Ethical Assessment

Discussion in 'Psychology [Psy.D. / Ph.D.]' started by TiptoeConqueror, Dec 4, 2018.

  1. TiptoeConqueror

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    There seems to be a lot of variability in testing hours out there. What amount (lower and upper cutoffs) of neuropsychological testing do you consider to be unethical? I’d love to hear from those in a variety of different settings (e.g., PP, AMCs, VAs, etc...). What factors should one consider?

    I’m hoping this will generate some interesting discussion about ethical neuropsychological practice.
     
  2. WisNeuro

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    It depends on the referral question. Some things are easily answered by 1-2 hours of testing. Some require 4+ hours. If you're one of those doing comprehensive LD testing, even more much of the time. Also, when working with insurance, sometimes the insurance chooses your cap for you.
     
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  3. dynamicdog

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    I conduct very comprehensive evaluations in PP (IQ, academic, neuro, projectives) almost exclusively for children and adolescents. I usually do about 8-12 hours just face to face and then at least an additional 10-20 hours of scoring, writing, feedback, etc. If I am going through insurance I check beforehand what, if any, limits they have on this service (I use CPT code 96101). In my experience I am able to get 50-60 hours ok'd by the insurance companies, which is very generous. I also have a psychotherapy caseload of about 25 so I can only ethically and realistically do about 1 eval per month at this point. I also don't have any (human) assistance with administrative stuff, which eats up a good amount of my time.
     
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  4. erg923

    erg923 Regional Clinical Officer, Cenpatico National
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    Not sure you can frame it that way. Just because you trained alot in using a hammer doesn't mean you have to use your hammer in every case, right?

    Some cases (particularly blatant psychiatric ones) probably don't need any neuropsychological testing. Similarly, how much testing time (and money) do we want to waste on someone who is clearly feigning or malingering? Some patients need a DRS and one of two other things (1-2 hours?) because they are too impaired to do anything else. Baseline eval on a student athlete? 1-3 hours. I also think this depends on if you are just trying to get a dx, or a dx and other comprehensive information about functioning and/or other factors that can generate alot of specific treatment planning suggestions. I wouldn't suggest just a WISC and an ADOS in a suspected ASD case, but people do it and I dont think it's "unethical" or anything.
     
    #4 erg923, Dec 5, 2018
    Last edited: Dec 5, 2018
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  5. AcronymAllergy

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    Agreed; there's going to be a lot of variability depending on referral source and question, patient characteristics, and available records. My (adult, non-forensic) outpatient evaluations typically run anywhere from 2 to 4 hours for interview and face-to-face testing, with a few extra hours for records review, scoring, and report writing. But I could see situations where 8-10 (or possibly more) hours of testing is beneficial.

    My approach is generally to do the minimum amount of testing necessary to answer the referral question.
     
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  6. erg923

    erg923 Regional Clinical Officer, Cenpatico National
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    What universe is this?
     
  7. dynamicdog

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    Commercial insurance companies in NY State. I don't use it all but I like to get as much hours approved during a prior authorization. I found I read and write more slowly than my colleagues so its less stressful knowing insurance will pay.
     
  8. ClinicalABA

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    Could you give us an example of a referral question that would require this amount of time to answer?

    I’m intrigued by the parenthetical. Do you have non-human assistance?!?!
     
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  9. WisNeuro

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    Just so people know, this is FAR from the norm. For example, BCBS in my area will limit any and all memory disorder type evals to 7 total hours (includes chart review, interview, testing, scoring report writing, feedback). I think I would get laughed off the phone in peer review if I requested anything more than 15 hours for an eval. 60 hours is simply absurd outside of forensic contexts.
     
  10. ClinicalABA

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    Be VERY CAREFUL with this. You might not want to say that to an insurance authorizor or auditor
     
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  11. erg923

    erg923 Regional Clinical Officer, Cenpatico National
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    So, are you saying you are making/getting reimbursed 20-30K per assessment case? I am skeptical of this.
     
  12. WisNeuro

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    Yeah, now that I'm done with my morning eval and thought about this. I have no idea how a fraud investigation has not been initiated in this case if it is legit.
     
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  13. psych.meout

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    I'm a grad student and I could easily do all this within that 7 hours.

    Yeah, my eyes bugged out when I read that 50-60 hours stuff.
     
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  14. WisNeuro

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    Most of the time, pretty easy. If I'm evaluating something atypical, or something like Parkinsons dementia vs Parkinsons plus, 7 hours can be a little tight. I usually just test what I need and my hospital eats the extra cost. So far I have no pushback.
     
