VA Mental Health Provider Venting / Problem-solving / Peer Support Thread

[WisNeuro]

Yeah, I have a lot of issues with the Whole Health initiative.

Don't worry, pretty soon we'll just give every Vet a "service dog" and everything will be fixed. It'll all be unicorns, rainbows, and SC checks for everyone for life!

---

Members don't see this ad.

 

[AbnormalPsych]

Don't worry, pretty soon we'll just give every Vet a "service dog" and everything will be fixed. It'll all be unicorns, rainbows, and SC checks for everyone for life!

Sigh. It hurts bc its true. I run across masters level trained people with this view somewhat frequently.
Engaging them in conversations about their thought process behind this pretty much just ends up with them thinking I hate dogs Go figure.

 

[Fan_of_Meehl]

Eleven-Year-Old Debunks Therapeutic Touch: The Case of Emily Rosa

An "alternative" therapy is put to the test.

www.psychologytoday.com

Yup.

And this is just another manifest example of the incoherent (and self-contradictory) approach to MH treatment that the VA (as an overall organization) enacts. If we're going to be an open-ended, unscientific, unlimited funding, handholding #BeThere entitlement-based PR and BS-factory, then fine. If we're going to be a hard-nosed, 'evidence-based,' penny-pinching, aggressive, #DontWasteMHResources managed-care PHQ-9/PCL-5 score reduction-factory, then fine. But we can't be expected to enact both visions...simultaneously...with every single patient...regardless of the context or circumstances.

 

[Fan_of_Meehl]

Don't worry, pretty soon we'll just give every Vet a "service dog" and everything will be fixed. It'll all be unicorns, rainbows, and SC checks for everyone for life!

I've joked at/with? the patient advocate that--within 5 to 10 years--all of the 'PTSD Specialty Clinics' in the VA system will be nothing but large 'medical marijuana' plantations and service dog kennels.

 

[cara susanna]

I've joked at/with? the patient advocate that--within 5 to 10 years--all of the 'PTSD Specialty Clinics' in the VA system will be nothing but large 'medical marijuana' plantations and service dog kennels.

One of the VAs I used to be at had a running joke - when you retire, open a clinic called Pot and Puppies. You'd make millions!

 

[AcronymAllergy]

Sigh, don't get me started on healing touch.

 

[Therapist4Chnge]

Eleven-Year-Old Debunks Therapeutic Touch: The Case of Emily Rosa

An "alternative" therapy is put to the test.

www.psychologytoday.com

Typically, the more unrecognizable credentials after someone's name, the less I trust them.

 

[PsyDr]

Sigh, don't get me started on healing touch.

I know a guy in Chicago with a boat and some cocaine who seems like he does a lot of touching.

 

[erg923]

I know a guy in Chicago with a boat and some cocaine who seems like he does a lot of touching.

sic burn!

 

[Sanman]

I know a guy in Chicago with a boat and some cocaine who seems like he does a lot of touching.

 

[erg923]

I am copying this from another thread I just posted on. I have always wondered about VA.gov | Veterans Affairs

"As an aside, I was in the VA for 5 years, and as many here can attest, it is highly inefficient and quite a dysfunctional "business" in pockets. I have no idea where these people are in all this? I never saw or met any of them, nor did I ever even hear about their projects or mission within the system. Seems strange to me, especially considering there are almost 30 of them on staff in this department."

Does anyone have inside knowledge of this division? The best kept secret in the world? The most underutilized department in world? What? Never saw them, never met them. Never heard about them other than the website and post-doc. Never heard a peep during the 2014 access scandal. Never heard from them during the disastrous roll-out of the "Choice Program" in 2014-2015. Never heard from them about all the supposed HR and hiring process reforms in 2015-2016 under McDonald? Never heard from them during those "VA Voices" trainings. They don't do marketing or any actual PR from what I can tell? Is this a division of MI-6 or something? Anyone know?

 

[Fan_of_Meehl]

I am copying this from another thread I just posted on. I have always wondered about VA.gov | Veterans Affairs

"As an aside, I was in the VA for 5 years, and as many here can attest, it is highly inefficient and quite a dysfunctional "business" in pockets. I have no idea where these people are in all this? I never saw or met any of them, nor did I ever even hear about their projects or mission within the system. Seems strange to me, especially considering there are almost 30 of them on staff in this department."

