The evolution of genetic counseling at Johns Hopkins Hospital and beyond.

In celebration of the 100th birthday of Dr. Victor A. McKusick, we look back at the history of genetic counseling at Johns Hopkins Hospital and at some milestones for the profession. With the first students graduating from the Human Genetics program at Sarah Lawrence College in 1971, the genetic counseling profession is celebrating its 50th anniversary this year. The profession has seen growth in numbers and scope of practice, the evolution of a national society, the advent of certification and accreditation, the proliferation of graduate programs, the pursuit of state licensure, and collaboration with fellow genetics professionals. Many of the early jobs were at academic centers, such as Johns Hopkins Hospital, while today counselors are employed in a multitude of settings and engaged in a variety of roles.

Cap a la genètica assistencial interdisciplinària i transversal: evolució de cinquanta anys en un hospital terciari a partir de la pediatria / Hacia la genètica asistencial interdisciplinaria y transversal: evolución de cincuenta años en un hospital terciario a partir de la pediatría / Towards interdisciplinary and transversal clinical genetics: a 50-year evolution from pediatrics in a tertiary hospital

L’objectiu d’aquest treball és analitzar l’evolució de la demanda assistencial i les possibilitats diagnòstiques, en laconsulta de genètica clínica d’un hospital de tercer nivell durant els últims cinquanta anys i també a partir dels seus inicis com a consulta específica de Pediatria.S’hi analitzen tant els motius de consulta com les proves de laboratori disponibles per arribar al diagnòstic dels pacients valorats durant el període 1968-2018, a la consulta de Genètica Clínica i al Laboratori de Genètica. A partir de 200 consultes anuals, en els primers anys, arribem a l’actualitat, en què se’n fan al voltant de 8.000 (entre primeres, successives i interconsultes), distribuïdes en Genètica Clínica i Assessorament Genètic, fins a un total de més de 32.000 pacients visitats durant aquests cinquanta anys.Al Laboratori de Genètica, l’evolució abasta des de l’estudi del cariotip convencional fins a l’aplicació de les tecnologies genòmiques actuals, i s’hi fan més de 9.000 estudis anuals de pacients de l’Hospital. Amb la incorporació de noves tecnologies moleculars s’ha canviat el paradigma de l’estudi genètic i s’ha aconseguit un rendiment millor: s’han pogut incrementar els diagnòstics i també s’ha reduït el temps necessari per obtenir-los.A més de la transformació del genetista que col·labora en el seguiment multidisciplinari dels pacients, s’evidencia uncanvi i una diversificació del motiu de consulta i s’estableix el valor de la incorporació, a partir del 2010, de professionals especialitzats en assessorament genètic per donar resposta a aquesta demanda.Els canvis experimentats en els motius de consulta, els diagnòstics i les proves de laboratori fetes durant tots aquests anys reflecteixen la importància de la incorporació i la interacció, en una mateixa àrea o unitat assistencial, de professionals especialitzats en genètica clínica, assessorament genètic i laboratori de genètica integral (també ambbioinformàtics). (AU)

El objetivo de este trabajo es analizar la evolución de la demandaasistencial y las posibilidades diagnósticas en la consulta de genética clínica de un hospital de tercer nivel a lo largo de los últimos50 años a partir de sus inicios como una consulta específica dePediatría.Se analizan los motivos de consulta y las pruebas de laboratorio disponibles para llegar al diagnóstico de los pacientes valorados en el período 1968-2018 en la Consulta de Genética Clínica y el Laboratorio de Genética. A partir de 200 consultas anuales en los primeros años llegamos a la actualidad, en que se realizan alrededor de 8.000 visitas (primeras, sucesivas e interconsultas) distribuidas en Genética Clínica y Asesoramiento Genético (32.000pacientes visitados hasta la fecha).En el laboratorio de Genética la evolución abarca desde el estudio del cariotipo convencional hasta la aplicación de las tecnologías genómicas actuales realizando más de 9.000 estudios anuales de pacientes del Hospital. Además de la transformación del genetista clínico colaborando en el seguimiento multidisciplinar de los pacientes, se evidencia un cambio y diversificación del motivo de consulta y se establece el valor de la incorporación de profesionales especializados en asesoramiento genético (a partir de 2010) para dar respuesta a esta demanda. Con la incorporación de nuevas tecnologías moleculares se ha cambiado el paradigma del estudio genético con un incremento importante del rendimiento y mejoría en el tiempo en obtener resultados diagnósticos. Los cambios experimentados en los motivos de consulta, los diagnósticos y las pruebas de laboratorio realizadas a lo largo de estos años reflejan la importancia de la incorporación e interacción, en una misma área/unidad asistencial, de profesionales especializados en genética clínica, asesores genéticos y laboratorio de genética integral (incluyendo bioinformáticos). (AU)

