There Ought To Be A Word For That

Sometimes we don’t have the professional vocabulary to describe certain common counseling situations or patient experiences. So, as a service to my genetic counseling colleagues, I offer the below terms, acronyms, groaners, and neologisms to fill in some of the gaps in our lexicon. A few have nothing to do with genetics but I thought I’d claim author’s prerogative and include them anyway.

Roomba Session – A genetic counseling session with a patient whose thoughts, questions, and concerns are expressed in a stream of consciousness, non-linear fashion, jumping in a seemingly random manner from topic to topic, like a robot vacuum cleaner (hoover, for UK readers) pinballing around your living room floor. The apparent randomness is usually a function of the genetic counselor’s viewpoint; to patients, their comments and questions make perfectly logical sense (To raise a tangential paradox, if someone describes a vacuum cleaner by saying “It really sucks!” does that mean the device is a really good vacuum or a really bad vacuum?).

Portrait Session or Rembrandt Session – A genetic counseling session with impassive patients who never change their facial expression, i.e., like they are sitting for a portrait. They speak occasionally and then only in short non-emotional statements or “Mmmhmms,” despite your best efforts to engage them in meaningful dialogue with open-ended questions and probing statements. You never quite know where you stand with them or what they got out of your time together.

Gene Selfie – When healthy consumers undergo exome or genome sequencing without a clinical indication, just to see what their genes look like, and then share it with everyone on their social media accounts.

MTPNTUS – Acronym for Maybe This, Possibly Not That, Uncertain Significance. What many consumers learn about their hereditary disease risks from a gene selfie.

SOTSOT – Acronym for Some of This, Some Of That. What many consumers learn about their mixed ancestry after undergoing DNA-based ancestry testing, e.g., some German, some English, some French, a little bit of Neanderthal.

“I just got my Hominin Ancestry DNA results and I found out that I am 25% Denisovan! My father would be so upset if he knew – he thought they were an evolutionary dead end. And in a hundred thousand years my descendants will be 25% Irish, 30% Germanic, 25% Slavic, 18% Spanish, and 2% Ashkenazi Jewish. And Genghis Khan will have 5% of my DNA.”

Man-cestry Testing – Ancestry testing based on Y chromosome markers.

Manicure – Ridding a man of obnoxious common male habits and behaviors like manspreading and mansplaining (for the women reading this, let me explain what these terms mean …..).

Circumvent – The parental decision to avoid having their son circumcised. Among Jews, this can be much to the chagrin of mohels and mohalots.

There are two experiences that occur during the simple act of walking that are common occurrences in all of our lives and yet there are no words for them in the English language. The first of these is when two people, often strangers, are walking towards each other from opposite directions on the same side of the street or hallway. When they get close, they both maneuver in mirror-image to each other, simultaneously sidling in the same mirror-image direction several times to avoid walking into each other. It is often followed by the question “Shall we dance?” The motor vehicle equivalent occurs when two cars arrive simultaneously at right angles to each other at a 4-way Stop. Both cars inch out at the same time, then continue to stop and start synchronously, until one driver finally gives up and signals with either a hand wave or a flashing of headlights for the other driver to go first.

The other unnamed common experience is the uncanny ability of slow-walking people to obliviously occupy all the available walking space such that it is impossible to walk around them without bumping into them or seriously  breaching their personal space. I have found it to be common in hospital hallways, where I often encounter several families members walking 3 or 4 abreast, like an O-line trying to prevent the defense from tackling the quarterback. The frequency of such encounters in hallways and streets has dramatically increased over the last decade because nearly everybody is looking at or talking into their smartphones while walking. Nothing against walking slowly; we all walk at our own comfortable paces. Just do so with a sense of awareness of the world around you.

Do any of the Good Readers of the DNA Exchange have suggestions for terms to describe these latter two phenomena? How about terms for other common but unnamed genetic counseling experiences?


Yet again, many thanks to Emily Singh for help with graphics.

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A Diagnosis Is Not The End Of The Odyssey

by Robert Resta, Jennifer A. Sullivan, Allyn McConkie-Rosell

Allyn McConkie-Rosell, Ph.D., CGC, is a Professor in the Division of Medical Genetics at Duke University Medical Center. Jennifer A. Sullivan, MS, CGC is a
Senior Genetic Counselor in the Division of Medical Genetics at Duke University Medical Center. Robert Resta, MS, CGC, is a genetic counselor at Swedish Medical Center in Seattle and a frequent contributor to The DNA Exchange.

