Barriers to Diversity in Genetic Counseling Programs

“Wow. You guys are all the same!” my friend said to me after he met another genetic counselor. He was referring to the fact that we were both young women with a bubbly personality and a high level of enthusiasm for genetics (dare I say, nerdy?). Though his sample size was small, he hit one fact square on the head: genetic counselors are a very homogenous group.

According to the 2019 NSGC Professional Status Survey (PSS), 95% of genetic counselors in the U.S. are women and 90% identify as white/caucasian. For a group that strives to be understanding and culturally sensitive to our clients, this fact has some of us looking at ourselves and wondering why. How do we increase diversity and inclusion in our field? This has become a hot topic of debate within our profession.

Gate Keepers

The initial gate keepers to our profession are our genetic counseling graduate programs. There were only 468 seats available for GC grad students in 2019, and over twice as many applicants vying for those positions. Our grad programs have the upper hand in this highly competitive environment. We can and should choose only the “best” candidates to invite into the fold. But are the metrics we’re using to judge those candidates measuring what we think they’re measuring?

What are we Actually Measuring?

High academic achievement. Well-rounded experience. Compassionate and personable. These are some of the things we’re looking for in a GC applicant. How do we ensure our candidates have those qualities? We set requirements that must be achieved in order to prove they meet our standards. This approach seems straight forward, but we must look at these requirements at every angle to make sure we’re actually measuring what we want to measure.

The GRE

The Graduate Record Examination (GRE) is a staple among graduate school admissions requirements across the country, but studies have brought into question its usefulness in predicting outcomes. Two studies published in 2017 concluded that the GRE is a poor predictor of a student’s academic success.

When I was applying to GC school (over a decade ago), I called my first-choice program to and asked them what a passing score on the GRE was. They couldn’t tell me. I then asked in general, what’s considered a “good” score? They wouldn’t tell me that either. So, I took the exam once, then called again to tell them my score, just to see if I needed to try again. When I told them what my score was, they said “Oh yeah, that’s fine.” Their reaction didn’t convey the sense that this test was important. Maybe other schools would have reacted differently, but this one made me feel like the GRE was just a pay-wall. An extra fee of both time and money that wouldn’t make an actual difference except to deem me “unqualified” if I failed to jump through the hoops.

Any requirement that’s just a box on the list to check off, but costs the applicant time and money, is going to disproportionately affect those with fewer resources. If the GRE isn’t actually good at measuring the applicant’s academic aptitude, then requiring it is more likely to measure the applicant’s financial aptitude. Last I checked, “high financial achievement” isn’t on the list of things that make a good GC.

Admission Interviews

Of all of the grad school requirements, I believe the interview is one of the most important. If done right, it can identify those who will shine as a GC, but it also has the potential to be the great homogenizer of our profession.

Genetic counseling can be a very emotional job. We interact with patients when they are dealing with very difficult situations. We support clients who are making some the toughest decisions of their lives. We start practically every session by asking people for very personal information about themselves and their family members. The capacity to be sensitive, show compassion, and demonstrate empathy are not typically apparent on an undergraduate report card. The interview helps admission committees evaluate candidates in this regard.

Because this interview process is more “touchy-feely,” it also means it is vulnerable to subjectivity and personal bias. If you are excited about a candidate after their interview, that’s wonderful! Now take a moment to think deeper about why. Why did you “click” with that her? Was it because her cultural values mirror yours? Did her demeanor make you feel comfortable? Does she present herself the in way you expect a good candidate to? Do you feel like you’re on the same page? Those are great connections to have.

Now, think about the candidates that you didn’t “click” with. Did he not fit your mental image of what a GC “should” be? Was her point of view different from yours or confusing? Did you just not get that same connection you did with the first candidate? Differences in cultural values, language, mannerisms, and appearance can all trigger that subconscious part of our brain that identifies “otherness” and may leave us feeling less enthusiastic about someone.

