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

[Sanman]

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Since I left the VA system (and even before) I started to believe that a healthcare system that is based solely on ones former occupation is unnecessary, unjustified, and...unjust to the rest of society. I have since been of the opinion that a nationwide VHA Healthcare System should NOT exist at all. I have disclosed this opinion before, but not FULLY discussed it here. SDN is NOT really the most friendly place to discus such an unpopular point of view.

I'm not sure that would be the most unpopular stance in the world, though I won't be voting for you while VHA helps pay the bills.

 

[erg923]

I am still interested in hearing your point of view, if you care to run the risk of becoming unpopular here.

I mean, that's kind of it. I don't think the level/amount of a humans healthcare provisions/coverage should be based on ones former occupation...at all.

The connection to/between occupation and health coverage that people in this country seem to hold so dear is totally bizarre to me. That notion really only came about less than 50 years ago.

 

[hum1]

I mean, that's kind of it. I don't think the level/amount of a humans healthcare provisions/coverage should be based on ones former occupation...at all.

The connection to/between occupation and health coverage that people in this country seem to hold so dear is totally bizarre to me. That notion really only came about less than 50 years ago.

I hadn’t thought about this as I came from a country that has a national health care system that offers all of its citizens free access to healthcare. I guess I have never really thought about the VA in the way you’ve describe it because I always saw it as the part of the national health care system that is specialized in veterans. But then wait a minute… there is no national health care system…

 

[AcronymAllergy]

RE: productivity mandates, I'll say that I see the point of them, because there are certainly providers who "coast" and then complain when called out on it. And from an efficiency standpoint, it helps to have a way of tracking how time is being spent, if policies are having intended effects, etc. All that being said, what happens with VA (and probably other systems) is that the selected productivity metric becomes the only piece of information used, rather than it being one among many (including actually talking with the providers, especially when setting the guidelines and in reviewing situations of people who aren't meeting them).

As for training, I can see it from both sides. It's not uncommon for people not involved in training to think those in training have a pretty cushy setup and aren't actually doing all that much. Especially if those individuals shave protected time. For those involved in training, especially if you work at a facility that isn't especially supportive to training (or psychology training specifically) to begin with, they might already feel spread too thin by the ungodly amount of administrative and other time-sink tasks that pop up every day and for which they may receive little or no protected time. For example, training faculty might get time offsets for providing supervision, but not for attending training meetings, leading/attending seminars and trainee presentations, completing trainee paperwork, etc. Much like many other non-clinical VA duties, those are just things you're supposed to find the time to do.

 

[WisNeuro]

I mean, that's kind of it. I don't think the level/amount of a humans healthcare provisions/coverage should be based on ones former occupation...at all.

The connection to/between occupation and health coverage that people in this country seem to hold so dear is totally bizarre to me. That notion really only came about less than 50 years ago.

Well, for a good portion of non-VA patients, it's based on one's current occupation. Not sure that's a better option, either.

 

[cara susanna]

The astonishing thing about 'productivity' as they measure it (some sort of RVU ratio that they use to calculate a 'percentage' that basically are your quarterly RVU's divided by the 'expected' (100%) RVUs which is just some median RVU (for a full-time VA psychologist) that they calculated in some sample years ago) is that there is literally NOTHING you can change in your behavior to meaningfully increase it. I mean, if all of your slots are full and you don't do your own scheduling (we don't) and you see everyone who shows up for their appointments (we do) then the only things that are making this number 'too low' are either: (a) you are not mapped for 'enough' clinical hours in your grid--this is not your fault, someone else determines your grid, not you; or (b) you have a good number of no-shows/ cancellations which, again, is not your fault.

Has anyone here been given feedback that your 'productivity' is 'too low' according to their metric? What were you given as suggestions in terms of behavior change (on your part) that could possibly 'increase' your 'productivity' as measured in this manner? If they ever take adverse action against someone for the crime of 'low productivity' how would that stick? I mean, it can be demonstrated that we don't/can't do much (if anything) to 'increase' our productivity (see above). It also just smacks of the inherent philosophy of 'blame the provider' (and never, ever, ever, look at systems issues or other factors) whenever the big wigs at national come up with a solution in search of a problem.

