Settle a disagreement

[psychma]

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I have a colleague/friend who works for a hospital system. She has a client with cluster b traits that is fairly stable. Her problem has been that you can’t add traits to the problem list. So she added bpd to the problem list since traits weren’t available. Honestly, I had a problem with it. The client fired her and has filed a complaint she will lose. So was my colleague right to add bpd when it was just traits or was I right to say not to add a stigmatizing diagnosis that was not accurate??

 

[Freud’sMommy]

What motivated your friend to add the dx? What's the tx advantage of having that on the pt's record?

 

[summerbabe]

Since there were likely more accurate diagnoses such as unspecified personality disorder, unspecified mood/affective disorder or a Z code, your colleague is probably in the wrong.

It also sounds like there was a lack of transparency. I work for the VA and I write all my notes as if people will read them so I don’t want anybody to find a surprise if they ever do.

 

[PsyDr]

Get outta here with “stigmatizing diagnosis”. Either the patient had the diagnosis or they don’t. How anyone feels about a diagnosis is immaterial. We tell people the truth. That’s not hurting them. An oncologist doesn’t withhold a cancer diagnosis because the patient might get upset by the information.

*spelling

 

[psych.meout]

Get outta here with “stigmatizing diagnosis”. Either the patient had the diagnosis or they don’t. How anyone feels about a diagnosis is immaterial. We tell people the truth. That’s not hurting them. An oncologist doesn’t without a cancer diagnosis because the patient might get upset by the information.

Yes, and isn't the stigma reinforced when providers are hesitant or avoidant of diagnosing these disorders when patients meet criteria?

I.e., if you won't diagnose a disorder when it presents itself, aren't you effectively saying that this is something that we shouldn't talk about, acknowledge, record in a medical record, etc. and thereby increase the taboo and stigma?

 

[Sanman]

At the end of the day, if you are not going to stand behind a diagnosis, don't diagnose it. If you are seeing cluster B traits, state that in your documentation. If you actually think the the patient has BPD and can back it up, diagnose it. The only question I have here is what does the clinician believe?

 

[BuckeyeLove]

Our hospital system just switch to EPIC and people have been having concerns about this kind of stuff (they can see pretty much everything with ease on their my chart, vs having to go through an arm and a leg with our old system to get the records). I’m with others. The diagnosis is the diagnosis. Sounds like the client likely is BPD. Your colleague has nothing to worry about. This kind of complaint would be unsubstantiated and open and shut real quick.

 

[AcronymAllergy]

Our hospital system just switch to EPIC and people have been having concerns about this kind of stuff (they can see pretty much everything with ease on their my chart, vs having to go through an arm and a leg with our old system to get the records). I’m with others. The diagnosis is the diagnosis. Sounds like the client likely is BPD. Your colleague has nothing to worry about. This kind of complaint would be unsubstantiated and open and shut real quick.

I remember concerns coming out about this when legislation was enacted (can't remember which, but it was maybe ~5 years ago?) requiring that patients be given access to their EMR. This is one thing that VA was ahead of the game on, as summerbabe said--patients in the VA system have been readily able to access notes for well over a decade. I agree that you generally shouldn't have anything in a chart note that you wouldn't be comfortable discussing with the patient and/or that would surprise them. Process notes, if you have them, are a different story. If the diagnosis is supported and relevant, include it. If it's not, but there are patient characteristics that you think are relevant to therapy and/or for other providers to know, you could include it in the body of the note. If it's inconsequential to what you're doing, it probably shouldn't be in there.

 

[smalltownpsych]

When BPD traits is code for difficult patient, which is how many clinicians use it, then that is a problem. I really don’t understand why so many persist in this thinking. I find annoying and obnoxious patients in every diagnostic category and pleasant and motivated patients in every category. Whether someone is being a jerk or being nice is not a mental health question and except for antisocial PD doesn’t really have much diagnostic relevance.

 

[PsyDr]

Yes, and isn't the stigma reinforced when providers are hesitant or avoidant of diagnosing these disorders when patients meet criteria?

I.e., if you won't diagnose a disorder when it presents itself, aren't you effectively saying that this is something that we shouldn't talk about, acknowledge, record in a medical record, etc. and thereby increase the taboo and stigma?

The majority of our job is asking questions no one wants to ask and making statements that no one wants to say. I don't understand why a psychologist would be hesitant to ask or say ANYTHING. We are paid to have very difficult conversations.

