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

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Fan_of_Meehl

Fan_of_Meehl

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Post all your concerns, frustrations, ideas, and experiences as a VA mental health provider of any discipline.
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I think we need to fund mandatory Moral Reconation Therapy for all VA administrators nationwide.
 
Push an EBP, have clinicians sign up for said EBP, provide no logistical support for said EBP (Had to print out my own Handbook, buy my own folders to handout to veterans, etc). Then they wonder what is limiting clinicians from implementing EBPs.

Oh, and useless bureaucracy everywhere designed to make you give up trying to get stuff like travel reimbursements.
 
Sanman said:
Oh, and useless bureaucracy everywhere designed to make you give up trying to get stuff like travel reimbursements.
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Yeah, having several thousand dollar a year for conferences and CE sure is nice. Also, not having to pay for licensure or board certification. I don't miss having to fill out a **** ton of forms to have like a 25% chance of reimbursement in the VA for one conference a year.
 
Pragma said:
1926 wRVUs isn't so bad. Unless it doesn't matter and you do 1.5-2X of that anyways because of unfunded mandates.
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Precisely. Management would freak out if 'productiviy' dropped below 90% but has no problem with providers logging 140%+ and being held to the same standard...all the while cooing about how devoted they are to helping providers 'avoid burnout.'

Another gripe is the instantiation of two diametrically opposed 'access' philosophies with providers caught in between: (a) on the one hand, they push open-access for all, same day walk-in appointments, wraparound whole health open-ended OMFG we can't skimp on treatment becase #BeThere and one-suicide-is-too-many, spare no expense and multiple followup calls after multiple no-shows while, simultaneously, screeching about how we need to adopt a (b) hard-assed managed-care 'shape your ass up and do highly structured EBT protocols so we can demonstrate progressive symptom checklist score drops resulting in full remission in 12 weeks or GTFO of therapy' approach.

It's a schizophrenogenic place.
 
I think I'm still a practicum student at one VA. HR was insistent I have a structured exit interview and return my badge. They then didn't answer their phone for two months and only called me back to tell me when they were going on vacation and couldn't see me. They refused to see me when I showed up in-person, figuring I could at least return the badge.

I don't intend for this to apply to providers, but I always got the impression VAs were at least 50% charity programs designed to give "jobs" to vets who are basically unemployable. Haven't run the numbers, but I could see it actually being cheaper to just give them welfare and replace them with functioning adults, but I'm guessing that isn't politically acceptable.
 
Ollie123 said:
I think I'm still a practicum student at one VA. HR was insistent I have a structured exit interview and return my badge. They then didn't answer their phone for two months and only called me back to tell me when they were going on vacation and couldn't see me. They refused to see me when I showed up in-person, figuring I could at least return the badge.

I don't intend for this to apply to providers, but I always got the impression VAs were at least 50% charity programs designed to give "jobs" to vets who are basically unemployable. Haven't run the numbers, but I could see it actually being cheaper to just give them welfare and replace them with functioning adults, but I'm guessing that isn't politically acceptable.
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Well, service connection is essentially welfare for many. But yeah, VA HR is where incompetent people go to get jobs.
 
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WisNeuro said:
Well, service connection is essentially welfare for many. But yeah, VA HR is where incompetent people go to get jobs.
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Which brings up another issue...expecting that--across the board--that patients (and their families) who are completely financially dependent on monthly disability payments which are theoretically related to the severity of their mental health condition are not going to have a problem accurately lowering their symptom self-report during treatment.

I mean, of course I've had tons of 'success' cases who've reported significant symptom reduction over time but to think that there's not a significant proportion of that population who ain't reporting reduced psychiatric sxs for anything in the world is just plain out of touch.

On a somewhat related note, before coming to the VA, I'd never had to engage in a back and forth debate with a non-psychotic pt who was trying to convince me that they were indeed 'paranoid' (a psychotic symptom). Of couse the appropriate reframe is to highlight the boundary between extreme suspiciousness/cynicism with psychotic 'paranoia' (which pays better). The subtle irony of conceptualizing the thoroughgoing insight of a self-reporting paranoiac is often lost on this particular population, though.
 
