Genetic Counseling Practice Advanced Concepts and ... - (Chapter 15 "Oh The Places You'll Go!" The Genetic Counselor Profession... )

341
15
“Oh The Places You’ll Go!” The Genetic Counselor Professional

Development Journey*
Catherine A. Reiser
Department of Pediatrics, University of Wisconsin-School of Medicine and Public Health, Madison, WI, USA
OBJECTIVES
●● Discuss professional development from the perspective of the genetic counseling student, the practicing
genetic counselor, and the profession.
●● Create an iterative professional development plan that incorporates reflective practices.
●● Describe utilization of core genetic counseling skills in leadership development.
Introduction
“What do you want to be when you grow up?” Almost everyone gets asked this question, likely at predictable
times of transition: the five-year-old at kindergarten graduation, the middle school student in occupa-
tional inventories given by their guidance counselor, and the high school graduate embarking upon post-
secondary training. Even the Muppet Babies grappled with this question (Season 1 Episode 8; 1984).
Copyright © 2020. John Wiley & Sons, Incorporated. All rights reserved.
Spoiler alert: Kermit eventually chose cab driver.

While a career choice is an important question, it can be extraordinarily difficult to decide especially
as a person gains more experience and realizes the possibilities are endless. Choices include astronaut,
engineer, reality TV star, or any of the 867 different occupational categories listed in the federal 2018
Standard Occupational Classification system (BLS.gov). Although genetic counselor is on that list, it is
hard to imagine a kindergartener or even a middle school student choosing this career path. It is likely
not in their reality. It is not uncommon, however, for a High School student to make this choice (this
author did!), or the college undergraduate or recent graduate.
The next question to be asked is “How do you get to be a genetic counselor?” According to the National
Matching Service, 464 individuals figured it out and successfully obtained entrance for fall 2019 to a
* The phrase “Oh the places you’ll go” is the title of a Dr. Seuss book (1990) that is often given to students upon graduation.
Genetic Counseling Practice: Advanced Concepts and Skills, Second Edition. Edited by Bonnie S. LeRoy,
Patricia McCarthy Veach, and Nancy P. Callanan.
© 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.
Genetic Counseling Practice : Advanced Concepts and Skills, edited by Bonnie S. LeRoy, et al., John Wiley & Sons, Incorporated, 2020. ProQuest Ebook
Central, http://ebookcentral.proquest.com/lib/cityuhk/detail.action?docID=6348422.
Created from cityuhk on 2023-08-10 02:50:39.
342 Genetic Counseling Practice
genetic counseling graduate program accredited by the Accreditation Council for Genetic Counseling
(ACGC) (National Matching Service 2019). And while they may not know it, or even think in these
terms, they began their professional development journey. Part of that journey is to understand their
professional development doesn’t end with graduation. The questions don’t stop.
The entry level genetic counselor should continue to ask questions that further define their profes-
sional goals. Answers to these questions in genetic counseling are also endless – consider the changes
that have occurred since the first program opened at Sarah Lawrence College in 1969 (Stern 2009). The
National Society of Genetic Counselors (NSGC) Membership Trends Report for 1980–2002 of the
Professional Status Survey (PSS), identified 11 specialty areas of practice, with almost 60% of respond-
ents reporting that they worked in Prenatal (NSGC 2004, Membership Trends 1980–2002); the 2019 PSS
included more than twice that number of practice areas (23), with just less than one-third (29%) of
genetic counseling respondents reporting prenatal as their area of specialty practice (NSGC, PSS 2019).
The genetic counseling literature now includes articles about using genetic counseling skills as supervi-
sors for students, in biotech companies, the laboratory, and in start-ups (Atzinger et al. 2014; Field et al.
2016; Goodenberger et al. 2014; Rabideau et al. 2016). And the questions don’t end with the delineation
of a goal or the vision about an individual’s professional future. A vision is nothing more than an idea,
unless one asks the follow up question: “What will it take to get there?”
A question to be continually asked might be “What is a professional development plan that will assist with
the journey?” not because there is an end to the journey but rather because a professional journey requires
continual review and revision. It is positively and negatively influenced by both intentional and random
events and changes along the way. Lastly, just as the answer to the career choice question Kermit grappled
with depends on the developmental stage of the person being asked, the professional development jour-
ney depends on whether the plan is for a novice, experienced, or master genetic counselor (MGC).
Why is professional development important? Genetic counselors need look no further for evidence of
the importance of professional development than the ACGC practice based competencies (PBC’s). The
ACGC (2015) defines these competencies as not only the skills an “entry-level provider must demonstrate
to successfully practice as a genetic counselor,” but also skills that serve as a guide “for maintenance of
competency of practicing genetic counselors” (p.2). Domain IV, which exclusively considers Professional
Development and Practice, requires that genetic counselors “Demonstrate a self-reflective, evidenced-based,
and current approach to genetic counseling practice” (ACGC 2015, p. 2).

Confirmation of the necessity of professional development is also evident in the NSGC Code of Ethics
(COE) (2017), the document that guides the conduct of the practicing genetic counselors “so that the
goals and values of the profession might best be served” (p. 2). The code, which is relationship-based,
includes the value of competence (a natural extension from the PBC’s) in the first relationship
considered, namely genetic counselors themselves. Genetic counselors are expected to “Continue their
education and training to keep abreast of relevant guidelines, regulations, position statements, and
standards of genetic counseling practice” (p. 2). Similarly, in the relationship between genetic counselors
and their colleague’s they should “Share their knowledge and provide mentorship and guidance for the
professional development of other genetic counselors, employees, trainees and colleagues” (p. 2). (Thus,
not only are genetic counselors responsible for their own professional development but also for that of
their colleagues, both practicing genetic counselors and genetic counseling trainees.
This chapter is intended to help answer the questions raised in the previous paragraphs. As with any
discussion it is necessary to speak a common language and understand varied perspectives. Definitions
Chapter 15 “Oh The Places You’ll Go” 343
of professional development will be presented as well as how those definitions might change as an
individual transitions from student to practicing professional and, the influence of changes in the
profession. Reflective practices, which are a key component of professional development, will also be
discussed. Lastly, as the leadership skills of the first generation of genetic counselors were directly
responsible for the development of the genetic counseling profession, a discussion of tapping into leadership
potential is included.
Literature Review
What Is Professional Development in Genetic Counseling?

