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[00:00:00] Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

PAR offers the RIAS-2 and RIST-2 remote, to remotely assess or screen clients for intelligence and in-person e-Stimulus books for these two tests for in-person administration. Learn more at parinc.com.

Hey everybody, here we are again, with a business episode. Today, I’m talking about writing a fantastic job ad. Why am I talking about this? You might ask. Well, I have had conversations with many of my consulting clients, as well as group practice owners around the country who are having a really hard time hiring over the past several [00:01:00] months. So I’ve talked about this idea of writing a fantastic job ad as a component in finding the right person for your job and wanted to expand on that a bit here in the podcast and share it with more of you.

Here are a couple of things that we’re going to talk about. I think this will be a relatively quick and hard-hitting episode where you can take away a couple of key action items to put into place if you’re looking to hire anytime soon. I’m going to talk about some reasons why we’re having a hard time hiring and why the typical ad just isn’t going to work anymore. I’m going to talk about a couple of components that can set your job ad apart from the others. And then I’ll do a little bit of a bonus recap about where to advertise your job in hopes of finding the best candidates. So, let’s go ahead and jump [00:02:00] to that discussion.

All right y’all, let’s get right down to it. Like I said, this will be a relatively quick business episode where you can just take away a couple of tips that will hopefully enhance your chances of hiring someone in the next few months.

There is a ton of business out there. Lots of practices around the country are just full, including our own. Our waitlist has grown longer and longer and I feel like we can’t hire staff fast enough. And this is a common problem from what I can tell in talking with my group practice colleagues, [00:03:00] as well as my advanced practice owners who are looking to hire in my consulting world. This is a big problem for a lot of us.

There are a few reasons that I think we are having a hard time hiring. One is just pandemic. Let’s just call it that. #Pandemic. I feel like people are burned out. People are a little overwhelmed. People are exhausted and they may just not be looking for jobs as much as they maybe were in the past, they’re dialing back or they might be looking for more stability like in a hospital or an agency or something like that. So, we’ll just call it #pandemic.

A couple of other factors though. 1) On the flip side, there is a big temptation to [00:04:00] go into solo practice right now because there are a ton of referrals. I mean, there’s a lot of business out there in most parts of the country. And like I said in the intro, many practices have waitlists miles and miles long, especially for an in-demand service like testing. I think we’re losing some of our potential hires to the temptation of solo practice and the allure and perhaps the illusion of making more money in solo practice. There are a lot of variables there that I’m not going to get into, but many folks I think are trying their hand at solo practice.

Beyond that, this is just bigger trends in the mental health world, there are a number of mental health startups who are coming along and hiring mental health clinicians, not so much for testing by any means, but certainly for therapy. And I think that [00:05:00] some psychologists might be getting sucked up into those funnels as well.

What does this mean for us as group practice owners who are trying to hire people?

I think what it means for us is that we have to go above and beyond to set our practices apart from all the other employment options that are out there. We have to go beyond. We have to set ourselves apart. You have to convince the applicant or entice the applicant into your practice and convince them that that’s the place they want to be.

I think that this is compounded just a bit as well because I think the cohort or maybe generation of early career psychologists or neuropsychologists who are a lot of [00:06:00] folks that we are… that’s kind of the generation where we’re looking to hire in many cases. A lot of early career psychologists are looking for a different work environment than some older psychologists. These individuals are looking for unique, almost like boutique practices or practice atmospheres that provide them an opportunity to really showcase their strengths and atmospheres or practices that feel more personal.

So, the typical job ad that many of us have been able to get by over the years just isn’t working. It’s not personal enough. It’s not unique enough. It doesn’t have some of those nuances that people might be looking for.

When I say the typical job ad, just to give an example of [00:07:00] what I don’t think should work or I don’t think is working anymore is the job ad that starts off with a description of the practice and then a fairly generic description of the position that says something like, “We are looking for a fulltime neuropsychologist to conduct psychological and neuropsychological assessment with children ages 5 to 18 for presenting concerns like autism, ADHD, learning disorders and mood disorder.” And then lists the job responsibilities, the desired qualifications, maybe the salary range, maybe not. And that’s it.

That’s kind of your typical job ad. And I just don’t think that cuts it anymore. We got to flip the script a little bit. We have to get a little flesh in our job ads. Here are a couple of things that I have found that [00:08:00] I think work well in doing that.

1) Restructure the ad.

So instead of putting the practice first, and when I say put the practice first, it’s usually, again, kind of a generic-ish paragraph where it says, “Colorado Center for Assessment and Counseling as an outpatient private practice founded in 2009 that specializes in so on and so forth.” We need to flip the script a little bit. We need to rewrite this ad with your job applicant at the center of the story, not putting your practice front and center, but putting the job applicant front and center.

There are a couple of ways to think about this concept.

One borrows heavily from the StoryBrand Framework. I’ve mentioned StoryBrand here on the podcast [00:09:00] before. It’s a framework. There’s a book, there’s a podcast, all coming from Don Miller. Great resources. I’ll put those in the show notes, but it’s really anchored into the StoryBrand idea that you want your job applicant to be the “Hero of the story. The architect of their destiny. The person in control of their life.”

You don’t want to put the practice front and center and put the practice as the hero of the story, because again when someone is looking to join your practice, I think they want to see themselves in that role. They want to have some agency in that role. They want to know that they’re going to be the ones making a difference. That they’re sort of taking the reins of their career. And so, putting the applicant front and center at the top of the job ad is a great way to do [00:10:00] that.

When I say put them front and center, what does that actually mean?

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[00:11:00] All right, let’s get back to the podcast.

So that means almost writing the job ad as if you were speaking to your ideal client. Instead of putting the practice details first, you might say something like, “Are you a motivated, energetic Neuropsychologist who loves diving deep and helping families get the resources that they need? Are you passionate about your work with adults?” So on and so forth.

So, asking questions, really speaking directly to the applicant to communicate that you:

1) Know exactly what kind of applicant you’re looking for that really helps paint the picture of the applicant that you’re looking for, but it [00:12:00] also helps them identify with that position. It just makes it more personal. It makes it easier to anchor into so that they can really see themselves in the story, and the story of course is working at your practice. So the first thing is to really flip the script and write the ad with the applicant as the hero of your story.

Then when you do talk about your practice, instead of just a generic description of your practice, “Outpatient, private practice, Neuropsych Evals, kids, adults, whatever,” really put some time into describing your practice values and bringing those practice values to life. I’ve talked about values on the podcast before. I think that values are a huge driver of workplace culture and it really helps [00:13:00] set your practice apart from others who may not have as well-defined values.

So, when I talk about putting them in your job ad, you don’t have to go overboard, but instead of that fairly general description of your practice, speak directly to your values like, “We are a practice that highly values having fun and being kind to one another. We love being authentic and living with intention in our practice. We try to invest in ourselves and we will support you in an inclusive environment.”

I’m just kind of pulling values out of the air there. Some of them are some of our values, but you get the idea. Really try to bring your practice to life [00:14:00] when you’re talking about your values. Describing your values in such a meaningful way will help the applicant figure out if those are values that they have too. Think about it. A generic description is just that. There is nothing to anchor onto. There is nothing to identify with. That person could be working at any practice in the country and have no idea what it’s about. So this is your chance to help your practice elevate and rise above the other jobs ads out there.

Now, if you don’t know your values, that’s okay. There are several ways to define values in your practice. If you are just trying to throw something together for the sake of writing a [00:15:00] job ad, I don’t know that it’s going to come across as genuine and it might not be easy. I’d advise you to spend a little bit of time actually defining some values in your practice before you sit down to write this job ad. And you can do that in any number of ways. If you have a bigger practice with multiple clinicians, you could do something like the Jim Collins Mission to Mars exercise, I think is what it’s called. That’s what we used in our practice to help define values. You could simply do a search for values and figure out what words you identify with and build values around that.

So there are a few ways to explore and define some values, but I think it is worth it to go through that process. Whether you’re hiring or not, that’s going to be very valuable, but especially in the context of hiring, having solid values drives your [00:16:00] hiring decisions and it drives your workplace culture. And it really provides a nice north star for your business as you continue to grow.

So those are just two very simple but actionable tips for rewriting your job ads. The last thing that I will say is I think we are in a time when we have to advertise salaries. In the past, I’ve seen job ads that give a range, or actually I take that. Giving a range is fine. If you’re giving a range for your salary, I think that’s totally fine.

The job ads that I think are less desirable are the ones that say competitive salary and benefits or something like that, or competitive compensation and benefits. Everybody thinks their compensation is competitive, but you’re not going to know that unless you actually put the numbers out there. [00:17:00] And this day and age, people look at the salary right off the bat and need or want to know what that looks like. So don’t be afraid to put your salary out there.

All right. A little bit of bonus content here with where to advertise your job. I’ve done podcast episodes on where to advertise your job. So I’m not going to go into great detail, but just to recap, I have had really good luck with indeed.com, especially with a sponsored job post. So one that you pay for and not the free version. You don’t have to pay very much, $200 or $300 a month has been very successful for me.

I’m hearing really good things about a site called wizehire.com. People in the mental health world, other practice owners are saying really good things about that site. [00:18:00] LinkedIn jobs can be helpful. There are any number of other resources to post your jobs. I think the best job applicant is still a warm referral. So check with your network, look into the friends of friends option to find your next applicant. And that just cuts through a lot of the mistrust or vetting that you might have to do with a cold applicant.

All right. So a few quick tips and ideas to get you thinking about rewriting your job ads to find folks that are a great fit for your practice. I hope that this has been helpful.

If you are looking to start or grow your practice, I am recruiting for the next cohorts of the beginner and advanced practice mastermind groups. You can get more information and schedule a pre-group [00:19:00] call at thetestingpsychologist.com/beginner or thetestingpsychologist.com/advanced, depending on what you’re interested in.

Okay. That’ll do it for today. Let’s wrap this up. Y’all take care. I will talk to you next time.

The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. Please note that no doctor-patient relationship is formed here, and similarly, no [00:20:00] supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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[00:00:00] Dr. Sharp: Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

The BRIEF-2 ADHD form uses BRIEF-2 scores to predict the likelihood of ADHD. It is available on PARiConnect-PAR’s online assessment platform. Learn more at parinc.com.

Hey everyone, welcome back. Today we’re talking about dimensional diagnosis and dimensional conceptualization. I’ve had a number of guests over the years. I’m thinking of Dr. Jenni Pacheco from RDoC, Dr. Katherine Jonas from HiTOP, the guys from the SPECTRA, and any number of folks who have talked about dimensional models of mental health. And today I [00:01:00] have another esteemed guest and expert who has literally written the book on dimensional models and makes a pretty compelling argument for why we might want to switch to a dimensional model of mental health.

So, my guest, Dr. Ben Lahey is a clinical child psychologist, who is the Irving B Harris professor of epidemiology, psychiatry, and behavioral neuroscience at the University of Chicago. His research has focused on the identification of dimensions of psychological problems across the lifespan but mostly in children using longitudinal studies of population-based samples.

We’re going to speak a lot about his new book. It’s called Dimensions of Psychological Problems: Replacing Diagnostic Categories with a More Science-Based and Less Stigmatizing Alternative. You can find the link to the book in the show notes, of course.

The material from [00:02:00] our interview today is largely drawn from the book simply because it is so rich, and really dives deep on the why’s and how’s of a dementia model.

So just a few things we talk about are: why now could possibly be a tipping point in moving from a categorical model to a dimensional model. We talk about why Ben calls the dimensional model a “positive revolution” in our world. We talk about the influence of genes and the environment on psychological problems. We also get into some of the downsides of a dimensional model among many other things. Again, this is just a jam-packed interview with really rich content from a true expert in this area.

Without further ado, let’s jump to my conversation with Dr. Ben [00:03:00] Lahey.

Ben, welcome to the podcast.

Dr. Ben: Thank you very much for inviting me. It’s a pleasure.

Dr. Sharp: Pleasure is all mine. I’m honored to be talking with you. I know you’ve had a long career and have done many things over the years but I am particularly excited to be talking with you about your recent work and your recent upcoming book on the dimensional diagnosis. So, I’m just glad to have some of your time. I really appreciate it.

I want to start with the typical first question for our podcast here. And that question is always why is this work important to you? Why [00:04:00] do this out of everything?

Dr. Ben: Well, I’ve spent a good bit of my career trying to find the optimal ways to describe the psychological problems of children originally. And as my longitudinal samples grew into adults, we can’t understand the causes of X unless we can define X. So we are trying to… when I say we, the hundreds of psychologists and psychiatrists are doing the same thing …we’re trying to carve nature at its joints in the most optimal way to understand the origins of psychological problems and to help find the best ways to prevent and treat them.

[00:05:00] Specifically in writing this book, I made the decision to add my voice to hundreds of other people in the field, to call for a positive revolution that is in one sense something is happening here and now but it’s been brewing for over 50 years and is only now reaching a tipping point.

Some of the most important papers and books on this top topic were written by Albert Bandura and Tom Achenbach and Harry Stack Sullivan over 50 years ago.

This revolution, it’s urging all of us to reconsider how we view psychological problems and in a very pointed way to leave behind [00:06:00] the binary diagnostic categories of mental disorders and DSM-5 and the international classification of diseases.

Dr. Sharp: Sure. So you mentioned so much during that brief piece there. Let us pull it apart and let’s dive right in. You used the term positive revolution in your references history. I wonder if we might just set some context here as we get going. Can you talk through a little bit of the history around the diagnosis and how we have approached this over the years and how this dimensional view really got started?

Dr. Ben: Well, classically, diagnosis is an outcome of the revolution that happened in the 1800s [00:07:00] and earlier in which individuals who were troubled with very serious problems, such as general paresis were thought to have for the first time had a medical problem. Devin and others discovered that the germ that causes syphilis, if untreated, and it was always untreated at that point, goes on to destroy brain cells and create what was then the most common diagnosis referred to institutions for dealing with individuals with serious problems which was, as I say, general paresis.

That, very understandably, set into motion the belief that [00:08:00] every psychological problem will ultimately be discovered to be the result of some kind of infection or medical problem that led to renaming institutions to asylums and mental hospitals and physicians were put in charge for the first time. The physicians who were in charge got together and created an organization that they call the American Psychiatric Association. And from then on, psychiatrists, psychologists, and other mental health practitioners viewed psychological problems as a result of mental illness.

When no more germs were discovered but a few more were discovered, then most individuals [00:09:00] struggled to maintain that categorical diagnosis by turning the medical model into an analogy. So then they were trying to diagnose an abnormal mind rather than find an underlying abnormality of the brain. We’re still stuck there with binary categories.

Now, the revolution is in part to get away from the stigmatizing view that we are normal until we have another problem. And then we’re still normal. And then we have another problem and we’re still normal. And then all of a sudden, we reached the diagnostic threshold and fall into the abyss of mental illness. Trying to get away from that terribly [00:10:00] stigmatizing view not just because we’re humanists but because that’s what science is saying.

It’s very clear from many years of research now that everything that we call a mental disorder is dimensional, not categorical, that there is a linear relationship between the number and severity of psychological problems. So, by psychological problem, I’m using a non-stigmatizing synonym for symptoms because that’s all in medical model thinking. So as the number and severity of, say, depression problems increases, there’s a simple linear increase in the amount of distress and impairment in our life functioning.

By drawing an artificial [00:11:00] line between normal and abnormal, we create stigma and we also make our measurement far less reliable and valid because there are many subthreshold cases if you use diagnostic language where the individual might be terribly impaired with just false symptoms of depression, and if a clinician were to follow the rules exactly, they would say, “No, you’re perfectly fine. Go home” even though they’re telling you that they’re actively suicidal with just the false symptoms. I’m exaggerating, but by putting everything into binary Benz, we reduced our liability and the validity of measurement.

So the [00:12:00] revolution has another aspect that flows from that, that although psychological problems are very distressing often, very problematic for people who are going through those problems often, they’re actually, I think better thought of as perfectly ordinary variations in behavior in two ways: They arise through the same psychological and biological processes as adaptive behavior. They’re just aspects of our behavior. They’re individual differences in our behavior that are sometimes impairing and distressing.

The other way in which I think we need to recognize that psychological problems are ordinary is that [00:13:00] longitudinal studies have been taking place over the last 15 years and are finally to the point where they can look back show that psychological problems are far more commonplace than anyone ever expected even if you use DSM diagnostic criteria which ignores people with impairing sub-threshold problems.

Moffitt and Caspi and other studies show that over 80% of us at some time in our life meet the criteria for at least one DSM mental disorder. And if you then think about the sub-threshold problems, it’s basically all of us. What’s very unusual is for somebody to cruise through life [00:14:00] without any aspects of their behavior creating distress and interfering with their lives.

Dr. Sharp: Right. Well, there’s a lot of good information in there. Where do we even start to dig in? So you use the phrase tipping point a while back. I’m curious what leads you in that direction? Like why now? Why are we at this tipping point for a push toward more dimensional classification compared to say 10 years ago, 5 years ago, 20 years ago, what is it that’s leading you to use that term?

Dr. Ben: That’s a really interesting question. I thought long and hard before writing this book because I know that it’s [00:15:00] going to add another target tattooed to my chest for slings and arrows that not everybody’s going to be happy with what I’m saying. And I was convinced that this view is correct. But being a bit of a coward like most people, I wanted to not send this out in the wilderness and become another Thomas Szasz who is perhaps the most misquoted person in psychiatry and psychology. Everybody knows what Thomas Szasz said, but nobody’s actually read Thomas Szasz, almost nobody. He didn’t actually say there’s no such thing as mental health problems. He just was opposed to the medical model.

But I didn’t want to be just an odd character [00:16:00] urging us to change our view of something in a way that other people have tried and failed in. So, part of it was the social psychology of the moment that an increasing number of very credible individuals in the field, in articles, in journals have been calling for this revolution. And includes people like Bob Krueger and Leanna Clark who are not people to be ignored. They have a crowd phenomenon that encourages all to speak out and raise our hand and say, yeah, this really is an important revolution that needs to take place, and I’m going to stand in the front lines with [00:17:00] you.

But there are two other things that are important. So those people that I just mentioned, Bob Krueger and Leanna Clark, and a number of others, Tom Whitaker, very bravely were part of the DSM–5 workgroup on personality disorders and tried to get DSM–5 changed just in the personality disorder section to a dimensional approach and they failed or they succeeded only partially. They got a backhanded compliment and a little bit was put into the DSM–5 that’s dimensional. And I think that angered a lot of us that these folks who were very sensible, very databases in their approach [00:18:00] we’re not allowed by the establishment to change how we thought. So not only are there a lot of us speaking up now, we’re a little bit angry. And I just avoided some synonyms for angry there.

But I am a scientist. I have worked in the trenches of research throughout my career and I wouldn’t be jumping into this battle line, even with people that I deeply respect if there weren’t so much new data. So this is very much a database revolution. Albert Bandura and others did not have access to the data that we have now: to the many studies that have formally [00:19:00] tested the dimensions of psychopathology or psychological problems, to the longitudinal studies that look at people over time and so on.

So we’re beginning to see things that really help us think about psychological problems I haven’t mentioned yet. One is, when we look dimensionally at psychological problems, we see that they’re highly correlated more so than you see when you look at odds ratios between different diagnoses or to what extent they overlap. And those correlations reveal a number of really fascinating things.

So by correlation, I mean, [00:20:00] let’s say we’re doing a large longitudinal study and at time one, the first time we assess everybody we correlate these counts of problems, counts of depression problems, counts of separation anxiety problems, attention problems. We correlate them and we get a pattern of cross-sectional correlations. So keep that in mind as I start to talk. So the first implication of those very high correlations is when you correlate, say, inattention problems with say depression problems and you find that there’s a strong correlation, what that means is, if you have a high number of inattention problems you also have a high number of depression problems.

If you think about that for just a moment more, what that means is our psychological problems don’t come in [00:21:00] independent silos. People tend to have lots of problems from lots of dimensions at the same time. And the extent to which these cross-sectional correlations are high. You’re going to have more of a mish-mash of these problems. So even though DSM says, look for children that have six symptoms of inattention, and six symptoms of hyperactivity-impulsivity, you’re not going to find many, if any, who only have that, who only display those problems.

And there’s a tendency once you’ve made a diagnosis to ignore everything else, to use the analogy of the procrustean bed, the Robert Baron Procrustes brought [00:22:00] travelers into his home and had them sleep in his special metal bed but he wanted them to all fit the bed. So he stretched parts of their body that didn’t quite fit on one side and he chopped off parts of the body but that didn’t fit on the other side to make everybody fit the procrustean bed perfectly.

Well, we have a tendency to do that with diagnoses, say, “Yes, this child has ADHD” and chomp off the depression symptoms and the oppositional behaviors and so on unless they also meet diagnostic criteria for something else.

So one implication is don’t expect people to come to you for help that just has problems of one sort. That mishmash combination is what we’re going to [00:23:00] expect to find. And if you stop and think about your practice for even just a second, I think most of you would agree.

The other thing that’s that we found out that is amazing and revealing is that over time, there is continuity. So people who have psychological problems one year tend to have psychological problems in the next year and the year after that. But there are two kinds of continuity. Some of it is continuity and that the same dimension of problems is high over time. So they might have high levels of inattention every year. But there’s also a great deal of heterotopic continuity in the sense that every psychological problem that correlates its baseline [00:24:00] cross-sectionally, predicts future problems of other kinds at that same level.

So that’s to say, let me just slip into a diagnostic language to make it simple, people who meet the criteria for depression, adults, in the three years later are at increased risk for every other diagnosis that was measured. Every other one. The extent to which they predict other diagnoses is consistent with the cross-sectional correlation. So at baseline, people often have generalized anxiety disorder and depression symptoms at the same time. So depression predicts future generalized anxiety disorder much better [00:25:00] than it predicts, for example, any social personality disorder. But it predicts everything.

And if you look at the relationship between the cross-sectional correlation and the prognostic correlation it’s 0.9. So psychopathology is not only highly correlated, which makes the boundaries between the bins very fuzzy. It is fuzzy over time so that we see lots of change but the change is predictable by how correlated the problems are. In chemistry, if carbon over time changed into calcium, you’d be really surprised. Something would be wrong with the science. But in the science of [00:26:00] psychological problems, we need to expect lots of change.

