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

[Shiori]

If anyone is curious, they did no-show. I noticed this was their second time no-showing me. My call went straight to voicemail, and the mailbox was full. I imagine they'll still end up on my schedule in the next few weeks.

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[ccpsych16]

I’m really tired of non-MH providers adamantly diagnosing folks with PTSD and referring them to counseling. I always ask people what made them seek counseling now and about half say “my PCP told me I have PTSD”. Then it gets noted in their chart which sets off unnecessary clinical reminders (same for depression). Some have been upset when I told them they don’t meet criteria. I had someone drop out of therapy after I told him he did not meet criteria because he had no Criterion A event. The event he identified was FOMO from being discharged while his friends stayed in and did “cool missions”. I think the cherry on top was that he is service connected for PTSD. Needless to say he did not like me very much, was very sensitive to constructive feedback, and he did not have specific treatment goals.

 

[AcronymAllergy]

I’m really tired of non-MH providers adamantly diagnosing folks with PTSD and referring them to counseling. I always ask people what made them seek counseling now and about half say “my PCP told me I have PTSD”. Then it gets noted in their chart which sets off unnecessary clinical reminders (same for depression). Some have been upset when I told them they don’t meet criteria. I had someone drop out of therapy after I told him he did not meet criteria because he had no Criterion A event. The event he identified was FOMO from being discharged while his friends stayed in and did “cool missions”. I think the cherry on top was that he is service connected for PTSD. Needless to say he did not like me very much, was very sensitive to constructive feedback, and he did not have specific treatment goals.

Yeah, this is particularly problematic in a system like VA that clearly incentivizes a diagnosis like PTSD. So even if a person isn't actively trying to work their way into the diagnosis, they can (incorrectly) end up with it documented in the chart, have that thought planted in their mind and/or start the C&P process for it, and then the MH provider is the one who has to tell them all that was wrong. Or even worse, the diagnosis just gets permanently perpetuated in the chart because no one actually ends up evaluating it further, especially if they never actually see MH.

 

[Fan_of_Meehl]

If anyone is curious, they did no-show. I noticed this was their second time no-showing me. My call went straight to voicemail, and the mailbox was full. I imagine they'll still end up on my schedule in the next few weeks.

I'd estimate--no joke--that around 80% of my outpatient 'psychotherapy' appointments are with 'waste of time' cases. It's just the reality in outpatient VA psychotherapy right now. A reality that, unfortunately, gets no attention as an actual problem or issue that people are willing to acknowledge and/or address. The gap between the rhetoric and the reality is really quite astonishing.

 

[cara susanna]

We had a psychiatry resident give a seminar on PTSD to Primary Care staff with the emphasis on what actually constitutes meeting PTSD criteria and they seemed really receptive to that feedback.

 

[deleted1129370]

Fine.

I can play 'pick up sticks' all day long if they want to pay 'full price' for a psychologist to do that.

It's just sad/demoralizing to see all the 'waste' in the system due to 'leadership's' failures to actually make any decisions that could possibly, in some universe, under ideal circumstances, possibly...piss off a veteran, family member, or congressperson.

A sliding-scale $5 - $25 copay would simultaneously SOLVE so many problems (including so-called 'access issues') it's unreal.

Or....charge them a $125 no show/late cancellation fee. That's what I do in my PP and my no shows/late cancellations are like.....zero. It motivates them to do the responsible thing....to pick up the damn phone and call me to cancel or re-schedule at least 24 hours in advance so I don't waste my time and slots.

 

[Sanman]

Or....charge them a $125 no show/late cancellation fee. That's what I do in my PP and my no shows/late cancellations are like.....zero. It motivates them to do the responsible thing....to pick up the damn phone and call me to cancel or re-schedule at least 24 hours in advance so I don't waste my time and slots.

"But I'm a veteran, I served my country! You can't charge me a no show fee! Where's your free coffee?"

I literally had a veteran go on a rant like this because the interest rate on a loan he just took out from a VA loan provider was too high for his taste.

 

[Fan_of_Meehl]

Or....charge them a $125 no show/late cancellation fee. That's what I do in my PP and my no shows/late cancellations are like.....zero. It motivates them to do the responsible thing....to pick up the damn phone and call me to cancel or re-schedule at least 24 hours in advance so I don't waste my time and slots.