Ask five genetic counselors to define professional development and likely five different definitions will
emerge. Most will probably include the concept of continuing education (CEU) with an eventual goal of
moving up the career ladder. While CEU and promotion are often part of a professional development
discussion, they are only two components of what is a “more complex and multi-faceted” topic (Callanan
and Redlinger-Grosse 2016, p. 615).
As a still relatively young field, definitions of professional development in genetic counseling
research typically draw upon the counseling psychology field. A 2016 issue of the Journal of Genetic
Counseling (JOGC), entirely devoted to the topic of professional development, used an American
Psychological Association (APA) definition of professional development for psychologists (Elman
et al. 2005):
“[P]rofessional development is the developmental process of acquiring, expanding, refining, and

sustaining knowledge, proficiency, skill, and qualifications for competent professional function-
ing that result in professionalism. It comprises both a) the internal tasks of clarifying professional
objectives, crystallizing professional identity, increasing self-awareness and confidence, and
sharpening reasoning, thinking, reflecting, and judgment and b) the social/contextual dimension
of enhancing interpersonal aspects of professional functioning and broadening professional
autonomy” (p. 368).
While a formal definition guides research and provides a framework for discussion, the description of
genetic counselor professional development as asserted by Zahm et al. (2016) provides a more practical
view of necessary components: “experience in combination with reflection upon that experience
(through introspection, self-reflection, informal discussion with colleagues, or other means) is essential
to professional development. Moreover, professional development is an on-going, non-linear and grad-
ual process, with defining moments’ or key events providing additional ‘bursts’ of influence” (p. 830).
Alternatively, professional development can be thought of as an iterative process requiring a genetic
counselor to uncover the meaning of their experiences and apply that meaning to their work (McCarthy
Veach et al. 2010). The process should not be stagnant but requires continual review and revision to take
advantage of new opportunities (serendipitous opportunities or purposely sought out) and incorporation
of the lessons learned from both professional and personal experiences into their professional identity
(Zahm et al. 2016).
What Might a Professional Development Journey Look Like?

The first genetic counselors did not have a road map for their professional development journey as the
field was not even universally recognized as a profession. To continue the journey metaphor, not only did
the first generation of genetic counselors drive their own cars, they provided the fuel for the trip and built
the road that was to be followed by generations to come. As Baty (2018) explains “The growth of the
profession paralleled individual career development of pioneers from within the profession, and the
main body of practitioners whose roles were slowly but inexorably growing. Pioneering individuals were
critical to all of the {profession’s} milestones …. It took vision, courage, thoughtful assessment, diplo-
macy, and effective action to promote both individual and professional advancement” (p. 56).
There is still no specific road map for genetic counselors to follow, no “well-charted courses for
advancement, improvement, growth or promotion” (Hippman et al. 2016, p. 720). A review of genetic
counseling literature does, however, provide discussions that can serve as a guide along the way: descrip-
tions of career ladders, lattices, and trajectories, consideration of evaluative milestones and outcomes,
the characteristics of an “expert” genetic counselor and – the topic that binds these into a meaningful
whole – self-reflection as integral to the process.
Ladders, Lattices, and Trajectories

As noted earlier, many individuals probably equate career ladders and professional development.
Although it has been acknowledged that professional development is so much more (Callanan and
Redlinger-Grosse 2016), any discussion would be incomplete if the idea of a genetic counselor ladder was
not mentioned. Although published literature about genetic counselor career ladders is sparse, the PSS
and three recent articles in the JOGC provide important context.
Information about career ladders was included for the first time in the 2018 NSGC PSS (NSGC 2018).
Slightly less than one-third (29%) of respondents had an established career ladder (compared to 34% in
2019), and another 20% reported that a career ladder was being developed (compared to 13% in 2019). For
both the 2018 and 2019 surveys, respondents who indicated they did not provide direct patient care were
the most likely to have a career ladder. Similarly, in each year, genetic counselors who had a career ladder
cited a variety of elements that were considered for advancement with the single most important crite-
rion for advancement across all groups being managerial responsibility for staff (not including students),
followed by research activities. Lastly, the following data remained the same, with 87% of respondents
who had a career ladder reporting that the ladder had three levels or more, and 24% reporting at least five
levels to their career ladder.
Kofman et al. (2016) described creating a structured system of advancement within a single organiza-
tion for an approximately 20 strong genetic counseling workforce. Based on their review of the literature,
these authors note that career ladders enhance retention which is beneficial not only for employers but
employees as well. “These benefits include optimized clinical performance and professional develop-
ment for the employee, and reduced turnover, recruitment, and training expenses for the organization.
By providing advanced opportunities, career ladders incentivize accepting additional responsibilities,
which in turn drive development of new skills, knowledge, and proficiencies” (p. 644). While the authors
do not explicitly define a career ladder, the structure they developed parallels the description offered by
the Society for Human Resource Management “Career ladders are the progression of jobs in an organization’s
specific occupational fields ranked from highest to lowest based on level of responsibility and pay” which
implies promotion (a vertical step) that comes with increased responsibilities and compensation (Society
for Human Resource Management 2018, n.d.). As with professional development in general, the struc-
ture of the career ladder described by these authors is multi-faceted; it spans an individual’s entire career
(ongoing) and has vertical and lateral steps (accommodates development of expertise and broadening of
current skills).
While Kofman et al. (2016) describe the building of a career ladder at one institution, another article
(Baty et al. 2016) refers to a career ladder in the context of a broader discussion on career advancement.
Baty et al. investigated varied paths to post-masters training and career development and designed three
separate but interconnected grids that depict advancement through the lens of the skills needed to
advance, ways to obtain these skills, and existing positions that offer change or advancement. They speci-
fied, “Advanced training includes training beyond the attainment of genetic counseling competencies
provided in all master’s genetic counseling programs” (Baty et al. 2016, p. 629) thus, adhering to the
PBC’s and the COE which require a genetic counselor to not only maintain competence but to continue
their education and training. The grid specific to skills (Figure 15.1) is perhaps most germane to the dis-
cussion of professional development as it includes the genetic counselor’s rationale and motivation for
seeking advanced training.
Paths Grid
Skills Grid Duration/time
commitment
Rationale/
motivation Cost
Skills Domain
Resources Format
Benefits/
limitations
Paths
Skills-
Specific
Positions Grid
Track
Title
Role description
Support role category

