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The Practice of Clinical Neuropsychology: Viability, Utility, Future Directions?

Discussion in 'Psychology [Psy.D. / Ph.D.]' started by erg923, Mar 19, 2011.

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  1. erg923

    erg923 Psychologist 10+ Year Member

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    There is a raging debate on the national npsych listserve (this happens every few years there) regarding the state and future viability of the profession. Although you really need to read the posts to understand all the issues and the true scope of its seriousness, the crux of the argument is that there is not enough research showing the medical value of what we do in order for our services to continue, in their current form, for much longer.

    The vast majority of the opinion seems to be that this is our own fault due to the fact that we have remained factionalized (eg., the "my board is better than your board" nonsense), have not lobbied nationally, have not produced many studies that demonstrate the cost-effectiveness of our services (although this may be because they dont exist or that effect sizes are too small to convince insurance companies), have not been able to restrict the practice of npsych by other providers, by and large have NOT embraced computerized technology in our assessment methods, have NOT been able to fight off the computer assessment programs that are marketed to neurologists and other MDs (eg., neurotrax, Mindsteam), continue to give 6-8 hour paper-pencil batteries that are ripe for scoring errors, take a month to get back the refferal source, and produce 10 page reports full of process-oriented musings that MDs and neurologists find obtuse and not very user-friendly. Whew that was alot!:D

    Embedded in all this is how this has significantly impacted the financial bottom line of many practitioners (one stating that her group practice now makes 2/3 of their revenue from therapy and psychopharm rather than npsych....3 years ago it was just the opposite). In fact, this is nothing new. The npsych list serve is always full of posts regarding how to bill for this or that, how to get a at least an 80% reimbursement from this or that insurance company, how this case and that case had to be written-off due to billing complications or flat out denial of the claim. In other words, insurance companies dont value us and dont like us! If these people don't think we have a necessary and valuable service to offer, we are going to disappear! At the moment, the only people I see who truly value npysch is US (psychologists and other neuropsychologists)...and a some (certainly not all) of our physician referral sources. Thats nice and all, but our referral sources aren't the ones making the reimbursement policies/decisions.

    I jumped ship on pursuing neuropsychology as a full-time career specialty a couple years ago due to this "writing on the wall" and the changing nature/attitude of healthcare, healthcare reimbursement, and the perceived blindness with which most practitioners approached these market issues. I don't think its all doom and gloom necessarily, but the issues ARE there and my npsych supervisors seemed blind to the fact that neuropsychology will be probably HAVE to change dramatically over the next 10-20 years. Instead, they practiced that way they were taught, 8 hour batteries, gave full WAISs to elderly demented patients, wrote insanely long reports that no one ever read, and seemed like they could care less if the information was actually utilized or impacted patient care/tx planning for the better (although I did have one practicum where npsych was embedded in a larger team and did indeed contribute to medical tx recommendations that were implemented). I found most of my neuropsych practicum experience to be an exercise in futile-ism.... and occasionally, intellectual masturbation about block-design placements. I'll let you in on a little secret, no one cares but you...and maybe some other neuropsychologist down the hall. The principle players in all this (docs, insurance companies) DO NOT. :)

    After all the set up, I suppose my actual question is for those younger grad students who are so eagerly going into the practice of professional neuropsychology. Are you aware of these issues? Do faculty or supervisors talk with you about these issues? Are you aware of how replaceable and undervalued your services are in many settings? Are you aware that unless you work in a VA or large academic hospital, the nature of your evals, services, and your billing expectations are going to have to change from what you were probably taught in your program and on your practicums? Are you aware that their is frightening little empirical research to even justify the cost-benefit ratio of your services?

    For everyone, what do you think the solution is? Massive lobbying? A massive research effort to demonstrate the utility of our services (is that even possible? Will our services even pass the cost-benefit test used in modern healthcare?)? A unification of the boards so we can advocate better/stronger? Restricting the practice of neuropsychology? Increasing the numbers of practicing of neuropsychologists (more numbers equals more power...look at the AMA)?

    My personal view is that the perfect storm has been brewing for years and that its a declining field. Well, at least a decline from the way we currently know, understand, and practice it in grad school. Am I wrong?
     
    Last edited: Mar 19, 2011
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  3. Jon Snow

    Jon Snow Senior Member 10+ Year Member

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    A few things:

    The value of what neuropsychologists do is not really the question. We've developed testing techniques and concepts that the medical community and others value. This is also true of clinical psychology in general with respect to assessment and treatment techniques. Further, we've (psychologists) substantially contributed to the understanding of how the brain works, interface with behavior across a huge range of topics. The issue is our **** is being stolen by multiple fields (psychiatry, neurology, speech pathology, among others) and we don't have the advocacy to defend our expertise. Incremental value is an interesting concept. So, what is out incremental value? What is any field's incremental value? Can we, as one individual posted on that listserv, automate neurologists? Certainly, everything we deal with (we, being the medical world, and others) is information. Is it enough to replace us with a computer generated report? Having watched this and how that data is used by physicains, I'd say no, they don't get it right. But, does it matter? If our reports are not understood, or are understood at the level that some of these physician interpretations suggest, the nuance of our formulations don't matter much. I don't know where this is going to go. The current use of the computer testing thing in some physician workspaces is just an easy money grab (mindstreams trains office staff to administer the computer testing, and physicians bill medicare for it).
     
  4. erg923

    erg923 Psychologist 10+ Year Member

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    I don't think anyone really debates that point, but I think that is a higher level issue.

    What I was primarily speaking to, and what others were speaking to, is does the modal neuropsychological evaluation of the dementia patient, suspected MCI patient, or the typical "name that tune" patient, have incremental value? That is, is the money an insurance company invests in that evaluation worth it? Does it really reap benefits for the patient? Does it improve future care? Does it decrease future costs of caring for that patient in any substantial way? Thats the question the healthcare system is asking, and I'm not sure we have a very equivocal answer for them in most cases. And until we do, I fear third-party payers will continue to cut reimbursement, make preapprovals for npsych evals more difficult obtain, and start favoring and encouraging a much more streamlined evaluation-similar to those offered by these computerized testing systems. What will practitioners (not academics) do then?

