Resolving discrepancies between providers

[smalltownpsych]

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Just had an issue crop up, again, that is always dicey form me. I think that I handled it fairly well by empowering the patient to decide but there are downsides to that at times. In short, prescribers will often diagnose something that is treatable with medications and then insist that the patient needs to take this medication. A great example is Bipolar verses Borderline and that one is actually somewhat understandable because they both are characterized by emotional lability. Another is ADHD verse anxiety.

The one I had the other day wasn't even close though and the patient was very clear that they wanted my input because they had their own doubts. I resolved it by going through the DSM-5 criteria with the patient and let them make the call. I don't like to throw others under the bus, well my grandiose narcissistic self would love to do it 😛, but my highly trained professional psychologist self prefers to handle it more diplomatically.

Long story short, just wondering about others thinking about how to resolve these types of dilemmas.

 

[WisNeuro]

Just had an issue crop up, again, that is always dicey form me. I think that I handled it fairly well by empowering the patient to decide but there are downsides to that at times. In short, prescribers will often diagnose something that is treatable with medications and then insist that the patient needs to take this medication. A great example is Bipolar verses Borderline and that one is actually somewhat understandable because they both are characterized by emotional lability. Another is ADHD verse anxiety.

The one I had the other day wasn't even close though and the patient was very clear that they wanted my input because they had their own doubts. I resolved it by going through the DSM-5 criteria with the patient and let them make the call. I don't like to throw others under the bus,well my grandiose narcissistic self would love to do it 😛, but my highly trained professional psychologist self prefers to handle it more diplomatically.

Long story short, just wondering about others thinking about how to resolve these types of dilemmas.

I see the misdiagnoses a lot, but it's usually due to very lazy diagnosing. Usually a couple questions regarding necessary components of a diagnosis and I clearly see they were misdiagnosed (e.g., diagnosed with Bipolar with nothing close to a hypo/manic episode, ADHD with no history or inclination whatsoever of childhood problems). In that case, I have no problem throwing someone under the bus. If you want to do a sloppy job, you better get used to being called out on it.

 

[smalltownpsych]

I see the misdiagnoses a lot, but it's usually due to very lazy diagnosing. Usually a couple questions regarding necessary components of a diagnosis and I clearly see they were misdiagnosed (e.g., diagnosed with Bipolar with nothing close to a hypo/manic episode, ADHD with no history or inclination whatsoever of childhood problems). In that case, I have no problem throwing someone under the bus. If you want to do a sloppy job, you better get used to being called out on it.

I think that this is one area where our training is weak. The MDs that I work with do this all day long. They start calling each other out on sloppy thinking from day one. When I was in the doctoral program, that seemed to be discouraged and it was more of a.... I don't even know how to describe it other than touchy, feely, don't say anything to hurt someones feelings. Of course, we had one professor who called it like he saw it and felt that we needed to be stronger. Made a few students cry. When I was young, I had truck drivers working for me and I knew how to talk to them when they were wrong!

 

[deleted343839]

I generally adopt your approach. I explain to the patient what I see, my rationale for favoring a given diagnosis (or a given conceptualization of the "problem"), and how that guides the treatment plan. I ultimately let the patient decide what seems best fitting to them. It's a second opinion. The other clinician is usually peripheral to this discussion (unless, of course, the other clinician was doing something flagrantly unethical).

You went to a nicer graduate program than I did because we would get ripped over an impressionistic diagnosis!

I mainly work with physicians who have almost no mental health training and are usually pretty happy to accept my assessments. But in my setting I see a lot of second opinions about medical issues, and while my physician colleagues might argue amongst themselves about a diagnosis, they are fairly diplomatic (to the patient) when referring to the work of physicians outside our center.

 

[WisNeuro]

I think that this is one area where our training is weak. The MDs that I work with do this all day long. They start calling each other out on sloppy thinking from day one. When I was in the doctoral program, that seemed to be discouraged and it was more of a.... I don't even know how to describe it other than touchy, feely, don't say anything to hurt someones feelings. Of course, we had one professor who called it like he saw it and felt that we needed to be stronger. Made a few students cry. When I was young, I had truck drivers working for me and I knew how to talk to them when they were wrong!

I think this is highly variable. My training model throughout stages has always been having to explain the rationale behind your decision making and getting called out for sloppiness. Granted, I chose certain places (postdoc) exactly for this type of atmosphere, but I wouldn't say we as a field as a whole are like this. Although, I may have a different view of this coming from npsych.

