Inpatient Genetic Counseling - Glenna Noska

When I first learned about genetic counseling during my last semester of nursing school, I was only aware of the three core outpatient specialty areas within the profession: prenatal, pediatrics, and cancer. It wasn’t until entering genetic counseling graduate school that I learned of the many subspecialty areas in the field. I wasn’t aware, for example, that inpatient genetic counseling even existed, let alone the possibility that I may really enjoy it. But after having the opportunity to spend time in inpatient during my pediatric clinical rotation, that’s exactly what happened.

According to an article published in the Journal of Genetic Counseling in 2021, Characterization of Genetic Counselor practices in inpatient care settings, over 130 genetic counselors (GCs) provide care in the inpatient setting. However, the exact number of inpatient GCs is unknown (Magness et al., 2021). For comparison, according to the National Society of Genetic Counselors 2022 professional status survey, the number of certified genetic counselors in the United States as of April 2021 is 5,629 (National Society of Genetic Counselors, 2022). But despite the relatively small number of GCs working in inpatient, there is no denying how valuable of a role they play as part of the patient care team. Among the many roles they provide, having inpatient GCs increases patients' access to genetic services and testing and provides patients at the bedside with valuable support and continuity of care. Their genetic knowledge and expertise also guide healthcare providers and helps ensure the most appropriate genetic tests are being ordered. Having inpatient genetic counselors’ benefits patients and their families and the healthcare system as a whole.

As genetic counseling students at Pitt, we have 9-week clinical rotations in prenatal, cancer, and pediatrics, which includes two weeks with the inpatient pediatric GCs at the Children’s Hospital of Pittsburgh (CHP). During my pediatric rotation, I observed inpatient clinical rounds with the Geneticist and was given the opportunity to provide patients with pre/post-test counseling, genetics education, result disclosures, and psychosocial counseling.

I found my time in inpatient to be challenging, given the reduced preparation time as compared to outpatient, but also incredibly rewarding for its fast pace and multidisciplinary approach. I enjoyed having to think quickly on my feet and loved the opportunity to provide one-on-one counseling to patients at the bedside.

Still, my experience inpatient was only two weeks. For more insight into what it means to be an inpatient GC, I spoke to two from CHP who have been at it much longer than I have: Leslie Cyprych, LCGC, and Linford Williams, LCGC. Here’s what they had to say about inpatient genetic counseling:

What is an average day like for you as an inpatient genetic counselor?

Linford: Day to day on inpatient varies so much. Often it includes seeing around 1-2 new consults or new patients (on average), checking in on some patients you've seen earlier who are still admitted to discuss their thoughts on the recommended genetic testing, speaking to families about genetic testing results.

Throughout every day we're communicating with various other hospital teams as well such as ICU teams (ex – NICU, PICU), specialty teams (ex – cardiology, neurology) or general pediatrics teams.

Leslie: The genetic inpatient genetic counselors are the "first call" for genetics from 8a-4pm, so we carry a pager and a cell phone and triage calls throughout the day. Whenever a team in the hospital thinks their patient could have a genetic condition they page us, we prep the chart, and go see the patient. From there, it's pretty similar to an outpatient genetics appointment… you're just usually standing up at a patient's bedside rather than sitting across a table from them. We work alongside our geneticists to make sure the patient gets appropriate testing and counseling for whatever the concern is that has them admitted to the hospital.

We also field calls from all sorts of other folks who might be paging the Genetics service… Pediatricians and other doctors who have questions, labs with urgent results (like an abnormal newborn screen), and families who need to speak with a geneticist immediately.

In any time that I'm not actively seeing a new patient or handling incoming calls, I follow up on patients who have left the hospital by doing results disclosures, writing notes, and helping to get them established with our outpatient team for follow-up.

What is your favorite part of being an inpatient genetic counselor?

Linford: There are two aspects of this role which I enjoy a lot. One is the flexibility in terms of time you get to spend with a patient/their family. Unlike outpatient, we're not necessarily bound by any schedule, so we're able to meet with families for as long as or as many times as they need to fully process our discussions. There are many families that I've met several times to talk through their thoughts on genetic testing or any abnormal results for their child. I often find that I'm able to build much more rapport and meaningful relationships with inpatient families because of this.