    PS: What do you think of Bilder's suggestion that in order to survive, neuropsych assessment methods must move aways from the traditional paper-pencil, hand scoring model and into a more computerized assessment model.... as well as embracing and utilizing web assessment?
    I know many practitioners have been pretty disappointed with our profession's attempt at "test development" thus far. WAIS-IV and WMS-IV for example. Definitely not much new or innovative there...with the exception of a poorly made and horribly unuser-friendly spatial additions board.
     
    Last edited: Mar 19, 2011
  5. cognosco

    cognosco

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    A few comments...
    I could not disagree more with your perspective. First of all, giving a full WAIS to a dementia patient is not a function of neuropsych; it's a function of ignorance. No one with half a brain would attempt it UNLESS cog impairment was not severe and diff diagnosis was required (eg dementia vs depression).
    Second the reason we don't embrace computerized assessment is bc for the most part, it's terribly unreliable for all but the most textbook of patients. Take the Conners CPT-II for example.
    Finally I disagree that the field will have to undergo a "fundamental" shift over the next 10-15 years. We provide a service that is unique and valuable (ie assessment). Neurologists can't do it. Master level practitioners can't either. Computer programs may one day provide more assistance in this process, but it's not likely to ever replace us due to the complex requirements of our field. My mom is a chemist and deals with relatively static variables that we know the exact mathematical properties of. A computer hasn't replaced her. The idea is simply ridiculous.
    Concerning the list serve you mentioned, I would venture to guess that you have collected a skewed sample and that the majority of us aren't dissatisfied, going broke, or spending hrs trying to determine how to bill for services. Just my 2 cents...forgive the spelling errors as this is from my iPhone.
     
  6. Jon Snow

    Jon Snow Senior Member 10+ Year Member

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    Hey, I'm right there with you, except other groups DO believe they can do what they need to do with regards to what we provide. . . without us. Neurologists and general care practitioners CAN and DO setup a computer, train a nurse or office assistant to administer a test, add the generated report to their eval, bill for it, and then don't refer to neuropsychology.
     
    Last edited: Mar 20, 2011
  7. Jon Snow

    Jon Snow Senior Member 10+ Year Member

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    This isn't a problem related only to neuropsychology though. It's a problem that spans many areas. And, it's one without a simple solution. Take primary care docs, as an example. How do they determine when to refer out? It's their discretion whether to refer to a medical specialist. Who prescribes the highest percentage of psychoactive medications? It's not psychiatrists. So, what's the incremental validity of psychiatry? I mean, what they have provided in terms of knowledge is important, but we can prescribe psychoactive meds without them. We can assess mental illness without them. Same with primary care. Do we need primary care physicians? Nope. We can use nurses. This is, in my opinion, all about the general trend of lowering the quality of healthcare by putting it into the hands of those least educated. The mechanism is similar. You have groups of people who don't know what they don't know who assume simplicity where it doesn't exist. "Oh, I can do that. What's the big deal?"
     
  8. O Gurl

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    I heard some about this from my npsych supervisor last rotation. He is an ABCN certified provider in neurology. His practice was different from the typical, rigid one you described above. None of our batteries were longer than 4 hours (typically including interview) and reports were about 4-5 pages max. He was also sensible enough to use effort testing (VA setting) and computerized options (at least for WMT, Wisconsin Card Sorting, Stroop) appropriately and was not afraid of abbreviated batteries when the person was severely demented (DRS and such). He was also included in treatment planning and interventions like WADA evals and pre- and post-tests following lumbar punctures for NPH patients. Outside of that, my experiences with neuropsych have been in rehab settings, where the neuropsychologist was also part of the team (polytrauma inpatient, SCI, blind rehab). I have avoided those who engage in the old-fart approach and can see how it is in jeopardy. Perhaps the key for npsych is, like you hinted above and I have witnessed in my training, in making sure it is embedded within larger contexts where the services are user-friendly, referrer-friendly, applied, and valued.
     
  9. erg923

    erg923 Psychologist 10+ Year Member

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    I am gonna have to repeat my overarching concern, because you guys seem to be dismissing it without providing me any citations. What articles to we have that address the following?

    "That is, is the money an insurance company invests in that evaluation worth it? Does it really reap benefits for the patient? Does it improve future care? Does it decrease future costs of caring for that patient in any substantial way? Thats the question the healthcare system is asking, and I'm not sure we have a very equivocal answer for them in most cases." Don't you think we should have answers to these questions to justify our assessments...and people paying us for them?
     
    Last edited: Mar 20, 2011
  10. Zigman

    Zigman Neuropsych Fellow 2+ Year Member

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    I subscribe to the npsych listserv as well, and these debates have certainly concerned me as I pursue the focused internship-postdoc-ABCN route. I understand the issues of encroachment by different disciplines using computerized (and poorly constructed ones at that) screeners, etc. And I've heard locally as to the problems with reimbursement in private practice.

    However, it seems that the concern is primarily coming from these private practitioners. Is this correct?

    This, I think, is why NP isn't in grave danger....at least in these settings. This may be an expression of my naivete here, but I can't see VAs doing away with NPs any time soon. I can't see rehab units, epilepsy services, or many other highly specialized institutional settings doing away with NPs. Am I wrong here? It seems that if we can make our services as functionally relevant as possible and the findings easily digestible, we are going to be fine....at least in institutional settings, for a while to come.

    My practica thus far has given me experience in 4 institutional settings in which NP services were all highly valued, generally integrated into a broader treatment context, and seemingly not in danger of extinction.

    As I look towards internship this summer, my training is going to involve quite a bit of inpatient CL neuro work (diff dx, capacity/independence determinations), as well as outpatient evals from highly varied referral sources in which reports never exceed 4 pages. This seems to me to be appropriate to how NPs must adapt. How does this sound? Am I just convincing myself that there will still be a market for someone with this background in the near future?

