Continuing on from my post of 3/17/15 on the Kafkaesque nature of the VA bureaucracy, their motto seemed to be, "If we find a problem in the system, we'll come up with a ridiculous solution that may make the problem even worse. Or at the very least, create a whole new set of problems."
For example, not too long ago there
were a couple of serious foul-ups at the VA Memphis hospital that were caused by patients
being mis-identified by staff and given the wrong treatment. This sort of thing can have
disastrous consequences, of course, and it happens from time to time in almost all hospitals. It is quite a serious issue. Of course, in these cases dire consequences are most
likely to result with surgery or in a busy emergency room; such events are fairly rare in
outpatient clinics.
The VA solution:
Every doctor was instructed to verify every patient's full social security number
and full name immediately at the beginning of every single appointment. We were told to do
this, not just for patients we did not recognize, but even for our regular
patients who we have been seeing for years! And we were told that we had to
document that we had done this - again every single time - in the patient's electronic medical record (EMR). No one anywhere else does this.
That may seem like a
small although illogical request that wouldn't take much time. The trouble
was, we were asked to document a whole bunch of other things almost every
visit. Most of these things were completely irrelevant to the visit at hand. For instance,
there are so-called "clinical reminders" to ask about certain
information at most visits whether it concerned the reason for the patient's
visit or not (example shortly).
With limited time to
see each patient and to document the relevant information in the EMR, this added a
significant amount of time to a visit that would then not be available to
actually evaluate the patient's progress for the problem that was being actively treated.
Most of the clinical
reminders were checklists, about which I have complained many times on this
blog. One particularly ridiculous clinical reminder was a requirement to
perform a depression screening checklist, the PHQ-9. This is just what it says
it is - a screening test to see who should be evaluated
further for depression.
It is meant to be
used by primary care docs and other non-psychiatric physicians to determine who
should be referred to a psychiatrist for these further evaluation, and who does not need one. It is meant to cast a wide net, meaning a positive test does not
mean that you have a clinical depression - only that you might and should
therefore be screened further.
The VA wanted the psychiatrists to ask their patients to fill one out! If a patient is already being evaluated by a psychiatrist, the
purpose of PHQ-9 is no longer operant, so filling one out is completely
pointless and an utter waste of time. Unless, of course, someone is such a bad psychiatrist that they
think a psychiatric evaluation does not include an evaluation for depression.
I refused to do the
PHQ-9's, because I perform a complete bio-psycho-social psychiatric evaluation
when I first see a new patient, and I was not going to short change my patients by further shortening our already limited time together by asking questions I
already knew the answer to, or was about to go into far more detail about than
is possible with a PHQ-9.
Actually, there was
at least one psychiatrist on staff who did not do a complete evaluation of every
patient. Because this psychiatrist did not make waves, that clinician was allowed to practice what I consider to be piss poor
psychiatry for years. Then the doc left. I will discuss what happened in that
situation in Part III of this post.
I work in psych, and ever too often hear derogatory remarks about certain patients, especially repeat patients ... even heard the f ... and s ... words uttered by my fellow workers ... I know, my comment might be a bit beside the point you are making, but this mess all started at some point, am I not right ? Love, cat.
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