Communicating evidence base to other providers?

[Intrusive Thots]

For context, I am a first-year Ph.D. student currently completing a summer internship in community mental health.

I am running into some challenges when communicating my rationale for making treatment recommendations, primarily for anxiety-related conditions to psychiatric nurses in the clinic. To elaborate, my research and clinical focus is on OCD, which is the condition for which I have the best grasp on the available literature. Some of the psychiatrists here have recommended my clients stop or postpone ERP -- some of whom I have seen for months at this point -- due to transient increases in distress as we move up their exposure hierarchy. They have also made other suggestions that conflict with the empirical literature, like advising clients to take time away from employment, etc.

There is a group of psychiatric nurses who do the leg work for coordinating these clients for the psychiatrist who has been coming to see me and asking why I stated in reports that the psychiatrist's current treatment plan is at odds with the OCD literature and how they are likely to increase dysfunction. These nurses rely on anecdotes, and I am having a hard time knowing how to convey research findings that justify my case conceptualization and treatment plan without sounding like I am beating them over the head with scientific findings.

I am looking for those of you with experience communicating research findings to other professions who may not have a background in statistics and research methods without sounding like a complete condescending prick.

Thank you.

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[neurotic_cow]

What exactly is your role in this position? What does your supervisor say?

 

[Sanman]

For context, I am a first-year Ph.D. student currently completing a summer internship in community mental health.

I am running into some challenges when communicating my rationale for making treatment recommendations, primarily for anxiety-related conditions to psychiatric nurses in the clinic. To elaborate, my research and clinical focus is on OCD, which is the condition for which I have the best grasp on the available literature. Some of the psychiatrists here have recommended my clients stop or postpone ERP -- some of whom I have seen for months at this point -- due to transient increases in distress as we move up their exposure hierarchy. They have also made other suggestions that conflict with the empirical literature, like advising clients to take time away from employment, etc.

There is a group of psychiatric nurses who do the leg work for coordinating these clients for the psychiatrist who has been coming to see me and asking why I stated in reports that the psychiatrist's current treatment plan is at odds with the OCD literature and how they are likely to increase dysfunction. These nurses rely on anecdotes, and I am having a hard time knowing how to convey research findings that justify my case conceptualization and treatment plan without sounding like I am beating them over the head with scientific findings.

I am looking for those of you with experience communicating research findings to other professions who may not have a background in statistics and research methods without sounding like a complete condescending prick.

Thank you.

Are they asking you about the scientific literature/treatment planning or telling you to sit down and shut up? There is a way to communicate if it is the former and there is a way to bang your head against the wall and get in trouble if it is the latter.

 

[Shiori]

You'll have your whole career to be right. I would settle in and take the opportunity to see why and when folks deviate from the literature. You might totally disagree with them, but you'll have a firmer grasp on your own understanding of things. I have worked with supervisors with totally different theoretical orientations and got a lot out of the experience. With the guidance of your supervisor, I would take the time to explore the messiness of working with other disciplines. Ms. Frizzle comes to mind.

 

[Intrusive Thots]

What exactly is your role in this position? What does your supervisor say?

My role was originally conducting co-therapy with my supervisor in the room, observing me and stepping in if necessary. Now I have moved on to seeing clients by myself. A contributing factor and why I came to SDN is that my supervisor is currently on vacation.

 

[AcronymAllergy]

In terms of professional politics, it's probably not good optics to directly call out another provider in notes or reports, particularly as a trainee and if those notes go into the medical record.

I would agree with neurotic_cow in that one of the first things I'd do is approach your supervisor. After all, you're working under their license and it's their relationship with these other providers that might be impacted. And with Sanman and Shiori in that a lot can depend on how the other providers have actually approached you about the issue, and that even if you don't agree with them, knowing why they recommend the things they do can be a useful training experience.

After that, in general, often the first step in these types of situations is to ask to briefly speak with the other provider(s) about your concerns. You can then review what your goals are with therapy and discuss that temporary increases in symptom severity are to be expected at times with ERP and can help to show the treatment is working, and that you want to work with the other provider to maximize the effectiveness of both of your treatments. You could then say how X or Y may actually interfere with treatment gains and, counterintuitively, exacerbate the underlying condition. And that because this is counterintuitive and because the patient may temporarily experience an increase in symptoms, that's why it's so important that they receive a consistent message. I don't know that you really need to go very far down the research rabbit hole unless they ask for more information or challenge what you're saying. And ultimately, at the end of the day, you can't control what other providers do, particularly if it doesn't rise to the level of malpractice.

However, as a trainee, I probably wouldn't do any of that without checking in with a supervisor first.

 

[summerbabe]

There is a group of psychiatric nurses who do the leg work for coordinating these clients for the psychiatrist who has been coming to see me and asking why I stated in reports that the psychiatrist's current treatment plan is at odds with the OCD literature and how they are likely to increase dysfunction.

Ah yes, welcome to what might be your first really valuable lesson in navigating interdisciplinary care, where managing relationships and collaborating well with other providers is often either just as important and sometimes even more important than your skills/knowledge base when it comes to maximizing effective care for patients.

