Dr. Jeremy Sharp (01:22)
Hey everyone, welcome back to the podcast. I have a fantastic clinical episode for us today. I’m talking with Dr. John Mietchen. He’s a pediatric neuropsychologist and assistant professor in the Department of Neurology at the University of Wisconsin Madison School of Medicine and Public Health, where he works to make neuropsychological care more accessible to children and families across Wisconsin.
He sees codes for comprehensive outpatient evaluations, routine cog screenings, and clinical consultation in multidisciplinary clinics for kids with neurocutaneous disorders, congenital heart disease, and concussion, and brain injury. With his colleague, Dr. Alana Kessler-Jones, he co-developed an innovative telehealth triage model that increased access to neuropsych services while simultaneously reducing wait times for evaluations.
And that is what we are talking about today. We’re talking about the model that he and his colleague developed at the hospital. It’s called the telehealth triage consultation appointment. And like I said, you know, this is implemented in an academic medical center, right? But I think there are a lot of parallels and a lot of takeaways for private practice as well. So we talk about the waitlist crisis
And the fact that referrals have increased year over year for neuropsych testing around the country. We talk about why that may have happened. we talk about the problem with such a long wait list. I think many of us are aware of that. And we get into the nuances of this triage referral process, where John and now his colleagues are implementing a triage appointment to determine who
Truly needs testing and who may be maybe able to walk away with comprehensive referrals and recommendations without a full battery. So if you are practicing in an area where there are long, long wait lists or you yourself have a very long wait list, again, there is a lot of applicable information from this episode where we talk all about the details of a triage model and how to navigate.
Such a model with referral sources and with clients and many other aspects of this approach. So, without further ado, let’s get to my conversation with Dr. John Meechin.
Dr. Jeremy Sharp (03:57)
John Hey, welcome to the podcast.
Jonathan Mietchen (03:59)
Yeah, thank you for having me. It’s a pleasure to be here.
Dr. Jeremy Sharp (04:03)
Thank you for being here. Yeah, I this this topic is so fascinating to me. I’m having a hard time. Like I wanna just jump right into it because, you know,
Jonathan Mietchen (04:11)
Yeah.
Dr. Jeremy Sharp (04:12)
This is a topic that comes up a lot in private practice and, you know, other entities, hospitals, et cetera, around the country. So yeah, thanks for being here. This is gonna be a good conversation, I think.
Jonathan Mietchen (04:23)
Yeah, yeah, I think so.
Dr. Jeremy Sharp (04:25)
So I’ll start with a question that I always start with, which is you know, you could do a lot of things with your time and energy as a neuropsychologist. So why this? Like why dedicate time and energy to to looking into this topic?
Jonathan Mietchen (04:38)
Yeah, yeah. So you know, just I think like everybody were trying to manage what seemed to be like longer, longer wait lists. and we had tried a lot of different things, right? We had we tried doing a lot of education with different referring providers and referring departments on kind of when neuropsychology might be helpful, when it’s maybe less helpful. We tried sort of modifying our referral form.
Say, you know, like these are the types of questions that might be helpful. These are kind of the criteria that we’re looking for. and it kind of felt like whatever we were doing, we were our wait list is g was getting longer. You know, we’re getting referrals that are essentially saying things like evaluate and treat, which is kind of a it’s hard it’s it’s hard to know kind of the urgency of, you know, how quickly does this kid need to be seen when we’re not really quite sure what the referral question is.
And so I think we just as a group here we’re kind of getting just I think a little frustrated and kind of like not sure quite sure, you know, knowing how do we solve this problem, our wait list is just getting longer.
And so so I think we had you know the the primary goal going into this was to get a better idea of who’s on our wait list, what type of testing might they need with kind of the ultimate goal of hopefully cutting down the wait time for people who are waiting on that wait list. And I think as we were doing this, I think other benefits sort of made themselves known. But that was kind of the
Dr. Jeremy Sharp (06:05)
Mm.
Jonathan Mietchen (06:06)
initial purpose was to to figure out that wait list problem.
Dr. Jeremy Sharp (06:11)
Yeah. Yeah. It’s a big problem. I feel like there I hear this all the time and have experienced it. You know, I’m in Colorado, about an hour north of Denver. So, you know, we hear about Denver Children’s Hospital and it seems like their wait list
Jonathan Mietchen (06:24)
Yeah.
Dr. Jeremy Sharp (06:25)
runs from anywhere from twelve to thirty six months, depending on factors.
Jonathan Mietchen (06:29)
Yeah, right.
Dr. Jeremy Sharp (06:31)
And then a lot of private practices are saying like we’re booked out months and months and especially if you take insurance, it’s
you know, the wait lists just keep on growing.
Jonathan Mietchen (06:41)
Right.
Dr. Jeremy Sharp (06:42)
So when y’all were getting started with all this, were you did you find research to actually quantify or figure out like are the referrals grow like are we getting more referrals or is there just less access or what do you how what do you attribute the growth in wait lists to?
Jonathan Mietchen (07:01)
So definitely an increase in referrals. So we had kind of seen that year on year. we only reported it in the in the paper we reported the referral rate just over the years that we were kind of doing this pilot study. But leading
Dr. Jeremy Sharp (07:14)
Mm-hmm.
Jonathan Mietchen (07:15)
Up to 2022, we had definitely seen just an ever increasing number of referrals year on year. So there was like an actual increase in number of referrals.
I think the pandemic set things back, right? Where when a clinic is closed for I mean, we we opened up I wanna say May, but that was like, you know, we weren’t seeing the same volume of patients, and then we’re still trying to ramp up. And so I think that had something to do with it. right. And so going into 2022, like it was, you know, I still felt like we were kind of playing a little bit of catch up.
plus again, just the sort of increase in referrals over time.
Dr. Jeremy Sharp (07:57)
Yeah, yeah. And w were you able to get any deeper sense of where the increase in referrals was coming from? Is it like self referred or physician referred or something else or some combination?
Jonathan Mietchen (08:07)
Yeah.
Yeah, so we don’t accept self refer in our in our clinic specifically. So it would have been and and it really was primary care.
Dr. Jeremy Sharp (08:15)
Mm-hmm.
Jonathan Mietchen (08:17)
I think was the big sort of where we were seeing a lot of those referrals come in was primary care providers with, you know, questions about ADHD, learning disability, is really kind of where that increase
But the most notable increase, I think across the board we noticed an increase as our department grew too. But the the bulk of that was by primary care. Yeah. And I think
Dr. Jeremy Sharp (08:44)
Okay. Okay. Yeah. Yeah.
Jonathan Mietchen (08:48)
I was gonna say I think some of those were like the referral technically came from primary care, but it was I think there was an increase in like parent-driven referrals, right? So the primary care doctor has to be the one to place the the referral at least at our institution.
But a lot of it was like a my chart message saying, Hey, I want my kid to get neuropsych and then that referral coming through
Dr. Jeremy Sharp (09:08)
Mm-hmm. Mm-hmm. I wondered about that. So it’s almost like a backdoor self referral.
Jonathan Mietchen (09:10)
So yeah.
Yeah. So I I guess to kind of correct what I said earlier, I think that there was an increase in self refer. It’s just there’s an extra step to for
Dr. Jeremy Sharp (09:20)
Right.
Jonathan Mietchen (09:21)
that to happen, yeah.
Dr. Jeremy Sharp (09:22)
Gotcha. Gotcha. Yeah, I think that matches our experience as well. You know, we do kind of say, even though we’re a private practice, but yeah, lots of primary care referrals, lots of physician referrals. and yeah, I mean, it’s a double edged sword to me, you know, it’s like I’m glad people are there’s more awareness for mental health and people are kind of tuned
Jonathan Mietchen (09:40)
Mm-hmm.
Dr. Jeremy Sharp (09:41)
in, parents are tuned into their kids’ needs and and whatnot. And it, you know, leads to
Some questions certainly around well, who needs testing and what kind of testing and does everyone need testing? All those kinds of questions, which y’all sort of set out to to figure out. So can you
Jonathan Mietchen (09:57)
Yeah, yeah. Yeah. Yeah.
Dr. Jeremy Sharp (09:59)
maybe maybe as we get into this, could you give an overview of the like the pilot that you did and the model that y’all developed? I think that’d be interesting for folks to know.
