Shulkin Out as VA Secretary

[Fan_of_Meehl]

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I predict that the VA will talk about improving healthcare and especially mental health for the vets while cutting programs, decreasing clinicians compensation. and increasing hiring of midlevels then adding more layers of bureaucracy and executive compensation. Or maybe I’m just a cynic.

1) you *are* a cynic (and that's one of the reasons I admire you)
2) you are also 100% correct

There are two completely separate types of employees at VA (and the gulf between them is increasing over time):
a) the professional 'talker' (and Powerpoint creator) class - i.e., not the providers
b) the professional 'do-ers' (the providers who see veterans and provide clinical services)

The professional 'talker'/politician class will continue to engage in their 'rituals' (e.g., fostering events/pageants to 'raise awareness' about veteran suicide [seriously...at this point...just who in the hell working at VA is UNAWARE of the problem of veteran suicide?]).

The professional 'do-ers' will continue to raise hell about the fact that, while we've collectively pledged to 'end veteran suicide ['no more suicides'], we still have to devote a great deal of our time to help veterans desperate to refill their antidepressant medications navigate an unnecessarily complex system and do case management, begging other staff and providers to do their jobs and help refill the damn meds.

From now on, every time anyone mentions the 'zero suicide' initiative, I will point out that a reasonable pre-requisite to an outcome of 'zero suicide' would be a 'zero lapsed (not refilled) antidepressant medication initiative.'

 

[psych.meout]

Okay. This is funny--I don't care who you are 🙂

Why, thank you.

 

[cara susanna]

1) you *are* a cynic (and that's one of the reasons I admire you)
2) you are also 100% correct

There are two completely separate types of employees at VA (and the gulf between them is increasing over time):
a) the professional 'talker' (and Powerpoint creator) class - i.e., not the providers
b) the professional 'do-ers' (the providers who see veterans and provide clinical services)

The professional 'talker'/politician class will continue to engage in their 'rituals' (e.g., fostering events/pageants to 'raise awareness' about veteran suicide [seriously...at this point...just who in the hell working at VA is UNAWARE of the problem of veteran suicide?]).

The professional 'do-ers' will continue to raise hell about the fact that, while we've collectively pledged to 'end veteran suicide ['no more suicides'], we still have to devote a great deal of our time to help veterans desperate to refill their antidepressant medications navigate an unnecessarily complex system and do case management, begging other staff and providers to do their jobs and help refill the damn meds.

From now on, every time anyone mentions the 'zero suicide' initiative, I will point out that a reasonable pre-requisite to an outcome of 'zero suicide' would be a 'zero lapsed (not refilled) antidepressant medication initiative.'

I'd also like them to know that improving "access" doesn't really matter if 1. we can't provide quality services because we're too focused on access and 2. people won't engage in treatment or follow our recommendations.

Also that suicide is a problem that has plagued mankind throughout the years and no number of administrative measures will probably ever completely eliminate it, but that's another conversation...

 

[futureapppsy2]

1) you *are* a cynic (and that's one of the reasons I admire you)
2) you are also 100% correct

There are two completely separate types of employees at VA (and the gulf between them is increasing over time):
a) the professional 'talker' (and Powerpoint creator) class - i.e., not the providerstghar
b) the professional 'do-ers' (the providers who see veterans and provide clinical services)

The professional 'talker'/politician class will continue to engage in their 'rituals' (e.g., fostering events/pageants to 'raise awareness' about veteran suicide [seriously...at this point...just who in the hell working at VA is UNAWARE of the problem of veteran suicide?]).

The professional 'do-ers' will continue to raise hell about the fact that, while we've collectively pledged to 'end veteran suicide ['no more suicides'], we still have to devote a great deal of our time to help veterans desperate to refill their antidepressant medications navigate an unnecessarily complex system and do case management, begging other staff and providers to do their jobs and help refill the damn meds.

From now on, every time anyone mentions the 'zero suicide' initiative, I will point out that a reasonable pre-requisite to an outcome of 'zero suicide' would be a 'zero lapsed (not refilled) antidepressant medication initiative.'

