Successful Private Practice in Neuropsychology and Neuro-Rehabilitation

A Scientist-Practitioner Model

Mary Pepping

• Publisher: Academic Press
• Year: 2014
• Print ISBN: 9780128002582
• eBook ISBN: 9780128004883
• Edition: 2
• Topic: Psychology
• Subtopic: Neuropsychology
• Index: Psychology

This second edition (of the original Successful Private Practice in Neuropsychology) provides an updated overview of key principles and processes for establishing, maintaining and developing neuropsychology practice and neuro-rehabilitation program (NRP) treatment in medical center and/or private practice settings. Essential elements of an entrepreneurial model that work well in the medical center context and the necessary role of variety and peer review in the private practice setting are also discussed. - How to gather and report NPE and other evaluation findings with a neuro- rehabilitation focus that lead to specific neuro-rehabilitation recommendations. Benefit: this will make your evaluations and reports more desirable and sought after in the setting and community where you work. - Updated billing/diagnostic code recommendations to accurately capture the actual time spent in evaluating and/or treating patients. Benefit: increased appropriate billing and collections for your time - Recommendations for clinical neuropsychology postdoctoral fellowship training of a Navy psychologist. Benefit: you may be able to obtain funding for an experienced Navy clinical psychologist who wants formal training in neuropsychology. This can expand your clinical services, increase variety and quality of your training program and ultimately support improved care for returning American military personnel.

Chapter 1

The Challenges of Practice in Neuropsychology

Overview of Key Issues and Effective Solutions

Mary Pepping, Ph.D., ABPP-CN

Abstract

Would you like to maximize what is best about your practice setting and manage its difficulties?

For example, in the institutional setting, you typically have a dependable salary and benefits and an array of system supports, including testing equipment, office space and furniture, help with triage and scheduling, and a billing and collections department. However, you may also have very little choice about the nature or location of your office, the patient groups that you will see, or the number of evaluations or treatment patients you are required to schedule each week.

In private practice, you have the ability to choose your office location and set your own schedule with respect to days for clinical work, paperwork, research, or teaching. You decide which patient populations you wish to see, set your own fees, and you keep what you collect. However, you also bear all of the financial responsibility for your practice. You may not have clinical coverage available when you need to be out of the office. If you are in solo practice, you may be somewhat isolated.

Whether you are institution-based or in private practice, or some combination of each, this chapter can help you begin to create a more satisfying practice by integrating the advantages of each setting.

Keywords

Institutional setting

High-level skills

Interdisciplinary network

Educational opportunities

Income

Malpractice

Personality factors

Ongoing consultation

Pros and Cons of the Institutional Setting

One of the major challenges in a scientist–practitioner model of private practice is to preserve what is best about the academic and clinical aspects of full-time institutional work, while reducing the less attractive features such employment can bring.

On the positive side of the ledger, institutions such as hospitals, clinics, or universities typically provide an array of supports for their professional staff. This usually includes a regular salary, office space, transcription support, scheduling help, at least some built-in referrals from other departments, and billing and collections personnel. Paid sick leave and vacation days are typical, while retirement benefits and perhaps some financial support for continuing education may also be part of the package. In addition, one may have on-site opportunity for grand rounds or other in-service training. Regular contact with like-minded colleagues can provide very helpful interpersonal and professional support and stimulation.

On the negative side of the ledger, one may be subject to a very high and unreasonable workflow of patients that the institution has made a commitment to serve, but for whom sufficient clinical personnel have not been hired. You may have very little control in the patient selection process (e.g., if patients are part of that system and need to see a neuropsychologist, you will see them). You may also be subject at times to the political vagaries of poor administrators or supervisors, to bureaucratic inefficiencies that affect daily quality of work life, or problematic support staff. And there may not be a fair linkage between your level of productivity and your salary, nor, perhaps, room to grow and advance within your profession.

At those times, the joys of private practice exert a strong pull. These include designing the type of practice you want, e.g., evaluation only, evaluation and treatment, medical–legal consultation, and part-time teaching as part of the mix. It includes a choice about which days of the week you work, and other aspects of your schedule. You are free to decide when to take vacation, or to schedule personal appointments at convenient times. Ironically, in my private practice years I also found it far easier to protect large blocks of time for record review, test data review, report preparation, journal reading, and various writing and research projects than has ever been true in the institutional setting. I also had more space in which to work than the typical institutional office provides.