The Diagnostic Odyssey – that meandering, lengthy, and frustrating quest for a diagnosis. Genetic counselors, medical geneticists, and patients with rare disorders and their families are achingly familiar with it. The allusion to Homer’s Odyssey is apt. Odysseus’s decade of wanderings are replete with perils, disappointment, love, wonder, whimsical gods, adventure, and frustration. Surely some specialist somewhere in the world can tell me what condition my child has been born with, and I will brave the wine dark seas for as long as I must to find that expert! Genetic testing technologies like whole exome/genome sequencing have shortened the quest for many patients, though perhaps not as often as one would have hoped.

The label Diagnostic Odyssey suggests that the diagnosis is the end of the odyssey. And therein lies the problem. Many families and patients discover that a diagnosis does not necessarily allow them to settle down happily with Penelope in the kingdom of Ithaca. A successful diagnostic workup may be the end of the odyssey for clinicians, but for patients and families the diagnostic quest is just one phase in the life cycle of genetic disorders.

A diagnosis may answer some questions such as cause and recurrence risk, but it can also create a whole new set of issues. For patients diagnosed with ultra-rare conditions, families may be faced with frustration from a lack of available knowledge about treatment or prognosis. Even if medical interventions are possible, finding and accessing those resources, and getting health insurers to pay for them, can be a major undertaking. Or a condition’s rarity may make it impossible to form an effective patient/family community to provide advocacy and support. The diagnostic odyssey may result in some patients feeling like diagnostic oddities.

If a newly diagnosed syndrome turns out to be untreatable or life-shortening, parents may lose all hope and descend into existential despair. A non-diagnosis at least holds the glimmer of a chance for a treatment or cure out there somewhere. Patients who have a diagnosis changed from a previous incorrect diagnosis may lose the sense of identity and support supplied by the disease community that they had been involved with for years.

The label Diagnostic Odyssey focuses on one medical aspect of a condition. Clinicians can take much-deserved professional satisfaction in having finally solved a long-standing mystery. But for many families, living with a genetic condition is not a temporally demarcated event and, above all, not only a medical experience. Patients will also still need to implement strategies and solutions to the social, educational, lifestyle, and psychological ramifications of the disorder. It is an ongoing journey, one that continues to unfold as patients age and develop new symptoms, family structures evolve over time, medical treatment advances, and sociocultural changes re-shape attitudes toward inclusivity and the availability of resources. A genetic condition, named or not, will continually present new challenges throughout the entire life of a patient.

We do not mean to imply that a diagnosis is unimportant. We recognize the emotional and potential medical value of finally “putting a name on it.” But the name just points the ship in a new direction to unexplored regions with different threats, problems, and rewards.

Perhaps the Diagnostic Odyssey label needs to be retired or renamed to more accurately reflect its role in the process of living with, and adapting to, genetic conditions. So we turn to the Good Readers of The DNA Exchange to offer their suggestions – what do you think?


Genetic Counselor Talent Show Friday, November 16th

Are you attending the 2018 Annual Education Conference of the National Society of Genetic Counselors in Atlanta next week? Worried that days of  PowerPoint presentations and polite applause will make you forget what fun is? Want to have a blast one evening and see your genetic counseling colleagues in a very different light? Then attend the Genetic Support Foundation’s GC’s Got Talent  2018 genetic counselor talent show on Friday evening November 16th. Cancel all your other evening plans for Friday, November 16th. Trust me – there will be nothing even close for entertainment. With Yours Truly, Bob Resta, as Master of Ceremonies, how could anything beat it? Can you dance, sing, or play an instrument? Are you a Slam Poet? Then show off your talents to your colleagues! Or, if like me, you have Zero Talent, then join me as part of the Story Telling Crew. I have a goofy and weird story to tell. But we all also have poignant, tragic, comic – or all of the above – tales to tell. If I can do it, then you can do it. If you wish to impress your colleagues with your talent, send an email to info@geneticsupport.org to sign up. Show up et regarder les bon temps rouler.

For more information, visit: https://geneticsupportfoundation.org/gc2018

 

 

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Black-ish, Jewish-ish, and Scientific-ish: Some Problems Created By Racial Admixture

Race. I don’t think there is a more controversial and polarizing issue today. Skin color-based racial categories are considered scientifically invalid, yet race is included in government-collected population data as well as in scientific research.  But racial categories – real or imagined –  always create social problems. Those problems can become magnified – and the absurdity of classifications highlighted – when the discussion turns to racial admixture. Population genetics  tell us that no one is purely of any one race. Since hominids first wandered out of Africa, lust and wanderlust have combined to produce a species that is basically a bunch of “polyhybrid heterogeneous bastards.” The recent discovery of a fossil from a half Neanderthal/half Denisovan female in a Siberian cave proves that this genetic messiness has been going on for a long time.

