They do everything from benefits checks, to entering payments and ERAs, to collecting on balances. They do it all. They’re super responsive. They specialize in mental health and they have helped our practice increase our collections. It keeps going up. I think we’re at 20 to 30% more than we have typically been collecting since we transitioned over to them.
So if you need a billing service or you just have questions, you can go to practicesol.com/jeremy and shoot them a message, and they will get you hooked up with whatever you might need. [00:01:00] If you use that link, you’ll also get discounted services for your first month. Now on to the episode.
Hey everybody. Welcome to another episode of The Testing Psychologist podcast. I’m Dr. Jeremy Sharp. We are back today with our first interview in several weeks. We just wrapped up our 5 quick tips series and I am thrilled to jump back into the interview game with someone that many of you have probably heard of or read some books or read some articles. I’m here today with Jacobus Donders.
Dr. Donders is the Chief Psychologist at Mary Free Bed Rehabilitation Hospital in Grand Rapids, Michigan. He is board-certified in [00:02:00] Clinical Neuropsychology, Pediatric Clinical Neuropsychology, and Rehabilitation Psychology through the American Board of Professional Neuropsychology.
In addition to being an active clinical practitioner, he has served on multiple editorial and executive boards, has authored or co-authored more than 100 publications in peer-reviewed journals, and has edited or co-edited 5 textbooks. Dr. Donders is a current associate editor of the journal Child Neuropsychology and Archives of Clinical Neuropsychology.
He’s a Fellow of the American Psychological Association and of the National Academy of Neuropsychology. His main interests, at this point, include validity of neuropsychological tests and prediction of outcome after brain injury.
Dr. Donders or Jacobus, welcome to the podcast.
Dr. Donders: Nice to be here.
Dr. Sharp: Thank you so much for taking the time to come on and talk with us. That’s a heck of a bio. You have a lot [00:03:00] of very esteemed titles and designations in there. I’d like to maybe start a little bit with where you’re at right now with your career and what you’re doing day to day in your work, and we can take it from there.
I know people are really excited to get into some discussion about feedback and reports and report writing but tell us a little bit about what you’re doing these days and what your work situation looks like.
Dr. Donders: Sure. Being 58 years old, I’m supposed to call myself late career, my job at the hospital is about half-time clinical and half-time administrative research in nature. Most of my work involves outpatient neuropsychological evaluations of persons who have either suspected, confirmed [00:04:00] or disputed acquired or congenital brain injuries.
I see a lot of head trauma in the adult population. I see a lot of mild cognitive impairment on the pediatric side, anything from spina bifida to cerebral palsy, you name it. I’ve always adhered to a lifespan approach.
I was initially trained to deal primarily with pediatrics. I later did some adult training. So I feel comfortable at both ends of the age spectrum. I enjoy children a little bit more but I see individuals across the age span, really.
My practice involves about, it varies on the year, but about between 12 and 14% forensic work as well. Forensic I mean personal injury, medical, legal. Besides the clinical work, I’m involved with some training. We have an APA-approved residency in clinical neuropsychology and [00:05:00] I have about a half a day a week to do research.
Dr. Sharp: Okay. What’s your research looking like these days?
Dr. Donders: There’s two things we’re looking at, right now we’re looking at subtypes of MMPI-2-RF profiles in individuals who have sustained a traumatic brain injury and see whether the different profiles are related to either demographic variables or injury variables or comorbid psychosocial factors or financial compensation seeking or any combination of the above.
We’re also looking into the concept of what’s called sluggish tempo in children with brain injuries that’s becoming a more hot topic in general cognitive psychology, but neuropsychology has not looked into that very much.
Dr. Sharp: Both of those sound relevant and super interesting. Am I remembering right that I see an article [00:06:00] you are part of that was a review of neurofeedback as well. Is that …?
Dr. Donders: I don’t think so.
Dr. Sharp: No. Okay. That might just be me. There’s a lot out there. Just from this little brief introduction, you’re involved in a lot of things that I think would be incredibly interesting to our listeners. What we are going to focus on today is a lot around report writing.
This is something that you’ve been involved with for a long time, at least as far as I know. I remember that 1999 article that you wrote about reports being too long. I don’t know if you were doing research or looking into it before that, but it’s been at least 18 to nearly 20 years. And you just, within the last few years, wrote another book Neuropsychological Report Writing. Is that right?
Dr. Donders: Yeah. [00:07:00] I edited it. I had some of my colleagues be generous enough to donate their time and treasure to write chapters in it.
Dr. Sharp: Sure. I found that book very valuable and I think there are a lot of great chapters in there. I am curious how you decided to go down that route. You’ve written or edited several books, but why a book about reports? What led you down that path?
Dr. Donders: This is the one I actually always wanted to do. I wasn’t always sure whether it had merit to the book or yet another article in the peer-reviewed journal. When I wrote that original article in Child Neuropsychology in the mid to late 1990s, it was more out of frustration with what I saw coming across my desk in terms of reports from other psychologists and [00:08:00] neuropsychologists that would go on for 12, 18 or more pages and basically said very little.