Had an intake scheduled via vvc this am. Pt had already no-showed earlier intake (same consult w/another provider). Third no show call note indicates pt excuse for no-show (to a vvc appointment...on smartphone) was she was 'having a bad day' and 'too anxious' to 'attend' the virtual appointment.

8am, no patient. Call patient. Patient surprised (thought it was at 9am appt.). Says, "I'm at work right now can we just do this by telephone." I say no, must be by vvc or in person. "Well, can you give me an evening appt like this evening or somethin?" No, I am booked all day today and I do not have 'evening' appointments. Moreover, you need to take leave from work so that you are fully available during our medical appointments, it is inappropriate to schedule these while you are "on duty' during work hours. If you need to r/s I can give you a warm handoff to the front desk.

"No, I'll just call back later."

Works for me, lady.

By the way, she did not sound anxious in the least.

 

[deleted1129370]

"But I'm a veteran, I served my country! You can't charge me a no show fee! Where's your free coffee?"

I literally had a veteran go on a rant like this because the interest rate on a loan he just took out from a VA loan provider was too high for his taste.

So fun fact - a couple of weeks ago I was putting the final touches on a contract I signed with TriWest to be a community care provider via my PP since I'm leaving the VA in 2 weeks. It never dawned on me to ask this in advance before I signed the contract with them, but I emailed them and asked them if I am not allowed to charge for a no show or late cancellation fee and the rep. shared a screen shot of their contract and highlighted it where it said I was not permitted to charge ANY fees.

So...I told her "my practice has a standard policy of charging a no show/late cancellation fee if a 24 hours advance notice is not provided - we apply this charge to all of our patients uniformly." She emailed me back asking "so, do you want to cancel the contract?" And I said "it looks like we will have to, so yes." I am not going to have my practice mimic that of the VA...hell no.

 

[deleted1129370]

Had an intake scheduled via vvc this am. Pt had already no-showed earlier intake (same consult w/another provider). Third no show call note indicates pt excuse for no-show (to a vvc appointment...on smartphone) was she was 'having a bad day' and 'too anxious' to 'attend' the virtual apoointment.

8am, no patient. Call patient. Patient surprised (thought it was at 9am appt.). Says, "I'm at work right now can we just do this by telephone." I say no, must be by vvc or in person. "Well, can you give me an evening appt like this evening or somethin?" No, I am booked all day today and I do not have 'evening' appointments. Moreover, you need to take leave from work so that you are fully available during our medical appointments, it is inappropriate to schedule these while you are "on duty' during work hours. If you need to r/s I can give you a warm handoff to the front desk.

"No, I'll just call back later."

Works for me, lady.

By the way, she did not sound anxious in the least.

I also put firm boundaries for modality. I do not do phone visits. I do exactly the same that you just described.

 

[Fan_of_Meehl]

"But I'm a veteran, I served my country! You can't charge me a no show fee! Where's your free coffee?"

I literally had a veteran go on a rant like this because the interest rate on a loan he just took out from a VA loan provider was too high for his taste.

I had tried to get admin support formally for enforcing the "no therapy appts while on duty" boundary, but got rebuffed. They didn't want to support me on it (this was 2 years ago). But, this time around, I am enforcing this boundary with any/all patients with vvc appts. It is, among many other things, a safety issue. They do not need to suddenly disappear from the session during a CSRE or safety planning intervention because their boss is "looking for them" and has "found them." I have had patient just friggin disappear in the middle of a VVC intake and when I finally reach them by phone to see WTF happened they say their boss needed them so they just flat out left the appointment in a puff of smoke. Un-bleeping-acceptable!

I also am not comfortable condoning and aiding/abetting straight up time card fraud (esp if they are a Federal employee).

If admin gives me pushback on enforcing this boundary with patients, I should seriously consider an OIG fraud/waste/abuse complaint.