Fan_of_Meehl said:
Precisely. Management would freak out if 'productiviy' dropped below 90% but has no problem with providers logging 140%+ and being held to the same standard...all the while cooing about how devoted they are to helping providers 'avoid burnout.'

Another gripe is the instantiation of two diametrically opposed 'access' philosophies with providers caught in between: (a) on the one hand, they push open-access for all, same day walk-in appointments, wraparound whole health open-ended OMFG we can't skimp on treatment becase #BeThere and one-suicide-is-too-many, spare no expense and multiple followup calls after multiple no-shows while, simultaneously, screeching about how we need to adopt a (b) hard-assed managed-care 'shape your ass up and do highly structured EBT protocols so we can demonstrate progressive symptom checklist score drops resulting in full remission in 12 weeks or GTFO of therapy' approach.

It's a schizophrenogenic place.
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So, you get it, cool.

The downside of my job in HBPC at a CBOC: I'm isolated from colleagues, administration, and the VA in general mostly left to do my own thing as no one really knows what I am doing or where I am.

The upside of my job in HBPC at a CBOC: I'm isolated from colleagues, administration, and the VA in general mostly left to do my own thing as no one really knows what I am doing or where I am.
 
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Sanman said:
Push an EBP, have clinicians sign up for said EBP, provide no logistical support for said EBP (Had to print out my own Handbook, buy my own folders to handout to veterans, etc). Then they wonder what is limiting clinicians from implementing EBPs.

Oh, and useless bureaucracy everywhere designed to make you give up trying to get stuff like travel reimbursements.
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I've only ever worked on the research side of the house, and I marvel at the willingness of the powers that be to overinterpret data when someone decides that it's time for a new policy or implementation.
 
The lack of support for administrative tasks can be frustrating. There are several things I do for my job that are surprisingly time-consuming (e.g., sourcing and ordering supplies, tracking down and submitting important non-clinical paperwork, etc.) and aren't part of my duties, but are necessary for the work that I do. Some of this is because we're short on administrative staff, and some of it is because our existing administrative staff just won't do it. I really don't want to have to take care of these pieces, but I'm the only one who is impacted (by which I mean, myself and my patients) by not having these pieces in place, so if I don't do them they just won't get done. I've done all of the problem-solving stuff with the higher ups, and nothing is changing for the foreseeable future.

It's not that I think I'm above a lot of these basic administrative tasks; I'm all about everyone working together and doing what needs to be done. And I enjoy the work that I do, so it really doesn't bother me that I regularly end up working extra hours on clinical and/or training tasks for which I am not compensated. What's frustrating about these particular tasks is that I'm effectively donating my time to do things that are already part of someone else's job.
 
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psychRA said:
It's not that I think I'm above a lot of these basic administrative tasks; I'm all about everyone working together and doing what needs to be done. And I enjoy the work that I do, so it really doesn't bother me that I regularly end up working extra hours on clinical and/or training tasks for which I am not compensated. What's frustrating about these particular tasks is that I'm effectively donating my time to do things that are already part of someone else's job.
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Personally, I dont mind doing my own admin stuff, but I draw the line at extra uncompensated hours. I work my 40 hrs, if you want to pay me GS-13 money for scheduling appts and silly paperwork, that is on the gubermint.
 
Fan_of_Meehl said:
Precisely. Management would freak out if 'productiviy' dropped below 90% but has no problem with providers logging 140%+ and being held to the same standard...all the while cooing about how devoted they are to helping providers 'avoid burnout.'

Another gripe is the instantiation of two diametrically opposed 'access' philosophies with providers caught in between: (a) on the one hand, they push open-access for all, same day walk-in appointments, wraparound whole health open-ended OMFG we can't skimp on treatment becase #BeThere and one-suicide-is-too-many, spare no expense and multiple followup calls after multiple no-shows while, simultaneously, screeching about how we need to adopt a (b) hard-assed managed-care 'shape your ass up and do highly structured EBT protocols so we can demonstrate progressive symptom checklist score drops resulting in full remission in 12 weeks or GTFO of therapy' approach.

It's a schizophrenogenic place.
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YES. This is it in a nutshell.

