VA Mental Health Provider Venting / Problem-solving / Peer Support Thread

[Sanman]

Medicare audits are a big nothing. They come in, look at your work, look at your billing, and say “looks about right”.

Perhaps, but I don't feel the need to go through the audit and some I have heard from some people who found it more traumatic than that. I certainly don't find the need to make myself a likely target for the crime of being in geriatrics, and thus a high comparative medicare biller.

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[Fan_of_Meehl]

Anyone have any good stories about getting pressured to write 'prescription' letters for service dogs or to write up a clinical justification for a full-time stay at home spousal 'caregiver' for a mental health condition?

 

[erg923]

I can't picture a better setting in which to be a psychologist.

With all do respect, I find this comment quite bizarre. I have never heard such a thing from any psychologist....ever.

I did not mean to suggest this as a VA bashing thread...as there are positives of course. For example, I think the rollout-out of PST (a big thing in 2016/2017 at least) is a noble effort in preventive psychopathology for some veterans. But...the VA as an ideal healthcare system and place to work as a psychologist? Best place you can imagine? Really? That's weird to me.

Your comment ignores the systemic issues presented by at least a dozen posters here that are present to a lesser extent or negligible-level in other healthcare settings. It also suggests that more care, and more resources, is "better." I don't think this is the case sans SPMHI/suicide risk...which most veterans aren't of course. If anything, the VA needs MORE rationing of its care and resources given its current "access issues." The idea that every veteran, regardless of status/diagnosis/functional impairment, should/is given (essentially) unlimited MH care benefits is cost prohibitive, and is not clinically or ethically reasonable/responsible. This is a large part of why there are so many "access issues" currently.

 

[psychRA]

Your comment ignores the systemic issues presented by at least a dozen posters here that are present to a lesser extent or negligible-level in other healthcare settings.

I have been in the VA system for many years, and am well aware of the issues raised by other posters. For me, those issues do not outweigh the positives of working in the system. I'm hardly alone in this. Many have commented that they got very good training at at VA, which means that psychologists have stuck around at least long enough to provide that training, yes? I have plenty of colleagues who share my overall opinion of our system. It's not for everyone, and that's fine.

I think it's an overreach to attribute my opinion to ignorance - the fact that I don't agree with your conclusion does not mean that I fail to understand the issues at hand.

 

[erg923]

I have been in the VA system for many years, and am well aware of the issues raised by other posters. For me, those issues do not outweigh the positives of working in the system. I'm hardly alone in this. Many have commented that they got very good training at at VA, which means that psychologists have stuck around at least long enough to provide that training, yes? I have plenty of colleagues who share my overall opinion of our system. It's not for everyone, and that's fine.

I think it's an overreach to attribute my opinion to ignorance - the fact that I don't agree with your conclusion does not mean that I fail to understand the issues at hand.

Good training? Yes! I was a formerly a TD at a VA. But there is also good training at CMHCs, right? No debate there. But also not really what I am talking about.

And, no, I do not think you are ignorant...we both worked in this setting.

 

[cara susanna]

With all due respect, the VA providers in this thread are not wanting to and/or not able to leave the VA at this time. I appreciate people's concerns and wanting to help. That being said, the purpose of this thread was not intended to be for us to have to justify not leaving this setting, but rather to provide mutual support and vent to each other. If any of us change our mind in the future, of course we will reach out to you former VA employees who made the transition to non-VA work.

 

[cara susanna]

To bring this thread back on course, I find it especially challenging working at a CBOC that's over an hour away from the main hospital. We have a fairly big population with limited resources. Unlike my previous jobs at main hospitals, we don't have specialty MH clinics or teams and have to treat everything. We also don't get involvement in a lot of the things that I love about working in the VA, like training programs and administrative roles (I used to have a coordinator position and loved it).

 

[WisNeuro]

I was only curious as the reasons many were giving to staying are things that are freely available in many places outside the VA. There seemed to be many misconceptions.

 

[PsyDr]

Anyone have any good stories about getting pressured to write 'prescription' letters for service dogs or to write up a clinical justification for a full-time stay at home spousal 'caregiver' for a mental health condition?

I've had IME try to come to their appointments with a wide variety of exotic "emotional support animals". There seems to be a lot of confusion about service animals vs emotional support animals. The ones that are just getting off on having the rules being different for them, tend to get really angry when I point out that they don't know what they're talking about and they don't have some magic power over me (e.g., trying to use an exotic animal under ADA, and getting furious when I explain that ADA only covers dogs and minihorses).