I actually had low RVUs about a year or two ago, which was my first year full time in OPMH. My supervisor was nice about it, told me that they thought I was just undercoding (which it turned out that I was). Basically they said what you said, it's not like I do my own scheduling that much so it's as much their job as mine to ensure productivity is met. I still met standards but I didn't get "exceeds" so no bonus. The frustrating thing was that was the first year of COVID and administration was disregarding productivity at that time. Ohh well.

I should add though that I've since taken on a part-time administrative/coordinator position that resulted in a lower FTE and therefore RVU target. I'm never going to be a high RVU generator because I refuse to just keep people in my office if there's nothing more for our agenda. It frustrates me that leave isn't taken into account, although I know one clinic lead who does do that (not at my facility, lol).

erg - honestly, I agree with you, but until we have Medicare for all or universal healthcare I see the VA as a necessary thing. I totally concur that it's unfair to the rest of the country, though.

 

[Sanman]

I actually had low RVUs about a year or two ago, which was my first year full time in OPMH. My supervisor was nice about it, told me that they thought I was just undercoding (which it turned out that I was). Basically they said what you said, it's not like I do my own scheduling that much so it's as much their job as mine to ensure productivity is met. I still met standards but I didn't get "exceeds" so no bonus. The frustrating thing was that was the first year of COVID and administration was disregarding productivity at that time. Ohh well.

I should add though that I've since taken on a part-time administrative/coordinator position that resulted in a lower FTE and therefore RVU target. I'm never going to be a high RVU generator because I refuse to just keep people in my office if there's nothing more for our agenda. It frustrates me that leave isn't taken into account, although I know one clinic lead who does do that (not at my facility, lol).

erg - honestly, I agree with you, but until we have Medicare for all or universal healthcare I see the VA as a necessary thing. I totally concur that it's unfair to the rest of the country, though.

That's the thing. The only thing you can do is code aggressively and maximize the billing for the people who show up (longer sessions or more sessions). This is why it ends up being bad policy. This encourages not discharging folks that are not making progress for the sake of numbers. You keep the people that consistently show up rather than see who needs help. That, ironically, creates a back up because it just makes sure you are doing something, not the right thing. I often feel stuck in that cycle because I am in a low volume specialty area and if I don't "find" rvus they send me to help in other areas, which has led to other services dumping nightmare cases on me.

 

[cara susanna]

That's the thing. The only thing you can do is code aggressively and maximize the billing for the people who show up (longer sessions or more sessions). This is why it ends up being bad policy. This encourages not discharging folks that are not making progress for the sake of numbers. You keep the people that consistently show up rather than see who needs help. That, ironically, creates a back up because it just makes sure you are doing something, not the right thing. I often feel stuck in that cycle because I am in a low volume specialty area and if I don't "find" rvus they send me to help in other areas, which has led to other services dumping nightmare cases on me.

YUP. You can get more RVUs doing 60 min supportive therapy where you just smile and nod and say "uh huh."

It's just yet another way that the VA prioritizes numbers over actual patient care and quality of care. Like we have patients who have asked us not to contact them, but then they're HRF so we have to make contact attempts or we'll fail the suicide prevention metrics. Like, how does that make any sense?

 

[Fan_of_Meehl]

YUP. You can get more RVUs doing 60 min supportive therapy where you just smile and nod and say "uh huh."

It's just yet another way that the VA prioritizes numbers over actual patient care and quality of care. Like we have patients who have asked us not to contact them, but then they're HRF so we have to make contact attempts or we'll fail the suicide prevention metrics. Like, how does that make any sense?

Not only that...

But, on one occasion (when the context is they are exhorting you to 'up your productivity numbers' by ensuring that you do at least a 53 minute session (I think it is) to get the 'high score' of 3.0 RVU's for the encounter (instead of 2.0 RVU's you get for a somewhat shorter session) the instruction is that you should do as many sessions as possible at 53+ minutes. If you don't want to falsify documentation (which we don't) you need to get really good at orchestrating a precise end time of the session somewhere between 0 and 7 mins prior to the start of your next session (which gets tricky/stressful). However, what kills me is that, on another occasion (when you're raising the issue of not having enough time between sessions to go to the bathroom, score your instruments, do your documentation, etc.) the response is that you need to do sessions of 45 mins or less so that you have adequate time to do those things. You literally cannot win. There is no emphasis on doing the right thing in terms of doing the length of session that makes sense for that client, at that point in therapy, and relative to the tasks that you need to accomplish that session and the items on the agenda. Everything is warped/bent around the 'god' of some population-level 'metric' so that people 'look good.'