Related positions
Figure 15.1 Advanced training for certified genetic counselors: An overview highlighting interconnections
between grids. Source: Baty et al. (2016, p. 630). Reprinted with permission.
An individual with motivation to advance their skills likely has a vision of where or who they want to
be, a vision being among the earlier questions posed in this chapter. Baty et al. (2016) suggest the grids
might provide a “potential framework for individual genetic counselors considering how they might
prepare for a specific, desired career opportunity …” (p. 630). For example, imagine a prenatal counselor
who envisions working in a program that provides care for families impacted by maternal morbidity due
to genetic disease. (S)he might choose to enhance her/his psychosocial skills through any number of
paths (e.g. suggesting topics for the annual conference, looking for relevant CEU programs, returning to
school for an advanced degree). A later article by Baty (2018) referenced the grids as not only being appli-
cable to “genetic counselors seeking personal growth in genetic counseling skills” (p. 57) but also to
genetic counselors seeking to climb a career ladder. Baty (2018) expanded the concept of a career ladder
for genetic counseling by using the term career trajectory to reference advancement or diversification
within the profession. The development of a career lattice expands the concepts of a career ladder and
trajectory as a lattice “includes both horizontal as well as vertical movements within career trajectories,
better capturing the richness of professional opportunities within a profession” (p. 59). A career lattice
may be a helpful structure for persons thinking about a career change. A lattice may also aid the develop-
ment of the profession (e.g. re-considering the scope of practice or finding new ways to use the core skills
genetic counselors possess).
How do we Know We’ve Arrived?

Evaluation is a vital component when any plan is carried out-educational or professional. Grading,
whether pass/fail, letter grade, or percentiles, are all used in colleges and universities. Health professions
training programs also use these markers but must adhere to additional guidelines as determined by
their accrediting organizations. Genetic counselors, physician’s assistants, physical therapists, and oth-
ers each have guidelines regarding the evaluative aspect of the programs they formally recognize, which
reference the specific competencies that guide student training (American Academy of Physician
Assistants 2012; ACGC 2015; Commission on Accreditation Physical Therapy Education 2017). Although
how to actually measure competence may be less clear, especially in genetic counseling. Whereas a
Doctorate in Physical Therapy (DPT) program might evaluate a student’s ability to correctly measure
elbow extension 80% of the time, there are no such measures for accurately assessing a genetic coun-
seling student’s ability to “promote client-centered, informed, non-coercive, and value-based decision-
making” (ACGC 2015 PBC, p. 2).
Guy (2016) suggested the ACGC and its accredited genetic counseling training programs consider mov-
ing in the direction of the Graduate Medical Educators (GME) (i.e. using a targeted, rubric-based evalua-
tion tool that describes what different levels of competence look like using competency-based milestones).
Milestones are “a significant point in development … that can be demonstrated progressively” (Accreditation
Council for Graduate Medical Education 2015) from needing significant oversite/assistance to independ-
ence in the task. Milestones might allow tracking of a student’s individual skills in all domains of the
PBC’s including the professional development domain from new student to entry-level genetic counselor.
Another approach to assessing students’ clinical skills is the Reporter-Interpreter-Manager-Educator
(RIME) structure. Developed in 1999 by Dr. Louis Pangaro RIME has been used in clinical training
programs to track a student’s journey to competence (i.e. from novice to expert using a 5-point scale [0–4,
with 4 being the highest], Pangaro (1999)). Whereas the RIME model follows the student from one
who can gather information and communicate the information they have obtained (the reporter) through
to mastery of skills they can now teach others (the educator), the milestones/checkpoints track the level
of independence of the student (i.e. from needing significant oversight to independence). Tables 15.1a,
15.1b and 15.2, respectively, contain examples of genetic counseling milestones/checkpoints and a RIME
structure using a genetic counseling setting.
As there are currently no agreed upon performance measures for technical skills (e.g. collecting a
three-generation family history) let alone the more complex skills related to professional behaviors (e.g.
act in accordance with ethical, legal and philosophical principles and values of the genetic counseling
profession) each genetic counselor training program is left to design their own evaluation tools that
capture a student’s progress toward competence in the PBCs.
Standards to assess the competence of the practicing genetic counseling are limited to American Board
of Genetic Counseling (ABGC) certification and maintenance of certification through CEU and approved
professional development opportunities (ABGC 2019). While achieving certification is an important
milestone for a genetic counselor, it is not evidence of their long-term competence or success in achiev-
ing professional goals. Maintenance of certification can be achieved by accruing CEU’s, a measure of
conference attendance but not competence. It is left to the employer and the counselor to assess, at the
very least, maintenance of entry level competence or, hopefully, advancing skill level. Achieving an
advanced skill level might be considered as mastery of the skill. Indeed, some careers define a path that
culminates in the title master (e.g. master carpenter or master electrician).
Imagine a MGC and how such a person would display competence. The word “expert,” which Merriam
Webster defines as an individual “having, involving, or displaying special skill or knowledge derived
from training or experience,” might come to mind. It is interesting that Merriam Webster (2019) now
considers “experienced” an obsolete synonym recognizing perhaps that experience in a subject does not
necessarily imply expertise. “Master,” however, is offered as a synonym. A 2016 article titled “Portrait of
the MGC Clinician: A qualitative investigation of expertise in genetic counseling” (Miranda et al. 2016)
describes a qualitative investigation of the personal characteristics of genetic counselors who are consid-
ered exemplary by their peers. The results offer insights into factors that promote optimal development
including, among others, increasing self-knowledge, the importance of mentoring, and experiences with
patients and colleagues that can be both influential and inspirational. The authors suggested possible
strategies for professional growth including on-going training in self-reflection, setting aside time to
intentionally reflect, and participating in peer supervision or consultation. It is noteworthy that all of the
suggestions referenced herein involve some aspect of reflection or developing a reflective practice.
Reflective Practice
What is Reflective Practice?