    Lastly, throughout all the concerns voiced on the listservs, I see virtually no mention of the viability of NPs in independent forensic evals. I see this niche as continually expanding and not replaceable, as we live in the most litigious society in the world. What do others think?
     
  11. erg923

    erg923 Psychologist 10+ Year Member

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    I think this demonstrates some wishful thinking. Others CAN do what we do (not very well, but it happens...alot). In fact, 96118 can be billed by ANY MD. There is nothing illegal about it. And they do it. And don't be so naive to think that neurotrax isnt stealing some of your sports team consultation refferals aways either. Are they replacing us? NO. But they are indeed skewing peoples perception of a what a thorough npsych eval is...and they are certainly faster and cheaper. The latter is important for both the docs and insurance companies remember.

    If we don't change some things, they are going to be taking more and more referrals away with time. I agree with the notion that some of the blindness and denial has been due to the fact that too many of our leadership positions have historically been filled by folks from academia who don't deal with insurance companies...or who work in academic hospitals where they might deal with insurance but they have an endless flow of patients who are referred by inhouse MD's.

    BTW, I think the the paradigm shift for neuropsychology is not all a bad thing. And alot of people see evidence that is coming. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3044645/
     
    Last edited: Mar 20, 2011
  12. erg923

    erg923 Psychologist 10+ Year Member

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    Just for the record, I did find my neuropsych work interesting and educational..just not all that rewarding. And, I think I was exaggerating some.

    I wouldn't call my experience to "old-school" or "old-fart" by any means. It was the typical hypothesis testing/flexible battery approach that was run like the typical C/L service that neuropsychology has been for years. My supervisor was ABPN-CN. Her batteries were definitely on the long side though. NOT 8 hours, but patients were often seen for 2 testing sessions of 3 to 3 and half hours. It wasn't terribly interdisciplinary (except for out inpatient psych consultations), but it certainly wasn't an unusual model in neuropsych. Referral came from the doc, we contacted patient...patient is scheduled by the clinic. Patient was evaluated and 2 or 3 weeks later we faxed the doc the report and offered the patient a feedback session. Some choose to take us up...some didn't. If it was a more urgent case such as medical decision making or competence issues (eg., DPA, etc.) then we called the doc immediately after the eval to give out impressions and suggestions

    I had another that was much more of a npsych team embedded in a treatment team, but I didn't particularly enjoy that either. It was alot of meetings, which I cant stand, and I always felt like my supervisor was too easily bullied, influenced, or biased by other members of the team and their belief about the patient and the patients' problems. Not sure if I am much a "team player" in those situations...:laugh:
     
    Last edited: Mar 20, 2011
  13. loveoforganic

    loveoforganic -Account Deactivated- 2+ Year Member

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    This might deviate a little from the main idea of the thread, but w/e, no need to respond if you don't like ;)

    There seems to be a political push (both through action and inaction) to make care cheaper by allowing lesser trained practitioners to increase their scope. It is, in my opinion, completely illogical, regardless of what camp you're in, to allow the lesser trained practitioners to bill equivalently for services rendered, but to my knowledge, this is the case for many (most?) things. It makes sense to me to allow the lesser trained scope increases as a screening tool (at reduced reimbursement) to guide referral to the better trained, getting the best mix of high quality care/affordable care.

    So, to what degree could that computerized NPsy eval be made to be used as a screening tool for those "who don't know what they don't know"? Could algorithms be formulated that would allow a reasonably accurate rate of "flag for referral" vs "easily interpretable report"? Same deal in medicine (although I don't expect you to be able to answer this one, just giving the example to show I'm coming from both sides). Could nurse practitioners training be altered so that there is a strong emphasis on "referral needed in x, y, z cases"? So PCP's would be missing out on seeing most strep throats, but would see the strep throat in the 80 y/o on 20 meds. etc. etc. etc.

    Obviously I'm in the position of not knowing crap in either case, so I can't judge the viability of either.
     
  14. erg923

    erg923 Psychologist 10+ Year Member

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    FYI, this is from Mindstream. Its clear what their goal is here. Its not even subtle! The "Favorable Reimbursement" issue stood out to me. To me, this is the crux of this whole matter..OUR ECONOMIC VIABILITY IN A WORLD WERE INSURANCE COMPANIES (WHO REIMBURSE THE VAST MAJORITY OF EVALS FOR US) AIM FOR THE MOST ECONOMICALLY VIABLE MODEL..NOT THE ONE WITH BEST TRAINED AND MOST BOARD CERTIFIED. Similar to what happened to psychotherapy during the 90s. Why should npsych be any different for them?
    ________________________________________________________________________________________________________________________
    Why Its Better
    · Proven Science
    MindStreams® research has been clinically validated by 168 total publications of which 112 are unique, and 38 of those are full length peer-reviewed research articles involving a total of over 3,500 patients to date. No other computerized diagnostic tool has as much clinical scientific substantiation.

    · Normative Scoring (for age and education)
    MindStreams® utilizes a proprietary research quality data base of over 1,500 healthy individuals (ages 9-95) to generate results for your clinical and research needs.

    · Precision
    MindStreams® provides accuracy far superior to paper-based tests. This added precision allows you to detect even very mild cognitive impairment, enabling early intervention.

    · Easily Track Patients
    MindStreams® offers high test-retest reliability and is easy to re-administer, making it ideal for tracking longitudinal changes in your patientsâ•˙ disease management over time.

    · Medical Technician-Administrable (no medical doctor required)
    MindStreams® can be easily administered by a technician on your staff (MindStreams® will train this person). As a medical professional you will perform the interpretation and report and write your impression.

    · Favorable Reimbursement
    Neuropsycholgical testing codes are well established and cover test supervisor face-to-face testing, interpretation and reporting. Your time interpreting and your technicianâ•˙s time testing are both covered.

