Public Health and Genetic Counseling

One unique aspect of the Pitt Genetic Counseling Program is its emphasis on public health. Students can pursue a dual degree with a MPH in Public Health Genetics and MS in Genetic Counseling or certificate in public health genetics in addition to their genetic counseling degree.  However, all genetic counseling students receive some training in public health, which allows them to appreciate the application of genetic counseling to population health. This week, some of our students share why public health is important to the field of genetic counseling.

The 10 essential public health service

Just like the way our genes work, nothing we do as genetic counselors happens in isolation. Our jobs places us within the complexity of family medicine issues, and our training in a public health setting helps prepare us for that. As genetic counselors, we must be constantly aware of how the aspects of our services, including genetic testing access, interpretation, and billing affect the broader community. By joining committees and working groups, genetic counselors can help improve this service landscape by suggesting CPT codes for test billing purposes, refining diagnostic criteria to improve test efficacy, and engaging with labs and insurance companies to form contracts and working agreements to expedite authorization and coverage. At Pitt, even non-dual degree genetic counseling students dive into public health training and concepts, with the opportunity to customize the experience. My thesis, for instance, involves measuring the positive predictive value of clinical epilepsy panel testing criteria. By doing this, we’ll be able to tweak the criteria to improve overall yield and make them better suited to finding a genetic etiology in patients. The goal is that these refined criteria can serve as a template for health insurance policy and improve patient cost and experience in the future.

-Andrew Fazenbaker, 2^nd year genetic counseling student

It’s hard to name an aspect of our lives that isn’t, in some way, related to public health. Genetics is no different. Public health can be important in bringing people to medical attention. Newborn Screening programs help identify newborns with serious and treatable conditions so treatment can be started as early as possible. Initiatives around CDC Tier One conditions help identify at-risk relatives through cascade screening for Hereditary Breast and Ovarian Cancer, Lynch syndrome, and Familial Hypercholesterolemia.  Public health is also responsible for people having access to care, and learning about public health makes us more equipped to advocate for good public health policies. For example, genetic counselors are not currently recognized as medical providers by the Centers for Medicare/Medicaid Services. If genetic counselors were recognized as Medicare providers, they could accept referrals directly and see Medicare patients without having to be under the supervision of a physician. In June 2019, a bill (H.R. 3235) was introduced to the House to change this. This would remove barriers for many patients and allow for easier access to genetic counseling. This bill is a prime example of how public health is important to genetic counseling - if it weren’t for genetic counselors practicing public health skills by writing and advocating for this bill, it would never have gotten to the House. (Stay tuned to see if it passes!)

-Vickie Bacon, 3^rd year dual degree student

When I was applying to genetic counseling programs, Pitt stood out to me because of its emphasis on public health. I love the one-on-one patient interactions, but after working in a genetics clinic for a year I felt that changes are needed at a broader, population level. There is a shortage of both genetic counselors and medical geneticists, and millions of Americans with inherited conditions whom doctors could better care for if their conditions were identified. The CDC lists three “tier 1” conditions (two hereditary cancer syndromes and one high cholesterol condition); if a person is found to have one of these conditions, action can be taken to decrease morbidity and mortality. More than 90% of Americans with these conditions are undiagnosed; the signs are there, but they are not being identified and referred for genetic services. The CDC lists specific steps to identify these individuals on a population level. When one person is diagnosed, relatives are at risk and can be tested. I strongly believe that the health care community can do a better job of identifying these individuals before they are diagnosed with stage 4 cancer or have a heart attack. Those of us being trained in public health genetics are learning skills that will help us use our genetics knowledge to improve health on a population level.

-Claire McDonald, 2^nd year dual degree student

Being educated in both public health and genetic counseling is important to me because it lets you see the bigger picture. Even though one-on-one communication with patients is a major part of why I chose genetic counseling, I also knew there was so much more that needed to happen to be truly effective at making an impact. And I don’t mean “bigger picture” in the sense that when you identify a genetic condition in one individual, you then have to expand your scope to look at the risk of their relatives, although this is important as well. “Bigger picture” is looking at the structural and systemic problems that are negatively impacting public health, and for me that means problems with access to genetic services. Having this access-focused public health mindset leads me to think about the patients who would clearly qualify for a genetics consult but never make it into the clinic at all. What’s stopping them from coming in? Is it that they don’t know about their options for genetic testing? Do their doctors not know what resources and referrals are available or not have a sufficient background in basic genetics to recognize when one of their patients could benefit from a referral to genetic counseling? Are the patients aware, but they don’t have the means to capitalize on a referral, either due to transportation issues, lack of insurance, or another barrier entirely? Once we start to think about these problems, we can start to work on overcoming them so that we can make a positive change in the health of our patients and the population as a whole.

-Trinity Sprague, 2^nd year dual degree student

Relatively speaking, the role of genetics in medicine is still new and expanding. There are already so many opportunities for public health interventions to maximize the impact of new technology and research. At the same time, I have no doubt as the field grows and changes, there will be new, unexpected ways that genetics will change the nature of healthcare. This is why it is essential to bring in a public health mindset from the very beginning, while the profession of genetic counseling is evolving. That is the best way to make sure that as advancements occur, they can be efficiently and rapidly brought to the population at large in equitable and affordable ways. It is easier to devise these strategies when professionals are already thinking about it in the beginning of the process, rather than trying to work their way backwards from it.

-Pooja Solanki, 2^nd year dual degree student