Jonathan Mietchen (10:09)
Yeah, yeah. So we you know, just as as kind of some background before we’ve we’ve always triaged referrals, but it was always just based on the information that we had in the referral form. And so we had kind of a an urgent wait list that wasn’t much of a wait list, right? If it’s a neurology saying, hey, this it might be going in for neurosurgery next month or getting
Dr. Jeremy Sharp (10:31)
Mm.
Jonathan Mietchen (10:31)
them in. So that would be kind of our urgent list would be sort of cases like that where there’s a medical urgency where that like we’re testing you really can’t wait.
Dr. Jeremy Sharp (10:40)
Mm-hmm.
Jonathan Mietchen (10:41)
and then there’s a priority wait list where you know maybe it’s new onset epilepsy and those kids are yeah you know late effects of chemotherapy treatment or radiation, a genetic disorder, those kids are kind of being put in on a priority list.
Dr. Jeremy Sharp (10:56)
Mm-hmm.
Jonathan Mietchen (10:56)
And then we have kind of that sort of like those vague
you know, does this kid have a learning disability or ADHD referral? and those were being put on kind of like our just sort of like traditional wait list that was mostly comprised of like medically healthy kids. and so we were triaging those just based on the referral that came in.
And so what we started doing was those kids that were initially being triaged onto sort of like that standard wait list, we were triaging them into a telehealth-only appointment. So urgent cases were just getting put on there.
quick wait list priority cases were just getting put on a wait list presuming that they were gonna need testing just because of the medical risk. And then rather than kind of making these kids wait a year and a half to two years to even have any contact with the neuropsychologist, we were putting
Dr. Jeremy Sharp (11:51)
Mm-hmm.
Jonathan Mietchen (11:51)
them on a telehealth only list for telehealth only and we were getting to the to them in about a month of for the time of referral. So
Dr. Jeremy Sharp (12:00)
Okay.
Jonathan Mietchen (12:02)
even though for those that ended up going on the wait list after that, which was about three quarters of them, ended up going on the wait list.
Dr. Jeremy Sharp (12:09)
Hmm.
Jonathan Mietchen (12:11)
so one quarter didn’t, we kind of deemed like, I don’t know that testing is gonna be the most helpful thing for you. We had that conversation with families and just for your listeners, like, you know, we we were never like super sticklers, you know, like if a family just really was like, I just really want testing, we kind of
you know, obliged and put them on that wait list. but it essentially cut down their time to have at least contact with the neuropsychologist from about two years down to a month. And that contact was telehealth, but we’re still doing essentially an intake, getting a clinical history for about 45 minutes and then spending the last 15 minutes giving any recommendations.
And and that recommendation could have included, let’s go on the wait list, but here’s some things to do in the meantime. Or
Dr. Jeremy Sharp (12:54)
Mm-hmm.
Jonathan Mietchen (12:54)
it could be, you know, I don’t know that testing is really gonna help answer the question you’re wanting to get answered. I think we need psychiatry. I think, you know, we need to talk talk about how do we talk to the school. but that’s kind of what was happening during that initial telehealth visit was that that was about a month after that initial referral.
and then for those that were put on the wait list, they waited and I think in our paper we cut our wait list down to about 17 months, which is half a school year from 24. and now we’re at less than a year, it’s probably 10 months is kind of where we’re at now.
So from from initial referral till time of testing. Uh-huh. so it did help us. Mm-hmm. Yep. Yeah. And we do have
Dr. Jeremy Sharp (13:37)
Okay. Okay. And that’s down from twenty four months? Okay. That’s remarkable.
Jonathan Mietchen (13:45)
yeah, we have an LPC who’s doing those intakes for us now.
So at at the at the beginning of all this, it was myself and my colleague Dr. Kessler Jones that we were kind of seeing these patients on our own.
Dr. Jeremy Sharp (14:00)
Okay.
Jonathan Mietchen (14:00)
Then after we were kind of able to show that this is working, we were able to hire an LPC who’s kind of helping us take on that work. yeah, so so yeah,
Dr. Jeremy Sharp (14:09)
Sure, sure. Yeah.
Jonathan Mietchen (14:12)
again with the goal of let’s give some recommendations in the meantime if they need testing, so that they’re
Dr. Jeremy Sharp (14:17)
Mm-hmm.
Jonathan Mietchen (14:17)
not just two years, it’s almost like why have a service? You know, like like that’s when the a lot of these needs are more immediate. So we were able to at least address the immediate need and then determine if they even needed testing. So do they need testing? What recommendations can we give in the meantime?
Dr. Jeremy Sharp (14:33)
Gotcha, gotcha. Yeah, this is this is fascinating. lots of questions here. So, tell me, maybe if you could go into a little bit more detail about that telehealth appointment. I’m really curious what’s happening on that triage appointment. So you
Jonathan Mietchen (14:47)
Yeah.
Dr. Jeremy Sharp (14:48)
you said initially this was it was you and another neuropsychologist, presumably. Okay. Yeah.
Jonathan Mietchen (14:50)
Mm. Yep. Yep. Yep. Yep.
Dr. Jeremy Sharp (14:54)
Give me a little more detail about those triage appointments. What were you asking? What were you evaluating?
How’s it different
Jonathan Mietchen (15:00)
Yeah.
Dr. Jeremy Sharp (15:00)
from like a typical intake, so to speak?
Jonathan Mietchen (15:02)
Yeah, I mean, I do think that it was very similar to a typical intake. I think
Dr. Jeremy Sharp (15:08)
Okay.
Jonathan Mietchen (15:09)
in a lot of ways, I think this actually really helped me sort of narrow
like like really kind of hone my clinical interview skills. Cause
Dr. Jeremy Sharp (15:23)
Mm-hmm.
Jonathan Mietchen (15:23)
I think before there was always this feeling of like, well, but I can rely on testing. I’m gonna get testing. I’m gonna get some checklists from these
Dr. Jeremy Sharp (15:30)
Mm-hmm.
Jonathan Mietchen (15:32)
patients and their parents. And when that’s when that’s kind of taken out of this and it’s it kind of is like, okay, I actually really need to drill down and just figure out as a clinician, what am I most concerned about? right, because to a parent they might be concerned about dyslexia, but
Dyslexia can mean a lot of different things to a lot of different people who aren’t trained clinicians. And so the appointment was really a pretty thorough clinical history. but I would usually just start out by letting them know, kind of like, this is why we’re doing this, just so that it didn’t feel like why are we here if we’re not if you’re not gonna see us for testing and
And for another year
Dr. Jeremy Sharp (16:10)
Yeah.
Jonathan Mietchen (16:11)
and a half to two years, right? So it was a lot of like, you
Dr. Jeremy Sharp (16:13)
Swell.
Jonathan Mietchen (16:14)
know, my goal here is just to make sure that testing’s actually going to be helpful to you. And that’s a decision we’ll make together. And
Dr. Jeremy Sharp (16:19)
Mm-hmm. Mm-hmm.
Jonathan Mietchen (16:21)
then I want to give you some recommendations in the meantime, right? So even if I think we need testing, what are some things we can do in the meantime? Whether that’s like how do we effectively talk to schools, because you don’t need to see a neuropsychologist to get additional school help of some kind.
Dr. Jeremy Sharp (16:37)
Mm-hmm.
Jonathan Mietchen (16:38)
Do we need to be addressing other mental health concerns in the meantime or at least trying to work on some of those things? And so I was kind of outlining the purpose pretty clearly with them and then really kind of doing an intake really focused on differentials. right, and kind of walking through and screening for things. And if I start to hear things that make are making me concerned about depression, I’m making sure I’m getting enough information to
So that I I know, like, do I think you’re depressed? Do I think you need to be talking to your primary care doctor and a therapist about depression or anxiety? was this
Dr. Jeremy Sharp (17:12)
Mm-hmm.
Jonathan Mietchen (17:13)
a referral that came in from a my chart message and I’m really concerned about ADHD? And primary care is a reasonable place to do have a first stop for something like that if no one’s asked to you know, done a sort of an evaluation for that in the primary care setting. So it it was really kind of focused on
those differentials and kind of what differentials am I concerned about and which of those differentials do I think testing is actually going to help us achieve diagnostic clarity for and treatment recommendations for. And so that was
Dr. Jeremy Sharp (17:47)
Right. Right.
Jonathan Mietchen (17:48)
really kind of the focus of how that that went. But they were I mean, like I said, they weren’t brief. They were scheduled for an hour and there were 45 minute to 50 minute interviews with 10 minutes of recommendations at the end.