In its most basic form, reflective practice means transformatively “learning from experience” (Skovholt
2001, p. 27), a deceptively difficult activity. Simply engaging in an experience or set of experiences – say,
a 10-week clinical rotation – is not enough to result in professional growth. For example, two genetic
counseling students in their initial second year rotation may differ widely in their professional growth
due in part to their willingness and ability to engage in reflective practice. Similarly, two practicing
Table 15.1a Targeted rubric-based evaluation tool (incorporating specific checkpoints).
Second
First checkpoint checkpoint Fourth checkpoint Third checkpoint Fifth checkpoint
Task/skill Unacceptable (Sem 1) (Sem 2) (Summer) (Sem 3) (Graduation)
Receptive to Rarely asks for or Consistently asks for feedback

feedback makes the time to
hear feedback
Integrates Rarely incorporates With guidance, implements Consistently Often transfers Consistently
feedback into feedback and feedback in similar situations implements feedback to new transfers to new
future continues to make feedback in similar situations situations
performance similar mistakes situations.
Demonstrates Rarely engages in With guidance is able to analyze Often analyzes Consistently, Consistently,
self-reflection analysis and and discuss counseling session session and analyzes session, analyzes session,
discussion of identifies strengths identifies strengths identifies strengths
counseling sessions and areas for and areas for and areas for change,
change. With change, and Often and consistently
guidance identifies identifies ways to identifies ways to
ways to modify modify modify performance
performance performance.
Culturally Rarely With With guidance Often identifies and responds to patients Consistently
responsive and demonstrates guidance identifies and concerns and feelings and elicits patients identifies and
respectful to all awareness of identifies and responds to concerns. responds to patients

clients interpersonal responds to patients concerns and feelings
boundaries. patients concerns and and elicits the
Interacts with concerns and feelings and patients’ perspectives
patients in a manner feelings. elicits the
that is patient’s
condescending, rude perspective.
or uncaring
Table 15.1b Practice-based competencies and milestones (reprinted from Guy et al. 2016, p. 639).
PBC #3 Construct relevant, targeted and comprehensive personal and family histories and pedigrees
Level 1 Level 2 Level 3 Level 4 Level 5
●● Obtains ●● Obtains and interprets a ●● Obtains and interprets a ●● Independently obtains ●● Makes a nationally
general family genetics-focused family genetics-focused family and interprets a recognized contribution to
history history with substantial history with minimal genetics-focused family the construction or
●● Constructs guidance guidance history interpretation of family
pedigrees ●● Constructs pedigree with ●● Constructs pedigree with ●● Independently history pedigrees.
substantial guidance minimal guidance constructs pedigree
●● Synthesizes findings to ask ●● Synthesizes findings to ●● Independently
additional targeted ask additional targeted synthesizes findings to
questions with substantial questions with minimal ask additional targeted
guidance guidance questions
Source: Adapted from Medical Genetics Milestones (The Accreditation Council for Graduate Medical Education and The American Board of Medical
Genetics, 2012).
Table 15.2 Examples of RIME structure applied to genetic counseling practice based competencies.
Reprinted with permission.
Level 1 Level 2 Level 3 Level 4 Level 5
Domain I: Genetics
Expertise and Analysis
Domain II: Interpersonal,