But I think the sentiment you are identifying is the field's move from therapeutic confrontation, to collusion with the patient. There are some areas in which psychology has not moved towards collusion (e.g., cognitive assessment). But psychotherapy sure seems to have transitioned from helping people overcome their struggles, to colluding with patients to tell them that their struggles make overcoming things impossible.

 

[R. Matey]

There is an actual difference between traits and a disorder. If traits exist and are not impairing, I don't see a reason to add them as a diagnosis.

 

[R. Matey]

Our hospital system just switch to EPIC and people have been having concerns about this kind of stuff (they can see pretty much everything with ease on their my chart, vs having to go through an arm and a leg with our old system to get the records). I’m with others. The diagnosis is the diagnosis. Sounds like the client likely is BPD. Your colleague has nothing to worry about. This kind of complaint would be unsubstantiated and open and shut real quick.

It's not that bad. I usually just tell patients what I'm putting in their chart.

 

[Sanman]

The majority of our job is asking questions no one wants to ask and making statements that no one wants to say. I don't understand why a psychologist would be hesitant to ask or say ANYTHING. We are paid to have very difficult conversations.

But I think the sentiment you are identifying is the field's move from therapeutic confrontation, to collusion with the patient. There are some areas in which psychology has not moved towards collusion (e.g., cognitive assessment). But psychotherapy sure seems to have transitioned from helping people overcome their struggles, to colluding with patients to tell them that their struggles make overcoming things impossible.

The tough part about psychotherapy is that there is a fine line between providing a healthcare service and giving a patient what they want. In this day and age of patient satisfaction scores and healthcare as a business, it seems to get even tougher.

 

[psych.meout]

The tough part about psychotherapy is that there is a fine line between providing a healthcare service and giving a patient what they want. In this day and age of patient satisfaction scores and healthcare a business, it seems to get even tougher.

For my first practicum, there were a couple of patients who didn't get what they wanted and they posted bad reviews of my supervisor online and lied about what happened in-session to obfuscate why they were upset. It was funny being a newish grad student and being mentioned in your supervisor's only negative reviews available.

Edit: Just checked, the reviews are still posted.

 

[statsprof]

Since there were likely more accurate diagnoses such as unspecified personality disorder, unspecified mood/affective disorder or a Z code, your colleague is probably in the wrong.

It also sounds like there was a lack of transparency. I work for the VA and I write all my notes as if people will read them so I don’t want anybody to find a surprise if they ever do.

Agreed. BPD has its own specific criteria that trails from what psychma described. Either BPD fits or it does not.

 

[statsprof]

For my first practicum, there were a couple of patients who didn't get what they wanted and they posted bad reviews of my supervisor online and lied about what happened in-session to obfuscate why they were upset. It was funny being a newish grad student and being mentioned in your supervisor's only negative reviews available.

Edit: Just checked, the reviews are still posted.

That must have been a bit of a shock to say the least.

 

[psychma]

So obviously, a dx of bpd is a dx of bpd. She believes this client to have traits but listed it on EPIC as cluster b personality disorder as there was no way to add traits but in her individual notes. Personally, I feel she was wrong. I wouldn’t do it. The other mistake she made was not telling her client who discovered it and was confused. I don’t think you change the diagnosis that you’ve discussed with your client without talking to them. But it’s not my client.

 

[statsprof]

So obviously, a dx of bpd is a dx of bpd. She believes this client to have traits but listed it on EPIC as cluster b personality disorder as there was no way to add traits but in her individual notes. Personally, I feel she was wrong. I wouldn’t do it. The other mistake she made was not telling her client who discovered it and was confused. I don’t think you change the diagnosis that you’ve discussed with your client without talking to them. But it’s not my client.

Right, not your client; true it was wrong.

 

[AcronymAllergy]

So obviously, a dx of bpd is a dx of bpd. She believes this client to have traits but listed it on EPIC as cluster b personality disorder as there was no way to add traits but in her individual notes. Personally, I feel she was wrong. I wouldn’t do it. The other mistake she made was not telling her client who discovered it and was confused. I don’t think you change the diagnosis that you’ve discussed with your client without talking to them. But it’s not my client.

I dislike adding diagnoses to a problem list that aren't diagnoses; that said, it happens all the time (you should see the size of some of the problem lists at VA). Doesn't make it good care, but your colleague isn't alone in doing it. In my opinion, the notes are the more important part, but the issue with adding it to the problem list is now other providers will see it (many outside MH) and lack all context for it.

I still don't really see what's gained by adding the diagnosis to the problem list, though. If the traits/characteristics are of enough interest to the provider seeing the patient, they'll read the chart, see your colleague's notes, and have an idea of what's going on.

