Genetic counseling globally: Where are we now?

The genetic counseling profession is continuing to develop globally, with countries in various stages of development. In some, the profession has been in existence for decades and is increasingly recognized as an important provider of allied health, while in others it is just beginning. In this article, we describe the current global landscape of the genetic counseling specialty field's professional development. Using examples of the United States, United Kingdom, Canada, Australia, South Africa, and various countries in Asia, we highlight the following: (a) status of genetic counseling training programs, (b) availability of credentialing through government and professional bodies (certification, registration, and licensure), and potential for international reciprocity, (c) scope of clinical practice, and (d) health‐care system disparities and cultural differences impacting on practice. The successful global implementation of precision medicine will require both an increased awareness of the importance of the profession of “genetic counselor” and flexibility in how genetic counselors are incorporated into each country's health‐care market. In turn, this will require more collaboration within and across nations, along with continuing engagement of existing genetic counseling professional societies.

The genetic counseling profession is continuing to develop globally, with countries in various stages of development. In some, the profession has been in existence for decades and is increasingly recognized as an important provider of allied health, while in others it is just beginning. In this article, we describe the current global landscape of the genetic counseling specialty field's professional development. Using examples of the United States, United Kingdom, Canada, Australia, South Africa, and various countries in Asia, we highlight the following: (a) status of genetic counseling training programs, (b) availability of credentialing through government and professional bodies (certification, registration, and licensure), and potential for international reciprocity, (c) scope of clinical practice, and (d) health-care system disparities and cultural differences impacting on practice. The successful global implementation of precision medicine will require both an increased awareness of the importance of the profession of "genetic counselor" and flexibility in how genetic counselors are incorporated into each country's health-care market. In turn, this will require more collaboration within and across nations, along with continuing engagement of existing genetic counseling professional societies.

| I N TR ODU C TI ON
The profession of genetic counseling started in the United States with the advent of the first master's level training program at Sarah Lawrence College in New York in 1969. Since then, the profession has expanded globally, and in early 2018 we estimate there are nearly 7,000 genetic counselors in over 28 countries (see Table 1). In some countries (South America, many parts of Africa and Asia, and some European countries), physicians primarily provide genetic counseling; in some cases that is even a legal requirement as genetic counseling is considered a medical service. However, even in these countries, genetic service development is In this article, we explore development of the genetic counseling profession using the four countries where genetic counseling is most well developed as a profession: United States, Canada, the United Kingdom, and Australasia (which includes Australia and New Zealand, but we will call Australia for the sake of simplicity). We will also highlight efforts in South Africa and across Asia. We discuss similarities and differences in training, scope of practice, and types of clinical services where genetic counselors practice, as well as country-and regionspecific issues (e.g., health-care systems, culture) that shape the manner in which genetic services, including genetic counseling, are offered. We refer readers interested in a more granular summary of development of the genetic counseling across the globe to a paper by Abacan et al. (personal communication, February 5, 2018).

| T RA I N IN G
In the late 1980s, nearly 20 years after the profession of genetic counseling was established, approximately 15 genetic counseling masters programs existed in the United States. A certification examination had been developed in 1981 in conjunction with credentialing of medical geneticists, and work was underway to establish more rigorous and consistent criteria for genetic counseling training (Scott, Walker, Eunpu, & Djurdjinovic, 1988;Walker et al., 1990)  Existence of the profession does not imply governmental acknowledgement of the profession or a regulatory process, but rather than the profession exists separate from physicians or other health-care providers offering genetic counseling services. Other countries not listed have small numbers of genetic counselors trained in other countries who may be offering both clinical services or consulting services through corporate or academic laboratories. The background and prior experience of students entering into the masters programs is another area of variation both between and within countries. Across all countries, students are expected to have a strong background in science and to demonstrate communication and empathy skills. While frequently this means students enter with their main degree in a scientific field, some countries will also allow well-qualified students to enter with a psychology or social science degree if they meet other course prerequisites. Given that the university-level training in some countries is very focused on the major area of study, it can be challenging for applicants from outside of the country to meet application prerequisites, and they may be required to take entrance examinations or document competence in basic principles in other ways. Within the United Kingdom, Australia, and South Africa in particular, it is preferable if students can demonstrate prior experience of working in a "caring role," which means that many graduates from genetic counseling programs have also had previous life experiences or volunteer work in nursing, psychology, or other areas of medicine or social or crisis support services. The United States and Canada tend to focus on applicants who have had experience specifically providing one-on-one counseling (preferably in an organization that provides structured training around active listening skills), for example, crisis counseling or social support services. Some countries (e.g., Philippines, Indonesia, Taiwan, etc.) have also focused on individuals with prior clinical training as physicians, physician assistants, or nurses, as these professions may already be recognized as health-care providers, allowing different clinical practice options. The opportunity to enroll in a genetic counseling training program provides these health-care professionals the chance to increase their knowledge of the genomic contribution to health, and addresses gaps when there are no medical genetics training programs or limited training slots for practitioners who are not specifically trained in pediatrics.

