Psychiatry and psychological tests

[heyjack70]

I dont know. I honestly have never come across a psychiatrist with an interest in doing any meaningful psychometrically based assesssment. The few I've seen that have employed SVTs into their work obviously did not put much critical thought into the issue beyond the cut score cited in the publisher's manual. Emabarrisng, if you ask me. And anything worth doing, is worth doing right, IMHO. I would assume the forensic patients who lives hang in balance would agree with that practice philosophy as well.

I think a good forensic psychiatrist would be motivated to find the truth, and to have a deep enough understanding of a test to survive cross examination.

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[whopper]

"I'd like to call a Daubert hearing and move to strike"

Totally agree. In fact if I were doing a mock-trial with a fellow, I'd pretty much do what you did PSYDR. The fellowship I graduated from had mock-trials with the guys at Case Western, and Rensick would torpedo his fellows while on the witness stand if they ever used a test they didn't have the expertise to conduct.

Several states and federal courts have what's called a Daubert Standard. The data an expert witness brings up must meet that standard. Most MDs/DOs won't be able to talk about several psychometric tests in a manner that'll meet that standard.

Like I said, we medical doctors can do some of these tests. Leave it to the psychologists for the others or learn how to do it.

 

[heyjack70]

Totally agree. In fact if I were doing a mock-trial with a fellow, I'd pretty much do what you did PSYDR. The fellowship I graduated from had mock-trials with the guys at Case Western, and Rensick would torpedo his fellows while on the witness stand if they ever used a test they didn't have the expertise to conduct.

Several states and federal courts have what's called a Daubert Standard. The data an expert witness brings up must meet that standard. Most MDs/DOs won't be able to talk about several psychometric tests in a manner that'll meet that standard.

Like I said, we medical doctors can do some of these tests. Leave it to the psychologists for the others or learn how to do it.

Can you give an example?

 

[mahasanti]

As someone with a strong background in mathematics and statistics prior to entering medicine, it is laughable how everyone here is pretending that psychologists are the gods of statistics.

It is true that psychology PhDs get more statistics than we do in medical school. It is also true that there are MDs with degrees in statistics. There are also many MDs with science PhDs who also have heavy statistics backgrounds.

And I have met MANY psychology PhDs who couldn't do math or statistics to save their lives.

It does seem important to understand the nuances of the test you are administering. I don't see why an MD can't be trained in this, especially in something like a forensics fellowship.

But, then again, I suppose some in the psychology world need to feel there is something that is exclusively theirs--something that psychiatrists can't do.

 

[edieb]

As someone with a strong background in mathematics and statistics prior to entering medicine, it is laughable how everyone here is pretending that psychologists are the gods of statistics.

It is true that psychology PhDs get more statistics than we do in medical school. It is also true that there are MDs with degrees in statistics. There are also many MDs with science PhDs who also have heavy statistics backgrounds.

And I have met MANY psychology PhDs who couldn't do math or statistics to save their lives.

It does seem important to understand the nuances of the test you are administering. I don't see why an MD can't be trained in this, especially in something like a forensics fellowship.

But, then again, I suppose some in the psychology world need to feel there is something that is exclusively theirs--something that psychiatrists can't do.

But I bet you oppose psycholoigst prescribing

 

[Therapist4Chnge]

lol…I was waiting for that.

I'm glad that someone is asking questions about the considerations for forensic assessment, as I've seen too many hacks (from multiple disciplines) try and do it all without having a fraction of the training. I think completing a formal fellowship in forensic assessment would be the bare minimum level of training (at least in my opinion) for a psychiatrist, as long as that fellowship included a large portion of supervision and mentorship because the true challenges in the work are in the interpretation…not the administration and scoring.

 

[smalltownpsych]

As someone with a strong background in mathematics and statistics prior to entering medicine, it is laughable how everyone here is pretending that psychologists are the gods of statistics.

It is true that psychology PhDs get more statistics than we do in medical school. It is also true that there are MDs with degrees in statistics. There are also many MDs with science PhDs who also have heavy statistics backgrounds.

And I have met MANY psychology PhDs who couldn't do math or statistics to save their lives.

It does seem important to understand the nuances of the test you are administering. I don't see why an MD can't be trained in this, especially in something like a forensics fellowship.

But, then again, I suppose some in the psychology world need to feel there is something that is exclusively theirs--something that psychiatrists can't do.