Dr. Jeremy Sharp (18:01)
Gotcha. Gotcha.
So let me this is where I I think struggle a little bit. So maybe you can help me. Cause we
Jonathan Mietchen (18:07)
Yeah, yeah.
Dr. Jeremy Sharp (18:08)
so we do two hour two hour intakes in our practice, right? We allot two hours. I if everything goes according to plan, like the person shows up on time, they’re a a good organized historian, and it’s a relatively uncomplicated, kind of straightforward.
case, I feel like
Jonathan Mietchen (18:26)
Yeah.
Dr. Jeremy Sharp (18:27)
I can maybe finish in like 75 minutes. But otherwise, you know, it’s like pushing an hour 40, an hour 45, hour 50, you know, before we are transitioning to logistics and so forth. So I am fascinated by how, you know, how you might be doing differential diagnosis in 45 to 50 minutes given like all the different rule outs. Can you shed any light on that process?
Jonathan Mietchen (18:47)
Yeah. Yeah.
Sure. So you know, the other thing I think that I guess so I guess one way th that would be different from from this is, you know, rarely at the end of this am I sort of
I mean, I guess sometimes like if it’s just like a clear major depression or generalized anxiety, right? but I think, you know, sometimes it’s maybe gathering enough information to know what types of recommendations,
Dr. Jeremy Sharp (19:17)
Mm.
Jonathan Mietchen (19:18)
right? So if I feel like, yeah, there’s clearly anxiety, I think there’s probably some social anxiety, or at least a component, do they meet full criteria for social anxiety disorder?
Or maybe
Dr. Jeremy Sharp (19:31)
Yeah.
Jonathan Mietchen (19:31)
not getting that specific in these in these intakes. right. So I guess maybe one framework would be I’m sort of going through and sort of trying to formulate and answer some questions about you know, I mean, do they do they need mental health treatment that they’re not getting? Right. And there
Dr. Jeremy Sharp (19:49)
Mm-hmm.
Jonathan Mietchen (19:49)
might be some really specific diagnostic clarity questions that are may are maybe sort of unanswered at at the end of that. Is it
Dystymia versus major depressive disorder versus you know generalized anxiety versus social anxiety versus agoraphobia. We might not be getting that specific, but we are gathering
Dr. Jeremy Sharp (20:09)
Mm-hmm.
Jonathan Mietchen (20:10)
enough information to say there’s clearly a mental health piece here, and we need
Dr. Jeremy Sharp (20:13)
Mm-hmm.
Jonathan Mietchen (20:14)
to get you connected to some mental health resources in the meantime.
Dr. Jeremy Sharp (20:18)
Gata. Gata.
Jonathan Mietchen (20:22)
and so you know, I think that that that sort of is is maybe sort of the level of clarity that we’re trying to achieve in something like this. and then,
Dr. Jeremy Sharp (20:32)
Mm-hmm. Sure, sure.
Jonathan Mietchen (20:35)
you know, I think one benefit, and I’m not sure if you have have the benefit of this, but you have the medical record.
Dr. Jeremy Sharp (20:41)
Mm.
Jonathan Mietchen (20:41)
And so a lot of these things we’re spending more than just that 50 minutes with the patient, but we’re doing a chart review before.
Right. And so for most patients, I’m not having to do a deep dive in, you know, gestation or some of these sort of like medical like a medical history. I kind of have that at my fingertips before I’m actually seeing the patient. So I’m not having to ask
Dr. Jeremy Sharp (21:05)
Mm.
Jonathan Mietchen (21:05)
detailed questions.
Dr. Jeremy Sharp (21:08)
Okay.
Jonathan Mietchen (21:08)
like I might run through and say, you know.
chart says development was normal as far as you know did they have any developmental delays right but if they have years of pediatrician visits documenting normal development i’m not having to sort of that’s not necessarily what i’m spending my time on with
Dr. Jeremy Sharp (21:27)
Mm-hmm.
Jonathan Mietchen (21:27)
with those patients does that make sense so it
Dr. Jeremy Sharp (21:30)
It does, it does.
Jonathan Mietchen (21:32)
it really is focused on sort of their presenting
presenting concern.
Dr. Jeremy Sharp (21:40)
Certainly.
Jonathan Mietchen (21:41)
and I think that to some degree there’s also just a focus on what questions are they wanting answered, right? If
Dr. Jeremy Sharp (21:47)
Mm.
Jonathan Mietchen (21:47)
if you know so some kids they they might already have a known history of ADHD and they just want to know if they have dyslexia. Now I’m gonna ask some ADHD questions because I want to know how well we think it’s being treated and controlled. But
I’m not necessarily trying to achieve clarity on that because it’s been achieved and so I’m really focused on the reading. it’s
Dr. Jeremy Sharp (22:08)
Yeah.
Jonathan Mietchen (22:08)
there is sort of a more focused
Dr. Jeremy Sharp (22:13)
Yeah.
Jonathan Mietchen (22:13)
Scope, I think, with some of that.
Dr. Jeremy Sharp (22:15)
That makes sense. That makes sense. So I have two follow up questions. One is are y’all utilizing any kind of screeners or rating scales during this triage process to give you more information or point you in a certain direction?
Jonathan Mietchen (22:29)
Yeah, so we that was something we had talked about and they are now, but when we were doing it, we had not implemented that yet.
Dr. Jeremy Sharp (22:36)
Okay. Okay.
Jonathan Mietchen (22:37)
I think we just hadn’t found an effective way to get that information beforehand, just
Dr. Jeremy Sharp (22:42)
huh.
Jonathan Mietchen (22:43)
with manpower, like just to who’s gonna send those and but that being said, like I we had talked about it and I do think that that would is actually like remarkably valuable to have something like that.
going into an appointment and kind of trusting the reliability and validity. And if no one is saying there’s internalizing problems, we should hopefully be able to trust that and focus on, you know, not saying don’t ask any questions, but yeah,
Dr. Jeremy Sharp (23:14)
Course.
Jonathan Mietchen (23:15)
I think I can I I think it can help with a more focused interview.
Dr. Jeremy Sharp (23:19)
Yeah, yeah. I gotcha. I gotcha. And then the second question there was, you know, how much are you at least poking around or kind of screening a little bit for like the more significant concerns that might be hiding behind the scenes, you know, like a a thought disorder or like a a bipolar kind of situation. it could be any number, trauma, you know, like were you getting into that at all? and if so yeah.
Jonathan Mietchen (23:42)
Yeah, yeah.
So I think I mean I think it depends on the patient, right? I think
Dr. Jeremy Sharp (23:47)
Mm-hmm, mm-hmm.
Jonathan Mietchen (23:48)
some of the this sort of I think skill with that would come with I think when I started this, I was, you know, like two years into independent practice.
Dr. Jeremy Sharp (24:00)
Mm-hmm.
Jonathan Mietchen (24:01)
So I kind of had like this rote like these are the questions I want to make sure. And I
Dr. Jeremy Sharp (24:04)
Yeah.
Jonathan Mietchen (24:04)
think throughout this it’s kind of like I need to make sure I follow up on
mood because of that comment they just made in the context of another question.
Dr. Jeremy Sharp (24:14)
Mm-hmm.
Jonathan Mietchen (24:15)
And so, you know, I I I think a lot of it is I I would say yes and the patients on the on the call, right? So I think if there’s a thought disorder, hopefully we’re picking up on some behavioral observations that are kind of making us concerned about something like that. You know, but I think
Some of this, you know, admittedly is again, if the question is, you know, does my kid have dyslexia? But they’ve, you know, got lots of friends, they’re doing well socially, they’re doing well with math, right? They’re sleeping well, they’re eating well, they’re not having big outbursts at home. Some of this it’s it’s kind of like, well, the likelihood of these things are low because we should be seeing some disruption. Some of
Dr. Jeremy Sharp (24:54)
Very low. Right, right.
Jonathan Mietchen (24:56)
these things. And so, but definitely you have those where
The concern is reading and we spend very little time talking about reading and most of the time talking about these other more concerning factors
Dr. Jeremy Sharp (25:09)
Right.
Jonathan Mietchen (25:10)
that are clearly not being being addressed. So I think the
Dr. Jeremy Sharp (25:14)
Right.
Jonathan Mietchen (25:15)
the answer is yes, but to varying degrees depending on the patient and their presenting problem. Yeah.