 

[WisNeuro]

I dislike adding diagnoses to a problem list that aren't diagnoses; that said, it happens all the time (you should see the size of some of the problem lists at VA). Doesn't make it good care, but your colleague isn't alone in doing it. In my opinion, the notes are the more important part, but the issue with adding it to the problem list is now other providers will see it (many outside MH) and lack all context for it.

I still don't really see what's gained by adding the diagnosis to the problem list, though. If the traits/characteristics are of enough interest to the provider seeing the patient, they'll read the chart, see your colleague's notes, and have an idea of what's going on.

And then some MDs who don't know how research works use that problem list to publish a bunch of junk science in JAMA...

 

[statsprof]

And then some MDs who don't know how research works use that problem list to publish a bunch of junk science in JAMA...

This ^^

 

[AcronymAllergy]

And then some MDs who don't know how research works use that problem list to publish a bunch of junk science in JAMA...

And certainly not just MDs. The number of horrible VA-based studies from psychologists is also staggering.

I shudder whenever I think of how often I saw dementia, ADHD, or bipolar slapped on a patient's chart because they reported mild forgetfulness, some recent trouble focusing, or problems sleeping.

 

[statsprof]

And certainly not just MDs. The number of horrible VA-based studies from psychologists is also staggering.

I shudder whenever I think of how often I saw dementia, ADHD, or bipolar slapped on a patient's chart because they reported mild forgetfulness, some recent trouble focusing, or problems sleeping.

Yes. I have seen bipolar slapped on as a label without meeting timelines and specific criteria; It is amazing how often clinicians mistake anxiety or slightly fast speech for pressured speech and spend 5 minutes to come the conclusion.

 

[Sanman]

And certainly not just MDs. The number of horrible VA-based studies from psychologists is also staggering.

I shudder whenever I think of how often I saw dementia, ADHD, or bipolar slapped on a patient's chart because they reported mild forgetfulness, some recent trouble focusing, or problems sleeping.

A byproduct of the American obsession with productivity. Why do quality research when I can sort through a dataset and publish some random stats? After all the number of publications on your CV is all that matters, not the quality of the work.

 

[statsprof]

A byproduct of the American obsession with productivity. Why do quality research when I can sort through a dataset and publish some random stats? After all the number of publications on your CV is all that matters, not the quality of the work.

I have seen this way too much across labs. Real shame. This is why I focused more on assessing methods and stats.

 

[cara susanna]

I have seen BPD a lot in charts where it's just a woman with PTSD who is sometimes hard to interact with

 

[AcronymAllergy]

I have seen BPD a lot in charts where it's just a woman with PTSD who is sometimes hard to interact with

Semi-related: I once knew of an NP who would call the VA police and/or add a behavior flag to a chart pretty much anytime a patient raised their voice. In any context, not just at the provider.

 

[clausewitz2]

I have seen BPD a lot in charts where it's just a woman with PTSD who is sometimes hard to interact with

I mean, you can explain an upsettingly large proportion of documented BPD diagnosed by assuming it means 'unsympathetic white woman.'

'Sympathetic white woman,' of course, is MDD

 

[psychma]

I have a client that saw a psychiatrist one time. She was depressed. He took her history, found out she had childhood trauma and told her she had bpd. She never went back, but the diagnosis is in her my chart. She had back surgery and while on the surgical unit, a nurse wrote condescending psych observations in her chart. The client asked why she had done this and the nurse said “you are a psych patient, this is what your notes will always look like. Get used to it.” She did not feel she could say or do anything. So stigma exists and I think we carefully have to think through diagnoses. This client no longer seeks out medical care.

 

[romanticscience]

 

[Manic Lobster]

I have seen BPD a lot in charts where it's just a woman with PTSD who is sometimes hard to interact with

It seems like an opportune time to repost this Borderline personality disorder: a spurious condition unsupported by science that should be abandoned - PMC

 

[futureapppsy2]

Semi-related: I once knew of an NP who would call the VA police and/or add a behavior flag to a chart pretty much anytime a patient raised their voice. In any context, not just at the provider.

I once a masters-level supervisee (thankfully not a position to add diagnoses formally) who said that EVERY patient who disagreed with her at all or didn't respond exactly how she wanted had a PD and was therefore never going to respond to treatment.

 

[romanticscience]

I also have to share this oldie-but-goodie blog post, albeit it's less funny.

