Blindsided during feedback

[Kadhir]

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I recently delivered neuropsych feedback to a Veteran very invested in his mTBI diagnosis (more accurately, characterization of his cognitive problems as chronic sequelae of remote mTBIs), reinforced by many healthcare providers. I know this is not an uncommon situation. However, at the outset of the session, he informed me that he knew what I was about to tell him and that "no offense, but.." I was assuming he is of average intellect when he is not. He also rattled off some percentile in which he had performed on a test, and dictated the first sentence of my Impressions to me. Curious to know how he got this information before my feedback, I asked. He shared that his SLP told him she used my report for treatment planning purposes, and that she had pulled up the report on the EMR and they had read through it together. He was not provided a copy of the report. He is undergoing a manualized cognitive training intervention with this SLP.

The case has been supervised and wrapped up, and we're not approaching the SLP or any other providers. Overall, we managed feedback OK. But I am wondering what others would do, if anything, in this situation.

 

[PsyDr]

I’d call up his/her department head and tell him/her that I’m gonna to read his/her chart notes to every patient that walks in my door because he/she finds this acceptable.

 

[bcliff]

I recently delivered neuropsych feedback to a Veteran very invested in his mTBI diagnosis (more accurately, characterization of his cognitive problems as chronic sequelae of remote mTBIs), reinforced by many healthcare providers. I know this is not an uncommon situation. However, at the outset of the session, he informed me that he knew what I was about to tell him and that "no offense, but.." I was assuming he is of average intellect when he is not. He also rattled off some percentile in which he had performed on a test, and dictated the first sentence of my Impressions to me. Curious to know how he got this information before my feedback, I asked. He shared that his SLP told him she used my report for treatment planning purposes, and that she had pulled up the report on the EMR and they had read through it together. He was not provided a copy of the report. He is undergoing a manualized cognitive training intervention with this SLP.

The case has been supervised and wrapped up, and we're not approaching the SLP or any other providers. Overall, we managed feedback OK. But I am wondering what others would do, if anything, in this situation.

Out of curiosity, is it common in your setting (I'm assuming VA) to upload reports prior to feedback?

 

[Kadhir]

Out of curiosity, is it common in your setting (I'm assuming VA) to upload reports prior to feedback?

It's the norm, yes. It can be a while until we get people in for feedback. As the Veteran (rightfully) pointed out, we want others to be able to access these reports asap so they can inform care. We do not expect that they will be reviewed independently with these providers (unless they are appropriately qualified). Another thing I should mention (for folks outside VA) is that Veterans have access to their chart records if they follow the necessary release of info procedures. To me, at least, this is still not the same as reading on with a provider and possibly being subjected to their implicit interpretations/biases.

 

[Pragma]

I’m pretty sure the veterans can download the report from their own account too. Think they can access the notes online.

 

[Kadhir]

I’m pretty sure the veterans can download the report from their own account too. Think they can access the notes online.

Yes, this is also true- via MyHealtheVet.

 

[temppsych123]

Non-neuro person here, but studying for the EPPP currently, and hence reviewing all our various ethical rules - my understanding is that we have an ethical obligation to provide feedback to clients in a way that's understandable and appropriate, and that it's not ethical to provide test scores only without interpretation (e.g., we shouldn't just mail a report full of scaled scores to a client to figure out on their own). I realize you didn't do this (as you scheduled a feedback session and, it sounds like, followed all the protocols in place), but it does seem shady to me at a system-wide level that someone without the necessary credentials gets to interpret a test and give the client their first feedback on it, especially when a feedback session is scheduled with the testing/report-writing provider. It is also odd to me that feedback sessions happen after, in theory, the report is already informing care choices - it sort of precludes the possibility that the client might tell us more information at the feedback session that leads to a different interpretation or a revised report, or the possibility that a client might disagree with the results (as they did here) and disagree with them being used to inform treatment.