Does anyone have inside knowledge of this division? The best kept secret in the world? The most underutilized department in world? What? Never saw them, never met them. Never heard about them other than the website and post-doc. Never heard a peep during the 2014 access scandal. Never heard from them during the disastrous roll-outs of the "Choice Program" in 2014-2015. Never heard from them about all the supposed HR and hiring process reforms in 2015-2016 under McDonald? Never heard from them during those "VA Voices" trainings. They don't do marketing or any actual PR from what I can tell? Is this a division of MI-6 or something? Anyone know?

My pet theory is that they are the descendants of the remnants of Goebbels Ministry of Propaganda from Nazi Germany secretly smuggled over after the war (cf. 'Operation Paperclip') and set up to be the 'brain trust' in charge of generating endless slogans, posters, t-shirts, pamphlets, emails, websites, banners, and sundry psychological and public relations operations for the VA. 'Operation Doublethink.'

Seriously, I have no idea who they are or could be but they don't seem to have a very good track record of 'success.' They do have the biggest pom-poms and most expensive pep rallies around, though.

 

[AbnormalPsych]

I am copying this from another thread I just posted on. I have always wondered about VA.gov | Veterans Affairs

"As an aside, I was in the VA for 5 years, and as many here can attest, it is highly inefficient and quite a dysfunctional "business" in pockets. I have no idea where these people are in all this? I never saw or met any of them, nor did I ever even hear about their projects or mission within the system. Seems strange to me, especially considering there are almost 30 of them on staff in this department."

Does anyone have inside knowledge of this division? The best kept secret in the world? The most underutilized department in world? What? Never saw them, never met them. Never heard about them other than the website and post-doc. Never heard a peep during the 2014 access scandal. Never heard from them during the disastrous roll-out of the "Choice Program" in 2014-2015. Never heard from them about all the supposed HR and hiring process reforms in 2015-2016 under McDonald? Never heard from them during those "VA Voices" trainings. They don't do marketing or any actual PR from what I can tell? Is this a division of MI-6 or something? Anyone know?

Woah. I trained in and worked for the VA for several years. Until this moment I have never heard of this national center...

 

[Fan_of_Meehl]

I am copying this from another thread I just posted on. I have always wondered about VA.gov | Veterans Affairs

"As an aside, I was in the VA for 5 years, and as many here can attest, it is highly inefficient and quite a dysfunctional "business" in pockets. I have no idea where these people are in all this? I never saw or met any of them, nor did I ever even hear about their projects or mission within the system. Seems strange to me, especially considering there are almost 30 of them on staff in this department."

Does anyone have inside knowledge of this division? The best kept secret in the world? The most underutilized department in world? What? Never saw them, never met them. Never heard about them other than the website and post-doc. Never heard a peep during the 2014 access scandal. Never heard from them during the disastrous roll-out of the "Choice Program" in 2014-2015. Never heard from them about all the supposed HR and hiring process reforms in 2015-2016 under McDonald? Never heard from them during those "VA Voices" trainings. They don't do marketing or any actual PR from what I can tell? Is this a division of MI-6 or something? Anyone know?

I notice that one of their claims is that they propagate the implementation of the concept of 'servant leadership' throughout the organization. ROFL-ing my azz off!

If you want to see a VA supervisor go red in the face, purse their lips and hit you with a stare that could turn you to stone on the spot...

Raise your hand in a departmental meeting and ask them what the concept of 'servant leadership' is all about.

 

[Ollie123]

Is it possible this group went defunct 20 years ago and HR/IT/etc. still hasn't figured it out? I mean....it IS the VA...

 

[Sanman]

I'm pretty sure they are responsible for sending out the all employee survey and collecting the data. Not sure they do anything else.

 

[erg923]

I'm pretty sure they are responsible for sending out the all employee survey and collecting the data. Not sure they do anything else.

Thats... thats not organization development.

 

[Fan_of_Meehl]

Thats... thats not organization development.

But it's SOOOOOOOOO VA, lol.