The objective of this work is to analyze the evolution of the demand and the diagnostic capabilities in the clinical genetics service of a tertiary hospital over the last 50 years from its initiationas a specific pediatric consultation. The reasons for consultationare analyzed as well as the laboratory tests available to reach thediagnosis of the patients evaluated in the period 1968-2018 at the Clinical Genetics Service and the Genetics Laboratory. From 200 consultations/year in the first years, we have reachedaround 8,000 visits (first, follow-up, and internal consultations) distributed in Clinical Genetics and Genetic Counseling (32,000patients visited to date).The Genetics Laboratory evolved from the study of the conventional karyotype to the application of state of the art genomic technologies, carrying out more than 9,000 annual studies from patients followed–up in the hospital.In addition to the transformation of the role of the clinical geneticist into a member of the multidisciplinary care team, there isevidence of a change and diversification of the reasons for consultation and in the value of incorporating professionals specializedin genetic counseling (starting in 2010) to respond to this demand. With the incorporation of new molecular technologies, theparadigm of the genetic study has changed, with a significant increase in performance and improving time to diagnostic results.The changes experienced in the reasons for consultation, diagnosesand laboratory tests carried out throughout these years reflect theimportance of the incorporation and interaction, in the same healthcare area or unit, of professionals specialized in clinical geneticsand genetic counseling, with a comprehensive genetics laboratory(including bioinformatics). (AU)

What have we been trying to do and have we been any good at it? A history of measuring the success of genetic counseling.

Genetic counseling as a formal clinical service was defined in 1947, though the first study of its effectiveness was not published until 1966. This history can be broadly divided in to 3 periods: 1) 1947-1980, when the focus was primarily on prevention of disability, 2) 1981-1995, when the rationales for counseling began to shift and the first studies on the psychosocial effects of genetic counseling started to appear, albeit still largely focused on reproduction, and 3) 1996 - Present, when genetic counselors increased their presence in oncology, cardiology, and other non-reproductive areas of genetic counseling. Changes in outcome measures of genetic counseling have been intertwined with technological advances in genetic testing, better and more sophisticated outcome measures, the growing professional independence and clinical positions of genetic counselors, and the influence of social scientists particularly from behavioral psychology. Despite advances, assessment of the effectiveness of genetic counseling continues is complicated by a lack of widespread agreement about the most appropriate outcome measures as well as research design problems. Broadly speaking though, genetic counseling tends to improve information recall, improve psychological well-being, and is generally well-regarded by patients.

The past, present and future of service delivery in genetic counseling: Keeping up in the era of precision medicine.

Precision medicine aims to approach disease treatment and prevention with consideration of the variability in genes, environment, and lifestyle for each person. This focus on the individual is also key to the practice of genetic counseling, whereby foundational professional values prioritize informed and autonomous patient decisions regarding their genetic health. Genetic counselors are ideally suited to help realize the goals of the precision medicine. However, a limited genetic counseling workforce at a time in which there is a rapidly growing need for services is challenging the balance of supply and demand. This article provides historical context to better understand what has informed traditional models of genetic counseling and considers some of the current forces that require genetic counselors to adapt their practice. New service delivery models can improve access to genetic healthcare by overcoming geographical barriers, allowing genetic counselors to see a higher volume of patients and supporting other healthcare providers to better provide genetic services to meet the needs of their patients. Approaches to genetic counseling service delivery are considered with a forward focus to the challenges and opportunities that lie ahead for genetic counselors in this age of precision health.

Screening for fetal chromosomal and subchromosomal disorders.