I have done a lot of practice but I used to see charts come in for children in which they’d been seen by other people say four times before and got four different diagnoses. And I thought it’s a good thing they came to me because I’ll give the accurate diagnosis. And what may very well be the case is that those children presented with different problems every time. I’ve been talking for a long time. Let me turn it back to you for your questions.

Dr. Sharp: Oh no, this is all good stuff. I think you’re describing an experience that a lot of us have had either, I think we’ve seen both sides of the coin where we are seeing a kid for a comprehensive [00:27:00] evaluation and end up with a laundry list of diagnoses because they just seem to meet the criteria for any number of things, it’s depression and anxiety and panic and maybe some ADHD and some ODD. We could theoretically list all those diagnoses just because they have so many symptoms but we’ve also had that experience of seeing those kids who have the laundry list and then thinking, oh, I’m going to get it right this time. I’m going to clarify this for the parents and for the kids.

Dr. Ben: Let’s take the data that I’ve just described and go back to the DSM. So the DSM wants us to believe, and of course, I don’t mean to be flippant, the founder or the people who write these diagnostic categories, they believe that there are distinct [00:28:00] unchanging categories of mental disorders. And that’s not what the data say. The dimensionality of psychological problems makes us question the binary Yes/No categories, but it’s also very important in terms of stigma.

In a dimensional approach, there’s no hard line between normal and abnormal. There’s no hard line between normal and ill to be sure. So that a person doesn’t need to think, I might be mentally ill to go and seek help, to go and ask if there’s something that can be done to make my life happier and more functional. They simply, in a dimensional [00:29:00] approach, if we can get these ideas out, which is one of the goals of the book, they simply have to say there are things about my behavior that just aren’t working. I want to go see if I can get some help.

Just like if you’re a tennis player and you are now serving the ball consistently into the net and you just can’t get it right, you don’t have to call up your tennis pro and say, I’ve fallen into the abyss of mental illness and I need your help. You just say, hey, something about my game isn’t working. Can you look at it? Talk to me about things that I can do to make it more functional for me. And so that that game can be the game of life. We can go in and seek help in a way that doesn’t require [00:30:00] admitting that we’re no longer like every other human being. We’ve become qualitatively different from them.

Dr. Sharp: Yeah, I’m glad that you brought that up. That was a question that was running through my mind as we were talking. This question of how then do we determine who needs treatment or not if we’re without these maybe the false security, I guess, of a binary diagnostic system to tell us when someone reaches the threshold for treatment. How do we think about that? How does someone know? How do we know as practitioners?

Dr. Ben: Yeah, that’s a very good question. I addressed it in the book. I know it’s going to be one of the fights coming up if this revolution comes about. And by that, I mean, if enough of us stand up and say, [00:31:00] DSM-6 either has to be a fully dimensional system or we’re going to leave it behind and we’re going to develop an alternative dimensional system. One of the fights that are going to happen is the insurance companies and maybe the APA- the American Psychiatric Association, are going to say, you can’t do that. It’s going to open the flood gates. Everybody’s going to want to come in and get services with their psychological problems.

So, there are two responses. First of all, we won’t know until we do try. It’s an empirical question. Secondly, it may not result in any increase at all because right now practitioners, and I don’t mean this in a negative way, for the benefit of the people that come [00:32:00] in seeking help, rarely turn people away. They find ways of giving diagnoses that will lead to reimbursement so that individuals can receive services. So there may be no more people receiving services but I hope there will be actually.

I hope that by reducing stigma, far more people will come in and say, I need help. I’m miserable and I’m not doing my job well and I’m missing work a lot. I lost it the other day and my wife wound up in the emergency room. Those people I hope under conditions of reduced stigma will come in for help [00:33:00] earlier and more often so that we are in the wonderful situation of having to fund more mental health services. I just lapsed into the old view and said mental health, but more services for psychological problems.

I’m perfectly happy for my insurance rates to go up a little, my taxes to go up a little to fund more services just because evidence-based practice is good for human beings. I think there are ways of making evidence-based interventions more cost-effective to bring the cost down a bit but if that individual and then the millions like him or her are able to get help for their depression and go back to [00:34:00] work consistently and be more productive, that will reduce the economic burden of psychological problems which is fast. So I think it would be a very good investment.

Now, please follow up on that if you wish because it’s important. But I want to not fail to mention a theoretical point that is near and dear to my heart before we finish.

Dr. Sharp: Yeah. By all means. You can go for it and I’ll hold my question here until you wrap up.

Dr. Ben: Okay. So one of the things that come to mind when you see that every dimension is correlated is that as Tom Achenbach saw in the 1960s, very brilliantly and ahead of the rest of us, you can create a second-order [00:35:00] factor of Internalizing and Externalizing problems. And now we know that you can have a third one of thought disorder kinds of problems.

And Tom noticed and honestly reported the internalizing and externalizing are correlated. So these second-order dimensions are themselves correlated at 0.5. It’s a big correlation. That’s not accounting for measurement error. And that has been bothering me since I was a graduate student. And notice how I’m pointing out that I was in graduate school when Tom Achenbach came up with this. I am not the oldest living psychologist in the field but I will admit that Tom Achenbach is far younger and healthier looking than I am.

So [00:36:00] Tom noticed that it bothered me because theoretically, I thought internalizing and externalizing should be negatively correlated. You either act in or you act out and you can’t do both. And it took years and years until I thought, wait a minute, maybe that’s telling us something. So we started looking at the correlations among dimensions of psychopathology not as something that we need to ignore because it didn’t fit our thinking but we started thinking about these correlations as the figures rather than the ground. As something that tells important information. I won’t go into the details, but you can then use the correlation among the internalizing and externalizing factors although we don’t literally do it that way, to define what I [00:37:00] called the general factor of psychopathology and what Avshalom Caspi and Terry Moffitt called the P factor.

So at the highest level, there’s a factor that accounts for variation in every psychological problem. And then below that, there are these second-order dimensions that independently explain further the correlations among internalizing externalizing and thought disorder. And with my colleagues in 2017, we published a paper in the Psychological Bulletin called a Causal Taxonomy of Psychopathology, I was still using the term psychopathology four years ago, which we said these correlations mean, and now there’s evidence to support this, that many of the ideological factors [00:38:00] for psychological problems are entirely diffused, entirely nonspecific.

And we now know that most of those are genetic predispositions which is to say that most of our genetic predisposition to psychological problems increases the risk for something but not any particular dimension of psychological problems. It’s other things that determine which kind we experienced. Some of those are specific genetic influences, but mostly its experiences. And it’s mostly the kind of experiences that each individual and their family has independently.

So one sibling is in a car accident or one sibling makes a deep friendship with a girl [00:39:00] who later committed suicide or these other experiences that the evidence from twin studies and even molecular genetic studies now suggest shape what particular problems we experience. And that is why they change over time, our hypothesis says, because over time, these experiences that are specific to each person change for us. I now get into college and I fall in with the group of individuals that are studious and are happy and play sports after they study. And that makes me less depressed and so on.

So this is why I think we’re coming to a new understanding. Robert Pohlman calls this a generalist [00:40:00] genes specialist environments hypothesis when he was doing his work on reading that genetic predisposition is not specific, which is why if a parent has a particular diagnosis, their children are at increased risk for any diagnosis, not just their particular one. So there’s this very non-specific predisposition that then is shaped by our experiences into the particular problems that we are having at that time.

Dr. Sharp: That’s so fascinating. So then this might be a leap. Point me in the right direction if I’m off base. TAre you saying, or does the research say rather that we can’t really say,  “depression is heritable” or [00:41:00] OCD is genetically transmitted or even things like thought disorder or autism spectrum disorder, things like that. I mean, are you saying that we’ve been saying it wrong over the years?

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All right, let’s get back to the podcast.

Dr. Sharp: Or are there some other problems that are more heavily linked to?

Dr. Ben: So let me restate what you’re saying in the way that I think the data are saying. I am not in any way challenging the heritability of any diagnostic category or dimension which we know to be substantial for everything. Very high for schizophrenia, autism spectrum, modest for anxiety, but everything is heritable. What I am saying is that most of what [00:43:00] makes depression, for example, heritable, is shared with every other dimension of psychological problems.

There are very few genetic variants that are specific to each particular dimension. They tend to be generalists but there are some. And I’m not saying they’re unimportant. And there’s much more to be discovered but there’s a paper in the press that has come from a big group called the Psychiatric Genomics Consortium that looked on their data on tens of thousands of individuals, and they found consistent with the model that I’m talking about that only about 20% of the genetic variance, and they’re looking at snips single-nucleotide [00:44:00] polymorphic variants, only about 20% are specific to one disorder. The other 80% are shared with other psychological problems.

So genetics is very important. But genetics is not mostly specific to any particular problem. What is specific to problems is more the experiences that individuals have, which gives us as psychologists and psychiatrists the targets for changing people with psychological interventions. Those experiences that each individual has include the experiences that therapists create for individuals using evidence to figure out what is the most [00:45:00] important experience this individual with Agoraphobia can have to change that particular set of psychological problems. And you hopefully go back to your training and see that guided exposure is what is needed here. That there’s the strongest evidence. And so you arrange for that experience. And can in many cases change the problems that the individual has. You can’t change the genetic predisposition, but you can certainly attack the environmental end of it.

Dr. Sharp: I see. Yeah, thanks for talking through that. This research is just fascinating to me. I do wonder how you conceptualize maybe some of the neurodevelopmental disorders, like learning disorders, certainly autism, maybe even ADHD. How [00:46:00] did those fit in a dimensional model? And is that any different than some of these things we’ve already discussed like anxiety, depression, etc?

Dr. Ben: I’m trying to decide where to start. First of all, I don’t like the DSM-5 broad category of neurodevelopmental disorder because everything is a neurodevelopmental disorder, and singling out some doesn’t make sense to me. Putting ADHD in the same broad category with the autism spectrum does that make sense to me. All the data suggests it should be with other externalizing problems, although it’s somewhat unique from them as well.

So the other issue is, does the dimensional approach work [00:47:00] for serious problems like autism spectrum or schizophrenia? There’s a lot of research none of which I’ve been involved in, this is from many other researchers who are looking at these uncommon problems in a dimensional way and making it very clear that they are also dimensional, but dimensional with distributions so that if you did a study of 10,000 people, you’d find many thousands of individual with a count of zero of those kinds of problems but you do then find people with one or two or three and so on.

And there’s a linear association between the number of those serious problems and how much they impact an individual’s lives. [00:48:00] My guess is although the autism spectrum isn’t defined in DSM in a way that you can easily count problems, it’s vaguer than I think it needs to be, my guess is that the big increase in the number of individuals that are considered to be on the autism spectrum is reflecting the recognition that people that are lower on this distribution of problems are often impaired as well. And so that the idea of the spectrum is to recognize their need for services just like the much more extreme problems that were perceived as ” autism services in the past.”

Dr. Sharp: [00:49:00] I see. Gosh, there are so many directions that we could take this. So I’m going to try to ask this question. It may not come out in a coherent manner. So bear with me and set me on the right path, if not. But I guess what I’m thinking about then is, as we conceptualize things in a dimensional way, does that preserve the… I’m trying to find a different word for psychopathology but I can’t. So I guess what I’m getting at is, how do we not turn everything into basically just a trait that everyone has to some degree and thereby wash out the significance? [00:50:00] So now’s where I asked. Does that question make any sense at all?

Dr. Ben: Oh yeah, it makes perfect sense. I’m really glad you asked it. So I mean this in the nicest possible way. Because we’re all trained to think in binary ways, we’re all trained to think that most people are normal but some people really need help because they’re abnormal. I have not said my message in a way yet that has penetrated. I’m trying to be really nice and find a way of saying, you’re missing the point.

[00:51:00] Dr. Sharp: There we go.

Dr. Ben: We are trying, I am, and I think most of the people in this group, and I mean mentioned a large group called HiTOP- the Hierarchical Taxonomy of Psychopathology group that I’m a member of. They share a lot of my views, although they still use the term psychopathology.

So all of us are trying to get people that think in terms of dimensions are saying everything is a trait. Everything is a dimension. There is no defensible point on that dimension where you can categorize it and say, it’s a disorder. It’s psychopathology. There’s just no defensible way of doing that.

As the severity of problems [00:52:00] goes up on every dimension, so does the amount of impairment and distress. And in my view, with the help of the psychologist or psychiatrist counselor, social worker, each individual who has these problems needs to decide, I’m at a point where it’s worse for me to just continue living with these problems than to seek help. So if I seek help, even if I’m not buying into the stigma, which is hard to do, hard to avoid, I’m going to have to say, well, at least I’m somebody that needs help. And even that’s a little stigmatizing. They might prescribe me a medication that’s going to give me an adverse reaction, or I’m at least maybe going to be paying out-of-pocket costs.

[00:53:00] There are some costs in seeking help, but every individual should be free. I think to say my level of inattention is to the point where I think I’m a pretty smart, capable person that I’m just not succeeding in my job. And I’m going to get hurt and I’m going to hurt my other employees if I don’t get some help.

Now, you can’t go to the DSM and look it up and say, “Oh, no, you only got five inattention problems, you don’t need help.” It’s a continuum. You have to just use common sense. I’m hoping that you’ll get away from thinking some people are disordered, some people aren’t. Again, I’m saying this in the nicest way. Ironically, we’re all nuts. Individual [00:54:00] differences in our behavior broadly define emotions, thinking, beliefs, perceptions, individual differences characterize the human race. And sometimes during our lives, our individual differences in almost all of us are going to cause us distress and impairment. And there’s a whole group of people all of whom I hope follow the tendency of evidence-based practice, who can help us reduce those problems: stop feeling the distress, and function better in life. And none of that involves a disorder.

Dr. Sharp: Thank you. So let me ask another question that might stir the pot a little bit. How do we conceptualize or reconcile maybe individuals [00:55:00] who perceive themselves to have some impairment in an area, whatever that might be, let’s just call it ADHD, you said inattention,  and yet I think we all run into these cases in our practices. Someone comes in and they say, “I’m really struggling. I can’t pay attention. I keep losing things. I don’t know what I’m doing.” But that’s not measurable. So others in their lives don’t see these concerns, maybe our objective test data doesn’t necessarily reflect those concerns. So I’m wrestling with how much do we trust or rely on an individual’s self-report of impairment, especially if it’s toward the lower end of the [00:56:00] dimension. Do you see what I’m getting at here?

Dr. Ben: Yeah, I do. You may be asking the approach that I’m advocating in the book to accomplish more than I’m setting out to do. I’m not upset with that. I’m just saying, you’re talking about a problem that can’t be solved necessarily by going from a dimensional point of view. We can solve a lot of problems, but you’re always going to have people coming in for help, or you’re just not sure what’s going on and not sure whether to take them seriously when you can’t get corroboration especially if it’s something where they’re hoping you’re going to [00:57:00] recommend either that the child be qualified for special education services that you’re not sure is needed or that you might recommend to a physician that they get Ritalin because they want an A-plus average instead of an A-minus average. Those are real issues that I don’t think are any easier in a dimensional versus a categorical approach.

But one thing I will say that I hope practitioners will do, and we maybe need more instruments to do this well, is not having someone come in and complain about ADHD problems and try and decide if they have ADHD like [00:58:00] I used to do years and years ago,  but to then ask them about the ODD disorder, major depression, et cetera, ask them about everything. So at the end of that you might decide, well, I’m not so sure about ADHD, but this person clearly has a high level of depression problems including difficulty paying attention which is a symptom of depression as well in the medical model approach.

So I’m asking people to be comprehensive in evaluating. Putting it all together, look at each person’s particular mishmash of problems and then do the validations of their reports as best as you can.

Dr. Sharp: I like that. As [00:59:00] we start to wrap up this discussion, it went by really fast. There are two other things I want to touch on. You mentioned toward the beginning, this idea that it’d be great to band together and say, DSM-6, if you are not going to go dimensional, then we’re doing something different. What path do you see toward doing something different? What would that even look like to get away from the DSM if it sticks with this categorical model?

Dr. Ben: All right. One thing that occurred to me is that I should write a book…

Dr. Sharp: Look at that.

Dr. Ben: …to try and explain in the best way that I can, and so dimensions of psychological problems which is coming out this month from Oxford [01:00:00] University Press the month in which this podcast is released. It is my attempt to persuade as many people as possible that this is something that needs to be done so that the pressure on the DSM and ICD establishment becomes acute.

Now, there are a lot of steps in that. The insurance companies are going to fight back. The people listening to this podcast are going to say, “Yeah, this is all fine, but I have to in the report that I write up, I have to put diagnoses in.”

What I’m advocating here is not let that requirement dissuade you from describing the psychological problems of the child or the adult [01:01:00] in dimensional terms and then say, this could be viewed in DSM terms as leading to the diagnosis of.. and even trying, if you can, in certain situations leave that part out. After you’ve described somebody fully and recommended what needs to be done, unless there’s a legal requirement for a diagnosis for a school or some other program, I hope I’ve convinced you to not feel the necessity to put them in.

As more and more people become convinced that this is an approach that is good for human beings and that you can adopt it in your practice and feel even better about it, there’ll be more pressure. But [01:02:00] it’s also going to require more papers, more books written by people that will be read by the founders of DSM. I am a friend of Darrel Regier who led the DSM-5 workgroup. I will send him a copy and I will hope to hear from him. I don’t want to distress him, but whoever’s going to be in charge of DSM-6 will certainly get a copy. And it’s this process to their credit, the American Psychiatric Association to their credit, always opens it up to public comment. And many of us will comment and I hope many of the listeners here will comment.

Dr. Sharp: Well, [01:03:00] I know that there’s a lot of energy around this. I think I mentioned even on the podcasts, we’ve had folks from RDoC and HiTOP and the guys that co-developed the SPECTRA, which is a dimensional assessment of personality and psychological problems. So there’s a lot of energy around it. And I think a lot of us in the field would say, this makes a lot of sense, and this is more aligned with research and what we know. And I mean, it all seems like things are pointing in that direction. It feels at the same time like a huge undertaking to shift this diagnostic model that we have grown up at, largely because it’s so rooted in healthcare. I mean, that’s a behemoth of an entity to take on. So I’m just glad that there are a lot of [01:04:00] folks out there doing good work and trying to push this and bring it to the forefront.

Dr. Ben: Well, I think it’s happening. Two days ago, I presented to a committee set up by the National Academy of Sciences Engineering and Medicine on how to best describe in their terms psychopathology. Tom Insel presented on HotDoc another dimensional approach. And I believe they’re going to make a recommendation that dimension approaches be explored further and funded more. I’m hoping. That’s the way the conversation seemed to be going. But even if they don’t, there are a lot of us who believe in this who are [01:05:00] excited by the data that are allowing us to move from opinion to well-informed views and that we think we see insight a change that’s going to get this monkey off the back of people who have psychological problems who have to endure the stigma which makes their problems even worse and may dissuade them from seeking services.

So I think there’s a way to be more scientifically valid and to fight the stigma that’s right there on the horizon. So join the army, help get DSM to think in the right way. And I just want to make sure everybody understands that this is not an anti-psychiatry [01:06:00] diatribe. This is, if anything, a diatribe against the book that they sell, that the American Psychiatric Association sells. Many psychiatrists are in favor of this book, and some of them are nice enough to write nice blurbs on the back of my book cover endorsing the view. So I hope everyone will read it and will get in contact with me with questions and pushback. If you feel like joining us, please do.

Dr. Sharp: That’s fantastic. I love that. Yeah, we’ll link to the book in the show notes, obviously, so people can check it out and get it if they’d like to do that. But I think that’s a nice note to close on. Here we have it, folks. Join the revolution. Join the dimensional revolution and help us provide better care with less [01:07:00] stigma.

So thanks, Ben. I really appreciate it. This is a fascinating and informative conversation and I really enjoyed it.

Dr. Ben: Thank you, Jeremy. It’s been my pleasure.

Dr. Sharp: All right. Thanks so much for listening. All the resources that we mentioned are listed in the show notes, including Ben’s book, like I said at the beginning. Definitely check that out if you have an interest in this topic. I think it’s a good one.

If you have not subscribed to the podcast, now is a great time to do that.  I always love to build the audience. And if you’re a practice owner, either at the beginning phase or the advanced stage, who’s looking to take your practice to the next level and just have some accountability and some guidance in doing so, I would love for you to check out the Beginner Practice or Advanced Practice Mastermind group. You can get more information at thetestingpsychologist.com/advanced or thetestingpsychologist.com/beginner, depending on where you’re [01:08:00] at. And we can schedule a pre-group call to see if it would be a good fit.

Okay, y’all, that’s it for today. I will be back with you next time.

The information contained in this podcast and on the testing psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of [01:09:00] this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one or area. Similarly, if you need support on clinical matters, please find a supervisor with expertise that fits your needs.

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[00:00:00] Dr. Sharp: Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

This episode is brought to you by PAR. The Feifer Assessment of Writing examines why students may struggle with writing. The FAW and the FAW screening form are available on PARiConnect-PAR’s online assessment platform. Learn more at parinc.com\faw.

Hey everyone. Here we are back with another business episode. This episode is for all of you who have considered transitioning from insurance to private pay and struggled with what to do in terms of access for folks who may not be able to pay. This is a [00:01:00] major topic of conversation during our interview today. And there are many other things that we talk about that I think will be super helpful.

Let me produce my guests, and then I’ll tell you a little bit more about the episode as we go along.

My guest today is a longtime friend,  Dr. Annie VanSkiver. Annie is a private practice owner in Williamsburg, Virginia. She opened her practice in 2017 after transitioning out of employment at a local State hospital where she served as assistant forensic coordinator for 8 years. The inspiration for her practice came from this podcast. So you can tell right away, this is aside, of course, that Annie is very complimentary of the podcast, both in her bio that she provided and during the interview. I’m not sure how to handle that because it’s very [00:02:00] humbling. But anyway, this is just the first instance and a little bit of warning that Annie is very complimentary. And I promise I didn’t pay her to say any of those things.

So as she was saying in her bio, as I was saying in her bio, Annie got her inspiration from the podcast. Her passion is testing and data, and she never thought that she could open a practice that only does testing. She loves working with kids and families to help those kiddos, especially around learning disabilities, autism, ADHD, and other developmental differences.