Instead of doing ACTUAL supervision (by walking around, picking up the phone, having conversations, thinking, making judgments, being accountable for said judgments, etc.), the organization does a once per year 'All Employee Survey' that has fixed Likert questions with pseudo-confidential results (which really biases responses) so they can point to some 'number' and say they're being wonderful supervisors. Their real priority is to utilize systems that are automated (no effort on their part) where they can point to a statistic that somehow says that they're 'doing their job.' Rinse. Repeat. Meanwhile, the 'data' that they really need to improve operations would be in the form of honest feedback from doctoral-level employees but any critical feedback 'from the front line providers' is inconsistent with the organizational schema 'the provider is always to blame' and would threaten their self-esteem if they admitted that there were systems problems that they, as 'leadership,' could take some accountability for.

 

[iliketohelppeople]

They actually have a post-doc. I know of one person who was there, and they talked about a lot of meetings with senior executive folks. I really don't think they liked it. I think the post-doc was halted this last year (not sure if permanent; it paid a bit more than clinical and one could still get a license).

 

[cara susanna]

I mean, there's like a group of 4-5 rich dudes with no relevant experience essentially running the VA as a shadow group.

 

[cara susanna]

So, because we have a bunch of therapists with terrible f/u access, our administration right now is on about "panel management." I keep thinking about Fan of Meehl's comment about how it seems to be a vague way of blaming providers instead of addressing systematic issues that prevent people from actually discharging patients. At least we have a new supervisor coming on board who seems receptive to some of the concerns that we've raised from the administrative standpoint.

 

[Fan_of_Meehl]

So, because we have a bunch of therapists with terrible f/u access, our administration right now is on about "panel management." I keep thinking about Fan of Meehl's comment about how it seems to be a vague way of blaming providers instead of addressing systematic issues that prevent people from actually discharging patients. At least we have a new supervisor coming on board who seems receptive to some of the concerns that we've raised from the administrative standpoint.

It's a rampant sytemic issue and--at the root of it--is a fundamentally incoherent and self-contradicting philosophy of MH care at VA. Until they acknowledge that, they can play 'blame-the-provider' and 'Measurement Based Care is the Holy Grail' all they want but providing free professional services with no end point, not charging for no shows, and paying people to self-report psychopathology are critical factors hampering 'access' that me slinging more PHQ9s, PCL5s, and GAD7s is NOT going to solve.

 

[cara susanna]

It's a rampant sytemic issue and--at the root of it--is a fundamentally incoherent and self-contradicting philosophy of MH care at VA. Until they acknowledge that, they can play 'blame-the-provider' and 'Measurement Based Care is the Holy Grail' all they want but providing free professional services with no end point, not charging for no shows, and paying people to self-report psychopathology are critical factors hampering 'access' that me slinging more PHQ9s, PCL5s, and GAD7s is NOT going to solve.

Yup! And right now we punish good access because those people get more new patients. What is the incentive to discharge?

 

[Fan_of_Meehl]

So, because we have a bunch of therapists with terrible f/u access, our administration right now is on about "panel management." I keep thinking about Fan of Meehl's comment about how it seems to be a vague way of blaming providers instead of addressing systematic issues that prevent people from actually discharging patients. At least we have a new supervisor coming on board who seems receptive to some of the concerns that we've raised from the administrative standpoint.

And--at least at my facility--converting some of the SW positions from all these Coordinator/Champion and Excellentologist/Expertologist roles (who never see patients) to clinical positions with caseloads would kinda help too.

 

[PsyDr]

What percentage of appointments are driven by a desire to get 100% disability?

 

[cara susanna]

What percentage of appointments are driven by a desire to get 100% disability?

I'd argue that it's not just disability (which is a huge issue) but also VA providers thinking that every patient with mental health issues needs a therapy referral.

 

[erg923]

I'd argue that it's not just disability (which is a huge issue) but also VA providers thinking that every patient with mental health issues needs a therapy referral.

That was more my experience as well. I got alot of "my husband was different when he came home from deployment." No ****? No specific symptoms, little if any functional impairment. The VA really wants to "treat" this as PTSD pathology this with no regard for how sending a person the the armpit of the earth in a gorilla warfare environment might just change his perspective on life and death a little bit.

 

[Fan_of_Meehl]

What percentage of appointments are driven by a desire to get 100% disability?

A decent portion. I know it sounds radical but sometimes I think the system would actually SAVE money by just giving everyone 100% (after doing a thorough eval process). It would certainly help access.

 

[WisNeuro]

That was more my experience as well. I got alot of "my husband was different when he came home from deployment." No ****? No specific symptoms, little if any functional impairment. The VA really wants to "treat" this as PTSD pathology this with no regard for how sending a person the the armpit of the earth in a gorilla warfare environment might just change his perspective on life and death a little bit.