I'll just leave this here:

Amazon product ASIN 0691174954

 

[Sanman]

Not only that...

But, on one occasion (when the context is they are exhorting you to 'up your productivity numbers' by ensuring that you do at least a 53 minute session (I think it is) to get the 'high score' of 3.0 RVU's for the encounter (instead of 2.0 RVU's you get for a somewhat shorter session) the instruction is that you should do as many sessions as possible at 53+ minutes. If you don't want to falsify documentation (which we don't) you need to get really good at orchestrating a precise end time of the session somewhere between 0 and 7 mins prior to the start of your next session (which gets tricky/stressful). However, what kills me is that, on another occasion (when you're raising the issue of not having enough time between sessions to go to the bathroom, score your instruments, do your documentation, etc.) the response is that you need to do sessions of 45 mins or less so that you have adequate time to do those things. You literally cannot win. There is no emphasis on doing the right thing in terms of doing the length of session that makes sense for that client, at that point in therapy, and relative to the tasks that you need to accomplish that session and the items on the agenda. Everything is warped/bent around the 'god' of some population-level 'metric' so that people 'look good.'

I'll just leave this here:

Amazon product ASIN 0691174954

Pretty much, I got very good at this skill working on the private end of things and wanting to be honest. Though, I am sure many people just lie. I have also noticed a huge trend in overbilling things like phone calls in some parts of the service. The unethical billing makes it harder for those trying to be ethical as we get pressured as the only ones not "keeping up" with the metrics.

 

[Pragma]

RVUs are generally irrelevant at VAs, right? It's so low there relative to other settings (like under 2k last I had seen). So why would they care about maximizing RVUs for individual therapy sessions if psychologists are hitting like 200% of their targets to meet all of the other BS bureaucratic mandates from central office and facility admins?

 

[Sanman]

RVUs are generally irrelevant at VAs, right? It's so low there relative to other settings (like under 2k last I had seen). So why would they care about maximizing RVUs for individual therapy sessions if psychologists are hitting like 200% of their targets to meet all of the other BS bureaucratic mandates from central office and facility admins?

That depends on how you setup the metrics. Locally, neuropsych and other specialty services got yelled at by hospital hire ups for not seeing 7 patients a day and having a grid. Good luck meeting that metric.

 

[Pragma]

That depends on how you setup the metrics. Locally, neuropsych and other specialty services got yelled at by hospital hire ups for not seeing 7 patients a day and having a grid. Good luck meeting that metric.

Well, that's what I mean by a BS bureaucratic mandate from facility admins 🤣

I have walked a mile in these shoes - don't they have dumber things to try to beancount than RVUs I suppose is a way to rephrase my question...

 

[Sanman]

Well, that's what I mean by a BS bureaucratic mandate from facility admins 🤣

I have walked a mile in these shoes - don't they have dumber things to try to beancount than RVUs I suppose is a way to rephrase my question...

Not this year. Numbers were a mess nationally in 2020. Another big issue is cannibalization of the patient population for a while. It used to be that OPMH was in the office, I was home-based primary care, PC-MHI was in the clinics. For a while we were all virtual and it was a mess. By the time the game of telephone happened I feel like we are dealing with the repercussions of 2020 in 2022. This is what happens when you try to walk forwards while constantly looking backwards, then wonder why you keep smacking into telephone poles.

 

[Pragma]

Not this year. Numbers were a mess nationally in 2020. Another big issue is cannibalization of the patient population for a while. It used to be that OPMH was in the office, I was home-based primary care, PC-MHI was in the clinics. For a while we were all virtual and it was a mess. By the time the game of telephone happened I feel like we are dealing with the repercussions of 2020 in 2022. This is what happens when you try to walk forwards while constantly looking backwards, then wonder why you keep smacking into telephone poles.

