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

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I would even venture to say most VA providers think therapists are magicians. I love when psychotherapy referrals are like "patient won't engage in treatment." And I'm like, uhh, so they're gonna engage in treatment with me? Psych testing, too, which often boils down to: "patient isn't improving, help". Or assessing for conditions that aren't easily measured by objective psych tests, like bipolar.
 
cara susanna said:
I literally once got a testing referral was like, please tell us if this patient is lying about having experienced childhood abuse
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Sometimes I want to tell people that if I could actually do that, then I could literally read minds, and would be making a lot more money.
 
cara susanna said:
The "any doctor can perform a capacity eval" part: GOD, yes, I feel so validated.
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Yes.

So I'm on the ethics committee here. I told some staff in the DOM that anyone can complete a capacity eval and they acted like I have 5 gazillion heads. They stated they didn't feel competent.
 
WisNeuro said:
In the case of MD attendings on the unit, I don't think it is fear, as much as not wanting to do it.
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The MDs I have worked with usually come in two flavors. Sign everything put in front of them or don't sign anything that is not normal. Capacity eval requests are the same as specialty consults for every little thing. It is all CYA medicine. Now, there is plenty of money to be made in CYA consults.
 
Sanman said:
I had not heard about that. Curious to see if that is a national thing, I will have to take a look.
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Sounds like a local/VISN effort.

Each template needs to be installed manually by the CAC and local facilities can request to have whatever put in or not in their system.

I imagine it received some type of approval at some national level (like EBP templates do before they are rolled out) but I wouldn’t expect widespread adoption unless a national mandate happens.
 
summerbabe said:
Sounds like a local/VISN effort.

Each template needs to be installed manually by the CAC and local facilities can request to have whatever put in or not in their system.

I imagine it received some type of approval at some national level (like EBP templates do before they are rolled out) but I wouldn’t expect widespread adoption unless a national mandate happens.
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Me either. However, I do know that there has been a recent national EBP training on geriatric capacity evaluation and I was curious if there was any VACO plans ro push for a standardized practice.
 
Sanman said:
had not heard about that. Curious to see if that is a national thing, I will have to take a look.
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It is a national template. Here is the link to the decision making sharepoint. Welcome to the Decision-Making Capacity Assessment SharePoint!



Even if you don't have access to the template. The training on the sharepoint is super helpful. Honestly the decision making sharepoint is great.

There is also a regular community of practice teams meeting that convenes at 2pm central time.
 
psycho1391 said:
So I'm on the ethics committee here. I told some staff in the DOM that anyone can complete a capacity eval and they acted like I have 5 gazillion heads. They stated they didn't feel competent.
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"SIr/Madam, it is not appropriate for you to not feel competent. You should feel positively incompetent, and feel this very strongly. The ability to make a capacitated decision is essential to informed consent, so if you are unable to assess capacity then you are unable to obtain informed consent. This falls substantially below the standards of competence, care and ethics. On a related note, which state are you licensed in, and what is that board's contact information for reports?"
 
cara susanna said:
I sent this to our PCMHI lead and they LOVED it.

The "any doctor can perform a capacity eval" part: GOD, yes, I feel so validated.
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🤣

As the guy who did most of the capacity evals at his AMCs...yes! Most of the time the referring doc just wanted me to agree with them, and often they were wrong and that wasn't what they wanted to hear.
 
cara susanna said:
I hate the new TMS

(I'm a ray of sunshine today, I know)
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It wouldn’t give me credit for an online training I took in full because I wasn’t registered for it (a recorded, online training that you couldn’t register for).
 
aim-agm said:
"SIr/Madam, it is not appropriate for you to not feel competent. You should feel positively incompetent, and feel this very strongly. The ability to make a capacitated decision is essential to informed consent, so if you are unable to assess capacity then you are unable to obtain informed consent. This falls substantially below the standards of competence, care and ethics. On a related note, which state are you licensed in, and what is that board's contact information for reports?"
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Our psychiatrist on the committee basically said this to the psychologist in question. I didn't have enough gusto.
 