I've had litigant questions about caregiver stuff. People tend to back down when I point out that if the spouse is so cognitively impaired as to need someone to handle their ADLs, that we need to get guardianship, and report their spouse the adult services. I also ask about sex, since if the impaired one is incapable of providing consent, sexual contact could be considered rape. And we need CPS involved too. Litigants don't really want to tell me more afterwards.

Sidenote: I've taken care of severely impaired people in clinical setting, and their spouses have few issues about guardianship, sex, etc, other than to be very very sad and conflicted about balancing their own needs with that of their spouses.

 

[Pragma]

As someone who has worked at both VA and non-VA hospitals, I see pros and cons to the VA environment. Personally, I felt like the ceiling is low in terms of both salary and professional growth opportunities at the VA. The former is consistent across VAs. The latter is going to vary considerably. If you are highly passionate about working with veterans, it is a good place to be, but not the only option available for working with that population.

 

[cara susanna]

Anyone have any good stories about getting pressured to write 'prescription' letters for service dogs or to write up a clinical justification for a full-time stay at home spousal 'caregiver' for a mental health condition?

My service is pretty strong about discouraging providers from writing emotional support/service animal letters.

 

[Fan_of_Meehl]

My service is pretty strong about discouraging providers from writing emotional support/service animal letters.

So far mine has left it up to the individual clinician to handle/resolve and it has not (so far) blown up administratively. It will be interesting when (if?) the results of the major clinical trial the VA is conducting on service and/or support animals on PTSD are published and if these results will result in new policies/procedures.

 

[Sanman]

I was only curious as the reasons many were giving to staying are things that are freely available in many places outside the VA. There seemed to be many misconceptions.

I'm actually curious about how common it is outside the VA as well. I haven't seen a lot hospital jobs advertised outside the VA that are not neuropsych/rehab. Certainly none in my area that pay VA money for psychotherapy positions, I am curious if others are seeing that a lot.

 

[cara susanna]

I'm actually curious about how common it is outside the VA as well. I haven't seen a lot hospital jobs advertised outside the VA that are not neuropsych/rehab. Certainly none in my area that pay VA money for psychotherapy positions, I am curious if others are seeing that a lot.

Ditto. The hospitals around here only hire psychologists for more administrative roles or assessment only positions.

 

[AcronymAllergy]

I'm actually curious about how common it is outside the VA as well. I haven't seen a lot hospital jobs advertised outside the VA that are not neuropsych/rehab. Certainly none in my area that pay VA money for psychotherapy positions, I am curious if others are seeing that a lot.

This is all anecdotal: I know of a psychologist who took a position at a pretty well-known and (relatively speaking) nearby AMC that paid about 30% more than what would've been that person's VA salary. And I know of multiple folks from my fellowship program who were non-neuropsych and non-rehab, and who ended up in hospitals (lots of BMed, pain, oncology). I don't know what their pay was, but I'm nearly certain they could've stayed VA if they'd wanted, so I imagine the compensation was at least comparable.

I'd imagine non-neuropsych/non-rehab hospital jobs are harder to come by outside big cities. I actually don't know if any of the local hospitals here (medium-to-small sized city) have any non-neuro psychologists on staff. But I imagine many of those hospitals might be open to hiring a psychologist if they knew what we do and how we could provide value.

 

[WisNeuro]

I'm actually curious about how common it is outside the VA as well. I haven't seen a lot hospital jobs advertised outside the VA that are not neuropsych/rehab. Certainly none in my area that pay VA money for psychotherapy positions, I am curious if others are seeing that a lot.

My hospital is not hiring therapy type positions, but a nearby AMC is, and they pay much better than VA. the jobs are out there, people just don't look all that widely. I imagine regional variations exist, but it's good pickings here. Moreso if you have a specialty skill, but still.

 

[cara susanna]

My hospital is not hiring therapy type positions, but a nearby AMC is, and they pay much better than VA. the jobs are out there, people just don't look all that widely. I imagine regional variations exist, but it's good pickings here. Moreso if you have a specialty skill, but still.

Thing is we aren't all in big cities. There aren't any AMCs where I live.