And how about the less desirable aspects of private practice? For me personally as a neuropsychologist I did not have as extensive a range of complex neurological cases in my years of private practice as I was able to see in the academic medical setting. While I was able to pull from several diagnostic groups by working on contract in a medical center combined with my own private referrals, I was still missing some major evaluation groups, e.g., people with brain tumors. I was also not an integral part of a neuro-rehabilitation team. By working as a contract consultant for a private rehabilitation company I had weekly or biweekly discussions with their key clinicians and neuro-rehab teams, but it was a periodic consultative rather than integral daily clinical role.

In the scientist–practitioner model for private practice in neuropsychology, you can create a career life that incorporates some of the best features of each world: the institutional and the self-employed. This approach allows for an ongoing refinement of your activities, in a manner that hopefully avoids or reduces some of the more egregious effects of bureaucracies and institutions and that offsets some of the negative aspects of private practice.

One way to maximize what institutions have to offer is to select an institution and department that you like and to negotiate a part-time contractual relationship with them (see Chapters 4 and 5 for more details). In this manner, you may be able to see patients who would not typically come to your private practice, but whose neurologic problems may be of great interest to you. You can also charge an hourly fee to the facility for your time and let them handle billing and collections. You are also more likely to remain somewhat free of institutional politics, i.e., you show up to see your patients, conduct the evaluations, and provide results and referrals. It is only when changes in referral patterns or billing practices are threatened that you may need to take a more active role in problem resolution with regular staff.

Maintaining High-Level Skills

When opportunities for continuing education are not built into your daily routines (such as stopping by grand rounds, weekly brain cuttings in neuropathology, listening to the neuroradiologists debate the merits of particular imaging approaches, or neuroanatomic details of an interesting case), you need to find solid and creative ways to fill this gap. Neuropsychologists must not neglect to update and expand their knowledge in the areas of neuroanatomy, neuropathology, and basic neurobehavioral issues associated with various diseases and syndromes once they have graduated from formal training. Although annual professional conferences and journal articles help, there is nothing like observation and discussion with expert colleagues to promote new growth in our own neuronal systems.

You may need to expand or supplement your reading of professional journals and develop a regular journal club meeting with colleagues. These activities can expose you to new knowledge and help ensure that you regularly hear informed perspectives on professional matters. Two helpful avenues for ongoing development of your skills include reviewing specific cases with other neuropsychologists who may have special areas of interest or developing an ongoing consultation relationship with a more experienced neuropsychologist.

Attending local meetings of your community's neuropsychology and neurology society meetings can be an excellent source of up-to-date clinical and research information and a potential source of referrals. These two groups can be particularly important for neuropsychologists, who need to be at the top of their form with respect to specific testing knowledge and broader neurobehavioral issues. The latter includes adequate understanding of the disease or injury from a medical standpoint, especially as it is likely to affect neuropsychological functions. There are also workshops, conferences, new books, and new test training opportunities. Although one may need to be selective, sharing the cost and use of these resources can be a very helpful approach in private practice. Books and test materials may be loaned to colleagues in similar circumstances. For some conferences, you and your colleagues may decide to rotate attendance, with the attendee bringing back specific ideas, reprints, and tapes to share.

It is important to acknowledge that scientist–practitioners in private practice are often caught between their training needs and the time and cost associated with leaving one's practice to pursue such opportunities. When we fly to a conference, give a talk, or attend a workshop, we not only bear the full training expense, but we must also continue to cover our rent and other overhead, while not earning any income during the time we are away. I am not sure if that constitutes a triple whammy, or merely a double whammy, but it is one of the more challenging aspects of self-employment.

Fortunately, a sole proprietor can keep an income stream flowing by hiring neuropsychologists to conduct evaluations in your absence, in a manner prenegotiated with some of your referral sources (see Chapter 7). And, if one implements some of the cost-sharing ideas described above for continuing education needs, you will find a stimulating and satisfying mix of information that doesn’t break the bank in the process. Finally, the heightened awareness, thoughtfulness, and energy that private practitioners must invest in their own training can produce a level of development in one's own craft not always found among personnel more safely ensconced in an institutional setting.