Her husband is a special education teacher and together they have three amazing kids through birth and adoption, one with complex needs. Her dogs are named after Harry Potter characters, which also adorn her office, which creates an excellent starting point for a conversation with her clients!

As you’ll see, Annie is [00:03:00] wonderful in all regards. I am just honored to be talking with her. I have been part of her journey over the years and to see where she has ended up, but now having her on the podcast is just an awesome experience.

So we are talking all about transitioning from insurance to private pay. We talk about, of course, how to get off insurance panels, logistically speaking. We talk about contracts that can help supplement private pay clients. We talk about how to let referral sources know when you’re going off panels. We also spend a lot of time, like I mentioned, on the topic of balancing access for clients with profitability. I think this is often a false dichotomy that gets set up that you either have to be private pay or you have to provide access for folks, and Annie has found a way to do both [00:04:00] and I think is doing it very well. And that’s a big reason I wanted to have her on the podcast so she could talk through her decision-making process and strategy with that.

So we cover a lot. This is chock full of amazing information, and I think there’s a lot to take away. So without further ado, let’s transition to my conversation with Dr. Annie VanSkiver.

Hey, Annie. Welcome to the podcast.

Dr. Annie: Hi, thanks for having me.

Dr. Sharp: Yes. I’m so glad that you agreed to come on and talk to me today. I feel like we’ve had so many interactions in so many different venues over the last few years that here we are at the pinnacle of our relationship with you coming on [00:05:00] the podcast.

Dr. Annie: Oh, thanks. I feel like I’ve achieved something great because I’m on your podcast since this is what literally started my practice.

Dr. Sharp: It’s full circle. Well, I’m seriously honored to have you. And I think it’s really cool having seen your journey over the last few years and knowing that you’ve gotten to this place, that feels really good. I’m excited to have a conversation with you about that and share that with other folks who might benefit as well. So, thanks. I’m glad you’re here.

Dr. Annie: Sure, thank you so much.

Dr. Sharp: Okay. So let’s dive in here. I wonder if we might set the stage for people. I would love to have you just describe your practice in the old days. So, pre-private pay. What did your practice look like when you first started and those first couple of years?

Dr. Annie: That’s a good question. So the practice [00:06:00] started, I have to throw on my plug for you because the practice started when I was adopting my third child and I was doing a lot of running because that is what I do when I’m stressed out about things. And I started listening to your podcast and it occurred to me that I could have this practice that was testing only. I’m a terrible therapist, quite frankly. So, I had never dreamed I could come into private practice, but I started listening to podcasts and the idea came into my head that we could maybe do this.

At the time, I was employed at a State hospital working with not guilty by reason of insanity equities predominantly and doing a lot of evaluation work around that. But in my former life, I was a school psychologist. I worked with children outpatient for a long time. So I had this thought of maybe blending the two ideas.

So when I originally went into practice, I went in with a partner who is amazing and wonderful. And we had this vision of doing all [00:07:00] evaluation, part forensic and part with children. And it worked really well, but we noticed, I’m sure everybody will laugh when they hear this, but it was really different. They were two completely different practices. And that’s what we ended up deciding to do was just to split the two practices into one, all forensic, which Dr. Andrew Osborne heads up, and mine, which is all children. And we figured that out when we got on the insurance panels because forensic work is all private pay. The insurance panels were a whole different animal.

So, when we first started, that’s how we organically evolved. And then it became me and myself with an admin assistant, practice manager now, and then myself with… I had a psychiatrist and then we had a couple of interns, but the whole time we were taking all health insurance. We were on every panel I could get my hands [00:08:00] on.

Dr. Sharp: Right. This is a little bit of a digression right off the bat. So forgive me for that. But when you set up the practice initially, were you partnered with Dr. Osborne? Was that a business partnership that you had to then dissolve when you split your practices?

Dr. Annie: That’s a great question. And it’s not really devolving. I should have mentioned that. So, no, we were actually in the process of forming the partnership. I had an LLC under just my name, and then we named the practice. We talked it through when we had this vision and then we got our attorney involved when I finally quit the State hospital. We were in the process of talking about merging it into an actual partnership when we started to realize that it was two different practices. So it worked out really well. My attorney was happy we figured it out early.

Dr. Sharp: I bet everybody was.

Dr. Annie: Yeah. And he actually advised us not to form a formal partnership unless there was a [00:09:00] really important reason to do so because it’s so hard to get out of it.

Dr. Sharp: Right. That’s the advice that I tend to give folks. If you can avoid a partnership, just avoid it and find another route.

Dr. Annie: Right.

Dr. Sharp: Yeah. It’s a tricky business. Okay. So help me understand. I know what my motivation was for getting on insurance panels in the beginning. I’m curious what your motivation was when you decided to jump on all these panels.

Dr. Annie: Sure. So, I’m the mom of three kiddos and I have my entire career worked with disenfranchised populations. So people without access to services. My first internship, I guess it would have been a practicum experience in graduate school, was in a rural area where we brought testing into the community. And we went specifically for preschoolers.

And I remember being in homes that were Amish because that was how they got services. [00:10:00] We were in a really rural area and I liked working with juvenile justice a lot. I’ve spent a lot of my career bringing services to people by accident. It was just the way it was set up, up there. That was in New York. Then I had my own kids. I was working at the State hospital and I started noticing some things with my first son developmentally that things were a little weird.

I kept mentioning it’s preschool and they didn’t say anything. They thought it was fine. He was just a boy being a boy. He was a typical child, blah, blah, blah. And by three years into this, they told us we needed to get him evaluated for autism. He was four years old. He was in preschool at that point. We sat on a waiting list for 10 months before we could get in. And that was just for the intake. We got through the intake and testing process, which took another three [00:11:00] months. When we finally got our diagnosis, we had lost all that time in early intervention.

So, that was my impetus for wanting to start a private practice in our area. I desperately wanted to not have that barrier for people trying to get access to services for early intervention. And then it became really noticeable that there were not any practices in town that were doing psychological testing that also were taking all health insurance and serving particularly Medicaid. That was really important to me. So that’s how the vision started with trying to bring testing to everyone. Just really weird when we talk about a private pay practice, but we’ll get there.

Dr. Sharp: Right. Well, yeah, I think we will get there because I think that’s a common misconception for folks that not taking insurance or being private pay means you don’t provide [00:12:00] access. We’re going to put a pin in that and circle back to it for sure. But I think that motivation is the same as for a lot of us. It’s an access issue and we think that insurance equals access and then it does in a lot of ways. I know for me too, it’s funny looking back, like, I didn’t even know that you couldn’t not take insurance.

Like I just thought that’s what you did. This was whatever it was 12 years ago or something, and I was like, my doctor takes insurance and every medical professional I’ve ever seen takes insurance. So I’ll take insurance.

Dr. Annie: Yeah, I thought the exact same thing.

Dr. Sharp: I didn’t know there was another option. And then the access. Access is important. So I had that in my mind as well. I think a lot of people probably jump on insurance panels to have a [00:13:00] steady referral stream and perceived ease of building a practice as well.

Dr. Annie: Yes. And that was a fear when we first started too. I actually had no clue that we couldn’t avoid insurance in any way, but I remember getting the first phone calls and being like, “Yes, people are going to be cool.” We chose not to offer therapy here, which I think could have financially helped a little bit in the beginning possibly. But I remember how many people I had to tell that we didn’t take health insurance yet just because we were waiting to be paneled and all of them freaking out and going to another practice and all these things.

So yeah, it’s nerve-wracking at first. You have to be prepared with the vision that it’s going to look a certain way, but it won’t end up that way, hopefully.

Dr. Sharp: Right. So where did things go from there? I’m really curious [00:14:00] to dive into or to learn more about the tipping point. How did insurance work for you? Was it working? Was it not working? When did you start to think, maybe I don’t want to do this anymore?

Dr. Annie: That’s a good question. You can’t see me because this is a podcast, but I’m laughing because all of those things are resonating. Our tipping points came later than it should have, I think. From the beginning, I’m a very social person. I like to talk to people. And that was something I missed when I went into private practice, the colleagues’ aspect of things. And so, I did consult with you a lot in order to feel like I had both partnerships in building this process but also somebody that I could ask all these hard questions I have.

[00:15:00] I did the beginner mastermind group and then we did private consulting, and I started to notice a lot of my questions were focusing on finances. How do I do this better? We had initially started billing ourselves. Then we hired a billing company, which was wonderful, but we ran into a lot of problems and we noticed that we were not getting reimbursed very much.

So we went through problem-solving with them quite a bit over a 6-month process and then figured out that probably wasn’t the best fit for us company-wise, so we decided to move to a different company. No big deal. Everything was fine. But I was still noticing a cash flow problem. So then I brought on a therapist, and I had this vision that we could make a more holistic practice, but I’m a terrible therapist. I’m not going to lie. And it just wasn’t the right fit for us and for me, and for what I had hoped this would be, which is an evaluations-only center that would bring services for testing specifically to [00:16:00] everybody.

Then COVID hit. And at that point, we were two and a half years into private practice. We are two years into taking insurance. We were still not profitable.

Dr. Sharp: Wait, can I pause you?

Dr. Annie: Yes, please.

Dr. Sharp: You mean, you literally were not profitable at that point? Like there was zero profit?

Dr. Annie: There was zero profit after we paid salaries. Yeah, that was …

Dr. Sharp: Right.

Dr. Annie: So we were getting to a point.. we felt really proud though because we were getting to a point where we could make payroll. That was a big deal. And again, not knowing this, we sort of thought that that was part of the process. And it is. So our accountant always said, it takes three years to build a business. And so we were [00:17:00] just going by the, I say weeks, it was my practice manager who I don’t think I could live without, that was really helping me through this process at this point.

We were just kind of going with the, all right, we were originally unable to pay ourselves. Then we got on the panels and we started getting more referrals. And then that started to organically work itself out. I actually kept all my datebooks and it’s funny to look at the number of referrals increase. And then, we were able to consistently make payroll. And then we were able to consistently maybe do a little more than payroll and then COVID hit.

So, it was interesting timing because we had already been struggling and you probably remember that was a lot of our private consulting, but the reason that we were struggling was not because of a lack of referrals or because of the reimbursed, which is not great all the time, but it was more because the type of [00:18:00] evaluations that I enjoyed doing, that I really loved and that I felt I was best at and what made us stand out were not able to be reimbursed in the way that would have made it profitable. If that makes any sense.

Dr. Sharp: Can you give some details around that when you say the type of evaluation and why they didn’t lend themselves to the reimbursement you needed?

Dr. Annie: Yeah. And this is all with the caveat that it’s also possible that we never learned very well how to maximize insurance reimbursement and that we still were making mistakes at the end there. But we had a great billing company. We still do. We still use them because we still accept TRICARE, and they’re amazing and I love them. And they kind of helped us find some problems.

But in our experience, and this might differ from state to state, but in our experience, insurance is very good about reimbursing psychological testing specifically for [00:19:00] what I like to think of as ruling things out and confirming a diagnosis. So they answer the question. So we have an ADHD diagnosis that we’re trying to find out if this is accurate or not, and they will answer the question with us, right? So they’ll pay for those services, but I enjoyed answering the question and then the follow-up question, which is, is it ADHD? No. Cool. What is it? And I wanted to do more.

And so that was part of what was happening. I would give, not in every case, but in some cases, I’d want to give these big, long batteries to try to figure stuff out and the insurance company would stop us at three hours or whatever. And part of that might’ve been us, and part of it was lousy luck. We would especially have that problem with Medicaid.

Dr. Sharp: Yeah, sure.

Dr. Annie: Yeah, it’s hard.

Dr. Sharp: It is. So y’all were noticing reimbursement problems. And, I’m kind of reading [00:20:00] between the lines, like working more than you were getting paid for, like just not getting and being limited in the kind of work that you liked.

Dr. Annie: Yeah, working more than we were getting paid for, for sure. Kim, who is my practice manager, was following our reimbursement rates and there were several times we’d get $200 for the whole thing. We know some of that was billing problems, but even with the help of an expert billing company, we were struggling. So yeah, it was, it was interesting. It was a little challenging.

Dr. Sharp: You’re holding it together really well, but I feel like a lot of people would be freaking out.

Dr. Annie: Well, honestly, that Facebook group was really helpful because so many people post questions, and then I had the opportunity. I spoke to you, two other members of the Facebook community who were running private practice companies that only took insurance. And it was really, [00:21:00] really validating to speak to those two women who explained how they did it, how they made it work. It just wasn’t fitting with the way I worked, which was, you see 6 to 8 clients and you turn around 6 to 8 reports a week or whatever it was. And I was like, “Oh, okay, well, I am not that good.”

Dr. Sharp: Sure. I think that at least in my experience, it helps a lot to have a testing practice that takes insurance if you are doing a lot of volume or you have a psychometrist model or you are scaling. All those fit together.

Dr. Annie: Right. And you have maybe you’re billing for therapy because that can certainly,… there’s a practice in town that is lovely and they do testing, but it’s about 10% of their work and the rest is all therapy. They always say that therapy practice carries us.

[00:22:00] Dr. Sharp: Sure. So COVID hits and you’re it sounds like struggling a little bit with the reimbursement and cash flow and that sort of thing. So then what happens?

Dr. Annie: So when COVID had it, we always chose to look at the bright side, and one thing that was positive for us was that because we had to shut down, we were able to deep dive into our books and figure out exactly what was going on. And so we used that time to really look at every claim, every reimbursement, and then to come up with averages. What are we averaging from each company? And at the same time, I’ll be honest, I was simultaneously applying for jobs because I didn’t know if this was going to work.

Dr. Sharp: Oh Geez. I did not know that part of the story.

Dr. Annie: I was thinking this wasn’t going to work. And so we started deep diving into books. We use the spreadsheet that you gave me. Thank you for that. And we realized that [00:23:00] we just weren’t going to be able to do it, not at the salary that is not even a good, I mean, it’s a great salary. I’m not complaining. But not even at the salary I was attempting to pay myself, which is just what we needed to kind of make the bills, so forget profit.

We had to have an honest discussion of… Oh, and at that point, I forgot this part of the story. We had hired a therapist and we made the decision that that wasn’t mutually beneficial. She wasn’t getting what she needed. We weren’t getting what we needed. And so she had moved on. So there was that income stream too.

So, we decided that we were facing the decision of closing the practice or switching off of insurance. That was the decision we had to make because we couldn’t sustain both.

Dr. Sharp: Oh my God. That feels heavy.

Dr. Annie: Yeah, It was a little heavy. And then there was like, Oh God, it’s crazy.

Dr. Sharp: Oh my God, what did that decision [00:24:00] making process look like? How’d you go about solving that problem?

Dr. Annie: A lot of it was just a hard look at the numbers and really breaking down what we needed for overhead per month, which was surprisingly hefty, and very interesting to do when you’re unable to even use your offices. I think it was really the first time that I had thought about, we’re paying money to make money, right? Like sort of seeing it in that way and not worrying about paying the rent separate from paying Kim separate from paying myself.

So putting it all together and seeing that on a spreadsheet was really eye-opening and disturbing. And then, we followed a process. I [00:25:00] mean, Kim is a budgeter by nature and we figured out what we needed to make per month. And then how many insurance testing cases that would be. And there was no way we could do it and sustain it. So that was when we had that hard conversation of, okay, I think we need to make some major decisions here.

Dr. Sharp: Right. Now, were you working with an accountant during that time, or was it, Kim? I mean, is that just part of her job as the office manager?

Dr. Annie: It’s funny. It wasn’t intentionally part of her job. We do have an accountant and we were not working with her. However, if I didn’t have Kim, I would have been working with her. Kim, her background is in budgeting.

I will tell you though, I was awful at seeing that. It is not the way my brain works and I would never have figured that out without seeking help from an outside person. So I [00:26:00] think, if you end up deep diving into your own books, your accountant or your bookkeeper is where it’s at. That was 100% necessary.

Dr. Sharp: Yeah, I couldn’t agree more. I consider myself fairly math adept and comfortable with numbers, and so forth. But yeah, getting a really good accountant or bookkeeper has been a game-changer, the way that they can break down the numbers. I don’t know if this applies to you, but for me, it was super helpful to have someone external who would take the emotion out of it. And just, it’s like black and white, this is what we need. Here’s what we’d have to do to make that money. That’s it. There’s no emotion. It’s just facts and now we can work with them. I don’t know about your experience.

Dr. Annie: It’s exactly right because our heart is in our business. I remember every new consulting experience with you, we start with, [00:27:00] what is your major goal? And I’d always say, “Oh, I want to bring testing to everybody. That’s what I want to do. I want to just be ease of access.” And when that’s what you’re worried about and focusing on, or the kiddos that you’re serving or you’re worried that Johnny next month is not going to get his IEP if you don’t help, this part is really hard. So yeah, I agree. Working with an outside person who knows money is good.

Dr. Sharp: It helps. Well, I think a lot of us have that. I think a lot of us struggle. The emotional part is huge. 

So you look at your numbers and you make this decision. I’m curious about the process of figuring out, Hey, going off insurance is a better choice than closing the practice. How did you ballpark what you would be bringing in as a private pay practice when you hadn’t really done that before?

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Dr. Annie: Great question. I think I just was winging a prayer. No, I really, really didn’t want to close [00:29:00] the practice, but I knew, so we’re a two-income household and we have to be, it’s not by choice. Well, it is by choice. So we knew we had to do something so that I had to work. When we looked at the number of insurance evaluations we had to do, I didn’t think it was sustainable and I didn’t think it would be a comfortable life plan for me to try to bang out that many evals and things like that and then also, still have the fun that goes along with having a private practice, which is, being able to take your kid to school or whatever.

So, we looked at numbers, then we started doing some research into what other people were charging, which was really fun because nobody wants to tell you that. So we would cold-call other agencies and find out, and then so many people are kind and put their fees on their website. So that was helpful. And [00:30:00] then we looked at, of course, demographically. These guys are in Atlanta, Georgia, and we’re here in Williamsburg, Virginia, what could that comparatively mean? And figured out what we thought was a fair rate, which we actually very quickly increased, but I’ll get to that.

And then, lastly, and this was just my choice and I don’t think we had to do it this way, but I also chose to seek out some contracts so that I had a steady stream of something just in case things went south. So, we have contracts with a couple of residential treatment facilities to do testing for them. Then that just made me feel better to know that that was there just in case.

Dr. Sharp: Of course. I’m glad you brought that up. I know that’s been a big part of your practice over the years. I want to highlight that because people think it’s either I take insurance or I go all cash payments, but these contracts, if you can get a contract, there are a [00:31:00] number of contracts with different entities that pay at or above market rate, and it’s pretty easy to do the billing, and it’s simple.

Dr. Annie: Oh, it’s wonderful. I had one residential contract when we first started. And that was what made me feel comfortable taking the leap into private practice from a state gig. It’s very wonderful, and not something I think that we think about a lot because we’re not business-minded maybe. We have six now.

Dr. Sharp: I was going to say, what kinds of contracts have you sought out?

Dr. Annie: So, the one that I accidentally got was through just a friend of mine who is retired from other types of psychology work and she has just been testing for a residential. And so she introduced me there. That was the first one I got. Then I got a second residential because of the first one. [00:32:00] Then we got a third residential. It’s very interesting. If you know local residential treatment centers or other kinds of things for children, group homes, things like that, if you go on their websites, often you’ll see something that looks like they’re looking for something with testing, but it’s never a clear ad. That’s what I found anyway.

So I cold-called one and just said, Hey, I’m not looking for a full-time job, but I’m a psychologist. I specialize in testing. That was kind of a neat way to do it too. So kind of networking and knowing that this was a service they offered and then asking if they needed more people just being a little obnoxious was helpful.

So, that’s how we got these residential treatment facilities. And then, we ended up getting some contracts with school districts. We did some of that. [00:33:00] This might be a little too much in the weeds, but we also, on Dr. Jeremy Sharp’s advice, by the way, got a relationship going with a local training program. And so we started being… that’s brand new… so we started working with the local school. And that got us hooked up with another contract, which is working pretty closely with their law school to do some educational testing for cases that they’re doing educational advocacy work for.

All of that kind of culminated into my last contract, which we’re trying really hard to work at now, which is with county mental health. They don’t have a psychologist. And in many parts of the country, I think that that’s a problem. So county mental health agencies either can’t afford or can’t hire or can’t find psychologists. So they’re looking for some help in that area too. So if you just kind of pop in and do some testing and pop back out, it can be a good income stream.

Dr. Sharp: Sure. [00:34:00] Well, I want to point out, I don’t know if this is your experience, but for me, there’s a trade-off where like maybe the rates in the contract are slightly lower than your out-of-pocket rates, but it’s guaranteed and it’s easy and you’re not filing claims and calling and all that nonsense that goes along with insurance sometimes.

Dr. Annie: Right. That’s probably the most important part to point out about that work is that it took all the leg work out of the hard part about getting reimbursed. Juvenile Justice is another great place to look for contracts. We work with them too. All we have to do is an invoice and it’s so much easier. And there is a trade-off and it’s definitely lower than a private pay rate, but it is so worth it. And another wonderful way to bring services to kids who may not otherwise get services because they’re getting it covered through another agency.

Dr. Sharp: Well, I wonder, [00:35:00] is that the place where we start to dovetail with this access question? I’m curious how you worked through that for yourself in this decision to go off of insurance panels, like how were you thinking about access during that process?

Dr. Annie: My original dream was that we could stay on Medicaid, but in the state of Virginia, Medicaid is all managed. And so in order to take Medicaid, I had to also be on Blue Cross Blue Shield or whatever. So that was kind of heartbreaking. I talked a lot to my mentor who said to think about how we’re providing access through services like the residentials and Juvenile Justice and all that stuff. And that was helpful. And it helped me feel better. And I do like that because you also get a lot of autonomy with testing through those kinds of contracts.

And so [00:36:00] they may be wondering if a child has autism, but they’re certainly not going to get upset if you also look at a learning disability because you think that that’s happening too. And that can bring a whole world of access to kiddos. So I do like that. But still, it didn’t feel like enough. And so, we started exploring the idea of pro bono services. That’s actually how we try to cross the access barrier right now is through pro bono testing.