 

[PsyDWannabe]

I’m really tired of non-MH providers adamantly diagnosing folks with PTSD and referring them to counseling. I always ask people what made them seek counseling now and about half say “my PCP told me I have PTSD”. Then it gets noted in their chart which sets off unnecessary clinical reminders (same for depression). Some have been upset when I told them they don’t meet criteria. I had someone drop out of therapy after I told him he did not meet criteria because he had no Criterion A event. The event he identified was FOMO from being discharged while his friends stayed in and did “cool missions”. I think the cherry on top was that he is service connected for PTSD. Needless to say he did not like me very much, was very sensitive to constructive feedback, and he did not have specific treatment goals.

My theory is that some non-mental health providers do this out of fear of retribution/violence from veterans who can get quite irate and combative when they feel their benefits are being threatened. There’s been some scary stories in recent history that may be keeping these non-mental health providers on their toes. It’s crazy to me thought that mental health staff are the ones bold enough, despite said scary stories, to stand up to the veterans and tell them that they don’t have whatever diagnosis it is they’re seeking.

 

[Fan_of_Meehl]

My theory is that some non-mental health providers do this out of fear of retribution/violence from veterans who can get quite irate and combative when they feel their benefits are being threatened. There’s been some scary stories in recent history that may be keeping these non-mental health providers on their toes. It’s crazy to me thought that mental health staff are the ones bold enough, despite said scary stories, to stand up to the veterans and tell them that they don’t have whatever diagnosis it is they’re seeking.

Provider cowardice definitely contributes greatly to inflated service-connection rates, including mental health providers.

In the VA system, cowardice and lack of integrity are generally materially rewarded and their opposites punished.

 

[psycho1391]

Or....charge them a $125 no show/late cancellation fee. That's what I do in my PP and my no shows/late cancellations are like.....zero. It motivates them to do the responsible thing....to pick up the damn phone and call me to cancel or re-schedule at least 24 hours in advance so I don't waste my time and slots.

Oh man. I wish I could do this for everyone in our virtual program.

So, our Vets get educated that they can chose either our virtual pain program or in-person. When they chose virtual, they are given information about how their appointments work by three different people (me, the nurse navigator, and peer support). Information is also sent to them in the mail. Without fail on the first day of the program, someone can't work their video or "forgets" their appointments. More often then not they drop of of the program.

Note that our program is "closed" 13 week pain program. So if someone drops out we can't fill that spot. So, what happens is we have a huge waitlist because Vets feel like they have to do the program to appease their prescribers and then drop out. Its fun 🙂

 

[Sanman]

Provider cowardice definitely contributes greatly to inflated service-connection rates, including mental health providers.

In the VA system, cowardice and lack of integrity are generally materially rewarded and their opposites punished.

Can you call it provider cowardice when the system is designed to be dysfunctional? I mean we don't even do C&P anymore. It was sold lock, stock, and barrel to the lowest bidder. In what world is that a good way to do what is essentially forensic work?

 

[WisNeuro]

Can you call it provider cowardice when the system is designed to be dysfunctional? I mean we don't even do C&P anymore. It was sold lock, stock, and barrel to the lowest bidder. In what world is that a good way to do what is essentially forensic work?

I pretty regulatory get contacted by these contractors to do C&P exams in this area. "Sure, I'd love to take a nearly 75% paycut to do forensic work for your company."

 

[Fan_of_Meehl]

Can you call it provider cowardice when the system is designed to be dysfunctional? I mean we don't even do C&P anymore. It was sold lock, stock, and barrel to the lowest bidder. In what world is that a good way to do what is essentially forensic work?

I think a lot of it is cowardice.

Collusive lying is still lying, at the end of the day.

I don't expect anyone to accuse/catch any veterans 'malingering' or even overreporting in OP care...I don't do this because it is futile and because I stay within a therapeutic (not forensic) role.

But I do not co-sign patients' BS, either. I do not say I believe something when I don't. I don't even imply that I believe something when I truly don't.

I see many who do. I also see a lot of rubber stamping of even initial ptsd dx's and, yes, in my experience, the fear of saying no is the reason most people don't say no.

If doing the right thing even when you're fearful is 'courage' then what antonym to courage should we choose to describe the opposite state of mind?

 

[Fan_of_Meehl]

Oh man. I wish I could do this for everyone in our virtual program.