I am not sure how other facilities were nationwide, but the one I was at was heavily mandating every provider to be telehealth-ready (years before the pandemic). I am guessing that those sites were able to pivot a little more quickly. But, knowing VA, that's probably a bad guess and I should assume some sort of administrative catch-22 emerged.

 

[Sanman]

I am not sure how other facilities were nationwide, but the one I was at was heavily mandating every provider to be telehealth-ready (years before the pandemic). I am guessing that those sites were able to pivot a little more quickly. But, knowing VA, that's probably a bad guess and I should assume some sort of administrative catch-22 emerged.

Ours was not ready and it was a mess. Add to that poor communication between services and I was gobsmacked at the the stupidity. Nothing like a provider referring a patient who can't/won't attend telephone/VVC appts to another service who was also virtual at the time. Dude, we are all providing the same care, what do you think is getting done here?

 

[cara susanna]

I've mentioned this, but our service is especially obsessed with converting phone to VVC. Why? There isn't any evidence that video is better than phone. Some patients prefer phone to video, and let's not get started on Zoom fatigue...

 

[Sanman]

I've mentioned this, but our service is especially obsessed with converting phone to VVC. Why? There isn't any evidence that video is better than phone. Some patients prefer phone to video, and let's not get started on Zoom fatigue...

National mandate...phone services may be phased out at some point after the emergency order expires. Not that we can't continue doing it at the VA anyway, but they won't if they can bill for the services another way. There may be a way around that though now.

 

[cara susanna]

Also, my local supervisor is at least very understanding of session length and encourages us to keep sessions to 45 min to give us charting time. I do really appreciate that, especially reading what some of you are dealing with!

Everyone I know who is super behind and stressed out about notes (including working on weekends) does longer sessions.

 

[Fan_of_Meehl]

RVUs are generally irrelevant at VAs, right? It's so low there relative to other settings (like under 2k last I had seen). So why would they care about maximizing RVUs for individual therapy sessions if psychologists are hitting like 200% of their targets to meet all of the other BS bureaucratic mandates from central office and facility admins?

Real answer? Because it's consistent with the organizational schema of 'The provider is always to blame / must be punished.' Pick (or just make up) your 'offense.'

 

[AcronymAllergy]

RVUs are generally irrelevant at VAs, right? It's so low there relative to other settings (like under 2k last I had seen). So why would they care about maximizing RVUs for individual therapy sessions if psychologists are hitting like 200% of their targets to meet all of the other BS bureaucratic mandates from central office and facility admins?

I don't remember the exact numbers VA had, but I think the 50th percentile for psychologists was in the low to mid-2000's. Although that doesn't mean local sites have to stick to that exact goal.

But for the reasons listed above, this is why I would say management and supervisors should consider multiple metrics, including your utilization and no-show rates. I suspect the reason they don't incorporate leave into the wRVU expectation is that theoretically, the wRVU data that are used to set the goals were obtained by/from psychologists working in a similar setting (i.e., with similar amounts of leave taken).

 

[Pragma]

I don't remember the exact numbers VA had, but I think the 50th percentile for psychologists was in the low to mid-2000's. Although that doesn't mean local sites have to stick to that exact goal.

But for the reasons listed above, this is why I would say management and supervisors should consider multiple metrics, including your utilization and no-show rates. I suspect the reason they don't incorporate leave into the wRVU expectation is that theoretically, the wRVU data that are used to set the goals were obtained by/from psychologists working in a similar setting (i.e., with similar amounts of leave taken).

Yes, I have heard of benchmarks of 3000 to even 4000 that “take leave into account” 🤣

The number 1967 is what I remember from VA. Thought it was national - maybe not!

 

[AcronymAllergy]

Yes, I have heard of benchmarks of 3000 to even 4000 that “take leave into account” 🤣

The number 1967 is what I remember from VA. Thought it was national - maybe not!

Yeah, I'd seen the national data somewhere, somehow. I think. But I don't remember what it was.

It's hazy at this point, but I think my numbers were usually around 2500-ish.

