currently, there is no
netics and genomic testing, competency 2). The use of consensus in accepted pedigree symbols to represent
higher-order tasks in these updates aim to reduce focus on these individuals, which can perpetuate discrimination
memorization and instead help foster appreciation for un- and contribute to barriers in care.38 The National So-
derstanding and application of these concepts to better ciety of Genetic Counselors is currently in the process
prepare the students for eventual independent practice. of publishing an update of the 2008 standardized hu-
Significant effort was made to update the competencies man pedigree nomenclature.39 An important aspect of
to embrace diversity, inclusivity, and strive for equity. A disrupting the root cause of inequity is using updated
tool to describe health equity as ranging from less produc- affirming pedigree nomenclature to embrace
tive to more productive exists.30 Examples of less produc- inclusivity.
tive actions include discrediting, distracting, or disregarding
evidence about what causes health inequities. Progressively An effort was made to group similar concepts together
more productive health actions include acknowledging, and minimize redundancy to aid in interpretation of the
illuminating, and disrupting the systems and structures that goals and ease of reference. An example of this is in the 3
unfairly distribute power, resources, and wealth in the so- competencies in cytogenetics and molecular genetics in
ciety. With the use of this tool, we have tried to acknowl- which each competency was worded used the same
edge root causes, illuminate how the root causes lead to framework (“compare and contrast the uses and limita-
inequities, and disrupt the root causes of inequities. tions”) of 3 different categories of techniques (cytoge-
netic, sequencing, and alternative molecular techniques).
• Acknowledging recognizes an inequitable action. An Some of the competencies were initially more narrowly
example of acknowledging a root cause of inequity can be focused and under more specific headings (eg, cancer
found in Box 1 (medical knowledge, population genetics, genetics), however, the concept was also true more
competency 1 and systems-based practice, competency broadly. These competency’s scopes were expanded and
3). In these competencies, we acknowledge that there are moved to a more generalized competency subgroup, for
differences between genetic ancestry and the social con- example Box 2 (patient care, treatment and management,
structs of race and ethnicity, and by not recognizing these competency 3). Each objective was carefully considered
differences, there is a risk of making incorrect inferences to ensure that it was included in the most appropriate
about health in individuals and groups. Acknowledging section. For example, the nomenclature and uses of lim-
these differences is a first step toward a more promising itations of different genetic testing techniques are included
way to drive change to embrace diversity, inclusivity, and in Box 1 (medical knowledge, cytogenetics and molecular
strive for equity. genetics). The interpretation of these tests was moved to
• Illuminating seeks to explain the understanding of how Box 2 (patient care, genetic and genomic testing) because
the root cause led to the inequity. An example of illu- this relates more to the care of a patient than basic
minating can be found in Box 1 (medical knowledge, knowledge. The variants of uncertain significance com-
population genetics, competency 4). In this compe- petency was moved to Box 3 (interpersonal and commu-
tency, we highlight that a root cause of inequity in nication skills) from its previous location (patient care,
research studies and databases includes inequitable genetic testing) reflecting the importance of understanding
data collection because there has been limited diversity underlying concepts and the ability to communicate with
in populations used for these analyses. This is shown patients and other providers about the different types of
by the fact that together, people of African and Latin genetic testing results.
2178 L.J. Massingham et al.
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