results of a licensure needs assessment survey of michigan genetic counselors

Results of a Licensure Results of a Licensure Needs Assessment Survey Needs Assessment Survey

of Michigan Genetic of Michigan Genetic CounselorsCounselors

Jessica Mester, B.S.Jessica Mester, B.S.

MAGiC Meeting, March 9MAGiC Meeting, March 9thth, , 20052005

What is a Needs What is a Needs Assessment?Assessment? Important first stepImportant first step

Literally, assesses a need in a Literally, assesses a need in a

community regarding a specific community regarding a specific issueissue

Why Perform a Needs Why Perform a Needs Assessment?Assessment? Discover how Michigan genetic Discover how Michigan genetic

counselors and Ph.D. Medical counselors and Ph.D. Medical Geneticists feel about licensureGeneticists feel about licensure

Uncover any misconceptions Uncover any misconceptions about licensureabout licensure

Gather opinions on “controversial Gather opinions on “controversial issues” (i.e. eligibility, issues” (i.e. eligibility, supervision, ordering tests)supervision, ordering tests)

Survey DesignSurvey Design

Summer 2004: Contacted leaders Summer 2004: Contacted leaders of licensure efforts in other states of licensure efforts in other states listed on NSGC websitelisted on NSGC website

July 2004: Obtained sample July 2004: Obtained sample surveys from Texas and California surveys from Texas and California Licensure Working GroupsLicensure Working Groups

Survey DesignSurvey Design

Gathered input from a variety of Gathered input from a variety of sources:sources:– Michigan Licensure Working GroupMichigan Licensure Working Group– NSGC Licensure SubcommitteeNSGC Licensure Subcommittee– U of M Research CommitteeU of M Research Committee

Several revisions of survey Several revisions of survey instrumentinstrument

Reviewed and approved by IRBMED Reviewed and approved by IRBMED at the University of Michiganat the University of Michigan

Survey MethodologySurvey Methodology

36 questions long36 questions long Sent by e-mail to 66 individuals in MichiganSent by e-mail to 66 individuals in Michigan

– 63 genetic counselors, 3 Ph.D. Medical 63 genetic counselors, 3 Ph.D. Medical GeneticistsGeneticists

– 1 e-mail rejected, 3 GCs moved to other 1 e-mail rejected, 3 GCs moved to other statesstates

Received responses from 41 individualsReceived responses from 41 individuals– 38 genetic counselors, 3 Ph.D. Medical 38 genetic counselors, 3 Ph.D. Medical

GeneticistsGeneticists– 38 by e-mail, 3 by postal mail38 by e-mail, 3 by postal mail

Study LimitationsStudy Limitations

Response rate: at least 66% (41/62) Response rate: at least 66% (41/62) within a 3 week time periodwithin a 3 week time period– Ascertainment bias?Ascertainment bias?

Small sample sizes → difficulty Small sample sizes → difficulty determining statistical significancedetermining statistical significance– only 3 Ph.D. Medical Geneticists only 3 Ph.D. Medical Geneticists

surveyedsurveyed

Data analysisData analysis

Statistical significance: p<0.05Statistical significance: p<0.05 Trends: p<0.10Trends: p<0.10 Used Chi-Square analysis and Used Chi-Square analysis and

logistic regression as logistic regression as implemented in SPSS v. 13.0implemented in SPSS v. 13.0

InterpretationInterpretation

Unless specifically noted, there Unless specifically noted, there were no statistically significant were no statistically significant differences between demographic differences between demographic groups (i.e. board-certified vs. groups (i.e. board-certified vs. board-eligible counselors, clinical board-eligible counselors, clinical vs. other roles, etc.)vs. other roles, etc.)

Results: OverviewResults: Overview

Section I: Demographic Section I: Demographic InformationInformation

Section III: Thoughts on LicensureSection III: Thoughts on Licensure

Section II: Language in a Potential Section II: Language in a Potential BillBill

Certification StatusCertification Status

28 ABGC/ABMG-certified Genetic 28 ABGC/ABMG-certified Genetic Counselors (GCs)Counselors (GCs)– 1 not currently in practice; data not 1 not currently in practice; data not

includedincluded 10 ABGC-eligible GCs10 ABGC-eligible GCs

– All planning to take next board examAll planning to take next board exam 3 ABMG-certified Ph.D. Medical 3 ABMG-certified Ph.D. Medical

Geneticists (MGs)Geneticists (MGs)

Years EmployedYears Employed

05

101520253035404550

0-5 5-10 10-15 15+

MichiganNSGC

%

Gender Gender

0

20

40

60

80

100

FemaleMale

%

Highest academic Highest academic degreedegree

0

20

40

60

80

100

GCs MGs

Ph.D.M.S.