There is a wide variation in skill set for assessment between psychologists. It really depends on what their area of expertise is. Forensic Psychologists and Neuropsychologists are usually going to be the stand-out experts in this area. There are also psychologists who specialize in employment screenings or psychologists who specialize in educational assessments. When a patient presents to me with a question that is outside my scope of practice, then I refer. Most typically, in my setting that would be for neuropsych due to TBI or other organic brain issues and I sure as heck am not going to provide expert witness in a criminal case since I have very limited experience with SIRS or TOMM or even PCL-R or criminals in general for that matter.

 

[smalltownpsych]

p.s. I am posting alot as I wait for my patient to finish the MMPI.

 

[heyjack70]

"Doctor, thank you for joining us today. Can you outline your education and training for us?"
"That's a pretty impressive training. You would agree that being proper education is important for a professional, correct?"
"For example, you wouldn't have your taxes prepared by someone with no education, correct?"
"Doctor, what is a t score??"
"How is it calculated?"
"what is the formula for a t score?"
"where was this first published?"
"Isn't that story fairly famous?"
"so you don't know how the MMPI is scored?"
"Doctor, can you tell me the formula for the binomial theorem?"
"Doctor, isn't it true that the manual for XYZ test calls for training in statistics, psychometrics, etc"
"Can you show me where in your education, you received any formal education in statistics , psychometrics, ?"
"What is a confidence interval?"
"So Doctor, you administered a variety of these standardized tests which you used to make this opinion. How did you select these tests?"
"What is the error rate for this particular battery of tests?"
"Can you cite some peer reviewed studies that support your opinion and technique?"
"How did you administer these tests?"


"So Doctor, you used a battery of tests, which you no education, which you are unable to cite the error rate for, the literature of which you are unfamiliar, which were administered not according to standards, to make this opinion?"

"I'd like to call a Daubert hearing and move to strike"

I think this is a stretch. Cardiologists know how to use a stethoscope and what heart murmurs sounds like, even though they may not know who invented the stethoscope, or the exact difference in air flow physics that make use of the bell vs diaphragm more appropriate for different things. But you could hardly argue that a cardiologist is not an expert at using a stethoscope as a tool to diagnose heart conditions. In parallel, a psychiatrist who is trained to administer and interpret certain tests in light of the test's statistics, may not be have the statistical knowledge or acumen to develop such a test (or know who first published the t test), but he could certainly use it appropriately.

 

[erg923]

I think this is a stretch. Cardiologists know how to use a stethoscope and what heart murmurs sounds like, even though they may not know who invented the stethoscope, or the exact difference in air flow physics that make use of the bell vs diaphragm more appropriate for different things. But you could hardly argue that a cardiologist is not an expert at using a stethoscope as a tool to diagnose heart conditions. In parallel, a psychiatrist who is trained to administer and interpret certain tests in light of the test's statistics, may not be have the statistical knowledge or acumen to develop such a test (or know who first published the t test), but he could certainly use it appropriately.

I think, clinically, thats mostly true (ie., you're right). But, as someone who is going into forensic psychiatry (apparently?) you should also know that NONE of that actually matters. lol. Its a court room. Courtrooms could give a **** about clinical practice realities. You are at the whim of lawyers and judges and Daubert and case laws. And they all argue better than you do.

 

[notdeadyet]

But I bet you oppose psycholoigst prescribing

If learning how to score and interpret a SIRS is the equivalent of learning how to safely manage prescribe and manage medications, either some of us are way underestimating what goes into administering and scoring the SIRS or some of us are way underestimating the fund of knowledge needed to make sure medication A is not going to cause problems when prescribed to patient B, who suffers from C-F and is already taking R-Z.

 

[notdeadyet]

This thread has been helpful for learning some of the difficulty that goes into administration, evaluation, and interpretation of some tests. I don't have a good handle on which ones are easy and which ones are hard, nor the requirements deemed necessary for the easier ones, but I understand that's not likely to happen.

 

[Therapist4Chnge]

The thing is that it DOESN'T matter if you only know Test A & Test B if they are not appropriate for a particular case. You need to know most/all of the appropriate options, why one is preferred to another, and more importantly why certain ones are contraindicated for a given type of case.

This isn't like Angry Birds where you are arbitrarily restricted to a type or order. When you get caught up a creek bc you only know the "easy tests" (that's a misnomer btw), the opposing counsel will take you to the woodshed and/or convince the judge and jury that you are not credible. You can't "dabble" in this area bc you will quickly ruin your reputation. Nothing says fun like a lawyer digging up a case you got crushed bc you were unprepared/not suited to be an expert bc they will go right back for round 2, 3, 4, etc.