The tipping point for me came when, and that was actually included in that article that I wrote, there was a principal from a high school who had paid out of his own budget to get a neuropsychological evaluation of a young adolescent girl who had sustained a stroke. At that time, keep in mind, this was mid to late 1990s, so they spent more than $1,000 for that out of a rural school budget, and got a long report back that said, yes, she has brain damage. It’s on the left side of the brain. You need to work with visual methods and instruction.
That’s pretty much all it said. The rest was very detailed description of test results, scores, and everything. The man called me [00:09:00] and said, I already know she had brain damage. I’ve seen her hospital discharge summary. I know she had a stroke. I also know it’s on the left side of the brain. Look at her, she can’t even move her right side. This doesn’t help me. What does that mean, visual methods?
So I did that. That’s why I decided, okay, let’s write an article encouraging people to cut down on the unnecessary detail and focus more on what the reader is actually looking for. Doesn’t mean you have to tell them what they want to hear, but answer a question in a way that gives people new insights that tells them something they didn’t know before. And that then results in some practical recommendations that people can actually implement in a feasible or practical manner.
And then two years later, I did a nationwide [00:10:00] survey about report writing because I wanted to know why do people write the way they do because one psychologist or one neuropsychologist spreads differently in another way. I wanted to figure out what do people do and why do they do it?
It turned out there was no consensus in the field about how you should write a report. A lot of it differed with the practice setting. If you are in a medical setting and you write for a neurosurgeon as part of an epilepsy team and neurosurgeons, they’re very good at their job but with regard to reading reports, their attention spans probably 5 minutes at tops. So you need to get very concise information to them.
There’s very specific information that they’re looking for, such as, is this patient going to or not going to be at increased risk for cognitive decline after surgery? They don’t care about all this other stuff [00:11:00] about on this test and that test, they’d want that question answered.
On the other hand, if you are doing a child custody evaluation and you have to explain to a judge why parent A might be a better custodian of the person than parent B, you’re going to have to give some more information.
If I see a young adolescent who has a history of brain injury who is now approaching the age of majority and I’m asked to determine if this person has the mental capacity to function as his or her guardian, I need to answer very specific questions and using very specific terminology that are dictated essentially by the probate court.
I found out it depends a lot on who you’re writing with, what you’re comfortable with yourself. People doing pediatrics write different reports than people doing older adults. So it was a hodgepodge, [00:12:00] but there were several things that a lot of people agreed on what should be in the report.
I’ve seen reports where it was not at all clear who referred the patient. It’s important to know, is this a referral from a physician or from an attorney? I’ve seen reports where the date of the individual was not even mentioned. A person’s referred as a child, but I don’t know if I’m dealing with a 6-year-old or 12-year-old or anything in between.
What I wanted to write eventually, so we did that originally before a paper in the 1990s. It’s a survey published in early 2000, 2001, I think it was. What I wanted to write is one book that gave examples of if you write in this situation, be that a school, be that a court system, be that a medical system, here are some things that you need to know, here are some things that will be helpful in terms of serving your clientele. And the [00:13:00] clientele would be both the patient and the referring physician most of the time.
I wanted to do it in a format that eschewed the traditional cut-and-paste options that you get from some of these books. Okay, if you want to write a report here, just put this boilerplate in there, because that’s what I wanted to stay away from.
I wanted it to be meaningful and I wanted it to be individualized, but I wanted a format that in each chapter had, okay, here’s a good example of how to address this, and here’s a not-so-good example of how to address this. Here’s why example A is better than example B. That’s what I always wanted to do. It just took a long time to put it out here.
Dr. Sharp: Sure. I think that’s something that I appreciated about that book is that:
1. That it addressed writing reports for different audiences.
2. That you did give examples of [00:14:00] here’s a good way to do this and here’s a not-so-good way to do this. It’s nice to have really clear examples like that.
I would imagine I’m not the only one that found myself doing some things that were not so great but it’s nice to be able to change that up and have some examples from the field.
I think that we could certainly delve into the process of writing that book, I’m personally curious about that, but I know that a discussion that’s come up a lot in the podcast community and the Facebook group for testing psychologists is reports are just, they’re the bane of our existence in a lot of ways; the time involved and not getting reimbursed and things like that.
And so a lot of people are really excited to hear [00:15:00] about specific ideas about writing quality reports, but also balancing that with efficiency and making sure we’re not wasting time. At this point, I know it’s hard to cut across audiences, but do you have any general tips or thoughts on what are the core elements of a good report that should always be there?
Dr. Donders: What always should be there is who referred to patient and why, and what was the referral question? If I get a referral, it says, please evaluate, I typically send it back or I pull back and say, evaluate for what? Because I can throw a ton of tests at this individual, I don’t mind making the money. Tell me how I can best help you.