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  15. psych.meout

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    Yeah, I'm talking about just your standard dementia eval or some other more typical case. If there's imaging and/or a whole constellation of complicated medical and psychosocial issues to integrate and reconcile, that would take more time, but it still would be nowhere near 50-60 hours.
     
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  16. ClinicalABA

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    I like to give the benefit of the doubt, but those numbers are so highly unusual and the statement/justification of taking longer to read/write thus needing more hours authorized so clearly problematic that I’m thinking troll? If not, I honestly would like to hear more about what this is all about.
     
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  17. Therapist4Chnge

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    It all depends on the referral and level of functioning of the case. A dementia eval for someone moderately demented may include 1-2hr (of F2F) testing, and that could feel like forever for all involved. The interview of the patient and then family would be another hour or two, depending on severity. This isn’t my typical referral, so YMMV...but I typically see these evals on the short side, which I think is pretty common.

    A moderate brain injury (my typical case) could/should be 4hr-6h (F2F), then scoring, record review, and report writing...depending on the referral question.

    Forensic cases may get 6-8hr+ just for F2F testing with record review and report writing getting 6hr-10hr or more....but if the case has 3 bankers boxes of documentation, no one would raise an eyebrow at more.

    My typical mild-complicated TBI to moderate TBI is probably 4-6hr of actual testing time, plus scoring, plus report writing. It depends if I add a personality inventory, test limits, and/or if there are communication problems or significant processing delay problems that can double administration time. Typically if a case goes way over my estimated time for a battery it is because the patient is trying to fake bad, and they get flagged and weeded out early.

    I used to have a lengthier core battery when I was at AMCs, but I was much more likely to get zebra cases at them. In private practice, I see a much more narrow set of referrals (by choice). I don’t take commercial insurance or Medicare or Medicaid, so I have more flexibility to use my time how I see most appropriate. Patient need informs how I approach a case, though funding can too. Narrowing the scope of the referral question can be helpful when funding is more of a limitation.

    I take the most issue with crap test selection and/or 2-3 paragraph reports, which end up being mostly to completely useless. I rarely see bloated batteries or inflated report writing times, but i’m sure they happen.

    ps. 60hr?!
     
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  18. dynamicdog

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    No no no. I do NOT bill for anywhere close to that as that would be fraud/crazy. Insurance companies often require a prior authorization for testing and in that they will often give a max amount of hours they are willing to cover. In my experience they have said they allow up to 50 or 60 hours for the code. This in no way means I bill for even half that. Like I said earlier I do fairly comprehensive evals so I do bill 15-20 hours with everything included. Sorry if I wasn't clear earlier.
     
  19. dynamicdog

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    Actually I don't even think I have billed more than 15 hours to date.
     
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  20. WisNeuro

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    What insurance company is this? Because I have lived/billed in 4 different states, and this would be nigh impossible under 99.99% of contexts. Heck, most insurance companies won't allow that many hours for therapy for an entire year in most settings.
     
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  21. Justanothergrad

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    I've got a couple of questions.
    What codes are you using that allow that many hours?
    What insurance is this?
    What type of testing are you doing that requires 15-20 hours of your time to conclude?
    How many hours of testing/what testing are you conducting as part of that 15-20?


    I'm packing my bags now.
     
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  22. dynamicdog

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    You can PM me if you want that information. I don't know what to tell you. It is surprising for sure and I obviously haven't tested this since I DO NOT take or bill close to this amount.
     
  23. psych.meout

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    You're missing the point. It's not just about how many hours you're actually billing for (though that is suspect as well), it's also that you're seeking and being given pre-authorization for what is plainly an insane number of hours. Like, insurance fraud levels of hours.

    Also, "I read slower than other people" isn't really a good justification for this, nor is it a defense against fraud.

    You also have to consider the ethics of what you're doing, especially if you're ever doing cash pay directly from patients.
     
  24. WisNeuro

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    It's not protected knowledge or anything, we're just curious as to what insurance plan in NY allows this, as to my knowledge from conversations with the head of the state npsych association there, it's a particularly onerous place to get things approved.
     
  25. PSYDR

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    When insurance pays for neuropsychological evaluation, the purpose is almost exclusively diagnostic . The entire point of neuropsychological tests is to provide information by which to make deductions. There are several factors which can affect the length of the exam necessary to make a justifiable deduction. This may include: the knowledge of the neuropsychologist, the history of the patient, the presentation of the patient, etc.