Dr. Sharp: How did you figure out if you could do pro bono or how much you could do? And is it truly pro bono? Like for free?

Dr. Annie: Yeah, it’s truly pro bono. We’re still increasing our numbers. So right now we’re just at one per clinician, but I will say, and maybe we went a little backward here, but within three months of making the decision to go off of [00:37:00] insurance panels, we became profitable. And very profitable very quickly. And we figured out we had enough projected profit to hire. So we hired a second clinician, and then a third. And this is all within the last year. This has all happened. It’s crazy.

Within those first three months, we were able to see, okay, we may be able to spend two days a month doing work for free because we’re okay. We don’t have to spend every minute billing for billable time. So, that was eye-opening in the first three months. Within six months, I took my first pro bono case. And then within nine months, it’s a regular thing now. And we do limit it. We do try to do only one per clinician per month for high-needs cases. [00:38:00] And it’s worked really well. But we’re working in conjunction with the local county mental health and then hopefully a grant process so that we can continue to build this access. We can do that because we’re not going broke, which is great.

Dr. Sharp: Yeah, that helps. Not going broke gives you a lot of freedom to do a lot of things.

Dr. Annie: Which is even better.

Dr. Sharp: Yeah. Well, I know people can’t see your face, but it is clear that this is so meaningful and joyful for you to be able to provide access in that way to kids. So how do you figure out who gets the pro bono evaluations?

Dr. Annie: That’s a great question. We do need to work on that process a little bit better, but right now it’s been… so I like to do networking because like I said, I’m social and weird and I [00:39:00] get lonely.

Dr. Sharp: That’s not weird.

Dr. Annie: When I have clients with therapists or I will call the therapist and make connections and all these things. And right now it’s just been word of mouth. We don’t want to put it on the website because then it becomes a whole thing. So it’s just been word of mouth for really high-needs cases that are coming from a referral source. So whether it’s a county mental health or an attorney, maybe a school district, it says, we’ve done our testing and it’s maybe not a naive case, but we partner pretty closely with them or law enforcement. So it’s the director for all right now from another provider.

Dr. Sharp: I see. And are you doing, this may be too, too detailed, but are you doing like income checks or anything to determine… Are these folks with insurance who just can’t afford it? I’m just [00:40:00] curious about the details.

Dr. Annie: Oh, sure. No, we’re not. And that’s still part of the maybe we’re just being a little lazy. Because they’re coming directly from another provider, when we gather information, we ask those questions, like why are you referring this case? And so we rely on that data to tell us. And because we know these are trustworthy resources, they’re not just a physician from down the road calling, it has pretty organically worked out, but if we get grant money to continue to expand that process, obviously we’re going to have to do more, I think, to verify that.

Dr. Sharp: Of course. That’s fantastic. Like I said, that’s a big hurdle for a lot of folks as being concerned that you wouldn’t be able to provide access to some kids, but it sounds like you’ve really found a way to do it. That’s amazing.

Dr. Annie: Thanks. [00:41:00] Related to access, a lot of people feel very strongly that people won’t pay this or they’re not going to be able to in my area or different things like that. And I felt that way as well. I felt that we had a small percentage of our population that would pay for it, but that most people wouldn’t. And I am very surprised that I’m incorrect. As long as you provide some education and alternative ideas that when faced with this question of, do I want to go with this agency that I have to pay out of pocket but then this other stuff can happen or do I want to go with this other agency where I can take insurance?

We do well with retaining our clients. And I think that part of that is related to helping them to understand the value of the service [00:42:00] and why it’s different than they might get at a different agency, but also just explaining how superbills work, helping them with a superbill process, helping them understand the use of HSA cards. We’ve had families use adoption subsidy funds getting it through… There are all kinds of things in Virginia, but there are often financial services to cover uncovered services for children who are coming out of foster care or another high-risk situation.

So we really explore with our clients many different ways that they can cover the costs without paying out of pocket. And then we go to the paying out of pocket and then we work on payment plans and things like that. So I think you can’t just say, we’re going to go private pay and everybody’s just going to pay us. There’s a lot with client care that I think comes into with retention of our clients. So, that was helpful too. We had to figure that out.

Dr. Sharp: Oh, sure. Can you [00:43:00] speak to how you communicate that value, that component that you mentioned, why would I go to this private pay practice versus the insurance practice down the road? How are you sharing that or selling the service?

Dr. Annie: That’s a great question. It is 100% in sharing your vision with the person who answers your phone and having that person be just as excited as you are. I remember consulting with you about talking about the script for when people answer the phone and how important that first phone contact is with people.

We also started doing, which I know came from a recommendation from you, but also I’ve seen it on the Facebook page, 15 minute consultations with me for free before they book. And that’s just a wonderful way. I always say to them, I will be doing myself a disservice if I sell you something you [00:44:00] don’t need.

So I just as easily turn people away as I do book them. And I think those conversations are really helpful. And the clients feel like we’re connected to them and we’re really not going to do it if we don’t think we can do the best job. We’re also pretty small. And I think that that helps because it’s easy for us to be pretty personal. When our person who answers the phone talks to the client, if they come to me and they say, it feels like I was talking to a friend, it feels like she really understood and she wanted this to happen for me if we wanted it. I think that’s been really helpful too, but it’s a lot about that initial contact.

Dr. Sharp: Sure. It sounds like there’s a, what’s the word, culture piece in your practice that everybody’s bought in like everybody is on board and [00:45:00] I don’t know that you can… well, I think you can teach that actually to a degree. You can communicate that and hire well and make sure people share your values, but it sounds like that’s an important component.

Dr. Annie: Yeah, it certainly feels like it. Those first initial calls with clients are I think what makes people feel heard.

Dr. Sharp: Sure. Let me backtrack a little bit and just ask, how did you get off the insurance panels and how long did that take?

Dr. Annie: It’s a good question. It took 90 days approximately. I learned that the way to do so is by writing a letter. This might be too in the weeds, but honestly, it would have been really helpful if I understood this at the time, but often when you’re getting on a panel, you have some human at that insurance company that’s your contact and they’re emailing with you or your practice manager, whoever.

And I [00:46:00] had, like most of us, saved a bunch of my emails into a folder that’s labeled insurance. So I wrote the letters that I was supposed to write. And it said I want to get off the insurance. It included our EIN number and all that stuff. I’m happy to provide a copy of the letter if it would be helpful to anybody. And then I went back to those old emails that had various information, and I just emailed the people directly and said, Hey, I want to get off insurance. What do I do? And every time I got a response. It was really helpful except for one which is notoriously non-responsive in our state.

And I did call the provider number and they told me what to do, which in that case was fax a letter. So, it’s easy. It’s simple. It’s just not easy to find out how to do it.

Dr. Sharp: Right. But you found that it really did work. The 90 days [00:47:00] held true?

Dr. Annie: It did. And we were very fortunate because we were still working with our billing company and they were incredibly helpful. What they did was they would just call the insurance company and find out if we were unpanelled but I could’ve just as easily done it myself. It didn’t feel like something I needed somebody extra to do. And even with all our amazing administrative support here, I did all that myself and it was fine. I’m not very good at complicating stuff.

Dr. Sharp: Okay. That’s fair. So during those three months, what were you doing? How did you prepare? Or did you prepare? What was happening during those three months?

Dr. Annie: It was insane. It makes me laugh to think back on it. If Kim was here, she would laugh really hard and then probably fall over and run screaming. So along with [00:48:00] access to services, I couldn’t stomach the idea of, because, like many of us, I always thought I’m never going to have a waitlist. It’s going to be amazing. And of course, I had like a huge waitlist and clients booked out till eight months, whatever it was. It was really far.

And so when we decided to get off panels and we sent in our letters and we had written on our calendar check, Blue Cross Blue Shield, you’ll be off on which date it was. And so every client that was scheduled, we booked into those three months. So, anybody who had already had an appointment, we moved them up and it was insane.

Dr. Sharp: Oh my gosh.

Dr. Annie: Yeah. That’s what it would’ve felt like if I sustained the practice insurance only. It was crazy. It was really uncomfortable, but it reminded me a lot of when I made the jump from this full-time state job to private practice, which for me, just because of the way my brain works, I worked my 40 hours at the State and then I would work [00:49:00] 20 more building the practice and then I could make the leap. That was what we did.

And this was advice from another person on the Facebook page that I did consult with, I keep gesturing to the wall. You can’t see my calendar. In addition to moving all the insurance cases up, we also developed a philosophy with private pay clients. We wanted to serve them as concierge as we possibly could. And that meant seeing them as soon as we could. And so we’re seeing 100 million insurance cases and then also immediately booking our private pays within a month. So it was nuts, but we survived and it was fine.

Dr. Sharp: Oh my God. Yeah, that sounds completely insane. So what was your private pay referral stream like before you got off insurance panels? Like what percentage?

Dr. Annie: 0%.

Dr. Sharp: Okay.

Dr. Annie: Yeah, we did not do [00:50:00] any private pay cases before that.

Dr. Sharp: Got you.

Dr. Annie: That’s not true. I think I might’ve done one and it was just because I don’t know why they didn’t want to use their insurance, but yeah, it was 0%. What we chose to do before sending a letter to insurance was to reach out to all of our referral sources and explain to them. I used hard data. I would call the physicians and I talked to practice managers or the physicians themselves or the therapist or whoever. Therapists were great because they really understood this stuff cause they did too.

And I said, we billed at $80,000 in the last X number of months, we recouped $22, 000, and we have tried every avenue we can think of to fix this problem. So we’re going to make this move to a different model. We want to still be able to support you if we can. If you have an urgent case, that’s really, really not going to be able to pay out of pocket and you just [00:51:00] really feel like you want to partner with us on it, let us know. So that’s the pro bono thing.

Most people did not take advantage of that. They were wonderful. They were so supportive. We followed up with a letter explaining all that stuff again, and also explaining why we felt we stood out from other practices that take insurance in our area, not just in our area. That sounds terrible. I’m not criticizing anybody, but what made us stand out, we thought.

Dr. Sharp: What were some of the things that you feel made you stand out or make you stand out included in the letter?

Dr. Annie: Probably a big part of it is these values that we keep dancing around. The desire to really understand the child as a learner and as an emotional being in the world. [00:52:00] And wanting to do whatever we need to do to deep dive and figure that part out, and partnering with parents and schools in that process. Collateral work is hugely important to us. And not just quickly assigning or not assigning a diagnosis, but more explaining all of it. I think our reports are pretty thorough. We do the backward pyramid thing, and just really try to include as many important people in that kiddo’s life as we can.

Private pay allows us to do a couple of things that are a bit a step further than you can do with insurance. So for example, I love to do in-person observations, but that’s hard to bill for, and especially when COVID restrictions started to lift them, we were able to see kids again, we’ll go to the dance class. We’ll go to T-ball, we’ll go wherever to do our [00:53:00] observations. And I think those little things are fun and they make you stand out to other providers. Maybe parents don’t realize that’s weird, but kind of little stuff like that. But the providers were amazing and they were so supportive.

And then we found that they would set the stage for us because they would explain it to their clients, and say, oh, insurance can really suck sometimes. They weren’t getting reimbursed, so they do this but do it anyway. They’re going to help you get in… The superbill thing is huge. They’re going to help you with getting as much reimbursement as you can get. And it wasn’t a problem, but it was really our partnership with referral sources. And they weren’t close personal friends. We don’t really know most of these people.

Dr. Sharp: Sure. I’m so glad that you’re talking about this because I think this is a huge hurdle for a lot of folks in going private pay is I will disappoint my referral sources or [00:54:00] nobody will refer to me, or people are going to think I’m greedy or people are thinking I’m going to think I’m selling out or whatever it might be.

So I appreciate you articulating how you went through that process. You’ve used the word values so many times and I love that. It seems anchored. When you have clear values that resonate with others, you can do a lot. That gives you a lot of flexibility because people trust you.

Dr. Annie: Hopefully, so. I think that’s true, but it sort of stops you from maybe wanting to do the things that we always sort of picture about, you know, greed or pushing your services or doing whatever. I would say probably a list of maybe 30 referral sources, and most of them, we only get one a year. They’re just these random therapists or whatever, but we reach out to every single one of them.

There [00:55:00] was just one that was ticked off that we went to the private pay route. And once we really had to sit down because I felt bad about that. Even she came around. I was very surprised. Everything about this journey has been surprising and not what I would’ve expected hearing some of the fears that we think are real about it.

Dr. Sharp: Sure. I want to ask about any other surprises that you’ve encountered, but I want to hold that for just a second and ask just very practically when you contacted the referral sources with this announcement, was that a phone call? Was it a letter? Was it an email? Was it a fax? How did you get that information out there?

Dr. Annie: All of the above. So if it was a referral source that we work with super frequently, I called. [00:56:00] If it was somebody that we also have email contact with, we would send a follow-up email. And if it was like most of the people that we don’t speak to as much on the phone but maybe we email or fax records back and forth or whatever, we just sent a letter in the mail, an actual letter, and then an email copy of that letter and fax if they had it. So we did all of it. I remember we did it over Christmas break. We shut down for like a week and mailed letters.

Dr. Sharp: Sure. I’m going to get back to the surprises questions. What other surprises did you run into during this process, either positive or negative?

Dr. Annie: I was just astounded at the financial difference. It was [00:57:00] just mind-blowing. And it made me kind of sad, but that was one really nice surprise, and the comfort I felt in the ability to do what I love to do without worrying that I couldn’t pay myself a paycheck because that was real for us for a long time.

I was shocked. I mean it. Just shocked at how many people were willing to pay. It really was so surprising to me. And I was very surprised at the power that word of mouth has when you know you can put your time and energy into a really good product and then how far that reaches.

Another wonderful referral source that we discovered that we didn’t work with before is private schools because when you are billing insurance, often you can’t do straight LD testing or whatever. And so that became another [00:58:00] great partnership and place for referral sources. So those kinds of things really surprised me. I was really surprised at how well received we were by the local physicians and staff too. I was for sure thinking that that was going to be a nightmare. But it was great.

Dr. Sharp: Yeah. It’s really cool to hear that. Looking back, is there anything that you would have done differently or advice for somebody who might be considering taking the leap as well?

Dr. Annie: I wouldn’t do anything differently. I wouldn’t go backward and do anything differently. I know a lot of people say, I wish I had done it sooner. And my pocketbook does wish I had done it sooner because I think it would have just been a little bit less frightening to be in private practice, but I’m glad we made all those mistakes and I’m glad we took insurance for as long as we did because that allowed us to build up that referral source. If we hadn’t taken insurance, nobody would have known us.

[00:59:00] So I think that it’s an important part of making the choices, maybe knowing your audience and how long you’ve worked to build relationships in the community. To be clear, we haven’t been around very long, so it’s not like we have a 15-year relationship with these people. It’s just that it worked really well. So, that’s one part of my thought for anybody thinking of doing this is really being confident in your referral sources and knowing that you’re delivering a good product no matter who is paying for it.

I think the other piece is being clear on what your purpose is, not a philosophical purpose, but if you want to move off of panels but you have this design to do whatever it is, for me, it was serve Medicaid and [01:00:00] other access issues, to figure out those ways beforehand so that you’re ready to rock. I think you can do that through brainstorming with yourself or your team, but I also think consulting can be really helpful for that. Just going back and forth with other business owners to say, how could I do this? If I really wanted to do this, how could this work financially? And get that on paper beforehand because you’ll feel more comfortable.

And then lastly, if you’re a person like me who needs a little bit of stability and can’t just go willingly, maybe think about finding just one contract where you know you’re going to get paid so that you’ll feel better.

Dr. Sharp: Yeah, I think that’s an important point as well. It doesn’t have to be all or nothing. It’s not all insurance and or all private pay. You can do a hybrid or you can do it slowly. Like you don’t have to get off all the panels at the same time.

[01:01:00] Dr. Annie: Oh yeah. My practice manager, Kim, was realistic to me because I want it to jump off of everything at once. We were a little sub. We did it over a month, but I will say, and I mentioned this very briefly and forgot to highlight it, but we still take TRICARE because we think military families have enough to deal with. They don’t need to worry about private paying for things too.

That also is reassuring because we also know, well, that’s one insurance panel that will pay even if we didn’t have the contracts and nobody else wanted to pay. So maybe keep one for a while.

Dr. Sharp: Sure. There’s so much good stuff in this conversation. I feel like we’ve covered a lot of ground and I’ve been taking a lot of notes. I hope that people are taking quite a bit away from our discussion here. And if nothing else, you’ve given some people some confidence to consider this leap. It seems like it’s working for you.

Dr. Annie: It is. It’s wonderful. [01:02:00] It’s exactly what I envisioned when I opened the place, except better.

Dr. Sharp: Amazing. That’s what you want to hear. Oh my gosh. It’s so cool to see where you have landed. I know it was a journey, but here you are. It’s really cool just to see everything you’ve got going on.

Dr. Annie: Thank you so much. And truthfully, I have to just drop my plug for you that I really could not have done any of this without your support and all of your consulting work with me over the past two and a half years. Just saying. He did not tell me to say that.

Dr. Sharp: I’m glad people can’t see us. I’m blushing. No, thank you. It’s been a joy really. And like I said, awesome to come full circle and let you share your experience with other people because I think it encompasses a lot of feelings and [01:03:00] hardships that others have gone through. I’m glad you came back. Glad you’re doing this.

Dr. Annie: Thanks.

Dr. Sharp: Yeah. So thanks for everything, Annie. We can chat about any resources that you mentioned and maybe including those in the show notes, but if folks do want to reach out to get in touch with you, one, are you open to that? And if so, what’s the best way to do that?

Dr. Annie: Absolutely. Yeah, that would be fun. I am more than willing and I will give you my email and you can share for people.

Dr. Sharp: Okay. That sounds good. All right. Thanks so much. It was great to talk to you.

Dr. Annie: Thank you too. Bye-bye.

Dr. Sharp: Thanks for listening y’all. I hope you enjoyed that conversation with Annie. I definitely did. I love talking to her. I love her energy and I think she’s doing great things in that practice. Hopefully, you’re taking some inspiration and some ideas for how to [01:04:00] incorporate more private pay and private pay adjacent services in your practice. I know a lot of us wrestle with this idea.

Thanks for listening. If you are interested in taking your practice to the next level or even getting your practice to a level, we’ve got open cohorts of the Beginner Practice Mastermind and Advanced Practice Mastermind. You can get more information for each of those at thetestingpsychologists.com/advanced and thetestingpsychologists.com/beginner. I would love to chat with you to see if either of those could be a good fit depending on where you’re at in your practice.

All right. That is all for today. Hope you’re all doing well. Getting ready for the start of the school year. That’s the theme in our house right now. By the time this is released, we might even be in school. [01:05:00] We will see. So thanks as always for listening. Love y’all. Take care.

The information contained in this podcast and on The Testing Psychologists website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. Please note that no doctor-patient relationship is formed here. And similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you [01:06:00] need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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[00:00:00] Dr. Sharp: Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

This episode is brought to you by PAR. The Feifer Assessment of Writing examines why students may struggle with writing. The FAW and the FAW screening form are available on PARiConnect- PAR’s online assessment platform. Learn more at parinc.com\faw.

Hello, everyone. And welcome back. Glad to be here with you. Glad to be back with another clinical episode, the first in a long time. So today I am talking with Dr. Jen Engle all about assessing motor-impaired children.

Let me tell you a little bit about Jen, and then I’ll tell you [00:01:00] a little bit about the episode. Dr. Jen Engle is a pediatric neuropsychologist who works at BC Children’s Hospital in Vancouver, Canada. She is Board Certified in pediatric neuropsychology through the American Academy of Pediatric Neuropsychology. In addition to providing direct neuropsychology services, she offers training and consultations for psychologists who wish to develop their expertise in special populations, particularly children with neuromotor conditions and children with visual impairments.

Jen has also written an ebook with several strategies and guidelines around assessing motor-impaired kids and visually-impaired kids. That’ll be linked in the show notes. I invite you to check that out. Jen was so kind and such a fantastic guest. She was super knowledgeable.

We cover a lot of ground in this interview where we’re talking about a [00:02:00] number of things related to assessing motor-impaired kids. We talk about what that even means. So some definitions and etiology of motor impairment. Different types. We talk about why it’s important to make accommodations for this population of kids. We talk about which tests Jen prefers for kids with motor impairments. We spend quite a bit of time talking through how to break standardization, when to break standardization, what to do with that data once you have it. We talk about interpreting the data. We talk about different strategies for setting up the room for kids who may have motor impairments.

So we cover a lot of ground and I think there is a lot to take [00:03:00] away from this episode. Even if you are not going to specialize in working with this population, you’re actually the perfect audience because this material is really aimed at school psychologists or clinical psychologists who may see these kids in their practices and want some handy knowledge and strategies to make sure that we’re doing the best job that we can.

So without further ado, I will give you my interview with Dr. Jen Engle.

Hey, Jen, welcome to the podcast.

Dr. Jen: Thanks. Happy to be here.

Dr. Sharp: Yes, I am happy to have you. I am [00:04:00] amazed at all of the topics that we still have not covered on the podcast even after 200 plus episodes. And this is absolutely one of those topics. I am so glad that you’re here to talk with us about assessment with motor-impaired kids.

As usual, I want to start with this question of why this work, in particular, is important to you out of everything that you could do within assessment or psychology?

Dr. Jen: Well, I work at BC Children’s. It’s a tertiary care center in Vancouver. And part of our mission is to help build capacity in the community for people who care for children. In this case is, these kids can come to the hospital. We do have special programs for assessment for kids who are deaf or hard of hearing or visual impairments or neuromotor conditions, but we’re not really able to serve [00:05:00] all of the kids in the private province, especially those with neuromotor conditions. There’s a lot of them. And actually, I think that they’re really best served in their home community by their home psychologist who can do things like classroom observations that I’m not able to do at the hospital. And also to save these kids who often have complex medical conditions from traveling. So the idea behind this project of mine was to help build capacity in our community for these kids to be seen in an accurate and meaningful way in their home community by building the capacity in the psychologist.

Dr. Sharp: I love that mission, if you want to call it that, that’s bringing services to the kids who need it the most and probably have a harder time accessing it. That’s amazing.

Dr. Jen: Yeah.

