When a supervisor and supervisee "speak" different languages

[ExpertHoopJumper]

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A couple of the faculty in my postdoc at an academic-medical setting would be considered, at least, "older adults" in the research literature and exceed that arbitrary age distinction by multiple years. Occasionally, when they are my attending on a case, we use different language to explain the same thing, use a different diagnostic system resulting in differing clinical opinions, or they are not up-to-date on the literature. For example, rather than use DSM-5 nomenclature like major/mild neurocognitive disorder, they prefer to use mild cognitive impairment, dementia, or otherwise. I believe this is simply a result of training era. Like, I began grad school following the publication of DSM-5 and do not really know its predecessors (ditto ICD-10), whereas they have worked through multiple iterations of DSM and DSM-5 is still super new to them. The majority of the time these differences are not an issue. In fact, I enjoy seeing how established professionals write and communicate because then I can steal what I like and meld into my own clinical skills. But sometimes the differences are substantial, like suggesting someone has vascular dementia, but per DSM-5, they meet criteria for mild vascular neurocognitive disorder. Maybe functionally the outcomes for the patient remain the same, but I still have to code and bill and possibly defend this report to the referring provider or a lawyer/judge. On the clinical research end of this, we occasionally want to challenge how things are done based on relatively new research and these faculty push back because they are unfamiliar with that research. It puts me in a weird spot because on one hand, they are my supervisor and I am working under their license right now, but on the other hand, this reluctance to admit new knowledge into their repertoire is not how we should be doing things.

Any suggestions on how to handle these types of situations? Am I being a punk who doesn't appreciate/respect their elders?

 

[AcronymAllergy]

Major/Mild Neurocognitive Disorder vs. MCI and dementia, I wouldn't necessarily argue the points too much. MCI and dementia are still viable diagnoses, depending on the coding system used.

Vascular dementia vs. mild neurocognitive disorder is a bigger issue. Dementia, even in the more-recent older uses, implies functional impairment, whereas MCI or mild NCD does not. That's a point worth discussing further with supervisors.

Although if the report is conducted under supervision and your supervisors are co-signing, they're ultimately the ones responsible for its content. If they say code vascular dementia while you say MCI/mild NCD, state licensing laws can explicitly require that if there's a disagreement between supervisor and supervisee, the supervisor's determination must be what stands. You could always keep electronic copies of your report drafts if you're worried you for some reason need to defend it later.

RE: reluctance to admit new research, that could certainly be the case. Although as an alternative, perhaps they're cautious to significantly alter long-standing and hopefully well-supported views every time new findings come out (some of which may not hold up over time)?

 

[ExpertHoopJumper]

RE: reluctance to admit new research, that could certainly be the case. Although as an alternative, perhaps they're cautious to significantly alter long-standing and hopefully well-supported views every time new findings come out (some of which may not hold up over time)?
[/QUOTE]

Admittedly, sometimes it is exactly this. They are unmoved by the new literature because they do not find it compelling. However, sometimes they argue against stuff simply because they do not understand the methodology and/or the findings contradict a dearly held opinion so it must be untrue or premature or "it's just not the way things are done here."

 

[deleted343839]

To echo what AcronymAllergy said, I think both perspectives can be valid and in some tension with one another. With respect to diagnosis, consider that some of your senior colleagues may rub elbows with neurologists or other physicians at least as often as with other psychologists, and they may gravitate toward medical diagnostic classification systems other than DSM-5. By all means, use the proper terminology in your documentation and billing, but also learn to differentiate semantics from genuine disagreement about functional impairment, pathophysiology, and so on.

I think it is fair to say that more senior faculty may be less attuned to some new research because they are not consuming it in the way that trainees do. Maybe they're not reading the literature as consistently. But it's also possible that they have learned over time to better filter what is really groundbreaking and practice-changing from what is simply new (or rehashed), incremental, and possibly subject to further replication. A good, but imperfect, yardstick is to find out who is still involved in activities that keep them in touch with the cutting edge - practice guideline committees, study sections, leadership in the discipline, etc. - versus who is just still active locally. People usually start to age out of these leadership roles in their later careers but there is no consistent timeline for that.

The best solution I can offer is to cultivate multiple mentoring relationships. If the people who are more experienced than you are agreeing with one another more often than not, that should tell you something. But if you are not being mentored by people who are still getting grants, still leading professional initiatives, still being tapped routinely for their expertise in national roles, then you need to find some of these people as well to mentor you, especially for research.

 

[bcliff]

Most of my supervisors and colleagues in adult neuropsychology generally do not adhere strictly to use of specific DSM terminology within their reports -- So far as I can tell, MCI (i.e., G31.84) and dementia (i.e., F01, F02, & F03) both remain viable ICD-10 diagnoses, and I regularly use these descriptors and codes and see others routinely use them as well.

FWIW, I often find these labels to be clearer and more meaningful to patients than DSM terminology (e.g., mild vs. major NCD) -- For example, I can imagine a patient's child saying "at least my mom doesn't have dementia, she just has major neurocognitive disorder secondary to poorly managed vascular risk factors," which would likely be a gross mischaracterization of the message I was trying to convey.

I also think it's helpful to know the history of DSM-defined disorders, so if you're unfamiliar with the definitions from DSM-IV and earlier for disorders you're commonly seeing in clinical practice, then that might be something worth brushing up on. The changes made from one iteration of the DSM to the next are not always improvements and are not always firmly supported by empirical literature.

Interestingly, I've noticed (at least anecdotally) that pediatric neuropsychologists seem to use more DSM-specific language in their reports, which I attribute to the greater involvement of schools and other (non-healthcare) providers in the context of developmental disabilities and neurodevelopmental disorders.