%

Primary RolePrimary Role

Clinical

Research

Teaching

PublicHealthLaboratory

N=26

N=5

N=3

N=2N=1

Subspecialties (for Subspecialties (for Clinical GCs)Clinical GCs)

0

2

4

6

8

10

12

Prenatal Peds Cancer Adult Other

All clinicalGCs

N

Primary Employment Primary Employment SettingSetting

0

10

20

30

40

50

60

70

Univ. Private Public State Lab

MichiganNSGC

%

Outreach ParticipationOutreach Participation

0

10

20

30

40

50

60

70

80

Yes No

Overall%

Primary SupervisorPrimary Supervisor

0

2

4

6

8

10

12

14

CG PhDMG

GC Non-CG

phys.

None Other

All GCs

N

Results: OverviewResults: Overview

Section I: Demographic Section I: Demographic InformationInformation

Section III: Thoughts on LicensureSection III: Thoughts on Licensure

Section II: Language in a Potential Section II: Language in a Potential BillBill

Q31: Overall thoughts Q31: Overall thoughts about licensureabout licensure

StronglysupportSupport

Neither

Don't know

N=19 N=19

N=1

N=1

Groupwise Groupwise ComparisonsComparisons Board-certified counselors were Board-certified counselors were

about about sixsix times more likely than times more likely than board-eligible counselors to strongly board-eligible counselors to strongly support licensure (vs. support) support licensure (vs. support) [p=0.044, CI=1.049-34.317][p=0.044, CI=1.049-34.317]

Cancer counselors were significantly Cancer counselors were significantly more likely to strongly support more likely to strongly support licensure (vs. support) [p=0.026, licensure (vs. support) [p=0.026, OR=12.9]OR=12.9]

Q32: Reasons to Q32: Reasons to supportsupport ““I feel it is necessary to legally ensure I feel it is necessary to legally ensure

that only individuals with the that only individuals with the appropriate appropriate education education are providing the public with are providing the public with information about their genetic risks.”information about their genetic risks.”

““I feel it is necessary to have an I feel it is necessary to have an enforceable method of enforceable method of penalizationpenalization for for those who violate ethical standards of those who violate ethical standards of practice.”practice.”

““I believe it is necessary to have a legal I believe it is necessary to have a legal definition for who may and may not use definition for who may and may not use the the job titlejob title ‘genetic counselor’”. ‘genetic counselor’”.

Q32: Reasons to Q32: Reasons to supportsupport ““I feel it is important for genetic I feel it is important for genetic

counseling to be ‘in-line’ with other counseling to be ‘in-line’ with other healthcare professions that require a healthcare professions that require a license.”license.”

““I believe licensure would further I believe licensure would further legitimize genetic counseling as a legitimize genetic counseling as a distinct allied healthcare profession.”distinct allied healthcare profession.”

““I believe licensure will protect genetic I believe licensure will protect genetic counselors from litigation.”counselors from litigation.”

Two spaces to write in other responses.Two spaces to write in other responses.

Q32: Reasons to Q32: Reasons to supportsupport 11stst strongest: strongest:

– ““Appropriate Appropriate education” (20/37)education” (20/37)

– ““Legitimize GC as Legitimize GC as distinct HC prof.” distinct HC prof.” (10/37)(10/37)

– ““Imp. for GC to be Imp. for GC to be ‘in-line’” (4/37)‘in-line’” (4/37)

– ““Legal definition Legal definition for GC job title” for GC job title” (3/37)(3/37)

22ndnd strongest: strongest:– Tie: “Legal Tie: “Legal

definition” and definition” and “Legitimize” (10/37)“Legitimize” (10/37)

– Tie: “Appropriate Tie: “Appropriate education” and “In-education” and “In-line” (7/37)line” (7/37)

– ““Penalization for Penalization for ethical violations” ethical violations” (2/37)(2/37)

– Other: “for billing Other: “for billing purposes” (1/37)purposes” (1/37)