So if there’s a question about, does this patient have depression or dementia or does this child have a learning disability or attention deficit, is that what you’re worrying about? Okay, [00:16:00] that gives me an idea of what you’re struggling with.
That does not mean I cannot address anything else in my report or in my evaluation. If that child comes in and has a big bruise on their cheek, then I want to know where that bruise comes from. If that person comes in as an adult and looks very depressed, yes, then I will address their emotional adjustment, but who referred a patient? What was the referral question?
I am not in favor of regurgitating everything else that is already in a medical or in the school record that is already known to the reader. I might reference it very briefly but I’m going to assume that if a pediatrician sent that child to me, that pediatrician will know that child’s birth weight, her Apgar scores, the developmental milestones, and blah, blah. I don’t need to investigate all of that in the report.
Dr. Sharp: That’s interesting. Can I jump in real quick and ask how you handle that then? How would you [00:17:00] write the, let’s say, medical history then if you don’t regurgitate that stuff?
Dr. Donders: I had available to me the office notes from Dr. so and so, they revealed that Johnny’s medical history, language and motor development prior to the car accident in question were entirely unremarkable. Hearing it.
Dr. Sharp: Okay.
Dr. Donders: Sometimes I do that and if I don’t have that information, I will do an interview with the parent.
I will get all those milestones. I will know when that child started sitting up. I will know when they started crawling. I will know that when they said that first word. I will know when they got potty trained and all that. If I don’t find anything of significance, then I can say there was nothing unusual about this child’s development prior to the age of whatever we’re talking about.
And the people that I have worked with will know that I have asked, that is not boilerplate, that I’ve asked all those questions. [00:18:00] What I do feel strongly about, if you uncover something that people don’t know or have not appreciated, you need to draw attention to that in the report, whether that’s something about the history of observation it.
I have a patient here who supposedly was in a car accident and I read the emergency room report. There was nothing wrong, but now this patient’s sitting across from me at the table and I see a distinct nystagmus. I’m not an ENT, I’m not a neurologist, but I can’t ignore this nystagmus. So I will document that’s present.
Or if the person tells, my doctor has recommended this medication for me, this antidepressant and I told him I will think about it, but I don’t want to do that because I’ve tried that before and I had bad side effects, but there’s nothing in the doctor’s notes that the person has been tried on [00:19:00] psychotropic medication before, then I want to draw attention to that. Not to call the patient an evader or a liar, but that’s something that the referring physician should know that there’s a prior psychiatric history.
So tell the reader anything about the background that the reader doesn’t know yet. In your test results, focus on, and that includes also the behavioral observations, focus on what really makes a difference. If all the scores look normal, I’m not going to belabor them all of them.
I have a habit of attaching to my report a brief summary of all the standard scores, let’s say, a summary of the formal psychometric data is attached. The vast majority of these are within normal limits, specifically with no deficits in attention, language, perceptual skills, or memory. Only area where we find some difficulty is whatever x, y, and z, [00:20:00] and the nature of that difficulty appears to be a, b, and c, as evidenced by performance on these and these tests.
And that’s all I say if it’s a very uncomplicated situation. If it’s a very complicated situation, I will still say, I’m not going to go through every single test or every score, but let me highlight the most significant findings. This child has two problems:
1. This child can only pay attention to one thing at a time. You give him more than one thing to do, he gets lost, he starts missing things, starts making mistakes.
2. The second thing that’s going on with this child, he’s very critical of himself, any negative feedback, he panics, he has a catastrophic reaction, and that anxiety or that frustration associated with that will make him look more impaired than is in fact the [00:21:00] case. Here are some examples of how that played in the test.
I try to highlight what are the main findings and what are the main red threads throughout the report. When I come to the end, I am not in favor of appending a summary because I just went through a short report that should be one or two pages at most, why do I need a summary?
I’ve seen summaries that were a page and a half long. That’s not a summary. That’s basically saying the same thing. In the conclusions and recommendations, I basically say, listen, I do not think that this person has a learning disability. I do believe that they have post-traumatic stress disorder associated with the car accident in question.
I don’t believe that they need special education services because of head trauma because that head trauma is very minor. I am concerned about the way this person’s emotional status may negatively affect their educational success, so I’m going to ask for consideration of special education support [00:22:00] under the emotional impairment qualification. Here’s what I would do in a school setting. Beside that, this child needs individual psychotherapy or we should try a medication of Prozac or whatever.
I try to keep to the point very specific and then have some directions for follow-up. That’s pretty much what needs to be in the report; who referred? What was the question? What new information did I uncover? What does the balance of the interview, background, behavioral observations, and test results really tell me? What does that imply for this individual’s treatment and what’s the follow-up?
Dr. Sharp: Got you. I have a lot of questions about that. When you think about the history, I totally get doing a short medical history, getting really comfortable with the phrase within normal limits or unremarkable or whatever you might use.
How do you handle the, [00:23:00] let’s say, the presenting problem? How do you document that? Because that ends up being, for me, just being honest, probably at least a page where I’m talking about the parents or adults presenting concern; the history of that, the way it manifests. How do you handle that?