    · Practicality
    We designed MindStreams® to work in the ╲real╡ world and ensure that accurate data are gathered. For example, our systems automatically determine whether a patient has the ╲mouse╡ accuracy, visual acuity and color recognition to perform some or all of the tests, and adjusts the testing method accordingly. Additionally, Mindstreams® will detect effort and alert the medical professional if poor effort is suspected.
     
    Last edited: Mar 20, 2011
  15. loveoforganic

    loveoforganic -Account Deactivated- 2+ Year Member

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    I guess you're trying to get me to figure out where the push to create such a program would come from. I honestly don't know. There may be a policy solution, but I don't know enough about law, insurance, and such. I do think it's a fair assumption that the vast majority of health professionals have their patients' best interest in mind. Showing neurologists that they may be providing substandard care for their patients in some situations by using that software, the market for that software could decrease. Since there's financial benefit for them in using it as well though... Might have to have a reasonable alternative on hand to actually get them to stop using it or make use of it appropriately. As for how to actually go about that, your guess is manifold better than mine.
     
  16. edieb

    edieb Senior Member 10+ Year Member

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  17. Zigman

    Zigman Neuropsych Fellow 2+ Year Member

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    So this is really confusing.....

    I hear this talk of "psychology/neuropsychology is dead...and no one cares about fellowship/boarding except for you." Yet, I see a new VA Neuropsychologist position opening every other week. And, when searching more generally online, I see dozens of recently posted Neuropsychologist positions. Moreover, virtually every single one of these positions requires formal fellowship training and the vast majority want you boarded or board-eligible.

    So what gives?
     
  18. erg923

    erg923 Psychologist 10+ Year Member

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    Certainly, in some settings, npsych is not utilized and/or not valued. In other settings, it is. My VA experience was very different from edieb's, in that, psychologists were very prominent, plentiful, and highly respected. Although, I still dont know that our suggestions were really implemented with much frequency. Further, in my experience, tx rarely varied/changed, no matter what our differential diagnosis was. We did offer wonderfully valuable cog rehab services (to the right patients) though.

    Anyway, no, I don't think anyone has said we (npsych) are dead, but I do think that outside of the protective bubble of the VA and academic medicine, our services are not valued by our pay masters. As healthcare changes, npsych is going to have to change with it. Extinct? No. Different from the way its been practiced for the past 30 years, yes, definitely so. See my post above as to why this is. I think its the crux of the matter outside VA settings.
     
    Last edited: Mar 20, 2011
  19. edieb

    edieb Senior Member 10+ Year Member

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    Read for the main points: 1) I said that when the government is the PRIMARY employer of a profession (as opposed to the private sector), that is a poor prognostic sign

    2) I said a fellowship may help you land a job compared to someone without the same post-doc. However, it will likely not get you more money
     
  20. O Gurl

    O Gurl

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    I do not know the literature, as I am more health/rehab focused. But from my perspective, which again is limited to interdisciplinary teams and that one neurology experience, I can see how valuable the work is in treatment planning and thus, cost effectiveness. Take, for instance, an SCI rehab inpatient who is having difficulty meeting goals in PT, OT, or KT due to things like forgetting appointments, motivation, difficulty remembering steps from prior sessions, etc. A neuropsych evaluation can identify any cognitive issues and provide feedback on how to present information to the patient in a more useful way, such as using calendars, electronic organizers, or developing mnemonics. Helping a patient get the most out of their initial rehab prevents problems at home and returns to the unit for preventable issues like skin, bladder, or bowel infections.

    Again, I get why the traditional, stand-alone consultation approach may be in jeopardy. I do not necessarily see that as a bad thing. If we (psychologists) are billing for services, they should have practical implications. Whether rehab, forensic, sports medicine, medical/pediatrics, school, whatever, neuropsychologists should be training with a niche in mind that will value their services.
     
  21. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus 10+ Year Member

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    I agree....but in practice it can be a harder sell. For instance, speech language pathologists (2yr degree) often claim that they do "cognitive assessment". Their national association actively promotes this idea, which hasn't been met by much opposition. In reality they give limited screeners, but it clouds the water between SLP and nueropsych. It baffles the mind that this isn't shot down in about 2 seconds, but many physicians don't know/care about the difference when the majority of in-patient billing comes from OT/PT/other. NP seems to have been pushed mostly to out-pt, at least that is the view on the RP listserv.
     
  22. ThirdLittleBird

    ThirdLittleBird

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    Can you elaborate on this? And, btw, this thread is depressing as someone interested in neuropsych and just starting out (actually, haven't even technically started yet).
     
  23. Jon Snow

    Jon Snow Senior Member 10+ Year Member

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    Eh, I'm not sure what to think, honestly. I'm happy with my job at the moment. It's fun, I do lots off of very interesting things, I'm well respected, I work hard, and the money is decent. I don't know what the future holds and the constantly in flux health field can be daunting. It often seems like there is a fire to put out or doom on the horizon. Problem is I don't know whether that is something that is fatal. Meaning, will there all of the sudden be a time where I can't get a job and/or my income completely stalls or precipitously drops? Can't say. To combat this, my thought is to continue to develop and evolve skills as I go along. I've worked in many different settings; most have been quite good. I've been working in academia/VA pretty much the entire time, though I've spent a bit of time in a private practice (as a student). I have many friends that are in various types of private practices (pure assessment, a mix of assessment and treatment, forensic-criminal, forensic-civil). I see, on a research front, that neuropsychology/neuroscience is quite valued at present. So, while I see all of these pressures on the field and I've talked about them here, it still seems to be mostly an intellectual discussion (meaning, I'm not seeing a real world effect).
     
  24. O Gurl

    O Gurl

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    Outrageous and really sad to me, b/c so many of the Veterans I have seen need far more than a MMSE/MOCA. I could have sworn psychologists had some governing body to advocate for us.... they hold an annual conference each fall... starts with an A.... :rolleyes:

    But for now, I have to hold out hope that competent specialists in our field, particularly those who seek boarding for their areas, will continue to seek and secure the positions that allow us to PROVE our worth to our colleagues and patients.
     