Psychosocial and
Counseling Skills
Domain II: Education
Domain IV: Professional

Development and Practice
Didactic Courses Entry-level

Entry into MSGC
& Clinical Graduation Genetic
Program
Rotations Counselor
genetic counselors with dissimilar attitudes about participating in student supervision – to “give back”
vs. “it’s required” – will advance their skill in different ways … or, in the latter case, perhaps not at all.
Skovholt (2001) illustrates this notion by arguing that “The practitioner can have years of experi-
ence – rich, textured, illuminating, practice-changing professional experience in a helping, teaching, or
health occupation. Or a person can have one year of experience repeated over and over” (p. 27). He posits
that the discrepancy occurs because one has not used feedback from others and oneself to effectively
“transform practice.” If genetic counselors do not apply the results of self-reflection to make changes in
their conceptual frameworks, thoughts, and behaviors, they have not necessarily grown or developed
professionally. They are more or less running in place.
As discussed by Zahm (2010), while there is no standardized definition of reflective practice – or how
one “learns from experience” – much of the literature can be divided into two overarching conceptual-
izations: (i) reflective practice as an active, conscious, deliberate process comprised of several compo-
nents, and (ii) reflective practice as a hierarchy or continuum. Those who conceptualize reflection as an
active, multi-part process offer various definitions but overlap in their view that genetic counselors re-
evaluate and reconsider what they thought they knew, then subsequently change – perhaps by deepening –
their understanding of that experience. If conceptualized as a deliberate process, reflection necessitates
a conscious effort to examine one’s experiences and integrate the resultant reflections into one’s approach
to his/her practice. It also requires self-awareness and willingness to examine one’s experiences, beliefs,
perceptions, thoughts, and emotions.
Those who view reflective practice as a hierarchy purport there is utility in delineating levels or degrees
of reflection whereby the more highly skilled one is at reflective practice, the higher s/he falls on the
hierarchy. A well-known, hierarchy related to reflective practice is that of Bloom et al. (1956), who cre-
ated a six-level taxonomy of learning: knowledge, comprehension, application, analysis, synthesis, and
evaluation. Each level requires more complex skills and reflection. Another hierarchy is the “conscious
competence” model generally attributed to William Howell (1982), which posits that professionals use
reflective skills to move through four levels of knowing from unconscious incompetence to conscious
incompetence to conscious competence to unconscious competence. As described by Howell:
“Unconscious incompetence – this is the stage where you are not even aware that you do not have
a particular competence. Conscious incompetence – this is when you know that you want to learn
how to do something but you are incompetent at doing it. Conscious competence – this is when
you can achieve this particular task but you are very conscious about everything you do.
Unconscious competence- this is when you finally master it and you do not even think about what
you have such as when you have learned to ride a bike very successfully.”
(Howell 1982, pp. 29–33)
Combining the above descriptions a definition of “reflective practice” that can be used to describe genetic
counselors’ professional development consists of an active, three part process: experience (or recollection
of a previous experience), criVtical examination of that experience, and resultant change (of beliefs,
actions, etc.) (Boud et al. 1985; Boyd and Fales 1983; Peltier et al. 2005; Schon 1991). As such, reflection
is not simply thinking, or ruminating without purpose. Reflection is a process characterized by deliber-
ate, active seeking of growth and development involving both one’s professional and personal selves,
often including self-examination and subsequent changes in one’s beliefs, actions, and perspectives.
While a conscious process, reflection can occur spontaneously or deliberately and need not refer to a
monumental “defining moment” in order to lead to professional growth.
There is no single, prescribed way to practice reflectively. Rather, one needs to find personally effica-
cious and meaningful methods. Reflection can be done alone through journaling, written, or audio (e.g.
using the recording feature on a smartphone) to “hear” oneself talk through a particularly challenging
conversation. Whether the journaling is written or audio, such capturing would allow one to go back
after some time has passed and reconsider previous comments. Reflection can also be done with
colleagues through consultation or peer group supervision. Kennedy (2000) describes three different
models of supervision: individual where one counselor meets regularly with a more seasoned counselor;
peer group supervision where a group of counselors meet regularly to mentor each other; and leader led
peer group supervision where a seasoned counselor serves as a facilitator for a peer group.
It is also important to note that reflective practice is not simply venting to colleagues, although connect-
ing with colleagues to do so may be an immediate coping strategy for some counselors. Furthermore, it is
important to distinguish reflection from rumination or worry. For example, in one study, a genetic coun-
selor wrote, “I feel connected with the parents [of children in NICU] to the point of not being able to stop
thinking about their concerns, their fears, and their grief. I lose sleep over worrying about them” (Udipi
2007, p. 130). Another genetic counselor described her reaction after giving positive HD test results to a
father and daughter: “I didn’t sleep all weekend, thought about it over and over again all weekend, blaming
myself, stressed out, on edge, thinking of what to do, anxious, etc.” (Udipi 2007, p. 138).
These examples illustrate the type of rumination associated with compassion fatigue, and they high-
light the need for personal boundaries with one’s patients and one’s job. Furthermore, they may describe
normal initial responses to intense situations that occur throughout one’s career. However, in order to
move beyond compassion fatigue to reflective practice, the counselors would need to identify lessons
learned from these situations. This may include searching for answers to questions such as: What made
the situation difficult? How did I respond and why? Is there anything I could do differently the next time
I encounter a similar situation? This process may take time and require repeated consideration by the
genetic counselor through the methods suggested above. Indeed, the more reflective part of these sce-
narios would emerge from examining one’s thoughts, feeling, and actions surrounding the pervasiveness
of these intrusive thoughts about self. As practitioners, individuals need to take realistic responsibility
for their professional actions and for their personal reactions. It should be stressed that self-reflection
must be practiced honestly yet compassionately, as excessive self-blame may signal a more personal reac-
tion that is in need of professional attention (e.g. compassion fatigue, burnout, countertransference, or
other personal concerns).
Optimizing Self-Reflection
Genetic counseling students and practitioners are busy people. The most recent PSS (2019) indicates that
only 23% of respondents reported they did not work overtime hours, while 39% worked 1–4 extra hours,
26% worked 5–9 extra hours each week and 13% worked 10 or more extra hours each week. With the
ever-evolving demands of the workplace, burgeoning scientific/genetic technologies and knowledge,
and the multiple roles a genetic counselor is expected to fill personally and professionally, there is not
much “down time.” So where does reflective practice fit into an already busy professional and personal
life? Further, what happens once the inherent structures of reflective practice provided by being a stu-
dent are removed as genetic counselors graduate and become independently practicing professionals?
Recent research on the transition of novice counselors as they enter the workforce shows that the early
years have professional and personal challenges that can be addressed by support and guidance from
more experienced colleagues and peer supervision (Ramachandra et al. 2019). Following are suggestions
for cultivating reflective practice, as illustrated with clinical examples:
