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I'd probably try to give a month.
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VA Mental Health Provider Venting / Problem-solving / Peer Support Thread
Started by Fan_of_Meehl
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Need to? None, federal law prohibits federal employees from needing to give notice before leaving. Doesn't mean you won't burn bridges if you leave suddenly.
Ought to? Ideally long enough for your veterans to get scheduled in with other therapists in a timely manner. Depending on staffing and how full people are, that can take longer or shorter. But if your clinic can't do that within 2 months, that's on leadership really.
I'd probably do a month, which will both be too short to reschedule everyone but more than the VA leadership deserves.
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IMO one month would be OK and two months is more than enough for your management to deal with you leaving. , aim-agm is spot on.
PsynofTimes
Full Member
Thanks - I'm leaning toward 4-6 weeks because private practice patients aren't going to wait for me to become available. If I were leaving for another job I'd give more notice. I don't want to make anyone mad but I don't have a big financial cushion to hold me over while clientele builds.
Sanman
O.G.
Do you have the clientele booked? If not the extra month may provide pay with a light caseload and time to setup non clinical private practice stuff. If you doxhave them booked, go ahead and make it 4 wks.
Does anyone else think they make the TMS test out quizzes as esoteric and nitpicky as possible so you fail them?
Sanman
O.G.
Also, why does the test out require 100% correct when you only need 80% after doing the training?
I think one month is sufficient. That’ll likely give you time to see your patients one last time. Anything longer probably wouldn’t out-weigh the stress of staying longer than you want. They can’t post your position anyway until after you leave (that’s even if they’re allowed to fill it).
They seem to use the same questions every year I should just write them all down lol
Has anyone else heard about this new change to the CSSRS and risk ID process? Where it's now going to be "low, medium, high" care pathways based on item responses?
Is this actually evidence-based? Isn't a screener supposed to be dichotomous yes/no? Is it meant to be used to stratify people into risk severity levels?
Is this actually evidence-based? Isn't a screener supposed to be dichotomous yes/no? Is it meant to be used to stratify people into risk severity levels?
Last I checked, literally NOTHING in the VA/DOD Clinical Practice Guidelines (that the Church of Suicide Prevention preaches as catechism/gospel) is (strongly) 'evidence-based.'
Best they can do is 'Weak for,' or 'Neither for nor against'
Amen. Praise Jesus.
Also...
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I think I've heard it needs to happen before accepting tentative offer.
Sanman
O.G.
Negotiate once you receive the tentative offer before saying yes or accepting formally. Nothing is promised until you sign or really until you show up.
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Sanman
O.G.
Lateral transfer or promotion? Its getting hard to negotiate anything in this climate.
Lateral. It's a position much closer to home, so I can be closer to baby Shiori. My current job is trying to keep me but running into roadblocks higher up the chain. The place I'm applying to seems way more indifferent.
Sanman
O.G.
Yeah,, tough to really negotiate anything on a lateral transfer, but you shoud not be losing anything either. Laterals are good for improving quality of life.
Yeah, I am not losing anything. There are some really interesting aspects, but also some really significant cons. It's probably going to end up being a wash, but much closer to home.
PsynofTimes
Full Member
I put in my notice today.... I can't believe I'm doing this.
Sanman
O.G.
Good luck! Turns out you won't need the answers to TMS test out quizzes after all.
Cheers and good luck!
Welcome to the ever growing society of VA-Expats. Get ready for a far less maddening life from an occupational standpoint.
PsynofTimes
Full Member
Thank you everyone. I'm terrified that I'm making a huge mistake financially.
Sanman
O.G.
It is not a huge financial mistake. The worst it can be is a small financial mistake. There are plenty of jobs available to pay the bills even if they pay slightly less than the VA. A lot of handwringing goes into these decisions. However, at the end of the day (or life) most of us will end up in a similar financial position no matter the path we have chosen. We shouldn't be that afraid to try different things. It is the only way you will find the correct fit.
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Sing it along with me [strums Spanish guitar]:
'All the Federales say
We could have had him any day
We only let him slip away
Out of kindness, I suppose'
'All the Federales say
We could have had him any day
We only let him slip away
Out of kindness, I suppose'
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If it helps, I left a handful of years ago and have never taken a financial hit at any point. I also don't know anyone else who has. Not saying it doesn't happen, but the opportunity for success is strong. And like Sanman said, the chance of failure is limited, and there's pretty much always an employed position available if you need one.
Sanman
O.G.
Anyone being given actual answers as to how frequently they want MBC as it is now part of performance. I am being told to administer "more" without firm guidance as to frequency. I already administer on all patients that are capable at intake, half way through, and prior to discharge.
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We're getting told to do it in every session. There is also a new dashboard being developed to track provider usage.
Sanman
O.G.
This might be the dumbest thing I have ever heard. If there is no reported changes then why would it be clinically inidicated?
