Psych-Pain Eval?

[finalpsychyear]

I received a very vague consult request from a PCP who has a patient who is being seen by pain who are considering doing an implant of some sort for the patient. They apparently need a "psych-pain" eval before they can proceed.

What exactly is this? To rule out psychogenic pain/ somatization/conversion types of issues or something more than that?

---

Members don't see this ad.

 

[erg923]

I received a very vague consult request from a PCP who has a patient who is being seen by pain who are considering doing an implant of some sort for the patient. They apparently need a "psych-pain" eval before they can proceed.

What exactly is this? To rule out psychogenic pain/ somatization/conversion types of issues or something more than that?

A thorough psychological/psychiatric evaluation is standard part of presurgical clearance procedure for pain pumps or spnal cord stims. Much more often done by psychologists. I would not recommend doing this if one is not familiar with the literature in this area.

 

[finalpsychyear]

A thorough psychological/psychiatric evaluation is standard part of presurgical clearance procedure for pain pumps or spnal cord stims. Much more often done by psychologists. I would not recommend doing this if one is not familiar with the literature in this area.

I don't like the idea of not being aware of what this entails. Is it essentially doing a full MMPI-2? If it is to determine if they are suffering from a mood disorder which is not treated adequately such as concurrent depression that may be exacerbating their physical issues that I can do. The effect of potential SCS implants from literature that i have read ultimately leads to poorer outcomes when depression is not treated adequately. If I am missing something please let me know. This patient is already in my schedule for tomorrow so any input is appreciated. Thanks

 

[erg923]

I don't like the idea of not being aware of what this entails. Is it essentially doing a full MMPI-2? If it is to determine if they are suffering from a mood disorder which is not treated adequately such as concurrent depression that may be exacerbating their physical issues that I can do. The effect of potential SCS implants from literature that i have read ultimately leads to poorer outcomes when depression is not treated adequately. If I am missing something please let me know. This patient is already in my schedule for tomorrow so any input is appreciated. Thanks

Then you shouldn't do it...or get close supervision. I dont have a ready link to outlines/guidelines or templates, but they are out there. I do these for all our bariatric surgery candidates and there are some good guidelines from the ASMBS for these.

Outcome expectations, degree of somatization, sub abuse history, overall stability with regards to compliance. Lifestyle, support etc all need to be factored in. Doctoral-level clinicians with supervised experience minimum, I would argue. Health psych and addiction knowledgeable is preferred.

Quantification of symptoms/psych testing and validity scales are really helpful here. This is why psychiatrists typically defer to psychologists for this line of business.

 

[WisNeuro]

If you're doing any kind of pre-surg evals, make sure you have adequate supervision....or good liability insurance.

 

[hamstergang]

I don't like the idea of not being aware of what this entails. ...This patient is already in my schedule for tomorrow

This does not seem like a good combo.

 

[finalpsychyear]

Then you shouldn't do it...or get close supervision. I dont have a ready link to outlines/guidelines or templates, but they are out there. I do these for all our bariatric surgery candidates and there are some good guidelines from the ASMBS for these.

Outcome expectations, degree of somatization, sub abuse history, overall stability with regards to compliance. Lifestyle, support etc all need to be factored in. Doctoral-level clinicians with supervised experience minimum, I would argue. Health psych and addiction knowledgeable is preferred.

Quantification of symptoms/psych testing and validity scales are really helpful here. This is why psychiatrists typically defer to psychologists for this line of business.

I appreciate your input and you raise some excellent points. Are subsequent visits the usual standard of care in making this type of determination? I am probably going to cancel this appt.

 

[erg923]

I appreciate your input and you raise some excellent points. Are subsequent visits the usual standard of care in making this type of determination? I am probably going to cancel this appt.

No, because this is not treatment. This is a professional determination/opinion. Hence, you need to be ready to roll, and knowledgeable/confident in your process with this.