1) Make time for reflective practice – Take a few moments after a difficult case to process internally the
emotions, thoughts, and lessons that emerged or intentionally seek clinical supervision or consulta-
tion. While it may take time and energy now, carving time into your practice now can form a founda-
tion for lifelong professional growth and development.
2) Encourage reflective practice in others – Reflective practice should figure prominently in supervision
and supervisory relationships. Supervisors should reinforce its importance and supervisees should be
informed that self-reflection is an expectation. Supervisors should both operate from and model a
“reflective stance” (Ramachandra et al. 2019,Skovholt 2001, p. 28; Wherley et al. 2015), in which
supervisee questions are valued and encouraged. Encouraging and modeling reflective practice is
reinforced by the earlier reference to the PBC’s and COE which require that genetic counseling,
respectively, practice reflectively and, mentor and guide others.
3) Engage in peer group supervision – A growing body of literature on peer group supervision in genetic
counseling describes a number of potential benefits, including connecting with colleagues, engaging
in group-oriented reflective practice, and learning reflective practice by modeling (of other practitioners)
and trying out in vivo one’s own thoughts and ways of learning from experience (Bosco 2000; Hiller and
Rosenfeld 2000; Kennedy 2000a, b; Lewis et al. 2017; Likhite 2000; Middleton et al. 2007; Zahm et al.
2008). Further, peer group supervision may promote professional development and serve as a buffer
against burnout, compassion fatigue, and impairment (Abrams and Kessler 2002; Keilman 2002;
McCarthy Veach et al. 2002; Resta 2002; Young 2002). Reflective practice in this venue can occur both
intrapersonally (e.g. observation of colleagues engaged in self-reflection) and interpersonally (e.g. pro-
cessing one’s own experience with trusted colleagues who provide valuable feedback and support).
a) For example, Bosco (2000) describes a particularly difficult case involving a prenatal couple who
received a diagnosis of skeletal dysplasia. Bosco discussed with them the option of termination,
which was declined. However, later she learned of the woman’s subsequent suicide. Bosco
describes her experiences with her peer supervision group as “invaluable” (p. 425) for helping her
to reflect upon her thoughts and feelings about her experiences with this couple.
4) Value “tell[ing] your stories” (Abrams and Kessler 2002, p. 16) – This approach might involve writing
self-reflective articles for professional publications, participating in professional conferences and
presentations, and joining regional and national professional organizations. These activities provide
opportunities to reflect on practice with colleagues one might not otherwise encounter. For example,
Bennett (2002) encourages genetic counselors to share their stories and their work: “we are waiting to
hear YOUR voice” and “Each of us should be writing, presenting abstracts, and seeking funding for
research in the countless areas of genetic counseling that we work with every day” (p. 320). Sharing
of experiences not only promotes individual professional development and self-reflection but collec-
tive professional development and reflection for the field as a whole.
5) Periodically tape and critique a genetic counseling session or journal about experiences – Words, ges-
tures, or dynamics that were not as readily apparent while in session with a patient(s) may be more
easily noticed. An even more potentially fruitful variation of this strategy is to engage in tape critique
with peers, such as in a peer supervision group. Additionally, maintaining a professional journal is
one way that some professionals cultivate reflective practice. In 2011, a series of MGC tapes were
produced as part of a Jane Engleberg Memorial Fellowship (JEMF). The tapes were recorded sessions
of the MGC counseling a standardized patient followed by an interview with the counselor that
included their reflection on the session as well as how they incorporate self-reflection into their practice.
One of the MGC intentionally uses both audio-taping of patient sessions and journaling. When asked
to talk about ways these activities help her maintain or improve as a counselor, she replied, “Well, the
first one’s easy because I ask my students to tape. And it just feels inappropriate for me to ask my
students to do something that I wouldn’t do. So they tape. We listen. We look at things they’ve done
well. We look at missed opportunities, and we do exactly the same thing for me. And I can always find
missed opportunities … things that I can work on ….” She went on to say and “I journal …. it’s very
interesting sometimes to go back and review those to get kind of get a sense of where the similarities
are, where my style has come, developed. But also, I really – it’s amazing how much I learn when I
just pour it out of hand through a pen on to the paper” (NSGC 2011).
a) Questions about an experience that might prompt a discussion or a journal entry include: What
happened and how? What did I learn from this? How does/did this experience affect me person-
ally? Professionally? What do I wish I had done differently? What will I do differently in the future?
6) Challenge yourself in your genetic counseling practice – Avoid simply “coasting” through your work. Set
and keep a record of your professional development goals. At a regularly designated time (e.g. the first
day of the year, your birthday, anniversary of beginning your job) add to or revise your goals. These
goals may involve general career advancement objectives or specific knowledge or skills you would like
to master, but they also might include goals relating to how you internally process experiences, your
own “hot button” issues that come up in sessions, etc. Throughout the year, refer periodically to these
goals. Many institutions require performance evaluations that often include goal setting; use this
opportunity to consider professional development goals.
Leadership
The genetic counseling profession has relied on leaders from its inception to pave the way for those that
follow. Leadership is so vital that NSGC, the leading voice, authority, and advocate for the profession pre-
sents several annual Leadership Awards that “acknowledge the actions and behaviors of exemplary genetic
counselors” (NSGC n.d.). The common descriptor in each of the award categories is an NSGENETIC
COUNSELING member who has made “significant contributions” to the field. This is consistent with
many definitions of leadership including one proposed by Vroom and Jago (2007) as a process of motivating
people to work together to accomplish great things.
In commenting on the initial collection of individual genetic counselor essays on defining moments,
McCarthy Veach et al. (2002) note that for several of the authors, the defining moment demonstrated the
effectiveness of genetic counselors as activists. The authors state that genetic counselors must “take
deliberate action in order to help the profession gain the respect and credibility that it deserves, to move
the profession forward, to increase understanding of what genetic counselors do in sessions, to make
genetic counseling comprehensible and available to the public” (p. 335). Put into the context of leader-
ship, one could also say that genetic counselors must, and do, use their leadership skills to help the pro-
fession: “Leaders are people who use their passion, creativity, ideas, and influence skills to challenge the
status quo and foster change, and they do so the best way they know how” (Ambrose 2003, p. 66).
Often, leadership begins with the internal developmental struggles of the individual leader. It is by
integrating and learning from these crises that people can gain the stamina and tools of effective
leadership. One does not have to intentionally set out to “be a leader” in order to exercise leadership.
But, when confronted with choice points in our lives, the direction we choose for ourselves will deter-
mine whether we exercise leadership – creating the future we desire – or succumb to pressure or
complacency (Ambrose 2003).
As genetic counselors and health care professionals we will face multiple challenges and opportunities
over the course of our professional lives that can result in developing and using leadership skills. We may
find ourselves in difficult work environments. We may encounter situations when awareness of the chal-
lenges faced by our patients propels us to action. For example, the economic realities of the health care
system may necessitate creative changes in service delivery models. Changes in jobs or job descriptions