 

[WisNeuro]

Thing is we aren't all in big cities. There aren't any AMCs where I live.

That would be a mitigating factor if you aren't in a medium or larger city. In which case, there is always PP.

 

[ClinicalABA]

With all due respect, the VA providers in this thread are not wanting to and/or not able to leave the VA at this time. I appreciate people's concerns and wanting to help. That being said, the purpose of this thread was not intended to be for us to have to justify not leaving this setting, but rather to provide mutual support and vent to each other. If any of us change our mind in the future, of course we will reach out to you former VA employees who made the transition to non-VA work.

I certainly appreciate that, and also recognize that geography can play a big factor in where we work or why we stay at a job (heck- i can literally see the VA from my front yard and would overlook a lot of negatives to work next door). I asked my question about what's keeping people there out of honest curiosity (you must admit, some of the posters make it sound pretty horrible!). Also, as this board is primarily meant to be a resource for students, I do think it is important to correct misconceptions regarding career options, benefits, etc. I also have observed that some clinicians have spent their entire professional careers (including pre-doc) at the VA, and may not be real informed about what benefits exist elsewhere or how they compare to those at the VA (and there is a trend towards a "yeah, but the benefits are great" attitude around VA positions). It does sounds like there are some good benefits to working at the VA, but those may not be exclusive to the VA on the whole, but may YMMV based on what is available locally. Sounds like my area is similar to yours- relatively rural with little opportunities for psychologist to work within large medical care systems other than the VA. There are many other attractive options for psychologist, but the VA kinda has a monopoly on the large medical center setting.

I certainly don't want to come across as VA bashing. It is incredibly important work and most of those i have met who work there are relatively happy.

 

[Sanman]

To present a more fair and balanced portrait, I think we also have to acknowledge that certain jobs don't really exist outside the VA. HBPC could not exist in a for-profit system, certainly not in the exurbs/rural area I work. I am constantly astounded that I am paid so much for so little productivity. Out in the real world, my choices are LTC/ALF companies or more office based integrated care practice. LTC psych jobs range from $80-90k to start. I can make VA money there as a contractor with no benefits or as a manager with a significantly higher stress level. I've done the latter already.

While I could likely find an integrated care outpatient job it would:

A. Likely mean I am not eligible for ABPP boarding in geriatrics.

B. Necessitate a commute into the city or closer suburbs with hellish traffic or relocation to an area closer to the city that doubles my housing costs.

If I stay in this job long-term and my wife continues to work from home, it may mean a move to the outer suburbs with cheaper housing or more house overall. I find that this is the case for many rural CBOC, telework, or HBPC colleagues.

 

[psychRA]

That would be a mitigating factor if you aren't in a medium or larger city. In which case, there is always PP.

At this point in my life, private practice is the least appealing option imaginable for me. I honestly think that I would rather work in C&P.

 

[Sanman]

At this point in my life, private practice is the least appealing option imaginable for me. I honestly think that I would rather work in C&P.

Strong statement, why is that?

 

[iliketohelppeople]

I think my main frustration with the VA is what I have seen it do to some of the folks I work with. The immense patientization of folks (e.g., "I cannot do this") that is reinforced by things like service connection for mental health issues is really set apart from the recovery model (that I feel as though our field is built upon). It is incredibly sad, and I feel powerless at times as a clinician within this wider system. For this reason, I don't know if I could continue in the system for too long. I think if I did, I would need a really good group of folks to work with and consult with (which I feel I do currently).

Another frustration is the haphazard way in which VA often implements policy (e.g., the infamous suicide assessment policy last year) seems not well thought out and rushed, often to the detriment of clinicians and consumers. Then, they take their sweet time to update policy that could have been much smoother given time. The talk that the VA is not a healthcare organization, but a PR or politically driven organization is so real. Smaller, but still frustrating is the fact that trainees are not eligible to contribute to TSP plans.

 

[Therapist4Chnge]

This is all anecdotal: I know of a psychologist who took a position at a pretty well-known and (relatively speaking) nearby AMC that paid about 30% more than what would've been that person's VA salary. And I know of multiple folks from my fellowship program who were non-neuropsych and non-rehab, and who ended up in hospitals (lots of BMed, pain, oncology). I don't know what their pay was, but I'm nearly certain they could've stayed VA if they'd wanted, so I imagine the compensation was at least comparable.

