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

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cara susanna said:
Well, the new SOP also says you don't have to make rescheduling efforts with 2 consecutive cx/ns or 3 during an episode of care, so there's that.
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I like that part.

But, wait...the new policy lets you not even attempt/document a no show followup call if it's the 2nd in a row or 3rd in current episode of care? That would be awesome.
 
The dopamine amphetamine (amphetamine) has specific use-cases, primarily for ADHD, but has issues with abuse potential.

The norepinephrine amphetamine (phentermine) has specific use-cases, primarily for appetite suppression, but has issues with abuse potential.

The serotonin amphetamine (MDMA) might also have specific use-cases, but definitely has issues with abuse potential.

A thought that occurs is that the first two is that they were studied for their use-cases when there were no alternatives. e.g. phentermine might have utility in treating ADHD, but its never been studied because what marginal utility would that have over amphetamines or methylphenidate? If GLP-1 agonists had been discovered and deployed before phentermine, the latter may never have found a clinical indication. What use does MDMA have that isn't already well addressed by other, safer medications? If I had a case of truly treatment resistant PTSD (i.e. failing SRIs, NRIs, DRIs, sympatholytics, buspirone, etc.), why would I use MDMA over an MAOi?
 
aim-agm said:
The dopamine amphetamine (amphetamine) has specific use-cases, primarily for ADHD, but has issues with abuse potential.

The norepinephrine amphetamine (phentermine) has specific use-cases, primarily for appetite suppression, but has issues with abuse potential.

The serotonin amphetamine (MDMA) might also have specific use-cases, but definitely has issues with abuse potential.

A thought that occurs is that the first two is that they were studied for their use-cases when there were no alternatives. e.g. phentermine might have utility in treating ADHD, but its never been studied because what marginal utility would that have over amphetamines or methylphenidate? If GLP-1 agonists had been discovered and deployed before phentermine, the latter may never have found a clinical indication. What use does MDMA have that isn't already well addressed by other, safer medications? If I had a case of truly treatment resistant PTSD (i.e. failing SRIs, NRIs, DRIs, sympatholytics, buspirone, etc.), why would I use MDMA over an MAOi?
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Because people don't want to hug other people and dance with glowsticks while listening to terrible house music on an MAOi?
 
We were told today we MUST complete all VA and non-VA medical forms and provide medical statements per a VHA policy.

There goes all my admin time filling out ESA letters and crap. We've had a pretty firm clinic policy of not doing forms/letters unless desired by both provider and patient so it's agitating they're coming down so hard on this from up above.
 
Grenth said:
We were told today we MUST complete all VA and non-VA medical forms and provide medical statements per a VHA policy.

There goes all my admin time filling out ESA letters and crap. We've had a pretty firm clinic policy of not doing forms/letters unless desired by both provider and patient so it's agitating they're coming down so hard on this from up above.
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What? Do you have to complete them like the patient wants you to, or are you just required to complete them?
 
cara susanna said:
What? Do you have to complete them like the patient wants you to, or are you just required to complete them?
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The language is "must assist when requested in completion of VA and non-VA medical forms and provide medical statements with respect to the patient's medical condition and functionality." But it was primarily in response to Veterans complaining about DBQs and ESA letters or so I've heard.

Even filling out a form to say "No" is going to be such a time suck.

Before we could refuse and say "all the information I can provide about diagnosis and treatment and attendence is available in your medical records upon request." To many many things.
 
aim-agm said:
The dopamine amphetamine (amphetamine) has specific use-cases, primarily for ADHD, but has issues with abuse potential.

The norepinephrine amphetamine (phentermine) has specific use-cases, primarily for appetite suppression, but has issues with abuse potential.

The serotonin amphetamine (MDMA) might also have specific use-cases, but definitely has issues with abuse potential.

A thought that occurs is that the first two is that they were studied for their use-cases when there were no alternatives. e.g. phentermine might have utility in treating ADHD, but its never been studied because what marginal utility would that have over amphetamines or methylphenidate? If GLP-1 agonists had been discovered and deployed before phentermine, the latter may never have found a clinical indication. What use does MDMA have that isn't already well addressed by other, safer medications? If I had a case of truly treatment resistant PTSD (i.e. failing SRIs, NRIs, DRIs, sympatholytics, buspirone, etc.), why would I use MDMA over an MAOi?
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There are a lot of issues with the psychedelic literature, to be brief:

Great Expectations: recommendations for improving the methodological rigor of psychedelic clinical trials - PMC

Psychedelic research continues to garner significant public and scientific interest with a growing number of clinical studies examining a wide range of conditions and disorders. However, expectancy effects and effective condition masking have been ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
clausewitz2 said:
There are a lot of issues with the psychedelic literature, to be brief:

Great Expectations: recommendations for improving the methodological rigor of psychedelic clinical trials - PMC

Psychedelic research continues to garner significant public and scientific interest with a growing number of clinical studies examining a wide range of conditions and disorders. However, expectancy effects and effective condition masking have been ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
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My read of the lit that I've actually read (mostly for PTSD) is essentially, there's promise, and we should definitely keep exploring, but the reported benefits are so far above and beyond what the actual empirical data says, and that we're really not at the place of rolling this out widely in clinical settings.
 