0

2

4

6

8

10

12

14

16

18

20

Education Penalize Job Title In-line Legitimize Litigation Other

1st2nd

Q32: Reasons to Q32: Reasons to supportsupport

N

Q32: Significant Q32: Significant TrendsTrends Those practicing adult genetics Those practicing adult genetics

and those supervised by PhD and those supervised by PhD Medical Geneticists Medical Geneticists allall selected selected “appropriate education” as either “appropriate education” as either their first or second choicetheir first or second choice

No person supervised by a non-No person supervised by a non-geneticist subspecialty physician geneticist subspecialty physician chose “job title” as either their chose “job title” as either their first or second choice [p=0.033] first or second choice [p=0.033]

Q32: Significant Q32: Significant TrendsTrends Board-eligible counselors were more likely to Board-eligible counselors were more likely to

select “further legitimize” than board-select “further legitimize” than board-certified counselors [p=0.009, OR=13.0]certified counselors [p=0.009, OR=13.0]

Those working 5 or more years were more Those working 5 or more years were more likely to select “in-line” [p=0.041, OR=6.86]likely to select “in-line” [p=0.041, OR=6.86]

Cancer and Adult Genetics counselors were Cancer and Adult Genetics counselors were less likely to select “further legitimize” than less likely to select “further legitimize” than others [p=0.009, OR=18.0 and p=0.048, others [p=0.009, OR=18.0 and p=0.048, OR=12.86 respectively]OR=12.86 respectively]

Q29: Need for GC to be Q29: Need for GC to be licensed?licensed?

YesDon't know

N=33 N=7

Q30a: Public Q30a: Public protectionprotection

Would helpprotectNo impact

Would nothelp protect

N=30

N=8

N=2

Q30b: Further Q30b: Further legitimizelegitimize

WouldfurtherlegitimizeWould notfurtherlegitimize

N=39

N=1

Q30c: LawsuitsQ30c: Lawsuits

IncreaseNo impactDecrease

N=18 N=21

N=1

Q30d: Practice Q30d: Practice independentlyindependently

Would give

Would notgive

N=26

N=13

Q34-35: Harm caused Q34-35: Harm caused by inaccurate by inaccurate informationinformation Q34: From a genetic counselor?Q34: From a genetic counselor?

– 3 of 39 (7.7%) answered “Yes”3 of 39 (7.7%) answered “Yes” Q35: From another healthcare Q35: From another healthcare

worker?worker?– 21 of 38 (55.3%) answered “Yes”21 of 38 (55.3%) answered “Yes”– ““I clean up A LOT of messes, especially I clean up A LOT of messes, especially

with VUS in BRCA ½. No patient has with VUS in BRCA ½. No patient has DIED, but the psychosocial impact is DIED, but the psychosocial impact is something difficult to measure.”something difficult to measure.”

Results: OverviewResults: Overview

Section I: Demographic Section I: Demographic InformationInformation

Section III: Thoughts on LicensureSection III: Thoughts on Licensure

Section II: Language in a Potential Section II: Language in a Potential BillBill

Q11: Who should be Q11: Who should be eligible to obtain a GC eligible to obtain a GC license?license?

0

20

40

60

80

100

BCGC

BEGC

BCMG

BEMG

Other

Overall%

Q11: GCs compared to Q11: GCs compared to MGsMGs

0102030405060708090

100

BC GC BE GC BC MG BE MG Other

GCsMGs

%

Q12: What GC roles Q12: What GC roles should require a should require a license? license?

0102030405060708090

100

Clinical Research Teaching PublicHealth

Lab Other

Overall%

Q12 TrendsQ12 Trends

Those whose primary role is Those whose primary role is teachingteaching were were lessless likely to say likely to say that GCs in a teaching role should that GCs in a teaching role should require a license than those in require a license than those in other primary roles. other primary roles.

Teaching Teaching should NOT should NOT be includedbe included

Teaching Teaching SHOULD be SHOULD be includedincluded

Primary role is Primary role is teachingteaching

22 11

Primary role is Primary role is other than other than teachingteaching

66 3131

p=0.096

OR=10.3

Q12 TrendsQ12 Trends

0102030405060708090

Teaching GCsshould require

license

Teaching

Non-teaching

%

Q13: What kind of Q13: What kind of exam?exam?

ABGC MI Other

N=37

N=1

N=4

Other responses:

“If board certified- no exam”

“The Michigan licensure board should be responsible for a licensing examination for those who are waiting for the ABGC certification exam”

“ACMG boards”

“Above should read ‘ABMG OR ABGC certification examination…”

Q14: Continuing Q14: Continuing education education requirements?requirements?