Thomas Jefferson, for one, fretted about racial admixture. And not in an abstract or philosophical way. He was very much concerned with the practical question of whether the children he fathered with Sally Hemmings, one of the more than 600 slaves he owned throughout his life, would be considered black, and thus slaves, or white, and therefore free people. Hemmings was 16 and Jefferson was 46 when they conceived the first of seven children she was to bear by him. According to Virginia law at the time, a person who was 7/8 white was considered, well, white.

Hemmings had white ancestry; she was the half-sister of Jefferson’s (white) wife. As recounted in These Truths, Jill Lepore’s recently published delightful history of the United States, Jefferson engaged in some mendelian-sounding calculations about his children’s racial status (comments in brackets added by me):

“Let the third crossing be of q [Hemmings] and C [Jefferson], their offspring will be q/2 + C/2 = A/8 [a “pure” white] + B/4 [ a second “pure” white] + C/2, call this e (eighth), who having less than 1/4 of a, or pure negro blood, to wit 1/8 only, is no longer a mulatto, so that a third cross clears the blood.”

In other words, Jefferson calculated that his 4 surviving children with the partially black Hemmings would be considered white under Virginia law and thus would not technically be slaves, even if they were de facto slaves. In practice, he freed one of the four during his lifetime, a second he “let” escape, and the other two were freed in his will. Incidentally, Jefferson was not alone among presidents in owning slaves –  18 US presidents owned slaves, some while they were in the White House. A seemingly insignificant bit of trivia underscores the inhumanity with which even the “good guys” viewed slaves – 9 of the teeth in George Washington’s dentures likely came from the mouths of his slaves (which, in a manner of speaking, would make Washington a racial hybrid – teeth of a black man, jaws of a white man). The slaves may have been paid for this but that hardly justifies the act. Ethically, it is no different than when desperately poor people sell their organs for money to feed their families.

George Washington’s dentures

 

Medical geneticists have had to struggle with problems stemming from racial admixture and trying to define race. For example, one of the most common reasons for referral to American genetics clinics in the 1940s and 1950s was to determine the future racial appearance of children put up for adoption, often the product of trans-racial matings. Adoption agencies usually had a policy of trying to match the race of the child with the race of the adoptive parents. Some Southern states even passed legislation that banned trans-racial adoptions. Geneticists were often tasked with predicting the future physical appearance of children, based on their skin color or the presence or absence of certain traits thought to be more or less common in different races. By assigning a child to a specific race, geneticists also assigned that child to a social and economic life dictated by that race. No doubt many of these geneticists – like today’s genetic counselors – would never describe themselves as racists. Nonetheless, the clinical services they provided helped reinforce the pervasive racism of American society.

Felix von Luschan’s skin color charts, a common way of assessing skin color up to the 1950s

Current day geneticists continue to struggle with the problem of the biological validity of race and racial admixture. Mis-assigned or mixed ancestry, either by researchers or participants themselves, can lead to false conclusions about the pathogenicity of gene variants or generate false positive or false negative associations in SNP studies. We have also begun to see genetic ancestry tests, what some see as a modern pseudo-scientific racism, enter into the clinic. Genetic counselors typically query clients about their ancestry when constructing a pedigree. In my experience – which I am pretty sure is not unique – many patients respond that they have taken a direct-to-consumer ancestry test and then recite a scientific sounding breakdown of the different percentages of their genetic ancestry, e.g. 23% Welsh, 21% Irish, 10% French. Where this can become a problem is when it is used to guide genetic testing decisions. How much Ashkenazi Jewish ancestry warrants a specific genetic test or set of tests considered appropriate to that population (expanded carrier screening avoids that particular problem in some settings, but it has its own set of other issues)?

A recent referral to our clinic highlighted this dilemma. We were asked to see a patient for BRCA testing because she was reportedly Ashkenazi Jewish. As it turned out, an ancestry test had indicated that she was “1% Ashkenazi Jewish.” We have had several other referrals where this has come up. To keep our referring providers happy, we have very arbitrarily set a policy of a 10% rule – for patients who have had an ancestry, results should indicate at least 10% Ashkenazi Jewish ancestry before we consider them “Jewish.” Sort of our equivalent of Virginia’s 7/8 rule. Meshugunnah, I know. Never mind who your mother is.