WisNeuro said:
My read of the lit that I've actually read (mostly for PTSD) is essentially, there's promise, and we should definitely keep exploring, but the reported benefits are so far above and beyond what the actual empirical data says, and that we're really not at the place of rolling this out widely in clinical settings.
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So, you're saying it is the perfect time for the VA to announce a massive national initiative and then bungle the roll out?
 
Grenth said:
The language is "must assist when requested in completion of VA and non-VA medical forms and provide medical statements with respect to the patient's medical condition and functionality." But it was primarily in response to Veterans complaining about DBQs and ESA letters or so I've heard.

Even filling out a form to say "No" is going to be such a time suck.

Before we could refuse and say "all the information I can provide about diagnosis and treatment and attendence is available in your medical records upon request." To many many things.
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"Back in the day," we were explicitly told by our supervisors and service line leadership to refuse to complete DBQs, and we were tacitly encouraged to refuse to complete ESA documentation. They even gave a presentation on DBQs and why it can be problematic for clinical MH staff to complete them. This change, by itself, would make me consider leaving a VA job. Sorry to hear you're having to now deal with it.
 
Do I want to do a specialty consult for one of my niche roles here or am I asking for more trouble than its worth?
 
Grenth said:
We were told today we MUST complete all VA and non-VA medical forms and provide medical statements per a VHA policy.

There goes all my admin time filling out ESA letters and crap. We've had a pretty firm clinic policy of not doing forms/letters unless desired by both provider and patient so it's agitating they're coming down so hard on this from up above.
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The first and only question to ask is will they be providing blocked admin time for this? If not, where do you send the comp time or overtime requests. When the OT budget goes over, we'll see what happens.
 
Grenth said:
We were told today we MUST complete all VA and non-VA medical forms and provide medical statements per a VHA policy.

There goes all my admin time filling out ESA letters and crap. We've had a pretty firm clinic policy of not doing forms/letters unless desired by both provider and patient so it's agitating they're coming down so hard on this from up above.
Click to expand...
Or else...what? At some point provider autonomy needs to be considered. In the OMH setting providers are already forced to provide forever supportive treatment (despite the constant push for episodes of care there is no support for removing such folks off our caseload, kind of at odds with one another) unless they can convince/annoy their veterans to choose another option/take a break. Now you HAVE to respond to all form requests? Because reasons?
 
Shiori said:
Do I want to do a specialty consult for one of my niche roles here or am I asking for more trouble than its worth?
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Fantastic question! I'd be thinking about the following:

- Are you able to provide this service currently? Are there barriers? What positive changes are you hoping for?
- How much are you looking to increase these types of cases in your caseload? And what will happen if too many referrals are being submitted? Would you have to take them all or would there be other providers/community care options?
- How would these referrals be processed? Would they go into your normal intake slots? Newly created intake slots? Just slotted into your next available?
- Managing a niche consult can be time consuming. People will submit inappropriate referrals, have questions, submit referrals where the veteran was never consulted etc etc etc so potentially lots of 'hey can you jump onto a Teams call right now?' & random administrative duties (I manage one of these 'niche' consults currently).
 
summerbabe said:
Fantastic question! I'd be thinking about the following:

- Are you able to provide this service currently? Are there barriers? What positive changes are you hoping for?
- How much are you looking to increase these types of cases in your caseload? And what will happen if too many referrals are being submitted? Would you have to take them all or would there be other providers/community care options?
- How would these referrals be processed? Would they go into your normal intake slots? Newly created intake slots? Just slotted into your next available?
- Managing a niche consult can be time consuming. People will submit inappropriate referrals, have questions, submit referrals where the veteran was never consulted etc etc etc so potentially lots of 'hey can you jump onto a Teams call right now?' & random administrative duties (I manage one of these 'niche' consults currently).
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Agreed, I would also think about timeline to answer the consults. If you cannot set aside time for both providing the service and the admin duties, you may want to consider holding off. I often suggest folks email me for the first few months with consults rather than placing a formal consult so that I can gauge interest and see the level of time necessary. You can always schedule the folks in informally at first. Keep in mind, I self-schedule and don't have an MSA. If they won't work with you, this will be more difficult. Nothing like getting in trouble for untimely consults that you created to be helpful.
 