Same as ABGC Other

N=36

N=1

Other response:

“Not sure what they should be, but individuals in specialized fields may not be able/allowed to attend enough educational activities to fulfill ABCG [sic] requirements.”

Q15: Need for Q15: Need for temporary licenses?temporary licenses?

YesNoDon't know

N=30

N=6

N=3

Q15: Comparison Q15: Comparison between groupsbetween groups

0

20

40

60

80

100

BC GCs BE GCs MGs

YesNoDon't Know

%

Q16: Who should have Q16: Who should have a temporary license?a temporary license?

0102030405060708090

100

BE GCs BE MGs GC gradstudents

Other

"Yes" to Q15%

Q17: Limit on Q17: Limit on temporary licenses?temporary licenses?

Yes, as long as ABGC-active Other

N=28

N=1

Other response:

“I think that there is a question missing here – this is assuming that ABGC is the key”

Q22: Supervision Q22: Supervision required for fully required for fully licensed GCs?licensed GCs?

YesNoDon't know

N=11

N=17

N=9

Q22: BC compared to Q22: BC compared to BE GCsBE GCs

0

10

20

30

40

50

Yes No Don'tKnow

BCBE

%

Q23: Who may Q23: Who may supervise?supervise?

0

2

4

6

8

10

12

14

16

18

BC CGs BC MGs Phys. inGC area

Any CG BE MGs Anysubspec.

phys.

Other

GCs whoanswered"Yes" or"Don't Know"to Q22 (N=20)

N

Q24: Additional sup. Q24: Additional sup. for GCs with temp. for GCs with temp. licenses?licenses?

YesNoDon't Know

N=23 N=9

N=5

Q24: BC compared to Q24: BC compared to BE GCsBE GCs

0

10

20

30

40

50

60

70

Yes No Don'tKnow

BCBE

%

Q25: Who may Q25: Who may supervise GCs with supervise GCs with temp. licenses?temp. licenses?

0

5

10

15

20

25

30

Fully-licensed

GCs

BC CGs BC MGs Phys. inGC area

Any CG BE MGs Anysubspec.

phys.

All GCs whoanswered"Yes" or "Don'tKnow" to Q24(N=28)

N

Q18: How are your Q18: How are your visits arranged?visits arranged?

Sup. on site Sup. reviews all casesSup. meets for billing Sup. in room for entire visitOther

N=8

N=3N=12

N=6

Other responses:

“Part of my time is spent in private practice and I have no supervision.”

“Note: Supervisor in room only if a physical exam is required.”

“I am part of a team and MD sees all patients.”

“MD is available in person, phone or page to discuss case if needed and co-sign clinic notes for billing purposes.”

Q19: How would you Q19: How would you prefer visits arranged if prefer visits arranged if licensed?licensed?

Sup. on site Sup. reviews all casesSup. meets for billing Sup. in room for entire visitSup. not necessary Other

N=14

N=7N=6

N=9

N=1

Other responses:

“Supervision only necessary if a physical exam or medical treatment/procedure is appropriate during the appointment.”

“Supervisor review non-routine cases.”

“No supervision for ‘counseling’ visits, supervisor present for cases involving exam.”

“This needs to be flexible, based on the setting.”

“Supervisor is available but not necessarily on site”

Changes within groupsChanges within groups

Have: Supervisor on site (8)Have: Supervisor on site (8)– 7: Same response7: Same response– 1: Supervisor reviews all cases1: Supervisor reviews all cases– 1: Supervision not necessary1: Supervision not necessary

Have: Supervisor reviews all cases (3)Have: Supervisor reviews all cases (3)– 2: Same response2: Same response– 2: Supervisor meets with each for billing2: Supervisor meets with each for billing– 1: Other1: Other

Changes within groupsChanges within groups

Have: Supervisor meets for billing (12)Have: Supervisor meets for billing (12)– 7: Supervisor available on site7: Supervisor available on site– 4: Supervisor reviews all cases4: Supervisor reviews all cases– 2: Same Response2: Same Response– 1: Supervision not necessary1: Supervision not necessary– 1: Other1: Other

Have: Other (5)Have: Other (5)– 1: Supervisor reviews all cases1: Supervisor reviews all cases– 4: Same Response4: Same Response

Q20: What type for Q20: What type for cases with only GC?cases with only GC?