    I disagree with T4C in regards to the length of the report. I assume a reasonable neuropsych can look at my data and understand why I made such a call. I also think that psychology should follow the same standards as our medical colleagues, and make decisions; as opposed to showing 5 pages of work in an effort to justify ourselves before making a decision. My forensic evals also FAR exceed the length of his forensic evals.

    Example A: You have a late 60s patient who describes the classic symptoms of PCA. Is 10hrs of testing going to significantly change your impressions?

    Example B: Patient is elderly male, transported to the hospital after being discovered walking down the highway naked. You cannot get a reliable social or psychiatric history, patient has to be redirected every 3 minutes, there's no medical history, and you're charged with figuring out what the hell is going on. Testing is going to take a lot longer, even if the battery is short.
     
  26. psych.meout

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    I don't know why people assume that a longer report is better or even that other, non-psychology providers read the entire report, regardless of its length. Reports should be about usefulness, not demonstrating how smart you are as a clinician and scientist.

    Sometimes lengthier testing and reports are necessary, but this shouldn't be the standard or normal practice irrespective of the patient's problems, history, and presentation,
     
  27. dynamicdog

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    Aetna will apparently pay for thrice weekly psychotherapy for an unlimited amount of time. I do NOT do this but I know people who do.
     
  28. PSYDR

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    1) It's a style of writing taught to students, so that professors can readily assess the underlying basis. Just like in grades school where you were required to show your work on division. I believe that this is inappropriate at the level of independent practice. It wastes other professionals' time. It opens you up to having arguments about information that has nothing to do with your diagnosis. And the literature shows that this style isn't what patients want.

    2) It's almost like we're paid hourly....
     
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  29. psych.meout

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    I can't wait until i get paid hourly again. My reports will make James Joyce blush.
     
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  30. Justanothergrad

    Justanothergrad Counseling Psychologist
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    If I can't say what I need in 3 pages or less then I'm doing something wrong. I require students to write integrative 2-3 page reports in my assessment course because the 15 page junk is just that in almost all cases
     
  31. Therapist4Chnge

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    Agreed. My example about a few paragraphs wasn’t in regard to a cut and dry dementia case, but instead a typical brain injury case.

    I don’t write lengthy reports, probably 3-5 pages for most, as I periodically solicit feedback from referrers about what they like/don’t like...and almost universally from clinicians I hear brief is best. I include a summary sheet so another neuropsych has what they need for the case.
     
  32. erg923

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    After all this, we might want to clarify what you meant by "testing hours?" Did you mean the length and comprehensiveness of the test list/test battery? Or, the actual full/total time spent for a modal neuropsychological evaluation (admin, scoring, interpretation and report writing)?

    As @PSYDR mentioned, you pretty much only get time to diagnose the condition under most insurance plans (it is largely assumed that the diagnosis itself guides the treatment/treatment plan/treatment recommendations). i.e., "medical necessity." ASD might be a slightly notable exception here, as many would agree that multiple other factors about functioning need to be known in order to tailor treatment to the individual, since this is such a heterogeneous disorder/presentation.

    Personally, I think over-testing is much more of a problem/issue than under-testing in our profession. I have come across both long and short test batteries that are pretty ludicrous and lack an evidence base for contributing to diagnosis and/or treatment needs/planning. However, I maintain that the more tests one gives, the more likely they are to find something erroneous/abnormal that may not actually mean much, clinically.

    I am convinced that 12 and 16 hour long evals (as opposed to 6 or 8) don't contribute to meaningful treatment planning as much as they might actually "muddy the waters" for the people who are actually treating these folks. Which is usually NOT the neuropsychologist who did the evaluation. It's largely psychiatrists and masters-level practitioners.

    Its important to keep mind mind that certain factors or features that psychologists/neuropsychologists might hold dear (or are curious about) in their assessments/testing are actually academic musings and not typically translatable to changing or impacting the treatment of said patient in any significant way.
     
    #32 erg923, Dec 5, 2018
    Last edited: Dec 5, 2018
  33. psych.meout

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    Bravo!

    From all the reports I've read and all the providers of various levels of training with whom I've spoken, there seems to be two fairly significant problems: (1) not basing assessment and intervention decision on the empirical evidence (e.g., which tests/measures to use, usage of PVTs/SVTs) and (2) ignoring pragmatism. These excessively long, and often fixed, assessment batteries are mix of both problems, as are the huge tomes of integrated reports that come from them.
     