Are you rural? Surgeons and pain management docs do not typically "wing" these things with a stranger doc. There are many things in psychiatric medicine with more risk/liability certainly, but this should should not be taken lightly either.

I would not worry about cancelling. "Clearance" for these types of surgical procedures are expected to take months from the time of initiation due to their specialized nature. Better safe than sorry.

 

[nexus73]

I appreciate your input and you raise some excellent points. Are subsequent visits the usual standard of care in making this type of determination? I am probably going to cancel this appt.

You're not struggling to fill your practice, right? There's no reason to take on this evaluation.

 

[finalpsychyear]

No, because this is not treatment. This is a professional determination/opinion. Hence, you need to be ready to roll, and knowledgeable/confident in your process with this.

Are you rural? Surgeons and pain management docs do not typically "wing" these things with a stranger doc. There are many things in psychiatric medicine with more risk/liability certainly, but this should should not be taken lightly either.

I would not worry about cancelling. "Clearance" for these types of surgical procedures are expected to take months from the time of initiation due to their specialized nature. Better safe than sorry.

One thing i found strange is this came from a pcp directly rather than the pain specialist. I would think they would send it directly.

All i know this guy has a hx of depression. If he is doing well and stable, has a clear understanding of the process and reasonable expectations and there is no psychosis i don't really see the harm in a 7-10 day stim as long as he is not being coerced. I feel this is more of a insurance based hurdle.

 

[erg923]

All i know this guy has a hx of depression..

As do 90% of patients with chronic pain conditions.

For some insurance plans, that may be the case actually. But this does not absolve you of the responsibility of performing sound clinical duties and practicing medicine within your scope of practice for the good of the patient.

This is not a formal forensic context (unlike workers comp/IMEs), so this person still is your "patient."

 

[Armadillos]

Have you talked to the consulting PCP to be sure you actually know what specifically the expectations are for the consult? Maybe something got lost in translation, or maybe the PCP is new to town and accidentally referred to the wrong person.

 

[finalpsychyear]

You're not struggling to fill your practice, right? There's no reason to take on this evaluation.

True, I am not.

As do 90% of patients with chronic pain conditions.

For some insurance plans, that may be the case actually. But this does not absolve you of the responsibility of performing sound clinical duties and practicing medicine within your scope of practice for the good of the patient.

This is not a formal forensic context (unlike workers comp/IMEs), so this person still is your "patient."

Hi. I appreciate your input. I do full assessments usually 60-90 min initial evals so I feel I am doing thorough work although it may not be monetarily ideal it gives me satisfaction to know I've spent a reasonable time in assessing the patient.

 

[erg923]

That's nice, but you have a very specific consultive/referral question here, right?

 

[WisNeuro]

All of these assessments are vastly different, require vastly different questions and measures, and require a vastly different report. Thorough doesn't matter if you're not hitting the required elements. What I do for a pre-DBS, vs a MTL resection, vs a SCS, vs medical decision making capacity, etc, looks very different and incorporates different literature and relevant state laws. Thorough doesn't matter if you're not really sure what is necessary. I'd see if there is a specialist in the area to refer out to, or get some significant consultation.

 

[nexus73]

Despite the requirement by local surgeons to have these presurgical evaluations, it seems all the patients on my inpatient unit post gastric bypass have really bad borderline personality disorder, never stuck to their diets, and the stomach pouch stretched back out. But hey, at least the surgeon got paid right? Perhaps the pre surgical screenings in these cases were done incompetently.

 

[WisNeuro]

Sounds like confirmation bias, poor assessments, or both to me. 🙂

 

[smalltownpsych]

Despite the requirement by local surgeons to have these presurgical evaluations, it seems all the patients on my inpatient unit post gastric bypass have really bad borderline personality disorder, never stuck to their diets, and the stomach pouch stretched back out. But hey, at least the surgeon got paid right? Perhaps the pre surgical screenings in these cases were done incompetently.