  25. erg923

    erg923 Psychologist 10+ Year Member

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    What edieb meant was when you are valued/prized in a setting in which there is no need to make profit and can, in-fact, operate on a losing bottom line (ie., the VA healthcare system) but you are not in others...thats a big statement regarding the economic justifiability of your profession. Meaning, as I and others have stated, there is really not an overwhelming body of data that shows the utility of clinical neuropsychological evaluation, in most cases (thats doesn't mean it doesn't exist, but DOES mean we have done a poor job delineating it). There are some pieces of hard data here and there, but its not much frankly. Insurance companies know this. We, for whatever reason, seem to not want to face this fact.
     
    Last edited: Mar 20, 2011
  26. edieb

    edieb Senior Member 10+ Year Member

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    I don't think the economic viability of neuropsychology is the only losing battle we have: The whole profession of clinical psychology is no longer viable.
     
  27. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus 10+ Year Member

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    I'm not sure there is data out there about decreasing future costs, though that probably has more to do with study design than lack of efficacy. Many NP assessments are done to confirm what is already thought to be the issue, though I think where the $ is saved is on cases that "float" through the system and only weeks/months/years later result in a diagnosis. Unfortunately many have learned/been told that NP is a luxury, so many patients go without it.



    VAs are definitely still in need of NP services because of the wars (and related head traumas that are far too common), though that doesn't mean there are a plethora of spots to go around. There are spots now, but competition is getting more and more competitive, and the hiring process at a VA can be ridiculously slow.

    I think that can be a good niche, though there are far too many neuropsychologists and rehabilitation psychologists for this to be anything but a minor area of practice. I have done this type of work in both VA and academic medicine settings, and I think it is a good niche. It's worth noting that rehabilitation psychology and neuropsychology are competing for many of the same positions.



    Agreed. We need to develop more niche areas like this to stay employed. There is some pressure from neurology/psychiatry to encroach on "expert opinion", but I think in most states NP should be fine.




    There is definitely a focus on board-eligible/boarded recruiting (which I favor). The positions at top VAs and major metropolitan areas are still highly competitive. I feel pretty comfortable in my training that I won't hurt for a position, but that doesn't mean everyone in the field will be fine. I'm far from special, but there is something to be said for jumping through all of these hoops and then fighting for positions at mediocre places.

    I'm also in a place that values NP-related services, though billing is still an issue. There is a noticeable shift to have most NP done on an out-patient basis. There is far less money (for a hospital) in conducting NP assessment on an in-patient basis, and that is what really matters to a hospital. We still do in-patient NP assessment, but most are very brief assessments (1-2hr assessments). I'm not averse to brief assessments, but they make billing a much bigger issue because the $ has to be made up by volume.

    As for the MMSE/MOCA/Cognistat/RBANS/etc…I'm right there with you. I had the flexibility in the VA system to put together a real NP battery, though it is much hard to do when you are dealing with private insurance in the public setting. Then there are other practitioners (MA/MS-level) who are encroaching on the assessment side of things, which further causes problems.
    The APA has disappointed us again. I think Div 40 and Div 22 have tried to influence hospital policy and perception, but it is an uphill battle with insurance companies. In the VA system I didn't see as much of a focus on boarding, but it definitely is topical in academic medicine. There is a push within our dept. to have all clinical psych staff boarded. It is already the requirement for our physician colleagues, and while I think it is the right thing to do, it's a hard sell for those 20-30+ years out who are some of the best in the field. Moving forward boarding needs to be more of a focus.
     
  28. Jon Snow

    Jon Snow Senior Member 10+ Year Member

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    Dx is complicated. Many patients float around with incorrect diagnoses ad infinitum. Psychology/neuropsychology has a valuable role to play in that regard. But, even with cases where there is some idea that the person has Alzheimer's, or whatever, I think neuropsychology is valuable. We can document functional status. Or, with someone that has a memory complaint, we can establish a baseline. That way, it's not guesswork when the problem accelerates, people can be prepared, and accommodations/treatments can be implemented. It's not just about interpreting tests, in my neuropsych evals I spend a lot of time interviewing the patient, sometimes as much as an 1.5 hours. This is psychology; we are making interpretive decisions on a very large subset of data.
     
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  29. Jon Snow

    Jon Snow Senior Member 10+ Year Member

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    I like the RBANS. I like to use that first in a eval, often.
     
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  30. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus 10+ Year Member

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    "Establish a baseline" is my mantra. :laugh: It can be a hard sell sometimes, so an RBANS seems to be the easiest compromise that can be done in a brief amount of time. It is the most common thing I use for brief in-patient experience (along with parts of the DKEFS, sometimes an aphasia screener, etc). Depending on the Dx, I also like to dig into executive functioning stuff, as that can often be overlooked in day to day interactions because of pre-existing/learned compensatory strategies.

    Interviewing patients is one area I wish I had more time to do on an out-patient basis. On an in-patient unit I've found a lot more flexibility in gathering information, evaluating variance in presentation day to day, etc.
     
  31. IT514

    IT514 Neuropsychologist 7+ Year Member

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    Speaking as a naive 3rd year, my experience has been pretty good overall in terms of having supervisors who are not naive to the rest of the world. I've had npsych placements in private practice, academic VA (1st or 2nd largest in terms of patient volume), and specialty neurology clinic. I've never written more than a 6 page report, and my VA reports were often less than that. At the neurology clinic they have very savvy business people dealing with insurance changes, and my advisor hasnt seen a change in his salary because of that (he also seems to know his stuff when it comes to billing).

    Last year at the clinic, the neuropsychologists saw more patients than ever and are considering adding more staff. They get pretty much all of the forensic referrals in the practice, which I'm sure helps. They also lead a lot of the research done in the stroke, dementia, MS, and autism centers within the clinic. Also, a brand new neuroscience center just popped up in a hospital near my hometown with 2 neuropsychologists on staff and an APA internship. So, while it is a little unnerving to read those list-servs, I feel ok about my future for now.
     