I agree that zero suicide measures are unrealistic and are never going to be achieved and that a lot of suicide "awareness" campaigns are kind of, well, dumb (especially the ones that just consist of people posting the suicide hotline number--or, as I call them, "suicidal people don't know how to use Google" campaigns). That said, a *lot* of providers don't know anything about basic suicide risk assessment, suicide gatekeeping, or crisis intervention. Suicidality, particularly suicide gatekeeping, is one of my core research areas, and I once went to a suicide gatekeeping training, presented by a psychologist, where the information he gave was so wrong as to be dangerous (things like telling people NOT to query suicide directly, saying that they should just tell suicidal people to be happy because there's so much beauty in the world, etc). It was so alarming that I actually offered to give another, evidence-based training to same group, free of charge.

 

[MAClinician]

That said, a *lot* of providers don't know anything about basic suicide risk assessment, suicide gatekeeping, or crisis intervention. Suicidality, particularly suicide gatekeeping, is one of my core research areas, and I once went to a suicide gatekeeping training, presented by a psychologist, where the information he gave was so wrong as to be dangerous (things like telling people NOT to query suicide directly, saying that they should just tell suicidal people to be happy because there's so much beauty in the world, etc). It was so alarming that I actually offered to give another, evidence-based training to same group, free of charge.

 

[Fan_of_Meehl]

I agree that zero suicide measures are unrealistic and are never going to be achieved and that a lot of suicide "awareness" campaigns are kind of, well, dumb (especially the ones that just consist of people posting the suicide hotline number--or, as I call them, "suicidal people don't know how to use Google" campaigns). That said, a *lot* of providers don't know anything about basic suicide risk assessment, suicide gatekeeping, or crisis intervention. Suicidality, particularly suicide gatekeeping, is one of my core research areas, and I once went to a suicide gatekeeping training, presented by a psychologist, where the information he gave was so wrong as to be dangerous (things like telling people NOT to query suicide directly, saying that they should just tell suicidal people to be happy because there's so much beauty in the world, etc). It was so alarming that I actually offered to give another, evidence-based training to same group, free of charge.

I think that a high-quality (implemented and supervised by actual competent clinical supervisors) rollout training ensuring basic competencies in the area of suicide prevention would make a lot of sense and be quite valuable for VA clinicians. But, yeah...I can do without the 'walks (around the quad)' to end suicide, the banners, the multiple-e-mails-per-day, and the other empty 'rituals' and sloganeering.

 

[Temperance]

I once went to a suicide gatekeeping training, presented by a psychologist, where the information he gave was so wrong as to be dangerous (things like telling people NOT to query suicide directly, saying that they should just tell suicidal people to be happy because there's so much beauty in the world, etc). It was so alarming that I actually offered to give another, evidence-based training to same group, free of charge.

This is horrifying. How did that even become a gatekeeper training? Asking about suicide directly should be 101-level stuff by now!

 

[Fan_of_Meehl]

This is horrifying. How did that even become a gatekeeper training? Asking about suicide directly should be 101-level stuff by now!

Yup. And there's a lot of crap the VA mandates (as if it's dogma) that doesn't necessarily comport with the most recent literature (or, I would argue, clinical common sense), like focusing on repeatedly addressing a fixed, long list of mostly structural variables in separate 'outpatient suicide risk assessment' note templates and categorizations of 'low,' 'moderate,' and 'high' levels of risk (but, of course, what level one assigns is not standardized in any way).

 

[Therapist4Chnge]

I once went to a suicide gatekeeping training, presented by a psychologist, where the information he gave was so wrong as to be dangerous (things like telling people NOT to query suicide directly, saying that they should just tell suicidal people to be happy because there's so much beauty in the world, etc). It was so alarming that I actually offered to give another, evidence-based training to same group, free of charge.

Did they take you up on your offer?

 

[cara susanna]

Yup. And there's a lot of crap the VA mandates (as if it's dogma) that doesn't necessarily comport with the most recent literature (or, I would argue, clinical common sense), like focusing on repeatedly addressing a fixed, long list of mostly structural variables in separate 'outpatient suicide risk assessment' note templates and categorizations of 'low,' 'moderate,' and 'high' levels of risk (but, of course, what level one assigns is not standardized in any way).