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  34. erg923

    erg923 Regional Clinical Officer, Cenpatico National
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    Frankly, I think there are many more problems than this.


    1. I think psychologists/neuropsychologists (at least in the US) are waaaaay too test bound/reliant. One example: There are multiple 200+ page books written about proper WAIS-IV indices interpretation that I have no idea how would would actually meaningful contribute to patient treatment.

    2. Clinical exam/interviewing methods are woefully under-trained/under-taught for modern clinical psychologists. A by-product of #1...and likely of current CPT codes.

    3. The neurobehavioral exam (think Edith Kaplan and the desert island) is under-utilized and under-trained for most modern clinical psychologists and neuropsychologists. Again, look at our training programs and current CPT codes. And no, I am not pretending to be a House-level physician with this.

    4. Reports are too long and talk about "set-shifting." Stick to your audience.

    5. Treatment recommendations from psychological and neuropsychological testing reports are often too much, or ironically, too little to be useful in a modal treatment plan. Make it succinct and find a balance.

    6. House-Tree-Persons (HTP), Rorschach Inkblot, Thematic Apperception Test (TAT) and other such measures are pretty useless for developing operational/measurable treatment goals/recommendations, although they might be "interesting" to speculate about.

    7. "Objective" assessment is not a thing. There really is no such thing. "Our tests" have biases and flaws in much the same way that talking to your brother about you does. Most all neuropsychological/psychological tests (and rating scales) have fairly poor ecological validity as far as I am aware? Relatedly, don't just give rating scales and brief symptoms inventories and tell referring providers this is an "objective assessment" compared to their multiple collateral interviews/information just because these measures have norms.

    8. The more tests you give, the more likely you are to find "abnormality" that you think might need treatment/a treatment recommendation. This over-pathologizes and wastes time for clinicians doing treatment.

    9. The idea/premise that you need to know every detail about a patient's current symptoms (or their diagnostic origin) prior to initiating treatment with them is complete nonsense, and a relatively recent idea. Psychiatric and neuropsychologic diagnoses were always intended to be flexible and continent upon gaining further information during the course of treatment.

    10. Although none of us like to admit it, with some few exceptions, our treatments work best on specific symptoms rather than on the various "diagnoses" we render from our current our manuals/nomenclature.
     
    #34 erg923, Dec 5, 2018
    Last edited: Dec 5, 2018
  35. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    I think you've been around too many poorly trained clinicians. While those are all problems to an extent, in certain contexts, there are many rebuttals for most points. For example, this one. Neuropsychological tests are more sensitive to disease progression in neurodegenerative disorders than neuroimaging last it was studied. Or for #9, do you know the danger of prescribing a neuroleptic for an elderly person who is having hallucinations, when they are actually suffering from Lewy Body. And on and on. While many of the things you mention are a problem for psychologists who do neuropsychological testing, it's not a problem for most properly trained neuropsychologists.
     
  36. jdawg2017

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    I am glad to hear this. I am studying to become a clinical neuropsychologist at a fairly reputable PhD program that is more known for its psychotherapy training. The external pracs for clinical neuro in the area are amazing, but the internal neuro prac is awful (writing 15-20 page reports, conducted full WAIS-IVs +, only evaluating LD/ADHD, etc.).
     
  37. WisNeuro

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    That's pretty par for the course in internal pracs. Usually these are earlier in the training and the emphasis is on getting you trained up on administration and early conceptualization. Many could probably do a better job of transitioning to a more real world model as they go, but it's a decent starting point for most students.
     
  38. MCParent

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    I was trained from the get-go to do a 1 or 2 (if it's complex) executive summary that is written for anyone to read and contains only the information they will want, and then include the details of the report in a longer detailed summary so if it needs to get re-read by someone later the patient doesn't have to come asking for the original test results.

    I hate it when people write a report like a story and the diagnosis is the climax. It's so stupid.
     
  39. WisNeuro

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    My interns and postdocs get trained to write up a quick results summary/impression and rec right up front in the report, and include the full report afterwards. In conversations with my referral sources, they tend to appreciate getting the quick and dirty right there without having to search for it.
     
  40. TiptoeConqueror

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    I was just referring to time of test administration and test battery but I appreciated hearing about report length and other factors. I feel like I’ve been exposed to a range of different styles and wanted to get a better understanding of the norm for adult assessments. Thank you all for your responses! I didn’t expect this to generate so many replies.
     
  41. psych.meout

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    I was talking about two general themes of problems, and your listed problems can pretty much fall under one or the other.