I'd imagine non-neuropsych/non-rehab hospital jobs are harder to come by outside big cities. I actually don't know if any of the local hospitals here (medium-to-small sized city) have any non-neuro psychologists on staff. But I imagine many of those hospitals might be open to hiring a psychologist if they knew what we do and how we could provide value.

This is the lynchpin. We need to demonstrate value and know how to speak "hospital administrator".

 

[Fan_of_Meehl]

I think my main frustration with the VA is what I have seen it do to some of the folks I work with. The immense patientization of folks (e.g., "I cannot do this") that is reinforced by things like service connection for mental health issues is really set apart from the recovery model (that I feel as though our field is built upon). It is incredibly sad, and I feel powerless at times as a clinician within this wider system. For this reason, I don't know if I could continue in the system for too long. I think if I did, I would need a really good group of folks to work with and consult with (which I feel I do currently).

Another frustration is the haphazard way in which VA often implements policy (e.g., the infamous suicide assessment policy last year) seems not well thought out and rushed, often to the detriment of clinicians and consumers. Then, they take their sweet time to update policy that could have been much smoother given time. The talk that the VA is not a healthcare organization, but a PR or politically driven organization is so real. Smaller, but still frustrating is the fact that trainees are not eligible to contribute to TSP plans.

When I worked on the inpatient unit for a while and veterans asked what I did (as a psychologist) I was fond of saying that I was basically 'the opposite of a patient advocate' in that, when you think that the problem is other people's behavior, you seek help from the patient advocate...but when you believe (or are open to considering) that it's YOUR behavior or thoughts that are the problem, that's when you come talk to me. It kinda helped separate the wheat from the chaff in terms of readiness for behavior change.

 

[gradstudent2015]

I'm so glad to see this thread getting started!

At the risk of derailing the conversation, I'd like to ask for thoughts on the state of research within the VA. I'm at a research-ish VA postdoc and, while I think a VA career (at least at this early stage) has several appealing aspects that have been mentioned above, I'm concerned about the availability and long-term feasibility of research-oriented positions. From the limited information I have, it seems like a research job in the VA is essentially soft money-- that is, contingent on funding through grants that you will need to apply for every few years. I'm concerned about that for several reasons, not least is that I find the idea of continual hoop-jumping to be pretty aversive (to that extent, at least. Obviously most if not all positions will have performance standards, CEs, etc., which I can certainly accept). Is this even an accurate impression of VA research positions?

 

[cara susanna]

I'm so glad to see this thread getting started!

At the risk of derailing the conversation, I'd like to ask for thoughts on the state of research within the VA. I'm at a research-ish VA postdoc and, while I think a VA career (at least at this early stage) has several appealing aspects that have been mentioned above, I'm concerned about the availability and long-term feasibility of research-oriented positions. From the limited information I have, it seems like a research job in the VA is essentially soft money-- that is, contingent on funding through grants that you will need to apply for every few years. I'm concerned about that for several reasons, not least is that I find the idea of continual hoop-jumping to be pretty aversive (to that extent, at least. Obviously most if not all positions will have performance standards, CEs, etc., which I can certainly accept). Is this even an accurate impression of VA research positions?

I completed a research post doc in the VA and this seems accurate. A majority of our seminars were about how to secure grant funding and keep ensuring funding. The only thing I believe is that if you get a CDA the VA is required to hire you. However, if your CDA runs out without additional funding afterwards your time gets eaten up more and more by clinical work. I know a lot of psychologists that this happened to in the VA. One of them told me that your best bet is to get an academic faculty gig and maintain research ties to a VA so you can use their data and resources.

That being said, some places seem to always have soft money or funding available for research psychologists (VISN 19 MIRECC being a good example). National Center for PTSD also seems to have research positions that aren't just tied to grant funding, but I'm sure that's incredibly competitive.

 

[iliketohelppeople]

When I worked on the inpatient unit for a while and veterans asked what I did (as a psychologist) I was fond of saying that I was basically 'the opposite of a patient advocate' in that, when you think that the problem is other people's behavior, you seek help from the patient advocate...but when you believe (or are open to considering) that it's YOUR behavior or thoughts that are the problem, that's when you come talk to me. It kinda helped separate the wheat from the chaff in terms of readiness for behavior change.

Thanks for this phrase. Mind if I steal it?

