Dr. Sharp: [00:00:00] Hey y’all, welcome to another episode of The Testing Psychologist podcast. This is episode 46. I’m Dr. Jeremy Sharp.
Before we get into today’s episode with Dr. Serena Enke talking all about bariatric evaluations in your private practice, I want to give you a heads-up about The Testing Psychologist mastermind group. This is a group coaching experience starting March 1st. We’re going to meet every other Thursday from that point forward until the end of May.
This is a group consulting/coaching experience where you will be meeting with myself as a facilitator and up to seven other testing clinicians who are focused specifically on building testing services in their practices and consulting on issues that are very relevant to testing folks. So if this is interesting at all to you, go to thetestingpsychologist.com/mastermind to find out a little more.
All right, on to our episode with Serena.
[00:01:00] Hey everybody. Welcome to another episode of The Testing Psychologist podcast. I’m Dr. Jeremy Sharp. Today, I have with me Dr. Serena Enke. Serena is an old friend of mine. We met our very first year in graduate school and we went through graduate school together at Colorado State in their counseling PhD program.I have worked with Serena in graduate school and then we’ve chatted a few times over the years, and at this point, it’s been cool to see she’s in private practice in California and also works at the VA, right, Serena?
Dr. Serena: That’s right.
Dr. Sharp: So we’re going to talk all about bariatric evaluations today. First of all, Serena, thank you [00:02:00] so much for coming on the podcast.
Dr. Serena: No problem. I’m happy to be here.
Dr. Sharp: It’s good to see you here or talk to you here. I was talking before we got started here about interviewing Rachel as well. I’m not sure when these episodes might air related to one another, but for me, this has been a throwback week to all of our CSU alumni, which has been nice reflecting fondly on graduate school, all those relationships.
Dr. Serena: I was thinking about that recently because that’s one of the things that we got in graduate school that a lot of people didn’t is a lot of assessment experience and it’s ended up being incredibly valuable to me career-wise for sure.
Dr. Sharp: I totally agree. That’s funny, right now I have two CSU graduates who work in our practice and we’ve had some conversations too about how our program prepared us well for assessment. [00:03:00] It’s been hard as I’ve hired other folks and read through a lot of applications and reports and things like that. It’s become more clear that we got good training in assessment. I’m super thankful for.
Dr. Serena: Yeah, agreed.
Dr. Sharp: Today, we’re going to be talking all about bariatric assessment which is admittedly something that I know very little about in terms of the ins and outs, how you do it, and what it looks like. So I’m super excited to be talking with you about this.
Before we totally jump into it, can you maybe just talk about what your professional life looks like at this point, how you spend your time, and what your practice looks like?
Dr. Serena: Sure. I am half-time at the VA, so I do 20 hours a week at the VA. I’m at a CBOC, which is a Community-Based Outpatient Clinic, so I’m not at the main hospital. I’m at a little clinic that does primary care and mental health and that’s it.
[00:04:00] There, I do a bunch of groups like anger management, and anxiety management. I do an acceptance and commitment therapy group, and then I do some individual therapy, including telehealth. I’m the only person there who does telehealth over the computer for people who can’t make it into their appointments and whatever.Dr. Sharp: Did you do a separate certification or training for that?
Dr. Serena: I did. The VA requires that. We have an online training thing that we do for that.
Dr. Sharp: Got you. Okay.
Dr. Serena: It’s been good. The technology’s changing such that there’s a new system that the call quality is a lot poorer. So I’m not that thrilled with it right now, but in general, I’m pretty happy with it though. So that’s my VA job.
What’s interesting is I did learn bariatric assessment and spinal cord assessment at the VA. Not really though, because I was going to do it there but I knew I was going to do it in private practice. So I had some freedom with my time in that period and I used some of my [00:05:00] VA hours and petitioned people at the VA to teach me.
So I shadowed them and got materials from them and sample reports and templates and all of that sort of stuff. Even though I never did these evaluations for the VA except while I was training to do them because it wasn’t a part of my VA job and it’s still not a part of my VA job. So at this point, now that I’m not in training anymore, I don’t do for the VA at all and that’s very deliberate. They certainly need people to do them, but I am so incredibly booked at the VA that for me to spend my time on that. So that’s my VA job.