Dr. Sharp: Well, I feel like there’s a lot to dive into and I will undoubtedly [00:06:00] ask a number of naive questions as we go through this conversation, but let’s start at the beginning. We’re talking about motor-impaired kids. You used the phrase kids with neuromotor weaknesses, I think, or deficits. So what does that mean? What are we actually talking about?

Dr. Jen: Neuromotor is a broad term that means any kind of developmental or acquired disorder that affects things like movement, posture, motor ability, but it’s caused by damage to the central nervous system, the brain. And well, it’s not a spinal cord-only injury. That’s just different. Although functionally, the kind of adaptations we might make for motor impairments would be the same, but the conditions that we’re talking about, the reason why they’re coming to us in psychology is that it affects the brain.

So it’s the brain plus motor condition. Cerebral palsy being the number [00:07:00] one in children that we see the most often. That’s the one people probably know the best which is something that is basically a non-progressive abnormality of the developing brain which usually is from the prenatal or perinatal period.

Dr. Sharp: I got you. Is there anything else you could add as far as the etiology of cerebral palsy and how that comes about?

Dr. Jen: Yeah, probably the most common cause would be children who were born premature and their brain is really vulnerable to a bleed. That can happen around the time just after birth when they’re really vulnerable and there are all kinds of things going on in their brain and their body and their lungs. But there can also be, for example, a stroke that happens prenatally or postnatally. All of those, if they happened around that time and [00:08:00] cause the motor dysfunction would be called cerebral palsy.

Dr. Sharp: Sure. I know it’s maybe beyond the scope of the podcast to really get in the weeds as far as the neurology and everything that’s happening there but are there any other primary drivers for some of these motor impairments we might see or that you see?

Dr. Jen: Yeah, that is the biggest group other than what we could see any acquired injury, brain injuries may lead to motor conditions like hemiplegia with a brain injury or quadriplegia. Those are the conditions that happen from birth. And generally, the kids I’m talking about in this presentation are the ones who’ve had lifelong conditions and developmental. And [00:09:00] most of them will have not most of them, but with the kids that I’m talking about doing this assessment with where you have to do things really differently, are the kids with really severe cognitive impairments. You can have acquired conditions like that, but it’s different from intellectual disability when it happens in an acquired way.

Dr. Sharp: Of course. I know there’s a broad spectrum of impairments that might result, but is there any way to generally describe when we say motor impairment, what does that actually look like in real life?

Dr. Jen: Yeah. Some of the terminologies that people have heard probably, let’s just go over them. One that’s common is hemiplegia- so that would be one side of the body affected i.e, right arm and legs sometimes it’s the right arm worse than the right leg or vice [00:10:00] versa. The second most common probably is quadriplegia- so all four limbs are affected. Less commonly would be diplegia- so that’s usually just the legs affected and would affect our testing a lot less if they’re able to use their hands effectively.

A lot of kids with hemiplegia or hemiparesis can use their hands pretty functionally. It can be from anything from just like discoordination or shakiness or weakness in their hand to really a full completely… their hand is so spastic or tight, they can’t move it for anything in the assessment. So the range is huge- from kids who can only use their eyes to communicate to those who just have some kind of weakness in their hands.

Dr. Sharp: Sure. And you have worked with kids that run the gamut, it sounds like.

Dr. Jen: Yeah, we do see them all.

Dr. Sharp: Oh [00:11:00] my goodness. I know we’re going to really dive into the accommodations and different ways of working with these kiddos, but just right off the bat, it almost sounds like two different worlds in a way, like working with a kiddo who has maybe a little tremor or some weakness in their hands to a kiddo who can only communicate with their eyes. That’s a wide range of presentations that we have to be mindful of.

Dr. Jen: Yeah, and often, because the problem comes from the brain, it’s not just motor functioning. So that’s the thing. It goes along with cognitive impairments and social, emotional delays, epilepsy, often learning difficulties in general, sensory, often you see visual impairments particularly critical cerebral visual [00:12:00] impairment and also hearing impairments. So you can have any and all of those together.

Dr. Sharp: Right. Well, I know that the ebook that you put together has several sections and you get into each of these areas. And I think it’s too much for us to tackle just on an hour-long podcast, but just for folks to know that that is out there, we’ll link your book in the show notes.

We’ll try to focus just on adaptations for motor impairments here today, but it seems complicated right off the bat. I’m like, “This sounds very complicated.” And how in the world are we getting accurate assessment results with some of these nontraditional presentations maybe is a word for it. I’m sure there’s a better term for it, but non-standardized administrations maybe. So yeah, I would love to dive into the actual assessment [00:13:00] process. So maybe we start big picture. I know you work in a hospital setting, so what are the referral questions? Do you even have referral questions or is it just assess this kid and tell us what’s going on?

Dr. Jen: Usually in this clinic, it is pretty broad needs and assessments. Sometimes it is specific to accessing community supports, getting that diagnosis of intellectual disability. Other times it’s about the school wanting some guidance on either what program they should be in like a life skill versus academic, or just wanting some guidance of how to reach them, how to engage them, what to expect of them. Sometimes they come like a little mystery of help us understand this kid. Again that’s pretty broad. [00:14:00] Yeah, they are often very broad as the referrals.

Dr. Sharp: I’m sure. Can you walk me through the clinical decision-making process then? When you get one of these referrals, how do you tackle an assessment like this? Where do you even start with a broad question like that?

Dr. Jen: Well, at the hospital, I’m lucky that I have access to all their medical records here. I can review that at my first stop. And then next step is we collect information from the family and the school. They fill out lots of questionnaires for us. And then I do interviews with the family and sometimes with the school as well, and make my initial plan for this assessment from there. That helps me to narrow down the question of what I’m focusing on and also get to know the child.

I need to know the basics of like what their motor abilities are, [00:15:00] what is their communication like? Are they using words or gestures or a communication device? And what’s their capacity? Some kids can really only handle 5-10 minutes at a time, whereas other kids can handle a full assessment. I need to try to figure out as much as I can ahead of time about that, but I also need to be super flexible so that I’m ready for anything when they get there. And I usually will pull a whole bunch of different tests than the room just looks like stocked with staff so that I can quickly go, oh, this isn’t working, and then switch to something else because as much as I try to be prepared, I don’t always know what I’m doing until I get in the room.

Dr. Sharp: I can imagine that. So it sounds like right off the bat, flexibility is key in being ready for anything. Okay. So you’re [00:16:00] combing through records. You’re talking with the family. I think of just traditional outpatient evaluations where we are meeting with the family or the parents on a separate day for separate intake. Is that the way that you approach it as well?

Dr. Jen: Yes. Traditionally, before COVID, always been able to do that but now it’s routine certainly as prior to COVID that we do virtual meetings ahead of time and I won’t go back. That’s been fantastic to be able to do that in advance. And a lot of the families are coming from far, so having that information ahead of time for me is really important.

Another thing that I’ve done for this population specifically is when I can, I’ll get the kid on zoom so that I can see them myself a bit beforehand. And even sometimes when I’ve done these sometimes in [00:17:00] collaboration with a pediatrician when there’s an autism question, we’ll have them do a few things with their parents in their home or in their school. And that’s been amazing. This is a new thing since COVID. Everyone’s on zoom in their house or in their school. That’s been a big benefit and something I’m just learning to take advantage of.

Dr. Sharp: Sure. We found that remote assessment was a pain in the ass in a lot of ways, but it was also really nice to be able to see into people’s homes and get kids in their natural environment and hopefully a little more comfortable. You get to see the room. You get to see the state of the house and it was beneficial in that way. It sounds like y’all capitalize on that too.

Dr. Jen: Yeah, I never did go to remote assessment for most of my work. I’m a neuropsychologist in the hospitals. We were able to see kids pretty quickly here during COVID, but for this population, [00:18:00] for the specific group that I will offer a virtual in-home assessment for when the kids are not able to speak, they don’t have yes, no responses, they don’t do any choice-making. So those kids, I can walk their parents or their teachers through some things so I could observe enough to feel confident to give them that enough information and consultation and diagnosis just from interview and observation, because I know even if I had them in the room, I couldn’t do any standardized testing with them.

Dr. Sharp: That’s fair. So when you’re thinking through the assessment process, what approach do you take? Is this a pretty comprehensive battery or are you trying to get a sense of a variety of domains or are you really focusing on only intelligence or academic or social? [00:19:00] How do you approach that?

Dr. Jen: It really could vary. For the kids with severe cognitive impairment who come in maybe as a teenager and I know ahead of time that their functioning is somewhere under 3 developmentally, I know I’m not going to be doing a full battery of testing. Even if they didn’t have motor impairments, I wouldn’t be testing everything under the sun. I’d be keeping myself pretty focused. But other kids might have just more subtle motor impairments but may have counter-complex cognitive profiles that need investigating. So again, it could be a really broad range, but for the kids with severe cognitive impairment, I’m trying my best to get a full cognitive assessment in as much of a standardized way as I can. And then if I can’t, then I’m moving on to my next step of then what after that?

[00:20:00] Dr. Sharp: Yes. And I think we’ll talk about that then, but yeah, that’s a big part here. I got you. I know I’m asking a lot of questions just about logistics, but again, just super curious about what this process might look like. Are you testing over multiple days or a specific time period or only a couple hours at a time or a couple of minutes at a time, how’s this?

Dr. Jen: I always start with the idea that I could get an assessment done in one day and that’s my goal always. Many of the kids are coming from far and it’s not convenient for them to come for multiple days. So I try to get in and out as quickly as I can. I’m just always open to rebooking them for other days if I need to. I just start with one and then I go from there. And that’s another benefit of these kids being seen in their schools because the school psychologists have a much better ability. They do it over three days and pull them out [00:21:00] of their classroom for an hour at a time. Then that probably works better for everybody. And they get to see them over multiple days, which is really nice too. If I happen to get them on a day that they didn’t sleep well or something, then I may be getting a different picture.

Dr. Sharp: Yeah. I want to make that explicit. I think this will be in the introduction as well. In case people aren’t picking up, that’s a big part of your job, right? It’s like helping other professionals do these assessments in…  and what’s the word I’m looking for? …research-supported way or best practices, which is great.

So we’re talking about your practice, but you also help clinicians do this when you can’t get to them or when the kids have to travel or can’t do it or whatever it might be.

Dr. Jen: Yeah, exactly.

Dr. Sharp: Okay. Just to make that super clear. So, we’ve got some logistics and just background for [00:22:00] how you might set up the assessment. Are there any considerations around how you set up the room or what the setting looks like that may be different than typical?

Dr. Jen: Yes, definitely. So one thing that I do really differently in this population of kids is I will almost always have a caregiver in the room with me. Kids who have significant impairment of cognitive-communication motor impairments, many of them would be understandably wary of strangers. And I just put myself in their shoes and think, I’m put in a strange room with a stranger that I don’t know. I can’t get up and leave because I’m in a wheelchair. I can’t even speak and tell them I don’t like something. And they’re asking me to do things that I have no idea what they’re asking me to do. So I can just really imagine how that might [00:23:00] feel for a child and how uncomfortable they may be with that.

I would have the parent. Occasionally an EA has come to an assessment, an educational assistant who is somebody who works really well and gets this child gets the best out of them every day. And they are able to come to the assessment and help me get the best out of them. So that’s been occasional, but usually, it’s the parent. So that’s my number one.

But also it’s the physical setup of the room. So if the kid’s in a wheelchair, obviously we need to be wheelchair accessible. We have special tables here that go up and down and you can fit a wheelchair under them. So, if you look under your desk and if there are any legs there, up and down, vertical legs, then you can’t fit a wheel tray under there. It’s going to be hard to do material work at the table with the child. So in that case, if you’re in that setting and I sometimes do tests out of my main office, then [00:24:00] most wheelchairs will have a tray but parents don’t always bring trays with them. So you just have to tell the parents, bring your tray for the wheelchair because then at least you’d have an ergonomically correct place to work with the child. Those are the big setups.

A lot of kids have difficulty with trunk support. So hopefully, they will come with their appropriate seating and their wheelchair. It’s often some kind of strap that would help them stay upright. And this is something I found really striking when I started this work is appreciating that kids with these neuromotor conditions, they’re putting a lot of effort into all kinds of things. People who don’t have neuromotor conditions don’t even think about breathing and upright trunk support, walking, talking, these things take really quite a lot of effort for some kids, and then how much effort do they have leftover to do the other tasks that you’re asking me to do? [00:25:00] So that’s why we do need to be aware of all of those things to optimize.

Dr. Sharp: Right. I have two questions out of that just going all the way back to the beginning with having someone else in the room with them. How do you get around, and I know there’s a precedent for this and maybe other approaches, but just test security, that sort of thing?

Dr. Jen: Most of the time when I’m doing these assessments, I’m not doing level B assessments. It might be more of a developmental assessment or a psychology unstandardized assessment, but sometimes I am doing standardized tests. You’re right. But it’s something that we know that we’re not going to get a good assessment of a kid.

Sometimes a preschooler or a child who’s very anxious needs their parent in the room or they’re just not going to stay with you. [00:26:00] Like you said, there are precedents for this and your test security obviously, that’s always good to mention to people that everything should be kept in the room. But the main thing that I think if you are doing standardized tests and this is a hard part, is to not get them to help their child because they do want to check your notes. I always tell parents, I know your job normally to help your child and jump in there and give encouragement, but for this part, I know it’s really hard but I’m going to ask you to only get involved when I need you or ask you to, and that can be difficult for parents.

Dr. Sharp: Right. Yeah. The most experience I have with something like that is during the earlier modules of the ADOS where the parents are supposed to be in the room. And even though we always say, don’t guide them, don’t tell them to do anything, it’s so hard for so many parents [00:27:00] not to jump in, “Hey, what about that? Did you see that? What about this toy? Hey, look.” It’s tough. I can only imagine in this setting it’s just as challenging if not more.

Dr. Jen: But sometimes I need them actually because the child won’t bond me and they will only respond to the parent. So I do need sometimes the parents to do things with them so that I could see what they can do.

Dr. Sharp: So I know again, just getting in the weeds, but there are so many specifics that are interesting to me about this type of assessment. What do you say to the parent? Is there a disclaimer at the beginning? Is there a, “Hey, don’t say anything unless I ask you to like”? How do you navigate that with the parent in the room?

Dr. Jen: Yeah. If I’m doing standardized testing, I do spend a little time talking to them about that saying, I know it’s really hard, but I’ll ask you to… [00:28:00] for example, if they get up and you want to help settle them back at the table, that’s fine. But the normal things you do with your kid are to help them and encourage them and help them to learn, today is not about that. Today is just about you get doing what they can with them.

I sometimes will give them a piece of paper and a pen and I’ll say, do you have anything you noticed that you want to tell me about like, oh, they normally would know that one or something like that. I’ll just say, write it down on a piece of paper and then afterward let’s talk about it so that they’re not like interrupting at the moment to tell me those things. And some parents have no problem. They just pull up their phone and they don’t even look up the whole time. And other parents, like you said, it’s really tough. And I think I try to tell them I appreciate it. I know how hard this is but it’s important that [00:29:00] we try to keep it just the two of us doing the activities.

Dr. Sharp: Right. And I wonder I could be generalizing here,  I’m sure I’m generalizing, but you have mentioned a lot of these assessments, a lot of these kids are working with intellectual disabilities or cognitive delays. So I’ll try to formulate this question the way that I’m thinking it, which is, is there any amount of emotional management with parents coming into an evaluation where in a way, like how bad is my kid? Like how bad off is this? I think if I were a parent would be like, I don’t know if there’s a whole lot of hope for “strengths” or obvious they Excel necessarily. And again, maybe a gross generalization, but I’m just thinking about it from a parent perspective what that might be like.

[00:30:00] Dr. Jen: Yeah. I’ve seen parents come with so many different perspectives to this, some who are just very realistic, like this is what my kid’s able to do. I look at all these they’re lovely things they have about them. But I know that learning is hard and I know they’ll always need help and support and very frank and other parents who are not there and they are able to really try that…

I guess the most difficult times are when parents are telling me that they just know their kid understands everything and really gets everything, but they can’t tell me why they know that. So I do ask a lot of questions about those things. Like, give me examples of when you’ve seen them do this or how they understand. I’m getting a bit off track, but [00:31:00] my approach is always to meet parents where they’re at. I’m not here to surprise you or shock you with some information.

I always take the time, in the beginning, to know the parent’s own perspective about their child and I want to work with them during the assessment, towards the end of the assessment, so that nothing I say at the end is really a surprise to them. They’ve come along with me the whole way. So that by the time I get to the end and I say, you remember how we talked about this? And you gave me this example of this and what we call that is intellectual disability. So we’ve already brought them along and there shouldn’t be any really big surprises by the end of it.

Dr. Sharp: Yeah, I think that’s always the hope. It seems particularly challenging in this population. I think it’d be [00:32:00] tough for some parents.

Dr. Jen: For sure, for some parents.

Dr. Sharp: Well, let me pivot a little bit and back into the assessment process. I wonder if we might look at it starting top-down, like the macro to micro. It sounds like you do start with or try to do a standardized assessment as much as possible. So I wonder if we could walk through a sort of, how might I phrase it, like a decision-making model? How to know when to break standardization or not even attempt a standardized measure. Does that fit for you?

Dr. Jen: Yeah. So I don’t want to make any presumptions to start. So I do want to always have in mind that I would like to try to get a standardized IQ test done if I can. [00:33:00] And what I want to think about is, what are the things you need to do to do an IQ test, like the blocks and block design- you have to be able to see the blocks and move the blocks, right? And then what are the child’s characteristics? So what are the communication and motor and visual and hearing characteristics that might impact on that? And so then I’m trying to think of what’s a good fit for that child. And also developmentally, I should’ve already, by the time I need the child, to have a sense that this is a child very significantly delayed or maybe somewhere in the middle or not. If they are very significant, if I think there’s a chance that they’re under 3 developmentally, that’s where we have the hardest time using our standardized tests.

Some standardized tests do like the Stanford–Binet goes down to 20 and the DAS down to two and a half. Those are my [00:34:00] best bets for the kids who are lower functioning in terms of their general cognitive abilities. So if I can, I would do a DAS. That would be the best because that is both developmentally appropriate and age-appropriate so that I can move them anywhere from their age level all the way down to two and a half developmentally on that same measure and still get a standardized score out of it. That’s ideal.

But some kids can’t manage the demands of something like the DAS. So they maybe can’t look at a page with a bunch of pictures and understand that I’m asking them to choose something. They just don’t understand that concept. And in that case, I might go first to the Stanford–Binet because it starts with a hands-on task where they look at objects and answer questions about objects. So that’s kind of my go-to. And if I can’t do that, then I’m probably moving [00:35:00] away from standardized testing and doing something a little bit different.

The other class would be the Nonverbal tests, especially for kids that have significant communication impairments or are unable to understand or speak. Some of the non-verbal like just though not all of them can be easily adapted to kids so they can respond by making a choice in some other way, other than a moving thing. So like the lighter, you’re supposed to match on the lighter to move a little block from one spot to another, but you can think of other ways somebody can indicate that by pointing or by saying the letter that goes along with it.

Dr. Sharp: Sure. Yeah, I’m just struck by the need to have many instruments at your disposal and the ability to really think on your feet and just [00:36:00] say, okay, this is not working. Let’s pivot.

Dr. Jen: Yeah, exactly.

Dr. Sharp: I hear you. So outside of IQ testing, are there other options? I’m just trying to think of other options for assessing, like, are you trying to even dig into something like the NEPSY or more like other domains, memory, and things like that?

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Dr. Jen: Well it’s again, for the kids who are maybe very motor-impaired but depending a lot on their language, then I would like to test their language abilities and understanding receptive and expressive and verbal memory, absolutely essential. There are also visual memory tests where they can respond with like saying a number. The WRAML is my normal memory test that you need motor skills. You’d be able to use a pencil to do WRAML [00:38:00] for the visual memory. So other ones, for example, the ChAMP, where you just choose from an array. So if they’re able to speak but not use their hands that’s an option for sure.

There are probably tests in every domain if you wanted to that are motor-free and motor-free visual perception tests. There are motor-free attention tests. But I would say that I personally do those too often. I’m usually pretty pleased if I can get like a digit span to measure attention and working memory. The other thing about.. this isn’t obvious. Nothing is true of all of the kids with neuromotor conditions, but often they are not going to last for long assessments. Their attention span is like I said, they’re working hard just to keep their trunk control. And [00:39:00] speaking can be slow and labored and asking them to do that for hours and hours on end, I’m trying to condense my battery to the real essentials that answer the question that they came for. So I’m not often going too far off there, but there are exceptional cases for sure. Sometimes kids come in with more discreet motor problems that you’re answering more neuro-psychological questions about them. And then you need to pull in a whole battery.

Dr. Sharp: Sure. Are you working with kids where you are trying to assess motor skills at all? Like, are you doing like a Grooved Pegboard or something, or is that a foregone conclusion? We’re not even really concerned about that aspect?

Dr. Jen: The Grooved Pegboard is part of my routine in my neuropsychology job. I do it with essentially all the kids, but when they’re very motor-impaired, [00:40:00] it’s not necessary. Honestly, it’s going to be still painful and slow and difficult. They’re going to be off the charts and there are ad scores. It’s not going to be particularly interesting to you as a finding. But I do look for things like, I will often do the VMI because it’s very functional. And I want to know about their writing. I’m looking at their pencil grip and what kind of writing instruments they’re able to use. And then I can try different things with them too.

So it’s more like I’m thinking about recommendations and what I need to know about this kid because for example, pencils, you need to put a bit of pressure on to make the marks, and often these kids with motor weaknesses or difficulties with their hands, they can’t put enough pressure on the pencil to [00:41:00] make marks properly. And a typical ballpoint pen actually needs to be held at a certain angle to work. And sometimes they can’t hold it at that angle and they can’t do it properly. So using a felt tip pen can work and I’ll use that often in my assessments. I’ll let them do the right thing with a felt tip pen better than a pencil. I’m not doing motor testing but I’m doing things like that in my assessment.

Dr. Sharp: Yeah, it sounds like there’s a little bit of ecological assessment almost during that time to see what actually works. That makes sense.