Dr. Jeremy Sharp (25:21)
Certainly, certainly. Yeah,
you made a a comment earlier that that really struck me that something around the line or along the lines of you know, going through this process really kind of forced you to hone your interviewing skills. And I’m guessing, you know, people are wondering about that as well. You know, I’m curious, was there I mean, is there anything kind of concrete that you distilled from all of this in terms of like, yeah, what you did differently, how you approached these interviews, what you learned.
Jonathan Mietchen (25:47)
Yeah. Yeah. I mean, a lot of them are you know, some of this I think is came from like trying to sort of we’ve done some presentations with pediatricians within our own healthcare system and just within the community. but I think one thing that really sort of like one framework that really sort of helped me and I was taught it in grad school, but I think it just kind of helped me really sort of get
you know better at clinical interviewing is you know like understanding symptoms onset and course. I think that
Dr. Jeremy Sharp (26:16)
Mm.
Jonathan Mietchen (26:17)
three things can really help us differentiate between different disorders, right? So dyslexia is neurodevelopmental. And I’m not saying that it has to show up in kindergarten or first grade, but it shouldn’t just come out of nowhere at age 16 either. Right. And
Dr. Jeremy Sharp (26:34)
Right.
Jonathan Mietchen (26:35)
so if we’re having school problems and that’s what’s
making us concerned about dyslexia is just an out-of-the-blue school problem at 16. I’m that’s making me think like, well, that’s probably unlikely to be a learning disability, right? It’s it’s because you want to get a good clinical history to just kind of see like what did that reading progression look like, right?
Dr. Jeremy Sharp (26:56)
Mm-hmm.
Jonathan Mietchen (26:57)
is it just that now they’re in AP classes and they could compensate for it, or is it really just kind of out of the blue?
And then I think just honestly, like finding ways to word questions so that they’re like a little heavy hitting. right. So like one that I found just as an example, right? Instead of like marching through you know, the DSM criteria for what we might expect with dyslexia.
Dr. Jeremy Sharp (27:21)
Mm-hmm.
Jonathan Mietchen (27:23)
right, like one that I found is really helpful that will sort of cube.
parents to give me really helpful information is like, well, when your kid reads out loud, what does it sound like? And that
Dr. Jeremy Sharp (27:31)
Mm.
Jonathan Mietchen (27:32)
can kind of wrap up four questions into one, right? Because if they’re saying like, well, they can’t decode, they might use a different word than decoding, but that is what they’re describing, right? Their fluency is poor. you know, their reading is choppy,
Dr. Jeremy Sharp (27:44)
I love that question.
Jonathan Mietchen (27:45)
it’s slow, it’s effortful. I’m getting like I’m getting a lot of really sort of rich clinical data on that one question rather than asking, can they decode?
Are they reading fluently? Right. So I think just learning sort of that, I think, what questions can really help me.
Dr. Jeremy Sharp (28:04)
Mm-hmm.
Jonathan Mietchen (28:05)
pull some of that rich clinical data.
Dr. Jeremy Sharp (28:09)
Yeah, I love that. Do you have other
Jonathan Mietchen (28:10)
So won’t.
Dr. Jeremy Sharp (28:12)
hard hitting questions like that that you can think of off the top of your head? That’s a good one.
Jonathan Mietchen (28:13)
Yeah. Yeah.
Yeah. let’s see. I mean things like
You know, like if I’m concerned about like maybe an intellectual disability, right? Questions like, you know, what are things that we want to do sibling comparison, but like what are the some things that their siblings were doing at that age that like they just can’t seem to do, right?
Dr. Jeremy Sharp (28:33)
Mm-hmm.
Jonathan Mietchen (28:36)
or you know, what are some things if they don’t have siblings that like their peers are doing it, you’re hoping they’d be able to do by age twelve, but we just can’t, right? And that’s sort
Dr. Jeremy Sharp (28:45)
Uh-huh.
Jonathan Mietchen (28:45)
of they they’re kind of offering this information rather than talking about
hygiene and can they make a simple meal and do they need help picking the right clothes out for the right kind of weather? And they might still need some prompting. but I think finding questions that sort of kind of help pull out sort of like I said, that kind of rich clinical information that you’re looking for without having to do like this symptom checklist.
Dr. Jeremy Sharp (29:10)
Sure.
Jonathan Mietchen (29:11)
yeah.
Dr. Jeremy Sharp (29:12)
I like that. I like that. You know, this is interesting. It’s maybe counterintuitive to how I might think these interviews will go. Like I would I would almost think like a triage appointment would be like boom, boom, boom, boom, like symptom, symptom, symptom, symptom. You know, like you’re just kind of like running through a checklist. But at least from these questions, it feels like there’s a little more of a qualitative nature to it or
You know, it’s a little more open ended. I I really like that. That matches my typical interview style a lot better. so it’s
Jonathan Mietchen (29:40)
Yeah.
Dr. Jeremy Sharp (29:41)
good to know that we don’t have to maybe abandon that if that’s your style.
Jonathan Mietchen (29:44)
Yeah, no, like so we we didn’t have like a we we each kind of used our own templates and you know, I have a template
Dr. Jeremy Sharp (29:53)
Mm-hmm.
Jonathan Mietchen (29:54)
that I work from, but I don’t have I don’t have specific questions within that template that I’m sort of checking off.
Dr. Jeremy Sharp (29:59)
Right.
Jonathan Mietchen (29:59)
Sort of like an algorithm. And so like,
Dr. Jeremy Sharp (30:02)
Yeah.
Jonathan Mietchen (30:03)
You know, I think one of the things that we were kind of hoping to achieve with that paper is like letting people know like being the clinician is like it like that I think is the goal. Is like you ac we actually have a lot of clinical knowledge and that trusting algorith algorithms and checklists and do you have this symptom, do you have that symptom? you know, what’s this test score and what’s this number? That I think is not necessarily what makes a clinician different. Like we can we can teach a computer to make an algorithm.
Dr. Jeremy Sharp (30:36)
Great point.
Jonathan Mietchen (30:37)
Of checklists,
right? And I think but it’s more like that sort of like richness of like
you know, what is my sort of clinical experience telling me? and
Dr. Jeremy Sharp (30:47)
Absolutely. Yeah.
Jonathan Mietchen (30:49)
letting that guide the conversation. Yeah. So yeah, yeah.
Dr. Jeremy Sharp (30:52)
Hmm. Hmm. I like that. I’m glad to hear that. Yeah.
So maybe maybe we shift to talking about outcome. Or actually, I’m not sure. Maybe we can wrap this into the, you know, the actual triaging discussion. But
Jonathan Mietchen (31:06)
Sure.
Dr. Jeremy Sharp (31:07)
I mean, how did you like I I guess I could see how you decide who doesn’t get testing, but like how did you decide, how’d you find the folks who you would say like need testing and what happens to them?
Jonathan Mietchen (33:43)
Yeah, yeah. I mean so sub there’s gonna be some like subjectivity to to this, right? I think it kind of depends
Dr. Jeremy Sharp (33:49)
Of course.
Jonathan Mietchen (33:50)
on on on the clinician and it is diffic triage is inherently difficult because at some point you’re saying like
This person has greater need, and that’s gonna depend on who you’re talking to as far as who thinks that, right?
Dr. Jeremy Sharp (34:07)
Yes.
Jonathan Mietchen (34:08)
but I think those that we had sort of felt like, you know, we don’t need
neuropsych testing, right? Now we are different in that like there’s places that would do just sort of psych testing. right, and I think that that’s different, but at least sort of within our practice, right? It would be, you know, an example of like rapid onset school problems at 16, whereas before they were a really good student, and then that’s also accompanied the onset sort of matches with symptoms of depression and anxiety, maybe some sort of like rule breaking
and the door’s always open. We’re never saying you don’t ever get to come back, but that might be one where we’re saying, like, you know, this really doesn’t follow the trajectory of what we know about learning disabilities. That’s more unlikely. Their grades
Dr. Jeremy Sharp (34:53)
Mm-hmm. Yeah.
Jonathan Mietchen (34:55)
are low, not because they don’t understand the content, it’s because they’re skipping class. That’s right. And so I think what we need is let’s talk to our PCP and then I’m gonna put in a referral for psychiatry, psychology, you know.
primary care, behavioral health. so though that would be an example of maybe someone who’s who’s not being referred. And I think in the paper in the
Dr. Jeremy Sharp (35:18)
Mm.