So, our Vets get educated that they can chose either our virtual pain program or in-person. When they chose virtual, they are given information about how their appointments work by three different people (me, the nurse navigator, and peer support). Information is also sent to them in the mail. Without fail on the first day of the program, someone can't work their video or "forgets" their appointments. More often then not they drop of of the program.

Note that our program is "closed" 13 week pain program. So if someone drops out we can't fill that spot. So, what happens is we have a huge waitlist because Vets feel like they have to do the program to appease their prescribers and then drop out. Its fun 🙂

I had 5 total appts today including a virtual intake. Guess how many attended the sessions on time.

ZERO.

Including not one of the three virtual appts this morning.

- I forgot
-I thought the appt was at 9 (was at 8)
- I thought the appt was 1:30 (was at 1:00)
- I thought the reminder was for my ortho appt

ALL of these pts tried various passive aggressive cluster b tactics to try to control/manipulate the situation and get me to squeeze them in somewhere. Nope, held those boundaries. See you at next scheduled session and we can problem solve around this therapy-interfering behavior.

Correction, 0 for 4 so far. Have a 2pm who still may show but not counting on it.

Edit: the patients pitched a shut out today...zero out of five attended on time.

 

[WisNeuro]

I had 5 total appts today including a virtual intake. Guess how many attended the sessions on time.

ZERO.

Including not one of the three virtual appts this morning.

- I forgot
-I thought the appt was at 9 (was at 8)
- I thought the appt was 1:30 (was at 1:00)
- I thought the reminder was for my ortho appt

ALL of these pts tried various passive aggressive cluster b tactics to try to control/manipulate the situation and get me to squeeze them in somewhere. Nope, held those boundaries. See you at next scheduled session and we can problem solve around this therapy-interfering behavior.

Correction, 0 for 4 so far. Have a 2pm who still may show but not counting on it.

I used to get so much reading done in the VA, with my ~30-40% no show rate.

 

[Sanman]

I used to get so much reading done in the VA, with my ~30-40% no show rate.

I just consider them a sponsor of my SDN commenting career.

 

[AcronymAllergy]

My VA no-show rate was probably "only" ~20%. But it definitely seemed to come in spurts. Much, much lower outside VA.

 

[WisNeuro]

My VA no-show rate was probably "only" ~20%. But it definitely seemed to come in spurts. Much, much lower outside VA.

In almost 3 years of pure private practice, I've had 3 technical no-shows of clinical patients total, IIRC. 1 of those had been hospitalized the night before the appointment and 1 passed away the week of the appointment. Worlds different than my VA clinic.

 

[PsyDuck90]

Can we also talk about the diagnosis of “vascular dementia” or AD on veteran’s problem lists based on a MoCA done by the PACT social worker? I’ve seen a string of these recently, and it’s becoming more than a little frustrating.

 

[Sanman]

Can we also talk about the diagnosis of “vascular dementia” or AD on veteran’s problem lists based on a MoCA done by the PACT social worker? I’ve seen a string of these recently, and it’s becoming more than a little frustrating.

What not comprehensive enough for you? If only there were a service or services where the SW could refer the veteran for further evaluation...

 

[Fan_of_Meehl]

Can we also talk about the diagnosis of “vascular dementia” or AD on veteran’s problem lists based on a MoCA done by the PACT social worker? I’ve seen a string of these recently, and it’s becoming more than a little frustrating.

"Best Care Anywhere"

(Just ask us!!!!)

 

[WisNeuro]

Can we also talk about the diagnosis of “vascular dementia” or AD on veteran’s problem lists based on a MoCA done by the PACT social worker? I’ve seen a string of these recently, and it’s becoming more than a little frustrating.

Hey now, MDs rely on those diagnoses to write terrible manuscripts that get published in JAMA and mischaracterize the TBI/dementia literature!

 

[Shiori]

I have a new least favorite consult cycle:
Vet is pulled off either opioids or stimulants
They get referred to me even though the Veteran is very pissed off and not anywhere near ready for change
I explain my role and what I can and can't do
I attempt MI because I'm still youthful and optimistic
We both know in our souls they don't want to a psychotherapeutic approach for their symptoms, but they agree
I do the long, tedious biopsychosocial and treatment plan
They stick around for a few sessions because they think it might convince their prescriber that their symptoms are "real" and they should go back on their prescribed drug of choice.
Slow drop off from my schedule

I'm so glad I love most of my job because some of the stuff is pretty unpleasant.