And then the rest of my time is in private practice. So I’m halftime at the VA, which I do over three short days and then I have two long days of private practice that are typically 10, 11 hour days easily.
Dr. Sharp: Oh my goodness.
Dr. Serena: Oh, yeah, and I was back to back for 10 hours, which I don’t know that I’d recommend.
Dr. Sharp: Well, there’s [00:06:00] something to be said for batching but that might be taking it to the extreme a little bit.
Dr. Serena: I’m pretty darn efficient with them right now. They used to take me three hours each so doing three in a day was like plenty, and that was a full day for me. I would do my interviews and testing and then write-ups and whatnot. And overall, those three evaluations would take me typically about nine hours, which I’m okay with but I’m more efficient now than I used to be. Now I can pack in four and have a pretty decent day.
And then if I’m feeling overambitious or to be honest, it’s like this is horrible but it’s pressure from patients who are like, oh my goodness, you can’t get me in for a month and a half. Don’t you have anything sooner? I want to get this done or whatever. I might be like, oh, okay. I’m at the end of my day and I’ll see how my people are scheduled in a row.
I don’t do that as much now. I try not to [00:07:00] because I now have a better system for filling in canceled spots. So now if I have a day packed full of people but the day before, I have an automated reminder system that people have to confirm their appointments on and they’ll also cancel their appointments. I keep a list of people who want to get in and it’s almost exclusively evaluation people.
If I see a cancellation, I’ll just go to my cancellation list, text somebody, and be like, hey, there’s an opening tomorrow, ten o’clock, do you want it? And they’ll take it. So now that, I’m less likely to book five evaluations because each of them books for two hours. So I’m less likely to do that now. I’ll just do four and I’ll know that I will see four because I’m going to fill in so anybody who cancels.
Dr. Sharp: That’s a good system. Do you maintain that yourself or do you have a VA?
Dr. Serena: Oh gosh, no, I do everything myself right now, everything. I do insurance verification, phone calls, et cetera. I’m trying to move away from this. [00:08:00] I’m working on incorporating. I need to expand. I have way more business than I can handle. I do everything myself and it’s not a good thing right now actually.
Dr. Sharp: Well, that’s a big can of worms. Maybe we can talk about that another time.
Dr. Serena: Yeah. Oh, anyway, you asked me how my time is spent though. In my private practice right now, over those two roughly 10-hour days, I do at least half of my time but probably closer to two-thirds doing evaluations and then the rest of it’s therapy. I’m doing mostly bariatric evaluations but I do more and more spinal cord evaluations as well.
I would say normally each week; I have one full day that’s just nothing but evaluations. Typically, Thursdays are my evaluation day. And then Tuesdays, I’ll have therapy but I typically have one or two or sometimes three evaluations on those [00:09:00] days as well. Right now, I’m typically only seeing maybe four or five therapy patients a week in the private office, that is
Dr. Sharp: Sure. So it sounds like you’re doing a lot of bariatric evaluations and spinal cord evaluations, but you’re steeped in that world right now.
Dr. Serena: For sure. I like it that way. It’s low-stress in a way for me. That’s one of the reasons I like them. I can never have anticipatory anxiety about a bariatric evaluation because I don’t know the person. So I don’t even think about it before they come in.
I don’t have to sit there and be like, oh gosh, what are we doing in this next session? Where are we in this protocol or whatever? No, it’s the same thing every time. The same questions. It’s not like they’re not hard because some are very challenging but I don’t worry about it ahead of time. So it’s very low stress for me.
Dr. Sharp: That’s great. Low stress is good.
Dr. Serena: And it pays more too, which I also like.
Dr. Sharp: Oh my gosh. The magic combination, geez. Well, let’s talk about this then. Gosh, I have a lot of [00:10:00] questions; what does the process look like? Can you give just an overview of how you get from start to finish with a bariatric evaluation?
Dr. Serena: Sure. I get a referral. It’s typically, I’ll get a little notation that’s faxed to me saying, hey, you’ve got a new referral, but I don’t even depend on that. Every time I’m at work, I log into these two insurance companies’ websites, and I see what my new referrals are.