You either know what you are doing or you are praying they don't sniff you out. A formal fellowship should be the absolute minimum and even then you better train w a credible person/group and continue supervision until you have a number of cases under your belt.

 

[whopper]

But I bet you oppose psycholoigst prescribing

Agree. The argument from psychiatrists is that psychologists don't have the training.

Now I hear psychiatrists wanting to do testing in areas where they don't have the training.

If you believe in something, stick to your guns. Besides, I've seen these tests. I've done a lot of them. I'd rather have the psychologist do them anyway!

In parallel, a psychiatrist who is trained to administer and interpret certain tests in light of the test's statistics, may not be have the statistical knowledge or acumen to develop such a test (or know who first published the t test), but he could certainly use it appropriately.

And one could argue that a psychologist could prescribe simply using Epocrates. After all gives dosing guidelines.

Many psychologists couldn't develop many of the tests they use, just as we psychiatrists (for the overwhelming majority) wouldn't have been able to manufacture the meds we prescribe, but they do have better training in several aspects of these tests, statistics aside. Psychometrics, for example, is something not taught in psychiatry residencies. That's a separate but related field to statistics.

As much as you argue that psychologists are not needed, you fuel the argument that doctors aren't needed. Let NPs do everything we do. Let nurses do everything. Heck let a layman prescribe so long as he feels he has a specific disorder and has access to Epocrates.

I don't know one psychiatrist that could sit down and explain more than a few of the psychological tests well, let alone administer them that are done by psychologists. I'm not talking about a HAM-D. I'm talking about an MMPI or an IQ test.

A psychiatrist could master those tests with extensive study and training, just like a psychologist could read several textbooks of psychiatry and ask to shadow a doctor and attend some medical school courses, but then, why not just become an MD?

This isn't about you reading a book and thinking you could do something. Heck maybe you can do it right. This is about creating a line in the sand, and saying that if someone crosses this line, then as a society, it's considered acceptable and professional practice because you or I, a judge, jury, hospital, what have you aren't not in the habit of hiring the one-in-a-million exception Good Will Hunting type that can do the job better than anyone else who defied the odds and never got the training in the first place.

That's what a lot of people here aren't getting.

You want to do these tests? Yay! Let's get the surgeon to start working without the anesthesiologist because that surgeon had a passion for that field too, read the textbook and he can read an EKG too. Let's have the psychiatrist that kicked butt during Ob-Gyn do deliveries.

Those people that think we have to get a license, or residency, or degree? Screw them!

The possibilities are limitless!

 

[whopper]

Rensick would torpedo his fellows while on the witness stand if they ever used a test they didn't have the expertise to conduct.

Could you give an example?

Sure.

Resnick, time and time again, during a mock trial will set traps for his fellows. He'll ask a fellow if they did something, the fellow says yes, and then he'll drop a ton of data on them showing that the psychiatrist doesn't have expertise in this area at all.

E.g., he'll ask a fellow, "in your expert opinion" if he believes a defendant is telling the truth.
The fellow (let's say for argument's sake) says no.

He'd then demand to know what studies back a psychiatrist's ability to discern if someone is telling the truth. (Studies show psychiatrists have no ability over a layman to tell if someone is lying). Then show a study showing that psychiatrists have no ability over a layman in this area. Then he'll ask the fellow where he came up with his opinion, and show it's no "expert" opinion at all.

The fellow then has the following options 1-admit his error 2-come up with more BS that'll just lead to more assaults from Resnick making the fellow look like a complete idiot.

I've seen this happen several times. I've seen it happen where the fellow chose option 2 again and again and kept getting hammered and hammered and hammered for over an hour.

http://www.hoax-slayer.com/two-crane-accident-photos.shtml

So reading this, guess what he'd likely do to a fellow that used a test that specifically did not include psychiatrists among the group that is considered appropriate to administer the test?

 

[heyjack70]

And one could argue that a psychologist could prescribe simply using Epocrates. After all gives dosing guidelines.

You could argue anything. Come on Whopper. You've seen the TOMM and the SIRS, right? Tell me that it would take a 5 year PhD to learn this stuff. These are specific tests with some nuance that you could learn in a forensic psychiatry fellowship, given the appropriate supervision. I think it's important to repeat that I was never advocating learning the MMPI or WAIS.

Can anyone remind me which tests specifically exclude psychiatrists, and/or state only psychologists can administer them?

