Outlook for neuropsychology

[mlm55]

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With the declining reimbursement rates and competition from master's level clinicians, it seems like specializing is the way to go. Does the future for neuropsych still look promising, or are there problems in that area as well? It's an area I am interested in.

 

[mlm55]

Please respond if you have any knowledge about this! I've heard things recently about reimbursement rates being cut and don't want to commit a decade of my life to grad school/postdoc if there won't be jobs when I get out!!

 

[erg923]

The answer will depend alot on if the person who responds is a npsych or not. From an outsiders perspective (although I specialized in npsych in grad school), it will be around for many years, but will lose alot of clout (if you can say it ever had any) due to poor marketing, lack of outcome data that shows it reduces health-care costs, lack of inclusion in workgroups, and antiquated methods. If others do not find you helpful or necessary (physcians and patients alike) then you are never going to be considered a "go-to" specialty.

 

[docma]

A neuropsychologist I work with told the current intern cohort he thinks the "golden age" of neuropsych has past as MRI technology and other forms of imaging can now do quicker-better-less expensive diagnosis for localization. What MRI cannot do is more specific idiographic functional analysis and rehab planning. Given the aging demographics and increasing cultural violence that guarantees TBIs,I don't think the need for neuropsychology will decline drastically but given the numbers seeking to enter the field it will--like other recently "popular" niches--forensics, geropsychology--become more crowded and suppy/demand dynamics will be in effect.

 

[Therapist4Chnge]

With the declining reimbursement rates and competition from master's level clinicians, it seems like specializing is the way to go. Does the future for neuropsych still look promising, or are there problems in that area as well? It's an area I am interested in.

Specialization is great (and I agree opens more doors than being a generalist), but you need to really enjoy the speciality area because the jobs that seek out those clinicians expect you to work in those areas. I'd strongly disagree talking with multiple neuropsychologists in different settings so the day-to-day work is better understood. It's kind of a mess out there, and in some states it is still very much the Wild West because standards are being tossed out the window. In community practice many clinicians are dropping off of insurance panels. In-pt billing is continuing to tank (as all formal assessment is getting pushed off to out-pt...and then fought then).

Do not go into neuropsych unless you really really enjoy the work. The competition is very high and the standards are becoming more rigid (which is a good thing). Rehab Psych is also pushing standardization, which I think will benefit neuropsychology because more clinicians will be supportive of fellowship training and boarding.

The reimbursement decreases are definitely problematic and should be a concern for anyone in the field. In regard to mid-level "competition"...it really doesn't exist because they cannot practice in the area (at least ethically and in many states legally). If an OT, mid-level school psychologist, or SLP attempts to do assessment in the area and call it neuropsychology than that is a different matter (and grossly out of scope). Having a generalist or otherwise untrained psychologist attempt to do neuropsychology "on the side" is also grossly out of scope.

 

[WisNeuro]

We have some of the old guard in the field wearing figurative sandwich boards warning about the End Times, but I wouldn't pay them any heed. Neuropsych will be around for a while, especially with an aging population and no promising developments in AD vaccines/treatments. As for the marketing problem, that's psychology-wide, not just us. That being said, the field is changing. Get used to working in multidisciplinary settings and focusing a little more on rehab. As for us losing our roles as lesion localizers, who cares? We were never really good at it anyway. The people who are foretelling our doom are usually these old-school localizers who don't have any other skill sets.

Oh yeah, forensic work for neuropsychs is exploding right now. Pays a pretty sum if you're competent too.

 

[PsyDr]

Caveat: I do well for myself and I am friends with many older neuropsychologists.

IMO: It's probably not great. Diagnostic neuropsychology has been dying a slow death for some time. Technology will continue to improve, encroaching on most areas. For example fMRI offers superior localization of language than neuropsych; Pittsburgh compound can allow visualization of B amyloid, etc. Reimbursement will probably continue to fall,. Many are entering into this subfield as a way to preserve income, which will undoubtedly increase competition and stagnate or lower private pay patients. There will continue to be midlevel encroachment. Finally, the test publisher have completely sold us out, computerizing everything. I am positive they will offer computer generated reports, which will allow RNs, SLPs, etc to administer the test with unqualified MDs to interpret. Unqualified people will add on neuropsych tests and call themselves neuropsychologists, reducing the regard for the profession. The old guard is 100% not interested in helping anyone. They will continue to use up students and then not help them at all. In short, it's not good.