Jonathan Mietchen (35:19)
in some of the supplemental materials, we have like an example note there of someone that might
Dr. Jeremy Sharp (35:23)
Nice.
Jonathan Mietchen (35:23)
not be referred. And you know, I was always I was nervous to start this because I just was under the assumption like everyone just wants testing. And
Dr. Jeremy Sharp (35:32)
Yeah.
Jonathan Mietchen (35:32)
I think people just want help.
And I think there’s a number of people who just are fine with not doing testing or happy to not do testing if it’s not gonna be helpful in them getting the help they need. Yeah, no, go ahead.
Dr. Jeremy Sharp (35:45)
Hm. I just wanna sorry, I love that quote. I just wanna highlight that. We don’t have to do anything with it, but just to say it again, like people don’t always want testing, they just want help. And it’s easy
Jonathan Mietchen (35:57)
Yeah.
Dr. Jeremy Sharp (35:58)
to equate testing with help, but there’s lots of different ways to help people. That’s not a full comprehensive battery. Yeah. Yeah. That’s a cool insight.
Jonathan Mietchen (36:05)
Yeah, right, right. Yeah.
Dr. Jeremy Sharp (36:08)
Yeah.
Jonathan Mietchen (36:08)
Yeah. And then, you know, I think those that were saying, you know, I think maybe you actually do need more urgent testing would be some of this just is like someone squeaked through with a a referral that was not very clear. And then after
Dr. Jeremy Sharp (36:22)
Mm.
Jonathan Mietchen (36:22)
talking to the family, right, it’s like,
You know, like an example would be if I suspect it’s a twelve year old with an an undiagnosed intellectual disability and like they just
Dr. Jeremy Sharp (36:33)
Mm.
Jonathan Mietchen (36:34)
can’t stay caught up in school, but they don’t have an IEP, right? They’re getting almost no support. that might be one where we’re saying we’ve done the interview, like let’s get you in for a couple hours of testing.
And so so for those that were moved for more rapid testing, that intake sort of triage appointment then just sort of became their intake for their testing appointment. And then we moved forward with testing within a couple of weeks of that appointment. Yeah. Yeah.
Dr. Jeremy Sharp (37:03)
Okay, gotcha. That
raises a good maybe side question. So, you know, for the folks who go through the triage process, do they then do a separate intake? or does the triage serve as the intake?
Jonathan Mietchen (37:15)
Yeah, so we actually would do separate intake.
Dr. Jeremy Sharp (37:18)
Okay.
Jonathan Mietchen (37:19)
you know, it it was a year and a half later and now it’s about nine to ten months later. that we’re doing that. It’s just
Dr. Jeremy Sharp (37:25)
Yeah, that makes sense. Things might change.
Jonathan Mietchen (37:28)
it’s just yep, right. I mean, I’d say for the most part, those that I’m seeing I’m I’m and put them on the wait list and then seeing them for for testing.
Dr. Jeremy Sharp (37:38)
Uh-huh.
Jonathan Mietchen (37:38)
There have been a handful where, like, in those recommendations, we’re sort of saying, like, you know, you don’t need a diagnosis to get school help. Here’s how we can kind of get the school on board without you needing testing from me in the meantime. And then we see them a year later, and they cut up and their reading is okay, and there’s no other concerns. And of course, our door is always open, but there are families who are opting at that point not to do testing because they’re not concerned about.
sort of what they were initially anymore. So so
Dr. Jeremy Sharp (38:09)
Yeah, yeah.
Jonathan Mietchen (38:10)
yeah, yeah, we are seeing them again for for sort of that updated intake just to see what’s changed.
Dr. Jeremy Sharp (38:17)
Great, great. Yeah. Now earlier you mentioned a statistic of some sort. I think you said twenty five percent or seventy five percent one way or the other, in terms of the outcome of the triage. Did I make that up?
Jonathan Mietchen (38:30)
Yeah.
No, that’s right. So like like one in four didn’t need testing, I guess, as deemed by us and agreed to by the parents, and they were not put on the wait list and sort of followed through with other recommendations.
Dr. Jeremy Sharp (38:43)
Okay. So a quarter of the folks that you triaged did not need testing. They just went through the triage, took the recommendations, and went on their way. Mm-hmm.
Jonathan Mietchen (38:53)
Yeah, yeah. And and some some of that is kind of based on how our clinic is structured.
Dr. Jeremy Sharp (38:59)
Okay.
Jonathan Mietchen (39:00)
right. So for there’s gonna be a subset of those. We have a a Department of Developmental Pediatrics here and they have a pretty robust autism program. And so neuropsychology is separate from that. And so
Dr. Jeremy Sharp (39:12)
Okay,
Jonathan Mietchen (39:12)
there’s gonna be a subset of kids where they get referred for a learning problem, but then you talk to the family and they’re actually just saying, like, I’m actually not concerned about.
that I actually think my kid has autism. And so we’re kind of saying like, okay, well let’s just divert you over to to them. and and maybe
Dr. Jeremy Sharp (39:31)
Gotcha. Gotcha.
Jonathan Mietchen (39:32)
providing some additional community resources. That’s a pretty small number because I think that is pretty well established when they’re within our system that we don’t see autism, but the number’s not zero. And then you know for some of these kids, right, it’s it’s
If the question really is like a routine garden variety ADHD question, we just don’t have the capacity to take every one of those either. So we are sort of referring them back to their pediatrician for that. And sometimes there’s some back and forth with the pediatrician, but so so that is gonna account for some of those. so that 10 that 25% is gonna account for some different reasons why, but kind of at the end of the day.
Coming in for a couple hours of testing is probably not gonna answer the question that you’re wanting to get answered.
Dr. Jeremy Sharp (40:18)
Gotcha. Yeah.
Jonathan Mietchen (40:19)
Yeah.
Dr. Jeremy Sharp (40:20)
And of the folks who did not need testing, did you get any more granular than that, like within that that group of folks? Were there any differences in terms of I don’t know, age, socioeconomic status, insurance versus private pay? Did you look at any of that kind of stuff?
Jonathan Mietchen (40:37)
We did look at a few. there weren’t any major differences in that in that group. there was some like I think meaningful differences in the group that was sent in for more immediate testing. So those who were
Dr. Jeremy Sharp (40:52)
okay.
Jonathan Mietchen (40:53)
sent in for more immediate testing, there were higher percentages of people on like public insurance.
Dr. Jeremy Sharp (41:00)
Mm.
Jonathan Mietchen (41:02)
is I mean I think that there’s some importance there in that at least here we’re kind of the main clinic that’s gonna take public insurance. A lot of the private practices
Dr. Jeremy Sharp (41:15)
Mm-hmm.
Jonathan Mietchen (41:16)
are not and so they kind have one place to go. whereas private insurance they’re gonna have a few different options depending on their
Dr. Jeremy Sharp (41:23)
That’s fair.
Jonathan Mietchen (41:24)
insurance but
Dr. Jeremy Sharp (41:26)
Right. And just to be clear, when you say public insurance, you mean like Medicaid or Medicare. Yeah. Okay. Okay. Gotcha.
Jonathan Mietchen (41:28)
Like Yep. Yes, yep. Mm-hmm. Yeah. Yeah.
Dr. Jeremy Sharp (41:34)
that’s interesting. Let me I want to repeat that back and make sure that I understand it. So there was a bigger percentage of folks who were referred for urgent testing with public insurance.
Jonathan Mietchen (41:44)
compared to those on private. So about about half of the people referred for
Urgent testing had some form of public insurance. but the they represented a smaller number of the total overall group of people, if that makes sense. So and so it
Dr. Jeremy Sharp (42:02)
Okay. Yeah, yeah. Yeah.
Jonathan Mietchen (42:06)
was a higher proportion that ended up needing more immediate
Dr. Jeremy Sharp (42:11)
Gotcha,
gotcha. Were you able to draw any conclusions from that or have any theories around what that was about?
Jonathan Mietchen (42:18)
Yeah, I mean, you know, I think the like here at UW, I think I think that’s where the area deprivation index sort of the birthplace of the 80 high, right? I think
Dr. Jeremy Sharp (42:30)
Mm.
Jonathan Mietchen (42:30)
that’s kind of what we know is if if you’re on public insurance, you’re more likely to live in areas with lower area deprivation index. If you’re in areas of lower deprivation index, you’re gonna be more likely to have things like developmental delay.
learning disabilities, ADHD, and and and also have so higher rates of those things with lower access. And
Dr. Jeremy Sharp (42:54)
Mm-hmm.