 

[michaelrack]

You could argue anything. Come on Whopper. You've seen the TOMM and the SIRS, right? Tell me that it would take a 5 year PhD to learn this stuff. These are specific tests with some nuance that you could learn in a forensic psychiatry fellowship, given the appropriate supervision. I think it's important to repeat that I was never advocating learning the MMPI or WAIS.

Can anyone remind me which tests specifically exclude psychiatrists, and/or state only psychologists can administer them?

Forensics is one issue, and I have no disagreement with what Whopper is saying regarding psych testing in forensics.

The one test that I know of that is for psychologists only is the MMPI. I view this (limiting psychiatrists from performing psychological testing in a non-forensic setting) as a restraint of trade issue- similar to when pscyhoanalytic institutes excluded psychologists and other non-physicians. I wonder if this has ever been legally challenged???

 

[PsyDr]

heyjack,

I actually do this stuff for a living. If you think an interrogatory that I spent less than 5 minutes to create is a stretch, you are sorely mistaken. That's a soft pitch. I'm not even getting mean. And everything becomes forensics when a malpractice suit comes up.

 

[whopper]

You could argue anything. Come on Whopper. You've seen the TOMM and the SIRS, right? Tell me that it would take a 5 year PhD to learn this stuff. These are specific tests with some nuance that you could learn in a forensic psychiatry fellowship, given the appropriate supervision. I think it's important to repeat that I was never advocating learning the MMPI or WAIS.

You could argue anything. Come on HeyJack. You've seen Citalopram and Fluoxetine, right? Tell me that it would take 4 years of medical school and 4 years of residency to learn this stuff.

OK, now to address this...
These are specific tests with some nuance that you could learn in a forensic psychiatry fellowship, given the appropriate supervision. I think it's important to repeat that I was never advocating learning the MMPI or WAIS.

I've mentioned this before. I do believe that some tests that are recommended only by psychologists could be done by psychiatrists in some situations. In a forensic situation you got to take it very seriously because like I said, even if you could do the test effectively, you're going to look bad for having done a test that the manufacturer/producer/author of the test wrote you shouldn't. As PSYDR said, any situation could become forensic.

With appropriate supervision, forensic psychiatrists IMHO could learn some of the psychologist-only tests, but the fact of the matter is most forensic fellowships from what I've seen don't supervise or educate their fellows well enough to categorically elevate us to the the position psychologists are in. I remember asking some people during my interviews "Will you go over the SIRS in fellowship?" and many of them answered "I never heard of it."

And I mentioned this before. You could very well educate yourself on some of these tests, but then you're in the Good Will Hunting category. You might even be able to do it better than several psychologists but you're going to look very very odd doing so, just like a psychiatrist could memorize a surgery text and ask the hospital for surgery privileges. No matter how you slice or dice that one, expect the hospital to say no, even if you show them a video of you doing surgery very effectively on some poor guy that volunteered for your video.

 

[whopper]

The one test that I know of that is for psychologists only is the MMPI. I view this (limiting psychiatrists from performing psychological testing in a non-forensic setting) as a restraint of trade issue- similar to when pscyhoanalytic institutes excluded psychologists and other non-physicians. I wonder if this has ever been legally challenged???

I don't know if it has, but there are equations in the formulas used in the MMPI where psychologists do get appropriate training and psychiatrists do not. Counselors also do get training in it but in several states, only psychologists are authorized to use the MMPI. Some of it, arguably are simply guild issues with one group trying to maintain the control. That said, psychiatrists don't get the training.

So, let's say there's a psychiatrist that wants to be able to do an MMPI? Must he truly be able to go through graduate school and get a doctorate to be able to do it on a level comparable to a competent psychologist---for real? IMHO no. One could probably make a series of courses that could fill in the gaps that could allow a psychiatrist to do so including graduate level statistics, psychometrics, and a course specifically using the equations used in the MMPI.

Such a series of courses doesn't exist in a structured program just for psychiatrists. If you did it, you'd be in the Good Will Hunting category. Hardly anyone would see you as someone they'd want for such as test and would rather go to a psychologist.

If any of the psychiatrists here are peeved about this situation, the answer is to change our training regimen to include much more psychology than we currently receive, complete with tests at the end of the courses. I remember half the classes taught in residency were low priority because most residents were catching up on sleep and none of them were graded. If you are in a place where you need testing done and don't have a psychologist, get the institution to hire one.