Given the history of extreme persecution of Jews and other groups like the Rohingya in Myanmar or the Japanese Americans who were put into internment camps in the US during WWII, along with the rise of anti-immigrant sentiments and political intolerance, genetic testing that allegedly “proves” ancestry should be not be publicly available information. Somewhere, in some part of the world, at some future time, being “10% Jewish” or whatever ancestry could be a very harmful data point. Admixture can determine your life’s trajectory. Or enslave. Or kill.

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Expanded Carrier Sequencing: Would You Rather?

On summer road trips, my kids loves to play a game Would you rather?  For instance, would you rather eat a bowl of spaghetti noodles without sauce or a bowl of spaghetti sauce without noodles?  Would you rather have a unicorn horn or a squirrel tail?

In the spirit of summer road trips and the holiday weekend, I’d like to play a game of Would you rather? that only genetic counselors can appreciate.

This is a trade off we have to make with carrier screening.

Carrier screening programs intended for the general population as supported by the practice guidelines put forth by our professional societies tend to favor Option B. The reason being that more harm than good may result when providing information that is uncertain or ambiguous, especially in the context of reproductive decision making.

These days however, Option A is becoming increasingly common. Although at odds with society recommendations, which generally recommend a more targeted approach, the use of expanded carrier screening (ECS) panels that utilize sequencing are being more commonly accepted into practice with labs often claiming that more prenatal testing is better.

But is more really better?  

In theory, it makes sense to offer screening that provides as much information as possible. However, we know that what makes sense in theory does not necessarily lead to good medical practice. And there are warning tales of screening programs that were initiated with good intention but led to unfortunate, unintended consequences.

Consider the early days of carrier screening for cystic fibrosis (CF) as an example. After years of careful study and deliberation, in 2002 experts from the American College of Medical Genetics together with American College of Obstetricians and Gynecologists published recommendations for use a panel of 25 mutations in the CFTR gene. However this initial panel was revised in 2004  when it became evident that one of the originally defined mutations,  p.I148T (c.443TC) was in fact a benign polymorphism.

On a panel of just 25 mutations, in a well known gene, for a well defined condition, after years of critical expert evaluation, a mutation that  was initially included on a panel as causative of disease was eventually determined not not be, only after being put into practice. It is likely that Option A was a reality for some families in the early days of CF carrier screening.

Now consider that with expanded carrier screening panels that increasingly perform whole exon sequencing, often of >100 genes, one can imagine that many of the mutations being called with carrier screening are not disease causing. I believe that Option A will become much more frequent with greater utilization of carrier screening panels that use sequencing.  

And in addition to the possibility of incorrect variant classification, there is also a concern for increased false positive results as carrier screening expands. A reality with any screening test is that the rarer the condition, the more likely a positive result is a false positive result.

 

When questions arise regarding interpretation of variants on ECS panels, the labs often respond that they follow the ACMG Standards and Guidelines for Interpretation of Sequence Variants.

But here’s the thing, these guidelines were not developed for carrier screening in a healthy population. To quote the ACMG document: “The following approach to evaluating evidence for a variant is intended for interpretation of variants observed in patients with suspected inherited (primarily Mendelian) disorders in a clinical diagnostic laboratory setting.”

 

The authors of the ACMG Standards also warn: “Caution must be exercised when using these guidelines to evaluate variants in healthy or asymptomatic individuals or to interpret incidental findings unrelated to the primary indication for testing. In these cases the likelihood of any identified variant being pathogenic may be far less than when performing disease-targeted testing. As such, the required evidence to call a variant pathogenic should be higher, and extra caution should be exercised. In addition, the predicted penetrance of pathogenic variants found in the absence of a phenotype or family history may be far less than predicted based on historical data from patients ascertained as having disease.”

 

As genetic counselors we are trusted to advise patients of this information, and knowing that such information is used to make life changing reproductive decisions (i.e utilizing prenatal diagnosis, pregnancy termination, undergoing assisted reproductive technologies and preimplantation genetic diagnosis, or deciding not to have biological children) we know how important it is that the information we provide patients is unambiguous, accurate, and evidenced based.

However, we seem to be accepting the move to expanded carrier screening panels using sequencing rather than more targeted genotyping panels with little question about whether this is the right thing to do.

While many have accepted that expanded carrier screening with sequence analysis is the new normal, we should note that despite the marketing spin by the companies that this method of testing is superior, there are still no prospective studies that demonstrate clinical validity and utility of expanded carrier screening panels with sequencing. And guidance from our professional societies recommends a more limited approach to carrier screening.