 

[Fan_of_Meehl]

Thanks for this phrase. Mind if I steal it?
[/QUOTE]
LOL, not at all. It's surprising what we learn working in the VA system that may or may not match up with what's in the textbooks...at least in terms of what may be useful ways to phrase or conceptualize roles/responsibilities.

 

[Fan_of_Meehl]

Thanks for this phrase. Mind if I steal it?

I also like the following frame for characterizing the task of engagement in psychotherapy (can't remember who I stole it from but it goes something like):

'Every client has a part of themselves that actually wants to get better and it's my job to befriend that part of them'

 

[Temperance]

At the VA where I am, research faculty are WOC hires with courtesy appointments at the affiliate university, and their salaries are wholly soft money.

 

[deleted106747]

Welcome to the club. Once you get to a year, you get a chip. Haven't read it yet, but read a decent article with him, and it's on my list.

It’s an interesting read so far. Some ideas he had I think worked — more partnerships with community providers but no privatization— and some I think were in the ballpark but are problematic in execution like increased mental health access but no plan for improved access to ongoing care.

 

[Fan_of_Meehl]

It’s an interesting read so far. Some ideas he had I think worked — more partnerships with community providers but no privatization— and some I think were in the ballpark but are problematic in execution like increased mental health access but no plan for improved access to ongoing care.

'increased mental health access but no plan for improved access to ongoing care'
THIS x 1000!

The idiot administrators in mental health (at the level of implementation) are implementing the whole 'initial access' push at the level of 'same day access' (which I agree is cool and make sense) for a triage intake and/or a full intake (arguably 'session #1'). Fine.

However, this has resulted in some areas--especially in CBOCs or in 'open access' 'generalist' mental health settings such as post-deployment clinics, psychology clinics, etc.--being placed in the ridiculous situation of being so overloaded with clients (HUGE caseload numbers) such that the AVERAGE time between sessions (even ignoring no-shows or cancellations) would have to be between 30 and 60 days IN BETWEEN SESSIONS.

No mental health provider can consider such infrequently occurring therapy sessions to constitute standard of care/practice psychotherapy. However, whenever this is brought up to administrators, they immediately play 'blame the provider' and default to 'you need to manage your caseload better.' Now, this MAY be a fair point or argument to make, assuming equal influx and efflux of cases across clinics. However, there are often HUGE shifts in rate of referrals to various clinics (and extreme inequities in terms of patient flow) and basic arithmetic/logic and logistical planning in order to try to influence caseloads to be approximately comparable across clinicians or clinics is never applied to the problem of an overloaded clinic (at least at my facility). The problem is either ignored or explanations arbitrarily and automatically blame the provider in some way.

Compounding the problem are inflexible 'mental health no-show followup' policies/procedures that MANDATE that--after any no-show, for example--the provider MUST call (and document on separate days) at least three attempts to contact the veteran by phone, then the clerk must send a letter to the veteran, then (if 14 days have passed with no response), the ball gets kicked back to the clinician who has to do a 'risk assessment' of the client/situation to determine 'what to do from there' (including performing a welfare check by the cops). And try to document a 'risk assessment' process when a) you have no client information to feed into that process (since it's likely been several weeks or even months since you had any contact with them) and b) you have to justify why you're NOT taking the step of sending the cops over to their place to check on them. What is so ridiculous about this is that there are tons of folks who are simply in the pre-contemplation phase (or they vacillate up to the contemplation or action phases of a transtheoretical model of behavior change and then back down again) and who are simply trying to self-select (passively) out of therapy. Now, of course in the context of repeated no-shows, not answering phone calls, etc. as a therapist I directly address this behavior with the veteran when/if I get ahold of them or when they come back into therapy 6 to 18 months later. However, many veterans (esp. those who depend on service-connection for income/housing/medical/educational benefits) are EXTREMELY reluctant to acknowledge either not needing or wanting therapy at any point in time because they figure that it will 'mess with their benefits.' The whole system is a dumpster fire because there is absolutely no leadership above the level of the rank-and-file clinicians who are willing to a) acknowledge and address certain inconvenient truths in the system (e.g., that we are paying people to be and to remain sick and this influences their behavior) and/or b) make a choice between logically contradictory philosophical approaches to, say, outpatient mental health service delivery (on the one hand, OMG we have to provide it to everyone, all the time, with no limitations or rationing because #BeThere and one suicide is too many while, on the other hand, OMG we have a budget crisis so we need people in your caseload to only be there for the 12 weeks it takes for them to successfully complete an EBT protocol and get better so they never have to use the MH system again).