Jonathan Mietchen (42:54)
so I think for some of for sort of that group specifically, we were able to kind of increase that that
Dr. Jeremy Sharp (43:00)
Mm-hmm.
Jonathan Mietchen (43:00)
access for them.
Dr. Jeremy Sharp (43:03)
Okay.
Jonathan Mietchen (43:04)
So
Dr. Jeremy Sharp (43:06)
So in an interesting way, I mean this I don’t know if you set out with this as the intent, but it almost sounds like this like triage model is a I don’t know, like an access to intervention lever or something. You know, like you know, it’s
Jonathan Mietchen (43:20)
Yeah.
Dr. Jeremy Sharp (43:20)
like increasing ac it’s almost like an equity, an equity play, you know, as a practitioner. Does that make sense?
Jonathan Mietchen (43:26)
For right.
Yeah. Yeah. And I think in in a lot of ways too. I think socioeconomically that’s true. but again, you know, ten referrals that I’ll say evaluate and treat aren’t created equally. And so even just from like a clinical needs standpoint, I think it is creating equity in that regard as well.
Dr. Jeremy Sharp (43:47)
Mm-hmm.
Jonathan Mietchen (43:47)
As far as those with really more immediate, and I think i again, each clinician is gonna maybe have
of their own way, but I think as a group, I bet we could get pretty close to agreeing on like, because we’ve seen it, we’ve seen people it’s like, man, they needed help six months ago. You know,
Dr. Jeremy Sharp (44:06)
Mm, for sure.
Jonathan Mietchen (44:07)
and and then those where they’ve got a really supportive household, really support, you know, they’re they go to a good school that has resources to give them the supports they need and and so I think in a lot of ways it does provide that equity that
clumping everybody into a single wait list might not always do that.
Dr. Jeremy Sharp (44:28)
Yeah, yeah, certainly. Certainly. Maybe I could ask some questions around mm the client relationship for lack of a better term. Like I’m really
Jonathan Mietchen (44:36)
Yeah.
Dr. Jeremy Sharp (44:37)
curious, yeah, like how how this is presented from the initial phone call, you know, before they get booked into a triage appointment. Like is that one, is that your admin staff or is a
Jonathan Mietchen (44:50)
Yeah, they’re yeah, they are doing
that. mm-hmm.
Dr. Jeremy Sharp (44:52)
Okay, so they’re doing kind of the initial screening. Like what do they
how do they present this option to people who are presumably calling thinking they’re getting testing? how do they present that?
Jonathan Mietchen (45:00)
Yeah, so we did we did, I don’t have that in front of me. We did kind of have a script that they could follow
Dr. Jeremy Sharp (45:06)
Mm.
Jonathan Mietchen (45:07)
and you know, we it as they saw fit, but they at first they were kind of like, I don’t know how to talk to these families about this, right? And
Dr. Jeremy Sharp (45:16)
Right.
Jonathan Mietchen (45:17)
so we did kind of write a script for them, right? And so I think the way that we presented it was really trying to help them understand that like, yes, it’s technically one extra appointment.
but I
Dr. Jeremy Sharp (45:29)
Mm-hmm.
Jonathan Mietchen (45:30)
think that what we’re really trying to do is like be as helpful as we can be and try and kind of sell them on the value of that,
Dr. Jeremy Sharp (45:37)
Mm-hmm.
Jonathan Mietchen (45:38)
right? So right off the bat we are letting them know that there’s a wait list for testing and that wait
Dr. Jeremy Sharp (45:44)
Okay.
Jonathan Mietchen (45:45)
list is about X number of months depending on when they got the phone call.
But in the meantime, we want to make sure that if there are other things that you’re needing help with, that the provider can then talk to you and give you some recommendations in the meantime. So there’s at least some things you can be doing while you’re waiting to help your kids so that it’s not just sort of lost time sitting and waiting for this thing that we’re some people don’t even really know what it is, right? But they know they’re
Dr. Jeremy Sharp (46:16)
Sure.
Jonathan Mietchen (46:16)
on a wait list somewhere.
And so that’s kind of how our our staff was sort of talking to them about that.
Dr. Jeremy Sharp (46:25)
Nice, nice. So they would present it like, Well, you have to wait this long and in the meantime, here’s this thing that could be really helpful and yeah. Okay.
Jonathan Mietchen (46:34)
Right, right. I mean ’cause
before they weren’t I I don’t they weren’t getting a a call. We were sending out a letter, letting them know like we got your referral. But they weren’t
Dr. Jeremy Sharp (46:43)
Yes.
Jonathan Mietchen (46:43)
getting a call and so at least now like we know they’ve had contact, we know they know there’s a wait list and they know that the purpose of this is actually to be helpful to them while they’re waiting.
Dr. Jeremy Sharp (46:55)
I like that. I like that.
Jonathan Mietchen (46:56)
Yeah.
Dr. Jeremy Sharp (46:56)
Yeah. And how how so I don’t know if you can discern or distinguish between, you know, how people responded at that point, if it was like generally okay or positive or not so positive. And then of course I wanna know like how they respond after the triage appointment when you send
Jonathan Mietchen (47:11)
Yeah. Yeah.
Dr. Jeremy Sharp (47:12)
for testing or don’t. Yeah.
Jonathan Mietchen (47:14)
Yeah.
You know, I I don’t think anyone wants to hear that you’re on a eighteen or twenty four month wait list. So right. So like I think that there’s just
Dr. Jeremy Sharp (47:20)
Sure. That’s a great point.
Jonathan Mietchen (47:23)
inherent frustration with that.
Dr. Jeremy Sharp (47:25)
Yeah.
Yeah.
Jonathan Mietchen (47:28)
But you know, I mean, I think by the end of the the appointment, I think they were grateful to have someone who was at least willing to listen to them. And and now they have at least some action steps, right? So
Dr. Jeremy Sharp (47:39)
Mm.
Jonathan Mietchen (47:40)
a number of people that were like, Yeah, you know, like, I talked to his teacher, but they said they can’t do anything without a diagnosis. Well,
Dr. Jeremy Sharp (47:46)
Mm-hmm.
Jonathan Mietchen (47:46)
let’s spend fifteen minutes and talking about how that’s actually not true. Education law doesn’t it’s not related to diagnosis, it’s related to academic need, right? And so we had a we sort of had a template that we could send to them and kind of like the appendix of our note. I think that’s actually a supplemental material in our paper, too, that we could send them that would kind of just teach them like this is how you communicate to the school, right? A a one-off comment at a parent teacher conference is not enough to get the school to do something. You have to write a formal letter.
They don’t have to give your kid an IEP, they don’t have to give them supports, but they have to reply to that letter. They can’t just let a formal letter sit. right.
Dr. Jeremy Sharp (48:32)
That’s great.
Jonathan Mietchen (48:32)
And and and so and I mean, there’s some people that were like, I actually don’t want to diagnose this. I just want my kid to get help. That’s another group of people that didn’t necessarily
Dr. Jeremy Sharp (48:41)
Mm-hmm.
Jonathan Mietchen (48:41)
get on the wait list for testing because they’re uninterested in the label. They just want their kid to get help, and there are ways to
Dr. Jeremy Sharp (48:46)
Mm-hmm.
Jonathan Mietchen (48:47)
do that without doing
formal testing with you know you might need to do formal testing with the school, but yeah.
Dr. Jeremy Sharp (48:56)
Sure. Sure.
I’m curious about the school component. We we wrestle
Jonathan Mietchen (49:00)
Yeah.
Dr. Jeremy Sharp (49:01)
with this. it sounds like y’all were having a lot of conversations around bridging the gap back to school. and I know of course like every district is different, different states have different po you know. I’m interested to hear if y’all found any good ways to kind of suggest that the school maybe do more than they’re doing or you know,
Jonathan Mietchen (49:21)
Yeah.
Dr. Jeremy Sharp (49:22)
help parents navigate that process without you know, coming across as like you’re dictating some kind of intervention in school, which our local schools do not appreciate very much. So yeah, how did you how’d you navigate all that if you have thoughts?
Jonathan Mietchen (49:32)
Right, right, right. Yeah. Yeah.
I mean I do think as clinicians we tend to have an idea of what works and what helps kids. And so I do think that I don’t think I I I hope I don’t frame things as I’m dictating that this is what the school has to do, but I do kind of
Dr. Jeremy Sharp (49:50)
Mm-hmm, mm-hmm.
