Let’s face it – lots of genetic counseling is repetitious. Most of us have subconsciously scripted our own version of a counseling session that we follow more rigidly than we like to admit, the inevitable outcome of seeing hundreds of fairly similar patients a year, year in and year out. On particularly busy days, you may even lose track of where you were in the session when a patient asks a tangential question or there is a knock on your door. It can be a slog, a Groundhog Day-like re-playing of the same film with only minor variations.
This repetition stems to some extent from the educational component of genetic counseling, the need to impart complicated biomedical information with the ultimate goal of helping patients making good decisions about their medical care and lives. We want to combine knowledge with emotional guidance so patients can gain wisdom and personal insight. Sometimes, though, as you watch dazed patients stumble out of your office, you start to wonder just how effective or helpful you have been.
On the other hand, there is a zen-like quality to constant repetition of the same act. By focusing strictly on the task at hand you master it through endless repetition. You eventually perform without thinking of the mechanics of performing, and achieve a state of mastery without thought . Chop that wood, carry that water. Brush left, brush right, Karate Kid. This frees the mind, making it receptive to sudden, unanticipated moments of enlightenment – satori, in the language of Zen. With a free mind, you can subconsciously pick up cues from patients’ words, expressions, and postures, and suddenly, you see into the heart and soul of your patient – Wumen’s thunderclap out of a clear blue sky. Ah – this cancer patient is angry because his mother walked out on the family when his father was diagnosed with terminal colon cancer, not because I kept them waiting 15 minutes for the appointment. Look – all the worry left her face when I said she really did not need to have an amniocentesis; she just needed someone in authority to tell her that it was a good decision.
What we really want, though, is for our patients to also have these small satori, those magical moments when their faces light up, their eyes open wide, and everything falls into place for them. These are some of the most rewarding and exciting moments of genetic counseling. Yes, yes, of course – I must tell my sister about my BRCA results to make sure she does not get ovarian cancer. She’s my sister ; I love her even if we are always bickering. You know – I just realized I do not need to have an amniocentesis; for some crazy reason, I was going to do it for my friends.
Repetition is critical to our professional development. In quiet, not-quite-perceptible ways, it builds our confidence, enhances our ability to understand our patients on a deep level, and plows the soil for the seeds of personal growth. For the compassionate bodhisattvas among us – like Jon Weil, June Peters, Luba Djurdjinovic and a few others – thunderclaps are second nature. For the rest of us – well, it’s back to chopping wood and carrying water.
The DNA Exchange 
I really enjoyed this post…validates how I sometimes feel on autopilot when talking about maternal age, genes, and chromosomes. But being comfortable with the information means I can focus attention on other things. Thanks Bob!
Great post. I enjoyed reading it. Very close to home. Thanks Rob!
Wow Bob!
Now that is an interesting spin on the use of didactic spiels in genetic counseling!
Adults learn experientially-with a give and take based on an accurate assessment of discovering what they already know and how they best learn.
There is no evidence that people need the same or even similar information.
The time we are spending giving out rote information could be spent exploring what it means for our clients.
A model that suggests that we lull ourselves into a realization about what the client needs rather than actively engage to explore what the client is seeking is pathetic (I am using strong language because we have a sound relationship and can have debate, not because I disrespect you. Rather, I admire your thoughtfulness and find the blog useful. But here we disagree).
GC should not look or be the same from session to session. Clients need all sorts of different things from us and frequently it’s not information. It’s certainly not routine, un-tailored information. Since you love history, where did this format of giving similar information out to client after client originate? Where is the justification or belief that it is desired, useful or the goal of counseling? How do senior folks like us help to train new GCs in models that explore client understanding and needs, tailor information, use multiple modes of teaching, view each client as unique and a story to unfold, and use what they learn about the client to convey empathic understanding of their unique circumstances? Yikes I hope its not simply when something occurs to them during their passive recitation of repetitive facts.
Blame the Nazis, not me.
It’s reasonable to begin with the horrors of Nazi experimentation and the resulting Nuremberg Code. Informed consent is a core ethical value of this simple but profound doctrine (from the minds of a military tribunal, no less). Education is an important part of consent, but certainly not the end in and of itself. This has worked its way into medical practice in the form of the Informed Consent form. For better or worse, many genetic counseling sessions conclude with a patient signing an informed consent document, which typically states that the risks, benefits, and limits have been explained to the patient. While clients may have different informational needs and styles, there has to be a certain amount of uniformity to make this a valid document.
Of course, genetic counseling (hopefully!) extends far beyond informed consent alone, and informed consent involves more than education alone. But education is nonetheless a key component. No matter how creative you are, no matter how much you tailor to the specific patient, after a couple of thousand patients, repetition to varying degrees is inevitable. The entire session should not be strictly educational, and, if you have good enough counseling skills, how you present the information and what information you present, should dovetail with the counseling aspects. This is what we hope results in patient satoris, stemming from the right information, delivered in the right way, enmeshed with a good psychological understanding of the patient. When a counselor has his or her own moment of insight, that gets integrated into the session so that the patient benefits from the counselors insight.
While the information we relay to patients does get repetitious, I would not want to be counseled by someone who feels they are a broken record. If we cannot connect with the information we say, or how we say it, then we cannot truly connect with how patients perceive it. Most people can pick up when someone is repeating routine information to them… it’s usually void of genuine expression and thought. Consequently, even if we want to “pick up cues from patients” in response to the information, the disingenuous vibes they get from that session most probably keep them reserved and void of expression.
I think there are 2 main reasons for why this might happen to a daily job of a counselor:
1) The center they work for books more appointments for them than humanly possible. It is one of those situations where a counselor sees 1 case every 20 mins or so. It doesn’t matter how routine the indication for referral is, we need to do the job right, and that is to fully engage with our patients.
2) It’s a personal attribute of the counselor him/herself. Some of us are naturally capable of connecting with most of our patients, and thus can tailor the routine information to their needs. Others may fail short of these skills, and it’s just the way it is. However, I believe everyone has the ability to improve if the motivation is there.
Bob, your post struck a chord here. After years of prenatal counseling, I have to make a conscious effort some days to not come across like an automaton to my patients. But I also am excited upon waking each work day that I have a bit of unpredictability to my day ahead of me.
It is interesting that we genetic counselors are considered the “teachers” in the g.c. session when I find myself learning from my patients every day. I have also realized that student supervision, although sometimes burdensome, actually helps me out of a rut in my counseling. When a student has developed a particularly effective spiel on chromosomes or has a more sensitive way of describing a particular syndrome, I find myself borrowing and integrating my student’s phrasing into future sessions of my own.
Not every interaction with a patient or supervision of a student leads me to feelings of enlightenment. But looking back on my gradual transformation from new grad to experienced counselor, I realize that YES — it was a series of small, unanticipated moments of satori that got me to where I am today.
Wax on, wax off.
The long term meditation subjects of recent neuro-imaging studies have 10,000 – 54,000 hours of practice. – the Davidson Lab, PNAS, 2007.
Sometimes our work is tiring, sometimes liberating – I personally have a long way to go before resting…
warmly,
june
Exhausted, I sought
a country inn, but found
wisteria in bloom.
– Basho