None of this is to suggest you did anything wrong, OP - it sounds like this is standard practice in your system, albeit maybe unusual for a provider to go through the results in detail with the client when that provider didn't do the testing. It does seem like an issue to flag to higher-ups, though, in terms of how to avoid this type of situation in the future?

 

[Fan_of_Meehl]

Out of curiosity, is it common in your setting (I'm assuming VA) to upload reports prior to feedback?

Fairly common presentation at VA:
- high percentage service connection for PTSD (70%-100% disability rating)
- severe clinical depression
- severe insomnia (obviously a sx of PTSD, but I'm highlighting it as an equally obvious etiological factor for 'post-concussive' symptoms like difficulties concentrating, irritability, low energy)
- drinking heavily (say, a fifth of whiskey a night)
- uncontrolled obstructive sleep apnea ('I just can't wear my mask, I've tried everything')
- toxic, enmeshed relationships, emotional instability, high levels of financial and/or relational/familial stressors

and...

oh yeah...

- 8 years ago on deployment I hit my head and lost consciousness for 30-60 seconds, felt dazed/confused when regained consciousness, no post-traumatic amnesia; secondary evaluation confirmed history of combat-related concussion (history of mTBI or, 'mTBI')

Obviously, the veteran's problems with moodiness, depression, anxiety, irritability, problems concentrating, inability to work, inability to remember, inability to remember to take meds, etc.

must be due to the history of combat-related concussion.

Every time.

I have my own form of a variant of the Hippocratic oath (sort of a Hippocratic oath for psychotherapists):

I DON'T LIE TO MY PATIENTS

I may not know what the absolute TRUTH is for every individual veteran I see, but I DON'T LIE TO MY PATIENTS.

Me telling a veteran with the history described above that I had reason to believe that any of his current problems are related to the history of combat-related concussion would, in my view, be me lying to my patient.

 

[Fan_of_Meehl]

Fairly common presentation at VA:
- high percentage service connection for PTSD (70%-100% disability rating)
- severe insomnia (obviously a sx of PTSD, but I'm highlighting it as an equally obvious etiological factor for 'post-concussive' symptoms like difficulties concentrating, irritability, low energy)
- drinking heavily (say, a fifth of whiskey a night)
- uncontrolled obstructive sleep apnea ('I just can't wear my mask, I've tried everything')
- toxic, enmeshed relationships, emotional instability, high levels of financial and/or relational/familial stressors

and...

oh yeah...

- 8 years ago on deployment I hit my head and lost consciousness for 30-60 seconds, felt dazed/confused when regained consciousness, no post-traumatic amnesia; secondary evaluation confirmed history of combat-related concussion (history of mTBI or, 'mTBI')

Obviously, the veteran's problems with moodiness, depression, anxiety, irritability, problems concentrating, inability to work, inability to remember, inability to remember to take meds, etc.

must be due to the history of combat-related concussion.

Every time.

I have my own form of a variant of the Hippocratic oath (sort of a Hippocratic oath for psychotherapists):

I DON'T LIE TO MY PATIENTS

I may not know what the absolute TRUTH is for every individual veteran I see, but I DON'T LIE TO MY PATIENTS.

Me telling a veteran with the history described above that I had reason to believe that any of his current problems are related to the history of combat-related concussion would, in my view, be me lying to my patient.

Edit: briarcliff, I apologize, I accidentally replied to your message and not to a different (more relevant to my comment) post.

 

[AcronymAllergy]

I think contacting the SLP and discussing the situation, along with a request that reports not be reviewed with the patient by them until you've had a chance to do so yourself (e.g., as verified by a feedback note being in the chart) for various reasons, would be reasonable and appropriate.

Also, I think it's important to note that yes, ethically, we should discuss the results with patients or ensure that the ordering provider is doing so appropriately (when the examinee is our client). But a patient disagreeing with results does not necessarily mean the data should not be considered when guiding treatment. I also generally do not to alter a report based on feedback with the patient, as the report was written with the information I had available at that time. If needed, I'll include an addendum with any pertinent new information.