Jonathan Mietchen (49:51)
frame things on like well they have a pr already have a diagnosis of ADHD. We know that.
And they’re getting no supports for it. Here are the things
Dr. Jeremy Sharp (49:58)
Mm-hmm.
Jonathan Mietchen (49:59)
we know work. And I think this kid needs that. so I think it’s more like I am sort of saying, like, this is my clinical recommendation as a professional, that this is what I think this kid needs. Now the schools can kind of decide to do with that, you know, what they what they want to. but
Dr. Jeremy Sharp (50:16)
Yeah. Yeah.
Jonathan Mietchen (50:18)
I mean, I think a lot of the parents, I mean, I do feel like it just empowered them to know.
Types of language, right? I don’t know if you’ve run into this, but I know sometimes we have where like if you ask the school for a dyslexia evaluation, they’ll say, We don’t do that. Right.
Dr. Jeremy Sharp (50:33)
Yeah.
Jonathan Mietchen (50:33)
And it’s like we have to reframe this. And actually, what you’re asking them for is to see if your kid qualifies for reading support. right. And it’s
Dr. Jeremy Sharp (50:41)
Sure.
Jonathan Mietchen (50:41)
so little things like that, I think just kind of taking the time to help them have kind of a basic understanding of.
school system and medicine are not the same thing and a diagnosis in one doesn’t result in supports in another and supports in one doesn’t result in a diagnosis in another. They’re not synonymous. and so
Dr. Jeremy Sharp (50:58)
Mm-hmm. Yes, yes.
Jonathan Mietchen (51:01)
yeah so I think a lot of that was trying to sort of communicate with the parents as a clinician what I think is going to help your child and then talking to them about how they can advocate rather than sort of going and saying like this doctor said
you need to do this. I don’t think that happened. I don’t think anyone ever said told a a school I said they had to do something. But it’s more just I think teaching parents on how can we advocate for
Dr. Jeremy Sharp (51:29)
That’s a good way to put it.
Jonathan Mietchen (51:30)
Mean time.
Dr. Jeremy Sharp (51:32)
Yeah, yeah. I like that. I like that. Can you think of any cases where I know you said you weren’t super rigid necessarily, but any cases where folks definitely wanted testing and you didn’t really didn’t think it was it was necessary? How did you handle those?
Jonathan Mietchen (51:48)
Yeah, yeah. I mean, I think from there I’m sort of framing things as You know, to them, I think it’s true, but I think to them sometimes I’ve found like framing it as like, well, then we’re gonna talk about like that’s an important part of informed consent, right? If if I think we’re gonna undergo a procedure that’s probably not necessary, you deserve to know that I think it’s not necessary and you deserve to know why. and
Dr. Jeremy Sharp (52:14)
Mm hmm, mm hmm.
Jonathan Mietchen (52:16)
then that’s when I’ll kind of go through and do some psychoeducation on again, kind of what’s the neurodevelopmental trajectory of learning disabilities. And
right, poor school performance can be from a lot of different reasons. Learning disabilities isn’t just one of them. Anxiety and depression can cause real significant problems with school performance. you know, helping them understand.
You know, I think I think even within the realm of test testing psychology, there’s probably some could have a lively debate on the utility of actual testing for ADHD, right? But helping
Dr. Jeremy Sharp (52:50)
sure.
Jonathan Mietchen (52:51)
helping them understand that, like, you know, on a continuous performance test, if you’re anxious, you can do poorly on it. If you didn’t sleep well the night before, you can do poorly on it. If you have ADHD and it’s given at the right time of day in a quiet room with one-on-one, you know, with kind of that level of support, you can also do okay on it. So like it doesn’t always totally
Not a one-to-one you do poorly on an attention test, that means you have ADHD. right.
Dr. Jeremy Sharp (53:16)
Course.
Jonathan Mietchen (53:17)
So sometimes I think it’s just a matter of like doing a lot of psychoeducation. I’m like, here’s why I think testing is not going to be very helpful for you. And if after that I still want to pursue it, I’m usually not pushing. I think, yeah, yeah. I I would kind of still put them on that list. So
Dr. Jeremy Sharp (53:35)
Yeah, yeah, yeah. That sounds good. That sounds good. How have the referral sources reacted to this process?
Jonathan Mietchen (53:44)
Yeah. so we did actually do a
what’s it called a study kind of looking at kind of how happy they were referral sources specifically with the
Dr. Jeremy Sharp (53:55)
Okay.
Jonathan Mietchen (53:56)
with the service and that it’s kind of that those findings are in that paper as well satisfaction survey and you know like they still expressed frustration with the wait list but I think at the end of the day it was kind of like but I’d rather have them see you and get some recommendations a month later.
Rather than just like radio silence for 18 months. and I think it’s kind of helping them know like here’s some ways that I think you can help your patient in the meantime, right? I I think they’re depressed. I think they need to at least, you know, and it’s for in some cases they’ve been depressed for years. Or we know
Dr. Jeremy Sharp (54:28)
Yeah.
Jonathan Mietchen (54:29)
they’re depressed and they’re they went off their antidepressant and they think they need to go back on. But you’re kind of giving the family some action steps as well as pediatrician or the the referring provider some action steps on like, hey, I think this actually would be a valuable use of your time and their time.
In the meantime would be, you know, placing referral to occupational therapy or, you know, these kinds of things so that they’re not just kind of left waiting.
Dr. Jeremy Sharp (54:56)
Yeah, yeah. Did you have to do any education prior to implementing this triage system, with the referral sources specifi did you, you know, warn them quote unquote or let them know things were changing or?
Jonathan Mietchen (55:08)
Yeah, so we did within our own system.
Dr. Jeremy Sharp (55:11)
Yeah.
Jonathan Mietchen (55:13)
and we sort of accompanied that with like a pathway. So don’t
Dr. Jeremy Sharp (55:16)
Yeah.
Jonathan Mietchen (55:17)
know if you’re like the within Epic, you can have pathways. They’re
usually used for like emergency medicine, but they did
Dr. Jeremy Sharp (55:23)
Okay.
Jonathan Mietchen (55:24)
actually let us make one where it’s like walking them through. If a patient comes in and they’re worried about dyslexia, these are the questions you should be asking, and then it’s kind of walking them through. So we sort of implemented
that along with, by the way, we’re gonna see your patients much sooner for telehealth, but they’re the their their weight for testing is essentially gonna be the same.
Dr. Jeremy Sharp (55:47)
Gotcha.
Jonathan Mietchen (55:48)
And so yeah. But
outside referrals, like I that just sort of was like that would be I think too difficult to sort of cover. Just within our catchment area, there’s a lot of different primary care practices and yeah. Yeah.
Dr. Jeremy Sharp (56:03)
Of course, of course. Yes. Yes.
Well, this is this is so interesting. I’m thinking you know, every now and again I’ll have these interviews where it’s actually hard to stay focused because I’m thinking about how to implement these ideas,
Jonathan Mietchen (56:15)
Yeah, yeah, yeah.
Dr. Jeremy Sharp (56:16)
you know, in my own in my own practice. so this is one of those. But as we start to wind it down, I wonder anything, I don’t know, that you have learned through this process, like anything kind of remarkable
that you would pass along to other folks who might be considering a model like this, thinking about implementing a trio system.
Jonathan Mietchen (56:35)
Yeah. you know, I think one of the critiques was like, well, you know, isn’t the time you’re spending on this time you could just be spending seeing patients for testing, right?
Dr. Jeremy Sharp (56:43)
Doing the testing. Yeah.
Jonathan Mietchen (56:46)
and I think that depends on sort of the practice that you’re in, right? So we are limited in space, so we couldn’t really expand for us to see more testing patients than we already were because of.
space constraints, we have a psychometrist model here. And so with like a psychometrist support, we couldn’t necessarily expand for a couple of those reasons.
Dr. Jeremy Sharp (57:09)
Yes.
Jonathan Mietchen (57:11)
you know, but I I think the one thing that it did allow us to do now is train someone on how to do this. And that took a couple of months of us training, but they are doing that
Dr. Jeremy Sharp (57:21)
Mm-hmm.
Jonathan Mietchen (57:22)
for us and that is their full-time job is
doing these triage intakes for for that for that person. Yep. That’s that is their that is yep. Yep.
Dr. Jeremy Sharp (57:28)
It’s a full time job now at this point. Like this person’s doing twenty five or thirty of these a week or yeah.