Can I just express my frustration that other MH providers in different disciplines are allowed to be like "welp, I'm just gonna refer for testing" and not have to do any leg work like chart review or review of past service treatment records? And it all falls to me, this one person who only is allotted four hours in which to do all this? And the referral question is pretty much like "rule out other mental health conditions." I HAVE FOUR HOURS
 
cara susanna said:
Can I just express my frustration that other MH providers in different disciplines are allowed to be like "welp, I'm just gonna refer for testing" and not have to do any leg work like chart review or review of past service treatment records? And it all falls to me, this one person who only is allotted four hours in which to do all this? And the referral question is pretty much like "rule out other mental health conditions." I HAVE FOUR HOURS
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Cancel the consult and tell them to do that. The specialist physicians do it all the time to PCPs.
 
Sanman said:
Cancel the consult and tell them to do that. The specialist physicians do it all the time to PCPs.
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Yep, saw who knows how many neurology referrals canceled b/c referring provider didn't do appropriate legwork ahead of time (e.g., they'd usually be asked to get an MRI and certain labs done, sometimes a sleep study, etc.).

You could basically say something like, "please perform at least a cursory chart review and indicate the primary rule-out(s) of interest." Or just, "please be more specific with your referral question."
 
The problem is another psychologist had previously consulted on this referral and agreed it was appropriate, so I didn't do a ton of legwork.
 
It can write nice, generic language when your brain has given up the ability turn gibberish into sentences.
 
Does anyone else have very negative judgments about their inpatient psychiatric unit, particularly discharging too early or discharging without a solid plan (like, sure this patient really needs a higher level of care but they're declining, so let's let outpatient deal with it)?
 
cara susanna said:
Does anyone else have very negative judgments about their inpatient psychiatric unit, particularly discharging too early or discharging without a solid plan (like, sure this patient really needs a higher level of care but they're declining, so let's let outpatient deal with it)?
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Our acute folks are really great and collaborative. I have had several check in with me to ensure a smooth transition prior to discharge.
 
cara susanna said:
(like, sure this patient really needs a higher level of care but they're declining, so let's let outpatient deal with it)?
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Having worked in acute inpt, sometimes our hands are tied. Like when a patient is adamant about discharge and they have stabilized just enough to no longer warrant a hold/filing for involuntary commitment. And they will absolutely cause problems if you cant discharge them quickly when they are of that mindset.

And patients who are frequent users of acute inpt and know the tricks of how to get admitted and how to get discharged, there’s not much that even the most dedicated staff can do.

And of course, it’s also definitely poor care in some scenarios, which is almost always driven by a bad attending psychiatrist.
 
cara susanna said:
Does anyone else have very negative judgments about their inpatient psychiatric unit, particularly discharging too early or discharging without a solid plan (like, sure this patient really needs a higher level of care but they're declining, so let's let outpatient deal with it)?
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I don't have a problem with acute inpatient as much as I do folks that think I am their garbage man and that they don't need proper discharge planning. Like, sure he is violent, punching holes in a wall, and tried to burn down a building but I am not going to suggest an ER visit. Send the HBPC people to his house to talk him out of violence and psychosis. Consult rejected!
 
God I love the privacy and information security TMS training scenarios. The choices are SO OBVIOUS. It's like the choices are 1) Secure your workstation by storing away sensitive documents, locking your computer, and removing your PIV card vs 2) Print out patient social security numbers and sell them on the street for cash (although apparently even that won't get you that harsh of a sentence!)
 
I am trying to remind myself that patients having access to their notes can have benefits, but it has been a headache lately. I write my notes with the mindset that they're reading their notes, but I don't always write them to be completely understood by someone without clinical training. My my documentation around SI or just diagnostic information leads to panic during comp and pen evals or when folks are fighting over custody. Maybe I should invest the effort into doing collaborative note writing.
 
cara susanna said:
God I love the privacy and information security TMS training scenarios. The choices are SO OBVIOUS. It's like the choices are 1) Secure your workstation by storing away sensitive documents, locking your computer, and removing your PIV card vs 2) Print out patient social security numbers and sell them on the street for cash (although apparently even that won't get you that harsh of a sentence!)
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For employees, yep. But I actually know of at least one intern who was dismissed due to significant lapses with HPI.

And yeah, the TMS trainings are golden. I always loved the videos in whichever training it was that covered gifting.
 
AcronymAllergy said:
For employees, yep. But I actually know of at least one intern who was dismissed due to significant lapses with HPI.

And yeah, the TMS trainings are golden. I always loved the videos in whichever training it was that covered gifting.
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How badly did they **** up to get dismissed? I've seen so many trainees get passed along that never should have, I can't imagine what it would take to get someone dismissed.
 
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