Guerilla, you leave the Great Apes out of this.

 

[erg923]

Guerilla, you leave the Great Apes out of this.

Ha! Good catch

 

[cara susanna]

A decent portion. I know it sounds radical but sometimes I think the system would actually SAVE money by just giving everyone 100% (after doing a thorough eval process). It would certainly help access.

... This is actually a very good point that I hadn't considered.

Although back in my last clinic almost everyone I saw had 100% and they were not doing well.

 

[Fan_of_Meehl]

... This is actually a very good point that I hadn't considered.

Although back in my last clinic almost everyone I saw had 100% and they were not doing well.

The other idea is "more radical." It would end payments altogether but provide 'gold-plated' TREATMENT commensurate with level of disability. 100%? Residential. 70%? Intensive outpatient. 50% or below? Unlimited outpatient therapy. But I would charge for no-shows and last minute cancellations and, after a time, insist on a small co-pay.

This way, veterans reporting increased symptoms would be manding for more intensive treatment rather than more monthly income.

And, just to appease the PR Gods, all the cannabis and service animals you want. Well, probably not that last part.

 

[Sanman]

A decent portion. I know it sounds radical but sometimes I think the system would actually SAVE money by just giving everyone 100% (after doing a thorough eval process). It would certainly help access.

Forget that, what percentage of appts is veterans showing up and lying so they are not deemed non-compliant, which may result in losing their benefits. I have several on my caseload that are doing just enough to not lose benefits and no more. Habitually just barely compliant. At least one of those, I am pretty sure, is diverting opioids to make additional cash.

 

[Fan_of_Meehl]

Forget that, what percentage of appts is veterans showing up and lying so they are not deemed non-compliant, which may result in losing their benefits. I have several on my caseload that are doing just enough to not lose benefits and no more. Habitually just barely complaint. At least one of those, I am pretty sure, is diverting opioids to make additional cash.

Yup. The over-reporting / service-connection issue is almost always (by necessity) part of the (unspoken) clinical case formulation but it isn't something that can be addressed openly as even existing in the system. Blasphemy.[/QUOTE]

 

[clausewitz2]

Forget that, what percentage of appts is veterans showing up and lying so they are not deemed non-compliant, which may result in losing their benefits. I have several on my caseload that are doing just enough to not lose benefits and no more. Habitually just barely compliant. At least one of those, I am pretty sure, is diverting opioids to make additional cash.

Not the only place this happens. My caseloads in CMHC settings so far typically involve a number of people who show up once every year just so they don't lose service coordination/case management without identifiable syndromal syndromes of any kind. Free rides and someone else doing paperwork is a big incentive for some people.

For a while I would keep deleting totally baseless psychotic disorder diagnoses from the chart but their SCs would inevitably add them back again. At some point I realized Canute was not even my middle name and that while commanding the tide thing didn't even work out for him.

 

[erg923]

1. Can someone working in the system update on the "Mission Act" thing? When I was there (not all that long ago) the Choice Program was a disaster and pretty non-functional for mental health. And only marginally better for pure medical stuff.

2. I did a didactic recently for the intern class at my local VA and talked to some former colleagues.
There are now MORE supervisors (CBOC supervisors) that are in charge of the Mental Health Clinics practitioners---with only a very modest expansion in front line provider/clinician staff. This seems totally opposite to what I would have expected and wanted in our VA and its CBOCs. Maybe better coordination and communication, maybe more support...but another layer of VA administration (GS-14s, I assume)?! No. Is this a trend nationwide?
And get this: The design of our new CBOC doesn't even have designated rooms for psychotherapy/MH consultation. Its a all exam rooms that are "borrowed" by MH staff (who apparently reside in a bull-pin of sorts) when primary care isn't using them. WTF?!

 

[AcronymAllergy]

From what I've seen so far, Mission Act seems to be going a bit more smoothly than Choice did. Or there are at least more community providers that seem to have signed up, which means maybe it's working better for them.

 

[Fan_of_Meehl]

1. Can someone working in the system update on the "Mission Act" thing? When I was there (not all that long ago) the Choice Program was a disaster and pretty non-functional for mental health. And only marginally better for pure medical stuff.