 

[smalltownpsych]

It seems like an opportune time to repost this Borderline personality disorder: a spurious condition unsupported by science that should be abandoned - PMC

This article reflects many of my own thoughts and observations. Although I think that the problem is more with misapplication of criteria and adding in illusory concepts of the diagnosis than the category itself necessarily.

I once a masters-level supervisee (thankfully not a position to add diagnoses formally) who said that EVERY patient who disagreed with her at all or didn't respond exactly how she wanted had a PD and was therefore never going to respond to treatment.

I have seen this play out way more often than I would like. Even currently I am contending with new supervisees who are being told by others in their program that any difficulty that they have with patients is because the patient is obviously borderline. Other midlevel clinicians will openly question my judgement and our treatment program to supervisees when I challenge this. I guess standard of care for difficult patients has become get rid of them. Kind of like a version of nimby.

 

[BuckeyeLove]

Even currently I am combating new supervisees who are being told by others in their program that any difficulty that they have with patients is because the patient is obviously borderline.

This would appear to me to be more likely diagnostic of the clinician or supervisee rather than the patient/client.

 

[Freud’sMommy]

I once a masters-level supervisee (thankfully not a position to add diagnoses formally) who said that EVERY patient who disagreed with her at all or didn't respond exactly how she wanted had a PD and was therefore never going to respond to treatment.

We have a PsyD like this at my institution. Somehow nearly all of her patients are antisocial or narcissistic with no likelihood of improvement... They usually improve after transfer of care though. She ought to be fired as she's harmed patients for decades.

 

[Sanman]

We have a PsyD like this at my institution. Somehow nearly all of her patients are antisocial or narcissistic with no likelihood of improvement... They usually improve after transfer of care though. She ought to be fired as she's harmed patients for decades.

Then why bother seeing them? I am always confused by this when I hear about these people. You believe all these folks are unfixable but continue showing up to "fix" them.

 

[smalltownpsych]

Then why bother seeing them? I am always confused by this when I hear about these people. You believe all these folks are unfixable but continue showing up to "fix" them.

Some people like to play the martyr and many people will naively respond to it. “I am so glad that you work so hard for these poor people, you must be such a devoted, patient, and long suffering therapist.”

 

[Sanman]

Some people like to play the martyr and many people will naively respond to it. “I am so glad that you work so hard for these poor people, you must be such a devoted, patient, and long suffering therapist.”

My take: You continue to take money from people that you believe you cannot help. You are a fraud.

 

[smalltownpsych]

My take: You continue to take money from people that you believe you cannot help. You are a fraud.

Agreed. Was just thinking about their potential justification/rationalization and why they continue to work despite sucking at the job. As someone who has hired many therapists and fired quite a few who suck at their job, I have seen some real doozies.

 

[BuckeyeLove]

and fired quite a few who suck at their job,

Just curious, what were some of the reasons which led to making the decision to let them go? I worked for a group practice for a few years after my postdoc and some of the stuff i saw other clinicians do was....astounding.

 

[AcronymAllergy]

Agreed. Was just thinking about their potential justification/rationalization and why they continue to work despite sucking at the job. As someone who has hired many therapists and fired quite a few who suck at their job, I have seen some real doozies.

There's certainly a stereotype that VA providers work at VA because they basically couldn't get a job anywhere else. Probably more so in the past, and maybe more with non-MH providers. With MH (and specifically psychologists), my experience has generally been the opposite, but as with any large institution, it definitely rang true in a few situations.

That said, it is really difficult to get fired from VA. And as much as we complain about the level of oversight, the productivity expectations, etc., they are generally less intense/invasive than many other medical systems.

 

[Sanman]

There's certainly a stereotype that VA providers work at VA because they basically couldn't get a job anywhere else. Probably more so in the past, and maybe more with non-MH providers. With MH (and specifically psychologists), my experience has generally been the opposite, but as with any large institution, it definitely rang true in a few situations.

That said, it is really difficult to get fired from VA. And as much as we complain about the level of oversight, the productivity expectations, etc., they are generally less intense/invasive than many other medical systems.

My experience with some MSAs and office staff is the stereotype is true. Then again, for many jobs in the VA there are no standard qualifications. The reality for MH is that I have not seen a health system that pays better overall.

 

[smalltownpsych]

Just curious, what were some of the reasons which led to making the decision to let them go? I worked for a group practice for a few years after my postdoc and some of the stuff i saw other clinicians do was....astounding.