BUT: I remember hearing a talk from head of a MAJOR academic center telling everyone that he/she was ready to quit when MRI came around. So there's that. There's also some people making some decent money.

 

[Therapist4Chnge]

Get used to working in multidisciplinary settings and focusing a little more on rehab.

This is very true. Competition is on the way up as more traditionally trained neuropsychologists try and push into rehabilitation psychology. I spend 60-70% of my time in a multi-disc rehab setting and it is great, but the work is a lot different than traditional out-pt neuropsych assessment.

Oh yeah, forensic work for neuropsychs is exploding right now. Pays a pretty sum if you're competent too.

Yes...but it's stressful, requires a high level of skill (at least to do it well), and most people won't have the stomach for it. I am very hesitant to recommend anyone pursue forensic neuropsych bc it has a pretty harsh learning curve.

 

[erg923]

PsyDr., who is the "old guard" in your opinion?

 

[PsyDr]

Most of the older, established neuropsychologists.

 

[erg923]

Yes, but I meant are you referring to academics and training programs, or purely practitioners out in the field?

 

[WisNeuro]

Most of the older, established neuropsychologists.

I disagree. I think of the old Reitaners as the old guard. Most of the established neuropsychs that I have worked with have been very involved with training and advocacy. Probably depends on where you come from. But I have had a very different experience than you personally in relation to your "they 100% don't give a **** about you" comment.

 

[AcronymAllergy]

I disagree. I think of the old Reitaners as the old guard. Most of the established neuropsychs that I have worked with have been very involved with training and advocacy. Probably depends on where you come from. But I have had a very different experience than you personally in relation to your "they 100% don't give a **** about you" comment.

This has been my experience as well (i.e., that the "old guard" I've worked with have been very involved in training and, to a lesser extent, advocacy). But like you said, it probably varies by location. I do wonder what the "majority" approach is, but I've heard that some of the more major metropolitan areas (California and parts of the northeast in particular) are similar to what PSRDR mentioned. That's just hearsay on my end, though.

As for the outlook, I think T4C gave solid advice--don't go into neuropsych unless you really enjoy the work. Neuropsych is different enough from many other areas of clinical psych that going into it solely for job security and/or income (when mixed with the competitiveness and general uncertainty/in-flux status of the current market) probably wouldn't turn out well.

 

[erg923]

A person on the npsych list serve posted a mesage recetly about his attemt to suggest a npsych eval (it wasnt a thought mentioned by anyone else) for a patient being discussed at a medical conference. He cited the reaction was one of dismay and they docs cited numerous reasons why they didnt consider it helpful. I think npsychs, by in large, work with sources that already value them, so they may become blind to the prevailing opinion and underutilization of the service in the wider healthcare system.

 

[WisNeuro]

A person on the npsych list serve posted a mesage recetly about his attemt to suggest a npsych eval (it wasnt a thought mentioned by anyone else) for a patient being discussed at a medical conference. He cited the reaction was one of dismay and they docs cited numerous reasons why they didnt consider it helpful. I think npsychs, by in large, work with sources that already value them, so they may become blind to the prevailing opinion and underutilization of the service in the wider healthcare system.

To borrow from a source that I no longer remember:

"Data is not the plural of anecdote"

 

[Therapist4Chnge]

I think npsychs, by in large, work with sources that already value them, so they may become blind to the prevailing opinion and underutilization of the service in the wider healthcare system.

This is a very fair point. I believe I'd have a much different experience if I had to actively convince colleagues to utilize my services. The most common complaint I hear from my physician colleagues (where I get 99% of my referrals) is that they struggle to find neuropsychologists that can see their patients in a timely manner. More and more neuropsychs are dropping off of panels because of dwindling reimbursements. I am still on most insurance panels, but I'll probably start to be pickier in the common year. I already cherry pick cases in my niche area and pass them on to others (e.g. stroke, disability, etc.).

