CLN - Focus on Laboratory Stewardship

Finding My Niche in Laboratory Stewardship as a Genetic Counselor

Special Section: Laboratory Stewardship Focus

Susan Schowalter, MS, CGC

Working in laboratory stewardship is not where I expected to find myself when I was in graduate school for genetic counseling. In my training program, I was introduced to a wide range of settings where genetic counselors can work. In clinical settings, I saw genetic counselors meeting with patients, coordinating and providing education about genetic testing. While I enjoyed rotating in these clinics, I struggled with the reality that wait times to be seen by the genetics clinic were far too long to accommodate all the patients that could benefit from genetic testing, and genetic teams were stretched thin to care for existing patients too.

I had a glimpse into the ways genetic counselors could contribute to genetic lab utilization in a short lab rotation. That was when I realized genetics teams were not the only departments that were being impacted by the increasing utility of genetic testing. Providers from all specialties were struggling to coordinate genetic testing for a variety of reasons, including the challenge of keeping up with rapidly evolving testing options.

The genetic counselors who work in lab stewardship have a unique skillset tailored to educating clinicians about genetic testing (1). Their support in test selection can result in significant cost savings for laboratories and patients (2). In addition, when they help select and review test orders at the time of preauthorization, research shows that insurance denial rates improve and delays in reimbursement are less frequent (3).

This article offers suggestions for how genetic counselors might assess their interest in working in a laboratory stewardship setting. It also provides a general outline of the role genetic counselors fill within institutions and laboratories for those less familiar with the field.

Comparing Lab and Clinical Genetic Counselor Roles and Skills

How does being a lab stewardship genetic counselor change the way you think about genetic testing?

One of my main responsibilities is helping ordering providers who have a unique situation on their hands. In one recent case, we had to look for a lab that could accept a buccal swab for Fragile X testing. The clinical features of the patient required this alternate specimen type, and the provider needed the test for clinical decision making. However, most labs don’t accept buccal swabs as a specimen type for Fragile X testing because they can be difficult to use given the methodology of the test.

Complex cases like these, often with social and logistical challenges, require support from lab stewardship genetic counselors. Because I help providers work through complex situations, I can identify patterns and note areas where improvements need to be made to increase the utility and accessibility of genetic testing.

What does a day in the life of a lab stewardship genetic counselor look like?

There is a lot of day-to-day variation in this role. I review orders, assess preauthorization requests, and monitor emails, calls, and messages for questions about ordering genetic testing. I also meet with other lab and clinical teams to share new information or to tackle systemic challenges. For example, I might offer important updates about new ways for patients to collect samples for testing or support a department that would like to offer genetic testing for a new indication.

Long-term goals for this position include contributing to development of new lab offerings and participating in research around test stewardship processes. This role is an exciting combination of daily tasks and long-term projects.

Who do genetic counselors work with in lab stewardship and why would counseling skills be useful?

People often ask whether lab genetic counselors use their counseling skills. I personally believe that the counseling skills we learn in our course work are some of the most important skills I use when engaging with providers.

The providers I work with on a regular basis are generally busy, sometimes confused by the process of genetic counseling, and very focused on doing everything they can for their patients. Effective communication requires empathy, unconditional positive regard, and understanding.

I rely on my counseling background to establish good rapport with ordering providers and make sure both patients and providers are having their needs met.

What are things lab stewardship genetic counselors must actively stay up to date on?

All genetic counselors are an important source of knowledge when it comes to ordering genetic tests. In the lab, we take that knowledge a step further by diving into the specific methodology of genetic tests, preferred specimen type, and the ability of the test to detect specific variants.

Staying current on this information requires regularly connecting with the lab team, networking with reference labs, and participating in professional conferences and meetings for continuing education.

How do genetic counselors support patients while working in lab stewardship?

One of the questions I was asked during my interview for this position was about how I would handle not working with patients daily. While much of my training emphasized the ways genetic counselors support patients as their clinical provider, this lab role asks me to think about patients even when I am not their clinical provider.

From the lab perspective, I try to consider the patient’s best interest with every order. I cannot provide the support of a listening ear, but I can advocate for getting each patient the most informative test as soon as possible, while working with insurance to avoid high out-of-pocket costs for testing.

I also advocate for better insurance coverage of genetic testing and support the development of educational materials to aid providers in the best strategies for ordering genetic tests. I don’t see patients in person every day, but I certainly aim to help patients access and benefit from genetic testing every day.

Do genetic counseling training programs and/or clinical genetic counseling experience teach the skills needed to work in lab stewardship?

Yes. Check out the diagram below to see how genetic counseling competencies can fit into the lab setting (4). 

Susan Schowalter, MS, CGC is a genetic counselor in the department of laboratories at Seattle Children’s Hospital in Seattle. +Email: [email protected]


1. Conta, Jessie (2019) “Laboratory Stewardship for Clinical Genetic Testing,” Current Genetic Medicine Reports, 7, 180-186.

2. Kieke, M.C. et al. (2021) “The current landscape of Genetic Test Stewardship: A multi‐center prospective study,” Journal of Genetic Counseling [Preprint]. Available at:

3. Conway, M. E., Kalejta, C. D., Sternen, D. L., & Singh, I. R. (2020). The Importance of Genetics Experts in Optimizing Genetic Test Orders through Prospective and Retrospective Reviews. American Journal of Clinical Pathology, 153(4), 537–547.

4. Accreditation Counsel for Genetic Counseling. (2019) “Practice-Based Competencies for Genetic Counselors,” Available at:

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