 

[smalltownpsych]

I generally adopt your approach. I explain to the patient what I see, my rationale for favoring a given diagnosis (or a given conceptualization of the "problem"), and how that guides the treatment plan. I ultimately let the patient decide what seems best fitting to them. It's a second opinion. The other clinician is usually peripheral to this discussion (unless, of course, the other clinician was doing something flagrantly unethical).

You went to a nicer graduate program than I did because we would get ripped over an impressionistic diagnosis!

I mainly work with physicians who have almost no mental health training and are usually pretty happy to accept my assessments. But in my setting I see a lot of second opinions about medical issues, and while my physician colleagues might argue amongst themselves about a diagnosis, they are fairly diplomatic (to the patient) when referring to the work of physicians outside our center.

I wish that I had gone to one that would rip people a bit more. I remember one time when a student was taking a client out to coffee for two hour sessions because they felt like the therapy room was too formal and confining and after the instructor equivocated about ethics and boundaries and said nothing. I became so frustrated that I finally stated sarcastically cause that's how I express my anger, "To me, that's not therapy that's a date." I remember supervisions with students from other programs at a practicum site that would say ridiculous things and the supervisor would be nice and I felt like leaping out of my chair but was afraid that I would be called out for being too confrontational or something. probably the whole southern California thing. I have more of an east coast attitude, too bad I never lived there!

 

[Therapist4Chnge]

I think this is highly variable. My training model throughout stages has always been having to explain the rationale behind your decision making and getting called out for sloppiness. Granted, I chose certain places (postdoc) exactly for this type of atmosphere, but I wouldn't say we as a field as a whole are like this. Although, I may have a different view of this coming from npsych.

Same. Being sloppy w. a differential was probably the most common way to get reamed. Frankly, that is the way it should be because being wishy-washy is generally a waste of time. We need to trust in our data and be confident (when appropriate) in our rationale and dx.

Physicians refer to us because they need an expert to give their 2 cents, they don't need us to go, "Well…it could be this…or maybe it could be that…" If you don't know between two dx, fine…but say that and have a good reason. If the reason for your hesitancy is that it is in conflict w. a prior dx…well…suck it up and either back it up or concede you don't know. They don't expect us to be right 100% of the time, but providing a wishy-washy/non-committal pile of junk doesn't help anyone.

 

[smalltownpsych]

I think this is highly variable. My training model throughout stages has always been having to explain the rationale behind your decision making and getting called out for sloppiness. Granted, I chose certain places (postdoc) exactly for this type of atmosphere, but I wouldn't say we as a field as a whole are like this. Although, I may have a different view of this coming from npsych.

Same. Being sloppy w. a differential was probably the most common way to get reamed. Frankly, that is the way it should be because being wishy-washy is generally a waste of time. We need to trust in our data and be confident (when appropriate) in our rationale and dx.

Physicians refer to us because they need an expert to give their 2 cents, they don't need us to go, "Well…it could be this…or maybe it could be that…" If you don't know between two dx, fine…but say that and have a good reason. If the reason for your hesitancy is that it is in conflict w. a prior dx…well…suck it up and either back it up or concede you don't know. They don't expect us to be right 100% of the time, but providing a wishy-washy/non-committal pile of junk doesn't help anyone.

It might be a different in neuropsych since coming up with a diagnosis is the referral question. I have never felt conflicted about putting my diagnosis in an assessment. In fact, if I know there is potential for conflict, then I just document it all the more carefully. It is definitely a lot more challenging when the patient is seeing two of us for ongoing and evolving mental health treatment and one says one thing and the other says another.

 

[473912]

I think that this is one area where our training is weak. The MDs that I work with do this all day long. They start calling each other out on sloppy thinking from day one. When I was in the doctoral program, that seemed to be discouraged and it was more of a.... I don't even know how to describe it other than touchy, feely, don't say anything to hurt someones feelings. Of course, we had one professor who called it like he saw it and felt that we needed to be stronger. Made a few students cry. When I was young, I had truck drivers working for me and I knew how to talk to them when they were wrong!

I hear that a lot about my future program. Apparently, there's a emphasis put on not hurting your classmate's feelings. I don't get that at all.

 

[Pragma]

Same. Being sloppy w. a differential was probably the most common way to get reamed. Frankly, that is the way it should be because being wishy-washy is generally a waste of time. We need to trust in our data and be confident (when appropriate) in our rationale and dx.

Physicians refer to us because they need an expert to give their 2 cents, they don't need us to go, "Well…it could be this…or maybe it could be that…" If you don't know between two dx, fine…but say that and have a good reason. If the reason for your hesitancy is that it is in conflict w. a prior dx…well…suck it up and either back it up or concede you don't know. They don't expect us to be right 100% of the time, but providing a wishy-washy/non-committal pile of junk doesn't help anyone.