may result not only in new opportunities but necessitate new approaches to managing our time and/or
our professional relationships. We may find ourselves put in obvious positions of leadership, for exam-
ple, being promoted to a supervisory position. Or, we may appreciate the need for leadership in other
professional roles, such as teaching or supervising students. We may seek opportunities for professional
growth by actively volunteering for local, regional, or national leadership positions. Being a leader can
make the difference between experiencing genetic counseling as a “career” versus a “job.”
Making Leadership Skills Work for You: Ten Things to Keep in Mind
1) Leadership is not about position. You do not need to be granted a specific position or title in order to
exercise leadership. In fact, demonstrating leadership in your daily work environment will probably
result in opportunities for your growth in terms of both influence and position. Leadership is about
influence and motivating people to work together toward goals. Many of the skills associated with
effective leadership can be learned and practiced. People notice leadership behaviors, and as you
build your skills (and influence) you may find that opportunities to advance become available.
2) Genetic counselors possess many of the skills that are commonly associated with leadership. There is a
good fit between the qualities and skills associated with effective leadership and those associated
with genetic counseling. Some of these include: critical thinking skills, intelligence, ability to per-
form complex tasks, and commitment to life-long learning; communication skills; empathy and
emotional intelligence; and problem-solving and decision-making skills.
3) Self-awareness is a good first step in developing your leadership skills. Having insight and clarity about
your core values, beliefs, attitudes, and feelings is the first step in developing authentic leadership.
Evaluating your motivations to lead, and assessing your strengths and weaknesses are also
important.
4) There are many things you can do to develop your leadership skills including reading about leader-
ship, attending workshops on leadership, observing effective leaders, and participating in coaching or
mentoring relationships. Opportunities that challenge you to apply your skills in new situations,
especially when coupled with critical reflection on how you applied leadership skills in meeting
these new challenges, provide additional ways to develop your skills. Sometimes, you just need to
“go out on a limb” and push your limits in order to develop skills.
5) You are responsible for your own career satisfaction and success. Just showing up each day and com-
pleting all of the tasks assigned to you does not automatically put you in a position to advance. If you
want increased professional recognition, advancement, reward, or new ways to achieve personal
satisfaction, you must seek opportunities to demonstrate your leadership skills. This is the difference
between viewing genetic counseling as a job or as a career. If you are offered an opportunity, take it,
even if it is not associated with a new title or increase in salary. A common mistake is to stick too
closely to your job description. If you do this, it is likely that you will miss great opportunities for
personal and professional growth and ultimately for advancement.
6) People will follow a leader. As the saying goes, if you think you are leading, but no one is following,
you are just taking a walk. To be a leader, you must act like a leader. It is not enough to identify
problems – you must also use your skills to develop creative solutions and to influence positive
change. You need to develop constructive relationships (partnerships) with other leaders as well as
the people that you lead.
7) One important aspect of leadership is developing leadership in others. Good leaders facilitate, pro-
mote, and celebrate the success of others. By modeling leadership skills, sharing what you know,
and inspiring and collaborating with others you can accomplish great things. Leadership involves
incremental influence. The more people you engage in the process, the greater your influence.
8) Leaders have the ability to manage their own emotions and the emotions of others. An important com-
ponent of leadership is the ability to first recognize and then manage your own emotions and the
emotions of those you lead. Empathy is a critical component of this ability. You can, and should,
make your counseling skills work for you in leadership situations. Effective leaders are skilled at
promoting optimism and reducing frustration in others.
9) Leaders must be open to change and willing to take risks. In order to be an effective leader you must
be willing to challenge the status quo, remain open to positive change and tolerate reasonable levels
of risk and ambiguity. This does not mean you must constantly change things for the sake of change
alone. But, you should strive to avoid complacency (“We’ve always done it that way”) and stay open-
minded to new ways of doing things. Often, this involves taking calculated risks and dealing with
uncertainty that the change will lead to the desired result. Leaders understand that failure happens
sometimes and often view failures as a learning experience.
10) There is no single leadership style that works in all situations. It is important to develop a range of
leadership skills and be flexible in your leadership style. Effective leaders adjust their style to the
motivation and capabilities of their followers.
Summary Points
●● Professional development was defined as a lifelong iterative process requiring a genetic counselor to
uncover the meaning of their experiences and apply that meaning to their work. The process should
not be stagnant but requires continual review and revision to take advantage of new opportunities
(serendipitous opportunities or purposely sought out) and incorporation of the lessons learned from
both professional and personal experiences. While multiple definitions exist, reflective practice was
defined in this chapter as an active process consisting of three parts: experience (or recollection of a
previous experience), critical examination of that experience, and resultant change (of beliefs and/or
actions) (Boud et al. 1985; Boyd and Fales 1983; Peltier et al. 2005; Schon 1991).
●● While career ladders are not synonymous with professional development, the existence of a ladder in
an organization is beneficial to both the employee and the employer; the employee may gain new skills
thereby optimizing their performance, and the employer experiences reduced turnover, and recruit-
ment and training expenses.
●● Literature on professional development in genetic counseling and related literatures widely corrobo-
rates the importance of reflective practice.
●● Reflective practice is not necessarily an isolated activity. While internal reflection is useful and neces-
sary, engaging in dialog with colleagues, supervisors, and trusted others in a supportive environment
is also important.
●● Strategies for practicing reflectively include focusing on this activity in clinical supervision; participat-
ing in peer group supervision; sharing “stories” and experiences with colleagues (e.g. through writing
or presentations), and early integration of self-reflection into practice in order to create a foundation
for lifelong learning and development.
●● Genetic counselors possess many of the values, behaviors and skills that have been associated with
effective leadership and they can employ strategies for developing their leadership skills.
●● There are many opportunities for genetic counselors to use leadership skills to enhance their own
professional satisfaction and to promote the growth and sustainability of the profession.
●● “Oh the places you’ll go” – By understanding professional development, modeling reflective practice
and encouraging others to do the same and, seeking opportunities to demonstrate leadership and pro-
moting leadership development in each other, genetic counselors can gain not only personal and pro-
fessional satisfaction and growth, but can also move the profession forward in positive directions.
Acknowledgments
Some of the content in this chapter is directly drawn from two chapters in the first edition of this book,
specifically:
Zahm, Kimberly W. Chapter 14: Development: Reflective Genetic Counseling Practice.
Callanan, Nancy P. Chapter 15: Mobilizing Genetic Counselor Leadership Skills.
Learning Activities
A) For the Genetic Counseling Student:
Activity 15.1 Creating a Professional Development Plan for Clinical Training