 

[Therapist4Chnge]

I wish I could like your post more than once.

 

[Sanman]

'increased mental health access but no plan for improved access to ongoing care'
THIS x 1000!

The idiot administrators in mental health (at the level of implementation) are implementing the whole 'initial access' push at the level of 'same day access' (which I agree is cool and make sense) for a triage intake and/or a full intake (arguably 'session #1'). Fine.

However, this has resulted in some areas--especially in CBOCs or in 'open access' 'generalist' mental health settings such as post-deployment clinics, psychology clinics, etc.--being placed in the ridiculous situation of being so overloaded with clients (HUGE caseload numbers) such that the AVERAGE time between sessions (even ignoring no-shows or cancellations) would have to be between 30 and 60 days IN BETWEEN SESSIONS.

No mental health provider can consider such infrequently occurring therapy sessions to constitute standard of care/practice psychotherapy. However, whenever this is brought up to administrators, they immediately play 'blame the provider' and default to 'you need to manage your caseload better.' Now, this MAY be a fair point or argument to make, assuming equal influx and efflux of cases across clinics. However, there are often HUGE shifts in rate of referrals to various clinics (and extreme inequities in terms of patient flow) and basic arithmetic/logic and logistical planning in order to try to influence caseloads to be approximately comparable across clinicians or clinics is never applied to the problem of an overloaded clinic (at least at my facility). The problem is either ignored or explanations arbitrarily and automatically blame the provider in some way.

Compounding the problem are inflexible 'mental health no-show followup' policies/procedures that MANDATE that--after any no-show, for example--the provider MUST call (and document on separate days) at least three attempts to contact the veteran by phone, then the clerk must send a letter to the veteran, then (if 14 days have passed with no response), the ball gets kicked back to the clinician who has to do a 'risk assessment' of the client/situation to determine 'what to do from there' (including performing a welfare check by the cops). And try to document a 'risk assessment' process when a) you have no client information to feed into that process (since it's likely been several weeks or even months since you had any contact with them) and b) you have to justify why you're NOT taking the step of sending the cops over to their place to check on them. What is so ridiculous about this is that there are tons of folks who are simply in the pre-contemplation phase (or they vacillate up to the contemplation or action phases of a transtheoretical model of behavior change and then back down again) and who are simply trying to self-select (passively) out of therapy. Now, of course in the context of repeated no-shows, not answering phone calls, etc. as a therapist I directly address this behavior with the veteran when/if I get ahold of them or when they come back into therapy 6 to 18 months later. However, many veterans (esp. those who depend on service-connection for income/housing/medical/educational benefits) are EXTREMELY reluctant to acknowledge either not needing or wanting therapy at any point in time because they figure that it will 'mess with their benefits.' The whole system is a dumpster fire because there is absolutely no leadership above the level of the rank-and-file clinicians who are willing to a) acknowledge and address certain inconvenient truths in the system (e.g., that we are paying people to be and to remain sick and this influences their behavior) and/or b) make a choice between logically contradictory philosophical approaches to, say, outpatient mental health service delivery (on the one hand, OMG we have to provide it to everyone, all the time, with no limitations or rationing because #BeThere and one suicide is too many while, on the other hand, OMG we have a budget crisis so we need people in your caseload to only be there for the 12 weeks it takes for them to successfully complete an EBT protocol and get better so they never have to use the MH system again).

100% agreed. This is why I could never take a MH clinic job there. PCMHI, CLC, inpatient, and HBPC are at least capped by beds available or medical staff availability.

In our area, sustained access is critically bad and referrals to community care are even worse.

 

[Fan_of_Meehl]

I've only ever worked on the research side of the house, and I marvel at the willingness of the powers that be to overinterpret data when someone decides that it's time for a new policy or implementation.

Some of my colleagues and I refer to that tendency to overinterpret data as 'The Fundamental Theorem of Statistically-Ignorant Autocrats.'

