I was investigated by a State Compliance Office for practicing without a license. At the time, my previous employers did not require or have a clear policy on licensing. I am grateful that my current employer (Progenity, Inc.) does have a clear policy in support of licensing genetic counseling employees.
My genetic counseling career has been unconventional; I’ve worked almost exclusively in industry, holding non-direct care positions at multiple laboratories. I believe my role fulfills a profound need for clinical support and oversight within the commercial space.
While I have always been supportive of licensure efforts and open to applying for licensure, I have struggled to understand how licensure applies to non-direct care roles. Self-led research wasn’t helpful; I got lost in legislative language, the scope of which is specific to clinical interactions, and found little guidance from professional organizations, colleagues, or friends. I ultimately deferred to my employers.
My first laboratory employer did not require licensure, as the central laboratory was in a state that had not passed legislation. I resided in a different state and spoke remotely to providers, and occasionally patients, across the United States. My second laboratory employer did not require licensure, as my role was educating providers. I worked within a designated geographic territory outside my state of residence, but also worked with providers across the country. For a portion of this time, I both lived and worked in states with licensure. At one point, I decided to apply for licensure in my state of residence to support local policy efforts. That was short lived, as the application required employer support, which I did not have. I felt stuck, but I thought it must be okay since internal legal counsel had reviewed and approved licensing policies.
It wasn’t until I started my current role that I was required to pursue licensure by a laboratory employer. I educate providers within a territory and sometimes across the United States. I do not typically speak to patients. I am currently licensed or in the process of becoming licensed in all 26 states with licensure — an impossible feat without resources, financial reimbursement, and administrative support (including a small but mighty group of genetic counseling assistants) from my employer.
Ironically, submitting a licensure application triggered my investigation. A previous state of residence filed a complaint after noting that I had lived in the state while working for former laboratory employers for years without a license. Upon learning of the investigation, I instantly felt sick. I was simultaneously outraged—at the system for being confusing, at previous employers for not protecting me, and at myself for letting it happen. Those feelings lingered for months as I went back and forth with prosecutors to submit documentation of my employment, job responsibilities, supervisor contacts, business papers (i.e. business cards, business stationary, email signatures) and an estimate of the number of days I worked during the period of time I did not have a license, to quantify my violations.
I was outraged- at the system for being confusing, at previous employers for not protecting me, and at myself for letting it happen.
Our profession is facing an enormous problem: The licensing system that we fought for, as it currently exists, does not serve our whole community. Legislative language is not inclusive of genetic counselors in non-direct care roles, which has perpetuated confusion among individual genetic counselors and employers, resulting in a lack of standards for licensing genetic counselors in these roles. Moreover, the existing framework and complexity has made multi-state licensing unthinkable for a growing workforce of laboratory employers and genetic counselors that support providers and/or patients across the country. We desperately need guidance on when and where licensing is required, and an easier process for nationwide licensing.
My investigation was ultimately dismissed with no formal charges filed, but it could have been different. Licensure laws have real consequences, including suspension or revocation of licenses and monetary civil penalties up to $10,000 per violation. Individual genetic counselors bear that burden. This experience has motivated me to contribute to the licensing dialogue and focus on work that could lead to positive change, including research on the burden of multi-state licensing and current industry standards for licensing. If this happened to me, it has most certainly happened to others, and it will continue to happen if we don’t find a solution.
Mia Salimbene Mackall, MS, CGC earned her Master of Science degree in Genetic Counseling from Brandeis University. She has over seven years of industry experience supporting women’s health genetic testing and is currently employed as a Medical Science Liaison at Progenity, Inc. She is leading research on industry standards for licensing laboratory genetic counselors and serving as a consultant on research with George Washington University exploring credentialing for laboratory genetic counselors.