 

[Fan_of_Meehl]

I have a new least favorite consult cycle:
Vet is pulled off either opioids or stimulants
They get referred to me even though the Veteran is very pissed off and not anywhere near ready for change
I explain my role and what I can and can't do
I attempt MI because I'm still youthful and optimistic
We both know in our souls they don't want to a psychotherapeutic approach for their symptoms, but they agree
I do the long, tedious biopsychosocial and treatment plan
They stick around for a few sessions because they think it might convince their prescriber that their symptoms are "real" and they should go back on their prescribed drug of choice.
Slow drop off from my schedule

I'm so glad I love most of my job because some of the stuff is pretty unpleasant.

It's the VA Outpatient psychotherapy slog. But I am developing SO many different tools, techniques, and approaches to deal with (counter?) various forms of active disengagement attempts from psychotherapy patients.

It's like developing your chess game.

"Ah...I know this opening...I have to keep up the pressure on the center pawns and counter with a vigorous queenside attack after we make the exchange."

It's really getting pretty ridiculous. They pay a PhD psychologist salary to me to painstakingly document all of my efforts to engage the patient in active treatment approaches along with every way in which they respond with active passivity.

 

[deleted1129370]

I like my no show policy. It works. I also have a whole section on misc. fees such as fees to fill out paperwork, write letters, etc. For example, I charge $550 per letter or form someone needs me to write or sign. I also have a policy for any legal correspondence or testimony, and any travel, lodging and meals associated with those requests that basically would require them to take out a second mortgage if they are considering putting me up on the stand (I try to de-incentivize people using me as their personal witness for whatever their reasons).

I have two more weeks until I finally am done with the VA, my last day is 10/27. I have spent this month and last month ensuring that I am seeing an average of 20-25 patients a week in my PP so that when I do finally leave, I am walking into a fully-stocked PP and I already have capital accrued to pay me. I have excellent business credit and credit cards (some good Chase business cards and a so so business AMEX). I have my accounting firm that does all of my books each month plus much more. Now I am trying to explore how the heck I can take on couples without saying "I won't take you if you are using insurance" and also trying to find a way to do psych testing that doesn't require me to go through insurance because I refuse to jump through the hoops to basically get less per hour in testing than I would in therapy.

 

[PsyDWannabe]

I had 5 total appts today including a virtual intake. Guess how many attended the sessions on time.

ZERO.

Including not one of the three virtual appts this morning.

- I forgot
-I thought the appt was at 9 (was at 8)
- I thought the appt was 1:30 (was at 1:00)
- I thought the reminder was for my ortho appt

ALL of these pts tried various passive aggressive cluster b tactics to try to control/manipulate the situation and get me to squeeze them in somewhere. Nope, held those boundaries. See you at next scheduled session and we can problem solve around this therapy-interfering behavior.

Correction, 0 for 4 so far. Have a 2pm who still may show but not counting on it.

Edit: the patients pitched a shut out today...zero out of five attended on time.

Sounds like you’re running a Dementia clinic over there…

 

[PsyDWannabe]

Can we also talk about the diagnosis of “vascular dementia” or AD on veteran’s problem lists based on a MoCA done by the PACT social worker? I’ve seen a string of these recently, and it’s becoming more than a little frustrating.

I can’t even laugh at this one like I do the others, this is just infuriating

 

[Fan_of_Meehl]

Sounds like you’re running a Dementia clinic over there…

Nah...

Actually a malingering Axis II funhouse full of those pretending to be demented ('muh mTBI')

 

[WisNeuro]

Nah...

Actually a malingering Axis II funhouse full of those pretending to be demented ('muh mTBI')

Yeah, actual dementia eval no-show rates are pretty low.