2. I did a didactic recently for the intern class at my local VA and talked to some former colleagues.
There are now MORE supervisors (CBOC supervisors) that are in charge of the Mental Health Clinics practitioners---with only a very modest expansion in front line provider/clinician staff. This seems totally opposite to what I would have expected and wanted in our VA and its CBOCs. Maybe better coordination and communication, maybe more support...but another layer of VA administration (GS-14s, I assume)?! No. Is this a trend nationwide?
And get this: The design of our new CBOC doesn't even have designated rooms for psychotherapy/MH consultation. Its a all exam rooms that are "borrowed" by MH staff (who apparently reside in a bull-pin of sorts) when primary care isn't using them. WTF?!

They are doubling down on their pathology.

They are creating all manner of additional 'specialist'/champion/coordinator positions (that don't carry caseloads or perform any meaningful clinical duties) while...

Not filling vacancies in mainline clinical positions (post-deployment, mental health, etc.), while...

Bitching about people having large caseloads (as if it's all our fault) and need for 'increased continuity of care' (translation: weekly appointments rather than monthly appointments, according to them), while...

Failing to appreciate the third grade arithmetic involved that demonstrates the impossibility of the above (given limited clinic grid slots and unlimited consults entering a caseload on a weekly basis), while...

Increasing (and never removing) requirements for the clinicians in the trenches, further diluting their time/energy/resources (the newest fad is a shiny new software program ('Behavior Health Lab') which probably will be nothing more than a glorified Excel spreadsheet with a damn Visual Basic programmed front end interface bolted onto it)...

etc. etc. etc.

I give us three to five more years.

 

[Fan_of_Meehl]

Unfortunately, there doesn't appear to be any meaningful quality control. Entered a consult for specialty behavioral treatment for sexual dysfunction and the veteran is being sent to an LPC (who, according to their website appeared to be a generalist clinician). So, YMMV.

On another note, I was following a C&P listserv today and it appears that the axe/guillotine is falling on C&P departments in VA nation-wide. This appears to be happening at different rates at different hospitals but it looks like the days of in-house C&P's at VA are coming to a rapid end. The future looks like it's going to be all contractor and private practice (many hired guns) doing C&P's.

The deleterious impact on the PTSD clinical/research database will likely continue into mid-century.

 

[Sanman]

From what I've seen so far, Mission Act seems to be going a bit more smoothly than Choice did. Or there are at least more community providers that seem to have signed up, which means maybe it's working better for them.

Exact opposite issue by me. Lack of community providers means 200+ day waits for community clinicians and many bounce backs to the VA MH clinics anyway.

 

[erg923]

Unfortunately, there doesn't appear to be any meaningful quality control. Entered a consult for specialty behavioral treatment for sexual dysfunction and the veteran is being sent to an LPC (who, according to their website appeared to be a generalist clinician). So, YMMV.

On another note, I was following a C&P listserv today and it appears that the axe/guillotine is falling on C&P departments in VA nation-wide. This appears to be happening at different rates at different hospitals but it looks like the days of in-house C&P's at VA are coming to a rapid end. The future looks like it's going to be all contractor and private practice (many hired guns) doing C&P's.

The deleterious impact on the PTSD clinical/research database will likely continue into mid-century.

I have wondered about this, as our local VA has a large and somewhat well tenured C&P staff (most there for over 10 years). That said, with all due respect, I got a semi-paniced email from them 3 years ago about this, and they are still there. I do not know how all of them (6-8?) justify there existence within our local VA though? There are 3 other VA Medical Centers in this (relatively small) state and there are the contract people too.

What is the Mission Act doing where you are? A psychologist on here a bit ago seemed to suggest that the choice program thing was pretty smooth where he/she was. That is hard to imagine.

 

[Fan_of_Meehl]

I have wondered about this, as our local VA has a large and somewhat well tenured C&P staff (most there for over 10 years). That said, with all due respect, I got an semi-paniced email from them 4 years ago about this, and they are still there.

I do not know how all of them (6-8?) justify there existence within our local VA though? There are 3 other VA Medical Centers in this (relatively small) state and there are the contract people too.

I have been following this listserv (for mental health C&P folks at VA) for the past four years on a daily/weekly basis. There have always been 'rumors' and rumblings and the occasional minor downsizing. This time it's for real. Multiple posters chiming in that they have just gotten word recently that the plan is to shut it all down. Some completely shut down very soon. Some departments will (if I remember correctly) try to eliminate roughly 25% of staff and assessments per quarter while increasing community exams commensurate with that draw down until they reach zero in-house exams. D-Day for C&P is here.