We tend to be drawn to those who are most like ourselves. This is not a conscious choice, and none of us really like to think we’re susceptible to it, but we are. It takes intentional action to counteract this tendency and identify our biases. Otherwise, we will continue to recruit those who fit the pre-established mold. If we only have one type of GC, we will only “click” with one type applicant, and one type of patient. Our profession will not have the diversity of experience it needs to grow our collective knowledge of how to best serve our diverse patient population.

In-Person Interviews

In a series of very unscientific polls I conducted on Twitter and Instagram, I asked GCs a few questions about their graduate school experiences. 61% reported going to 3 or more in-person interviews that required a significant amount of travel. Flights, lodging, and food, all add up very quickly, especially if you have to take time off work to go. This is a very significant pay-wall that needs to be closely scrutinized and justified.

Telecounseling is becoming more and more utilized. We understand the burden traveling to a clinic can have on a patient, and use phone and video tools to help mitigate that burden when we can. Technology has allowed genetic counselors to work from anywhere as well, with 35% of GC reporting on the PSS that they work remotely at least part-time. Why not utilize the same tools to interview our prospective students?

If the option of virtual interviews is to be offered, it needs to be offered whole-heartedly. If we don’t advertise their availability and only reserve them for emergencies, we dissuade people from asking for them for fear of appearing less dedicated. Viewing those who choose a virtual option as uncommitted puts an unfair judgment on those with fewer resources.

Paid Work During Grad School

In another unscientific social media poll I conducted, 62% of respondents said they worked for pay during graduate school. Some reported doing this even though it was discouraged by their program. We can’t be blind to the financial resources that it takes to get through school. Beyond tuition, students have to pay for books, supplies, rent, utilities, food, transportation, clothing, toilet paper, you know… life. At my school, we even had to pay for parking at some of our clinical rotations. To students who are economically disadvantaged, the price tag may be out of reach without some form of income.

Like many of respondents of my poll, I worked part-time during school as well. Finding a job that was flexible enough to fit in-between a busy schedule of classes, clinic rotations and thesis writing was a challenge. Schools can do a better job of giving their students opportunities to earn wages during graduate school, but need to do so carefully. The University of Pittsburgh advertises that they have paid positions available for their GC students that can usually lead to thesis opportunities. I think this is a great way to help students meet their financial needs, as long as care is taken to ensure the positions are truly flexible and will not overwhelm the students. As my employment had nothing to do with my school, I felt comfortable declining shifts or quitting when I needed to. A student who is employed by their school or program may fear being viewed negatively if they feel like the work is becoming too much to handle.

Relocation for Grad School

White-American culture has a heavy emphasis on independence. In general, kids are expected to “go off” to college, and coming back to live at home afterwards is considered “failure to launch.” Following your dreams wherever they may take you is part of the American dream for a lot of families. From this perspective, leaving your home state or country to attend grad school is a positive step to take, and a step that 72% of my online survey respondents reported taking. But that is not the case for every culture.

Many other cultures value interdependence over independence. In cultures where multi-family homes are the norm, a child moving across the country for school could be seen as an abandonment of family responsibilities. Some students may feel guilty spending financial resources to attend school rather than supporting their families.

Members of ethnic, cultural, religious and other minority groups might have a hard time finding members of their own communities to connect with in their new location. This can exasperate the feeling of isolation and “otherness” they might already feel in American culture.

One way to address this additional cultural burden on students would be to let them live where they want. Until we have a program in every city (or even just every state), distance learning may be the best option to avoid relocation. Online universities have been available for years, but remote-programs are just getting started for genetic counseling. Boise State University and Bay Path University now offer online learning with minimal travel required. Making this option more available will make becoming a GC more accessible for more people.

One of the arguments sometimes heard against diversity and inclusion initiatives is that we shouldn’t “lower our standards” in the name of diversity. I agree, but we need to judge applicants by the qualities that matter, not their ability to jump through and pay for arbitrary hoops. We need to be certain that our standards are serving their intended purpose, are measuring the metrics we actually want, and are not creating unintended burdens on our prospective students. We should strive to evaluate our requirements scientifically (thesis project anyone?), and be intentional about reducing bias. Removing financial, physical, and cultural barriers to graduate school is one step we can take in creating a more welcoming and inclusive community of highly qualified genetic counselors.