Sup. on site Sup. reviews all casesSup. meets for billing Sup. in room for entire visitSup. not necessary Other

N=22

N=5

N=5

N=6

N=5

Other responses:

“Supervisor available to discuss cases, not required on site.”

“A supervisor reviews all cases with a GC on a regular basis.”

“Case dependent”

“Available being the operative word in the first option – and not mandatory supervision…”

Q26: Support private Q26: Support private practice?practice?

YesNoDon't Know

N=28

N=10

N=2

Q26: TrendsQ26: Trends

Individuals who have a primarily Individuals who have a primarily clinical role were about clinical role were about 6 times 6 times less likelyless likely to support private to support private practice. [p =0.124]practice. [p =0.124]

YesYes No or No or Don’t Don’t KnowKnow

ClinicalClinical 1818 1111

Not Not clinicalclinical

1010 11

p=0.124

OR=6.1

Q27: Which components of genetic Q27: Which components of genetic testing should a fully-licensed GC be testing should a fully-licensed GC be able to perform independent of a able to perform independent of a physician?physician?

Deciding which genetic test to orderDeciding which genetic test to order Ordering the genetic test in the genetic Ordering the genetic test in the genetic

counselor’s namecounselor’s name Deciding which laboratory’s testing Deciding which laboratory’s testing

services to utilizeservices to utilize Obtaining informed consent from patients.Obtaining informed consent from patients. Interpreting genetic test results for Interpreting genetic test results for

patientspatients I do not feel that GCs should be able to I do not feel that GCs should be able to

perform any components of genetic perform any components of genetic testing independent of a physician.testing independent of a physician.

Q27: Components of Q27: Components of genetic testinggenetic testing

AllcomponentsAt least onecomponentNocomponents

N=23

N=2

N=14

Q27: Components of Q27: Components of genetic testinggenetic testing

0102030405060708090

100

Decidewhichtest

Order inGC'sname

Decidewhich lab

Obtaininformedconsent

Interpretresults

All whochose atleast onecomponent(N=37)

Q28: What types of genetic Q28: What types of genetic tests should a GC be able to tests should a GC be able to order independent of a order independent of a physician?physician? Prenatal screening testsPrenatal screening tests Fetal diagnostic testsFetal diagnostic tests Carrier testingCarrier testing Diagnostic genetic testing for adultsDiagnostic genetic testing for adults Diagnostic genetic testing for Diagnostic genetic testing for

childrenchildren Predictive genetic testingPredictive genetic testing Presymptomatic genetic testingPresymptomatic genetic testing

Q28: Types of genetic Q28: Types of genetic teststests

All typesSome typesNo types

N=11

N=20

N=7

Q28: Types of genetic Q28: Types of genetic teststests

0102030405060708090

100

Prenatalscreen

Fetal dx Carriertesting

Adult dx Child dx Predict.Presymp.

Those whochose all orsome types oftests

Q28: Notable Q28: Notable comparisonscomparisons Pediatric counselors were Pediatric counselors were more more

likelylikely to believe that GCs should be to believe that GCs should be able to order presymptomatic able to order presymptomatic genetic testing genetic testing PresymptomatPresymptomat

icicNot Not presymptomatpresymptomaticic

Pediatric Pediatric counselorscounselors

88 33

Non-Non-pediatric pediatric counselorscounselors

77 1111

p=0.077

OR=4.2

Q28: Notable Q28: Notable comparisonscomparisons Cancer counselors were Cancer counselors were more more

likelylikely to believe that GCs should to believe that GCs should be able to order diagnostic be able to order diagnostic testing for children.testing for children.

Dx testing Dx testing for childrenfor children

Not dx Not dx testing for testing for childrenchildren

Cancer Cancer counselorscounselors

44 22

Non-cancer Non-cancer counselorscounselors

55 1717

p=0.064

OR=6.8

Q28: TrendsQ28: Trends

PediatricPediatric counselors were counselors were more more likely to likely to believe that GCs should be able to order believe that GCs should be able to order fetal diagnostic tests.fetal diagnostic tests.

CancerCancer counselors were counselors were moremore likely to likely to believe that GCs should be able to order believe that GCs should be able to order diagnostic tests for adults.diagnostic tests for adults.

100% of counselors who participate in 100% of counselors who participate in outreachoutreach believe that GCs should be able believe that GCs should be able to order some types of tests to order some types of tests independently.independently.