 

[Armadillos]

Probably a naive question, but not coming from a math naive person (took linear algebra, stats, differential equations, quantum mechanics, etc.) in college, but what could possibly be so difficult when it comes to math that someone couldn't fairly easily learn to use the very specific application of some math to a specific test and then just repeatedly do that? (And then refer to someone else if that that particular test in not ideal for a certain situation)

Especially considering how user friendly various math computer programs are these days. Obviously its going to take high level knowledge to create that sort of thing, but teaching someone how to select an appropriate instrument and then solve/interpret a handful of specific problems over and over doesn't seem like that big of a deal.

 

[erg923]

Probably a naive question, but not coming from a math naive person (took linear algebra, stats, differential equations, quantum mechanics, etc.) in college, but what could possibly be so difficult when it comes to math that someone couldn't fairly easily learn to use the very specific application of some math to a specific test and then just repeatedly do that? (And then refer to someone else if that that particular test in not ideal for a certain situation)

Especially considering how user friendly various math computer programs are these days. Obviously its going to take high level knowledge to create that sort of thing, but teaching someone how to select an appropriate instrument and then solve/interpret a handful of specific problems over and over doesn't seem like that big of a deal.

Take everything you just said, replace "psychometric test" with "prescribing medications", then insert your rebuttal arguement. This would equal, approximatley, all of our (psychologists) retorts to your post. And don't take this too literally, cause then you miss the point.

 

[Armadillos]

Take everything you just said, replace "psychometric test" with "prescribing medications", then insert your rebuttal arguement. This would equal, approximatley, all of our (psychologists) retorts to your post. And don't take this too literally, cause then you miss the point.

I anticipated this response, but I don't think its a great analogy (hence why I still posted). I 100% understand how high level statistical training is needed to develop the instruments, but I'm not convinced its entirely necessary in order to employ them. I mean there are diagnostic procedures throughout medicine that took extremely high level math and physics to develop, but that doesn't mean the physician needs to understand all of it.

 

[erg923]

I think there has been too much focus on the stats aspect in this discussion, as I have mentioned before.

Suffice to say that there is sloppy utilization and intepretation of these tests by members of our own profession, so I have sufficient reason to believe that using even seemly "basic tests"(although if you read my post #45 I am not sure why people have labeled them as such) is obvioulsy very difficult and nuanced work. If it wasn't, people wouldn't **** it up so often.

 

[notdeadyet]

Suffice to say that there is sloppy utilization and intepretation of these tests by members of our own profession, so I have sufficient reason to believe that using even seemly "basic tests"(although if you read my post #45 I am not sure why people have labeled them as such) is obvioulsy very difficult and nuanced work.

I understand the logic here. I just find it odd that I've never been able to really hear the actual training requirements for a particular test. It just comes across a bit fishy when the same reply is given for the need for years of specialized training/psychometric coursework regardless of which test is being discussed. One of the tests asked about on this thread is the M-FAST, a screening test that takes about 10 minutes to give and less to score. Maybe it's just my ignorance, but I'm confused why this requires a PhD to administer and interpret.

 

[erg923]

It just seems fishy if we are unable/unwilling to acknowledge that some tests are challenging to administer/interpret and others less so. One of the tests that was discussed is the M-FAST, which takes about 10 minutes to give and 5 minutes to score. It's a screening test. I think it's fair to want to make a distinction between this test and one that is much more complex and nuanced. Falling back on the vague requirement of years of specialized training and psychometric coursework as if they were all created equal makes me suspect.

I think thats an awfully psychometrically (test) bound way of looking at the contruct of malingering, which is complex state-dependent behavior.

But, yes, of course some tests are more complex than others.

 

[notdeadyet]

I think thats an awfully psychometrically (test) bound way of looking at the contruct of malingering, which is complex state-dependent behavior.

Right. Yet this test gets lumped in with the others that DO require finesse and advanced training. I think this is what raises eyebrows.

Anyway, this thread has been enlightening (on multiple levels). It's been appreciated.

 

[Therapist4Chnge]

I anticipated this response, but I don't think its a great analogy (hence why I still posted).

When frequency of an adverse outcome is considered, more harm can come from shoddy assessment work than most poor prescribing. A prisoner cannot titrate down from death row, and discontinuation from it tends to be a one way street. Otherwise, I think the analogy is a good one.

 

[nancysinatra]

If it's a clinical opinion based on some objective data that's different (e.g. patient develops rash and is on lamotrigine, and there's data showing that med could cause Stevens-Johnson Syndrome, now that should be admissible as the med being a possible cause of the rash), but if it's just opinion, it's hogwash.

There is data showing that lamotrigine can cause Stevens-Johnson, but rashes are not all alike. Clinical judgment would be required by the dermatologist in looking at the rash and deciding whether they think it is related to the lamictal, and if so, how. A person on lamictal could have poison ivy, after all, or eczema, or many other things.