Dr. Donders: I focus on the highlights. A person comes in and says, I have memory problems, but then the more I talk to that person, they’re not talking about memory problems, but talking about the word-finding difficult.
I may, for example, say, even though the primary subjective complaint pertained to a memory problem, I got the distinct impression that there were more word retrieval issues, whereas this person did not indicate any problems with leaving the stove on, paying his bills, taking his medications or with a child doing his homework, remembering to turn in the homework, doing his chores, [00:24:00] whatever.
If the timeline is important, then I will elaborate on that. For example, if it’s an older adult who has a question about Lewy body disease, and according to the criteria, the emergence of cognitive and motor symptoms should be within approximately one year or less of each other, well, I will comment on that because that’s important for the diagnostic criteria. If it’s not all that important, I will not elaborate on it.
What I try to focus on is what is really important for the reader to understand in the conceptualization of this patient versus what might be interesting tidbits, but in the larger scheme of things really don’t matter all that much.
Dr. Sharp: I think that gets maybe a bigger question of or maybe logistics of when do you write the history in relation to the rest of the report? [00:25:00] Are you writing the history to fit the diagnosis or vice versa? Does that make sense?
Dr. Donders: I think the history is important regardless of the diagnosis. I may end up with a final diagnosis that this young boy indeed suffered a significant traumatic brain injury in the accident in question and that this child doesn’t need special education support and also needs outpatient occupational physical speech therapy services.
If I also uncover a history that this child has been sexually abused in the past on more than one occasion by close male relatives, I will probably put something in the recommendations that the therapy, particularly if it’s going to be physical therapy, should probably be done by a female, and that it’s very important if you’re going to touch that child, you’re going to [00:26:00] tell him in advance why you’re going to touch him, where you’re going to touch him, and you do it while you’re making eye contact with him instead of approaching him from behind.
I may not go into great detail about why that’s necessary because I consider that confidential, but I will put that in. So that’s where the history still becomes an issue even though it’s not necessarily germane to the final diagnosis.
Dr. Sharp: Right. That’s a great example. And so thinking about moving through the rest of the report, I think a lot of us separate into, there’s a section for test results and we go through each domain maybe or some people probably list out specific tests. And then there’s the section; interpretation or summary or conclusions, however you might phrase that.
Could you break that out a little bit more and say [00:27:00] what you would include in the test results versus the summary/interpretation and how those breakdown?
Dr. Donders: The test results should focus on exactly what it is. What tests did you give? What are the results? Again, I’m favoring of attaching a list of the standardized scores, and those should basically focus on what do those scores tell you sometimes with caveats based on behavioral observations like it might seem that this child is very poorly on block design, but you need to keep in mind this child has motor limitations as a result of his cerebral palsy.
Every time we gave him extended time or 10 or 15% extended time, he got them. There were several items, if the time limit was 60 seconds, he got it in 68 or 72 seconds. That should be in the test results.
The [00:28:00] interpretation/recommendation section should focus on how do I integrate those test results with what I’ve known from the medical records that I reviewed, sometimes academic records of this child, with the interview that I conducted, and the behavioral observations that I did.
So here I have all these test results that seem to suggest that this child has difficulty with word finding. There is some indication for relatively greater motor impairment on the right side of the body. I have a history from the hospital that this child had a tumor on the right side of the brain. And so my God, what’s going on here?
This doesn’t seem to fit, but then I need to keep in mind that this child is left-handed. Therefore, probably has atypical lateralization. So it still fits with the overall idea of some cognitive [00:29:00] impairment, language impairment, motor impairment, as a result of acquired neurological history, and therefore, I am recommending special education support.
So the integration part, and that’s what we’re getting paid to do for as neuropsychologists, anybody can give tests, it’s really not that hard to do. I prefer to use masters-level clinicians to do the testing for me because they’re also my eyes and ears. So the guy getting very good behavioral observations.
What you need a doctoral-level psychologist or neuropsychologist for is the integration of those test data with the history, with the interview, with the observations, and other information that you need to know. Like if you do evaluation for a probate court, there’s certain rules, certain criteria you need to follow. If you do an educational evaluation, you need to have some understanding of what special education law is in your state. So you need to integrate all of that.
[00:30:00] Dr. Sharp: Sure. You said you do append the scores at some point, at the end of the report, do you …?Dr. Donders: It’s a one-page thing that lists, in a normal battery, it would list the IQ scores. If it’s a child and I could get achieved scores, main results from tests of memory or problems or whatever tests were given with a caveat on the top of that page that those scores are for professional use only and they should never be interpreted without consultation of the accompanying report because scores are just scores. They need to be integrated with something else.
Dr. Sharp: Of course. Yes. I got you. Let me ask then, how long do your reports end up being generally, because there is variation?