 

[psycho1391]

I have a new least favorite consult cycle:
Vet is pulled off either opioids or stimulants
They get referred to me even though the Veteran is very pissed off and not anywhere near ready for change
I explain my role and what I can and can't do
I attempt MI because I'm still youthful and optimistic
We both know in our souls they don't want to a psychotherapeutic approach for their symptoms, but they agree
I do the long, tedious biopsychosocial and treatment plan
They stick around for a few sessions because they think it might convince their prescriber that their symptoms are "real" and they should go back on their prescribed drug of choice.
Slow drop off from my schedule

I'm so glad I love most of my job because some of the stuff is pretty unpleasant.

Sounds like some of my consults!

 

[Sanman]

My new favorite response from a recent admission to our primary care team for which I received a consult. Vet has MH and non-compliance issues going back decades. I call and explain the reason for the consult..."I already know I'm crazy, what do I need to talk to you for?"

A least he is honest.

 

[deleted1129370]

My new favorite response from a recent admission to our primary care team for which I received a consult. Vet has MH and non-compliance issues going back decades. I call and explain the reason for the consult..."I already know I'm crazy, what do I need to talk to you for?"

A least he is honest.

Ah....non-compliance issues. Sure...I'll take him on and we will MI him right through total obedience. But if you act now, for only $19.99 we can also ensure that he comes when called and pees in the cup every visit. This is a limited-time offer, so act now before our patience runs out.

 

[Sanman]

Ah....non-compliance issues. Sure...I'll take him on and we will MI him right through total obedience. But if you act now, for only $19.99 we can also ensure that he comes when called and pees in the cup every visit. This is a limited-time offer, so act now before our patience runs out.

I'm sure my magical powers will do something the previous dozen MH providers failed to do.

 

[cara susanna]

Yeah, I love when referrals are like "we don't know what to do with this patient, help." Like I'm gonna be any different?

 

[Fan_of_Meehl]

I'm sure my magical powers will do something the previous dozen MH providers failed to do.

Behavior is such a better indicator that voiced interest in 'getting help' in therapy.

These days, I 'offer help' in the form of time-limited but frequent/weekly episodes of care (6 to 12 sessions) and then evaluate: (1) veteran's track record of engagement (attendance, self-change focus/goals, homework completion) and (b) graphs of sx self-report measures.

The modal outcome of this process is:

(a) I have documented multiple, ongoing issues with client non-engagement with the offered/scheduled therapy

(b) sx self-report shows no improvement

(c) I try to problem-solve with the client to try to address these barriers to their engagement (e.g. 50% no show/cancellation rate)

(d) client takes it personally, gets pissed, say I'm not helping them

(e) I patiently, matter of factly, but steadfastly try to process their reactions in therapy to my suggestion we try to attend to engagement, motivational interviewing yadayadayada

(f) they passively drop out of therapy in the following weeks

 

[Fan_of_Meehl]

Yeah, I love when referrals are like "we don't know what to do with this patient, help." Like I'm gonna be any different?

My fave was a recent referral for specialty (PCT) "time limited EBP" tx for a veteran...

literally 4 wks after the referring psychologist had thrown in the towel after PE session 3 or 4 with the veteran, clearly documenting that the veteran never did any worksheets and was persistently refusing to do them and didn't have time to do them.

How is CPT virtually going to go any better?

Our PCT has become a dumping ground for CBOC providers to 'turf' annoying/noncompliant pts who happen to carry a ptsd dx.

 

[Sanman]

Behavior is such a better indicator that voiced interest in 'getting help' in therapy.

These days, I 'offer help' in the form of time-limited but frequent/weekly episodes of care (6 to 12 sessions) and then evaluate: (1) veteran's track record of engagement (attendance, self-change focus/goals, homework completion) and (b) graphs of sx self-report measures.

The modal outcome of this process is:

(a) I have documented multuple, ongoing issues with client non-engagement with the offered/scheduled therapy

(b) sx self-report shows no improvement

(c) I try to problem-solve with the client to try to address these barriers to their engagement (e.g. 50% no show/cancellation rate)

(d) client takes it personally, gets pissed, say I'm not helping them

(e) I patiently, matter of factly, but steadfastly try to process their reactions in therapy to my suggestion we try to attend to engagement, motivational interviewing yadayadayada

(f) they passively drop out of therapy in the following weeks

100% agree on the bolded. Now, you have no shortage of referrals for EBP therapy, so you can do that.