 

[Fan_of_Meehl]

I think the median (annual) total RVU for psychologists was 1926

I don't remember the exact numbers VA had, but I think the 50th percentile for psychologists was in the low to mid-2000's. Although that doesn't mean local sites have to stick to that exact goal.

But for the reasons listed above, this is why I would say management and supervisors should consider multiple metrics, including your utilization and no-show rates. I suspect the reason they don't incorporate leave into the wRVU expectation is that theoretically, the wRVU data that are used to set the goals were obtained by/from psychologists working in a similar setting (i.e., with similar amounts of leave taken).

 

[cara susanna]

Good thing I actually have a document with the RVU requirement saved:

Psychologists should strive for a yearly productivity target above 1926 per Outpatient FTE(c) though productivity within 1733-2119 (+/- 10 percent of the median) is considered as meeting the standard, taking care not to compromise quality and patient access standards.

 

[Pragma]

Good thing I actually have a document with the RVU requirement saved:

Ah, that is what it was. If only you could stop once you hit it! I knew people doubling it.

 

[Sanman]

Ah, that is what it was. If only you could stop once you hit it! I knew people doubling it.

Now try having them drive to everyone's house and see if they can still double it! 😉

If they can, I'll stop complaining.

EDIT: Only half joking here as that was the initial mandate put on us HBPC folks by hospital administration, just like it was neuropsych, CLC, Inpatient, and everyone else

 

[Fan_of_Meehl]

Good thing I actually have a document with the RVU requirement saved:

"psychologists should *STRIVE* for a yearly productivity target of..."

{cue imagery of a clipboard-wielding psychologist running full tilt with his tie blowing in the breeze to the Chariots of Fire theme song}...

dun dun dun dun DUN dah.....

dun dun dun dah deeeeeeeeeeeee......

 

[cara susanna]

I'm hearing some rumblings about national policy regarding telework changing? Anyone know anything about this?

Man, messing with telework would be the dumbest thing the VA could do.

 

[PsychPhDone]

I'm hearing some rumblings about national policy regarding telework changing? Anyone know anything about this?

Man, messing with telework would be the dumbest thing the VA could do.

I haven't heard anything. We did get that email about the risk level color codes. I think my area is red, which according to the guidelines means max telework?

 

[Sanman]

I'm hearing some rumblings about national policy regarding telework changing? Anyone know anything about this?

Man, messing with telework would be the dumbest thing the VA could do.

I haven't heard anything, but I do know that getting mental health back in the office nationally has been like pulling teeth. I imagine there will be some guidelines to mandate minimums for inpatient, emergency consultation, etc. That said, I see more quitting in the future.

 

[summerbabe]

I'm hearing some rumblings about national policy regarding telework changing? Anyone know anything about this?

Only 2 things from my front:

Interns at my facility were told to expect to go back in person 100% a few months ago but then COVID rates rose locally and it looks like they will finish at home (with the option to come in when they want/need).

Everybody did have to redo their telework agreements which seemed to come up out of the blue.

 

[bluecolourskies]

I was looking at some open psychologist positions with the VA, and looking at this thread makes me think I should not apply lol are there some that are better than others, or are the all affected by broad sweeping policies that affect each clinic? How do I suss this out in an interview or a job listing (since they're all the same)?
At this point I am exploring career options, so it's not that working for the VA is a life-long dream or anything. Should I nix it from my list?
(Apologies if this is offensive in any way! I did a practicum in a state agency that had a pretty terrible work environment, and even after I left, you hear things from people that are still there, and I knew for sure I would never want to come back and work there. I am wondering if VA will be the same way)

 

[Sanman]

I was looking at some open psychologist positions with the VA, and looking at this thread makes me think I should not apply lol are there some that are better than others, or are the all affected by broad sweeping policies that affect each clinic? How do I suss this out in an interview or a job listing (since they're all the same)?
At this point I am exploring career options, so it's not that working for the VA is a life-long dream or anything. Should I nix it from my list?
(Apologies if this is offensive in any way! I did a practicum in a state agency that had a pretty terrible work environment, and even after I left, you hear things from people that are still there, and I knew for sure I would never want to come back and work there. I am wondering if VA will be the same way)

I honestly wouldn't be scared away due to all the bellyaching. While I am not thrilled with the direction the VA is taking recently, most other large hospital systems have already been there. IMO, the VA used to be the better option and it is slowly just becoming another option if you need a job. The flip side is that telehealth is really changing the industry and increasing the appeal of things like private practice significantly. Apartments and living in the city/downtown close to a medical center has an appeal to some of the younger folks. The mid-career folks are less interested in commutes and struggles with raising families in areas with dense, expensive housing. Working from home or close to it and better quality of life is going to have an impact on what those with experience choose to do.