Dr. Donders: If I had to write them on a normal letterhead, they would probably be two [00:31:00] to three pages plus that addendum of the test scores. Some of my reports are very brief. There’s a lot of physicians in my hospital I know that they actually never read my full report because what I do when I’m done with a patient, I’ll send that physician an email that basically says, listen, this is Mr. Jones or child’s name, whatever, who you saw on clinical, that date, who has a history of fill in the blanks.
We will policy to multi-branch or whatever like that. You had a question about this, here’s what I think; A, B, C. I do it in bullet point. I recommend X, Y, and Z. There’ll be a full report to follow next week. I know they never read that full report. They want that email with those bullet points [00:32:00] that’s probably less than 500 characters total.
Dr. Sharp: That makes sense in the hospital.
Dr. Donders: The other day I called a physician from the outside and said, I know you’re concerned about the differentiation between mild cognitive impairment versus depression. I think it’s depression, but what I’m even more concerned about is that this person is self-medicating with alcohol. You should know about that because you’re also treating this person with pain with a narcotic.
This physician had absolutely no clue that this person was self-medicating with alcohol. In fact, he was washing his if I get in down with the alcohol. Then I said, you need to know this, you probably want to follow up right away.
The length of [00:33:00] report; I’d like it to be concise, I’d like it to be brief, I’d like it to the point, but length is not as much as important as content. What matters to me in terms of content is what does it tell the reader that the reader doesn’t know yet that helps the reader change or improve care for this particular patient.
My pet peeve about many neuropsychological or psychological reports is they go on and on, it becomes verbal diarrhea. It really doesn’t give the reader, whether that’s a teacher or an attorney or a physician, any new insights, anything new that they can actually work with and do something with.
As long as we focus on that, I don’t mind the report being a little bit longer, even though I prefer it concise, if it really accomplishes that. My concern is that many individuals seem to confuse quantity with quality. [00:34:00] If you just focus on, let’s put out a quality report that helps whoever sent this patient to me and in the end, my report will help improve care for this patient, that’s all that matters.
Dr. Sharp: I think a lot of people are probably out there thinking, oh my gosh, how do you get reports down to three pages? So I want to ask you about that but before we get to that kind of stuff, I am curious, the quality is so important, where do you find you spend the most energy or have the most focus? What section of the report is taking up the bulk of your time or your energy?
Dr. Donders: The bulk of my time probably is the interpretation and then subsequent recommendation section because that’s where the integration of everything is. It’s going to be lots of fun for a nerdy psychologist [00:35:00] to calculate where the score A is statistically significant different from score B and whether that meets the criteria for minimally clinically important difference.
The history might be juicy and all that, but what it boils down to is how do I integrate all this and how do I integrate this in a way that I can explain this to whoever reads this report, referred this patient to me in a succinct, intelligible manner that is going to ensure the best follow up?
The way I’ve taught myself to do this and the way I teach my residents to do it is, there’s two tricks that we use. One is, okay, the big news on when I was watching CNN this morning is that Twitter is going to go to 280 characters. All right, Twitter is just [00:36:00] 280 characters.
Let’s say you need to send out a tweet, and let’s say this tweet only goes to the referring physician, what can you say in 280 characters about this patient? I may change it to 280 words because 280 characters is a little bit too short, but let’s say 280 words. Or let’s say you need to leave a voicemail on this person’s voicemail machine, and you only have 100 seconds, what are you going to put in that voicemail?
That’s how you get to the point. In order to do that, in order to get to the point where I can say, okay, I can say in 280 words or in a little bit over 1.5 minutes, what I think is going on with this individual and what should happen to them, I need to do that integration.
I need to cut out the irrelevant details. I need to focus on the nitty gritty. I [00:37:00] need to keep in mind what the physician or the referring party already knows. I need to keep in mind all those external contingencies such as in the court or in special education law and say here is the bottom line.
If there’s anything I want you to know about this individual, if there’s anything I want you to do about him, here it is. If you train yourself to complete that task before you start writing or dictating anything, then your time to actually do the report is going to become very brief. I dictate most of my reports in less than 20 minutes.
Dr. Sharp: Less than 20 minutes, oh my goodness. I know there are people out there just crying right now.
Dr. Donders: I’m not trying to make anybody uncomfortable. I may spend more time than 20 minutes with the integration. I’m [00:38:00] thinking for a long period of time to how do these test data fit with this history. If I want to make a case for this child to get these kinds of services, what I’s do I need to dot, what T’s do I need to cross?
The way I try to think about it and the way I explain it to my residents is it’s an inverted pyramid. The top of the pyramid is where you want to be, you want to climb to the top of the pyramid. That’s where the golden ball is. And that’s my conclusion/recommendation.
And then I go back down and say, what are the foundations of that pyramid that allow me to say, yes, this is my conclusion, I need to address. A, B, C, and D. Another level down is here are some specifics if people need to get convinced or I need to put a little bit more meat on that bone that will support that I actually have looked at all those pillars for all those foundations.