Second is the variety. Every day on inpatient is different from the next. By nature of the position, you get exposed to numerous patient indications, diagnoses (common and rare), and different situations that families are in. It both keeps you engaged and grows your skillset quickly.

Leslie: I love the teamwork aspect of inpatient care. I interact daily with so many different specialists, nurses, dieticians, social workers, and more. I have learned so much in this position and have made so many wonderful professional connections.

I also really appreciate the opportunity to work with this specific patient population. It's a real privilege to be able to support families during such a vulnerable experience.

What is the most challenging aspect of being an inpatient genetic counselor?

Linford: The most challenging part is balancing all the demands on busy days and determining what can and can't be done in a day. Triaging each family's needs can be difficult because every patient and family we see is in some level of crisis that they haven't necessarily been in before. It's natural to be empathetic to each situation and hard to sometimes not try and do it all to not overwork yourself.

Leslie: Time management for sure! Since the inpatient genetic counselors are the first ones who get calls throughout the day, it's our job to triage a lot of the workflow for the day. For example, if you get more than one consult in a day, you need to be able to decide which one you're going to work up and see first. All while your pager keeps going off! It's one big rolling to-do list!

What advice would you give to students wishing to pursue a career in inpatient genetic counseling?

Linford: Inpatient genetic counseling is an evolving field and looks different across each institution and specialty. Sometimes the breadth of the role is also determined based on the administrative support of the institution.

The newly formed inpatient SIG is a great place to start getting some information about the ins and outs of inpatient genetic counseling across the specialties. Otherwise, I would advise purposefully seeking out positions which have some aspect of inpatient in the job description or advocate for that role when interviewing.

Finally, although you can never be fully prepared for what inpatient can throw at you, I would also advise starting with outpatient as a new grad (at least some of the time) to have a good foundation. Inpatient often involves quickly applying a knowledge base of genetic conditions as well as some of the ins and outs of the hospital you're working at to be the most successful, both of which come with some work experience. In an outpatient setting, this knowledge can be gained in a less time-sensitive manner.

Leslie: Try to get exposure to the specialty. We are very lucky at Pitt that inpatient experience is built into the pediatric rotation. I'm not sure I would have ever known this was a possibility if I hadn't had been part of Pitt's training program.

Other ways to get exposure would be to seek out inpatient counselors (ex: on the NSGC website), and joining the inpatient special interest group (SIG) within NSGC. The inpatient SIG is fairly new, but it has been a wonderful connection to other inpatient GCs so that we can share experiences and grow the specialty. The SIG also has a lecture series, which is great!

According to Magness et al. (2021), of the genetic counselors who work in the inpatient setting, 50% had not had exposure to inpatient genetic counseling during their graduate education. Gaining exposure to inpatient genetic counseling introduced me to a specialty area I didn't know existed, and it is a specialty I can see myself pursuing. Without this opportunity, I don't think I would have known that, and I am incredibly grateful that, as a student at Pitt, I had this unique opportunity.

I want to thank the Pitt GC program and the CHP pediatric genetics department staff, including the genetic counselors and physicians. I also want to thank Linford and Leslie for their willingness to provide their time and insight into this unique specialty.

Link to Inpatient Genetic Counseling SIG for more information:

https://www.nsgc.org/Members/Special-Interest-Groups-SIGs/Inpatient-SIG

References:

Magness, E., Magoulas, P., Moscarello, T., Ma, D., Helm, B. M., & Mizerik, E. (2021). Characterization of genetic counselor practices in inpatient care settings. Journal of Genetic Counseling. https://doi.org/10.1002/jgc4.1401

National Society of Genetic Counselors. (2022). NSGC > Policy, Research and Publications > Professional Status Survey. Www.nsgc.org. https://www.nsgc.org/Policy-Research-and-Publications/Professional-Status-Survey