This activity can be done individually as an assignment or in class for group discussion.
Students are directed to take a few moments to consider where they want to be when they graduate
(i.e. what they aspire to do as an entry level counselor). For example, do they aspire to practice clinically
and have an opportunity to teach genetic counseling students and other health professionals; or do
they want to search for a position that includes clinical trial opportunities?
1) Identify specific skills they need to develop (e.g. creating learning objectives)
2) List activities to help build these skills (e.g. Teaching Assistant [TA], attend seminars in relevant
departments, talk with instructors about campus resources available for graduate students wanting
an academic career).
3) How will they know they have progressed on this journey? (e.g. student evaluations from TA position
are positive)?
Estimated time: 30 minutes
Note to Instructor
If this is done in a group setting, students can gather as a group and discuss their thought process
and brainstorm about other options that might be available. This same exercise could be completed
at the end of every semester or some other checkpoint to see what has changed now that they know
more about the genetic counseling profession/have had more experience.
Activity 15.2 Applying Reflective Practice to Clinical Training: Case Presentation

Students prepare a case summary using the case presentation template provided in Appendix 15.A
and identify at least three counseling issues to discuss. Students should be directed to consider
cases where things did not necessarily go as well as they had hoped or that were challenging in
some way (either clinically, in supervision, due to system issues, etc.).
The case summary, which should be encrypted or de-identified, should be sent to classmates in
advance so time is not spent reading in class. A few minutes are allowed for classmates to ask clarifying
questions, followed by 15–20 minutes of non-judgmental discussion that includes the following:
lessons learned, what might have been done differently/other strategies, what might have been done
to prevent the problem in the first place, etc.
Estimated time: 30 minutes per case
Activity 15.3 Identifying Leadership Opportunities in Relevant Genetic Counseling Professional

Organizations
This can be done through a journaling exercise, online discussion board, or in-class activity.
Have students make a list of their strengths and at least one professional development goal. They
should then be directed to explore the NSGC, ABGC, and ACGC websites (mission, vision, opportunities
to get involved). Identify which organizations and opportunities align with their personal goals and
strengths.
B) For the Practicing Genetic Counselors:
Activity 15.4 Creating a Professional Development Plan

This activity can be done individually through journaling or in preparation for a discussion with a
peer group or identified mentor. The activity is based on the skills grid from the Baty et al. (2016)
article discussed in the chapter.
1) In writing, identify at least two professional development goals. Consider any domain discussed
(e.g. is it to climb the career ladder at your institution or create the ladder because one doesn’t
exist; or to incorporate reflection into your everyday practice or start a peer supervision group, get
involved in student supervision or enhance your student supervision skills). The options are
endless.
2) Brainstorm what it will take to get there; skills to be enhanced, resources to access that will help
develop the skills and who can/is available to help.
3) Develop a timeline for review and continued revision. Remember this an iterative and lifelong
process.
Activity 15.5 Applying Self-Reflection on a Critical Incident

In writing, describe the most difficult experience you have had as a genetic counselor to date (This
need not be a dramatic event, just an experience that was difficult for you in some way). What made
this experience difficult? How did you “resolve” the situation, including your own resultant thoughts
and feelings about the situation? What personal and professional factors contributed to making this
difficult experience so difficult? What did you learn about yourself from this experience and your
subsequent management of it? How has your practice changed since this experience?
This exercise, suitable for a peer supervision group, may work well as a two-part process of writing
(in order to provide adequate time for reflection), and subsequent sharing in a dyad or small group.
Activity 15.6 Applying Leadership Skills in the Workplace

Participants work in groups of three to five. They are asked to:
1) List three main organizational or unit goals for your current work setting.
2) Identify one or more barriers for meeting these goals.
3) Think of at least one strategy to overcome each barrier you identify.
4) Develop a plan for presenting the strategy to your manager and co-workers.
Small groups come back together and discuss their goals, strategies and plans with the larger group.
Feedback from the group can be used to modify the plan and strategy for each individual.
Appendix 15.A Case Discussion Template
Case Presentation Format (the template provides a formal structure for discussion. Learners should be
reminded that the discussion is an open, safe and non-judgmental forum)
GC Intern name:
Rotation:
Patient: initials only
Age:
Referred by:
Medical Hx: relevant past and current status. A brief description of the natural hx of a dx might be
included – but be prepared to answer questions that might arise.
Family Hx: relevant hx only
Psychosocial Assessment: a brief summary but be prepared to answer how you arrived at these initial
thoughts
Identified Counseling Issues: as requested by the counselee and as perceived by you
Interview Behavior: yours and theirs
Questions/Issues/Comments for Discussion: First consider issues that relate to the support and advo-
cacy components of genetic counseling and issues related to professional boundaries and ethics. Initiating a
discussion about explanation/education strategies would also be appropriate. In general, issues relating to
diagnosis, natural hx etc are generally not to be included since there are other forums for these discussions.
Additional comments: Cases should between 1 to 1 ½ pages (single spaced, 11 to 12 point). Bring enough
copies for everyone; please send me an electronic file for your portfolio. Each case will be allotted approxi-
mately 20 minutes beginning with silent reading of the written pages followed by questions for clarification
and discussions of identified questions/issues/comments. The discussion will include opportunities to share
ideas, offer suggestions, play devil’s advocate, etc. It is very important that the discussion remain open and
non-judgmental
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341

“Oh The Places You’ll Go!” The Genetic Counselor Professional

Spoiler alert: Kermit eventually chose cab driver.

and current approach to genetic counseling practice” (ACGC 2015, p. 2).

What Is Professional Development in Genetic Counseling?

“[P]rofessional development is the developmental process of acquiring, expanding, refining, and

autonomy” (p. 368).

What Might a Professional Development Journey Look Like?

Ladders, Lattices, and Trajectories

Support role category

How do we Know We’ve Arrived?

What is Reflective Practice?

Receptive to Rarely asks for or Consistently asks for feedback

respectful to all awareness of identifies and responds to concerns. responds to patients

Level 1 Level 2 Level 3 Level 4 Level 5

Level 1 Level 2 Level 3 Level 4 Level 5

Domain II: Interpersonal,

Domain II: Education

Domain IV: Professional

Didactic Courses Entry-level

A) For the Genetic Counseling Student:

Activity 15.1 Creating a Professional Development Plan for Clinical Training

Activity 15.2 Applying Reflective Practice to Clinical Training: Case Presentation

Activity 15.3 Identifying Leadership Opportunities in Relevant Genetic Counseling Professional

B) For the Practicing Genetic Counselors:

Activity 15.4 Creating a Professional Development Plan

Activity 15.5 Applying Self-Reflection on a Critical Incident

Activity 15.6 Applying Leadership Skills in the Workplace

Appendix 15.A Case Discussion Template

Patient: initials only

Family Hx: relevant hx only

Identified Counseling Issues: as requested by the counselee and as perceived by you

Interview Behavior: yours and theirs

Medical Genetics. Part C, Seminars in Medical Genetics 178: 54–62. https://doi.org/10.1002/ajmg.c.31601.

in ChangingMinds.org (n.d.). Conescious and Competence http://changingminds.org/explanations/

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