 

[Kadhir]

Fairly common presentation at VA:
- high percentage service connection for PTSD (70%-100% disability rating)
- severe clinical depression
- severe insomnia (obviously a sx of PTSD, but I'm highlighting it as an equally obvious etiological factor for 'post-concussive' symptoms like difficulties concentrating, irritability, low energy)
- drinking heavily (say, a fifth of whiskey a night)
- uncontrolled obstructive sleep apnea ('I just can't wear my mask, I've tried everything')
- toxic, enmeshed relationships, emotional instability, high levels of financial and/or relational/familial stressors

and...

oh yeah...

- 8 years ago on deployment I hit my head and lost consciousness for 30-60 seconds, felt dazed/confused when regained consciousness, no post-traumatic amnesia; secondary evaluation confirmed history of combat-related concussion (history of mTBI or, 'mTBI')

Obviously, the veteran's problems with moodiness, depression, anxiety, irritability, problems concentrating, inability to work, inability to remember, inability to remember to take meds, etc.

must be due to the history of combat-related concussion.

Every time.

I have my own form of a variant of the Hippocratic oath (sort of a Hippocratic oath for psychotherapists):

I DON'T LIE TO MY PATIENTS

I may not know what the absolute TRUTH is for every individual veteran I see, but I DON'T LIE TO MY PATIENTS.

Me telling a veteran with the history described above that I had reason to believe that any of his current problems are related to the history of combat-related concussion would, in my view, be me lying to my patient.

To be clear, I agree, entirely. And, unsurprisingly, many of those differentials would apply in this case as well, and we communicated the same. Feedback actually went fine. The patient was overwhelmed and very anxious but didn't contest the conceptualization once we got past the issue of premorbid functioning. I suspect this is why we're not approaching the SLP. But it was helpful to hear people's thoughts on this here, because I might not have kept my head down if I was practicing independently (I'm a fellow). There is a clear potential for this to happen again, and for it to be disastrous... so I worry about that. Even in this case, his sick role will continue to be reinforced long after we've seen him (he's seeking caregiver services- this is not an older Vet).

I think contacting the SLP and discussing the situation, along with a request that reports not be reviewed with the patient by them until you've had a chance to do so yourself (e.g., as verified by a feedback note being in the chart) for various reasons, would be reasonable and appropriate.

Also, I think it's important to note that yes, ethically, we should discuss the results with patients or ensure that the ordering provider is doing so appropriately (when the examinee is our client). But a patient disagreeing with results does not necessarily mean the data should not be considered when guiding treatment. I also generally do not to alter a report based on feedback with the patient, as the report was written with the information I had available at that time. If needed, I'll include an addendum with any pertinent new information.

Helpful, thanks. I also agree with your second point. Unless I seriously messed up or there were non-clinical issues interfering, whatever data I collected during the evaluation should be valid from an empirical perspective. Feedback sessions can clarify or enhance but don't usually change the message drastically in typical scenarios.

 

[Fan_of_Meehl]

And, to be fair, it's not the veteran's (or their families') fault for believing that the history of concussion is causing all their problems. Unfortunately, we have the popular media writing story after story about the scourge of mTBI and 'lack of recognition' of the clinical impact, etc., etc., etc., and we have clinicians who can't be bothered to read a book chapter or a review article from a scientifically credible source. And I also think that there's a HUGE temptation for the therapist to be able to say/think, 'Yeah, maybe the reason we're not making headway on your serious clinical problems (psychopathology) is because all this is neurologically based.'

 

[cara susanna]

First off, I would be pretty furious about this. I think you're being much nicer about it than I would.

Second, I work in the VA and am aware that there is a rule you're not supposed to give medical feedback to patients if you aren't competent in that area. For instance, I can access patients' blood test and radiology results in their chart, but I can't tell them what they say because I'm not qualified to discuss that particular part of their medical care. I've even had patients ask me to and I have to say no. Could you argue that principle was violated in this case?

 

[WisNeuro]

First off, I would be pretty furious about this. I think you're being much nicer about it than I would.