 

[Fan_of_Meehl]

I have wondered about this, as our local VA has a large and somewhat well tenured C&P staff (most there for over 10 years). That said, with all due respect, I got a semi-paniced email from them 3 years ago about this, and they are still there. I do not know how all of them (6-8?) justify there existence within our local VA though? There are 3 other VA Medical Centers in this (relatively small) state and there are the contract people too.

What is the Mission Act doing where you are? A psychologist on here a bit ago seemed to suggest that the choice program thing was pretty smooth where he/she was. That is hard to imagine.

If you're at Louisville, the head for C&P (MH) there was one of the ones posting about it. That person appears to be an awesome (and very competent) C&P examiner and supervisor. It's a real shame.

 

[erg923]

If you're at Louisville, the head for C&P (MH) there was one of the ones posting about it. That person appears to be an awesome (and very competent) C&P examiner and supervisor. It's a real shame.

Yep.

 

[WisNeuro]

Where will the VA get community providers to do these exams now that Argosy has shut down? Oh yeah, they still have Alliant, Albizu, and several others.

I've gotten several recruitment messages about these in my area. I was curious, so I inquired about compensation. In these, you either do a quarter assed exam in a minimal amount of time to cram as many of these in as you can, or you do a competent exam and get paid some of the worst rates I've ever seen. Maybe it's different regionally, but it's bottom of the barrel here.

 

[AcronymAllergy]

Exact opposite issue by me. Lack of community providers means 200+ day waits for community clinicians and many bounce backs to the VA MH clinics anyway.

Not surprising, we just had the opposite problem: working well (seemingly) for Mission, but a LOT of trouble getting community providers through Choice. I imagine it probably varies by area due to the staff setting up the contracts with providers (and how motivated, or unmotivated, they are).

RE: the quality of Mission Act providers, I think it's up to clinicians/administration in each facility to vet them, so I imagine that could vary substantially from one site to the next.

 

[PsyDr]

What’s up with the VA doing that thing where they have a bunch of veterans selling wood knickknacks?

 

[cara susanna]

We do C&P in house at our VA (meaning, all of us psychologists do some C&P work in addition to our clinical work) so I'm wondering how that will play out at places like this.

Concerning the Mission Act, it's been kind of a fustercluck here. It can take up to a month to get people scheduled.

 

[Therapist4Chnge]

Where will the VA get community providers to do these exams now that Argosy has shut down? Oh yeah, they still have Alliant, Albizu, and several others.

I've gotten several recruitment messages about these in my area. I was curious, so I inquired about compensation. In these, you either do a quarter assed exam in a minimal amount of time to cram as many of these in as you can, or you do a competent exam and get paid some of the worst rates I've ever seen. Maybe it's different regionally, but it's bottom of the barrel here.

It sounds like nothing has gotten better since they rolled out contractor c&p years ago. I too got curious about compensation, and it was on par w SSDI eval pay through a contractor, which is/was also pathetic.

I hope no one supports such horrible pay for sub-par work. It frankly isn't possible to write a decent report in either setting given the significant time constraints being pitched by contracting companies.

 

[Fan_of_Meehl]

It sounds like nothing has gotten better since they rolled out contractor c&p years ago. I too got curious about compensation, and it was on par w SSDI eval pay through a contractor, which is/was also pathetic.

I hope no one supports such horrible pay for sub-par work. It frankly isn't possible to write a decent report in either setting given the significant time constraints being pitched by contracting companies.

Sometimes a problem has to intensify (and a system/structure has to collapse completely) before people can no longer deny that the system is broken. I believe that the conscientious MH C&P examiners (mostly in-house at the VA) were trying to hold back the tide of 'rubber-stamping' PTSD diagnoses and service-connections. Soon, almost all C&P exams (like SSDI exams) will be conducted in a pro forma assembly line fashion by outside for-profit contractors with an overwhelming tendency to produce 'positive' (read, give em the diagnosis they want so everyone can get paid) results and 'customer satisfaction.' When I was doing the exams it occurred to me that the person(s) funding the disability payments (taxpayers) had absolutely no one representing/protecting their interests in the process (other than the conscience of the examiner). That problem is about to greatly intensify.