The Interdisciplinary Network

For me, the most difficult aspect of private practice was the absence in my daily practice of an established and mature team for the comprehensive interdisciplinary evaluation and treatment of neurologically compromised patients. Such a team typically includes speech language pathologists, occupational therapists, physical therapists, vocational rehabilitation counselors, social workers, recreational therapists, clinical psychologists and neuropsychologists, and rehabilitation medicine physicians. The absence of this kind of team was especially problematic for my patients of working age. For them, well-integrated team treatments are often critical if they are going to resume competitive employment and reestablish a more normal life of work, love, and play.

My neuropsychological evaluations documented the patient's cognitive, emotional, characterologic, and neurobehavioral disturbances and strengths. I also made recommendations for further work-up by other disciplines as appropriate for my evaluation patients. If the patient needed only a single service or treatment, it was a relatively simple matter to refer them to a good clinician.

It was otherwise a source of concern and frustration to witness the piecemeal and poorly integrated help some patients wound up receiving because they needed several different kinds of therapy and their various practitioners were scattered throughout the city. There was often no clear case manager and no good forum for effective communication among those providers.

Perhaps this varies significantly from city to city throughout the United States and Canada, or it may be different in other countries. In America, it seems relatively easy to find similar practitioners self-employed together (e.g., physicians, psychologists, neuropsychologists, speech pathologists, or vocational counselors), but more difficult to find self-employed interdisciplinary groups who provide comprehensive outpatient neuro-rehabilitation services. (An important exception in the United States is the interdisciplinary team care by the company, Rehab Without Walls.)

A number of approaches can be helpful for the solo practitioner. One obvious solution is to form good working relationships with as many of the various institution-based and private outpatient programs in the larger community as possible. One further advantage to starting out in an institution or program prior to becoming self-employed is that you have firsthand appreciation for the respective strengths and limitations of each program. You can then more effectively direct your own patients to programs likely to meet their treatment needs.

It is also possible to develop good working systems with therapists from various private practices who get to know one another over time through you and through patients that you have sent them to treat. It is important in this circumstance to make sure that someone has been designated as the clinical team leader. Sometimes the attending physician capably fills this role alone; at other times, an experienced rehabilitation therapist or neuropsychologist may need to monitor all of the treatment elements. This function of team leader in monitoring treatment is another practice option for the neuropsychologist.

In addition, the newly self-employed neuropsychologist could certainly learn from experienced private nurse case managers and private vocational rehabilitation counselors. They have typically developed extensive and reliable networks of interdisciplinary colleagues. They know firsthand the potential pitfalls of fractionated care for neurologically compromised patients, who are usually not able to function effectively as their own case managers.

Do Not Go Gently into That Research Decline

While you are busily evaluating an increasing flow of interesting patients, you may think it unlikely to have time for research. Yet one of the ironies of private practice is that you may have more time and freedom with which to explore research questions than when you were pushed for higher and higher cli...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Dedication
• Foreword to the Second Edition
• Preface
• Chapter 1: The Challenges of Practice in Neuropsychology: Overview of Key Issues and Effective Solutions
• Chapter 2: Other Potential Indignities
• Chapter 3: The Good News
• Chapter 4: Getting Started: Practical Preliminary Questions
• Chapter 5: A Practical Guide for Opening Your Business
• Chapter 6: Marketing and Other Matters
• Chapter 7: Creative Approaches to Financial Issues
• Chapter 8: Medical–Legal Work
• Chapter 9: Consultation and Supervision Practice
• Chapter 10: Psychometric Concerns
• Chapter 11: Treatment Practices for Neuropsychologists
• Chapter 12: Nuts and Bolts of Your Evaluation Practice
• Chapter 13: Neuro-Rehabilitation Program Treatment: Principles and Process
• Chapter 14: How to Design and Implement a Cognitive Group
• Chapter 15: The Value and Use of the MMPI in Neuropsychological Practice
• Chapter 16: Designing and Implementing a Clinical Neuropsychology Fellowship
• Chapter 17: Research as a Daily Reality
• Chapter 18: Summary and Conclusions
• Appendices
• Index