While labs promote certain conditions included on their carrier screens as “recommended” by the ACMG and ACOG, they fail to acknowledge that those professional societies specifically advise against whole exon sequencing, and instead recommend a more targeted approach that evaluates, and reports on only well characterized mutations.

From the ACMG Position Statement on Prenatal/Preconception Carrier Screening (2013):  “There must be validated clinical association between the mutation(s) detected and the severity of the disorder.”  And more recently, from the ACOG Committee Opinion 691 on Carrier Screening for Genetic Conditions (2017):  “Complete analysis of the CFTR gene by DNA sequencing is not appropriate for routine carrier screening.”

Who should decide which test is best?  The testing laboratories? The professional medical organizations?  Patients?

It seems that for now, that the laboratories are steering this ship. Despite the lack of evidence proving benefit and many cautions against it, several labs have sunsetted genotyping panels and have moved exclusively to sequencing, for what seems to be an ever growing number of rare conditions. It is becoming increasingly difficult for clinicians to follow the guideline recommendations when ordering tests for patients and we seem to be quickly entering a time where Option B is not an option at all.

It should not come as a surprise that the labs are pushing this new expanded testing as there is an incentive for labs to use sequencing over genotyping from a business perspective.

Sequencing genes rather than using a defined mutation panel allows for labs to boast of a higher detection of carriers, thus provides bragging rights for their marketing materials. One lab highlights on their website that their test identifies “30% more pregnancies affected with cystic fibrosis or spinal muscular atrophy” when compared to the ACMG and ACOG  recommended panel. What is omitted on their website is that for some of the mutations identified, we do not yet have definitive information about disease causation or phenotype. And thus we are asking patients to make reproductive decisions based on uncertain information.

Another compelling reason for the labs to expand to sequencing is that detecting more mutations in the patient begets more testing of their partners. And more testing is the name of the game with laboratories that aim to increase test sales. Understandably that is their goal as it should be, we need labs to sell test in order to stay in business and provide a needed service for patients and providers. That said, lab sales and profits should not be driving best practices for patient care.

 

While more may seem better in some situations, this notion should be especially scrutinized in the area of reproductive carrier screening. As the professionals that are trusted to interpret these tests results and help patients understand this information in the context of their own lives, we need evidence beyond modeled hypothetical disease risk to demonstrate that these expanded tests will truly benefit pregnancy outcomes. As has been discussed on the DNA Exchange in a prior post by Bob Resta, positive change to do best for our patients in this area will require work from multiple parties. Labs should put the brakes on with regards to marketing new tests and step back while independently funded research assesses the relative harms and benefits of testing. Governments need to fund such research. And clinicians need to critically evaluate the testing that is offered to patients, especially when unproven testing strategies are being introduced and promoted that may create more harm than good.

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Press Secretaries and Prenatal Diagnosis

The prevailing psychological paradigm views the human mind as two different interacting agencies – the unconscious and the conscious. The influence of the unconscious on the conscious mind began receiving scientific attention in the 19th century, reaching a critical juncture with Sigmund Freud’s deep dive into the murky and lurid waters of the unconscious. While many of Freud’s theories have not stood the test of time, his core concept that our unconscious mind is driven by darker instincts that our conscious mind tries to cover over is still widely accepted. And, in a sort of cosmic joke, it is extraordinarily difficult for us to know our own minds because our brains were shaped by evolution to deceive us into thinking we are good people who are conscientious members of society. We are really good at lying to, and believing, ourselves. I like the imagery employed in Kevin Simler’s and Robin Hanson’s recently published book The Elephant in The Brain that compares the conscious mind to a press secretary that tries to positively portray the less saintly aspects of the unconscious mind. Think of a governmental press secretary who has to explain a leader’s questionable statements and decisions without always being aware of what the leader is saying or doing.

So what does the deep mind and its personal Press Secretary have to do with genetic counseling? Well, a lot actually. In previous posts, I have discussed how the unconscious mind can influence genetic counselors’ perceptions of their conflicts of interest, how the pauses in a conversation between speakers can subliminally communicate meaning, and how I sometimes struggle to not let my darker thoughts insinuate themselves into my interactions with patients. In this posting, I look at the role of the unconscious mind in patients’ decisions to accept an offer of prenatal screening for Down syndrome and in deciding whether to continue a pregnancy in which a fetus has been diagnosed with this condition.