The benchmark for PCTs is at least 2 administrations, although for EBPs (like the PCT should mostly be doing) the gold standard is every session or 1x/week.
Probably a stupid question, but...
Is there an actual Obstructive Sleep Apnea clinical reminder screener that is supposed to be completed in primary care? I know there are screening instruments (like STOP-BANG) in the field but why isn't there an actual clinical reminder for screening for OSA? We have screeners for everything else.
It just seems like that nearly every single mental health intake I do (across PCT, BHIP) involves undetected OSA. "I don't remember my dreams, I just know my girlfriend says I stop breathing and wake up suddenly gasping for air and yelling...'are you tired during the day, like you could take a nap any time?' Oh hell yeah!'
I know I'm probably being stupid and just am not aware of the OSA screener/ clinical reminder in primary care, right?
Edit: Okay, so I Googled my own dumb question. So, apparently, they ARE supposed to screen for OSA in primary care. I guess they may just be 'pencil-whipping' it (not actually asking the questions) sometimes. Now I'm going to have to go back and look up the results of the screeners for these vets they got in primary care. Anyone else running into this all the time?
I guess it could also be the case that different sites may have different mandated clinical reminders (may be required at some VA sites to screen for OSA as a clinical reminder, but not others). Gonna have to remember to check some charts tomorrow on it.
Is there an actual Obstructive Sleep Apnea clinical reminder screener that is supposed to be completed in primary care? I know there are screening instruments (like STOP-BANG) in the field but why isn't there an actual clinical reminder for screening for OSA? We have screeners for everything else.
It just seems like that nearly every single mental health intake I do (across PCT, BHIP) involves undetected OSA. "I don't remember my dreams, I just know my girlfriend says I stop breathing and wake up suddenly gasping for air and yelling...'are you tired during the day, like you could take a nap any time?' Oh hell yeah!'
I know I'm probably being stupid and just am not aware of the OSA screener/ clinical reminder in primary care, right?
Edit: Okay, so I Googled my own dumb question. So, apparently, they ARE supposed to screen for OSA in primary care. I guess they may just be 'pencil-whipping' it (not actually asking the questions) sometimes. Now I'm going to have to go back and look up the results of the screeners for these vets they got in primary care. Anyone else running into this all the time?
I guess it could also be the case that different sites may have different mandated clinical reminders (may be required at some VA sites to screen for OSA as a clinical reminder, but not others). Gonna have to remember to check some charts tomorrow on it.
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Not the VA, but the Epworth is typically in our setting.
Sanman
O.G.
For certain EBPs, I can see utility. But blanket screening every session for every patient seems redundant and of limited utility. Did you do the homework? No. Did anything change since last session? No. Ok, let's do the PHQ-9 again. Your results are the same as the last week, when you didn't do the homework and made no changes. We should talk more about that now that I have burned 15 min with nonsense.
I remember being involved (as a protocol therapist) in an NIMH-funded treatment outcome study (a variant of cognitive therapy for depression) in the late 1990s. We used measures (I think BDI-II, ATQ, DAS(?)). The BDI-II was the main outcome variable. We didn't give it every session. It was like pre, mid, and post measurements (three measurement points during the treatment). And that was an NIMH-funded outcome study.
Yeah, I have been passively resisting. I will just send things through BHL Touch. They either fill it out or they don't. I regularly use MBC, but it's done with intention and case conceptualization in mind. Doing MBC for every session with every patient is just burdensome.
I think it goes back to the Tyranny of Metrics. Good clinicians use MBC to track outcomes and adjust treatment planning. Bad clinicians do not become good clinicians by forcing them to do MBC.
Sanman
O.G.
Yeah, my geriatric folks can barely figure out VVC with help. No chance of utilizing BHL Touch. Which means burning session time every week.
I mean, same. I still send it. If they actually need MBC, I do it in session. If they don't fill it out, I can point to my efforts on BHL Touch. It'll take them at least a year to pay any attention and yell at me.
I'm a trainer in an EBP and we really encourage weekly administrations.
Really, that often? I can see weekly for things like SUDs for PE therapy, but a BDI-II every session?
Sanman
O.G.
Is that in addition to things like a daily mood log or in lieu of it?
Given how high OSA is rated for SCD, I’m surprised that most veterans who aren’t already 100% aren’t asking to be screened for it for that reason alone.
In addition to. This is the PCL-5, though.
IME it's better to ask for it every week and then if you get it returned less frequently, it's less of an issue. But I actually have really good return rates on BHL Touch.
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Sanman
O.G.
I already have veterans complaining that all we do is fill out checklists and have no interest in helping people. This is going to go over gangbusters.
Yeah, and I have a lot more empathy with my patients after being given the EPDS every single visit at the OB for a while. It was one questionnaire, and I was ready to draw an X through the whole thing by the end with a giant "I'M FINE." Totally get why it's important. It didn't make it less aggravating in the moment when I just wanted to go home and catch up on sleep.