I’d love to dig into this area of non-standardized assessment. So again, I think for a lot of us, this is the wild world west. Like once you go off standardization beyond like testing limits or extending the time [00:42:00] limit or whatever, it’s like, what are we doing here? How do I interpret these results? And is this meaningful? So I guess I’ll ask a general question just around, where do you even start with non-standardized assessments, and then we can take it from there in terms of interpretation.

Dr. Jen: Yeah. So hopefully I’ve tried something in a standardized way, say I’ve completed a WISC but the raw scores are all zeros and 1s, you could make IQ scores out of that but it doesn’t really tell you much. It certainly doesn’t tell you what they can do. So then I’m thinking about what else I can do.

Well, what I’ve seen sometimes when people say this kid is not testable and then they write it up, not testable, intellectual [00:43:00] disability based on adaptive functioning, end of story. And if you have made a really good argument for that, I know our community services here, if you are very clear about the child’s history and you said what you tried in your testing and why doesn’t it work, they probably accept that. It is accepted without an IQ score. They’ll look carefully, but that would be okay.

But in terms of best quality service, I would want to go a little bit farther. So, my next step is to try something that’s a bit more structured than just observation and that would be a developmental assessment. So these are the kind of assessments I didn’t learn in grad school, but I learned after when I started this work at the hospital is to do the developmental [00:44:00] assessments, like the Bayley, the Battelle, the Mullen. Usually, people have their one favorite and they do them. Switching between them isn’t great because it’s lots of parts and moving pieces and you have to know them really well. So what we use most here at the hospitals is the Bayley, just out with a new version, which is quite nice. So I try to get a full Bayley, or at least at the very least of the cognitive measure on the Bayley.

And if I can, many of these kids can make it through essentially a full Bayley. And then what do you get out of that? Well, you get your observations or structured observations of their developmental skills, like object permanence, cause and effect reasoning, and things like that. And then you can get an age equivalent and we know age equivalents are psychometrically problematic for sure. And I think if you’re using age equivalence, you need to be super aware of all of [00:45:00] those limitations of age equivalent.

Dr. Sharp: Can I interrupt you real quick? Just in case there’s someone out there who’s like, why are there age equivalents psychometrically on sound, can you give us the by-size version?

Dr. Jen: Yeah. So age equivalence, I think we say them, we don’t really know what they are, where they’re calculated from. So that’s important first of all. The age equivalence is the age at which that raw score is equal to the median or mean raw score for that age level. So like if a 12-year-old has a raw score of 5 and 5 is the mean score for three and a half-year-olds, then their age equivalent is three and a half.

One issue is that they’re ordinal meaning age 3 equivalent is less than age 4 equivalent. The gap between them is different. So what’s the age equivalent [00:46:00] between the 6th-month gap between 3years and 3.5years, how much different that is, is totally different than between like 7yrs and 7.5years. So you can’t compare age equivalents even across sub-tests on the same test. Many of us have used the Vineland age equivalents and gone, the standard scores higher on this, but the age equivalent is higher on that. It doesn’t really make any sense. How does that even…?

So you can’t compare across subtests within one test. You can’t add them together or average them or anything like that. And they’re also less meaningful, I think, as kids get older. So if you have like a 14-year-old and you’re getting an age equivalent of 2years, are they’re really like a 2-year-old? It just becomes complicated that way in lots of different ways.

The way I think of them is that they’re one more piece of [00:47:00] information, just like my observations and my interviews and my records review. And they should never be turned into your test results like therefore they have an intellectual disability, but I see them as one more piece of information in my broader assessment because our assessment is more than our test results. I like to just think of them in that context, but I do find that useful. And I do find it can be useful when sometimes it’s hard to argue for an intellectual disability without a full-scale IQ because of the way community services are set up and having more structured “tests” `that you’ve given a kid that comes out with an age equivalent is one more thing you could use to help in that setting.

Dr. Sharp: That’s fair. I appreciate that explanation. I know I interrupted you and I think we were talking about just what you can gain from these measures when [00:48:00] you’re… Go on there.

Dr. Jen: So then I hopefully have seen more things about what the child can do, because while we’re talking often about it, it could be a moderate, severe, or profound intellectual disability. I want to be identifying not only what they can’t do, but what they can do. And so doing these kinds of measures will pull that out. You can do them on your own, the pull-out washcloths, and hide things under them, but doing it on the Bayley is just a standard structured way to do that essentially that gives you some guidance along the way.

And sometimes a kid is able to complete a Bayley and you ended up getting age equivalence and sometimes they are not. There’s a lot of parts to that, like motor wise that you just cannot put blocks in a cup and you ask them to put blocks in a cup, like no getting around that. That’s not supposed to be a motor test. It’s supposed to be a cognitive test. And it just may not work. [00:49:00] So in that case, you may be really just pulling pieces from the Bayley and doing what you can just to see what they can do. Do they have object permanence? They’re playing with something, and then it falls on the floor, and do they go look for it? It was just an observation on object permanence, then you go, well, I know object permanence develops around 9 months therefore probably they’ve built that far along. And so I’m then I’m looking for those things throughout the assessment.

Dr. Sharp: Sure. Is there another step beyond that? So, if the Bayley doesn’t work, then is there even more non-standardized assessment to be done?

Dr. Jen: Yeah, so this is the third step when I go to step three. And sometimes you’re not using one or the other you may be using all three of these. So like the standardized assessment [00:50:00] because like I said, maybe it gives you all zeros, but you’ve tried it, you’ve got a score and then you move on to do the Bayley and maybe you get a score or not, but maybe it still didn’t give you enough. Or, there are definitely kids who can do almost nothing from the Bayley and they’re not responsive to command. They don’t have any way of saying yes, using words to express themselves. So in this case, I’m looking for more play-based interactions and maybe use what I can from the kits and stuff. But sometimes it’s more like I need to find what their things are.

For example, I had a kid who didn’t speak and was in a wheelchair and the only thing I could see that he really loved would the spoon he carried with him and he liked the feel of it and he just holds it on his face and touch it and maybe bung in a little [00:51:00] bit, I had his father take it away from him. And stand behind him and ask him, do you want the spoon? Can I give you the spoon? Do you want it? And he didn’t respond or answer, but I knew this was something he really loved and wanted, and even when the father, I have said, can you just say it in one word, spoon, spoon? And even with that, he didn’t respond.

And then as soon as the dad put it to his space, he lit up and grabbed it and he was so excited. So that tells me that, I know he can hear. Hearing is not an issue, but he did not understand even a word for something that he loved and knew so well. So that’s the non-standard assessment. And so a lot of times you do need to focus on that kid. What drives that kid because that’s what’s going to drive them to show you what they know.

Dr. Sharp: Right. Yeah, I know I said this just a few minutes ago, [00:52:00] but again, there is another point that I’m struck by. You really going to be on your toes with this kind of thing. You going to paying attention. It’s not your typical route. We start with block design and go through the WISC. You got to really be in it. I guess that’s an indirect way. I’ll just say it directly that I admire the work that you’re doing and recognize the investment on your part to make sure you do what needs to be done and everything that you can do to honor a kid’s functioning.

Dr. Jen: Yeah. Well, it’s creative, but that could be fun too, to think outside the box a little.

Dr. Sharp: Yeah. Got you. So then is there a step four or it’s step 3 and that’s where we end up?

Dr. Jen: That example of his spoon might be about the end of the line. You’re thinking maybe something that you know that they care about [00:53:00] and trying to do some interaction with it because most of the time we’re using our materials and asking them to do something with it.

There are two people who have thought about this and put together structured ways of reaching kids. They are often around deaf-blind. Kids who are deaf-blind and or very severely impaired. And one thing that I really liked about this model of coherence of helping them to understand the world around them and what they do with them is helping them to… first, they have to just get them activated and interested in something, interact with it, understand it, and then move towards like labels for things. So this about assessment interacts with intervention here and it’s best done [00:54:00] long-term by people who work with them and not me and my one-time setting, but I do try to.

You asked about the last step. The last step would be just, sometimes they come to me, if we really don’t know what interests them, it’s nice to have on hand something from every sense. So things that light up, things that make noise, things that vibrate, things that are hot or cold so that you can try these things with them. And it’s almost like a, wow. The parent may be like, “Oh, they like things that vibrate. That’s new. I could use that.” And then that’s something they can work on to help them along their way in their learning journey. I’m playing a small role there to start that but I am only able to see them on time so I can’t follow up with their intervention.

Dr. Sharp: Sure. That makes sense. So I’d love to [00:55:00] talk with you about the report writing process. And maybe even actually before we get to that, it’s the interpretation of the data that then feeds the report. So I’m not sure how you might want to tackle that but how do you make sense of the data and then communicate your findings, especially when things are non-standardized? What are some considerations there?

Dr. Jen: I think one thing that I get a lot of questions about it I think that’s can be really tough it’s adaptive functioning because it’s something we, especially in these cases of nonstandardized assessment, we’re going to rely on a lot on adaptive functioning measures. What are they like out there in the real world? What are they able to do for themselves and their classroom and their home and their community? And as you think about the items on those measures and a lot of them are dependent on motor functioning or vision or hearing. So brings their dishes to the sink after eating, for example, What if you don’t [00:56:00] use your arms, right? How do you even think about that in terms of adaptive functioning, right?

And then some things are going to develop at different rates, like for kids, with visual impairments, identifying money and bills is just a much harder task than it is for typically developing kids. So they can learn it and they will if they have the skills by adulthood, but it’ll just take them longer to learn those things.

In terms of adaptive functioning, some tricks, or you probably need to look pretty carefully at the item level and think about the child and for example, why they can’t carry a dish to the sink. So you want to see some evidence of impairment on things that are not motor-related as well if it’s a motor issue and you probably need to look at the item level. The social skill, especially it’s good for that and the communication skill as [00:57:00] long as they are able to communicate verbally is also good because those are less reliant on motor skills.

But we also know that the social development of kids with disabilities is different. They’ve had different opportunities for playing, different opportunities for friendships. Their friends may be more like helpers than friends. So that all affect how they get rated on these things and how they develop. So that’s really tough but that’s our job to try to pull that apart and figure it out. And sometimes we may see them when they’re younger and we may not be ready to make that diagnosis yet. They may need more time to come back in the future after they’ve had more development. So I think we might feel unsettled to make a diagnosis for any kid when they’re young for a good reason.

Dr. Sharp: [00:58:00] That makes sense. Yeah, sometimes it’s okay to wait and see or say it. I don’t know.

With your thoughts about looking at item-level endorsements, does that lend itself to say more follow-up interviews with parents or educational staff to really dig into some of those items or do you find yourself doing that more than you might otherwise?

Dr. Jen: Yeah, I would say it’s pretty important that you do this in an interview format, the adaptive functioning for these kids. I almost always do the Vineland interview, and I do the Vineland interview for all ages at different times. Sometimes it can be long and difficult but for kids who are lower functioning, it’s actually not that long to do because you’re not going through the whole item set. You’re looking at the lower items set.

I think it’s really [00:59:00] important that we are aware of what handing these forms to parents feels like to them when we ask them to fill out questionnaires where they are having to write zero, zero, zero, No zero over and over and read questions that are inappropriate for their child, that doesn’t make any sense for their child. And I know that we have to do that, right? Sometimes we just have to do that but it’s important that we at least recognize that to parents that I realized these questions don’t really seem to apply and sorry, sometimes I just got to ask questions even if they’re not relevant. But yeah, Vineland’s interview is definitely the way to go.

Dr. Sharp: So you are making a disclaimer of sorts to parents during the process just saying like, Hey, I’m sorry. This might get tedious or however, you phrase it.

Dr. Jen: Yeah, if I have to have them fill out, I don’t usually do questionnaires like the BASC and BRIEF [01:00:00] for this population. It is just not relevant and parents would get very frustrated having to answer questions that like, do they look both ways before crossing the street? They are like, I push them in a wheelchair. They don’t have to. It seems really silly. I read the room. I think sometimes I don’t need to give too much pre-emptiveness or if I feel like there’s weariness, I’ll definitely explain why I’m giving questionnaires, but it just depends on the situation. It’s good to know how to say that if you need to.

Dr. Sharp: Of course. So how do you translate this to the report and actually, are you writing reports in your setting?

Dr. Jen: Yes, just because it really needed for the school, for the access to community resources. Yeah, for sure, I do write reports. The report format I like the best for, I’ve tried all different [01:01:00] things over the years but when I’m doing these non-standardized assessments, the format that works well for me is where I integrate everything together. So the same things like brief background and what I did in the assessment, any accommodations or things that were done differently.

And then my results section would be a combination of my observations, my interview, my records review, and any standardized tests I did. So like I might say, communication. I might divide into expressive and receptive? And I may talk about what was on the adaptive functioning measure, what the teacher told me, what goals they’re working on in school and what I observed in my study altogether in one spot. And if not long. There’s like half a paragraph, small paragraph, four sentences or [01:02:00] something. You try to pull it together and not a ton of detail. And then I do that for each domain.

And then the very end I do a pull it all together brief paragraph that gives the diagnosis and summarizes briefly the rest of the assessment. And then I always like to in the report in each of those sections, not just say expressive language is impaired, receptive language is impaired, but I say what they can do. So to communicate, they use facial expressions, gestures, and grabbing for what they want. They do not use any word approximations for spoken words. They tried technology for assistive communication and it was not successful. So that might summarize it so that I said what they’re not able to do and what they are able to do in one section.

Dr. Sharp: [01:03:00] I see. I like that that integrative model. It seems like it is maybe more important when you more often don’t have standard scores to fall back on the report, right?

Dr. Jen: Well, standard scores are like the lowest possible. Everything is below the first percentile. Like that’s not useful.

Dr. Sharp: That’s not helpful. Yeah, absolutely. And then recommendation-wise, I assume you’re making some recommendations.

Dr. Jen: Yeah. I would say the big three for this population are communication, sleep, and behavior. And some families may come with most things all wrapped up and they have the goals they’re working on and are working on them in a good way. And they don’t really need much for me but we do need to formalize these intellectual disabilities so they can access supports and services. Great. Okay. I can do that. You guys are good.

And then other times there is [01:04:00] just an incredible amount of things to work on, and it’s about prioritizing what to work on first. And oftentimes communication is a big one because communication can need behavior problems and other things, and in terms of their child’s own the ability to make decisions for themselves and feel good about themselves and have like a voice in the world. Like if they’re not able to even say when they’re in pain, that’s really tough. And you can see all things. Self-injurious behavior, lashing out physically at others, no cooperation and it can be really tough. I always get into detail on all of those three and see where they’re at.

Sleep can be an issue. A lot of these kids have sleep issues that are part of their condition that are just built into their biology. And it can be super difficult for [01:05:00] the family because they’re up often in the night a lot with these kids, and then you get the family stressed. So whatever we can do to help manage sleep can be really beneficial for everyone too.

Dr. Sharp: Of course. My gosh. I’m trying to think what else. I’ll turn it back over to you. I know our time is winding down, but what have we not covered or what feels like we need to say more about it before we start to wrap up here. We’ve covered so many points. I feel like this is just…

Dr. Jen: I think we didn’t talk too much about the difference between adaptations and modifications in testing. So maybe just to briefly mention that and the people could think about it and look in too. The schools use those terms, adaptation, and modification. Well, here is what the terms mean. Adaptation is when you need something in order to be successful and do the same work [01:06:00] as other kids, you just need them adaptation like braille instead of print or extra time or whatever. But modification is like a completely different program. And in terms of standardized testing, I think of like, for example, an easy adaptation would be instead of pointing to the answer, you say the letter attached to that answer.

But some things like say somebody you want to try block design. Maybe the kid tells you how to put the blocks. Oh, put the red corner down in the white corner up and then put a white one, to me, that’s a modification of the test. So for adaptations, I’m pretty confident that we can use the standard normative data. But we have to think carefully because there goes from easy ones, like saying a letter instead of pointing, and ones that are quite different. Like, [01:07:00] moving the blocks for the child. That’s something. To somewhere in the middle, like on picture span on the WISC. There are letters under there if they said the letters.

So in picture span, they see like 2 or 3 pictures and on the next page, they have to pick out those pictures in order. And instead of pointing to them they could say the name of the picture or point or say the letter because they can’t use their fingers to point. That’s an adaptation, but it does change the tasks. It makes it harder. They have to hold more in mind. So it’s subtle out of somewhere between an adaptation and a modification. And if it’s all you got then fine, you can try it. To me, because that makes the task harder, if they do well on it, I’m okay with that. But if they don’t do well on it, then I’m more cautious about interpreting that results.

And [01:08:00] handwriting, giving them a felt pen to write to me is an easy adaptation, you should be able to use the standard normative data. Typing as a little bit more of the adaptation. Some kids can’t handwrite, they only type in their everyday life. Typing is a modification but it’s a reasonable one. You just have to know that you’re comparing this child’s ability to type to every other child’s ability to write by hand.

And then another level of adaptation would be dictation. And so if they’re dictating to you to write down, that’s a full modification, right? Which is really oral expression instead of written expression. So you need to think through where on that spectrum of adaptation to modification. Am I confident in using the normative data for that?

Dr. Sharp: Right. Yeah. It just requires us to be Very mindful and cognizant of what we’re [01:09:00] actually looking at and what we’re trying to measure and what we’re going to use it for. That’s such a good point. I feel like there’s a lot more we could talk about. There were so many questions, that I did not ask as we were discussing but the takeaway from all this for me is just that it is doable to work with kids who may not fit the mold. And it’s like you said that not to be content with could not test intellectual disability by default or whatever, by virtue of no data. Like that’s just not doing these kids justice. And one thing that may go without saying but we’re going to say it anyway, I guess, is all these adaptations and modifications that you might make, I assume you’re documenting those in the report.

[01:10:00] Dr. Jen: Yeah, of course. And I would say that if you’re using modifications, especially if they’re tools, they should be tools that the child is already familiar with. For example, somebody asked me once, oh, I wonder if I could try iGave with this kid who doesn’t, and I was like, well, do they use iGave normally, because if they don’t, then you cannot because that’s something you need to train any kid. They need to learn to do iGave stuff. So just being in good touch with their team who knows them well, it’s an easy start.

Dr. Sharp: Right. That’s awesome. Well, thank you.

Dr. Jen: You’re welcome, my pleasure.

Dr. Sharp: This is lots of information. I feel like it was a firehose of information, but like I said at the beginning, we’ll put it in the show notes. I mean, you have an ebook I think that is really helpful in thinking through a lot of these points, and [01:11:00] you’re doing a lot of good work to help folks get more familiar with these approaches.

Dr. Jen: Yeah, I appreciate that. And it is open access, so anyone can check it out without any payment.

Dr. Sharp: Always nice. Well, Jen, I’m so appreciative of our time today. Thanks so much for being on here.

Dr. Jen: My pleasure.Thanks for having me.

Dr. Sharp: All right, y’all. Thank you so much for checking out this interview. I hope that you found it as illuminating and informative as I did. This was one of those interviews where I could have asked questions forever because Jen is so knowledgeable and so kind, and this is just a fascinating and necessary area to know about.

Let’s see what’s coming up on the horizon. Next business episode, we’re going to be talking about transitioning from [01:12:00] insurance to private pay. And then we have some clinical episodes on dimensional diagnosis and assessment, as well as the Mullen family of instruments. So stay tuned. If you have not subscribed to the podcast or followed the podcast on Spotify, now’s a good time to do so you won’t miss any upcoming episodes.

I’m glad to be back with you again. I hope everyone is doing well. Until next time.

The information contained in this podcast and on The Testing Psychologist websites is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, [01:13:00] psychological, psychiatric, or medical advice, diagnosis, or treatment. Please note that no doctor-patient relationship is formed here. And similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

Click here to listen instead!

[00:00:00] Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

This episode is brought to you by PAR. The Feifer Assessment of Writing examines why students may struggle with writing. The FAW and the FAW screening form are available on PARiConnect- PAR’s online assessment platform. Learn more at parinc.com\faw.

All right, everyone. Hey. Welcome back. Welcome back to myself, actually. It’s been a long, long time since I have recorded a new podcast episode.

Some of you have probably noticed that the podcast [00:01:00] release schedule has been a little slower over the summer, or a lot slower as a matter of fact. And that’s a big part of today’s episode.

I will admit right off the bat that the reduced content schedule was not deliberate. What happened was I ignored all of the advice that I have given on the podcast over the last four years and got completely overwhelmed, took on too many things and frankly just fell behind in nearly all aspects of my life for the first time in a long time. So that’s what I’m here to talk about. If it’s interesting at all to you to hear how I totally messed up and ignored everything that I’ve been preaching for a while and subsequently dug [00:02:00] myself back out, then this is the episode for you. My hope is that talking through this process will maybe help some of you who may be in a similar situation or who have found yourselves in this situation in the past.

So just a few things I’m going to talk about. I’m going to talk about a little bit of a post-mortem analysis of what went wrong over the last few months and things that I did that I shouldn’t have done, decisions I made that I shouldn’t have made or should have made differently. So I’m going to do a little analysis. I’m also going to talk about what I learned, how I fixed things and got back to normal, and at the end, have two small announcements about the podcast and my consulting world.

So welcome back. I hope [00:03:00] I didn’t lose too many of you in the interim, and I am excited to be back and chatting with you again. Let’s get to it.

Okay, here we are. We are back to talk about how I royally messed up over the last six months or so, what came of that, what I’ve learned, how that changed things, and what things are going to look like moving forward.

First and foremost, I want to apologize. Over the years, we’ve established this informal contract between myself and the audience whereby [00:04:00] y’all count on Testing Psychologist podcast episodes to come out on a regular schedule. Well, I’ve taken breaks in the past. They’ve been a little bit more planned and they have been shorter. So, I want to apologize to some of you out there who have contacted me, others who have not contacted me but undoubtedly have been wondering what is going on with the podcast and where are the new episodes?

Simply put, I just took on way too much over the past several months and got behind on the release schedule. So I apologize to all of you for that and I just want to acknowledge that this has been a bit of a humbling experience.

In general, this is a hard thing for me to talk about. It’s a little vulnerable because [00:05:00] I certainly have it in my mind that I need to have it all together. I’m one of the folks. There are plenty of podcasts out there on business strategy, but I have talked a lot about managing your schedule, being efficient, how to keep your tasks under control, and all sorts of things in that realm. And here I am a victim of busyness yet again, so a little bit of vulnerability.