Dermatology does have the advantage that at least certain things they can biopsy and get input from pathology. I sure wish we could do that in psychiatry.

Many psychiatrists, unfortunately, have a history of making expert witness opinions with people's lives in the balance not really having any science behind their statements, and when questioned, they back their credentials with bogus comments like "I'm a psychiatrist with decades of experience."

That's true throughout psychiatry. The only difference in forensic psychiatry is that it involves the possibility of people going to jail. It's amazing to me how much higher a standard of truth the legal world demands of people than the medical world does. I wonder how much systematic error occurs in our field as a result of overly confident clinicians who trust their clinical judgment?

A case in point is that I can personally name some quite well known academic psychiatrists who until last year seemed pretty darn sure they know how to diagnose and cure a case of OCPD or narcissistic PD. Oh but then suddenly they dropped out of the DSM. Hmm. Oh but we don't need lab tests, and oh no, there's no subjectivity in our field, and no one ever gets misdiagnosed.

 

[nancysinatra]

Here is a question I have about psychometrics. Statistics is all about probabilities, right? So if a person has a score X on psychometric test A, you can say there is a Y% chance that they have condition N. But condition N is still a psychological construct! There is no physical gold standard test to be compared the results to. Contrast this with, say, a surgeon who orders a CT scan to look for appendicitis. The error rate for such CT scans would be established by looking at tons of scans and comparing them to surgical and pathological findings in which appendicitis was actually confirmed. Is that right?

Now let's say I want to devise a psychometric test that is extremely reliable for diagnosing "wandering uterus?" And so I go around convincing people that this condition is real, and get other doctors to diagnose people with it, and then we use that cohort of patients as the basis for devising a psychometric test to look for it. Other than common sense what is there to prevent this?

 

[heyjack70]

heyjack,

I actually do this stuff for a living. If you think an interrogatory that I spent less than 5 minutes to create is a stretch, you are sorely mistaken. That's a soft pitch. I'm not even getting mean. And everything becomes forensics when a malpractice suit comes up.

This stuff meaning...forensic psychological testing...or planning cross examination of experts? I still haven't gotten a good explanation for why you must know the history of the t test.

 

[heyjack70]

You could argue anything. Come on HeyJack. You've seen Citalopram and Fluoxetine, right? Tell me that it would take 4 years of medical school and 4 years of residency to learn this stuff.

You seem really concerned about the turf war with psychologists?

 

[whopper]

Point is that a lot of people here (not specifically you) seem to have a 180 degree turn when the tables are turned on them in a debate with a lot of parallels.

I'll just go ahead and say it. I think psychiatry in it's scope of practice is extremely limited without the use of psychology, and whatever Wizard(s) of Oz that have commanded us to not do this or that and leave it to other fields have left us in a sense blind-sided.

Malingering testing is not heavily emphasized in academic training but it is a clinical reality especially since residency training is often in inner cities with lower socioeconomic people who see psych units as free housing, want a hit of Ativan, and want to use PESs as their place to treat drug withdrawal (or else I'll kill myself). While it's an extreme minority of people that do this, it's enough to give clinicians a lot of frustration.

We ought to get good training in malingering testing. We should have formalized methods to mutually agree-upon to kick out such patients. We don't. Most of the time when we do, we do it in a manner that textbooks and journals won't openly touch and declare is appropriate practice. Most attendings don't know how to do malingering tests. The ones out there are usually delegated for psychologists.

Now whoever made up this curriculum for psychiatrists IMHO needs to re-examine it. It should include psychometrics, malingering testing, and appropriate guidelines taught on when to kick out someone out of a PES or inpatient unit, not as esoteric materials that must be sought after at conventions, but open, easy-access, and freely taught to first year residents.

 

[heyjack70]

When frequency of an adverse outcome is considered, more harm can come from shoddy assessment work than most poor prescribing. A prisoner cannot titrate down from death row, and discontinuation from it tends to be a one way street. Otherwise, I think the analogy is a good one.

The problem with this argument in the forensic setting is that there are two sides. If a psychiatrist does a poor job and creates an opinion from his bad testing, a psychological expert should be able to tear the testing apart. In a treatment setting the physician is prescribing with no oversight, so a bad physician can really screw things up. Medications=/testing.

 

[heyjack70]

Forensics is one issue, and I have no disagreement with what Whopper is saying regarding psych testing in forensics.