Screening for fetal chromosomal disorders has evolved greatly over the last four decades. Initially, only maternal age-related risks of aneuploidy were provided to patients. This was followed by screening with maternal serum analytes and ultrasound markers, followed by the introduction and rapid uptake of maternal plasma cell-free DNA-based screening. Studies continue to demonstrate that cfDNA screening for common aneuploidies has impressive detection rates with low false-positive rates. The technology continues to push the boundaries of prenatal screening as it is now possible to screen for less common aneuploidies and subchromosomal disorders. The optimal method for incorporating cfDNA screening into existing programs continues to be debated. It is important that obstetricians understand the biological foundations and limitations of this technology and provide patients with up-to-date information regarding cfDNA screening.

Genetic counselling, patient education, and informed decision-making in the genomic era.

Genomic technologies are now being applied to reproductive genetic screening. Circulating cell-free DNA testing in pregnancy for fetal chromosomal abnormalities is becoming more widely used as a screening test, and expanded carrier screening for autosomal and X-linked recessive conditions for more than a hundred conditions is available to couples for testing before and during pregnancy. These are most typically available as a commercial test. The purpose of reproductive genetic screening is to facilitate autonomous reproductive choices. Previous studies would suggest that many women do not make informed decisions about prenatal genetic screening, and the introduction of genomic technologies has generally added to the ethical debate. Appropriate pre-test genetic counselling is recommended, and healthcare providers should include information that is balanced, accurate and up-to-date, comprising written and/or e-learning tools, as well as providing psychosocial support so that couples consider the pros and cons of being tested and can make informed decisions.

Carrier screening for single gene disorders.

Screening for genetic disorders began in 1963 with the initiation of newborn screening for phenylketonuria. Advances in molecular technology have made both newborn screening for newborns affected with serious disorders, and carrier screening of individuals at risk for offspring with genetic disorders, more complex and more widely available. Carrier screening today can be performed secondary to family history-based screening, ethnic-based screening, and expanded carrier screening (ECS). ECS is panel-based screening, which analyzes carrier status for hundreds of genetic disorders irrespective of patient race or ethnicity. In this article, we review the historical and current aspects of carrier screening for single gene disorders, including future research directions.

The Greatest Priority for Genetic Counseling: Effectively Meeting Our Clients' Needs 2014 NSGC Natalie Weissberger Paul National Achievement Award.

Receipt of the 2014 Natalie Weissberger Paul (NWP) National Achievement Award was a highlight of my career. Thank you to all who nominated me for this prestigious NSGC recognition. I am humbled to join past NWP award winners many of whom are admired mentors, treasured colleagues and friends. I would like to express what a privilege it is to honor Natalie Weissberger Paul for whom this award is named. Twenty-nine years ago I co-edited a volume of the Birth Defects Original Article Series with Natalie summarizing a conference co-funded by the March of Dimes and NSGC (Biesecker et al., 1987). Natalie demonstrated her devotion to children with special needs through her work at the March of Dimes. As such I believe she would concur with the focus of my remarks on the partners in our work: our clients.

The Emergence of Genetic Counseling in Sweden: Examples from Eugenics and Medical Genetics.

This paper examines the intertwined relations between eugenics and medical genetics from a Swedish perspective in the 1940s and 1950s. The Swedish case shows that a rudimentary form of genetic counseling emerged within eugenic practices in the applications of the Swedish Sterilization Act of 1941, here analyzed from the phenomenon of "heredophobia" (ärftlighetsskräck). At the same time genetic counseling also existed outside eugenic practices, within the discipline of medical genetics. The paper argues that a demand for genetic counseling increased in the 1940s and 1950s in response to a sense of reproductive responsibility engendered by earlier eugenic discourse. The paper also questions the claim made by theoreticians of biopolitics that biological citizens have emerged only during the last decades, especially in neoliberal societies. From the Swedish case it is possible to argue that this had already happened earlier in relation to the proliferation of various aspects of eugenics to the public.

Looking back and moving forward: an historical perspective from laboratory genetic counselors.