    As WisNeuro said, that's what you're typically going to get with an in-house practicum. Unless your program is within an academic medical center itself, you're not going to get the more complex and messier cases. This isn't a problem, because your first practicum, whether it's mainly assessment or intervention, is really about solidifying the skills and knowledge you're getting from your didactics.

    The only problem I see there are the long reports, though really, really thorough LD evals can be pretty long. Well, at least long compared to what I would find to be acceptable for a standard dementia eval.
     
  42. Justanothergrad

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    Happy to say I'm creating an in house assessment prac that follows the short/targeted reports approach for community referrals. Part of the class is gonna have a journal club/didactic component in addition to case formulation/presentations. Any favorite assessment articles that ya'll think I should make sure to include as required reading (non topic, instrument, or population specific) to reinforce big ideas? Stuff like Iverson (2005) is what I'm targeting - anything to make sure that the most important conceptual assessment ideas across specialty are hammered home.
     
  43. WisNeuro

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    Binder, Iverson, Brooks, 2009. To Err is Human: “Abnormal” Neuropsychological Scores and Variability are Common in Healthy Adults."
     
  44. jdawg2017

    jdawg2017 Doctoral Student of Clinical Psychology

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    Oh, I am aware. I am mostly griping because all of my cohort-mates and other students gripe to me about this, saying "why do people do this?" and things like that. I have to remind them that clinical neuropsych generally is not like this in-house prac. I tell them "out in the real world" where there is far less time to do comprehensive WAIS/WCJ/Etc., testing is hypothesis-driven based on the referral question. I think it's a good place to start if you have zero background in neuropsych; fortunately, my DCT lets me and other lab mates pass on this part of the broader house practicum since we will be doing 20+ hour/wk placements in neuro elsewhere.
     
  45. NeuroTrope

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    I think most of this reflects poor training rather than fundamental problems with the field.
     
  46. erg923

    erg923 Regional Clinical Officer, Cenpatico National
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    Yes, of course. That's the point. Its widespread in the community and thus reflects poor training and/or practice implementation vs what is suppose to be. I see if everyday.

    Why is this? Is this an issue in/with training programs? Post-doctoral training (or lack thereof)? Coding structure? Greed? Crazy variations in practice across regions? If was just old dudes doing this stuff, we'd have the answer, but its not.

    I am simply articulating that alot of what these people do (which is very common) are not valued in the larger healthcare world/system because they do not translate into anything substantial beyond our own academic musings.
     
    #46 erg923, Dec 9, 2018 at 4:33 PM
    Last edited: Dec 9, 2018 at 5:20 PM
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  47. psych.meout

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    How is poor training not a "fundamental problem" of the field?

    If people are being poorly trained, it has wide ranging effects for the rest of their careers. They are getting little to no training for the rest of their careers beyond CEUs, and those are not going to diagnose problems with their clinical practice or the training they received.

    Moreover, I'd suspect that these problems are more severe at poorer quality programs, like PsyD programs at professional schools, than at more rigorous ones, e.g., clinical science and PCSAS programs. The former often have cohorts larger than the entire student populations at the latter, meaning that they are graduating significantly more students with poor training than those who receive good training. This doesn't even begin to get into the scope of practice creep from mid-levels.

    Thus, poor training is probably a significant problem in the field.
     
  48. Justanothergrad

    Justanothergrad Counseling Psychologist
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    I think the training quality is probably fine in general (edit to add: with the usual programs known for poor quality not being considered). If you look at courses, they're intensive and cover the material well. The issue is likely limited quantity. People apply to internship with only a few IQ / personality administrations. You don't learn to ride a bike, do therapy, etc with one or two tries. It's a fairly nuanced point to separate this, but I think that is important.
     
    #48 Justanothergrad, Dec 9, 2018 at 5:17 PM
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  49. NeuroTrope

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    Erg's examples were pertaining to issues of psychological and neuropsychological assessment. Regardless, the issue of competent training is not really a "fundamental problem of the field" but an unfortunate issue that affects our service delivery (and reputation, but who cares about that right)? There are many excellent programs out there. The degree mills produce more variability, true. I primarily see it through psychologists who claim to practice "neuropsychology" as a side-gig and typically do it poorly. To answer Erg's question, I do think the primary motivator is money along with perhaps a desire to be in the "hip" crowd or whatever. Not that neuropsychologists are particularly hip, but that's another topic for another day...
     
  50. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    upload_2018-12-10_9-52-32.jpeg
     
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