I took the genetic counseling board examination in 1990, back when it was given by the American Board of Medical Genetics (ABMG), only in three or four cities across the U.S., and once every three years. So not only did it cost a fair amount to travel to an exam site, but if you failed the exam, you had to wait a very long time to take it again. After a series of events beyond the scope of this article, ABMG stopped certifying genetic counselors in 1992, and the American Board of Genetic Counseling (ABGC) was born of necessity. While current licensure requirements in those states that offer it vary, obtaining a license requires applicants to have passed the ABGC certification examination.

Regardless of who has promulgated the exam, it has always been a multiple choice standardized test. I am sure I am not alone in noticing that there seems to be very little correlation between one’s success on the exam and one’s ability to practice effectively. I’ve personally known genetic counselors who left the profession because they could not pass the exam, and these were bright, energetic, empathic people who we would be lucky to have amongst our colleagues. I’ve also had brilliant colleagues who had no trouble passing the exam, but who didn’t necessarily have the psychosocial skills to perform optimally in a clinical setting. Paraphrasing a GC friend, the exam may be a dumb hoop to jump through, but it’s the only hoop we have. I have told this to my students repeatedly, not because I’m trying to malign the exam or those writing it, but to underscore that their ability to pass the exam should not be taken as a measure of their ability to be successful genetic counselors, other than the fact that the lack of certification would make that all but impossible.

I am not for one moment suggesting that we do away with some form of certification mechanism. Clearly it is imperative to have a metric to prove to the public that we are capable, professional, and ethical, and to have a basis for state licensure. This is vital, but the way we do it can be changed.

For decades, we have been talking about increasing the diversity of our profession, not only because it is the right thing to do, but because it is important for our patients to see themselves represented in the healthcare professionals who treat them. But there is so much evidence to suggest that those from racial and ethnic minority populations do not pass standardized tests at a rate equivalent to those in the (at least for now) majority white population in the U.S. and Canada. Myers, et al (2022) summarized associations between select admissions requirements for GC training programs, demographics, and performance on the ABGC certification examination. They showed that female trainees and white trainees had a higher likelihood of passing the exam on the first attempt. Some of this may be traced back to those who are admitted to our programs to begin with, which is another whole area to study, and they pointed out that genetic counseling professional organizations need to continue assessing and eliminating outcome disparities in admissions, training, and certification.

There are many examples of disparities in standardized testing. Dawson et  al. (1994) performed a retrospective analysis of the performance of individuals from various racial and ethnic backgrounds on the National Board of Medical Examiners examination. In their study, white students had the highest scores, followed by Asian/Pacific  Islanders,  Hispanics,  and  Blacks. Dewhurst et  al. (2007) looked at whether self-declared ethnicity and gender correlated with pass rates among medical graduates taking the Membership of the Royal Colleges of Physicians examination in the U.K. Again, white candidates outperformed other ethnic groups. The popularity of high-stakes standardized testing in the U.S. is known to mask structural inequalities related to race and economic class, and this does not start with professional certification exams, but goes back as far back as elementary and secondary education (Au, W. 2013).

Initially, the assumption had been made that standardized tests would provide fair and objective measures, such that every test taker, regardless of class or privilege, would have a fair and equal shot at educational, social, and economic achievement (Au, 2013). However, this notion of people freely competing based on their own merit has not been the reality of standardized testing. Berliner (no relation to this author) (2012) explained that U.S. test scores are determined more by structural conditions affecting students than any student’s individual effort. The bottom line is that high-stakes standardized tests are far from being the objective measures that we would like them to be.

It seems to me that more subjective evaluation techniques are in order. While it would likely require a more time-consuming process, perhaps we can consider a case-based approach, requiring those sitting for the exam to explain how they would handle a case from start to finish, addressing various scenarios, testing methodologies, variant interpretation, or myriad other topics. It can be creative and challenging, but allow for evaluation of an applicant’s personalized and culturally competent approach. We can come up with many different ideas, perhaps even providing applicants a choice in how they are evaluated. I applaud the ABGC board’s recent effort to reduce exam fees and the addition of demographic questions on the exam application. Perhaps this will help a little in diversifying our profession, or at least reveal more about the racial and socioeconomic status of exam-takers, but none of this changes the appropriateness of the exam style. There is ample evidence to conclude that standardized testing increases racial disparities, and this awareness requires action to change the exam, and not simply to accumulate data.

The art of genetic counseling is not in the memorization of facts, as these can all be researched when needed. What we should be evaluating is whether someone will be a good genetic counselor, which, I would submit, is much better assessed with a more subjective approach. If you have ideas and would like to work together on this effort, please reach out to me.

References

Au, W. (2013). Hiding behind high-stakes testing: Meritocracy, objectivity and inequality in U.S. education. The International Education Journal: Comparative Perspectives, 12(2), 7–19.

Berliner, D. C. (2012). Effects of inequality and poverty vs. teachers and schooling on America’s youth. Teachers College Record, 116(1). Retrieved from http://www. tcrecord.org (2014 paper publication).

Dewhurst, N. G., McManus, C., Mollon, J., Dacre, J. E., & Vale, A. J. (2007). Performance in the MRCP(UK) examination 2003–4: Analysis of pass rates of UK graduates in relation to self-declared ethnicity and gender. BMC Medicine, 5, 8.

Myers, M. F., Bergner, A., Conway, L., Duquette, D., Durst, A. L., Yashar, B. M., Zhang, X., & Campion, M. (2022). A report of the AGCPD task force to evaluate associations between select admissions requirements, demographics, and performance on ABGC certification examination. Journal of Genetic Counseling, 31, 302–315. https://doi-org.baypath.idm.oclc.org/10.1002/jgc4.1537.

 

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