As a member of a primary care team, I am limited as far as referrals. If I did this to all my folks, I would not work. Then I will get yelled at about RVUs.

 

[clausewitz2]

My new favorite response from a recent admission to our primary care team for which I received a consult. Vet has MH and non-compliance issues going back decades. I call and explain the reason for the consult..."I already know I'm crazy, what do I need to talk to you for?"

A least he is honest.

Got a hospital consult once while doing C&L work, patient admitted for some kidney issue, consult is for "SI". Urgent, 3 PM type of consult. Patient turns out to have a very well-established and long-standing BPD diagnosis but is gainfully employed, in a reasonably stable relationship, generally hopeful. Thing is, they asked if she had thought about suicide as part of some screen, and she honestly answered yes, because "I have thought about suicide every day for ten years, that's what I have skills for."

Not quite as bad as an overnight stat consult for someone in active labor who screened "positive" on a PHQ-9. Like, what exactly is it I am going to do in this situation at 3 AM?

 

[Sanman]

Got a hospital consult once while doing C&L work, patient admitted for some kidney issue, consult is for "SI". Urgent, 3 PM type of consult. Patient turns out to have a very well-established and long-standing BPD diagnosis but is gainfully employed, in a reasonably stable relationship, generally hopeful. Thing is, they asked if she had thought about suicide as part of some screen, and she honestly answered yes, because "I have thought about suicide every day for ten years, that's what I have skills for."

Not quite as bad as an overnight stat consult for someone in active labor who screened "positive" on a PHQ-9. Like, what exactly is it I am going to do in this situation at 3 AM?

I once had a physician in a nursing home write a stat psych consult for a patient who stated "please shoot me" to his physical therapist in the middle of rehab. He was not amused when I woke him up at 11:30pm to do a risk assessment after driving over there after work. Neither was I.

Second story, (also a cluster B, but untreated), who once checked himself into the ER after having a fight with family and stated he would shoot himself. Once he got on the psych unit he tried to check out and take back the plan because they told him he could not smoke on the unit.

 

[Fan_of_Meehl]

I once had a physician in a nursing home write a stat psych consult for a patient who stated "please shoot me" to his physical therapist in the middle of rehab. He was not amused when I woke him up at 11:30pm to do a risk assessment after driving over there after work. Neither was I.

Second story, (also a cluster B, but untreated), who once checked himself into the ER after having a fight with family and stated he would shoot himself. Once he got on the psych unit he tried to check out and take back the plan because they told him he could not smoke on the unit.

In my experience, reports of 'pt said HI' 90%+ of the time isn't even HI and almost never is an actual serious, credible, and imminent threat to cause serious physical harm to another person with the apparent intent and ability to carry out the threat.

Very often the strong language ("kill" or "f*** him up!") merely represents the extreme degree of the felt/expressed emotion (anger/resentment) toward the target of the anger rather than homicidal ideation, per se. A little common sense interviewing around this can be done and documented.

Unfortunately, most people in the VA are IMMEDIATELY motivated to play "tag...you're it!!!!!" with a provider ASAP when an angry vet says something...angry in their presence...especially if it's super vague. Rather than attempt to clarify, they panic and try to pass the hot potato off to a nearby provider. My pet peeve is when other licensed MH providers try to pull this sh$$ on me in 'stealth mode.'

"Do you have any openings today? Mr. X needs him some CPT...STAT!!!!!."

Friggin' NP's, lol

"Nah...CPT session #1 will keep til next Thu...enter a consult for therapy."

 

[Fan_of_Meehl]

Can we also talk about the diagnosis of “vascular dementia” or AD on veteran’s problem lists based on a MoCA done by the PACT social worker? I’ve seen a string of these recently, and it’s becoming more than a little frustrating.

We had a (pseudo)neuropsychologist provider at our site (no longer here) who would explain (speculate?) ANY apparent lower than average test scores as, "likely due to microangiopathic changes in...blah blah blah." Like...DUDE...is there any actual specific evidence for this etiology/ underlying pathophysiology or do you just like typing "microangiopathic" over and over again?