As @AcronymAllergy mentioned, even if you strongly suspect that another provider's approach to treatment may be unhelpful or misguided, communicating that exclusively via medical notes (which may be seen by the patient, other providers, insurance companies, etc) is not going to win you (and your supervisor) friends.

More importantly, what does this actually accomplish? "Why did you write x in the medical record?" versus "How can we best treat this patient via our individual specialties collaboratively?" are two very different types of conversations and may even adversely impact patient care.

Clinical work often balances our intellectual side (the research base that you're aware of for OCD) with being interpersonally effective (how to elicit collaborative discussions that results in furthering care and best practices) and thus very different than engaging in a more strictly intellectual activity such as providing the alternative point of view in a class discussion, critiquing a journal article's flaws, etc.

I'm going to go on a limb that you're in a very clinical science heavy PhD program where the answer to many problems is "What does the research say?" For better and for worse, this academic instinct often does not apply outside of academia, which is also where just about all of the clinical work happens.

These nurses rely on anecdotes, and I am having a hard time knowing how to convey research findings that justify my case conceptualization and treatment plan without sounding like I am beating them over the head with scientific findings.

Sharing the empirical literature, which is often hard to digest even for seasoned psychologists, is probably not the winning approach.

A different strategy might be to validate the valid ("It's likely that patient x's distress will increase when they start ERP because they are having to do some really, really terrifying things and that might even include increased suicidal ideation, which is scary and should be monitored by this entire team) while also presenting your rationale ("And I think we should still pursue ERP because this is what the science says is our best option to break the OCD cycle that is causing this patient so much chronic distress and kept them in this clinic for x years. Can we brainstorm how else this patient can be supported while they do ERP and address the team's concerns?").

 

[Shiori]

There aren't many people I want to upset less than the psych nurses on a unit. They are the difference between a good and bad experience.

 

[thebalmofhurtminds]

This might not be possible in this particular case, but these situations are why it can be really helpful to have "informal"/friendly discussions with the interdisciplinary team in between meetings. I tend to do this and purposefully share relevant cool anecdotes, like how a previous ERP clinic I worked in had a clinic tarantula or a collection of knives. It allows for the discussion of how ERP (or insert whatever therapy) works without seeming preach-y about the research.

 

[psych.meout]

For context, I am a first-year Ph.D. student currently completing a summer internship in community mental health.

I am running into some challenges when communicating my rationale for making treatment recommendations, primarily for anxiety-related conditions to psychiatric nurses in the clinic. To elaborate, my research and clinical focus is on OCD, which is the condition for which I have the best grasp on the available literature. Some of the psychiatrists here have recommended my clients stop or postpone ERP -- some of whom I have seen for months at this point -- due to transient increases in distress as we move up their exposure hierarchy. They have also made other suggestions that conflict with the empirical literature, like advising clients to take time away from employment, etc.

There is a group of psychiatric nurses who do the leg work for coordinating these clients for the psychiatrist who has been coming to see me and asking why I stated in reports that the psychiatrist's current treatment plan is at odds with the OCD literature and how they are likely to increase dysfunction. These nurses rely on anecdotes, and I am having a hard time knowing how to convey research findings that justify my case conceptualization and treatment plan without sounding like I am beating them over the head with scientific findings.

I am looking for those of you with experience communicating research findings to other professions who may not have a background in statistics and research methods without sounding like a complete condescending prick.

Thank you.

You wrote what now in their medical records?!?

 

[WisNeuro]

You wrote what now in their medical records?!?

I call out other providers all the time in reports. I wouldn't have done it as a trainee. But, I now have no problem indicating how they are hastening my patient's demise with what they are doing.

 

[thebalmofhurtminds]

I call out other providers all the time in reports. I wouldn't have done it as a trainee. But, I now have no problem indicating how they are hastening my patient's demise with what they are doing.

To be fair, if you're working on an interdisciplinary team, there might be a few recommended steps to take before calling it out in notes. And absolutely not as a trainee without your supervisor's knowledge/approval.

 

[neurotic_cow]

My role was originally conducting co-therapy with my supervisor in the room, observing me and stepping in if necessary. Now I have moved on to seeing clients by myself. A contributing factor and why I came to SDN is that my supervisor is currently on vacation.

It doesn't sound like they are sending patients to you for evaluation or asking for your opinion on their treatment. Playing devil's advocate, I also think it is important to acknowledge that often as first year students we want to prove ourselves and you may not be as much of an expert on this topic as you think. Not trying to start anything, just simply something to consider. Who knows, maybe you are the leading OCD expert and I'm a numbskull, that's another possibility. I just know I went into my first year thinking I was an expert in neuroscience and dementia, but the longer I have been in training and in school, the more I have appreciated how little I know (and how very little I knew my first year!). It is also entirely possible the situation may be much more complex than what you are seeing, in my experience community mental health can be incredibly challenging and complicated and providers are often doing the best they can to keep themselves and their patients afloat and alive. I think explicitly calling these people out in medical records especially when that is not what is being asked of you is a dangerous game to play as a first year trainee. I'd encourage you to have an in depth discussion with your supervisor.