Despite a consistent increase in genetic counselors who report working in laboratory positions, there is a relative dearth of literature on laboratory genetic counseling. Semi-structured interviews were completed with nine laboratory genetic counselors to document how positions were created and have changed with time. Interview transcriptions were analyzed for emerging themes. Several common themes were identified, including that early positions were often part-time, laboratory-initiated and had a lack of job definition. Laboratory genetic counselors commented on their evolving roles and responsibilities, with their positions becoming more technical and specialized over time and many taking on managerial and supervisory roles. All genetic counselors surveyed reported using core genetic counseling skills in their positions. The expansion of diagnostic testing and quickly evolving technology were common themes in regards to the future of laboratory genetic counselors, and participants commented on laboratory genetic counselors having expanding roles with data management, result interpretation and reporting, and guidance of other healthcare providers. Other comments included the impact of competition among laboratories and how training programs can better prepare genetic counseling students for a career in the laboratory setting. This study describes the emergence, and subsequent evolution, of laboratory genetic counseling positions as a significant subspecialty of genetic counseling.

A ética na história do aconselhamento genético: um desafio à educação médica / The ethics of genetic counseling: a challenge for medical education

O aconselhamento genético é uma prática que surgiu nos Estados Unidos na década de 1940 e tem se difundido ao redor do mundo com a crescente popularização da informação genética e a profissionalização da genética na saúde pública. É por meio de sessões de aconselhamento que as pessoas são informadas sobre os resultados de testes genéticos e recebem orientações sobre probabilidades, riscos e possibilidades de doenças genéticas. Trata-se de uma prática profissional que combina saúde, assistência e educação. Este ensaio descreve o surgimento e o desenvolvimento da prática de aconselhamento genético e apresenta alguns de seus desafios éticos.

Genetic counseling is a biomedical practice that appeared in the United States in the 1940s and spread elsewhere in the world with the popularization of genetic information and the new genetics in public health. A genetic counseling session aims to inform and orient individuals on their genetic tests, presenting notions of probabilities, risks, and genetic diseases. Thus, this biomedical practice combines health care, social assistance, and education. This paper describes the emergence and development of genetic counseling and discusses some of its ethical challenges.

From nation to family: two careers in the recasting of eugenics.

By examining the professional lives of two popularizers of eugenic thought from the 1910s to the 1940s, this study illustrates the broader change from "mainline" to "reform" eugenics in the United States. Roswell Hill Johnson's university teaching, laboratory research, and later marriage counseling work contrasted greatly with George Seibel's forays into eugenic theater moral reform, and mass physical fitness movements. Yet both men shifted from a strict position of mandating other people's behavior in the name of national health and racial integrity to a more therapeutic stance that cast individual decisions in the context of managed family life. This study shows that for some, the transformation of eugenics in the 1930s meant adapting the traditional focus on superiority, inferiority, and reproduction by design to the language of a commercial marketplace.

A quiet revolution: the birth of the genetic counselor at Sarah Lawrence College, 1969.

In 1969 Melissa Richter founded the first master's degree genetic counseling program in the country at Sarah Lawrence College in Bronxville, New York. This article examines the myriad factors that contributed to the birth of the genetic counselor and situates this historical watershed in its social, cultural, academic, and medical context. This article highlights Richter's prescience and path-breaking vision, evaluates the Sarah Lawrence program during the years of her directorship (1969-1972), and explores how this early foundation subsequently shaped the field of genetic counseling. Close attention is paid to the ethical issues that concerned Richter and their ongoing relevance to genetic health professionals today. This article is based on historical research in archives, consultation of primary sources, and oral history interviews with genetic counselors, geneticists, and allied professionals.

A historical comparison of the development of specialist genetic nursing in the United Kingdom and Japan.

This paper reports the development of specialist genetic nursing in the UK and Japan. Between 1970 and 1990, significant technical advances in genetic testing occurred. These advances offered many families affected by genetic conditions more choices in diagnostic, predictive, and prenatal testing. It was recognized that genetic testing could significantly alter the life of the family and that supportive health services were required to accompany such testing. Nurses began to offer specialist services in this setting, but considerable professional development was required to ensure practitioners were competent. In the UK, the profession grew slowly over several decades. Concern to establish minimum standards of practice in this new professional setting culminated in the establishment of a set of competencies and a formal registration process. By comparison, in Japan, developments in genetic nursing have occurred over a shorter period of time, but minimum standards of competence already have been agreed upon.