 

[cara susanna]

I was looking at some open psychologist positions with the VA, and looking at this thread makes me think I should not apply lol are there some that are better than others, or are the all affected by broad sweeping policies that affect each clinic? How do I suss this out in an interview or a job listing (since they're all the same)?
At this point I am exploring career options, so it's not that working for the VA is a life-long dream or anything. Should I nix it from my list?
(Apologies if this is offensive in any way! I did a practicum in a state agency that had a pretty terrible work environment, and even after I left, you hear things from people that are still there, and I knew for sure I would never want to come back and work there. I am wondering if VA will be the same way)

Honestly, it depends on the facility and even the clinic. I personally would recommend specialty clinics or residential, but there is a lot of variation.

 

[bluecolourskies]

Honestly, it depends on the facility and even the clinic. I personally would recommend specialty clinics or residential, but there is a lot of variation.

Oh that is definitely what I’m more interested in! (inpatient/residential/IOP) so that’s good to know!! 🙂

 

[summerbabe]

How do I suss this out in an interview or a job listing (since they're all the same)?

BHIP (general mental health to use non-VA lingo) at a main medical center or any VA with poor mental health staffing is likely a workhorse position. Add in the possibility of bad leadership and you’ve got the potential for a crappy experience.

But BHIP at a non-metro VA or at an outlying clinic (CBOC in VA lingo) can have a lot more ups than downs, such as less micromanagement, more relaxed work environments, actually being able to take a real lunch, etc as long as patient access to timely care is being managed appropriately.

As cara susanna mentioned, speciality outpatient jobs (PTSD, SUDs, etc) are usually better because you have an actual chance to screen out patients who are a bad fit and discharge them (to BHIP) when you’re done with treatment. You also generally have more time allotted for things like team meetings and have increased training opportunities.

Inpt and residential can be some of the better VA jobs due to different productivity requirements and often less micromanaging. But each specific job/clinic/supervisor will be different and of course, your coworkers can range from amazing to toxic with little recourse if the latter is present (hard to fire federal workers).

Overall, the facility in question will really matter and your best bet is to try to get a sense of the work culture from people who currently work there. Unfortunately a number of VAs are experiencing enrollment demands that can’t match staff hiring/retention or are located in areas that will never be able to attract enough high-level providers, which will have negative impacts.

 

[bluecolourskies]

BHIP (general mental health to use non-VA lingo) at a main medical center or any VA with poor mental health staffing is likely a workhorse position. Add in the possibility of bad leadership and you’ve got the potential for a crappy experience.

But BHIP at a non-metro VA or at an outlying clinic (CBOC in VA lingo) can have a lot more ups than downs, such as less micromanagement, more relaxed work environments, actually being able to take a real lunch, etc as long as patient access to timely care is being managed appropriately.

As cara susanna mentioned, speciality outpatient jobs (PTSD, SUDs, etc) are usually better because you have an actual chance to screen out patients who are a bad fit and discharge them (to BHIP) when you’re done with treatment. You also generally have more time allotted for things like team meetings and have increased training opportunities.

Inpt and residential can be some of the better VA jobs due to different productivity requirements and often less micromanaging. But each specific job/clinic/supervisor will be different and of course, your coworkers can range from amazing to toxic with little recourse if the latter is present (hard to fire federal workers).