So I begin with [00:39:00] what’s my top ideal, where do I want to go? In order to make that case, what issues do I need to address and what sprinkling of details do I need to put in there? So if I’m ultimate conclusion after doing all that integration is, yes, this person does have cognitive difficulties that are a direct consequence of his traumatic brain injury, and they cannot be solely attributed to his premorbid history, then what do I need to say?
I want to say something about test results that are selectively impaired in areas that are typically affected by traumatic brain injury, such as processing speed. I also need to make a comparison between this child’s premorbid test scores and his post-morbid test scores, because I have a WISC from two years ago, where they fortunately gave the processing speed of this, and there’s a decline of 14 points that exceeds the minimally clinically, that’s a reliable change, [00:40:00] exceeds the criteria for minimally important.
I have been able to rule out that this child has a complicating anxiety or depression as has been suggested by some of the other providers. The child is frustrated. Here’s how I can tell because I did a PHQ-A, I did a GAD-7, I had the parents fill out a PIC and none of it suggested a complicating disorder.
Those are my three pillars. I can show that this child has impairments selectively on tests that are known to be sensitive to brain injury. I have compared this child’s test performance pre and post morbid, and I’ve ruled out other complicating factors. I sprinkled in there some details because I had processing speech scores, I had formal standardized ratings of mood and behavior. Now my inverted pyramid is essentially done.
Dr. Sharp: And that’s your interpretation section, huh? [00:41:00] That’s fantastic. What do you think about the, I’ve heard people call it the inverted pyramid of report writing, where you put the interpretation and maybe even the recommendations first and foremost at the front of the report and then follow with everything else. What do you think about that?
Dr. Donders: That’s personal preference. I know that if I write a report where I put in interpretation and the recommendation at the end, more than 90% of physicians really flipped to the last page.
They will not always tell you that. They say, oh, yeah, you’re right. I read your whole report. I know they’re lying but that doesn’t bother me. I’m more concerned about that they read that section that really bothers where I do the integration, where I pretty much advise them what to do, that I’m pretty confident for.
To me, it doesn’t matter upfront or in the back as long as it’s evidence-based, as long as it achieves [00:42:00] that objective of telling the reader something they don’t know and eventually helping the patient.
Dr. Sharp: I got you. I think listeners are probably dying to hear a little bit about how you get down to the point where you’re writing two or three page reports and dictating in 20 minutes. Did you start at that point or have you worked down to that point? And if so, how did you do that? What helps you with that? Tools, tricks, anything.
Dr. Donders: When I first started out, particularly during my internship and postdoctoral residency, of course, I took a lot more time. At that time, I was hand typing my report. I’ve been doing this for 29 years as an independent practice now, not counting my training, you get more [00:43:00] experience, you get more efficient.
There’s two things that I found helpful to do. One thing, for example, and some things are extremely simple. One thing is that my psychometrist, when she hands me the test data, the protocols, they’re always in the same order and always keep them in the same order because so if I know that I’m going to look for a certain test result, I don’t have to wade through all kinds of, oh, where is the test? Oh, where is this? I just saw it. No, it’s always in the same order. That sounds very little, but that saves a lot of time.
I’ve learned to, when the test results come back and the psychometrist gives me that summary sheet with all the test data on it, I eventually will append to the report. I will try to do a very [00:44:00] quick masked, we used to say blind, but you’re supposed to say masked.
We review those test results first because I’m involved with at least 6, sometimes 8 or 10 evaluations per week, and sometimes these test results come to me later in the day or the next day so it’s just, okay, let’s just look at this blindly and say, okay, I’ve got a 50-year-old man with 12 years of education who’s right handed or a 7-year-old girl who’s left handed. I look at these test results, what do I make of that provisionally? And just as an academic exercise. It takes me about 5 minutes.
Then I go back to my notes from the interview, I say, oh, okay. I need to keep in mind that this child is left handed or I need to keep in mind that this child has a history of foster placements, has been bounced around a number of times. Now it’s time to take a look at the behavioral observations from the psychometrist and the child was very anxious, withdrawn. Okay, [00:45:00] let’s now go back to the test results.
Yeah, no wonder that there’s some inconsistencies in these test results, because she’s anxious. She’s typically anxious when she’s being timed. Yeah, that appears to be a pretty consistent pattern. Her feeling being watched, judged, such as being timed, or only getting very succinct feedback, like on the Wisconsin Card Sorting Test, or a similar test where you don’t read, don’t write, or wrong, without an explanation why, we get more anxiety.
So I see a pattern here. This is a child with a lot of anxiety. You learn to do that in that fashion where you basically say okay, I’ve got all the test results on the same mark. I’m not wasting time waiting to see that. I can give a brief general conceptualization.
I’m going to check how that holds together with my history. I see a pattern emerge, but it’s okay. Let’s hold on to that pattern. Anxiety is one of the things I need to address in my report. That will be one of my pillars. [00:46:00] What’s another pillar? What’s another issue? And then I can put it all together and say, okay, here’s the final interpretation.