One we let go because no patients or families liked her. She seemed nice enough but could not establish rapport due to some social awkwardness that was difficult to detect during interviews. Another was arguing with families about diagnosis and if they didn’t agree said that it was racial. Another had relapsed on substances potentially and performance and interactions with patients were becoming increasingly erratic, offered help, but denied needing any and after a few more mistakes let go. Had one who was having an affair with other therapist and then confided in patient about it. Fired immediately. Had another who was telling adolescents with substance problems that marijuana was ok for them to use, wore a dress that showed cleavage, and argued and then yelled at our most experienced (and pretty mellow and helpful) therapist on team after only being with us for a couple of weeks. She didn’t make it a month. The record for shortest stay was the therapist who was obviously struggling with addiction and couldn’t make it through the first day because of the drug screen. It was an interesting day as she tried to water down the urine, lie about the lab, state that she just couldn’t pee and all the while was twitching and smoking like a fiend.

As I look at this, the theme is really that they don’t necessarily get fired for being bad at therapy as much as being bad employees in general which I am sure translates into awful therapist.

 

[psych.meout]

There's certainly a stereotype that VA providers work at VA because they basically couldn't get a job anywhere else. Probably more so in the past, and maybe more with non-MH providers. With MH (and specifically psychologists), my experience has generally been the opposite, but as with any large institution, it definitely rang true in a few situations.

That said, it is really difficult to get fired from VA. And as much as we complain about the level of oversight, the productivity expectations, etc., they are generally less intense/invasive than many other medical systems.

My experience with some MSAs and office staff is the stereotype is true. Then again, for many jobs in the VA there are no standard qualifications. The reality for MH is that I have not seen a health system that pays better overall.

That's my experience as well. Psychologist positions at VAs seem pretty competitive in more geographically desirable areas, especially for grads of unfunded programs hoping to get EDRP, PSLF, or other loan forgiveness. Those VAs have the luxury to be more selective when it comes to hiring psychologists, so the multiple VAs I've trained at seem to have quality psychology staff.

The midlevels seem to have the same problems as any other institution and the office staff are pretty bad. I know someone who was choked by a coworker at the VA and admin just moved the offender to a different department with zero other disciplinary action. The only thing that probably would have changed that outcome is if the victim filed criminal charges, which would have forced their hands.

 

[statsprof]

I've seen MMPI results disappear that a seasoned psychologist administered after 6 months of treatment for baseline that did not align with a diagnosis given in 5 minutes by a social worker in charge, and colleagues yelling at patients for not agreeing with them. Social workers yelling at psychologists and psychiatrists changing medication on a social worker's "orders."

 

[MCParent]

“Why I don’t attend case conferences” seems to have slipped from grad class reading lists.

 

[Therapist4Chnge]

The only thing worse than a lazy diagnostician is a biased one. I do a lot of document review and have seen all sorts of trash Dxs, especially in the workers comp (WC) system. I’ve picked up a bunch of WC referrals bc I’ll review a treatment plan and treatment progress and provide recs…including doing differential diagnosis to correct trash Dxs. I’ll list out the required Dx criteria & how each one has or has not been met. It’s not rocket surgery, but it sure helps curb-stomp the trash Dxs floating out there.

The lack of rigor and lack of knowing the basics in documentation usually jumps off of the page of a review. Bipolar v BPD and adjustment disorder w anxiety v “anxiety” v PTSD are two of the most common. Their incompetence makes my reviews easier, but those providers are commonly failing their patients. They are largely midlevel providers, but still too many psychologists and psychiatrists who should know better.

 

[BuckeyeLove]

The only thing worse than a lazy diagnostician is a biased one. I do a lot of document review and have seen all sorts of trash Dxs, especially in the workers comp (WC) system. I’ve picked up a bunch of WC referrals bc I’ll review a treatment plan and treatment progress and provide recs…including doing differential diagnosis to correct trash Dxs. I’ll list out the required Dx criteria & how each one has or has not been met. It’s not rocket surgery, but it sure helps curb-stomp the trash Dxs floating out there.

The lack of rigor and lack of knowing the basics in documentation usually jumps off of the page of a review. Bipolar v BPD and adjustment disorder w anxiety v “anxiety” v PTSD are two of the most common. Their incompetence makes my reviews easier, but those providers are commonly failing their patients. They are largely midlevel providers, but still too many psychologists and psychiatrists who should know better.

What happens to these providers after this sort of IME review and report?

 

[WisNeuro]

What happens to these providers after this sort of IME review and report?

If it's anything like here, nothing. Most of these people get work purely because they will throw out trash diagnoses, especially in the PI IME world.