Overall, the facility in question will really matter and your best bet is to try to get a sense of the work culture from people who currently work there. Unfortunately a number of VAs are experiencing enrollment demands that can’t match staff hiring/retention or are located in areas that will never be able to attract enough high-level providers, which will have negative impacts.

this is super helpful thank you 🙂

 

[AcronymAllergy]

I would agree with the above--VA jobs can vary substantially from one hospital to the next, and even within a hospital depending on where you work. General mental health seems to universally be the least-liked area, although I know some folks who've enjoyed it. Specialty, as was said, tends to be better/more desired, and better still (generally) if you're a psychologist working for a service other than behavioral/mental health.

All that being said, there are many positives about VA employment, especially if early- or late-career.

 

[Sanman]

BHIP (general mental health to use non-VA lingo) at a main medical center or any VA with poor mental health staffing is likely a workhorse position. Add in the possibility of bad leadership and you’ve got the potential for a crappy experience.

But BHIP at a non-metro VA or at an outlying clinic (CBOC in VA lingo) can have a lot more ups than downs, such as less micromanagement, more relaxed work environments, actually being able to take a real lunch, etc as long as patient access to timely care is being managed appropriately.

As cara susanna mentioned, speciality outpatient jobs (PTSD, SUDs, etc) are usually better because you have an actual chance to screen out patients who are a bad fit and discharge them (to BHIP) when you’re done with treatment. You also generally have more time allotted for things like team meetings and have increased training opportunities.

Inpt and residential can be some of the better VA jobs due to different productivity requirements and often less micromanaging. But each specific job/clinic/supervisor will be different and of course, your coworkers can range from amazing to toxic with little recourse if the latter is present (hard to fire federal workers).

Overall, the facility in question will really matter and your best bet is to try to get a sense of the work culture from people who currently work there. Unfortunately a number of VAs are experiencing enrollment demands that can’t match staff hiring/retention or are located in areas that will never be able to attract enough high-level providers, which will have negative impacts.

The only thing I would add is that unlike BHIP/OPMH, there is not always a nationwide rvu/productivity metric for all the specialty areas. So, if you are working in these areas make sure you have good local leadership that will work with you regarding getting the job done and setting realistic goals. If not, you get ridiculous asks like I did.

 

[AcronymAllergy]

The only thing I would add it that unlike BHIP/OPMH, there is not always a nationwide rvu/productivity metric for all the specialty areas. So, if you are working in these areas make sure you have good local leadership that will work with you regarding getting the job done and setting realistic goals. If not, you get ridiculous asks like I did.

Also true. Neuropsychology, for example, would have to sometimes justify why we couldn't realistically spend 32 hours per week face-to-face with patients unless we wanted them to just sit there while we scored and wrote reports.

 

[Sanman]

Also true. Neuropsychology, for example, would have to sometimes justify why we couldn't realistically spend 32 hours per week face-to-face with patients unless we wanted them to just sit there while we scored and wrote reports.

Yup HBPC needs to justify why we can't do the same while driving to people's houses. Then they want us to tell them what a realistic number is.

 

[WisNeuro]

Yup HBPC needs to justify why we can't do the same while driving to people's houses. Then they want us to tell them what a realistic number is.

Way back when in my HBPC rotation, sometimes the drive to a pt's house was 10 minutes from the VA, sometimes it was 35 minutes. How can you give a realistic number unless you limit the catchment area?

 

[Sanman]

Way back when in my HBPC rotation, sometimes the drive to a pt's house was 10 minutes from the VA, sometimes it was 35 minutes. How can you give a realistic number unless you limit the catchment area?

The catchment areas are limited, but are large. Mine is 60 miles, which can mean a one hour commute to/between patients. Not to mention finding a public bathroom after heading to some rural farm. As to how we can give them a realistic number, that's what we always ask (and get silence/ blank stares in return). There is a ballpark of 2-3 patients a day for productivity, but there are not always 2-3 patients in the same area either. Old hospital leadership administration didn't sweat it. New one wants numbers, numbers, numbers.

Let's not even get started on the issue of government cars being available following the pandemic. We just found out travel "lost" a bunch of cars....like a drunk frat guy who forgot where he parked last night.

 

[JeyRo]

Ultimately the whole idea of a need for "productivity standards" is borne of the core failings managed care / socialized medicine, really, it's a core failing when you remove market pricing / profit motive out of any given sector of the economy.