I print those out because I keep my phone log for people that I have not seen, they’re not my patients yet. I notate when I’ve called them on paper and I don’t keep that in my EHR until they become my patient, until I’ve seen them.
So I print that out and then I make a contact attempt. So I call them and try and schedule. Sometimes they call me first. That’s cool too. And then when I get a hold of them, I do a phone screening [00:11:00] which is to say, okay, hey, are you still interested in surgery? They typically are except for the spinal cord patients where a lot of times they’re like, oh, I don’t know. My doctor wants me to do this but I don’t know but the bariatric patients are almost always like, oh, yeah, I really want this.
And then the big question for the bariatric patients is okay, have you completed your pre-surgical weight loss program? Because I need them to have done that first.
Dr. Sharp: Is that pretty standard? Other people in the country also want to ask that question or is that specific to the insurance plans you’re working with?
Dr. Serena: Oh, yeah. It’s pretty standard that most insurance companies nowadays want you to have done six months of a weight loss program before surgery. You can get that shortened to three months if you have other factors. So if your BMI is over 50, that we’re talking people who are pushing 400, 500 [00:12:00] pounds. Sometimes, yes, some people over 400 rather BMI over 50, or if you have a pretty high BMI but a lot of secondary health issues; untreated sleep apnea, uncontrolled diabetes, other things like that, you can get that your requirements shortened to three months.
I do suspect that it’s actually going to be national because the vast majority of the people that I see are Medicaid or for here in California, Medi-Cal but those requirements are a national thing for the Medicaid patients.
Interestingly, if they have Medi-Cal, Medi-Cal won’t allow pre-surgical requirements. So if I have a Medi-Cal person, they oftentimes don’t have a weight loss requirement. And that puts me in an interesting spot because I still have to evaluate their ability to make behavioral changes. A lot of times they have gotten exactly zero guidance on what changes to make because they’ve never been through any sort of weight loss program. It’s a very interesting spot.
I talked with the guy [00:13:00] who got me into this, who’s the director of UM at a local HMO for Medi-Cal and Medicaid. He’s the one that recruited me for this job, if you will. I’m a contractor obviously, but still and he said, I know that we can’t require these people to do this program but that’s one of the big important roles that you play is that you can tell us, hey, yes, this person hasn’t done a program but there’re still reasonably well prepared or no, they haven’t done a program and it’s going to bite them in the butt.
They really need some help because if I, as the psychologist say, no, they need a program. They really need some help figuring out what to eat, what not to eat. I can put that requirement in, even though nationally, the bariatric surgeon can’t because of Medicare guidelines. It’s pretty much everyone’s going to have that sort of program.
[00:14:00] It’s interesting because some of the bariatric surgeons totally embrace it and view it as being incredibly helpful. Those are oftentimes the surgeons that have more recently started running their own programs and supporting that. Those bariatric surgeons, to be frank, I actually respect them a bit more. I’m very biased on that, I guess.So some of them embrace it and they’re like, yeah, we’re helping these people prepare better for surgery and they provide good nutritional guidance. Some of the surgeons hate it and view it as just some stupid insurance hoop to jump through. They have their patients do really crappy programs, which is typically, the crappy programs is when the patient will do sometimes Weight Watchers and then they have to have a monthly meetings with primary care in order to have it be “physician supervised”.
The problem though, is that for these patients, first of all, Weight Watchers is not a good pre-bariatric program. It doesn’t help you prepare that well. [00:15:00] Some people do okay with it, but it’s not that great for a typical bariatric patient. And then the physician supervision can be a joke because a lot of these primary care physicians know nothing about helping people lose weight.
Because what should be happening is they should go to their primary care physician, if they haven’t lost weight that month, because they have to meet monthly, if you haven’t lost any weight or you gained weight, they need to have a conversation with them that’s either like, okay, looking at adherence; have you actually been following this program? If you have not been following this program, let’s work on helping you follow it better. Okay.
Sometimes the patient will say, no, I’ve been following it. Here’s my food log. I’ve been doing exactly what Weight Watchers says, blah, blah, blah, and they’re still not losing weight. Then the physician needs to go in and be, say, okay, then we need to alter your program. Let’s talk about maybe having you drop your starch level or let’s look at these foods that may be causing you problems. Let’s refine what your nutritional program is so that you can lose weight.