There is a common and deep negative attitude toward people with disabilities, even among their care providers, that sometimes borders on fear. Pick your reasons for this – ego threat, announcing to the world your reproductive unfitness, an assault on your concept of an ideal child and family, selfishness to prevent the loss of how you want your life to play out, rejection of those different from us. Readers more astute than I at probing the unconscious can probably think of others. This negative attitude is the driving engine of the prenatal screening train – given a choice, many people do not want to raise a child who will have significant cognitive or physical impairments. Some of this stems from misunderstanding and misinformation about disability. But decisions are typically based on the darker motives of the unconscious mind, not on information.

Here is where the Press Secretary comes in to play. People prefer not to admit to these less socially acceptable thoughts. Instead, they manufacture very plausible explanations to justify their decisions. Mind you, I am not implying that people are liars, hypocrites, or morally derelict. Rather, the unconscious mind usually rules the roost and leaves it to the Press Secretary to put a positive spin on it. This is how the human mind works, and it is crucial to understanding how patients make difficult and morally ambiguous decisions. It is like a role reversal in the Wizard of Oz.* Professor Marvel, Acclaimed by the Crown Heads of Europe, isn’t behind the curtain. Instead, the flaming, smoking, blustering, self-important gigantic head of The Great and Terrible Oz is back there. Oz doesn’t have the heart or courage to fight the Wicked Witch of the West and manipulates Professor Marvel to impart the task to Dorothy the Small and Meek (and, yes, Toto too). Professor Marvel is a bad wizard trying to pass himself off as a good man.

 

For example, what I often heard from patients as an underlying reason for a decision to proceed with testing or terminations shifted the focus from darker to more personally and socially acceptable reasons:

  • “We wouldn’t want our other children to bear the burden of caring for a disabled sibling after we are gone.”
  • “It would be unfair to our other children if we had to devote so much attention to a disabled sibling.”
  • “My doctor thinks it is the right thing to do and really wants me to have the test.”
  • “The world can be cruel to people who are different. I remember how a boy with Down syndrome was mercilessly teased in my neighborhood when I was growing up. I would not want to put my child through that.”
  • “It would put too much of a strain on our marriage. I know I could deal with it, but it would be devastating to my spouse.”
  • “I want to take advantage of advances in medical testing and information to make sure my baby is healthy.”

As a counselor, there is nothing to be gained from criticizing any of these as being invalid justifications. Indeed there is a measure of truth to them that provides plausibility. Patients are not concocting nonsense reasons or blatant falsehoods. But they also transform the less desirable urges of the unconscious mind into a message that allows the conscious mind to maintain its self-image of a Good Person and to avoid the negative judgment of family, friends, and social networks. On top of this, a well-oiled medical and economic machinery capitalizes on negative attitudes toward disability and reinforces the idea that prenatal screening is a wise choice for responsible parents.

This also has implications for critics of prenatal testing who claim that if pregnant women better understood the quality of the lives of people with disabilities, then more people would reject prenatal screening. This is true only to an extent. The unconscious mind is not usually persuaded by mere facts and will ignore them, reframe “truth” to make it more compatible with the motives of the unconscious, or filter out the parts that it doesn’t want to hear. Bias against physically and cognitively different people is found in all cultures and over time, though there is variation as to which conditions are the focus of a society’s prejudices and fears. People with albinism have been traditionally well-integrated into Hopi society and often play special roles in ceremonial dances; in parts of Africa they fear for their lives. Education alone is unlikely to alter attitudes. Change will require large-scale cultural shifts in views towards specific disabilities and conditions.

Unless we appreciate how the unconscious mind drives behavior and choices, we will never understand our patients – or ourselves.


  • – The day after I drafted an early version of this posting, I came across the same allusion to the Wizard of Oz in Leonard Mlodinow’s Subliminal – How Your Unconscious Mind Rules Your BehaviorIncidentally, in L. Frank Baum’s Oz books, Professor Marvel explains that his full name is Oscar Zoroaster Phadrig Isaac Norman Henkle Emmannuel Ambroise Diggs, the acronym of which is OZPINHEAD. In yet one more example of bias towards people with disabilities, he chose his name by using the first two letters of that acronym – Oz – and dropping the “pinhead” part.

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When Perfection Causes Imperfection: A Potential Non-Genomic Complication Of Germline Editing

There is wide consensus that we should not only treat but also try to cure genetic conditions that cause profound suffering. CRISPR and related technologies have descended on us like a deus ex machina from the heavens and made it possible to “cure” genetic diseases through germline editing. Precision molecular microsurgery has stimulated provocative discussions about which diseases are serious, where we draw the line, the acceptance of people who are different in appearance and abilities, increasing the disparities between wealthy and poor, religious concerns, etc. I don’t have any helpful insights into these issues but I hope that vigorous debate continues and that if germline editing becomes a reality, we proceed veeerrrrrryyyyy slowly, cautiously, and incrementally.

