To refer or not to refer? Exploring the cognitive process of genetic counselors' decision to refer a patient to another professional.

Genetic Counselors (GCs) hold the dual responsibility to engage in patient-centered psychosocial counseling and to recognize when a patient's needs require referral to another healthcare professional (HCP). While previous work has shown that GCs use a variety of patient factors to determine when they could benefit from additional supportive services, we sought to better understand how GCs determine whether to refer a patient to another HCP or engage in more complex psychosocial counseling. Utilizing a multimethods approach, we used two sets of surveys to learn about our participants but ultimately prioritized the qualitative data from in-depth semistructured interviews with 15 participants (N = 15). Initial data collection and analysis relied on constructivist interpretive frameworks of grounded theory, which supported learning directly from participants while maintaining our ability to delve into issues raised by the participants. An iterative process of coding, reviewing, memoing, and testing resulted in the development of several conceptual models of possible theories. Through continued review of the data and guided by an interpretivism paradigm, we elected to honor the breadth of information shared by participants, abandoning our initial goal of defining a single theory to instead define three core conceptual categories related to GCs' consideration of providing psychosocial counseling or referring: (1) For GCs, it's personal! GC beliefs in themselves, their personal identities, and their conceptualization of the role of a "GC" influence their engagement in psychosocial assessment and support; (2) Training matters, but experience is key; and (3) Referrals occur when GCs are aware of and trust that another HCP/resource will be a good fit for a patient's need and that a patient can actually access it. These findings suggest that GC confidence in managing patient care evolves with experience and highlight the value of ongoing skill development for all practitioners.