 

[psych.meout]

To be fair, if you're working on an interdisciplinary team, there might be a few recommended steps to take before calling it out in notes. And absolutely not as a trainee without your supervisor's knowledge/approval.

This was my thought process. I've called out other providers as well, even as a trainee, but it was (1) with the explicit consent of my supervisor (with whom I had already done supervision over that issue at least once) and (2) after exhausting other avenues to correct the issue. Others here have done a great job of explaining other ways of addressing these issues before resorting to putting something like this in a patient's medical record.

One thing that has definitely helped is to have humility and check my ego. Sure, I could be right and they could be completely wrong, but maybe there's something I don't know about this patient that they do? Maybe the patient has some other complicated medical and/or mental health comorbidities that explain why the provider pursued a particular? Maybe the patient has a complicated personal and medical history that I don't know about that has been a barrier to adherence and care in the past? Is it just that this particular provider is set in their ways, not following EBPs, aren't familiar with the, literature, etc. or are there larger issues with how the interdisciplinary team functions? And am I an expert in every aspect of this particular area as a first year grad student or is my expertise narrower than I'd like to think it is?

Even if I'm completely right, what is my goal in this situation? Is it for me to be right and to prove this frustrating provider wrong? Is it for me to show them how to do the right thing and "fix" this situation? Is it to get the best treatment possible for this specific patient? Is it to change how things are done for patients like this are done and foster a more collaborative relationship with the other providers on the team? Is it to better understand the personality and interpersonal dynamics of the team and the best way to get things done while managing them? Are there any conflicts between these goals and/or with any of the solutions to them?

 

[borne_before]

If I may, I would like to give you some advice that that was shared with me by one of my most competent and wonderful mentors/supervisors. By the way, I did not particularly like the supervisor personally, what she did for me was one of the most important lessons I ever learned in training. I called her just a few months ago to get some advice about assessing a Deaf and visually impaired kid.

In one of my first true school based practicum settings, I went into it with a lot of experience and knowledge, and willingness to share it, just like you. I had a chip on my shoulder - I was ready to prove myself.

This supervisor actually had me watch "The Last Lecture" by Randy Pausch and ended up gifting it to me when the practicum was over. I gave her some cycling socks and glass gem corn.

At one point in the lecture, Pausch has a academic mentor say "It's such a shame that people perceive you as being so arrogant. Because it's going to limit what you're going to be able to accomplish in life."

My supervisor, rather gently, was telling me that I was arrogant. So, I did some introspection. I was concerned that is being viewed as arrogant–its not something that I value.

But I was more concerned, that my supervisor felt like she had to be very gentle and how she delivered that message. Now, she could just be a very highly conscientious person–she absolutely is–but, what was I doing to make it seem like I could not get this feedback directly.

She, rather correctly, presumed that I was guarding my ego by being arrogant. See, I was one of the older kids in my cohort, I had a learning disability, I had a masters degree, I was a better "researcher," I had been published, I was never "going to lower myself to working in the school." And yet, I still felt the need to communicate just how much I knew.

In school, we work in teams. Everything is a team decision. I used to resent that, I was Maverick and independent, but my supervisor also help me understand that we can rely on our team members.

Dude, you are just getting started. You have a long time to show how "right" you are. But life is not always about being correct. While you can do a lot of good with exposure and response prevention, practically, it is difficult to do a lot of good if no place will hire you because you are not passing the "beer test" and writing critical things on reports about colleagues. The "beer test" is one of the most important things you need to understand–people would rather work with someone they can have a beer with, rather than someone who was pain in the bottom. Put simply, it is better to be liked than correct. It is hard to do evidence-based interventions if you cannot get a job.

Also, it is likely that they know something you don't. Listen and try to understand. Maybe they're saying "Hey, slow down on the exposures a little, this patient is about to quit." Can you implement evidence based interventions if clients don't show?

This is about more than work place politics - it's about humility. It's about working on the "art" of working with others and it is an "art" that faciliates the ability deliver interventions.

Also, don't call people out - allow them to save face. I can’t think of a faster way to burn bridges and get on a **** list than documenting something like that in a report.

Jesus, bro. You’re stressing me out - you need to consider some apologies.

 

[WisNeuro]

To be fair, if you're working on an interdisciplinary team, there might be a few recommended steps to take before calling it out in notes. And absolutely not as a trainee without your supervisor's knowledge/approval.

Definitely not as a trainee. But, as a community provider, I have no problem in doing so when someone should know better or puts a patient's life at risk. It's their liability, I'm just putting citations to it and strongly recommending that the patient speak to the provider about it.

 

[psych.meout]

Definitely not as a trainee. But, as a community provider, I have no problem in doing so when someone should know better or puts a patient's life at risk. It's their liability, I'm just putting citations to it and strongly recommending that the patient speak to the provider about it.

Right, but even not as a trainee, there's a difference between laying it all out when some quack in the community is doing things wrong vs a colleague on an interdisciplinary team.