The other irritating thing is the implicit presumption that these self-report checklists (PHQ-9, GAD-7, PCL-5) are 'like checking your blood pressure' or 'checking your blood glucose' (for diabetics). I mean, I get the temptation to leverage the 'medical model/metaphor' in order to try to encourage compliance with the procedure...but...
They're different. For one thing, they are very subjective (as opposed to 'blood tests' or 'blood pressure readings'). They are heavily influenced by non-construct-related factors and generalized distress, especially in certain settings (*cough*--VA outpatient mental health) and with certain populations (*cough*--veterans concerned about service-connection). As you mention, they are not 'passive' tests that the patient just has to sit back and have administered to them. Come to think of it, these three 'measures' are especially egregious in that they represent, essentially, item-for-item and even literally word-for-word copy-and-paste listings of the official diagnostic criteria from the DSM-5 which were never meant (I would argue) to simply be presented to patients as a self-report 'checklist' for the purpose of, essentially, self-diagnosis. I know I'm going to catch flak about expressing this opinion, but it is what it is.
I'm not an 'anti-questionnaire' guy. They have their legitimate uses. But it really bugs me when people/organizations adopt the attitude that the administration of symptom self-report checklists somehow represents the pinnacle core clinical activity of an ultra-sophisticated clinical scientist or scientist practitioner. 'Checklist good. More checklist double-plus-good' sort of mentalities. They are one channel/source of data in a multi-method psychological assessment enterprise. They inform the clinical case formulation, they don't replace it. They do not, essentially, allow the patient/veteran to 'diagnose themselves' (see paragraph, above) according to official DSM-5 criteria with no filtering/ input from the provider. They are not 'just like all the other medical tests we give you at the doctor's office.' As an aside (here we go trying to get fired again) I have also not infrequently seen them used (especially the PCL-5 for 'confirming' a self-diagnosis of PTSD) by a pair of (a) lazy, pandering providers who diagnose everyone with PTSD and (b) self-diagnosing (with PTSD) patients colluding to 'confirm' a flimsy diagnosis of PTSD by pointing to extremely high scores on that measure as indicative of 'very severe PTSD' (PCL-5 score 75 or greater out of 80).
Some legitimate uses of the three common checklists that spring to mind for which they are very useful are:
a) quickly checking on status/severity of symptoms over time (at reasonable intervals) to see if treatment is working or not, or, doing a quick check-in if a patient has been away from therapy for several months or several years to compare with earlier readings
b) screening, especially in a population with a mixture of presence/absence of mental illness and/or widely ranging severity of same (e.g., primary care settings or general populations). A score of 1/27 on the PHQ-9, 2/21 on the GAD-7, and 2/80 on the PCL-5 is, all things considered, to be considered a 'negative screen' for the major mental health disorders of internalized distress (MDD, GAD, PTSD, persistent depressive disorder) unless some extreme underreporting is going on (due to some incentives, perhaps, to conceal psychopathology) or something really wacky is happening.
c) quickly getting a relative sense of whether a patient's main problems are more in the area of clinical depression, worry/anxiety, or trauma-related distress but--really--I find these measures very poor in terms of helping with any real differential diagnostic determinations in the populations I see regularly (BHIP, general mental health, PTSD specialty clinic) because all three all generally extremely intercorrelated, overlapping in content, and almost universally high.
I also find the preoccupation with administering the 'big three' (PHQ/GAD/PCL) symptom checklists as many times as possible to as many patients as possible (it's getting a little out of control) to be problematic. Collectively, they over-sample from the 'disorders of internalized distress' (PTSD, MDD, GAD) domain of psychopathology whilst completely ignoring the entire remainder of the symptom space (e.g., according to a HiTOP model or even the DSM) including, of course, externalizing disorders, psychotic disorders, personality dysfunction, somatization, etc. It leads to a 'pseudo-sophistication syndrome' where people (including interns) are going about just PHQ/GAD/PCL'ing everyone to death but, meanwhile, completely ignoring the remainder of the psychopathology landscape and clinical case formulations with their patients.
It's also a lazy way to 'supervise' the 'quality' of clinical work of doctoral level psychologists by simply having the computer/system spit out a report of what percentage of encounters they entered/scored a self-report checklist. Real clinical supervision is difficult and time-consuming. Nah, screw that, just have the system give me a percentage on Dr. X and how many PROMs (I love it) she administered over the past quarter.
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I agree that it's a stupid metric and just another way to add a number to something that's hard to measure, but it's also not incompatible with good clinical practice. My patients are fine with filling out the questionnaires weekly. I've only had pushback from maybe two people.
Also, I know providers who weren't giving ANY measures, and this includes specialty care and EBPs
Also, I know providers who weren't giving ANY measures, and this includes specialty care and EBPs
I wonder if this is a move to let AI create disability ratings through PCL responses.
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