I'd say the appropriateness of being "wishy washy" depends on the context, referral question, and patient. Let's say we do an inpatient eval in an acute medical setting with an unstable patient. Maybe we answer the primary question, but the referring doc is also curious if there is an underlying LD. I've got no problem saying maybe and then suggesting an outpatient eval following stabilization.

Not saying you said this, but we also have to be careful not to make diagnostic claims when the clinical context limits the information enough to make them questionable at best. Educating the referring doc about why is more important there, IMO.

 

[AcronymAllergy]

I'd say the appropriateness of being "wishy washy" depends on the context, referral question, and patient. Let's say we do an inpatient eval in an acute medical setting with an unstable patient. Maybe we answer the primary question, but the referring doc is also curious if there is an underlying LD. I've got no problem saying maybe and then suggesting an outpatient eval following stabilization.

Not saying you said this, but we also have to be careful not to make diagnostic claims when the clinical context limits the information enough to make them questionable at best. Educating the referring doc about why is more important there, IMO.

Agreed. In psychology, we typically come from a background (i.e., academia and research) where "it depends" is often the most appropriate answer. Unfortunately, that doesn't translate very well to clinical settings. However, I think that's something which can also work to our advantage, as (like you've mentioned) it keeps us from overstepping our evidentiary bounds and overstating the certainty of our decisions, which isn't always a characteristic often found in other disciplines with which we closely work.

We just need to get better at A) being willing to commit to a statement when it's warranted, B) standing our ground on said commitment if challenged, and C) condensing our output.

 

[hamstergang]

In short, prescribers will often diagnose something that is treatable with medications and then insist that the patient needs to take this medication. A great example is Bipolar verses Borderline and that one is actually somewhat understandable because they both are characterized by emotional lability. Another is ADHD verse anxiety.

This seems like an odd way to view the situation to me. There isn't much that I know of that you can't find evidence for prescribing something, so I don't see why one would choose one diagnosis over another for the purpose of justifying writing a prescription. Certainly your examples don't explain your case very well as all those diagnoses could justify the use of medications (even for Borderline PD there are practice guidelines that provide a flow chart of medications that are recommended if it is determined that medications are worth a try). I think, as mentioned, that laziness or poor training are more likely culprits.

The way I would deal with it would be to explain that this isn't a perfect science where we can just look at a lab value or head scan and given a definitive diagnosis (ignoring that even that isn't so definitive...). We can each only make a diagnosis based on what information we have, and based on the information I have, I feel this diagnosis is more fitting. I can't speak as to why the other provider felt differently, but given X, Y, and Z, I feel that this diagnosis better explains what you are experiencing.

This allows you to explain to the patient the diagnosis you are making without necessarily calling the other diagnosis wrong. I think it helps to build a therapeutic relationship without screwing the other guy. It also gives you an out in case the patient doesn't agree with you or new information later comes out proving you wrong. I've done things like this when inheriting patients that were started on medications I don't agree with and it's seemed to go alright.

 

[smalltownpsych]

This seems like an odd way to view the situation to me. There isn't much that I know of that you can't find evidence for prescribing something, so I don't see why one would choose one diagnosis over another for the purpose of justifying writing a prescription. Certainly your examples don't explain your case very well as all those diagnoses could justify the use of medications (even for Borderline PD there are practice guidelines that provide a flow chart of medications that are recommended if it is determined that medications are worth a try). I think, as mentioned, that laziness or poor training are more likely culprits.

The way I would deal with it would be to explain that this isn't a perfect science where we can just look at a lab value or head scan and given a definitive diagnosis (ignoring that even that isn't so definitive...). We can each only make a diagnosis based on what information we have, and based on the information I have, I feel this diagnosis is more fitting. I can't speak as to why the other provider felt differently, but given X, Y, and Z, I feel that this diagnosis better explains what you are experiencing.

This allows you to explain to the patient the diagnosis you are making without necessarily calling the other diagnosis wrong. I think it helps to build a therapeutic relationship without screwing the other guy. It also gives you an out in case the patient doesn't agree with you or new information later comes out proving you wrong. I've done things like this when inheriting patients that were started on medications I don't agree with and it's seemed to go alright.

Your post helped me to think about this dynamic more and I see that how I frame it probably gets in the way of my communications to the other professionals. I think I tend to get frustrated because medications are overemphasized as the solution by so many people. It is actually worse with the lesser trained in our profession IMO. Patient with schizophrenia is angry because case manager tells him he can't do something, response is to send patient back to psychiatrist to get "meds adjusted". That sort of thing.