    Last edited: Mar 22, 2011
  32. Psychology 76

    Psychology 76 2+ Year Member

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    I started a very similar thread a couple years ago
    http://forums.studentdoctor.net/showthread.php?t=680860

    and it seems many of the depressing points about the future of clinical neuropsychology are still (or even more) valid.

    i bailed on the whole clinical idea and will be attending an experimental psychology phd program next fall focusing on neuroimaging research. :)
     
  33. edieb

    edieb Senior Member 10+ Year Member

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    What you need to take into account:

    1 - Reimbursement for testing is decreasing rapidly. In fact, compared to other health services, I believe testing saw the most drastic reduction in reimbursement with the last round of insurance cuts.

    2 - The professional schools are steering more and more of their student into neuropsych

    3 - Decreased reimbursement + master's level encroachment + more psychologists = bad news

    I am sure you can still make a living but it will be much harder than in previous years
     
  34. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus 10+ Year Member

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    As a field it is in trouble, but on an individual level I think people can do well if they:

    1. Come from at least a mediocre university.
    2. APA internship, preferably with some kind of neuro experience.
    3. Secure a 2 yr fellowship.*
    4. Get ABPP boarded.

    *A 2 year ABCN fellowship at an academic medical center is ideal. There are also some solid spots at academically affiliated VAs. There are a handful of rehab fellowships with strong neuro components, though it can be a bit more of an uphill climb for ABBP-cn boarding. Div 40 and Div 22 don't see eye to eye on everything, but the training tends to be solid across both areas.

    Money was definitely easier 10-20+ years ago, or so I've been told. There are still quality opportunities, but they are getting more and more competitive. I'd caution anyone from going into neuropsych if you need to take an alternative route than above.
     
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  35. erg923

    erg923 Psychologist 10+ Year Member

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    Edieb is right on. Those are facts. Its doesn't mean (as I've tried to reiterate from the beginning) its all doom and gloom, but some responders here are way behind the issues, IMHO. Yes, non-forensic, C/L neuropsychology practices outside large VAs will be changing due to reimbursment issues. Many, many are in agreement here. I suggest reading Bilder's work on the issues...neuropsychoogy 3.0.

    For those that maintain that we have developed great innovations and techniques for assessing brain-behavior relationships that our referrals sources value--Yes, of course, there is truth in that. However, bottom line is that there is nothing illegal about a physician (of any kind) billing 96118...and they do it. Trust me. Moreover, many docs often find relatively brief evals and quick turnaround time methods (e.g., computer systems) to be preferential. Some neurologists would especially prefer this when the nearest npsych provider is 50 miles away and has a 3 month waiting list, right? Or, do you think there is a neuropsycholgist working in Plainville, Kansas? This is particuarly relevant when many of us continue the old practice of 6-8 hour batteries, 3 weeks turnaround times, 10 page reports etc. Not a very viable business model, IMHO (yes, you are running a business here people).

    I also hear people saying things like "yes, but it sounds like this will only affect PP npsych practitioners." Um...got news for ya folks, if your services arent valued in the real world (ie., healthcare settings outside academics and VA government systems), something is amiss. It should tell you something. It tells me the service isn't valued because it lacks outcome studies that show its effectiveness in terms of increasing quality of care/treatment and/or being cost effective. I find it interesting that no one has actually posted, or even suggested, an article that plainly concludes (by examing data) all the things people always tout as the benfits of npsych evaluation. That is, that proper npsych diagnosis changes treatment/informs treatment, increases qualify of life, prolongs functionality, and decreases medical costs. Dont get me wrong, I too think some of those could indeed be true (I've see some of them happen), but I don't know where any of those statements are backed up by hard data so that I can show them to UH when I request a preauthorization. Can someone tell me where that data is?

    Ignoring these issues because you have well trained office staff who handle preauthorizations, or because you work in a setting that doesn't have to deal with 3rd-party payers doesn't mean your services or necessarily more valueable there. You're still practicing the same profession as the PP guy. You just happen not to be under direct threat to pony-up with some evidence of the utility/incremental validity of your services.

    Similarly, there were some comments about how this isnt an issue in forensic npsych. Well, no its not, but again, read the above to see why the larger issue is still very much relevant to you. Moreover, keep in mind that many people can't get into forensic npsych without establishing themselves or at least starting out in non-forensic practice. Moreover, forensic npsych is very niched and I doubt that vast, vast majority of people in grad school specifically have forensic npysch as a career goal. It's a small market and one that not alot of people desire to do anyway.
     
    Last edited: Mar 22, 2011
  36. erg923

    erg923 Psychologist 10+ Year Member

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    There is one more thing I would like to clarify that I feel people keep misinterpreting and/or avoiding. Not sure which it is.

    "Outcomes data" is a completely different animal from "how well does this procedure clarify the diagnosis?" An expensive procedure may well help clarify a muddy diagnostic picture but have minimal impact on either the patient's clinical outcome or the cost of managing the patient.

    Simply put, we don't have these data. We have data that we can clarify diagnostic thinking and we even have some data that our results can predict some clinically important phenomena (e.g., disruptive behavior on nursing home units, legal competencies). But these are not "outcomes data."
     
    Last edited: Mar 22, 2011
  37. Zigman

    Zigman Neuropsych Fellow 2+ Year Member

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    Could you expand upon this? Why is an AMC ideal?
     