I feel like I’m supposed to have it all together and I have mastered all of these concepts and yet it was just another reminder that that is not the case. But I want to acknowledge that for two reasons. One, I want to keep myself accountable to you all and this contract that we’ve developed, but also I hope that [00:06:00] it might normalize this experience for any of you who may be having something similar going on. It’s okay. We know, we get overwhelmed. Things get out of balance and there’s always the opportunity to turn things around and get back to a better place.

So again, my apologies, and I’m so glad to be back and recording more episodes. Looking forward to the content that is to come.

Now, in thinking back to what happened, it’s pretty simple. The post-mortem could have been very, very simple and very straightforward. Essentially, I for some reason decided to take on literally every opportunity that was presented to me all at the same time over the last, let’s say six months. This really came to a head back in [00:07:00] April, May, June when I found myself incredibly busy and then had good fortune, of course, to be able to go on vacation, but these vacations were not pleasant because I had so much hanging over my head and that did not feel good, but I also did not work on vacation.

So, I took on everything. Here’s what I did. I took on more clinical work than I have done in probably three years. So I made the shift over the past, let’s say year to only doing one evaluation a month and only taking referrals from returning families of kids I’d previously evaluated or “special requests” from [00:08:00] therapists or colleagues here in the community for cases that were, let’s just say special for one reason or another or unique.

What I found though, is that that made it really hard to say no when people felt some urgency for an evaluation. Working with families I’d already worked with and with my close colleagues specifically, that made it really hard to say no. So I went from one evaluation a month to probably 6 to 8 evaluations a month for a few months, which was not a good move. I simply did not have the time in my schedule to do that.

And it’s just like I talked about in a previous episode about designing your schedule the right way. Intakes are the gateway drug. So at the time [00:09:00] when I was scheduling these intakes, it didn’t seem like I was taken on that much work. It’s just two hours here and there, but long behold, those reports came due and that was very troublesome.

Another thing that happened is I took on more one-on-one consulting clients than I really ever had before. I really enjoy consulting and did not want to say no to anyone. I took on a lot of folks which was fulfilling, but again, filled up my schedule as well. At the same time, as usual, I was doing my two mastermind groups concurrently. That’s pretty normal, but that was just part of the mix. 

Another extra thing, I chose to write a curriculum or develop a curriculum for a social-emotional learning class. [00:10:00] This is as a partnership with the pediatric practice that we are co-located or integrated with, and a great project, really fun, a lot of research that went into it also took up an insane amount of time. And then, on top of those things, I took on a few presentations here and there that I had to prepare for that were relatively important and it all just coalesced into a truly crazy schedule. It was not pleasant. And I realized, of course, too late that I was way over my head and had to dial it back. And then it took another two months to do that.

When I reflect [00:11:00] back and think about what led to all this, it is on the surface the desire to keep everyone happy. I didn’t want to say no to anyone. I did not want to disappoint anyone because there’s still enough of a performer in me too. I don’t want to disappoint anyone. I want to do everything. I want all the people to like me all the time. And this is just a recipe for disaster because the paradox, of course, is that by taking on all these things and not wanting to disappoint anyone, I actually ended up disappointing literally everyone because my reports were late or later than usual, podcasts were not getting published on the schedule that they should have [00:12:00] been, I ended up working on the weekend a few times, which I haven’t done in years, I let down my staff and my supervises because I wasn’t fulfilling what is now my primary role in addition to podcasting, which is, directing our practice and visioning and executing the big picture strategy for our practice. I did not do these things.

I want to say that again, one to keep myself accountable, but also to reinforce it for anyone who might be listening that my desire to not disappoint anyone actually led to disappointing, I think everyone. So keep that in mind.

I’ve talked before about how [00:13:00] saying yes to something means you are saying no to something else. You just don’t know what it is. And I truly learned how severe that can get with my experience the past few months. So, that’s what went wrong. On the surface, pretty simple, deeper level, I still need to work on not disappointing people and being okay with saying no.

So, what did I learn and how did I fix it?

Let’s take a quick break to hear from our featured. The Feifer Assessment of Writing or FAW is a comprehensive test of written expression that examines why students may struggle with writing. It joins the FAR and the FAM to complete the Feifer Family of diagnostic achievement test batteries, all of which examine subtypes of learning disabilities using a brain-behavior perspective. The FAW can identify the possibility of dysgraphia as well as the specific subtype. [00:14:00] Also available is the FAW screening form which can be completed in 20 minutes or less. Both the FAW and the FAW screening form are available on PARiConnect- PAR’s online assessment platform, allowing you to get results even faster. Learn more at parinc.com\faw.

All right, let’s get back to the podcast.

Well, one thing is that I really got back in touch with the part of me that is okay saying no and disappointing folks because deep down, I know that it’s okay to have boundaries and not take on absolutely everything. I just had to get back in touch with that.

So I recommitted to the Hell Yes/No philosophy that I mentioned a few [00:15:00] podcasts back or a few months back. The idea behind this is, when you’re checking in with yourself to decide whether to commit to something or take something on, you adopt a “hell yes or no” philosophy, which means that if the opportunity in front of you is not 100% amazing and right up your alley and sets you on fire, then there’s a really compelling reason to just turn it down. So I learned again that saying, no is was totally fine and that doing so actually keeps my doors open down the road to other things that could be hell Yeses.

Another big part of this, very logistically or practically speaking is that I revisited my schedule. Instead of having little blocks of [00:16:00] open time here and there where I previously was tempted to fill those in with urgent needs or things that other people might need, I went back in and blocked off my schedule again so that I was not as tempted to just plug appointments in where they don’t belong. I also just redid my schedule. I fought really hard about how I want to be spending my time, and I restructured things on my calendar. Now this takes some time to kick in, of course, but it is a really important exercise that I typically do every six months anyway, but I did a little bit of an interim update simply because things were so bad this time.

So I restructured my schedule. I also sat down and ran some more numbers. I’ve said many, many times [00:17:00] before that a lot of anxiety can be solved with math. I got back in touch with the numbers. I just realized or reinforced that I don’t need to be taking on as much as I did for any kind of financial gain. That’s not a primary motivation at this point, but it’s easy to get lost in that. As someone who certainly sees money as a route to security and stability, there’s always that temptation to do more and make more. And I think I had that script operating in the background a little bit as well. So I did some math to help combat any financial worries that may have been there.

And the last thing that I did that has been super helpful is that I got back into an accountability group to [00:18:00] help me refocus on my priorities and to have other folks keep me on track, people who will hold me accountable, people who will hold my feet to the fire make sure that I’m doing what I say I want to do. So that’s been super helpful as well.

Hopefully, hearing some of these things might be helpful to you. If you are finding yourself kind of overwhelmed or over-committed, I just want to give you some hope that you can absolutely change things. There are always choices that you can make to steer the ship in a different direction. It may take a couple of months or a few months, but it is totally doable. And so at this point, I am back on track and this leads into the announcements.

Podcasts will be resuming at the regularly scheduled, two episodes a week. I [00:19:00] will continue to do a clinical episode and a business episode each week.

The main change that is coming is with my consulting availability. What that means is I am shifting to primarily leading Mastermind groups rather than taking on more individual consulting spots or individual consultant clients. Now, I will continue to have a very limited number of individual consulting spots open for folks who are a really good fit and highly motivated to work. And at the same time, I’m going to be leading more groups because I love doing groups. They are so powerful. And as I continue to do cohort after cohort of mastermind groups, it’s clear that [00:20:00] the whole is greater than the sum of the parts, that the vicarious learning, the support, the accountability that happens in these mastermind groups is really pretty life-changing.

So, I will be focusing more on a mastermind group, which means there is more availability for mastermind groups, both at the beginner level and the advanced level and at intermediate level. The intermediate level is for folks who have mastered the beginning phases of practice, they have a solid referral stream, they do not have any aspirations of growing necessarily, but they would love to dial in their systems and make their practices more efficient, and use their time wisely and just run a really solid solo practice with maybe some admin support, but no aspirations to hire clinicians necessarily.

[00:21:00] There’ll be more announcements about that. In the meantime though, you can, of course, get information about upcoming cohorts for mastermind groups at thetestingpsychologists.com/advanced or thetestingpsychologists.com/beginner.

I’d like to close with an action item or question that can turn into an action item. And that question, is what is one thing that you could do this week to cut back on being overwhelmed? And even if you’re not completely overwhelmed, I think it’s worth going through this exercise. What’s one thing that you could cut out of your schedule, one thing that is extra that you wish you’d said no to but you actually said yes to? Just pick one thing and then find someone to keep you accountable to get rid of that thing. f you can do it really easily, if it’s just a matter of deleting it off your calendar, that’s fantastic. If you [00:22:00] need to get someone to keep you accountable, find that person and make that happen, but just pick one thing.

All right. I am so glad to be back. I love doing this. Hope that you have all had amazing summers. My kids are going back to school in two weeks somehow. And thankfully, we got a couple of vacations. I hope that some of you got to get out of town, relax a little bit and regroup and get your head straight. So, look forward to more episodes and continuing to interview amazing folks, talk about business and all the fun stuff that comes with this podcast.

That’s it for today. Take care, y’all. I’ll talk to you next time.

The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis or treatment. Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you [00:24:00] need supervision on clinical matters, please find a supervisor with an expertise that fits your needs.

Click here to listen instead!

[00:00:00]Dr. Sharp: Hello, everyone. Welcome to the Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

This episode is brought to you by PAR. The Feifer Assessment of Writing examines why students may struggle with writing. The FAW and the FAW screening form are available on PARiConnect- PAR’s online assessment platform. Learn more at parinc.com\faw.

Hey, y’all welcome back. Glad to have you here. My guest today is Dr. Michael Docktor. That’s right. Dr. Docktor, you heard that right.

Mike is the co-founder and CEO of Dock Health, a company founded at Boston Children’s Hospital, where he is also a practicing [00:01:00] Pediatric Gastroenterologist and former Clinical Director of Innovation.

Dock Health is a software platform that is built from the ground up for healthcare professionals. It is a task management software program specifically designed for healthcare professions.

If that catches your attention, you definitely want to stay tuned for this entire episode. I talked with Mike about a number of things. We talk about the reasons that healthcare professionals are kind of bad at creating user-friendly systems for task management. We talk about the cognitive burden that results from having a bad task management system. And of course, we talk about the software itself and some of the features that Dock Health offers to healthcare professionals.

Now, I’ve been messing with the [00:02:00] software for the past two months, and I’m really impressed, frankly, so much so that I have chosen to partner with Dock Health to design some testing specific workflows that capture a lot of the common processes that we go through as testing psychologists. So if you would like to access these workflows and give Dock Health a try, you can do that at dock.health/the-testing-psychologist. That link is in the show notes, but I want to make sure if anybody is interested, you can check out Dock Health, you can get a free trial, you can run through a demo with them and you can get access [00:03:00] to those custom workflows that I designed specifically for testing folks.

I hope you enjoy this episode. It is really meant to shine a light on a resource that I think could be helpful for a lot of us in our practices. I hope that you enjoy it. Without further delay, here is my interview with Dr. Michael Docktor.

Hey, Mike, welcome to the podcast.

Dr. Mike: Thank you for having me. Good to see you.

Dr. Sharp: Yes, you as well. I’m really excited to talk with you. I think that since our first connection a few weeks ago, it feels like we’re [00:04:00] in similar ballparks and have similar headspaces here being practitioners and business owners and entrepreneurs. I know you have a lot to say here, so I’m grateful for your time.

Dr. Mike: Thank you.

Dr. Sharp: I always start with this question. We’ll just jump right to it, of why this? Why are you doing this now? Why is it important?

Dr. Mike: I feel like this is a culmination of the last 20 years of experience for me as a clinician, as an innovator, as someone that wants to ultimately make life easier for fellow providers, other clinicians. The problem that we’re tackling at Dock Health it’s really managing all the to-dos of healthcare and all the administrative burden. And there was just no good way to do that for me. And my role in life feels like it needs to be, how do we help providers take care of themselves and ultimately take better care of their patients through our system? That’s the mission. And so I had [00:05:00] to be on it.

Dr. Sharp: Yeah. Well, just from that little piece, it sounds like you’re solving your own problem, which is what they always say to do when you start a business, right? 

Dr. Mike: Yeah, eat your own dog food or solve your own problem. This is very much solving my own problem and selfishly I was challenged and we’ll get into it I’m sure, but I was just challenged with managing all to-dos of clinical care and had the benefit of seeing what industries outside of healthcare use and do, and had the wherewithal and fortunately, the right resources to help build something that certainly helped me and looking forward to helping my other providers along the way.

Dr. Sharp: Yeah. I’m really curious about the origin story and the genesis of all this. I typically actually don’t go into a lot of background with guests, but I think you have a unique background that I’d love to ask about if we [00:06:00] could dive into some of that.

Dr. Mike: Yeah, absolutely. I’m a pediatric gastroenterologist at the Boston Children’s Hospital. I took that traditional route. My last name is Docktor, so I really didn’t have much of a choice in life, but I took a traditional route to medicine with some meandering along the way. I took a year off after college, before medical school, and worked for JP Morgan. And so I had some financial experience and just lived an enjoyable existence near your city for a year before I dove into medicine knowing full well that I wanted to do that. And did pediatric residency in Los Angeles, did my GI fellowship at Boston children’s.

And honestly, while I was spending a lot of time in the lab during the latter part of my fellowship, there’s just a lot of downtime. And it was right around the time that the iPhone and the App Store came online and I was just enamored with the user experience and the technology that was in my hand and fortunately, found some smart [00:07:00] people that were willing to try some experiments. And that first experiment was building an app. I had a young child at the time. I thought we should build a potty training app because I’m a gastroenterologist and I have a young kid. And so I met these MIT engineers that were curious about how to code and X code for the iPhone and app store. And that was the first experience I had in the app store and user experience and design. And I got totally bitten by the bug. And then it led me to just really start to look at things differently.

I started asking our IT and informatics people at Boston Children’s Hospital, how come we’re not using these iPhones and these great tools that it’s in everyone’s pockets? How come people are insecurely texting with just SMS because our paging system is so antiquated and painful? And that led to my first project as the director of clinical mobile solutions within the informatics program, [00:08:00] bringing secure messaging into Boston Children’s Network to other projects like mobile EHRs and using the Nuance’s Dragon products to dictate our notes.

And so that just got me into the role of informatics and clinician-facing tools. In part, the rest is history but that along with my clinical role and just feeling the pain points of that in my role in an innovation program at Boston Children’s Hospital that I was the clinical director of, and so I just had tons of exposure to the world outside of medicine. And I got to see how software engineers manage projects and how things as simple as my wife and I manage our shopping lists.

I told this story the other day, but if she needed me to pick up bananas when I was at Whole Foods, she put it on the list that would be Wunderlist. [00:09:00] And when I was shopping and I picked up the bananas, I clicked the box and she knew that I got the bananas and there was this like, magical moment where like, gosh, how does this not exist in healthcare? How do we get this clarity of purpose for all the tasks that we have to manage? And that was the inception of it.

We need a task management tool for healthcare. We need something that allows us the clinicians to work better with our administrative teams to reduce the administrative work, to have clarity of purpose, to have structure, accountability, all those things. And there’s a lot more in there, but ultimately we had the resources at Boston Children’s Hospital to actually build out what we call an MVP in the world of software development. It’s a minimal viable product. What is the least possible work you can do to create something that will prove the value of what you’re trying to do.

At first, I was just using Wunderlist. Initially, it was literally asking my nurse and my admin. Hey, would you do this? Share your task list with [00:10:00] me. And let’s not use our real patient names because it’s not HIPAA compliant. It was powerful. It had its own challenges, which is it wasn’t HIPAA compliant. But when we were able to prove the concept, and then we sought out to build a HIPAA-compliant task management tool. The rest is history. I’m sure we’ll have more time to get into it, but I was really trying to solve my own problem. And it’s always clear how you get there, but it was a meandering path initially.

Dr. Sharp: Yeah. It makes me want to ask. There are a few things that jumped out from everything you just said. One, the piece about working in finance before you went to medical school. Was that deliberate? Did you know that was going to be a path? Was that a plan? And if so, why?

Dr. Mike: No, the plan was… Well, fortune favors the prepared mind is my mantra, but things happen for a reason. I was [00:11:00] thinking for me, I didn’t do well on my MCATs the first time I took them. So, I had a year to study and I had a year to figure out what I was going to do. So I applied to med school the first time, I didn’t get in. And I said, okay. I can take my MCATs again. And I’m going to spend the year and enjoy myself and do something that I’ll probably never get a chance to do if I’m really going into a career in medicine, which was the plan all along.

And so I had just graduated college. It was from the New Jersey, New York area. And so I said, I’m going to move to the city like everyone else. And I found a job working downtown right by the World Trade Center. And it was with this offshoot of JP Morgan. And I had really no real interest in the job, but it was a great opportunity. I wanted to learn some business skills because everyone else told me that doctors had no idea about how to run a business. I thought it’d be good to be exposed to that. It was of interest to [00:12:00] me to be financially savvy. And it was just a great time because I had a 9 – 5 job and I could study and prepare for the MCATs, which ultimately I took again, did well enough to get into med school and the rest is history.

Dr. Sharp: Right. Do you feel like you took anything from that year, specifically that you can remember even now that knowledge from the business world translated easily or that has been particularly helpful in your clinical work or just the work that you’re doing now?

Dr. Mike: Yeah, I got really good at Excel spreadsheets. To be honest with you, it was more of a life experience. Just seeing what the business world was like. Right out of college, I was making good money and was more money than I was going to make for the decade to follow, which is just bananas.

So to me, it was just a great window into how the rest of the world [00:13:00] functions. And even at that time, this was back in 2000 which got scary how long ago that actually was, but it just makes me like there was decent technology at that time. And certainly, as you stepped into healthcare, you realize how antiquated and how a time warp it was to do anything in medicine.

I mean, at that time, when I went into medical school, which was just two years later, in the clinical aspect of things, we’re still writing paper charts and all. And so that was still pre-electronic health record days from early 2002 to 2003, when I was doing my initial clinical work. So exposure, I think in healthcare, is just one of my big ideas but certainly something I feel strongly about. In healthcare, we feel as though we’re special, we need to recreate and reinvent technology.

My mantra has always been, what’s learned from other industries that have [00:14:00] spent billions of dollars and have perfected these things over time? Why are we so special that we need to reinvent the wheel? Let’s take those learnings from other industries and apply them to healthcare. And that’s basically what we did at Dock Health.

Dr. Sharp: I love that. There’s a lot to dig into with that as well. I’m trying to hold off because I have these other questions. You sound like you’ve diversified your work quite a bit, and that’s been present ever since the beginning. Were you just a tech-minded individual? Did you have any background in programming? How does one stumble from gastroenterologists to IT and leading these divisions on innovation and whatnot?

Dr. Mike: I was always a technology-oriented person. I always loved technology. And my wife always jokes, like if I could have a tool to do some mundane task, I would do it like automatic, spun [00:15:00] little scrubber tools and things like that. So I’ve always been tech-oriented and I came by it honestly in full disclosure, I don’t know how to code. I’ve tried to take courses and that invariably failed. And so I’ve learned that it’s important to surround yourself with smart people and so that’s my claim to fame in developing any software is having good ideas and helping other people, designers and engineers build.

But for me, it was really just a real interest and it sparks following these things and then becoming an expert just in, I was in the early days of digital health. I remember being in the lab, studying this oral microbiome of inflammatory bowel disease, which was fascinating work and innovative and insomnia, but I have an opportunity to do something in a more traditional sense than academic medicine, which is getting an NIH-funded grant [00:16:00] and be a microbiome expert while I practiced clinical medicine or like go down this new and really exciting and interesting road of like digital medicine, which at the time, or digital health or health IT, whatever you call it. But that was a total novelty. So I had the option of being a new guy, blazing a trail in something that I was passionate about and excited about, and so opportunity versus being the lowest guy on the totem pole in an NIH-funded grant cycle. And for me, the choice is clear. I think I made the right one.

Dr. Sharp: It seems like it. It seems to be working.

So, let’s transition a little bit to talk more specifically about the tool that you all have created, Dock Health. And I’m going to back up and ask a philosophical question. Why do you think healthcare is so bad at this type of thing, at task management, coordination of responsibility, and so forth? Why are we struggling with this?

Dr. Mike: [00:17:00] It is amazing and really unfortunate because we are so bad at it. And I think for those that are in health care, we often try and avoid it as much as possible. Meaning, if you work in a hospital, you know it’s amazing things happen as well as they do, and gosh, we do anything possible to avoid it. The reality is we go into this with the best intentions, right? I went to medical school to look patients in the eyes and to help them in their journey. I didn’t go into it to document notes or dictate or type or do bills or never mind all the administrative stuff that we talk about. And that administrative work in my 20-year career in medicine has just probably 10 X in that time. It just continues to get worse and worse.

If you look at the system that we have, we have the electronic health record [00:18:00] which was built to be a clinical system for physicians and nurses, and clinicians to document, to bill, to review labs, to place orders or prescriptions. So that’s the core offering of electronic health records. And then we have these other systems to somehow manage the rest of healthcare. We call it the Dock health, the other half of healthcare, and that’s all the administrator to do that comes as part of clinical care.

For every prescription I write or order a place or thing I tell a patient to do, they’re actually many administrative tasks that have to be done by someone. Sometimes it’s me. Sometimes it’s someone at the front desk. Sometimes it’s an insurance person or a scheduler or what have you. There’s a team of people and arguably it’s 10 X with the number of providers or clinicians are who have to manage all those tasks and make sure that those things get done in order for that clinical thing that I wanted done to get actually [00:19:00] done.

And so, the tools that we have are things like email and post-it notes. And in many cases, electronic health records have an email function or an inbox function, which is like emails from 1996. But those are the tools of the trade and unfortunately, we don’t have anything collaborative or secure or really oriented around what these things ultimately are, which are tasks. And everything in healthcare is a task in our mind, fill out this form, do this study, call on this prescription and do this prior authorization. It’s all to-dos. And it’s a question of who’s doing it. And unfortunately, as providers, clinicians, we place the emphasis on the patient.