I once had a program manager be required to solicit from me an 'explanation' for why the no-show rate in my clinic varied by about 5-8% from quarter to quarter (there had been a recent 'increase'). I started off the email with a statement something like, ' Variability is a feature of the natural world...' and went on to outline various basic principles from intro to stats and experimental design from undergrad (assumptions, measures of central tendency, null hypothesis testing, the sampling distribution of means and other concepts from inferential statistics and the philosophy of science proper). It was fairly lengthy. It was cathartic. I've never been asked to 'explain' variability in no-show rates again (so far).

 

[ExpertHoopJumper]

I completed my internship at a large VAMC and am now at a large AMC for postdoc. The training, didactics, professional development opportunities, and research opportunities are so much better in the AMC environment that I'm annoyed with myself for going to a VA for internship. Like, it's so much better at the AMCE that the two may be in different universes. I will be competitive for any type of job coming out of this postdoc (academic, academic medicine, clinical) but I don't think I would have been nearly as competitive for jobs with significant research components had I stayed in the VA.

 

[cara susanna]

'increased mental health access but no plan for improved access to ongoing care'
THIS x 1000!

The idiot administrators in mental health (at the level of implementation) are implementing the whole 'initial access' push at the level of 'same day access' (which I agree is cool and make sense) for a triage intake and/or a full intake (arguably 'session #1'). Fine.

However, this has resulted in some areas--especially in CBOCs or in 'open access' 'generalist' mental health settings such as post-deployment clinics, psychology clinics, etc.--being placed in the ridiculous situation of being so overloaded with clients (HUGE caseload numbers) such that the AVERAGE time between sessions (even ignoring no-shows or cancellations) would have to be between 30 and 60 days IN BETWEEN SESSIONS.

No mental health provider can consider such infrequently occurring therapy sessions to constitute standard of care/practice psychotherapy. However, whenever this is brought up to administrators, they immediately play 'blame the provider' and default to 'you need to manage your caseload better.' Now, this MAY be a fair point or argument to make, assuming equal influx and efflux of cases across clinics. However, there are often HUGE shifts in rate of referrals to various clinics (and extreme inequities in terms of patient flow) and basic arithmetic/logic and logistical planning in order to try to influence caseloads to be approximately comparable across clinicians or clinics is never applied to the problem of an overloaded clinic (at least at my facility). The problem is either ignored or explanations arbitrarily and automatically blame the provider in some way.

Compounding the problem are inflexible 'mental health no-show followup' policies/procedures that MANDATE that--after any no-show, for example--the provider MUST call (and document on separate days) at least three attempts to contact the veteran by phone, then the clerk must send a letter to the veteran, then (if 14 days have passed with no response), the ball gets kicked back to the clinician who has to do a 'risk assessment' of the client/situation to determine 'what to do from there' (including performing a welfare check by the cops). And try to document a 'risk assessment' process when a) you have no client information to feed into that process (since it's likely been several weeks or even months since you had any contact with them) and b) you have to justify why you're NOT taking the step of sending the cops over to their place to check on them. What is so ridiculous about this is that there are tons of folks who are simply in the pre-contemplation phase (or they vacillate up to the contemplation or action phases of a transtheoretical model of behavior change and then back down again) and who are simply trying to self-select (passively) out of therapy. Now, of course in the context of repeated no-shows, not answering phone calls, etc. as a therapist I directly address this behavior with the veteran when/if I get ahold of them or when they come back into therapy 6 to 18 months later. However, many veterans (esp. those who depend on service-connection for income/housing/medical/educational benefits) are EXTREMELY reluctant to acknowledge either not needing or wanting therapy at any point in time because they figure that it will 'mess with their benefits.' The whole system is a dumpster fire because there is absolutely no leadership above the level of the rank-and-file clinicians who are willing to a) acknowledge and address certain inconvenient truths in the system (e.g., that we are paying people to be and to remain sick and this influences their behavior) and/or b) make a choice between logically contradictory philosophical approaches to, say, outpatient mental health service delivery (on the one hand, OMG we have to provide it to everyone, all the time, with no limitations or rationing because #BeThere and one suicide is too many while, on the other hand, OMG we have a budget crisis so we need people in your caseload to only be there for the 12 weeks it takes for them to successfully complete an EBT protocol and get better so they never have to use the MH system again).