  38. Jon Snow

    Jon Snow Senior Member 10+ Year Member

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    We have lots of outcomes data; it just depends on how you look at it. Remember, neuropsychology/psychology are involved in many assessment and treatment roles. For example, colleges often use us in learning disability/ADHD/MH evaluations for struggling students. Or, take cases, which some of you might throw into the forensic domain, like lead exposure and impact on cognition (children), or inorganic lead exposure and impact on cognition, or electrical injury, or parsing FTD from bipoloar disorder, etc. . . Diagnostic clarity is a form of outcomes data. Now, you might argue that in many cases the Dx doesn't matter much (e.g., various rare dementia cases in which we currently have no treatments and the patient is obviously unable to care for themselves). But, it often does (e.g., identifying delerium in an inpatient unit, or a motor neglect in a rehab unit, like the first case I Dx'ed on my internship [we have treatments to fix this]). The question is too broad in many ways. And, as I said, our expertise is valued; in some cases companies are capitalizing on that (e.g., mindstreams), in others, entire fields are capitalizing on that (speech pathology). This is not a matter of outcomes data (though more of that that is specifically about us would be nice); this is a matter of our expertise not being protected. The level of evaluation and execution and action would be similar to if I decided to setup shop right now doing psychiatric med checks or neurology evals. This almost purely a failure in our ability to protect our intellectual property and the public.

    Yes, our medicare reimbursement rates went down by a bunch. But, it was only a couple of years ago that we got a professional billing code and the rates had jumped a huge amount at that point. I see reasons for pessimism (movement towards paraprofessionals [masters level providers], poor regulation within field [weekend warriors], blatant misuse of our tests and ideas [mindstreams instead of neuroevals], and professional schools saturating the market with inferior product. But, I also see reasons for optimism (we are at the forefront of neuroscience research, clinically, professionals increasingly recognize the need to assess mental illness/emotion and cognition, neurorehab is increasingly more sophisticated; the application of neuropsychology/psychology is across the lifespan). I don't know where the cookie will crumble. As I've said previously, as a student, it's probably a safer bet to go the medical school route. But, I don't think it's all doom and gloom in psychology-land. We have some significant hurdles to jump, but with some good leadership, lobbying, research, and hard work I think we have a good shot.
     
    Last edited: Mar 22, 2011
  39. erg923

    erg923 Psychologist 10+ Year Member

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    Alright Snow, so here is comes. Which one do you pick?
    1. Unify the boards to make one big stance and advocacy organization?
    2. Continue with the 2 boards and continue to bicker and compete amongst ourselves (not too mention confuse the public and other professionals)?
    3. Boarding is irrelevant to the matters we have discussed in this thread.
     
    Last edited: Mar 22, 2011
  40. Jon Snow

    Jon Snow Senior Member 10+ Year Member

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    To be honest, I really don't know. Intuitively to me, it seems that a stronger advocating body could have a positive impact in selling our value. How to get there though. . .
     
  41. AcronymAllergy

    AcronymAllergy Neuropsychologist SDN Moderator 7+ Year Member

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    For anyone interested who's not on the listserve, it would seem AACN has been soliciting (and has recently accepted) grant proposals for neuropsychological outcome studies. Looks like the Charleston Consortium (specifically the VA med center) won the first grant from them and will be evaluating whether neuropsych services lower patients' "medical resource utilization." I recognize a few of the names attached to the study, so I'm hoping it'll be a good one: http://aacnf.org/
     
  42. erg923

    erg923 Psychologist 10+ Year Member

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  43. CogDoc

    CogDoc

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    A few comments from a practical clinician:
    - We all agree that a full 8 hour neuropsych evaluation can add clinical insight, but it is a rare luxury for most physicians (not too many available in most areas, long waiting for the appointment, high expense, long delay to get the report).
    - Computerized testing in the office can provide an important set of data to help support or refute the working diagnosis in the time frame that most physicians need.
    - I have been using Mindstreams for several years and have found it to provide excellent value. The company has done its homework and is very responsible. It supports the scientific validity with a wealth of data and publications, and it provides training as to how to interpret the results to answer specific clinical questions. Neurotrax does not claim to give the diagnosis on the computer printout, but rather urges consultation with a cognitive expert.
    - Mindstreams has been misunderstood on these lists and is wrongly considered a threat to neuropsychology. While some computerized cognitive testing companies claim that that their computer printout provides the answer, Neurotrax says that the Mindstreams report requires specific training and lets the qualified medical professional arrive at the clinical diagnosis.
    - I will continue to use Mindstreams, and believe that this represents the future direction of cognitive evaluation. Neuropsychologist should learn how to integrate Mindstreams to extend their practice and to take the leadership role in cognitive diagnostics.
     
  44. edieb

    edieb Senior Member 10+ Year Member

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    Your post contradicts itself: You say you use mindstream and that it, in essence, is more efficient that neuropsychological testing and also very reliable then you say it is not a threat.

    I don't blame you for wanting to use the most efficient and reliable means for testing but let's be forthright: of course it is a threat to neuropsychology because cognitive evaluations are usually a big part of a battery
     
  45. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus 10+ Year Member

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  46. Jon Snow

    Jon Snow Senior Member 10+ Year Member

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    To me, this sounds like the same weekend warrior nonsense that went on with the Halstead-Reitan for so many years. Mindstreams trains you in how to interpret the results? Really? If I bought a computer program that talked me through a physical and told me how to interpret various blood-based metrics and suggested Dx and medications, would that be okay? That's complete crap. Having worked with real live neurologists and psychiatrists, their knowledge of cognitive/behavioral testing issues is very limited, including when to refer, what questions to ask (in an eval), and how to ask the questions. That's not a knock on them, they spend very little time training on these issues. Mindstreams gives you an illusion of competence that's just not valid. To me, that you are doing this, and that's generally considered acceptable, shows just how much short shrift people give to behavior/cognition as a legitimate thing to think about.

    What we need is more physician education on what questions to ask, how to ask them, and when to refer. Any patient with brain related illness should be referred for a neuropsych at some point in the process.

    I agree with you on the turnover rate. It's my policy to complete reports within a week of seeing a patient and we coordinate with physicians with respect to follow-up appointments. If the follow-up is the next day, we either finish the report by the next day or we call the physician and give an abbreviated feedback of our results. That's what you want.

    IF you haven't done a behavioral neurology fellowship, as a physician, you are simply not trained to even think about these issues in any way. And, even then, you aren't a neuropsychologist, and haven't been trained in psychometrics, the range of available tests, and various constructs of cognition. You still NEED to refer out to be an ethical practitioner. This is a question of not knowing what you don't know (the same charge physicians level at nurses and their ever expanding scopes of practice and psychologists who want to do extra training to prescribe). I'll give an example.