 

[Shiori]

@borne_before, I just finished the Last Lecture and I'm ruined for the rest of the day. I am so happy to have seen it though.

 

[allantois]

Oh I really don't appreciate notes from therapists that say negative things about medical providers (I see it from new therapists). If I had a dollar every time a patient told me they don't like their therapist/or find it helpful I would be a rich man..

 

[neurotic_cow]

My role was originally conducting co-therapy with my supervisor in the room, observing me and stepping in if necessary. Now I have moved on to seeing clients by myself. A contributing factor and why I came to SDN is that my supervisor is currently on vacation.

Side note: I truly hope you are not seeing patients when your supervisor is out of the office and unavailable.

 

[BuckeyeLove]

Side note: I truly hope you are not seeing patients when your supervisor is out of the office and unavailable.

And coming here for guidance instead.

 

[AcronymAllergy]

Oh I really don't appreciate notes from therapists that say negative things about medical providers (I see it from new therapists). If I had a dollar every time a patient told me they don't like their therapist/or find it helpful I would be a rich man..

I agree that in general, it's important to be aware of, and judicious with, the information included in the medical record.

If a patient says they don't like one of their medical providers, unless it's germane to my evaluation, I'm not going to include that information in a medical chart note. If I do put anything in my report that a patient says about another provider (such as if it seems indicative of delusional thought content, or if for example they're saying Dr. X told them they should take 3x the prescribed dose when they're feeling "really anxious"), I'm going to directly quote the patient as much as possible.

Even in situations where I disagree with another provider, in clinical contexts, I've very seldom ever mentioned someone by name (which is probably just a "me" thing). I'll just state what I disagree with and why.

 

[WisNeuro]

I agree that in general, it's important to be aware of, and judicious with, the information included in the medical record.

If a patient says they don't like one of their medical providers, unless it's germane to my evaluation, I'm not going to include that information in a medical chart note. If I do put anything in my report that a patient says about another provider (such as if it seems indicative of delusional thought content, or if for example they're saying Dr. X told them they should take 3x the prescribed dose when they're feeling "really anxious"), I'm going to directly quote the patient as much as possible.

Even in situations where I disagree with another provider, in clinical contexts, I've very seldom ever mentioned someone by name (which is probably just a "me" thing). I'll just state what I disagree with and why.

Mine is more in the context of discussing why certain medication regimens are bad for my patient. Such as, complains of both memory and sleep problems (65+) so they are prescribed benedryl for sleep. Or, they are on several heavy anticholinergic medications. Or, they have mild anxiety and are started on maintenance xanax. I just cite the appropriate literature and recommend that they speak with their provider about possible medication changes to decrease effect on CNS. If it's a known bad provider, I'll recommend some of the geriatricians that I trust to do some med reconciliation.

 

[allantois]

Mine is more in the context of discussing why certain medication regimens are bad for my patient. Such as, complains of both memory and sleep problems (65+) so they are prescribed benedryl for sleep. Or, they are on several heavy anticholinergic medications. Or, they have mild anxiety and are started on maintenance xanax. I just cite the appropriate literature and recommend that they speak with their provider about possible medication changes to decrease effect on CNS. If it's a known bad provider, I'll recommend some of the geriatricians that I trust to do some med reconciliation.

This is interesting. I have seen therapists write out that patients are experiencing XYZ side effects of medications or that their medications are not working; but they just leave it at that - there is no note telling patient to follow up with their provider or attempt to contact the provider (this was when I worked in a large organization with therapy in house). To me it just looks bad that an issue of medication was brought up and nothing was done about it. I am not really sure how helpful feedback from a psychologist about medications would be (it doesn't sound like prescribing medications is something most psychologists do). I can't imagine prescribers receiving these notes are appreciating it. If you are concerned about medications your patient is on, I think it would be more appropriate to give a call to whomever is prescribing those medications.

 

[allantois]

I should probably send some notes to some therapists doing EMDR with my patients to do CPT instead.. lol I always chuckle when PCPs refer patients for CBT because.. well.. that's the only therapy they've heard about

 

[AcronymAllergy]

This is interesting. I have seen therapists write out that patients are experiencing XYZ side effects of medications or that their medications are not working; but they just leave it at that - there is no note telling patient to follow up with their provider or attempt to contact the provider (this was when I worked in a large organization with therapy in house). To me it just looks bad that an issue of medication was brought up and nothing was done about it. I am not really sure how helpful feedback from a psychologist about medications would be (it doesn't sound like prescribing medications is something most psychologists do). I can't imagine prescribers receiving these notes are appreciating it. If you are concerned about medications your patient is on, I think it would be more appropriate to give a call to whomever is prescribing those medications.

Most psychologists do no prescribe medications, no; some do, but not most. However, I definitely think psychologists can be helpful regarding medication adherence and feedback, particularly when working in concert with the prescribing provider.