The more ardent “germline utopians” envision a world where all fertilized embryos undergo germline editing to prevent the resulting offspring from developing genetic disorders. Of course, this will never happen universally. Even in a fantasy world of full acceptance of, and unrestricted access to, germline editing, pregnancies have a habit of, well, happening on their own. But for argument’s sake, let’s make the unlikely assumption that many parents will utilize germline editing to prevent their children from developing genetic conditions. Given that Western societies place great value on individual autonomy and considering the conditions that are currently screened for through prenatal diagnosis and carrier screening, it is likely that prospective parents would choose to “correct” traits ranging in severity from hearing loss to profound physical and developmental disorders, and all points in between. And to twist the complexity we might see the reverse scenario where deaf parents choose to “correct” a hearing-abled embryo. Should genetic enhancement – adding a few IQ points, tacking on centimeters of height, a slimmer habitus, Faye Dunaway zygomatics – become a reality then a goodly number of parents will take advantage of that as well (please I hope never because it will bring out the worst in us).

Of course, this model of genetic disease prevention depends on whether the technique actually works and that it is safe. There is reason to believe that germline editing and “correction” of genetic conditions are technically achievable. Safety, however, is more open to question. Off-target genetic effects, among other safety issues, could relegate germline editing to the What If category of debate.

But let’s posit a world where efficacy is proven and off-target effects are negligible. There would still be another safety issue, unrelated to genomics. Germline microsurgery requires in vitro fertilization/intracyoplasmic sperm injection (IVF/ICSI) in order to gain access to the gamete or the fertilized egg and to achieve a pregnancy. And therein lies the rub – IVF/ICSI is associated with a higher risk of complications in singleton and multiple gestations, such as prematurity, low birthweight, small for gestational age, perinatal mortality, and congenital anomalies. It reminds me of the introduction of a phenylalanine-restricted diet to reduce the impact of PKU that eventually created the phenomenon of maternal PKU, in which maternal hyperphenylalaninemia produced babies with microcephaly, heart defects, and intellectual disabilities. The attempt to cure one problem can create a whole new set of problems.

Now maybe the complications of IVF/ICSI are in part due to the underlying causes of the parental infertility, and thus fertile couples may have lower complication rates. Maybe. Perhaps IVF/ICSI will become safer. Perhaps. Still, it is likely that some parents will be willing to accept the risks of pregnancy complications in return for not having a child with Tay-Sachs disease or severe ichthyosis. But are the pregnancy risks worth it to prevent genetic hearing loss, increase a child’s IQ, or create a child with movie star beauty?

You might understandably say “My God, we finally have the chance to prevent serious genetic problems and improve people’s lives. How can we not take advantage of it? We are just trying to do good in a world full of suffering.” Indeed, the goal of reducing suffering is as old as the field of Medical Genetics. But when we march beneath the banners of Cure, Good Intentions, and Highly Ethical Motivations, and throw in an unhealthy dose of hubris, our enthusiasm may blind us to the harm that we might do. Perfection comes with a price.

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Work Shift: A (Wrong?) Prediction

Genetic counselors are engaging in a bit of preening now that CareerCast has listed our profession as the top-rated career for 2018. Actually, it’s a bit of history repeating itself. Back in 1980, the genetics equivalent of The Neolithic, I learned about the profession when I came across an article in Working Woman magazine (now defunct, and not to be confused with Working Women magazine, which is still in circulation) touting the top 10 careers for the modern woman of the 1980s. My other time-killing choices that day were People, Reader’s Digest, and Ranger Rick. If I had picked up a different magazine, well, just imagine Ranger Robert. Funny how our lives play out.  Incidentally, even today, National Society of Genetic Counselor (NSGC) membership is 95% female, so that article in Working Woman really had its finger on the socioeconomic pulse.

Ranger Robert. Graphics by Emily Singh

 

The CareerCast story appeared just a few weeks after the publication of the latest Professional Status Survey (PSS) by the NSGC. The two pieces got me to thinking about historical changes in the employment picture of the profession and eventually, perhaps after a beer or two, a prediction popped into my head about a trending shift in who employs genetic counselors. I am not the first to notice the trend, so my contribution is to suggest the extreme to which the trend will run as well as its implications.