I think that the main keys is being organized. When I do reports, my door is closed. I typically have open door policy. Everybody in my department means that if my door is closed, I’m either with somebody discussing something confidential or I’m dictating, please do not interrupt me.
And since my dictations do not take all that long because I don’t close that door until I’m ready to start dictating and not ready to start dictating until I’ve actually already done my integration, that door is only closed for 20 minutes and people will respect that. So I don’t get interrupted, and I’m organized before I start dictating.
I spend more time on integration of findings than I do on dictating the report. People often make the mistake and say, I’m going to [00:47:00] start writing and I’m going to start dictating and somehow magically God’s greatest insight into the nature of mankind will come to me while I’m doing that, and then they find themselves on page 11 or 12 or 13 while they’re still trying to figure it out. And then it takes so long.
I think if you do the integration beforehand, before you either even write or dictate a single word, then your work is already half done.
Dr. Sharp: So do you actually, I know I’m getting into the nitty gritty here, but do you physically write out these pillars in that pyramid model, or are you just thinking of it in your mind or how do you do that?
Dr. Donders: I do it now in my mind. When I first started doing this, I would sketch them out and I might sketch out a pyramid that says here’s the top and says, so conclusion child has PTSD, not both concussion syndrome.
[00:48:00] What are the pillars? I have a history here that the child has nightmares with accident-related content, is still very uncomfortable being a passenger in cars. Doesn’t appear to be generalized anxiety because there’s no anxiety about playing soccer with his friends.Why is not post-concussion syndrome? Because I don’t see any indication on any of the tests for cognitive difficulties, particularly not in areas of novel learning or speed of processing that I know are relatively sensitive to brain injury. I also know from the history there’s nothing in the pediatrician’s notes for this child prior difficulties with anxiety. So I know this is not a pre-existing condition.
So now I know I have the symptoms that fit with the diagnosis. I can rule out another diagnosis, potion question, because I have the data to do that. I can also say it’s causally related to this accident, not only because of the nature of the nightmares, but because also there’s nothing used in this child’s medical records. [00:49:00] This is just a prior interview or a prior problem with anxiety.
I used to sketch that out. I would have a triangle at the top with three or four columns at the bottom. And then under each column, I might write down, okay, make sure you discuss the Achenbach with regard to the anxiety or make sure you discuss Dr. Jones’s office notes or a few key words.
Having done this for more than 24 years, I can now do this in my head. I usually recommend to my residences sketch it out first, but don’t make it an art project.
Dr. Sharp: That’s a good way to put it. Sure, I like that. I think that’s something that over time I’ve probably been doing in my mind, but even to hear it articulated like that helps, it gives a little more organization and structure to [00:50:00] it. I know there are probably folks out there who are thinking, okay, this is good. I’m going to start literally sketching it out before doing the interpretation. I like that visual. That’s very cool.
Do you use any, aside from dictation, any sort of technology or apps or anything like that to keep you on track or stay efficient in your report writing?
Dr. Donders: I use a transcription service, so I think they can send back to me, I typically always review them to make sure that there’s no mistakes. The mistakes are usually mine that I mumbled too much and insignificant might come out as a significant.
As an interesting tidbit, my main transcriptionist is blind. [00:51:00] She transcribes in the most accurate manner, I watched her do it once. She has the option of playing back what she just wrote. Of course, she can’t see anything. She rarely makes mistakes.
She will email me, say, hey, you forgot to put a section on the CPT codes or whatever, very accurate. I use a transcription services, how we got on this topic. I know some of individuals like to use dictation software like Dragon or one of the other ones, either way, the necessity of being organized and doing the integration so forth, it will be the same.
One of the things that I’ve found just being organized, as I said, get all your ducks in a row before you start what you’re doing. While I’m dictating, I can see how much time has elapsed [00:52:00] since I started. It keeps track for me on the phone.
So if I’m only halfway down what I want to say and I’ve already 20 minutes in the same, then I probably pause the whole dang thing, I said, what am I really doing? Why am I getting off track? What do I need to do?
As I said, I avoid interruptions. Somebody has a patient on across the hall holding a gun to his head or somebody else’s head, yes, I will deal with that but otherwise, please do not interrupt me while I’m dictating, because I need to get this done in one session, if at all possible, because else I’ll lose that train of thought.
I do at least one and most often two neuropsychological evaluations per week. If I get distracted and I start breaking up in different time slots, I lose track of what I wanted to say because I do all the integration in my head. So making sure that I have the time to do that, it’s now almost [00:53:00] 11:30 AM, I can do this report in 20 minutes, but I need to do the integration. So let me do the integration between 11:30 AM and 12:00, let me dictate between 12:00 and 12:30 PM.
Do I have that on my calendar? No, because I already have a new meeting. Okay, then I’m going to set this report aside. I’ll do that later this afternoon when I have the time for it, and between now and twelve o’clock, I’m going to do something different. Those basic time management issues help me out quite a bit.