I would imagine, although don't have any data to back it up, that in the majority of cases in which a patient expresses concerns about their medication side-effects to the psychologist, the psychologist is going to encourage the patient to speak with their physician (or NP/PA) about those concerns. Similarly, if a psychologist has concerns about medications (e.g., cognitive side-effects in a patient with demonstrated cognitive impairment and/or concerns about cognitive abilities), I'm going to guess that in most cases, the psychologist would recommend the patient talk to whoever is prescribing the med(s).

In my case, if I have concerns about the potential cognitive effects of a medication, I may tell the patient something like, "research shows that this type of medicine can sometimes affect thinking skills/mental abilities. Since that's something you're concerned about/since the testing I've done with you shows you do have some cognitive impairments, you may want to talk with the doctor prescribing these medicines to see what they think." Which is always prefaced or followed by a statement to the effect of, "I'm not a physician, I can't give you any advice on your medications or prescribe any medication to you, and I'm most certainly not telling you to change anything about how you're taking your medicines."

I've heard of some non-prescribing psychologists tell their patients that they shouldn't be taking certain medications. I would not do or recommend this. I've also seen some psychologists make specific medication recommendations in their reports (e.g., reference specific medication names and doses). I also would not do or recommend this. Unless you're a prescriber, in which case, you do you.

Edit: Forgot to say, when I actually worked with the physicians, I would usually message them after meeting with the patient to tell them what the patient's concerns were. Or I would create a short addendum in the chart and alert them to it, such as if the patient had a question about changing a medication or starting a new one.

 

[Sanman]

This is interesting. I have seen therapists write out that patients are experiencing XYZ side effects of medications or that their medications are not working; but they just leave it at that - there is no note telling patient to follow up with their provider or attempt to contact the provider (this was when I worked in a large organization with therapy in house). To me it just looks bad that an issue of medication was brought up and nothing was done about it. I am not really sure how helpful feedback from a psychologist about medications would be (it doesn't sound like prescribing medications is something most psychologists do). I can't imagine prescribers receiving these notes are appreciating it. If you are concerned about medications your patient is on, I think it would be more appropriate to give a call to whomever is prescribing those medications.

Some medication providers are responsive and some are not. When I have done this, I recommend something related to medications it is generally one of two things that are easy to manage in a VA system (my current setting)

1. Given the severity of your sx, you may want to consult with psychiatry rather than a PCP/neurologist as there may be better alternatives than what you are currently receiving.

2. Symptoms are more frequent than the patient may have led a provider to believe, maybe they need to be off something like Xanax and put on something more appropriate for chronic anxiety.

I usually turf to a new provider (psychiatry/geropsych depending on complexity)

 

[Sanman]

I should probably send some notes to some therapists doing EMDR with my patients to do CPT instead.. lol I always chuckle when PCPs refer patients for CBT because.. well.. that's the only therapy they've heard about

You should.

 

[WisNeuro]

This is interesting. I have seen therapists write out that patients are experiencing XYZ side effects of medications or that their medications are not working; but they just leave it at that - there is no note telling patient to follow up with their provider or attempt to contact the provider (this was when I worked in a large organization with therapy in house). To me it just looks bad that an issue of medication was brought up and nothing was done about it. I am not really sure how helpful feedback from a psychologist about medications would be (it doesn't sound like prescribing medications is something most psychologists do). I can't imagine prescribers receiving these notes are appreciating it. If you are concerned about medications your patient is on, I think it would be more appropriate to give a call to whomever is prescribing those medications.

Already have in some instances, rarely changes the prescribing behavior IME. I generally don't comment much on the psychotropics unless there is major concern, and usually just defer back to the prescriber.

 

[borne_before]

Some medication providers are responsive and some are not. When I have done this, I recommend something related to medications it is generally one of two things that are easy to manage in a VA system (my current setting)

1. Given the severity of your sx, you may want to consult with psychiatry rather than a PCP/neurologist as there may be better alternatives than what you are currently receiving.

2. Symptoms are more frequent than the patient may have led a provider to believe, maybe they need to be off something like Xanax and put on something more appropriate for chronic anxiety.

I usually turf to a new provider (psychiatry/geropsych depending on complexity)

What do we think about prescription meddling? I work very closely with pediatric prescribers. I alway provide psychoeducation on how they work, side effects, potential pitfalls (the adderall isn't working great in the morning because the kid drank OJ with it). Hell, I saw a kid last week with a PRN rx for xanax for anxiety. I made sure the parent understood the risks to benzos, helping them to understand withdrawal, reinforcing anxiety, rebound anxiety and how benzo withdrawals are no joke. The med thing is always a convo - but, some patients do misinterpret what I say and tell the prescriber that "Dr. B said to give my kid addies."

 

[WisNeuro]

What do we think about prescription meddling? I work very closely with pediatric prescribers. I alway provide psychoeducation on how they work, side effects, potential pitfalls (the adderall isn't working great in the morning because the kid drank OJ with it). Hell, I saw a kid last week with a PRN rx for xanax for anxiety. I made sure the parent understood the risks to benzos, helping them to understand withdrawal, reinforcing anxiety, rebound anxiety and how benzo withdrawals are no joke. The med thing is always a convo - but, some patients do misinterpret what I say and tell the prescriber that "Dr. B said to give my kid addies."