YES. Not to mention I'm not sure how we're supposed to "manage our caseload" when we're not allowed to, you know, actually do things like set limits and stop therapy if the patient isn't engaging or doesn't need it. In my clinic, the discharge process is so arduous that I never end up doing it. And don't get me started on the "same day access" thing. Now we have this new access standard that's 20 days from when the consult is placed. Not the PID, the consult creation date. They're now making the non-intake therapists do intakes in our new patient slots (60 min, btw - try doing that with all of the clinical reminders and suicide risk protocols) in order to accommodate this new standard, which means that actual new patients get scheduled into our normal grids and take up f/u slots. How's that for helping continued access to services? I can generally only see pts every 30 days unless I get very creative or schedule them out a bunch.

You know how physical therapy is allowed to discharge pts if they aren't doing their exercises? Man, if only.

 

[Sanman]

On a slightly lighter , but no less annoying, note, Did any other current clinicians find the roll out of the new RQI Basic Life Support Training completely botched at their medical center?

I just got hounded for an updated certification by HR yet we have one functioning dummy to certify on at the medical center and none at any CBOC. So, you want everyone in the hospital system to line up and wait to certify on the one dummy?

 

[Fan_of_Meehl]

On a slightly lighter , but no less annoying, note, Did any other current clinicians find the roll out of the new RQI Basic Life Support Training completely botched at their medical center?

I just got hounded for an updated certification by HR yet we have one functioning dummy to certify on at the medical center and none at any CBOC. So, you want everyone in the hospital system to line up and wait to certify on the one dummy?

Last I heard, our local folks have determined that we will need to recertify on CPR (with in person demonstration) at minimum x4/ year going forward (whereas it had been once every two years). And I'm not even joking.

 

[Sanman]

Last I heard, our local folks have determined that we will need to recertify on CPR (with in person demonstration) at minimum x4/ year going forward (whereas it had been once every two years). And I'm not even joking.

I thought it was online only every 90 days after the initial qualifier in person. If I have to recertify in person every 90 days, I refuse on the grounds that I hate that dummy and want it to die.

 

[Fan_of_Meehl]

I thought it was online only every 90 days after the initial qualifier in person. If I have to recertify in person every 90 days, I refuse on the grounds that I hate that dummy and want it to die.

LOL, on the bright side, your facility may be the only one in the history of medicine to achieve the miraculous distinction of having a CPR dummy that has been 'resuscitated to death.'

 

[cara susanna]

On a slightly lighter , but no less annoying, note, Did any other current clinicians find the roll out of the new RQI Basic Life Support Training completely botched at their medical center?

I just got hounded for an updated certification by HR yet we have one functioning dummy to certify on at the medical center and none at any CBOC. So, you want everyone in the hospital system to line up and wait to certify on the one dummy?

Totally. Apparently our dummy stopped working now.

 

[Pragma]

I thought it was online only every 90 days after the initial qualifier in person. If I have to recertify in person every 90 days, I refuse on the grounds that I hate that dummy and want it to die.

I did it. I like it. 5 minutes every 90 days and it stays fresh vs. forgetting and relearning every 2 years...

 

[Therapist4Chnge]

I did it. I like it. 5 minutes every 90 days and it stays fresh vs. forgetting and relearning every 2 years...

There is probably an interval between 90 days and 2 years that could work better.

 

[clausewitz2]

There is probably an interval between 90 days and 2 years that could work better.

If only there was some intermediate unit of time between days and years, but alas...

 

[erg923]

Last I heard, our local folks have determined that we will need to recertify on CPR (with in person demonstration) at minimum x4/ year going forward (whereas it had been once every two years). And I'm not even joking.

Whaaaat?

 

[Fan_of_Meehl]

Whaaaat?

That's what I was told but--judging from the info posted from others above--it was probably erroneous. An online refresher (of knowledge) every 90 days after initial in-person training is tolerable. I hope that's what we're doing at our site but, if not, it wouldn't be the first time that our particular VA hospital found a way to 'turbo-charge' the insanity above and beyond what was required by national/VISN.

 

[Therapist4Chnge]

Never underestimate how odd/weird local VISN policies can become; rarely are they well thought out.

 

[AcronymAllergy]

I've heard refreshers being essentially about 5 minutes' worth of performing compressions on an autonomous training dummy. I'd probably rather do that than have to complete yet another TMS course.

I have no idea what our facility has implemented, though. But I did appreciate the move of essentially all the classroom learning to TMS as opposed to having to sit through a 4-hour class. Much easier to work around clinic schedules.