 

[AcronymAllergy]

I can at least say that from my end, the trend in training (at least in my experiences) has been towards not only further integrating neuropsych into hospital settings (which includes things like learning how to develop and effectively interact with referral sources; how to tailor your report, recommendations, and feedback to the referral question; etc.), but on educating trainees as to why this integration is important and how to advocate for your services in the future. Oh, and yes, faster turn-around on reports (or at least on feedback to the referral source) is also pushed.

 

[sockit]

why would MRIs obviate the need for neuropsychologists? you still have to actually map to functions, it's not like a tech can do it. & the tests are not authoritative on their own.

 

[AcronymAllergy]

why would MRIs obviate the need for neuropsychologists? you still have to actually map to functions, it's not like a tech can do it. & the tests are not authoritative on their own.

I'd imagine it just reflects the resistance to change that initially occurred when neuropsych had to shift from serving a primarily localizing function to other areas of practice. For a non-neuropsych example, I've definitely heard more than one "old guard" neuropsychologist say that they were basically planning to retire before having to shift from DSM-IV to DSM-V.

As for the tests, we should probably do a better job educating folks that the tests in and of themselves really aren't always all that useful, and that we can do a good bit more than just administering WAISes and CVLTs all day.

 

[Therapist4Chnge]

...we can do a good bit more than just administering WAISes and CVLTs all day.

This is where rehab psych is doing well. While I enjoy the diagnostic side of things, the "now what" is what most referrers want to know. I find that my recommendations section keeps growing.

 

[docma]

Yes. Both the Recovery Model and the aging population want to know "now what" and that is where psychology can have a lot to contribute.

 

[Therapist4Chnge]

Yes. Both the Recovery Model and the aging population want to know "now what" and that is where psychology can have a lot to contribute.

If clinicians can translate their knowledge into pragmatic interventions (Hello EBT research opportunities!!), then they can write their own ticket with work. Figuring out how to get paid is probably the next biggest challenge, as insurance companies will say no before they say yes. The alternative is to find an area (or areas) that is strictly private pay. If you get known in the community then opportunities will probably find you.

 

[Therapist4Chnge]

Most practices I have worked with have a turn around time of 1 to 2 weeks on a report. What's the problem?

*stares at a stack of 6 folders w. data that still need reports written*

If I knew that I think I'd be a lot better off. I'm still within the 1-2 wk mark, but it definitely can be a challenge to keep up with that turnaround time.

 

[sockit]

if actuaries and hospital administrators can just assert, on no basis other than their bottom line, that nurses, GPs & test companies can between them do the same job as neuropsychologists, that is outrageous. also, fraudulent. also, negligent.

but if it's the likeliest projected scenario by those who should know, seems to me you guys should lawyer up. (in canada, it's a criminal act to work outside your scope of practice, idk what happens in the us.)

 

[Sanman]

if actuaries and hospital administrators can just assert, on no basis other than their bottom line, that nurses, GPs & test companies can between them do the same job as neuropsychologists, that is outrageous. also, fraudulent. also, negligent.

but if it's the likeliest projected scenario by those who should know, seems to me you guys should lawyer up. (in canada, it's a criminal act to work outside your scope of practice, idk what happens in the us.)

The problem is that some of these things are legally in their scope of practice. In fact, as in CT recently, sometimes it is defined as in their scope of practice and not ours even though we are the ones that are trained for it.

 

[sockit]

The problem is that some of these things are legally in their scope of practice. In fact, as in CT recently, sometimes it is defined as in their scope of practice and not ours even though we are the ones that are trained for it.

well, that is shocking. did that decision get appealed?

edit: responding here so as not to divert the exchange below: Sanman, thank you for your reply!

Wouldn't billing practices necessarily have to follow legal constraints, though? If there is a demonstrated need (severity; prevalence) for intervention/assessment x, and only profession y is entitled to perform it, I don't see how insurance companies could avoid following suit (so to speak), given a solid evidence base (which in neuropsychology is firmly enough established in some areas, and growing quickly in others, right?)

(i also don't see how it is possible - even in principle - for any technology to have anything to say about this subject beyond correlation [until/unless something crazy happens in particle physics]. i think the "antiquated methods" of inference and deduction are the coolest things about neuropsychology.)