The obsession with access really gets me down. Also, my clinic acts like it supports EBPs but really doesn't in practice (e.g., threatening to close my EBP slots for "underutilization" so I have more time for the people who just come in and vent to me 1x/month). And don't get me started on how they reinforce therapy-interfering and life-threatening behavior.

Lately now they've started making us do intakes in 60 min slots. Apparently that's the standard other places. So, again, more time for "access" and less time for actual care.
 
I will say as a current trainee in neuropsych at a VA in a large city, the VA has certainly been a good training opportunity in what malingering (intentionally or otherwise) looks like in clinical practice. In only a few months I've been yelled at by at least half-a-dozen vets thinking I am in the business of denying them SC for conditions they clearly do not have. Fun times.

Also, more so than other locations I've trained at, it seems that CPRS is a) a total piece of crap technologically, and b) a repository of often contradictory information between providers. *sigh*
 
As a trainee, this thread is both enlightening and a little scary. I am currently doing a practicum at a research clinic in a VAMC, and I'm loving it and thinking about it as a full time option down the road. Other than the hiccups with getting my PIV card, I've been really enjoying the environment.
 
Hk328 said:
As a trainee, this thread is both enlightening and a little scary. I am currently doing a practicum at a research clinic in a VAMC, and I'm loving it and thinking about it as a full time option down the road. Other than the hiccups with getting my PIV card, I've been really enjoying the environment.
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Being a trainee in the VA is pretty awesome.
 
WisNeuro said:
Being a trainee in the VA is awesome. Being a faculty/provider in the VA, not so much.
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I will trust your expert opinion on all of this. To clarify, does the awesomeness continue to post-doc? Will try to maximize the ratio of awesome-to-not-awesome (LOL)
 
jdawg2017 said:
I will trust your expert opinion on all of this. To clarify, does the awesomeness continue to post-doc? Will try to maximize the ratio of awesome-to-not-awesome (LOL)
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It does. My VA post doc was amazing and I miss it.
 
jdawg2017 said:
I will trust your expert opinion on all of this. To clarify, does the awesomeness continue to post-doc? Will try to maximize the ratio of awesome-to-not-awesome (LOL)
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Yes. If I could do it all over again, I would still get my training in the VA, I would probably just not seek to stay there after training for a while like I did. The VA is still the place to be for training due to the time given to staff for training and the availability of great didactic opportunities.
 
jdawg2017 said:
I will trust your expert opinion on all of this. To clarify, does the awesomeness continue to post-doc? Will try to maximize the ratio of awesome-to-not-awesome (LOL)
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Yes. It does. I am a big fan of VA internships and post-docs. I have had fantastic opportunities. I feel like most of the trainees get shielded from some of the upper admin stuff that occur. I have found workloads to be pretty cushy, but also a high focus on didactics/trainings and supervision. To echo @WisNeuro, I would do my paid training in a heartbeat again at VAs. I get paid on the higher average compared to my peers and am getting really excellent training. I would just encourage you to find good people who you enjoy working with as supervisors, and if you can, it can be a terrific place.
 
WisNeuro said:
For those that are still there. What's keeping you there?
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Seriously? Inneffectual/inefficient systems? Contradictory mandates? Unclear adherence to mission? Lack of support from admin/HR/other departments? Inconsistent/unpredictable population who may be financially motivated to not change? Interminable bureaucracy and red tape? Inability to effect institutional change from your isolated perch?

Any one of those things is reason to jump ship. I hear a lot of "yeah, but the benefits..." What benefits? Pay seems pretty standard for the field in general- maybe higher than, say, a CMHC gig, but nobody's breaking the bank at a standard VA gig. I haven't paid for my own licensure, certifications, CEUs, or confference attendance (including travel and lodging) in years and I don't work at a VA. Research opportunities/reimbursement aren't unheard of in private sector either. I really don't get it! People are singing up for an sticking around VAs when I don't have an opening in my schedule until next June and we can't find psychologist to work in what I think is a pretty good gig and, based on you all's comments, is a much more user friendly system with a least equivalent benefits (although may VA has a better pension/retirement, but I'm not trading being miserable when I'm young for slightly less misery when I'm old!)