Hey, call my office in a week and check-in and see if that lab man came in or can you call my office and schedule your next appointment, or, Hey, I’m referring you to this physical therapist, call their office and make sure that they’ve got the form that they were supposed to get. Those are all to-dos. And unfortunately, we put pressure on the patient because we’re terrible at it as clinicians and providers. We’re terrible at managing all of that stuff. And so we say here is a patient who may or may not have the wherewithal or the resources to do those things, make sure you do this thing because we’re not reliable.

And so to me, that was just tragic. And when you look at other industries that have systems in place, whether it’s collaboration tools for communication or it’s collaboration tools for task management or project management, those are all things that have been invented. We didn’t do anything noble at Dock Health, we just applied it in healthcare, built it to be HIPAA compliant, built it to have the context of healthcare and obviously the workflows and integrations that are necessary for health care. But ultimately, healthcare needed to do something to manage the other half of healthcare, which is essential to [00:21:00] make the other clinical piece work.

Dr. Sharp: Right. I think people are probably getting a decent sense of the software, but I’d love to hear just straight from you. How would you describe this? What does Dock Health do and how does it fit into our practices?

Dr. Mike: Well, I appreciate the question because it is a novelty still in healthcare, this task management concept. So it’s helpful to do our best to explain it. At the end of the day, as I mentioned, everything in healthcare is a task. So for us, we’ve created a system that allows you to create a task, fill out this form, submit this prior authorization, call this patient back, schedule this, give that task patient context- that’s either done through an electronic health record integration where we allow smaller and medium-sized practices to just upload their patients into Dock Health.

So it’s creating this task, assigning this patient or receiving [00:22:00] associate this patient and then assign that task to someone on the team. It could be something that I have to do to remember. And for me, a lot of how I use Dock is, just remember to call this patient back and remember to fill out this form, remember to do this letter of recommendation for a resident that I was working with.

All the to-do is that that cognitive burden which Jeremy asks you to talk about some of this stuff, the cognitive burden the stress anxiety and I think subsequent burnout for providers is a lot of just managing all those to-dos and trying to figure out how to do it. So we give people the ability to just drop it into a secure place instead of carrying around that anxiety and all the to-dos that I have. Let’s figure out what the to-dos that I or my team have to do. If there’s something that I can assign out to someone I do that. If there’s a workflow or a more structured process or protocol that we have to follow, let’s create that structure so that we can follow these steps and know [00:23:00] where that thing is in flight. Know who’s responsible for what and close the loop. This is a concept that is so important to our own mental health. It is like not knowing that something that needs to be done for my patient is done or not is like a powerful thing.

And for me, it was a major source of my own burnout, frankly. It was like, I wanted to do the best for my patients. Feeling like I couldn’t because of the system. And then just being stressed and anxious about other things that I asked my colleagues to do for my patients, did they do that? And so we just create that structure. We create the ability to create a task, add a patient, assign it to someone. And then when that box is checked and you get notified, you know when that thing is done and there’s a longitudinal record at the patient level. So we know what we’ve done for patients over time, there are audit trails. So you can see how long this process took and hopefully, understand the bottlenecks and the efficiencies or inefficiencies of your practice and where we need more [00:24:00] resources, but it’s something super simple. It’s basically a shared to-do list, but we make it much more powerful with the healthcare context.

Dr. Sharp: I love that explanation. The way that I’ve conceptualized it, I don’t mean to compare to existing tools necessarily, but is something like Asana, for example, or you mentioned Wunderlist in your life, but it’s something like that except kind of on steroids and specifically for healthcare and its HIPAA compliant, which is crucial.

Dr. Mike: Yeah, for those that know what Asana is, and it’s shocking to me how few people don’t know. Asana is a publicly traded company. It’s an awesome tool. They’re not built for health care and that’s part of what makes us unique and awesome. I actually did a survey. I did a Twitter survey not that long ago and actually asked health care providers on Twitter if they’ve even heard of Asana [00:25:00] and I forget the numbers, but it was something like around 75% had never even heard of it, let alone used it.

So again, this speaks to when folks are in the clinic. You and I are clinicians who have a business mind and have practices to run. And so we’re looking for some of these tools but many of my colleagues and certainly many clinicians out there, I don’t think have any idea as to these tools that are out there. And this is why people are looking to reinvent the wheel, especially in healthcare, which I think is worth borrowing from a great company like Asana. All the things that they’ve educated the world on and then certainly transform industries let’s supply that in healthcare.

Dr. Sharp: Right. That’s a good point. I should know this. I’m shocked when you say those numbers, but I should know that, right? Like we’ve had discussions on the podcast before about systems [00:26:00] and have had a few guests over the last two months just about systems and the importance of systems. And I get a lot of feedback from the audience that makes me think, this is not on people’s minds. These ideas are revolutionary which is awesome.

Dr. Mike: I would put forth that in medical school, we should have courses running a business, on cost management, for example. I would love, and in fact, we’re offering it to any trainee out there in the world, Dock Health is free to any trainee in the world. I want people to understand as they’re learning their behaviors, as they’re learning their skills that they will take out into the world to help patients be thoughtful and structured about how you run your operations, how you manage all your to-dos, how you manage your cognitive burden, how you work well and collaborate with your team.

These are all skills that we don’t learn in medical [00:27:00] school. And unfortunately, we’re just run right into the fire and we learn to know a lot about the clinical stuff, but there’s a whole lot around how you run a business, how you run your own self, and how you manage your time, unfortunately, it’s not taught in medicine.

Dr. Sharp: Let’s take a quick break to hear from our featured partner.

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All right, let’s get back to the podcast.

Well, you mentioned the cognitive burden and in our world that falls under working memory as a cognitive construct, all those simple things we have to keep track of. And I often think of both The Checklist Manifesto, I’m guessing you’ve seen or read that it’s right?

Dr. Mike: It’s right over there. I’ve just got it. I have to read it.

Dr. Sharp: Right, but that whole idea that once you operationalize and take those items out of your mind and put them on paper or on a computer screen, that frees up the cognitive load and increases the quality of work that you can do. So you’re not worrying 100%.

Dr. Mike: Yeah. I used to tell the story if you’re going to indulge me for a minute. I [00:29:00] used to leave work on a Friday afternoon and literally feel the stress and anxiety that I had no doubt was going to forget something over the course of the weekend. And some poor patient of mine was going to end up in the emergency room or the parent was going to call and they’re frustrated that I forgot to call on a prescription or something like that. And that anxiety was palpable. And I think again, led to my own burnout in some ways.

When we were creating Dock and when I started using it in my clinical practice, that feeling went away. That weight on my shoulders on a Friday afternoon. Because I could leave and I may not have done everything, but I knew what had to be done. I knew who was responsible for it. And that feeling of just dumping your cognitive load into a system where it’s secure and where you know that you or your colleagues are going to manage it, it was a powerful paradigm shift for me to really just feel that comfort of [00:30:00] knowing not necessarily that I’ve done all the work, but then I know what needs to be done. I know who’s responsible for it. And I have that loop closure thing, which I mentioned was powerful.

Dr. Sharp: Right. Which is also a real cognitive phenomenon. We want to close loops that eat up a lot of resources in our brains.

Let me ask a meta-question before we dig into more details around the software. How do you recommend it to people or how did you personally even just get in the habit of using a system like this? Because that’s a leap for people too who may not be used to it or they’re doing post-it. How do you even start?

Dr. Mike: I think it’s hitting bottom. The truth of the matter is I have colleagues, bless their hearts, who have systems already in place. I have one colleague that carries around a black book like this, and she takes all the [00:31:00] little stickers from her clinic charts and she puts a sticker in the book, and then she writes a little box next to it, and she writes the to-do’s that she has for that patient. I don’t think that’s going to scale very well. And certainly, God forbid she ever lost her black book, but that’s a process and assistant that she did.

And for me, I was not like that. I was someone that remembered everything. I just had cognitive lists running in my head and I’d be in the shower and I’d be like, I forgot to do that thing for that person. Then you have these momentary lapses and then suddenly you recall something that you’re supposed to do like two weeks ago.

So to me, it was really intentional about needing a system because this is currently not working. And frankly, Dock Health again was really a solution to the problem I was trying to solve. I needed a system. I wasn’t a paper guy. I’m very much a digital, mobile guy. I needed an app [00:32:00] and I needed an app that was secure and I felt safe that I was protecting my patients’ privacy and data, and there is nothing out there.

To answer your question, I think it’s just important for people to recognize their own weaknesses but also just the reality of the system which is that, unless they have a panel of three patients, no one can manage all the to-do’s that they have. And no one can collaborate and work with their team with the current tools that we have, email, post-it notes, et cetera. No one is handing you back that post-it note with a checkbox and saying, here you go. I did it. I think for me, it was really, again solving my own problem. And I think if I had to hit bottom. I was getting emails from my colleagues and parents of my patients like, Hey doc, third request in big caps. I was like, [00:33:00] it feels terrible. I like to think I’m a really good doctor. And I started feeling like I wasn’t a good doctor because I wasn’t able to manage all of the to-do’s that came as part of the doctor.

Dr. Sharp: I think that statement right there is one of the most poignant of this whole interview, that people will probably really resonate with that. I think we’ve all had that experience. And I know that I have woken up early in the morning with that panic of, I didn’t do this or somebody is counting on me or what did I forget? I think it’s ubiquitous.

It’s interesting, just to put some numbers to this, in our collaboration I’ve been building out some workflows for a testing practice, and our testing workflow from start to finish for an evaluation I think it’s like between 20 and 30 steps. That’s a lot of things to do when you actually write it all out. And I was like, “Oh my gosh.” And if you’re seeing 4, [00:34:00] 5, 6, 8, 10 people a month, that’s a lot.

Dr. Mike: Yeah. Now add in the fact that in an ideal world, you’re working with other people. I add a social worker, into my world a dietician, and a surgeon. There are so many players all trying to get on the same page with this one workflow. In my world, it was prescribing an infusion to a Crohn’s or colitis patient. And just thinking about all the players in that and how dis coordinated and just all over the place we were and getting buried in replying to all emails and things, it’s just bananas and that’s healthcare. I mean, your neuropsychology work and in my prescribing biologics, are just two silly examples of the broader challenges of coordinating staff in healthcare. And email is not the way we do it.

Dr. Sharp: Oh gosh, no. And anybody who’s spent time, [00:35:00] I worked in a hospital for a few years here until just recently doing evaluations over there and working in Epic is a nightmare. I don’t know those systems aren’t there.

Dr. Mike: I can just call them out for a moment, it’s a great electronic health record and they certainly have the lion’s share of the market and they use larger academic centers, but they’re not managing tasks. They’re not helping. They have an inbox and I think for the naive and the people that don’t understand task management, they say, oh, there is nothing to do this. And very declaratively, I will tell you, well, how does Epic manage like remembering to call back a patient or filling out a form or doing all the 20 steps of a neuropsychology evaluation, like there are the clinical pieces and it’s great for that, the same with Asana and all the other EHRs. But there’s the administrative component, the other [00:36:00] half of healthcare, which I don’t think they have any idea about. And certainly, they’re not being mindful of all the people on your team and staff that are trying to coordinate and collaborate in this effort. And there is no system until Dock, really?

Dr. Sharp: I want to highlight two features that have jumped out to me that you’ve spoken a little bit about. 1) You just mentioned this collaboration with other disciplines. Can you explain how that works in the Dock system?

Dr. Mike: Yeah, the way that we’re structured is you create a list. A list can be any number of people on your team that’s brought into the list. On the lists are a number of tasks and those tasks on a patient context. So if you are running a small practice and you have a list of the people in that practice, you just can create tasks for patients in that list.

But what we also do is find that many practices are working with a [00:37:00] virtual assistant or they’re working with a billing company or they’re working with a compounding pharmacy or a radiology practice. Those are collaborators for patient care that we’re faxing things back and forth and picking up the phone and literally snail-mailing paper between those organizations, but they can be invited as a guest into Dock and they can have a secure view of the tasks for those patients in that list and share documents, share comments. So real-time communication, really those tasks now become the things that move between those organizations seamlessly.

And we let guests, at least for the moment, guests are free and unlimited. So if you use Dock in your practice, but you coordinate with this therapy practice over here or this virtual assistant over here, you can create those secure collaborations really at scale and eventually, not yet, but eventually, we’re going to bring the patient into that story [00:38:00] so that we can create tasks for patients because ultimately, while they shouldn’t get as many as they get today, they should be aware of the tasks that they’re actually being assigned and who’s doing what for them. And ideally be a contributor into the process where clinicians and the team have insight into what the patient is doing, what they’ve done, and arguably, there are some things that we as the clinical team need to give them to do.

Dr. Sharp: I love that idea. That is one of the things that jumped out to me. It was just the ability to have external folks join these lists because I know for us, just to bring it to life a little bit, we have contracts with two entities in our region, let’s say so a local DHS department or something, they’ll refer someone for an evaluation and then they will send us emails asking where we’re at in the evaluation process and it’s, I can’t even think of [00:39:00] the way it is, it’s annoying and time-consuming to have to respond and say, well, we’ve called this parent, but haven’t gotten a callback and we’re about to schedule testing, but it’s not, so…

Dr. Mike: That’s a perfect example. That’s like in the Dock world, you would create a list. You’ve been invited that DHS group or an individual from that organization into a list and you’d have a workflow built out for your evaluation process and they would then be able to see with perfect clarity that Dr. Sharp is on step 3 of 9. They could even place a comment and you can share documents seamlessly between those two organizations in a secure HIPAA compliant version. It takes all the friction and pain.

For me, I guess I’m easily frustrated. Maybe that’s my problem. Like, I just can’t believe that we do things like that. And I can’t believe that I spent all this time doing those really mundane and meaningless [00:40:00] tasks that ultimately of course, but for the patient and that’s why we do it, but it’s just unnecessary friction that we could be taking better, more reliable care of our patients if we had a thoughtfully structured process in order to do it.

Dr. Sharp: Right. It makes me think. I interviewed Natasha from Systems Rock two months ago, I think. And she said something along those lines about how we have these “systems”, but they don’t work well. There’s a lot of friction, but it’s like sunk costs. We have trouble getting out of it and it feels overwhelming. But the other options are just so much easier if we just take a little time.

Dr. Mike: Yeah. It takes inertia. That’s a whole nother topic. We’ve talked about change management. It’s difficult to get people to take on new things but the incumbent systems and processes are so [00:41:00] painful and so unreliable and often so insecure that it’s got to happen. And so for us, it’s just hopefully helping people understand the value and helping them overcome the inertia. And then the value is immediate and obvious.

Dr. Sharp: Right. You mentioned a little bit ago the concept of EHR integration as well. Can you speak to that?

Dr. Mike: Yeah. Unfortunately in healthcare, that is where we spend time. There’s good data to speak to how much time we actually spend there but it’s far more than any of us would care to. And so the reality is that you need to be integrated with the electronic health record in many cases in order for clinicians, particularly those in academic medical centers and places where there’s such a dependency on the EHR, you need to be integrated into those systems so that you can pull the patient [00:42:00] context and you can be embedded in the system so that they’re not going to find other things. And so when I was the Clinical Director of the Innovation at Boston Children’s Hospital, it was always like, the doctors don’t have time for another thing, so you have to embed. And so for us, it certainly is an area of a lot of work and interest in […]

And really what all that means is when you’re in a patient’s chart and you’re in the workflow of caring for them or looking information up or documenting or billing, you’ve got access to the task list or the to-do list in Dock Health with patient context. And still, you’re not going to have to log in to another place and shift your focus and attention. You’re doing an embedded. And our hope over time, and certainly, lots of work is going into this, is how do we start reducing the work for the clinicians and those we call providers, providers are really anyone helping to provide care. And so I don’t think providers are [00:43:00] just doctors or nurses or therapists. Providers are the people at the front desk and the people who help you schedule your appointment. Providers all need to be on the same system.

And so how do we help them all work together? And to me, it is the patient context that comes from the EHR and it’s giving them a secure place to do all that work together and automating more and more of that over time.  When I place an order for Remicade, which is an infusion I was talking about, how do we then kick off all the administrative tasks that are so important for that thing to actually happen? And it’s currently being done by just crossing our fingers and hoping it works because it has in the past usually.

So how do we automate some of these tasks based on orders or events and the electronic health record? That’s the next level for us. But at the same time, we don’t require electronic health records integration. And that’s part of what I think makes us special, particularly for [00:44:00] smaller practices that may or may not want to go through that effort. We just allow a practice to upload the therapy patients in an Excel file. And that way they have patient context when they’re creating tasks. But they’re not having to go through a potentially expensive process or lengthy process to do an integration with the EHR.

Dr. Sharp: I see. I would love to see mental health EHR be more open to integration, to be honest. I think historically, we operate in a fairly closed software system and has been cumbersome. In the beginning, I’ll understand, but yeah, I’m sure you will…

Dr. Mike: Yeah. Well, I think increasingly we’re going to see pressure from the government to mandate that EHR have APIs and have given a patient access to their data and give third parties access to their data so that they can integrate into it. So this is what we’re doing with Cerner and Epic. [00:45:00] we are talking to some mental health EHR and there are some good ones out there. And our hope is to integrate with them. We have APIs available that allow that to be quite easy from a technology perspective. But yeah, it makes for a more seamless experience for everyone. And hopefully, we add value to not only the EHRs but the providers using it.

Dr. Sharp: Sure. Well, I wonder, just as we may be starting to close, what are some other features? We’ve talked about a lot of things, but other things that you see that set Dock Health apart that might be unique that might be helpful for us that we should know about?

Dr. Mike: Yeah. First and foremost, it’s really important to us to make sure that we help providers and practices to overcome that initial inertia of not knowing how to use task management tools. And so [00:46:00] certainly what makes us different from Asana, we have a white glove concierge-like experience. So typically you will offer people at first a demo, understand their practice, figure out what are their error-prone workflows, are their challenges, and help them design a system in Dock that allows their team to work more efficiently and productively. And so that’s white-glove experience is really something that I think is essential because otherwise people would be scared off from taking on something new.

The other thing is that we’re ridiculously affordable. We’re $20 per user per month, which in a healthcare context is orders of magnitude cheaper than even the non-healthcare task management tools that are out there. And we don’t want price to be a barrier for people to use something that I think is ultimately going to improve patient care and improve their own lives.

And little things like we integrate with email, so you can forward an email to Dock and it [00:47:00] automatically becomes a task. People do that manually. For me, I’ll get a hundred emails a day but five of those are clinical tasks I have to remember to do. And I’ll just forward those to the Dock and they become a task and I can then manage and follow and put due dates on and all that. But we also do that at scale and we automate things so that if you get an email from say, […], it’s the most common thing, but someone fills out a form for a new patient visit request on your website.

That generates an email. And then someone has to go into your email and transcribe that email onto a post-it note and then call that patient back and track that whole process. We just automate that so that when that email comes in, it goes to the new patient visit requests list in Dock Health. It’ll automatically assign that task to someone in your practice. And that way that process becomes super automated and super reliable where it [00:48:00] used to be super manual and super unreliable.

So those are just some basic features, but every week we put out new stuff and we’re working hard to integrate with more and more systems that matter to people.

Dr. Sharp: That’s great. That last little bit about automating the clients but acquisition, that’s pretty magic and exciting.

Dr. Mike: Yeah. Sorry to interrupt you. The other piece is just the data because we’re turning manual things that are done in a not codified sort of antiquated or analog fashion, we’re turning it into digital. So you now know how long certain tasks take, you know how long a process will take, who’s responsible for what? And we’ve got all the data that we’re happy to share with the providers to know where the inefficiencies are, where the bottlenecks are, where we [00:49:00] need more resources on this piece of our practice because it should take three days since I’m taking seven days. Now we can show all that.

Dr. Sharp: I love the data you’ve got. That catches my interest right off the bat.

So, where are y’all headed in the future? It’s already a full-featured piece of software, but what’s on the horizon? What are you working on?

Dr. Mike: I think the focus in the short term is really integration and automation. It’s really increasingly making the product more valuable to the users whether it’s integrating with the HRS or just integrating with folks who talk about different forms that they’re using that they want to kick off workflows. So for us, it’s what are the triggering events that can kick off a workflow that brings a team together on working on a process and be more structured and thoughtful about it.

I agree and thank you. It’s [00:50:00] already a solid foundation but I think for us, it’s just making it easier to bring more and more of the ecosystem into Dock and allow us to be the hub for all this stuff a practice needs to manage a lot of the stuff that again is the other half of health care that no one’s really been thinking about today.

Dr. Sharp: Right. That’s exciting. I’ve enjoyed this conversation. And just personally, I love talking about this stuff and dreaming about technology and how that might help us. So this was an easy one for me.

Dr. Mike: Right there with you.

Dr. Sharp: Yeah, that’s great. This is the direction we’re headed. I always say, get on board now and figure it out as early as you can because this is where we’re going.

Dr. Mike: Yes, 100%.

Dr. Sharp: Well, Mike, thanks so much for talking through all these ideas and your story and the software that you’ve got going on. It’s pretty [00:51:00] exciting. I really appreciate it. I hope people are taking away some gems from this one.

Dr. Mike: I sure hope so. And thank you for the opportunity. As we mentioned, it is the early days of this concept in healthcare. So I appreciate you helping us get the word out and an opportunity to explain some of this. It’s been great.

Dr. Mike: Sure. We need to hear it. All right. Thank you.

Dr. Mike: Have a good one. Thank you.

Dr. Sharp: All right, y’all thanks so much for listening as always. I hope that you took a lot away from this conversation. This software is pretty amazing from the experience that I’ve had with it so far. It’s frankly, in the early stages and I’m excited to see what comes from this point because it is already pretty comprehensive and super helpful in our practice.

Again, if you want to get the built-in workflows that I have designed for Dock Health, you can go to [00:52:00] dock.health/the-testing-psychologist and you’ll get a free trial and a demo to walk through everything. And again, those built-in workflows that I developed specifically for testing.

All right. Hope you enjoyed this one. Stay tuned, subscribe to the podcast so you don’t miss any upcoming episodes and I’ll look forward to talking with you next time.

The information in this podcast and on the Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is [00:53:00] intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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