| C RE DE N TI A LI N G, R EGI ST RA TI ON , A ND I N TE RN A TI ONA L " R E CI P ROCI T Y"
Table 2 summarizes the current state of credentialing and continuing education requirements in several countries. As our profession becomes increasingly global, and given workforce shortages of genetic counselors in some countries (e.g., Dobson and DaVanzo, 2016), the potential for genetic counselors to become credentialed through processes of certification, registration, or licensure in countries other than where they have trained has become a critical issue. These terms are often used interchangeably but they have slightly different meanings and may be implemented in different manners even when the credentialing intent is similar. Key to this discussion is understanding that credentialing can occur through a statutory (governmental) regulation, either as a state-, province-or country-based format, or through professional organizations. In the United Kingdom, there is a state of flux, which is likely to be resolved throughout 2018; here, "registration," for part of the profession at least, will also mean "regulation," which entails a government supported licensure equivalent. Graduates from the new Masters Level genomic counseling degree apply for a Certificate of Attainment from the Academy for Healthcare Science (AHCS), which allows registration as a clinical scientist (genomic counselor) with the Health and Care Professions Council (HCPC). Registration with the HCPC comes with a legal protection for the title and government-recognized competency to practice. The genetic counseling profession in the United Kingdom has been campaigning for statutory regulation for more than 10 years and at the moment, the mechanisms to transition from voluntary to statutory regulation (also called "registration") are still being explored.
The United Kingdom also has "registration" through a professional body, which is assessed via a portfolio of work submitted to the Genetic Counsellor Registration Board (GCRB) within the United Kingdom and Republic of Ireland (ROI).
In areas where the profession of genetic counseling is wellestablished but it is not yet a legal requirement and no registration or licensure systems are in place or available, the professional societies and/or registration bodies have taken on this self-regulatory role while advocating for appropriate legislation and/or statutory regulation. The terms "registration" and "certification" are both used to describe voluntary credentialing by professional bodies. For example, in the European Union (EU), the European Board of Medical Genetics (EBMG) provides genetic counselor registration through an EBGC portfolio process similar to that established by the GCRB in the United Kingdom. In United States, Canada, and Australia, the term "certification" is used to describe this professional body credentialing, but it is achieved through different means; in this case, via examination through ABGC or CAGC, or through portfolio application to the Human Genetics Society of Australasia (HGSA). Additionally, the United States also has been lobbying for statutory regulation and since the early 2000s has achieved state-based licensure, a governmental regulatory process, in 201 of In some countries, credentialing is a legal requirement in order to practice clinically as a genetic counselor, while it is not in others. However, the many differences between training and credentialing processes have  Table 2) with varying country-based requirements, including a reduced portfolio in some cases, to fully meet requirements for examination or portfolio. The only true reciprocal arrangements between registration boards exist between United Kingdom, Australia, South Africa, and the EBMG (Genetic Nurse and Genetic Counsellor Branches). Singapore, Thailand), but the majority practice clinically as "generalists"

| SCOP E OF CL
in both private and public health-care settings across Asia.

| H EA LT H-CA R E SY STE M DI SP A R I TI ES A ND CU L TU R AL D I FF E RE NC ES
An important global difference in how genetic counseling is practiced can be traced back to the different type of health systems that exist, including which types of patients can be seen autonomously, which services and tests are available and how they are offered, billed, ordered, and reimbursed. Accessibility to genetic testing is based on several issues: availability of testing (including laws that may govern whether testing may occur internationally or only in-country), variation in what tests are covered by public and private payer systems, as well as who is permitted to order (request) tests. Below, we provide several examples of practice variation based on health-care system, contrasting systems that are primarily publically funded (e.g., United Kingdom, Canada, Taiwan, South Korea) with those who have mixed systems (e.g., Australia, South Africa, Philippines, etc.) and those that are primarily private payer systems (United States). We will also discuss how generation sequencing-based gene testing panels (2013). The commercial drive for genetic testing in the United States means that different companies offer different testing options; for example, cancer panels across different companies include a wide range of genes with a range of evidence around clinical validity and clinical utility, and a wide range of pricing. Their broad conceptual availability does not mean that all patients are able to access these technologies, however, and many are faced with justifying genetic test orders with letters of medical necessity, with high deductible co-payments and with denial of coverage.
In Canada, health-care services are publically funded, with the government setting health-care standards through the Canada Health Act, and through provincial funding for regional service delivery. Each province has its own health-care insurance plan, and there is variation regarding which professions are regulated (sometimes with diverse legislative approaches) and their scope of practice. Similarly, the specific types of genetic testing (e.g., NIPT, WES) that are covered by the health-care system, and for whom, may vary on a provincial/territorial basis. In the United Kingdom, most genetic counselors practice clinically within Regional Clinical Genetics Services (or the newly formed Genomic Medicine Centres) within the publicly funded National Health Service (i.e., genetic testing and genetic counseling is paid for by the government and not the patient). Genetic counselors work together with their clinical geneticist and clinical scientist colleagues as well as independently and autonomously with their own patient load. Although private practice for genetic counselors is on the increase, it is by no means the predominant role. As genomics becomes "mainstreamed," that is, testing is offered throughout a whole health-care setting, the roles for genetic counselors are evolving, with more involved in teaching, policy, research, and outreach clinical services (Middleton et al., 2017). With regard to genetic testing in both Canada and the United