What would you tell/think of a client who, despite options, continued to return to such an apparently miserable environment?

Sorry- rant over!
 
I guess when I was there, I just had no real conception of what it was like outside of the VA because I had been there for a while. I will say, everywhere you go has it's problems, bureaucracy , etc. But, I can deal with that much more easily when I am treated like a professional, and given a ton of flexibility. Having higher pay and a good benefits package also helps.
 
At least for why I stay there, I think it really depends on the job. I don't see a reason to stay if you work in straight mental health or in neuropsych. I also don't see a reason to stay if you live in the midwest or the south. The regional adjustments on the coasts makes it a higher paying gig and if you work in health psych, primarily therapy in PC-MHI, Tele-health positions from home, geriatrics, or inpatient work it can be a better gig. Personally, I get time to teach/supervise (which I enjoy), the schedule is more stable and the job has better benefits as compared to geriatrics in the private sector, being assigned to a CBOC in the suburbs can mean a very short commute compared to being into the city where many of the other jobs are (geographic arbitrage if you will).
 
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I like the 8 hr workday that doesn't require evening or weekend hrs, plus not having to worry about insurance or not getting paid if I have a cancellation.
 
cara susanna said:
I like the 8 hr workday that doesn't require evening or weekend hrs, plus not having to worry about insurance or not getting paid if I have a cancellation.
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Yes, but would you also like a 6-8 hour workday in which you also do not have to worry about getting paid if you have a cancellation, and also with staff to deal with insurance for you?
 
Well, all those great training opportunities need someone to run them, right...?

Back in my training days of yore, I anticipated being career VA. Nowadays, not so much.

In addition to training, I think the VA can be good for early-career folks to get their feet wet (and start getting an idea for what systems such as VA do well and less-well administratively, along with how you'd change that if you could). I also know of some folks who've gone VA toward the ends of their careers, such as when they're tired of managing a private practice. Although this seems to be more common on the medical side.

And if you have supportive mid- and upper-leadership at your facility, it can go a long way toward buffering some of the more frustrating aspects. If your mid- and/or upper-leadership leaves something to be desire, it can be miserable.
 
WisNeuro said:
Yes, but would you also like a 6-8 hour workday in which you also do not have to worry about getting paid if you have a cancellation, and also with staff to deal with insurance for you?
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I'm a VA lifer, so you'll have to be more specific. I don't know what life is like on the outside!

I should also add that right now I'm not licensed where I live, so that's a barrier to non-VA employment. I'm not really contemplating leaving or anything anyway, but that is still a major thing.
 
AcronymAllergy said:
I also know of some folks who've gone VA toward the ends of their careers, such as when they're tired of managing a private practice. Although this seems to be more common on the medical side.
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An old supervisor of mine did this exact thing. Still has a thriving sex offender assessment and treatment practice, got tired though, went to VA, and predictably hated not being able to do his own thing (like he had done for 30 years). Lasted a year maybe.
 
ClinicalABA said:
Seriously? Inneffectual/inefficient systems? Contradictory mandates? Unclear adherence to mission? Lack of support from admin/HR/other departments? Inconsistent/unpredictable population who may be financially motivated to not change? Interminable bureaucracy and red tape? Inability to effect institutional change from your isolated perch?

Any one of those things is reason to jump ship. I hear a lot of "yeah, but the benefits..." What benefits? Pay seems pretty standard for the field in general- maybe higher than, say, a CMHC gig, but nobody's breaking the bank at a standard VA gig. I haven't paid for my own licensure, certifications, CEUs, or confference attendance (including travel and lodging) in years and I don't work at a VA. Research opportunities/reimbursement aren't unheard of in private sector either. I really don't get it! People are singing up for an sticking around VAs when I don't have an opening in my schedule until next June and we can't find psychologist to work in what I think is a pretty good gig and, based on you all's comments, is a much more user friendly system with a least equivalent benefits (although may VA has a better pension/retirement, but I'm not trading being miserable when I'm young for slightly less misery when I'm old!)

What would you tell/think of a client who, despite options, continued to return to such an apparently miserable environment?