 

[Sanman]

Well, I believe it is getting appealed. There is a thread about it on here. It was an issue with us not being allowed to bill medical billing codes. Seems to happy to neuropsych every so often when new programs are rolled. I am not a CT resident or a neuropsych ( though I did train in it up to internship), so I have not kept up with the news about that in the CT health exchanges. Either way, them staying within their scope of practice is a moot point if we can't bill for services.

 

[PsyDr]

Jon Snow,

I am sure you are aware of the substantial difficulties with ecological validity of neuropsychological assessment.

IMO, there will come a time wherein Az, Pd, and such are treated based upon imaging; just like hypertension is treated on lab values and not on pt's report of headache/chest pain/etc.

I'll also say that while all of our shoulds are great, I do not share the hope that anyone other than our profession gives a crap about us. What we can do is great, but if no one is willing to pay for our services then we have a problems.

Or, to paraphrase Ellis, "we should on ourselves".

 

[NeuroTrope]

Jon Snow,

I am sure you are aware of the substantial difficulties with ecological validity of neuropsychological assessment.

IMO, there will come a time wherein Az, Pd, and such are treated based upon imaging; just like hypertension is treated on lab values and not on pt's report of headache/chest pain/etc.

I'll also say that while all of our shoulds are great, I do not share the hope that anyone other than our profession gives a crap about us. What we can do is great, but if no one is willing to pay for our services then we have a problems.

Or, to paraphrase Ellis, "we should on ourselves".

There's more ecological validity in some settings like pediatrics, particularly with achievement measures/academic ability. Imaging's ecological validity is not so great - in fact, that seems to be when neuropsychologists are used.

 

[PsyDr]

[YOUTUBE]http://www.youtube.com/watch?v=QzBmQMyYDBk[/YOUTUBE]

 

[WisNeuro]

Imaging, just like any diagnostic instrument, has it's problems with sensitivity and specificity. Ive seen patients with tons of white matter changes (both periventricular and focal mesial temporal) who have been above average or better on memory testing. And also patients with clean imaging who are densely amnestic. The research concerning white matter abnormalities, amyloid beta load, etc, shows the same thing. The association between what is thought to be the pathological vector and actual function are not great in imaging. We're not going anywhere in neuropsych, and imaging isn't replacing us. Rather, we're embracing these techniques as clinical correlation and expanding into a rehabilitative context to utilize our strengths.

It's not our ability to administer tests that sets us apart, it's our in depth understanding of brain/behavior relationships and how they interplay with a wide variety of medical and neurological ailments that sets us apart. Also, our understanding of things like sensitivity, specificity, PPV, NPV, etc. If you don't understand those as a neuropsychologist, you are useless, a chimp blindly flailing around with a hammer, unsure of it's exact purpose.

 

[Therapist4Chnge]

Imaging, just like any diagnostic instrument, has it's problems with sensitivity and specificity. Ive seen patients with tons of white matter changes (both periventricular and focal mesial temporal) who have been above average or better on memory testing. And also patients with clean imaging who are densely amnestic. The research concerning white matter abnormalities, amyloid beta load, etc, shows the same thing. The association between what is thought to be the pathological vector and actual function are not great in imaging. We're not going anywhere in neuropsych, and imaging isn't replacing us. Rather, we're embracing these techniques as clinical correlation and expanding into a rehabilitative context to utilize our strengths.

I just got a referral 5min ago to see a pt who had abnormal imaging findings and who is reporting a mix of deficits, but the neurologist is unsure if there are other deficits and/or if what he is seeing on imaging is actually having a meaningful functional impact on the pt's cognitive functioning.

As WiseNeuro astutely pointed out, imaging is a great tool for the toolbox, but it rarely (if ever) sufficiently captures all of the areas of deficit and/or can speak accurately to the severity of the impairment solely based on observed localized damage. Multiple Sclerosis is the example I use with my fellows to demonstrate how positive imaging findings can greatly vary in regard to actual functional impact. I have FLAIR MRI examples that light up like a christmas tree but the patient had minimal cognitive/physical impairments, while patients with much less pronounced findings were experiencing a much higher level of impairment.

 

[cara susanna]

I'm not in neuropsych, but around here we have neuropsychologists who do FAA evals and they get VERY good money for them. All out-of-pocket, too.