Jonathan Mietchen (57:34)
That is yeah. Yeah. So that is their that is their job. and so I think that sort of I think I that I think is part of the reason why things have really picked up and our wait list is substantially shorter is because before we were kind of splitting our time between doing the both of those and it still helped. But now we’ve
Dr. Jeremy Sharp (57:51)
Mm-hmm.
Jonathan Mietchen (57:51)
got someone doing that.
and so
Dr. Jeremy Sharp (57:55)
Absolutely.
Jonathan Mietchen (57:56)
I think just sort of thinking about, you know, when I first started here, something that someone was talking to me about was like just practicing at the top of your license. And so, you know, I I think that social workers and LPCs with sort of the right training can do jobs like this where they’re sort of walking through some differentials. And that’s been really helpful for us.
So kind of thinking about that, how how can we you know sort of do that? and then
Dr. Jeremy Sharp (58:25)
Certainly.
Jonathan Mietchen (58:29)
Yeah, you know, I mean something we haven’t really gotten to here, but that we’ve sort of talked about and there’s just been sort of like submit some administrative type barriers, right? But like are are there also ways to triage people based on how much testing we think they need and what types of testing? right. Even
Dr. Jeremy Sharp (58:48)
Hmm. Yeah, say more about that. Yeah.
Jonathan Mietchen (58:50)
yeah, like even within those who need testing, there’s probably differences in need, right? Of like
what types of tests and depending on what the referral question is, what you’re concerned about, what types of tests you think you need to give that can look different.
And so that’s sort of another I think thing that we’ve sort of thought about and I don’t have the answer on how to implement that, but someone someone out there might.
Dr. Jeremy Sharp (59:16)
Yeah.
Jonathan Mietchen (59:18)
but I think that’s worth thinking about. and then yeah, I mean I think another takeaway for this for me is like I think community like just my
Communicating with patients, I think I’ve gotten a lot better at it. Part of it is I was just seeing a lot more patience
Dr. Jeremy Sharp (59:37)
Yeah.
Jonathan Mietchen (59:38)
when doing this. but I think finding sort of the right types of ways to communicate information that I feel like they might not want to hear, but doing it in a way that helps them understand why I’m saying what I’m saying, that I think helped. it really
Dr. Jeremy Sharp (59:53)
See that.
Jonathan Mietchen (59:53)
sort of had me reformat my
notes so that my communication to the referring provider was really clear. I mean
Dr. Jeremy Sharp (1:00:01)
Mm-hmm.
Jonathan Mietchen (1:00:02)
almost just like a bulleted, this is what I need you to do. And in the past I was kind of just clumping recommendations together as kind of a young clinician. And now I think it’s very much more targeted on like you know, as a parent, no one is going to call the school and tell them that your kid needs reading help. That needs to be you. So here’s
Dr. Jeremy Sharp (1:00:23)
Mm.
Jonathan Mietchen (1:00:23)
You need to call them and here’s what you need to say, sort of a thing. And
Dr. Jeremy Sharp (1:00:26)
Mm-hmm.
Jonathan Mietchen (1:00:26)
so I think it really made my recommendations much more palatable and understandable that people can follow through on. yeah.
Dr. Jeremy Sharp (1:00:36)
Right. Right.
Jonathan Mietchen (1:00:38)
So
Dr. Jeremy Sharp (1:00:39)
Okay. Yeah. This is great. I wonder where things are headed from here. Do you have any sense of future directions for, you know, this kind of program or are do y’all have more research planned with other, you know, pilots or any extension of this? Yeah.
Jonathan Mietchen (1:00:56)
Yeah, so I think at the moment, not right now. but I think the next thing that we’ve sort of talked about is is sort of like that testing model, right? Like,
Dr. Jeremy Sharp (1:01:06)
Yeah.
Jonathan Mietchen (1:01:06)
does it make sense? And and we’ve kind of gone back and forth. That’s probably another thing we could have a lively debate on here about, right? But there are are there some patients where 90 minutes is is actually enough to answer the referral question that it that they really want answered.
Dr. Jeremy Sharp (1:01:22)
Yeah.
Jonathan Mietchen (1:01:22)
And if
that’s the case, then we actually can see more patients and cutting the wait
Dr. Jeremy Sharp (1:01:27)
Mm-hmm.
Jonathan Mietchen (1:01:27)
list down more if we’re not spending, you know, really long full day or half days.
testing. So I I think that’s kind of where we’re sort of thinking thinking about sort of landing
Dr. Jeremy Sharp (1:01:42)
Yeah. Yeah.
Jonathan Mietchen (1:01:43)
next is is is there a way to sort of further modify this to just kind of make sure people are getting the big big the the best, you know, bang for their buck and is yeah. So I think that’s kind of what we’re twenty with right now.
Dr. Jeremy Sharp (1:01:58)
Yeah, yeah. Yeah. This is I this has been a great conversation. Yeah, it’s really got my wheels turning and I think like we started with, this is a huge problem around the country, I think, for a lot of testing folks is just access and wait lists. And yeah, you’ve given us a lot to think about and potentially implement.
Jonathan Mietchen (1:02:16)
Yeah, yeah, I
hope so. Yeah. Yeah. It’s
Dr. Jeremy Sharp (1:02:19)
This is it.
Jonathan Mietchen (1:02:19)
yeah, yeah.
Dr. Jeremy Sharp (1:02:21)
Yeah, I mean, certainly, you know, you have some advantages being in a hospital system and some resources and infrastructure, I’m imagine that’s very helpful here. And, you know, again, I was kind of thinking through this in a private practice context as we went along. And it does it definitely doesn’t seem out of the realm of possibility. You know, like if you have some admin support and, you know, some
Jonathan Mietchen (1:02:42)
Mm-hmm.
Dr. Jeremy Sharp (1:02:42)
scheduling, you just, you know, there’s some scheduling differences to work through. But it seems like it’s doable even in private practice to implement something like this.
Jonathan Mietchen (1:02:51)
Yeah. Yeah. I mean, you know, before this too, we were sort of like you’d mentioned before, like we toyed with the idea of, you know, can we triage based on checklists? And that felt like we just still wouldn’t have the right amount of information. Like I’m not kidding, asking the question like what are you hoping to get out of this was so helpful because it’s they’re often looking for something different than what the referring provider is looking for
Dr. Jeremy Sharp (1:03:18)
Mm.
Jonathan Mietchen (1:03:19)
or what they say they are. And so
I think there was value in actually talking to the patient. But I think there’s a lot of different ways that you can do this, right? I think it doesn’t have to be a full intake. You can probably cut it down to fifteen or twenty minutes and just really sort of have a firm understanding of like what are you most concerned about and what are you looking for? And you know, I think
Dr. Jeremy Sharp (1:03:44)
Sure.
Jonathan Mietchen (1:03:45)
that is still more information than you’ll get on a referral.
A referral form is there.
Dr. Jeremy Sharp (1:03:51)
Right. Right. Yeah. Yeah. I yeah, I had the laugh. toward the beginning when you said that you get a lot of referrals and just say evaluate and treat. And we I mean we get a lot of those too. And it’s like, evaluate what? What are we doing here? You know? Yeah.
Jonathan Mietchen (1:04:00)
Yeah. Right, right,
right, yeah. So yeah, yeah.
Dr. Jeremy Sharp (1:04:09)
Well, I really appreciate it. yeah, this has been a lively, really interesting conversation. And I’m just I was so glad that that we found you and y’all’s research. you know, again, I just I love that you’re taking a problem that a lot of us have and have like opined on for a long time, but you’ve got some research to to back it up, you know, to to try a different model and and it seems to be helping with the wait list. So that’s great.
Jonathan Mietchen (1:04:31)
Yeah, yeah. Yeah. I mean I think
it works for us here and it would look different in private practice or other institutions, but I think yeah, I think it is valuable to I I think it’s I think it’s a valuable service that actually does not just shorten the wait list, but actually does provide real help to these families that are sitting on a wait list at no fault of their own, you know,
Dr. Jeremy Sharp (1:04:53)
Right.
Jonathan Mietchen (1:04:54)
and and can provide real support to them. So
Dr. Jeremy Sharp (1:04:57)
Yeah, yeah. Nice. Well, thanks again for coming on. Yeah, I really appreciate it. It’s great to chat with you.
Jonathan Mietchen (1:05:01)
Of course.
Yeah, yeah, you too.
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