Dr. Sharp: Yeah. I think that’s what is really standing out. There’s a lot of maybe self-awareness or self-monitoring in this process. I hear you also talking about batching your time which I’ve talked about a lot on the podcast in terms of being efficient.
So it’s like you know exactly how long a report should take you and then you just match that to your schedule. And if it doesn’t match, then you wait till you have the time, that sounds like.
Dr. Donders: Yeah. That works for me because I know what my schedule is, the [00:54:00] people around me know about my open-door policy and there’s a good reason for me to have the door closed. I know some people don’t have offices, they have cubicles or they may have more chaotic lifestyles, but try to make it easy for yourself. If at all possible, try to do that integration before you dictate so that way your dictation time will be actually be very brief and try to get it all done in one sitting.
Dr. Sharp: Yeah, that’s fantastic. Goodness, an hour has gone by really quickly. I feel like I’m looking at this long list of questions that we didn’t even really touch on, but this has been super valuable. I want to be respectful of your time.
Anything else, any kind of parting thoughts or strategies or anything like that, or even resources for folks who are trying to really tighten up their reports and make sure they’re doing a good job and not spending their lives [00:55:00] writing reports?
Dr. Donders: You mentioned my book. I don’t want to oversell it or anything like that, but I’ve pretty much put in a book on Neuropsychological Report Writing; what I think needs to be in there in terms of general guidelines and specific illustrations.
One thing that we haven’t touched on a lot is forensics or any other arena where you might beg to differ with another psychologist. What I have learned is I sleep much better and in the long run, I have much better relationships with my colleagues if I take the high road. I mean that the report is not a place to make snide remarks about another psychologist. It’s not a place to go into a micturition match. It’s not a place to be [00:56:00] passive-aggressive.
So even if I think that other psychologist is an idiot in terms that he can’t tell a cucumber from a frontal lobe, I’m not going to say that. I’m going to say, I’m a little bit puzzled by Dr. So and So’s conclusions because I don’t see a clear foundation for that. In fact, there are some other facts and those facts would be A, B, and C that would suggest otherwise.
If I find myself disagreeing, I try to phrase that in words that if my mother read it and would understand it with her 6th grade education, she would not be mad at me for being nice. You can disagree with somebody, but try to address it in a professional way.
Dr. Sharp: Yeah. Can I put you on the spot a little bit [00:57:00] to ask for maybe another example of how you would do that? What the wording would sound like to politely disagree?
Dr. Donders: This patient had a prior psychological evaluation with Dr. Jones. Dr. Jones gave her a diagnosis of a major cognitive disorder due to traumatic brain injury. I find this somewhat puzzling because we’re talking about an individual who is now more than two years after an uncomplicated mild traumatic brain injury and the literature suggests that the vast majority of people typically recover with a matter of weeks to months. That’s not just my private opinion, but here are some different literature references.
I questioned the terminology do too, because there’s clear evidence in the school records that this child had special education services because of cognitive impairment well before is brightened. It is excellent to ever have. And that’s all I say.
[00:58:00] Dr. Sharp: Okay. I like it. That was a great on-the-spot performance. Thanks for entertaining that. Like I said, this has been incredibly valuable. I’ve been taking a lot of notes. I think that listeners are going to find this very informative. I really appreciate your time. We will have links in the show notes to your book and any other resources that I might be able to dig up to support anything that you’ve said.So Jacobus Donders, I really appreciate it. Thank you so much for coming on The Testing Psychologist.
Dr. Donders: Oh, you’re welcome. It was fun.
Dr. Sharp: Good. Take care.
Dr. Donders: You too. Bye bye.
Dr. Sharp: Hey, y’all. Thanks again for listening to this interview with Jacobus Donders. Dr. Donders is obviously a very well-decorated member of our field and has done a ton over the years. I found this conversation valuable just to get some insight into [00:59:00] the elements of a report that are truly helpful and some ways to cut down our report writing time to deliver what is most important.
Like I mentioned during the podcast, we’ll have links to his book in the show notes. He has several articles published on a variety of topics that you can look up through Google Scholar or your university library.
A final shout-out to Practice Solutions. They’re a full-service billing agency just for mental health professionals. They do it all. They have greatly helped our practice. They will give you 20% off your first month if you follow up with them and mention The Testing Psychologist, or go to practicesol.com/jeremy.
So thank you as always for listening. This has been a big week. The size Facebook group has literally grown by about 20% maybe [01:00:00] 25% just this week. So something is happening. The word is getting out and people are jumping in, which is fantastic. If you are not a member of the Facebook group, come check us out. It’s The Testing Psychologist Community on Facebook.
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Of course, as always, if you are looking for consultation for your testing practice, feel free to give me a shout. That is what I do. That’s what I specialize in. I would love to talk with you about how to grow your testing practice or hone your testing services to make things more efficient and make sure that you’re making money like you should be. You can get that contact information at thetestingpsychologist.com. All right, y’all, take care. I will talk to you next time. [01:01:00] Bye bye.