Posting this for two reasons - one because I am genuinely interested in feedback from some of you about how you would handle this situation, but also because I think it may make for some interesting broader discussions about our field. Forgive me for being a little obtuse, but trying to be mindful of potentially liability issues putting some things in writing.
Background: I work for a major AMC. Primarily in a research role, but also see patients 1 day/week. Part of the AMCs largest outpatient - clinic as a whole is "generalist" though we each have our specialties. I'm certainly foremost a researcher and <most> people there are primarily clinicians. My research shop is elsewhere and largely unrelated to my current clinical work. My clinical training was focused on health psychology and SUDs, though obviously am also comfortable in generalist outpatient psychology "bread & butter" cases (depression, CBT, adjustment issues, etc.).
Issue: In light of the move to value-based care, our department is making a big push for "rapid access" right now. The shift unfortunately occurred immediately after I was fully licensed/credentialed and no longer under supervision. What this has amounted to is much more pressure to get folks in quickly and less opportunity for clinicians to be selective about cases, keep people on the waiting list until a more appropriate clinician becomes available, etc. I tried pushing back gently on the issue and continued getting sent cases clearly outside my wheelhouse (folks with multiple suicide attempts and a history of self-injury who clearly would benefit from DBT, folks with extensive trauma histories who clearly would ideally be matched with someone trained in CPT/PE). I can approach this from a general CBT/ACT framework and give it my all...but neither is something you really want to dabble in without backup. I gradually pushed back more forcefully and have basically been told it is what it is and to figure it out. Some things I'm working on (i.e. workshops, consultations - though it irks me that I'm simultaneously being told there is no money to support these things and no willingness to support my time to do it). At a minimum, training in evidence-based PTSD treatments is something I've been trying to get since Year 2 of grad school and through a fairly comical series of events was unable to get. Given my own time constraints though, this is likely to be a multiyear process, which doesn't help folks on my current caseload and that doesn't leave me feeling very good about things. I don't feel like we have yet reached a point where I've stretched professional ethics, but trending in a direction I could see some shaky situations if things continue.
Personal Question: How would you handle? What else would you do? Where do you draw your own "competence" boundaries in your practice? Part of my struggle is just bad timing. The shift occurred literally within weeks of me becoming independent and has been gradually escalating since that time - I imagine most newly independent practitioners go through this, but I kind of launched onto shaky ground from the start. How are your institutions changing with the shift to value-based care?
Broader Question: What do we think about this general shift in the field (which I'm certain is a national trend and not just here)? Where do we draw the line between access to care and access to the best possible care? Does this vary by setting (i.e. should there be greater expectations for specialty care at an academic hospital vs. a small community practice)? Is bad care better than no care (and how do we define bad care)? Is "okay" care better than no care? Where do we draw those lines?
Background: I work for a major AMC. Primarily in a research role, but also see patients 1 day/week. Part of the AMCs largest outpatient - clinic as a whole is "generalist" though we each have our specialties. I'm certainly foremost a researcher and <most> people there are primarily clinicians. My research shop is elsewhere and largely unrelated to my current clinical work. My clinical training was focused on health psychology and SUDs, though obviously am also comfortable in generalist outpatient psychology "bread & butter" cases (depression, CBT, adjustment issues, etc.).
Issue: In light of the move to value-based care, our department is making a big push for "rapid access" right now. The shift unfortunately occurred immediately after I was fully licensed/credentialed and no longer under supervision. What this has amounted to is much more pressure to get folks in quickly and less opportunity for clinicians to be selective about cases, keep people on the waiting list until a more appropriate clinician becomes available, etc. I tried pushing back gently on the issue and continued getting sent cases clearly outside my wheelhouse (folks with multiple suicide attempts and a history of self-injury who clearly would benefit from DBT, folks with extensive trauma histories who clearly would ideally be matched with someone trained in CPT/PE). I can approach this from a general CBT/ACT framework and give it my all...but neither is something you really want to dabble in without backup. I gradually pushed back more forcefully and have basically been told it is what it is and to figure it out. Some things I'm working on (i.e. workshops, consultations - though it irks me that I'm simultaneously being told there is no money to support these things and no willingness to support my time to do it). At a minimum, training in evidence-based PTSD treatments is something I've been trying to get since Year 2 of grad school and through a fairly comical series of events was unable to get. Given my own time constraints though, this is likely to be a multiyear process, which doesn't help folks on my current caseload and that doesn't leave me feeling very good about things. I don't feel like we have yet reached a point where I've stretched professional ethics, but trending in a direction I could see some shaky situations if things continue.
Personal Question: How would you handle? What else would you do? Where do you draw your own "competence" boundaries in your practice? Part of my struggle is just bad timing. The shift occurred literally within weeks of me becoming independent and has been gradually escalating since that time - I imagine most newly independent practitioners go through this, but I kind of launched onto shaky ground from the start. How are your institutions changing with the shift to value-based care?
Broader Question: What do we think about this general shift in the field (which I'm certain is a national trend and not just here)? Where do we draw the line between access to care and access to the best possible care? Does this vary by setting (i.e. should there be greater expectations for specialty care at an academic hospital vs. a small community practice)? Is bad care better than no care (and how do we define bad care)? Is "okay" care better than no care? Where do we draw those lines?