My prediction is that within the next 5-10 years, a significant majority of US genetic counselors will be employed  by laboratories and other biotech firms, in both patient contact and non-contact roles, and, to a lesser extent, by private practice groups that offer their services over the Internet or whatever communication technology is predominant in 2025. Until about a decade or so ago, the vast majority of genetic counselors were employed by private and academic medical centers. This is still true; if I am interpreting the 2018 PSS correctly, about 2/3 of genetic counselors are employed by medical centers, public hospitals, HMOs, private hospitals, and physician private practices. However, there were also changes in the percentage employed by laboratories and biotechs. In 2010, 10.5% of genetic counselors were employed by labs and biotechs. By 2018, that percentage more than doubled to 22.5%, and another 2% of genetic counselor were employed by telegenetics companies in 2018 (the 2010 PSS did not have an equivalent category). In other words, about a quarter of the current genetic counseling workforce is employed by labs, biotechs, and telegenetics companies.

There are several factors driving this trend. First off, more laboratories are offering direct genetic counseling services to patients and thus need to hire more counselors  – Counsyl and its new owner Myriad Genetics, Color Genomics, LabCorp, and Invitae, to name a few. Second, salaries of laboratory genetic counselors are typically a good 20% higher (plus more to be made in bonuses and stock options) than those offered by medical centers, making labs more enticing to prospective employees. Third, more medical centers and large medical practices are looking to include genetic counseling among the services they provide to their patients. Since genetic counselors don’t typically generate enough income to pay their costs, medical centers may be relieved to have a laboratory provide genetic counseling to their patients, either on site or via telegenetics. Clinics would bear minimal costs and labs would get a pipeline for specimens. This in turn will create a competitive environment among labs to offer their genetic counseling services to more clinics to ensure they maintain reasonable share of the testing market. A lesser trend will be the growth of telegenetic services offered by dedicated telegenetic counseling companies and individual private practitioners (together, currently 2.2% of genetic counselors). I suspect this latter group will be limited in its employment share, in part because they will have a hard time competing with the deeper pockets of large corporations. The net effect will be that the percentage of genetic counselors employed by medical centers will decrease significantly.

A natural extension of this trend is that bigger labs will continue to swallow smaller labs, and mega-corporations will swallow the bigger labs. Its hard to fight economy of scale. Konica Minolta owns Ambry Genetics. Eventually BGI may get in on the act (then watch out!). Heck, it’s not out of the question that many genetic counselors could one day work for Amazon (see my posting Sour Grapes, a dystopian satire about this possibility).

Both good and bad will emerge from these trends. More patients will have access to genetic counseling through telegenetics, whether from labs or dedicated genetic counseling companies. With genetic counselors on staff, labs and medical centers can be confident that testing is ordered and interpreted appropriately, improving patient care and reducing economic waste. More career opportunities will open up for genetic counselors as corporations recognize their skills and smarts. Salaries and other benefits will likely become more generous.

There is plenty to worry about too, at least for professional fretters like me. With more mergers and acquisitions, there will be fewer employers of genetic counselors and so the field will lose some of its practice diversity. Employers will expect their employees to adhere to certain business practices and philosophies unique to each employer. Practice diversity has been a rich source and testing ground for new and different ways to conduct genetic counseling. More concerning to me is the potential loss of  carefully considered patient decisions about whether to undergo a genetic test. Acquisitions and mergers are driven by the desire to increase market share and market penetration, not by an altruistic urge to ensure that patients carefully consider the benefits, downsides, and psychological impact of genetic testing (although undoubtedly labs support the right of each patient to make independent decisions). This will become even more concerning  as labs are subsumed by larger corporate entities that are further removed from the practice of medicine and the ethos of genetic counselors, generating real concerns about conflicts of interest. Another possibility is that large labs will either set up or help finance genetic counseling training programs. Why not have a steady source of prospective employees who can be trained to develop skills and a counseling approach that are shaped to a particular corporate milieu?

I acknowledge that this is a very America-centric view of the genetic counseling profession. This trend may not play out to the same degree, or at all, in other countries. On the other hand, telegenetics knows no borders. Conseil Gènètique Sans Frontières. Governments are looking for ways to cut health care spending in the UK, Canada, and Australia, among others. International mega-corporations – Big Genoma – can offer enticing cost-savings to legislators looking to reduce expenses without increasing taxes.

Of course, like most prophets and self-appointed pundits, my predictions will be off, and perhaps even laughably so. The thing about the future is that nobody knows what it’s going to be like. So if you disagree with me, or are outraged by my thoughts, take solace in knowing that I will likely be wrong yet again. But I think there is enough meat on this bone that it’s worth chewing over.

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