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That makes a lot of sense. It might be less cumbersome to just make a more comprehensive spreadsheet for myself. Thanks for the feedback!
 
What do folks see as the main pros and cons of self-scheduling in outpatient clinics vs. having MSAs handle it all?
 
If you're being required to complete DBQs, I'm pretty sure that's against national VA policy. MH has always been exempted. I would DEFINITELY fight that one.

butteredtoast27 said:
What do folks see as the main pros and cons of self-scheduling in outpatient clinics vs. having MSAs handle it all?
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Pros: more control
Cons: can result in errors, you have to be the one to tell patients your access sucks
 
Emaili
cara susanna said:
I'm so incensed by this I looked it up:

VA Directive 1134(2):

3. For requests for completion of mental health DBQs, it is recommended that the Veteran’s treating provider not complete the DBQ to maintain the integrity of the patient-provider relationship.
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Saving this, thank you!
 
cara susanna said:
I'm so incensed by this I looked it up:

VA Directive 1134(2):

3. For requests for completion of mental health DBQs, it is recommended that the Veteran’s treating provider not complete the DBQ to maintain the integrity of the patient-provider relationship.
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Thank you for this. So many leaders at VA citing made up directives to push their own agenda. Embarrassing
 
@Grenth

Professional standards, authored by the leadership from the Trust, say you should not fill out ESA letters:

Younggren, J. N., et al. (2016). "Examining Emotional Support Animals and Role Conflicts in Professional Psychology." Professional psychology, research and practice 47(4): 255-260.
 
PsyDr said:
@Grenth

Professional standards, authored by the leadership from the Trust, say you should not fill out ESA letters:

Younggren, J. N., et al. (2016). "Examining Emotional Support Animals and Role Conflicts in Professional Psychology." Professional psychology, research and practice 47(4): 255-260.
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I'll have to dig it out, but American Professional malpractice sent out a similar statement bit over a year ago.
 
WisNeuro said:
I'll have to dig it out, but American Professional malpractice sent out a similar statement bit over a year ago.
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If two different malpractice insurance companies are telling me not to do something, between that and local VA leadership, I know who I'm listening to.
 
WisNeuro said:
I'll have to dig it out, but American Professional malpractice sent out a similar statement bit over a year ago.
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To add to this, I believe that there have been recent lawsuits against people just firing off letters in support of 'emotional support animals.'
And, yes, I believe the national policy on completion of DBQ's by treating providers involves discouraging them from completing these.
Of course, local 'leadership' could just be engaging in peeing in their pants and bending over to veterans, which wouldn't be unprecedented.
 
Asking for a friend:

They recently applied for a VA psychologist job and received a ‘the referral certificate has been returned as cancelled and/or unused’ email.

They completed multiple rounds of interviews and was asked for references after the final interview.

Do we think this might be more related to the recent hiring freezes/losing permission to move forward on prev approved jobs or the facility not liking the choices and wanting to start over?
 
summerbabe said:
Asking for a friend:

They recently applied for a VA psychologist job and received a ‘the referral certificate has been returned as cancelled and/or unused’ email.

They completed multiple rounds of interviews and was asked for references after the final interview.

Do we think this might be more related to the recent hiring freezes/losing permission to move forward on prev approved jobs or the facility not liking the choices and wanting to start over?
Click to expand...

If they did not hear anything else, mostly likely budget related in this environment. That said, I received an automated rejection (position closed, not selected) for a job I currently have after they hired me. So, it may mean nothing.
 
cara susanna said:
We were just told that we're limiting our number of intakes because of the current difficulties with f/u access. I'm in shock, i didn't know we'd ever actually do this. Just nice to know that sometimes change can happen.
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Love that for you! Our clinic is taking the opposite strategy of having some of our therapists offer some more intakes which further reduces availability. Some of my colleagues will do almost anything to avoid doing individual therapy, but everything is fine.
 
Has there been an uptick in VA recruitment emails, or am I just a cool kid now?
 
R. Matey said:
I got a few from recruiters in the deep south, not sure if that makes me cool or not.
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Yeah, the recruitment emails/LinkedIn messages I get, VA and otherwise, are all for fairly undesirable locations or prison work.
 
Shiori said:
I just got my first consult specifically requesting IFS.
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I'd auto-cancel that baby and specifically say that I don't practice pseudoscience. Back in the VA days, we'd occasionally have referring providers request specific tests (e.g., please do CPT, MMPI, etc) and we'd accept the consult but specifically write back to that provider that we are not their lab and we will determine the appropriate measures to give based on the question at hand and our expertise as independently licensed doctoral providers.
 
Fan_of_Meehl said:
Wait til you have another provider pre-emptively write your treatment plan for you (without consulting you) under your name for a patient your haven't even had the opportunity to evaluate yet, lol.
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How exactly does this work?
 
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