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.
The DNA Exchange 
Wonderful article, as usual! However, there are many more factors than just salary that are driving GCs towards industry. Many of us shifted to industry for the ability to work from home, travel, more autonomy, career advancement opportunities, and the expansive job opportunities that industry offers. I’d love to see more GCs stay in hospitals and academic centers, but they need to put some time into adding more of these factors to the GC job description. Most of us didn’t enter this career for a high salary, but is is an added bonus on top of these other factors, making industry extremely appealing!
Excellent points Melissa, and I should have mentioned those other benefits of lab/biotech employment. I did not mean to imply that lab-based employees are only in it for the money! When I first entered the profession, I am pretty sure I was forced to take a Vow of Poverty, so high salary was not up there on my list for staying in the profession.
Bob
Thanks Bob. I have been thinking about this topic from a larger ‘professional identity and future work’ perspective lately. I thought your take on practice diversity is really interesting, and I had not really thought about that before. One thing I suppose we should all think about is how the labs’ growing influence in professional employment will affect practice diversity, especially when it comes to variant interpretation. A question I had, “Would a GC employed by a lab doing tele-based counseling go against their employing lab’s genetic testing report and disagree with a particular variant’s interpretation?” Variant interpretation is a microcosm of practice diversity, as we all know. I wonder if at some level, we sacrifice some independent thinking when it comes to variant interpretation if we work for a lab.
This came up maybe 1-2 years ago when working with a family with “Brugada syndrome.” I tracked down a distant aunt’s genetic testing (performed by a major lab), with a variant called likely pathogenic. It turns out there was conflicting data on the variant, and newer data (from ExAC/gnomAD) actually has this likely being a common population variant which probably isn’t a Mendelian cause of disease. Nonetheless, the tele-based lab GC counseled the aunt on her diagnosis (despite not knowing the patient, having detailed cardiology records to corroborate the genetic data, and not knowing the full family history).
This is not to point out fault of the lab GC, but I wonder: would that GC have gone on the line and gone against the lab’s interpretation if using good critical thinking of this variant (even based on data from that time)? Now that the variant has been reclassified, has that tele-based GC developed a relationship with the patient/family to the degree that she can go back to that aunt, re-review the findings, have the complicated discussion that the variant does not mean she has the diagnosis now, and come up with a new plan for that person’s care? Likely not.
DISCLAIMER: I am NOT implying that lab-employed GC’s sacrifice critical thinking, and I know many wonderful GC’s who help on the front end of good, critical variant interpretation with labs. This is more of a thought experiment based on a case I encountered.
But I think you are onto something. Maybe practice monopolies could lead to loss of practice independence? I’d also add that I have been reading a lot on artificial intelligence (Nick Bostrom) and its impact on larger economic forces. I sometimes worry about professions that become easily “algorithm-able” (i.e. what is happening in radiology at the moment) that then become easily supplanted by AI. If we start boiling down genetic counseling practice to something that can be made into an algorithm delivered by web portal by some Siri-like genetic counselor voice, we run the risk of algorithm-ing ourselves out of jobs 10-20 years from now.
Sorry for rambling. Thank you for your thoughts!
GIA, or the genetic information assistant chatbot, already exists! http://cleargenetics.com/ The algorithm-ing is already off and running. I just don’t see that we have made enough strides in making the profession a worthy one in the eyes of administrators or payors, and chatbots are another way in which we will have to defend our value. Or perhaps it is already too late and our profession is on its way to being disrupted by SV like taxi drivers.
I think some remote-based genetic counselors who work directly with patients probably don’t have as much of an opportunity to stretch their critical thinking skills in the sense that they’re often dealing with simpler/more straightforward cases than a clinically-/team-based genetic counselor working on complex cases. Truly understanding patient phenotype (and contribution of genotype to it) requires having access to detailed medical history (EHR) as well as ability to discuss patient with others on the care team. One of the great things about working in a clinical setting – the genetic counseling provided can be really personalized and specific.
Although Genetic Chatbots or Genetic Counseling assistants like ‘GeneFAX: Your Digital Genetic Health Companion’ exists, there are number of scenarios where the involvement of a human Genetic Counselor is a must and companies like OptraHEALTH ( https://www.optrahealth.com ) knows the value of genetic counselor community. So they made the product in such a way that more time of genetic counselors can be spent on interacting with patients.
Pingback: Bob has retired. What are the Resta us going to do now? | The DNA Exchange