The one test that I know of that is for psychologists only is the MMPI. I view this (limiting psychiatrists from performing psychological testing in a non-forensic setting) as a restraint of trade issue- similar to when pscyhoanalytic institutes excluded psychologists and other non-physicians. I wonder if this has ever been legally challenged???

Great point

 

[heyjack70]

Point is that a lot of people here (not specifically you) seem to have a 180 degree turn when the tables are turned on them in a debate with a lot of parallels.

I'll just go ahead and say it. I think psychiatry in it's scope of practice is extremely limited without the use of psychology, and whatever Wizard(s) of Oz that have commanded us to not do this or that and leave it to other fields have left us in a sense blind-sided.

Malingering testing is not heavily emphasized in academic training but it is a clinical reality especially since residency training is often in inner cities with lower socioeconomic people who see psych units as free housing, want a hit of Ativan, and want to use PESs as their place to treat drug withdrawal (or else I'll kill myself). While it's an extreme minority of people that do this, it's enough to give clinicians a lot of frustration.

We ought to get good training in malingering testing. We should have formalized methods to mutually agree-upon to kick out such patients. We don't. Most of the time when we do, we do it in a manner that textbooks and journals won't openly touch and declare is appropriate practice. Most attendings don't know how to do malingering tests. The ones out there are usually delegated for psychologists.

Now whoever made up this curriculum for psychiatrists IMHO needs to re-examine it. It should include psychometrics, malingering testing, and appropriate guidelines taught on when to kick out someone out of a PES or inpatient unit, not as esoteric materials that must be sought after at conventions, but open, easy-access, and freely taught to first year residents.

I agree completely. I guess my real argument is not that a psychiatrist should just buy the SIRS and start firing. I am advocating for appropriate training. Ideally an option in residency. But if not, every forensic psychiatry program should be setup to fully train fellows (if it's possible in a one year program) in the proper administration and interpretation of at least a handful of high yield tests.

 

[splik]

A case in point is that I can personally name some quite well known academic psychiatrists who until last year seemed pretty darn sure they know how to diagnose and cure a case of OCPD or narcissistic PD. Oh but then suddenly they dropped out of the DSM. Hmm. Oh but we don't need lab tests, and oh no, there's no subjectivity in our field, and no one ever gets misdiagnosed.

i get your point but none of the personality disorders have dropped out of the DSM nor have the criteria changed

 

[erg923]

I still haven't gotten a good explanation for why you must know the history of the t test.

Again, you are being a concrete with some of this. You don't in actual clinical practice (see my previous post #60). But that doesnt matter to lawyers and to the court. Its all about tearing apart the sway of the expert, and thus the evidence. Doctors hold a certain level of innate trust to most lay people, right? The job of a good lawyer is to create reasonable doubts, no? What is the most powerful way to destroy the power of argument? Go back to psych 101 text book...

That said, I do think there is a reasonable argument to be made that an extensive knowledge/understanding of the science beyond direct application is necessary to a certain extent. I am well aware that most commercial air flights are automated these days, but do I really want a pilot who can't explain the the Bernoulli's principle to me?

 

[Armadillos]

When frequency of an adverse outcome is considered, more harm can come from shoddy assessment work than most poor prescribing. A prisoner cannot titrate down from death row, and discontinuation from it tends to be a one way street. Otherwise, I think the analogy is a good one.

Not sure how frequency of adverse outcomes helps your case here, how many people do you think are (or hypothetically would be) on death row/life in prison who are there because they were evaluated by a forensic psychiatrist instead of a psychologist?

 

[Armadillos]

Basically my main issue with this thread is the idea that it would not be reasonable to train psychiatrists to do some of these assessments (and understand their limitations), I'm not saying that I think its a good idea for them to just go wild and do it with no training.

I think the comparisons to prescribing are intellectually dishonest. Diagnosis of mental illness is a cornerstone of all psychiatry training, so getting extra training in psychometric testing is a reasonable extension of these diagnostic capabilities. Physiology (not just neuro), pharmacology (not just neuro) and diagnosis/management of comorbid medical illness is not a hallmark of clinical psychology training so the two situations don't seem comparable at all.

 

[erg923]

Basically my main issue with this thread is the idea that it would not be reasonable to train psychiatrists to do some of these assessments.

What poster has said that?

I think many of us have voiced that appropriate training is needed, and that it is rare for this to occur, likely due to to this not being a priority for programs as well as difficulty insuring proper supervision. I have not heard any statement that is can not occur, however.

 

[hamstergang]

but do I really want a pilot who can't explain the the Bernoulli's principle to me?

So off topic, but that's basically not really why planes fly.