Nothing wrong with providing empirical literature to the patient so that they can have an informed discussion with their prescriber.

 

[Sanman]

What do we think about prescription meddling? I work very closely with pediatric prescribers. I alway provide psychoeducation on how they work, side effects, potential pitfalls (the adderall isn't working great in the morning because the kid drank OJ with it). Hell, I saw a kid last week with a PRN rx for xanax for anxiety. I made sure the parent understood the risks to benzos, helping them to understand withdrawal, reinforcing anxiety, rebound anxiety and how benzo withdrawals are no joke. The med thing is always a convo - but, some patients do misinterpret what I say and tell the prescriber that "Dr. B said to give my kid addies."

It depends on what the meddling is. Providing appropriate psychoeducation is not a bad thing, IMO. More often than not, the things I do are common sense. I had a caregiver providing a depressed patient (200lb male) with Sertraline 12.5 mg PRN and complaining that the meds did not work. Some basic psychoeducation about the process (give the medication as prescribed, this is a multi-month process so give psychiatry 3-6 months to find a therapeutic dose, etc.) helped to get things on the right track.

 

[allantois]

I honestly don't doubt psychologists concerns with medications.. in my experience most (all?) have a course in psychopharmacology in school. My psychopharmacology professor in undergrad was a medical psychologist. I will say that there are a lot of therapists out there (I really do not have a lot of patients who see psychologists) who try to undermine pharmacologic treatment (it's often blanket statements made to patients that they really do not need/should not be on their medications).. mind you some of these patients are being treated for bipolar disorder. There is a lot of politics in medicine than I think people from mental health but not medical background are not aware of.. generally we try not to throw each other under the bus in the notes (and it can come back to bite you IMHO if it is not documented in a certain way), so I think it is always best to tactfully reach out to the person first.
Conversely, I also see therapists suggesting that patients get on Xanax for anxiety (but this also happens with PCPs).

 

[PsyDr]

1) in forensics, I generally ridicule people. But In the words of the largest shareholder of smart water, I talk a lot of smack because I can back it up.
2) with patients, I use the literature from the dementia and terminal illness literatures. Those lines have some great insight into jamming information into succinct packages.
3) With referring providers, I phrase it so it’s obsequious. “I always thoughts that the literature said that the effect size for that was 1.3, but maybe he is aware of a more potent evidence base.”.

 

[erg923]

I honestly don't doubt psychologists concerns with medications.. in my experience most (all?) have a course in psychopharmacology in school. My psychopharmacology professor in undergrad was a medical psychologist. I will say that there are a lot of therapists out there (I really do not have a lot of patients who see psychologists) who try to undermine pharmacologic treatment (it's often blanket statements made to patients that they really do not need/should not be on their medications).. mind you some of these patients are being treated for bipolar disorder. There is a lot of politics in medicine than I think people from mental health but not medical background are not aware of.. generally we try not to throw each other under the bus in the notes (and it can come back to bite you IMHO if it is not documented in a certain way), so I think it is always best to tactfully reach out to the person first.
Conversely, I also see therapists suggesting that patients get on Xanax for anxiety (but this also happens with PCPs).

No one should throw anyone under any kind of bus of large moving object...that is CRYSTAL clear.

But I also do not think it reasonable to condone any kind of behavioral avoidance that may interfere with progress for patients that actually wish to function in said world. If that is indeed their stated goal? Sometimes, you have to be a hard ass, right? Your patient is just one object in the world....and the world will go on without them.

"You know when I wash my hands after going the bathroom?...When I ****ing **** on them."
-George Carlin

I generally think about it like I am telling a veteran who may (or may not?) be suffering from PTSD to STOP complaining about firework noises. This is an object therapeutic lesson for them to understand that they did NOT fight for individual freedoms in the USA only to tell their neighbors on the 4th of July to be quiet just because they get upset by it. This isn't how the world works.

 

[Sanman]

I honestly don't doubt psychologists concerns with medications.. in my experience most (all?) have a course in psychopharmacology in school. My psychopharmacology professor in undergrad was a medical psychologist. I will say that there are a lot of therapists out there (I really do not have a lot of patients who see psychologists) who try to undermine pharmacologic treatment (it's often blanket statements made to patients that they really do not need/should not be on their medications).. mind you some of these patients are being treated for bipolar disorder. There is a lot of politics in medicine than I think people from mental health but not medical background are not aware of.. generally we try not to throw each other under the bus in the notes (and it can come back to bite you IMHO if it is not documented in a certain way), so I think it is always best to tactfully reach out to the person first.
Conversely, I also see therapists suggesting that patients get on Xanax for anxiety (but this also happens with PCPs).

Basic psychopharmacology questions are on our national licensing exam. Any health service provider worth their salt should have a basic understanding of psychopharm if you work in mental health.

 

[Shiori]

I recently persuaded a client that their psychiatrist was likely not poisoning them. I find that I do this a lot in the VA. A Google search of side effects convinces them they are in the .0001% of worst case scenarios. I hope the medical providers in my clinics don't mind. I don't mind at all when they lightly push them toward therapy for things like sleep or pain.