Second, I work in the VA and am aware that there is a rule you're not supposed to give medical feedback to patients if you aren't competent in that area. For instance, I can access patients' blood test and radiology results in their chart, but I can't tell them what they say because I'm not qualified to discuss that particular part of their medical care. I've even had patients ask me to and I have to say no. Could you argue that principle was violated in this case?

I mean, you can. But in my VA experience, I'd say there's little to no chance of anything happening.

 

[smalltownpsych]

First off, I would be pretty furious about this. I think you're being much nicer about it than I would.

Second, I work in the VA and am aware that there is a rule you're not supposed to give medical feedback to patients if you aren't competent in that area. For instance, I can access patients' blood test and radiology results in their chart, but I can't tell them what they say because I'm not qualified to discuss that particular part of their medical care. I've even had patients ask me to and I have to say no. Could you argue that principle was violated in this case?

I would feel the same way. A call to the SLP to explain and educate them about this would be my move after I had calmed down from my first reaction so that I could maintain my professional demeanor. Working in an integrated system it is important for each individual to know how to handle these types of situations appropriately. They come up all the time. "My other provider said this and this about my mental health stuff." "My other provider said that my physical condition is probably in my head what do you think?" I actually had one the other day where the patient wanted me to access the results from a recent visit to alleviate their anxiety about cancer. Sorry, but there is no way I'm going to do that. Used it as an opportunity to help the patient work on how to advocate for themselves, cope with the anxiety, and allowed them to express their frustration with a difficult situation.

 

[futureapppsy2]

I’ve seen SLPs argue that they can interpret cognitive testing because “cognition is language.” It’s right up there with BCBAs arguing that the ACT workshop they attended one weekend makes them fully qualified psychotherapists because “ACT is ABA.”

 

[Kadhir]

First off, I would be pretty furious about this. I think you're being much nicer about it than I would.

Second, I work in the VA and am aware that there is a rule you're not supposed to give medical feedback to patients if you aren't competent in that area. For instance, I can access patients' blood test and radiology results in their chart, but I can't tell them what they say because I'm not qualified to discuss that particular part of their medical care. I've even had patients ask me to and I have to say no. Could you argue that principle was violated in this case?

I was, believe me. I almost immediately stormed into my supervisor's office and unloaded. I just did not want to unleash that drama here- just wondering if others have experienced something similar and what their reactions and courses of action would be. The parallel to radiology reports is exactly the one I drew when describing this to colleagues here. CT/MRI findings routinely figure into my reports, and I use them to support conclusions, but never would I read off a radiology note to a patient myself. I'll also note that the Veteran did say something like "well, she [SLP] said she couldn't really interpret stuff because it's not her area but... I mean she didn't give me a copy or anything but..." Clearly, even the patient here knew this was not acceptable. I'm disappointed in the provider, and by the fact that people don't really seem to be held accountable and are instead allowed to perpetuate iatrogenesis. I think my fury has simmered just a tad to frustration/exasperation, which is pretty much my baseline here. And so it goes.

I mean, you can. But in my VA experience, I'd say there's little to no chance of anything happening.

Precisely.

 

[psychRA]

I've been in somewhat similar situations, in the sense that other providers have done things that I don't feel are acceptable and I also think there's very little chance that anything will change.

First, I will point out that there's probably 0% chance that things will change spontaneously if I don't make some sort of attempt to give feedback to that person.

Second, I think there can still be some personal and professional benefit to giving feedback to someone who isn't necessarily going to change. To borrow from DBT, there's the self-respect effectiveness that comes with communicating, and advocating for, my perspective on this type of professional situation. This SLP clearly should know that it's inappropriate to share another provider's report before that provider has done so, but that doesn't mean that the SLP actually does know (or really understand) that. This an opportunity to communicate psychology's expectations about how these situations should be handled. If the SLP takes in that information, great. If not, at least you know that you tried.

I'm not suggesting that we all keep beating our heads against the proverbial wall for every single situation, but I also think there are many situations where nothing will change if nothing changes.