The Soviet economy grappled with this throughout it's history. Good article below

How Government Killed the Medical Profession

As health care gets more bureaucratic, will doctors go Galt?

reason.com

 

[Shiori]

I'm getting HR paperwork for my first grown-up position. I'm excited and nervous. I'm also continuing to read about private practice as my plan B.

 

[Fan_of_Meehl]

I'm getting HR paperwork for my first grown-up position. I'm excited and nervous. I'm also continuing to read about private practice as my plan B.

It's a great field, with a long heritage of excellent mentors, authors, scholars, researchers and clinicians. I'm still, professionally, 'in love' with the discipline of clinical psychology as properly conceptualized and practiced. When done well, it stands head-and-shoulders above the norm as a highly sophisticated and effective approach to conceptualizing and treating mental illness...one that is exceedingly rare in our current mental healthcare system, as practiced on a daily basis. It's a shame that the current practice environment has departed so much from a model where individual clinicians have authority/autonomy in addition to the high levels of responsibility inherent in their practice. But this is following what is happening in general medicine right now and it seems that, like never before, physicians are leaving medicine at rates unheard of in prior years. The entire society has become one where we are being ruled by a 'managerial' class (or, as I like to refer to them, 'expertologists' and 'excellentologists') who excel at nothing in particular but the 'skill' of posing as paragons of excellence (who don't actually, you know, carry a caseload) and who 'excel' at repetitively announcing their own 'excellence' (devoid of substance/practice). It's not just medicine or psychology. Hopefully, we are nearing the 'bottom' and some sort of pendulum will swing things back in the other direction.

 

[Fan_of_Meehl]

I mean, that's kind of it. I don't think the level/amount of a humans healthcare provisions/coverage should be based on ones former occupation...at all.

The connection to/between occupation and health coverage that people in this country seem to hold so dear is totally bizarre to me. That notion really only came about less than 50 years ago.

I have similar concerns about certain aspects of 'special treatment' and the effects (not always good) that it can have on those so 'specially treated' as well as society at large.

Take, for example, the recently popular spate of laws exempting veterans who are '100% service-connected for a disability (including MH disabilities like PTSD, depression, etc.)' from having to pay property taxes. As should be obvious to anyone working in mental health at VA, any system that ties substantial financial rewards/advantages to demonstrating continued severe mental health symptoms and impairment sets up a really perverse and potentially harmful (to the veteran patient) set of contingencies (e.g., 'at the VA, veterans are paid to be sick').

At the societal level, I'm not sure it's healthy to set up a de facto 'caste' system in which some subset of the population (e.g., veterans) are treated as 'super-citizens' (or Tier I citizens) as opposed to the 'masses' (Tier II citizens) such that Tier II citizens have to pay their property taxes but Tier I citizens are exempt. I think in the longer term it would serve to drive a wedge between those two 'classes of citizens.'

 

[WisNeuro]

I have similar concerns about certain aspects of 'special treatment' and the effects (not always good) that it can have on those so 'specially treated' as well as society at large.

Take, for example, the recently popular spate of laws exempting veterans who are '100% service-connected for a disability (including MH disabilities like PTSD, depression, etc.)' from having to pay property taxes. As should be obvious to anyone working in mental health at VA, any system that ties substantial financial rewards/advantages to demonstrating continued severe mental health symptoms and impairment sets up a really perverse and potentially harmful (to the veteran patient) set of contingencies (e.g., 'at the VA, veterans are paid to be sick').

At the societal level, I'm not sure it's healthy to set up a de facto 'caste' system in which some subset of the population (e.g., veterans) are treated as 'super-citizens' (or Tier I citizens) as opposed to the 'masses' (Tier II citizens) such that Tier II citizens have to pay their property taxes but Tier I citizens are exempt. I think in the longer term it would serve to drive a wedge between those two 'classes of citizens.'

My state currently allows a $300k exclusion for this very thing. Just mind boggling. Between stuff like this and churches, among other stupid things (defense budget), we subsidize a lot of BS with our tax dollars.

 

[cara susanna]

I think it's interesting how (relatively) easy it is to get SC compared to SSDI for mental health conditions.