 

[smalltownpsych]

First year practicum and you are going to call out others? Hell, you might actually be right, but you have no hope of doing anything to help your patient by calling out his psychiatrist. My first year I sent a kid to the psychiatrist because of his hallucinations. I was really shaken up because I was sure it was the onset of schizophrenia. Psychiatrist diagnosed MDD w/ Psychosis and a few years later, I realized he was almost certainly correct based on a very typical presentation. A few years later, trying to clarify diagnosis and the psychiatrist asked patient about sleep pattern, I forgot that one and so my uncertain diagnosis of Bipolar was nailed down. First time I went head to head with a psychiatrist was during internship when he was going to discharge my patient right before Christmas with some serious risk factors including recent loss of his spouse and no solid plan or supports in place to cope with the empty house. I told him my concerns and he was initially not convinced, but when I told him that I would list these concerns and my objection to the plan in my discharge. He agreed to wait till after Xmas.

More to the point, one of our ethical standards is cooperating with other professionals. We will be right at times and we will be wrong at times and the same can be said about the other professionals, and there is not an ethical standard about that. Don’t and I mean DO NOT conflate imperfect care or care that you don’t agree with as being unethical. That is something that you have to learn as a doctoral student so that you aren’t like the legions of midlevel counselors out there. Half the time they would use it to describe staff who aren’t doing what the therapist is telling them and then saying that is unethical. Never mind that unlicensed staff don’t have an ethics code and even if they did it wouldn’t say that their job is to execute therapist treatment plan. Actually trying to get staff to modify the way they interact with patients is the opposite of therapy. My job is to change the patient, not others.

Good luck with the rest of your training and remember, the difficult situations are the ones where we learn the most and you will have many more along the way. 😊

 

[tr]

For context, I am a first-year Ph.D. student currently completing a summer internship in community mental health.

I am running into some challenges when communicating my rationale for making treatment recommendations, primarily for anxiety-related conditions to psychiatric nurses in the clinic. To elaborate, my research and clinical focus is on OCD, which is the condition for which I have the best grasp on the available literature. Some of the psychiatrists here have recommended my clients stop or postpone ERP -- some of whom I have seen for months at this point -- due to transient increases in distress as we move up their exposure hierarchy. They have also made other suggestions that conflict with the empirical literature, like advising clients to take time away from employment, etc.

There is a group of psychiatric nurses who do the leg work for coordinating these clients for the psychiatrist who has been coming to see me and asking why I stated in reports that the psychiatrist's current treatment plan is at odds with the OCD literature and how they are likely to increase dysfunction. These nurses rely on anecdotes, and I am having a hard time knowing how to convey research findings that justify my case conceptualization and treatment plan without sounding like I am beating them over the head with scientific findings.

I am looking for those of you with experience communicating research findings to other professions who may not have a background in statistics and research methods without sounding like a complete condescending prick.

Thank you.

I'm not quite understanding what the communication medium is here. How did you find out about the problematic recommendations?

The medical chart is not the place to have a smack talk battle. If you disagree with the recs of another practitioner for your shared patient, the best thing to do is communicate directly (in person, phone, secure messaging, whatever).

Whoever started the paper trail here is the person in the wrong. If the psychiatrist wrote in the chart that you should stop ERP without discussing it with you first, that's bogus and you should call them up and have a conversation. If you heard second or third hand that they recommended such and then decided to put "BaD sHRinK iz WRONG" in your written report, well, I'd say you have already done a yeoman's job of appearing to be a condescending prick and it is going to be pretty difficult to fix things now.

 

[Peacemaker36]

If there were ever a lawsuit filed by the patient or their family, I'm pretty sure it would be bad for all clinicians involved if there were a flame war in the medical record. Imagine the family's reaction upon learning that you continued to see their loved one while being at war with the prescriber. Yikes.

Best advice I had in grad school is keep your head down and learn as much as you can.

 

[WisNeuro]

If there were ever a lawsuit filed by the patient or their family, I'm pretty sure it would be bad for all clinicians involved if there were a flame war in the medical record. Imagine the family's reaction upon learning that you continued to see their loved one while being at war with the prescriber. Yikes.

Best advice I had in grad school is keep your head down and learn as much as you can.

For those of us in the legal realm, we get good at calling people out in empirically driven and legally defensible ways But anyway, if you are needlessly putting a patient's life at risk with bad medicine, you deserve the extra liability from other providers commenting on it.

 

[Sanman]

For those of us in the legal realm, we get good at calling people out in empirically driven and legally defensible ways But anyway, if you are needlessly putting a patient's life at risk with bad medicine, you deserve the extra liability from other providers commenting on it.

As someone with their own license who is or able to work on their own, sure if you would like (I would probably do the same in some circumstances, I also don't care if I get fired). As a person working under another's license, check with the person who will face the ongoing consequences before lighting their job on fire.

 

[WisNeuro]

As someone with their own license who is or able to work on their own, sure if you would like (I would probably do the same in some circumstances, I also don't care if I get fired). As a person working under another's license, check with the person who will face the ongoing consequences before lighting their job on fire.