Sorry- rant over!
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Personally, the following:

1) decent pay/benefits with high job security and lessened malpractice risk
2) live <10 mins away (no commute) in a house that I don't want to sell
3) rural area so not a wide variety of clin psych jobs ar 6 figures+ for 40hrs/wk
4) not having to worry about financial hit from no-shows or cancellations
5) nice big corner office with private bathroom and set up just like I like it (I lucked out)
6) in my current gig I'm 80% time outpt therapy in post-deployment clinic and 20% time in TBI clinic / internship...which I find to be a nice mix
7) I like the fact that I get to do a good deal of longer term therapy without fussing withmanaged care
8) inertia/laziness
9) hope that things might eventually improve
 
WisNeuro said:
For those that are still there. What's keeping you there?
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I can't picture a better setting in which to be a psychologist.

Yes, I complain about the annoyances. Those annoyances are real. But they're not even close to outweighing the benefits of working here. And I'm not talking about employee benefits; I could make a lot more money at Kaiser, in private practice, etc. I mean the benefits of working in our country's largest integrated health care system. I've worked in several VA hospitals, and there simply is no other health care system that provides as much mental health care to its patients. People like to complain about VA care, but I can promise you that Kaiser, BC/BS, community mental health systems, etc. don't have anything close to the VA's resources.

Training: I get to provide excellent clinical training to a constant supply of new trainees. It's rewarding, and my system isn't constantly nagging me to reduce my supervision time.

Plus, there's the fact that I have never had to deal with a single insurance company during my entire career. That's priceless.
 
psychRA said:
Plus, there's the fact that I have never had to deal with a single insurance company during my entire career. That's priceless.
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This and an increase medicare audits for higher volume providers are the reasons I ultimately left the PP world and will be at the VA until at least 2021.
 
cara susanna said:
I'm a VA lifer, so you'll have to be more specific. I don't know what life is like on the outside!

I should also add that right now I'm not licensed where I live, so that's a barrier to non-VA employment. I'm not really contemplating leaving or anything anyway, but that is still a major thing.
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Licensure is fairly easy to get. And, most non-VA institutional jobs pay for your licensure, board certification, etc.
 
psychRA said:
Plus, there's the fact that I have never had to deal with a single insurance company during my entire career. That's priceless.
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Many of us don't have to do much. We have an entire department that deals with pror auths. Worst I have to do about once a month is sign off on a prior auth form that I've trained an assistant to pre-fill out.
 
Sanman said:
This and an increase medicare audits for higher volume providers are the reasons I ultimately left the PP world and will be at the VA until at least 2021.
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Medicare audits are a big nothing. They come in, look at your work, look at your billing, and say “looks about right”.
 
I left the VA about six months ago. Mostly I was frustrated with the lack of career growth; I felt like I hadn't done all the work I did to just be in a clinical rut. My new job is amazing on a lot of levels and I get to branch out and grow. There's things I miss about the VA, but my life has improved a lot not being there. Is anyone else reading Shulkin's book? I just started it yesterday. Interesting read so far.
 
Psycycle said:
I left the VA about six months ago. Mostly I was frustrated with the lack of career growth; I felt like I hadn't done all the work I did to just be in a clinical rut. My new job is amazing on a lot of levels and I get to branch out and grow. There's things I miss about the VA, but my life has improved a lot not being there. Is anyone else reading Shulkin's book? I just started it yesterday. Interesting read so far.
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Welcome to the club. Once you get to a year, you get a chip. Haven't read it yet, but read a decent article with him, and it's on my list.
 
It was great training, but I completely agree about trainees being mostly shielded from most of the admin/red tape/politics. Being able to receive plenty of supervision, didactics, etc. was great. I was fortunate to have supervisors who were rock stars within the system, which allowed me to maximize my training and continue to make connections within and outside of the VA system.

I think for early career it could work, but there isn't really much upward mobility if you want to do primarily clinical work and want to avoid middle management hell. The pay quickly tops out. I think most of my internship cohort stayed for the VA lifestyle bc they had families and they lined up sweet gigs. Myself and the other neuro person went the AMC route. Now that I'm settled into private practice, I'd likely never consider giving up the amount of flexibility and lifestyle improvements I have now.
 
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