And let's not forget reinforcing suicidal behavior. I've seen a lot of situations where patients threaten suicide to get what they want (like housing).

I also think that the VA needs to differentiate between chronic and imminent risk better. The Denver MIRECC has a lot of articles about it but I don't see it translating into clinical practice.

 

[Fan_of_Meehl]

And let's not forget reinforcing suicidal behavior. I've seen a lot of situations where patients threaten suicide to get what they want (like housing).

I also think that the VA needs to differentiate between chronic and imminent risk better. The Denver MIRECC has a lot of articles about it but I don't see it translating into clinical practice.

Sadly, I don't think that the VA, as an organization, is capable of developing beyond the sophistication of a 'checklist' + 'enforcement of medical model' level of thinking with regard to managing suicidal or homicidal risk. The clinicians--at the ground level--who have to deal with the messiness, appreciation of context, and chaos that characterizes daily practice have had very little success interfacing with the 'higher' levels of the organization where policy is made. I heard a recent anecdote about how doctors in Venezuelan hospitals are now prohibited by law (it's illegal) to list 'starvation' as the cause of death of a child in a hospital. It reminded me of VA leadership. For a brief time, a prior VA secretary (McDonald) was suggesting that we move from a policy/procedure (rule) based organization to a principle-based organization, which I thought was a good idea, but essentially went nowhere. The responsible and sophisticated application of principles to chaotic situations (in context) requires intelligence and flexible (if constrained within limits) thinking. And often--as a mentor of mine once remarked--intelligence is knowing what NOT to pay attention to. The VA leadership appears ideologically committed to the nonsensical notion that 'more' is always 'better' and if we just had 'another checklist' or 'more items' on the checklist that we already have or--even worse--more 'oversight' by committees filled with non-degreed non-clinicians, then we'd achieve clinical success and victory. The same concrete (vs. conceptual) thinking that would (and should) have gotten you kicked out of graduate programs in professional psychology is, unfortunately, the selection criteria for 'advancing' in the system. Until this 'process' variable within the organization (which, admittedly, may not exist at every VA) is addressed, we'll keep getting ever-longer checklists of items and multiple forms/policies/procedures that will be set forth as the 'solution' to the 'problem of suicide.'

 

[Sanman]

Don't get me started on the suicidal ideation and VA practices. It makes me want to bang my head against a wall. Someone reported a patient I inherited to the suicide prevention coordinator and their chart was flagged. So, the suicide prevention team called a bed bound veteran with ALS (who can't answer the phone) daily to address his SI. The VA at its best.

 

[Sanman]

I agree that zero suicide measures are unrealistic and are never going to be achieved and that a lot of suicide "awareness" campaigns are kind of, well, dumb (especially the ones that just consist of people posting the suicide hotline number--or, as I call them, "suicidal people don't know how to use Google" campaigns). That said, a *lot* of providers don't know anything about basic suicide risk assessment, suicide gatekeeping, or crisis intervention. Suicidality, particularly suicide gatekeeping, is one of my core research areas, and I once went to a suicide gatekeeping training, presented by a psychologist, where the information he gave was so wrong as to be dangerous (things like telling people NOT to query suicide directly, saying that they should just tell suicidal people to be happy because there's so much beauty in the world, etc). It was so alarming that I actually offered to give another, evidence-based training to same group, free of charge.

I know this method, does it go something like this:

1. Don't query SI directly
2. Document patient has no SI
3. Cover ass and never learn proper suicide risk assessment as you will never have a patient with SI.

 

[Fan_of_Meehl]

I know this method, does it go something like this:

1. Don't query SI directly
2. Document patient has no SI
3. Cover ass and never learn proper suicide risk assessment as you will never have a patient with SI.

They seem to take this approach on our inpatient unit. Apparently, in a southern US state (where an overwhelming majority of veterans have access to firearms), NO ONE who is on the inpatient unit ever owns or has access to firearms (outside the hospital). Or, at least that's what it says on their formal 'suicide risk assessment' progress notes.