    An otherwise very good neurologist, brilliant really, presented a grand rounds. The patient was a physician. Had developed some issues including optic neuritis, among other things. It quickly became clear that the patient had MS. Physician said, and I kid you not, "The patient is obviously well spoken and intelligent, there is no need to assess cognition." I'm sorry, what?? Not only not referred to a neuropsychologist, but not even assessed at all. Patient is a physician. Shouldn't we know his functional status before he goes back to work? If he has MS, a disease we know has recurring and often progressively severe course, shouldn't we get a baseline, so that we know what's going on down the road? In fact, shouldn't he be assessed yearly to make sure everything is okay given what he does? Hell, even the idea that the patient was okay because he was intelligent and spoke well. . . wow. That's what I'm talking about right there.
     
    Last edited: Jul 27, 2011
  47. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus 10+ Year Member

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    ...but...but, the Mindstream propaganda..uhm documentation says that if I buy the program it will give me what I need to know without bothering with real training or mentoring in neuropsychology! I'm so confused. :(

    Unethical does not begin to describe what they are trying to sell to professionals in other disciplines who don't understand a fraction of what they need to know to practice neuropsychology.
     
  48. IT514

    IT514 Neuropsychologist 7+ Year Member

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    Wow, cogdoc, you are clearly trying to sell this thing.

    Theres no way that a test with an age range from 9-95 with a sample of 1,500 can be meaningful for all populations. Seems like an over-marketed screener when we already have 10 of those that are actually quicker to give and more targeted. The competition with mindstreams is the RBANS and the dementia rating scale, and we dont really care about dementia in a 9 year old. We do care about things like autism, dyslexia, and kids 2 yrs s/p ALL with academic problems, which mindstreams doesnt cover at all.

    I'm all for quick screeners when appropriate, but if thats all you rely on, your patients will come back with the same problems over and over again. I'll bet you your MindStreams salary on it.

    Plus, a handful of the citations on your website are repeated over and over again...looks like the company is trying to inflate their resume. Real trustworthy.

    Sorry for the snarky tone, but you just dont help people make life decisions based on a handful of items that may or may not target their problem. Peoples lives and well being are at stake. Oh, and theres roughly 10 domains that the test doesnt cover...alll of which have pretty big implications for being able to function well in life.
     
    Last edited: Jul 27, 2011
  49. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus 10+ Year Member

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    I was looking for something else and stumbled across this thread again. Given the Obamacare talk and need for "justification" for $$ in the future...I thought it timely to bump this thread.

    Absolutely. I wonder if the AACN, Div 40, etc...would be willing to put together a PP presentation or similar that can summarize this information (or maybe they have done it already?). I'm not sure how many NPs are involved in medical education, but I think it could help.

    Yes...but when all you have is a hammer, everything is a nail. As a profession we need to be more involved in medical student and resident training so that we can help the next generation of physicians better understand how neuropsych can help inform Tx and Dx. Even more importantly, we need to provide them with sound science-based information that supports why referrals to us makes sense (monetarily and in regard to providing the best care to patients). EBM (evidence-based medicine) is being pounded into their heads now in school and on the floors of the hospital. We need to be able to translate the data we have so it gets added to their flow charts about when/why/how to make appropriate referrals when X, Y, Z symptoms pop up.
     
    Last edited: Jul 27, 2012
  50. Member6523

    Member6523 2+ Year Member

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    I see all this as challenges we must overcome.

    1. We need to unify. The list serves are ridiculous. Endless squabbling and armchair waving. We are the most pessimistic bunch of arseholes I've ever met. Us young folk need to reach out to the other boards. Not sure if and when we can merge, but the first step is open dialogue. Our new officers need to do this.
    2. We need to unify because we need a single voice. Other associations have it. We need lobbyists to protect our interests. We need APA to listen to us. To me, the fact that we're divided into three boards weakens us considerably. But having no boards will scatter us completely. The boards can protect us, but only when they have resolved their issues with each other.
    3. Our research CAN translate to practice. Neuroscience can be merged with neuropsychology. Our operational definitions of constructs may vary some, but they can generalize. We need to continue solidifying our ties to the neuroscience behind brain-behavior relationships.
    4. We need to educate to other practictioners on what we do. We need to overtly demonstrate our value to medical professionals. If we had a stronger voice, they'd take us more seriously. We could be involved with educating residents and fellows so that when they make a referral, they will know why.
    5. On that note, we need to educate ourselves on what we do. This ties in back with unity. We do provide value, but some people insist on overreaching, while others remain vague through esoteric and self-indulgent reports that pontificate irrelevant minutiae. Hopefully these reports will be forced out the door by the nature of rapid insurance driven turnover.

    I am actually optimistic. We all know there's a problem. It's not so severe we can't improve our field. The younger generations seem more willing to work together and get past their egos. As we transition to full professionals, I hope we maintain this and not turn into the older crowd who seem so stuck in their ways.
     
  51. AcronymAllergy

    AcronymAllergy Neuropsychologist SDN Moderator 7+ Year Member

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    This is just my opinion, but I wouldn't at all be surprised if the younger generation of neuropsychologists and neuropsychologists-in-training is much more successful with respect to unifying the various board accreditation bodies. Some of the biggest sticking points in the past were what information to include on exams, how much prior training and work (and what type of training) should be required and sufficient, who gets grandfathered in, etc. The newer generation doesn't have these same concerns, particularly with respect to grandfathering (i.e., no bruised egos). We've come up when neuropsychology has been at least somewhat more standardized in terms of training and, to some extent, knowledge. Board certification has been around essentially as long as we have (neuropsych-wise), and it's something many of us have come to accept as a reality needed to move the field forward.

    That's not to say it's universally-accepted by the newer neuropsychologists, of course, nor are the current boards and systems without their problems. But like you, I'm hopeful that some of the key differences could be resolved in the coming years.
     

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