Definitely, as a trainee, go along to get along. But, as a fully independent professional, feel free to piss people off. So far, hasn't stopped me from getting business. Booking out til October, and just had another neurology clinic call me about taking some of their referrals this morning.

 

[forcefive17]

For context, I am a first-year Ph.D. student currently completing a summer internship in community mental health.

I am running into some challenges when communicating my rationale for making treatment recommendations, primarily for anxiety-related conditions to psychiatric nurses in the clinic. To elaborate, my research and clinical focus is on OCD, which is the condition for which I have the best grasp on the available literature. Some of the psychiatrists here have recommended my clients stop or postpone ERP -- some of whom I have seen for months at this point -- due to transient increases in distress as we move up their exposure hierarchy. They have also made other suggestions that conflict with the empirical literature, like advising clients to take time away from employment, etc.

There is a group of psychiatric nurses who do the leg work for coordinating these clients for the psychiatrist who has been coming to see me and asking why I stated in reports that the psychiatrist's current treatment plan is at odds with the OCD literature and how they are likely to increase dysfunction. These nurses rely on anecdotes, and I am having a hard time knowing how to convey research findings that justify my case conceptualization and treatment plan without sounding like I am beating them over the head with scientific findings.

I am looking for those of you with experience communicating research findings to other professions who may not have a background in statistics and research methods without sounding like a complete condescending prick.

Thank you.

Gotta make some friends, young Padawan. Social capital gained from things like water cooler chats will take you a long way.

 

[cara susanna]

Definitely, as a trainee, go along to get along. But, as a fully independent professional, feel free to piss people off. So far, hasn't stopped me from getting business. Booking out til October, and just had another neurology clinic call me about taking some of their referrals this morning.

I dunno about this - you're a neuropsychologist, so you're probably more in demand and can afford to piss people off. Not sure if that's true for those of us who are less specialized.

 

[smalltownpsych]

I dunno about this - you're a neuropsychologist, so you're probably more in demand and can afford to piss people off. Not sure if that's true for those of us who are less specialized.

I also think @WisNeuro kind of likes pissing people off a bit which I’m sure helps when doing his forensic stuff. Some of us more therapy oriented types are always trying to be too nice. Sometimes being blunt and direct is a good skill to have. I’m always working on that one.

 

[AcronymAllergy]

I also think @WisNeuro kind of likes pissing people off a bit which I’m sure helps when doing his forensic stuff. Some of us more therapy oriented types are always trying to be too nice. Sometimes being blunt and direct is a good skill to have. I’m always working on that one.

As am I.

I wouldn't say you need to enjoy pissing people off for forensic work (the ABA I think at one point came out and said to attorneys that being a "zealous advocate" for your client doesn't mean you need to be a jerk), you just have to not be afraid to do so. Which, for many of us, is an acquired rather than innate skill.

 

[Sanman]

As am I.

I wouldn't say you need to enjoy pissing people off for forensic work (the ABA I think at one point came out and said to attorneys that being a "zealous advocate" for your client doesn't mean you need to be a jerk), you just have to not be afraid to do so. Which, for many of us, is an acquired rather than innate skill.

Being confrontational can be easy or hard depending on who your customer really is. I am pretty good at it as I really do not take is personally. However, it really depends on who you risk pissing off. Pissing off a client does not really matter to me. Pissing off a referral source is more of a problem. I often point out to my clients/patients, they are often not my customer.

 

[WisNeuro]

I also think @WisNeuro kind of likes pissing people off a bit which I’m sure helps when doing his forensic stuff. Some of us more therapy oriented types are always trying to be too nice. Sometimes being blunt and direct is a good skill to have. I’m always working on that one.

The people who deserve it, definitely. But, I still have much more of a treatment background than the average neuropsychologist, and my "therapy" skills definitely come out in neuropsych feedback sessions. I get a lot of repeat and word of mouth business, so I must be doing something right on that end too. Compartmentalizing is a great thing. Different clinical/forensic/advocacy situations call for different tactics.

 

[smalltownpsych]

The people who deserve it, definitely. But, I still have much more of a treatment background than the average neuropsychologist, and my "therapy" skills definitely come out in neuropsych feedback sessions. I get a lot of repeat and word of mouth business, so I must be doing something right on that end too. Compartmentalizing is a great thing. Different clinical/forensic/advocacy situations call for different tactics.

A good psychologist has a complex variety of interpersonal skills. I think that knowing when empathy and connection is what is needed and when direct and even harsh communication is indicated is part of what we do regardless of specialty or focus. I remember when my supervisor at the VA stood up and used the full command voice to an agitated psychotic vet while I was sitting there nervous. Our well-rounded training is another great strength as you touch on with commenting on having more therapy experience than the average neuropsychologist. Each of us has a wide exposure and thus diverse skills and experience by the time we do three years of practicums, a year of internship, and a postdoc. All of mine were in widely different settings and even states and that is the norm for us. I just worked with about four clinicians who had all of their training and experience at the one place we worked. Very limiting.