 

[aim-agm]

In my experience, reports of 'pt said HI' 90%+ of the time isn't even HI and almost never is an actual serious, credible, and imminent threat to cause serious physical harm to another person with the apparent intent and ability to carry out the threat.

Very often the strong language ("kill" or "f*** him up!") merely represents the extreme degree of the felt/expressed emotion (anger/resentment) toward the target of the anger rather than homicidal ideation, per se. A little common sense interviewing around this can be done and documented.

Unfortunately, most people in the VA are IMMEDIATELY motivated to play "tag...you're it!!!!!" with a provider ASAP when an angry vet says something...angry in their presence...especially if it's super vague. Rather than attempt to clarify, they panic and try to pass the hot potato off to a nearby provider. My pet peeve is when other licensed MH providers try to pull this sh$$ on me in 'stealth mode.'

"Do you have any openings today? Mr. X needs him some CPT...STAT!!!!!."

Friggin' NP's, lol

"Nah...CPT session #1 will keep til next Thu...enter a consult for therapy."

There's a part of me that fantasizes about saying the following:
"So you are saying that this person credibly threatened the life of a federal employee performing their duties, and your response just to send them to mental health rather than alert the police? Are you familiar with the federal crime of 'misprision of a felony'?"

 

[aim-agm]

Got a hospital consult once while doing C&L work, patient admitted for some kidney issue, consult is for "SI". Urgent, 3 PM type of consult. Patient turns out to have a very well-established and long-standing BPD diagnosis but is gainfully employed, in a reasonably stable relationship, generally hopeful. Thing is, they asked if she had thought about suicide as part of some screen, and she honestly answered yes, because "I have thought about suicide every day for ten years, that's what I have skills for."

Not quite as bad as an overnight stat consult for someone in active labor who screened "positive" on a PHQ-9. Like, what exactly is it I am going to do in this situation at 3 AM?

Two of my favorite STAT! consults:

1) Stab victim in ED. Consulted because he was loudly conspiring with his paramour to kill somebody...specifically, the person who stabbed him. ED would not let me speak to patient because they were scared he would explode. It got so much better from there.

2) Consult because a patient on medical floor fashioned an "improvised weapon" and they were concerned he was planning to attack staff.
Review of weapon found it to be a pair of butterknives taped together.
Review of patient found him to be a very pleasant man wondering where his backscratcher went.
Management:
-Counseled patient that if he replaced one of the knives with a fork, it would work better for its intended use.
-I was presenting case conference that day, so included case for impressions and input from peers.

 

[AcronymAllergy]

We had a (pseudo)neuropsychologist provider at our site (no longer here) who would explain (speculate?) ANY apparent lower than average test scores as, "likely due to microangiopathic changes in...blah blah blah." Like...DUDE...is there any actual specific evidence for this etiology/ underlying pathophysiology or do you just like typing "microangiopathic" over and over again?

Yeah, it can be an easy out. Although to be fair, cardiovascular disease, and cardiovascular risk factors, are pretty common, especially in VA, so it's almost always on the differential at least to start. Probably 80+% of the folks I saw in VA who were over 50 had at least two, and often all three, of: hypertension, hyperlipidemia, and type 2 diabetes.

Or writing "microangiopathic" in reports made him feel smarter. Could be both.

 

[deleted1129370]

My fave was a recent referral for specialty (PCT) "time limited EBP" tx for a veteran...

literally 4 wks after the referring psychologist had thrown in the towel after PE session 3 or 4 with the veteran, clearly documenting that the veteran never did any worksheets and was persistently refusing to do them and didn't have time to do them.

How is CPT virtually going to go any better?

Our PCT has become a dumping ground for CBOC providers to 'turf' annoying/noncompliant pts who happen to carry a ptsd dx.

My "time limited" EBP:

 

[deleted1129370]

Yeah, it can be an easy out. Although to be fair, cardiovascular disease, and cardiovascular risk factors, are pretty common, especially in VA, so it's almost always on the differential at least to start. Probably 80+% of the folks I saw in VA who were over 50 had at least two, and often all three, of: hypertension, hyperlipidemia, and type 2 diabetes.

Or writing "microangiopathic" in reports made him feel smarter. Could be both.

Didn't you hear? Placing "micro" in front of something is the newest trend these days.