Final commentsFinal comments

““I support licensure as long as it does I support licensure as long as it does not prevent certified GCs from going not prevent certified GCs from going into private practice. This would include into private practice. This would include seeing patients in other states. For seeing patients in other states. For instance, I currently live in Michigan but instance, I currently live in Michigan but through my private practice I provide GC through my private practice I provide GC services for an IVF clinic in Florida. I services for an IVF clinic in Florida. I would want to be able to continue this would want to be able to continue this arrangement as a licensed GC whether arrangement as a licensed GC whether or not in Florida, or any other state, had or not in Florida, or any other state, had licensure laws. Furthermore, I would licensure laws. Furthermore, I would support that only licensed GCs would be support that only licensed GCs would be able to go into private practice.”able to go into private practice.”

Final CommentsFinal Comments

““I think that there are some important points I think that there are some important points that have been missed above. I feel that that have been missed above. I feel that Myriad is a perfect example of ways that Myriad is a perfect example of ways that ‘others’ will by-pass the need for using the ‘others’ will by-pass the need for using the term ‘genetic counselor’, but yet still provide term ‘genetic counselor’, but yet still provide these services. So, will all this effort be for these services. So, will all this effort be for nothing? Also, will all this effort only be to nothing? Also, will all this effort only be to license a few select individuals in Michigan? license a few select individuals in Michigan? Will the public and other HC professionals Will the public and other HC professionals even realize this effort? Importantly, will this even realize this effort? Importantly, will this limit access to care??? This is the most limit access to care??? This is the most important question from insurers and PH important question from insurers and PH professionals! I think this question needs to professionals! I think this question needs to be desperately examined, and very carefully be desperately examined, and very carefully considered!”considered!”

Final CommentsFinal Comments

““The only question I had difficulty in The only question I had difficulty in answering is regarding our involvement answering is regarding our involvement with independently ordering tests. I feel with independently ordering tests. I feel we have the capability to order prenatal we have the capability to order prenatal tests for the majority of patients, but tests for the majority of patients, but pediatric cases should be assessed a PhD pediatric cases should be assessed a PhD or MD with their added medical training. I or MD with their added medical training. I feel we would be opening ourselves up to feel we would be opening ourselves up to tremendous liability and possible harm to tremendous liability and possible harm to our patients. On the other hand we are our patients. On the other hand we are often the ones ensuring all and correct often the ones ensuring all and correct tests are ordered especially when working tests are ordered especially when working with other physician specialists. Not sure with other physician specialists. Not sure what the right answer is.”what the right answer is.”

Final CommentsFinal Comments

““It is so clear that doing genetic It is so clear that doing genetic counseling is a highly specialized counseling is a highly specialized area of expertise, and that only area of expertise, and that only those that are licensed, following those that are licensed, following appropriate training and appropriate training and evaluation, should do GC.”evaluation, should do GC.”

““How is the issue of nursing in How is the issue of nursing in genetics being addressed? genetics being addressed? Genetic Nursing certification is Genetic Nursing certification is available at the BS and MS level.”available at the BS and MS level.”

AcknowledgementsAcknowledgements

Licensure Working Licensure Working GroupGroup– Cheryl Harper, MSCheryl Harper, MS– Angela Trepanier, MSAngela Trepanier, MS– Helga Toriello, PhDHelga Toriello, PhD– Jacquelyn Riley, MSJacquelyn Riley, MS– Breanna Cox, MSBreanna Cox, MS– Rajani Aatre-Rajani Aatre-

Keshavamurthy, MSKeshavamurthy, MS– Carrie Couyoumjjian, MSCarrie Couyoumjjian, MS

NSGC Licensure NSGC Licensure SubcommitteeSubcommittee– Chris Miller, MSChris Miller, MS– Sara Goldman, MPHSara Goldman, MPH– Dan Riconda, MSDan Riconda, MS– Karen Potter, MSKaren Potter, MS

University of Michigan University of Michigan Research CommitteeResearch Committee– Wendy Uhlmann, MSWendy Uhlmann, MS– Laura Rozek, MPHLaura Rozek, MPH– Beverly Yashar, PhD, MSBeverly Yashar, PhD, MS– Edward Goldman, JDEdward Goldman, JD– Cleopatra Caldwell, PhDCleopatra Caldwell, PhD– Jerome Gorski, MDJerome Gorski, MD

All survey All survey participants!participants!