One problem with surgical screening is that the findings are probabilistic and the patient is an individual. We can't really predict which patients will follow through and which will fail. "Patients with this perosnality profile tend to have worse outcomes and poor adherence to treatment follow-up." is the type of language that will be in the report. So when you have a patient in front of you that says that they need this surgery or they will die of the complications of obesity and "yes doc, I am going to my therapy and taking my meds." Can we really say no?
I agree wholeheartedly with Wisneuro that these and other types of assessments should be done by experts with experience with them. It can be difficult to set this professional boundary because everyone puts pressure on us to do them and just go ahead and give the green light. In a small town with limited referrals it can be even more difficult. I have been becoming more restrictive in my scope of practice as I get this and other types of referrals that would better be handled by someone with more expertise and am resisting the push to "just go ahead and do it because there is no one else". We don't do that with physiological medicine practice, why do we think it's okay with psychiatric or psychological practice?

 

[michaelrack]

We don't do that with physiological medicine practice, why do we think it's okay with psychiatric or psychological practice?

actually, it is done by "physiological medicine practice"

 

[smalltownpsych]

actually, it is done by "physiological medicine practice"

Have you guys been doing cardiac procedures on the side again? I think what I meant was that as an older profession, medicine and its various specialties are a bit more accepted and understood except for prsychiatry who is the red-headed stepchild of medicine and most of the time confused with psychology and vice versa. 😕

 

[michaelrack]

Have you guys been doing cardiac procedures on the side again? I think what I meant was that as an older profession, medicine and its various specialties are a bit more accepted and understood except for prsychiatry who is the red-headed stepchild of medicine and most of the time confused with psychology and vice versa. 😕

I know of primary care docs doing stress tests (which is appropriate); nerve conduction studies (which I disagree with), home sleep studies, etc

 

[Shikima]

I know of primary care docs doing stress tests (which is appropriate); nerve conduction studies (which I disagree with), home sleep studies, etc

How are they getting reimbursed for these based on the contract they have?

 

[erg923]

I know of primary care docs doing stress tests (which is appropriate); nerve conduction studies (which I disagree with), home sleep studies, etc

I think we are getting off on a tangent. The original poster didn't know what this was, why he was doing it, or the specific opinion to be rendered. Much less what specific areas need to be assessed that are relevant to the rationale for the assessment.

3 days later, hes doing it (without any supervision?). This is bad. This is not good clinical practice.

 

[nexus73]

0.00000000000000000000000000

We don't do that with physiological medicine practice, why do we think it's okay with psychiatric or psychological practice?

A big part is the sum total of psychiatry experience for most MDs is a month long inpatient rotation in 3rd year and whatever mental health patients they got exposed to doing family medicine rotations.

I think we are getting off on a tangent. The original poster didn't know what this was, why he was doing it, or the specific opinion to be rendered. Much less what specific areas need to be assessed that are relevant to the rationale for the assessment.

3 days later, hes doing it (without any supervision?). This is bad. This is not good clinical practice.

We'll soon have another borderline patient with a pain pump.

 

[Shikima]

I think we are getting off on a tangent. The original poster didn't know what this was, why he was doing it, or the specific opinion to be rendered. Much less what specific areas need to be assessed that are relevant to the rationale for the assessment.

3 days later, hes doing it (without any supervision?). This is bad. This is not good clinical practice.

residents are often forced to do stuff they're not "trained" to do.

 

[erg923]

residents are often forced to do stuff they're not "trained" to do.

He never suggested pressure from the institution or his attending though.

 

[Shikima]

He never suggested pressure from the institution or his attending though.

We often do not state this but it may be implicit.

 

[smalltownpsych]

He never suggested pressure from the institution or his attending though.

In my experience, the pressure comes when the patient shows up expecting me to give them the green light for whatever it is they want. I am lucky if I find out about it ahead of time and can put the kabosh on it. Lately we have had some turnover in our office department so we're getting more inappropriate referrals slipping through the cracks. It is especially problematic when the chief of our department has a different perspective on this and thinks we should be able to do just about anything and should because of rural nature of our clinic.