 

[erg923]

So off topic, but that's basically not really why planes fly.

I know, and that's the point, right? Its the "bench science," of sorts, underlying the phenomenon.

 

[Armadillos]

What poster has said that?

I think many of us have voiced that appropriate training is needed, and that it is rare for this to occur, likely due to to this not being a priority for programs as well as difficulty insuring proper supervision. I have not heard any statement that is can not occur, however.

I thought there was a lot of talk that several of these tests will not be sold to MDs, also someone said they were not allowed to attend their institutions PhD lecture/conference about these assessments, etc.

 

[erg923]

I thought there was a lot of talk that several of these tests will not be sold to MDs, also someone said they were not allowed to attend their institutions PhD lecture/conference about these assessments, etc.

Well, yes, the sale of the tests is restricted to those that can show proof of proper credentials or training. Sounds reasonable to me.

I have never heard of psychiatry residents not being allowed to attend grand rounds talks about symptom validity testing, however. Seems silly.

 

[PsyDr]

This stuff meaning...forensic psychological testing...or planning cross examination of experts? I still haven't gotten a good explanation for why you must know the history of the t test.

I do both. Asking why the history of the t test is important just like knowing whose face is on the DSM is important. Both datums are very well known. Each is associated with a line of questioning designed to discredit the expert.

 

[PsyDr]

Here is a question I have about psychometrics. Statistics is all about probabilities, right? So if a person has a score X on psychometric test A, you can say there is a Y% chance that they have condition N. But condition N is still a psychological construct! There is no physical gold standard test to be compared the results to. Contrast this with, say, a surgeon who orders a CT scan to look for appendicitis. The error rate for such CT scans would be established by looking at tons of scans and comparing them to surgical and pathological findings in which appendicitis was actually confirmed. Is that right?

Now let's say I want to devise a psychometric test that is extremely reliable for diagnosing "wandering uterus?" And so I go around convincing people that this condition is real, and get other doctors to diagnose people with it, and then we use that cohort of patients as the basis for devising a psychometric test to look for it. Other than common sense what is there to prevent this?

Nancy, what you are talking about does not just apply to psychometrics. EBM has been taking this on for years. Appendicitis is also a construct. There is no this is definitely appendicitis at this degree of inflamtion, but not at this degreee. In your example, at what value of is WBC going to considered elevated? What temp is elevated? How inflamed is the appendix? 5%? 10%? 20%? What are the PP/NP/kappa for those values?

EBM has been taking this on for years in other areas, as well. In 2013, the ACC/AHA guidelines lowered the threshold for the diagnosis of hypercholestremia and statin use. Does this mean the construct of elevated choelsterol is BS?

Finally, what about fibromyalgia? You know, the disorder that a doctor convinced was real and got other doctors to diagnose people with it?

Ironically, I am wearing a very nice pair of boots. I don't know if they were meant for walking, though.

 

[whopper]

In a treatment setting the physician is prescribing with no oversight

Agree, though I'm only stating this because I don't want students to get a wrong idea. Pharmacists, nurses, and other practitioners that also care for the patient are supposed to check and ask if they see something suspicious. The clinical reality, however, is unless something egregiously off, usually no one does anything. Even then I've seen several other people look the other way.

In forensics, everything has a significant chance of being highly scrutinized, even the small details.

And I forgot to add this.

Let's say that an MD did do all of the needed requirements to understand a test as well as a psychologist, but did not get the Ph.D. or Psy.D. --->
A court question on the acceptance of expert witness opinions or scientific data as evidence is if the scientific data meets the standards acceptable to the profession? Like I said, you could insert yourself into the Good Will Hunting position and the answer would still be no. A court will not be in a position, where they hardly know anything about the field, to take the years to understand what really is acceptable and what isn't. A judge isn't going to take a few years studying a psych test to understand. They're going to ask the lawyer instead to produce a witness or have a test done under the appropriate methods.

If you want to be the first MD to start doing tests like MMPIs, go ahead. I don't think it'll get you anywhere in court other than some local court in the middle of nowhere that'll take anyone. I wouldn't recommend it, but who am I to stop you?

Like I said, if you don't have a psychologist partnering with you, get one. You might be pleasantly surprised with the insights and opinions they can offer you.

 

[hamstergang]

is important just like knowing whose face is on the DSM is important. Both datums are very well known.

What??

 

[erg923]

What??

Its just hyperbole (ie., its basic, so you should know it whether its necessary or not, and if you dont, your credibility is gone). I think the sarcasm is getting lost here...