In reality, people who do this physician meetings once a month [00:16:00] get almost nothing, but this physician also abuse it as a hoop to jump through like, oh, gee, I guess you didn’t lose any weight this month. Well, all the more reason to get you some surgery or whatever and that’s it.
Dr. Sharp: There’s quite a bit of area.
Dr. Serena: Really poorly prepared. Frankly, they have a higher failure rate with me for sure.
Dr. Sharp: Okay. So what do you do? You call them, you ask if they’ve completed the weight loss program.
Dr. Serena: Right. If they have, then I’ll work on getting them scheduled. I’ll find a spot for them. And then oftentimes we’ll also put them on my cancellation list because I’m usually scheduled out about six weeks, which is longer than most people want to wait normally. And then I will email them a packet of materials, assuming they have email and they have a way to fill stuff out. They need to be able to print stuff.
If I have someone who doesn’t have a printer or doesn’t have email, then I’m going to typically have them come to the office about an hour ahead of time to fill out all the measures that I want them to do in the office but for most people, I email it [00:17:00] to them and they do it at home and bring it in that way.
People tend to take their time better with it at home and I get better responses when they fill it out at home than when they come to the office. The exception to that is if I do the MBMD, I can’t send that through email. So that’s always done in the office. But I don’t do that as always right now, I do it a minority of the time nowadays. I used to give it routinely, every single person did the MBMD and now I’m not doing that every time. So now most of it can be sent out through email. So then they come in for the day.
Dr. Sharp: Can I ask you, Serena, what’s in that initial packet that you email them?
Dr. Serena: Oh, yeah, that’s a great question. There’s my informed consent document. That’s just my generic one that I send to every single patient. That’s all the basic legal mumbo jumbo. But that does have in it some stuff specific to evaluations.
And then I also send a before your bariatric evaluation thing; it’s about one page and it says here’s what to [00:18:00] expect, here’s what to bring with you, I want you to bring your food logs, bring your weight logs, and here’s how long it’s going to take, and also remember this is for your benefit, I’m not trying to be a jerk about this, or whatever. Not in that language, but that’s in that one-page document. So those are just for them to read.`
And then I do what I think of as the full PHQ, I don’t know if you’ve seen this but I’m sure you’re familiar with the PHQ-9, right?
Dr. Sharp: Yeah, sure.
Dr. Serena: There’s also PHQ-15. Do you know that one?
Dr. Sharp: No.
Dr. Serena: PHQ-15 is a somaticizing measure. It’s 15 questions all about somatic complaints. So the full PHQ has the PHQ-9, and it has the PHQ-15, which is somaticizing. It has, of course, I pulled out the one in Spanish. It has a panic measure that’s mostly like, do you have panic? And if so, do all of these symptoms [00:19:00] go along with it? So it lets you see, okay, is what they’re calling panic, does it meet the criteria for panic? It has a generalized anxiety measure that is very similar to the GAD-7 but not identical.
And then it’s got some questions about binging and purging, and it has questions about alcohol use. Specifically, it’s not just, do you drink or do you not drink, but does it cause you this and this problem? So I send out a full PHQ. I also send a GAD-7 because the full PHQ, I’m not in love with their little anxiety measure on that. So I send the GAD-7, the PHQ full, and then also I send the DSM-5 Level 1 screener. Are you familiar with that at all?
Dr. Sharp: No, you can say as much about it as you want to.
Dr. Serena: [00:20:00] Okay. It’s a one-page thing that came out with the DSM-5, actually. In the DSM-5, when it came out, a bunch of free measures came out that are the level 1 and level 2 measures. So there’s one really broad Level 1 Cross-Cutting Symptom Measure. It goes over everything but it’s super brief. So it’s like, I don’t know if you’ve heard of a PHQ-2, which is only, do you have anhedonia? Do you have basic depression?
It’s like that but for a bunch of stuff. So it’s 23 questions. It goes over depression, irritability, basic like, is it possible you’re manic? Do you sleep less than usual but have a lot of energy? Do you start more projects and do risky things? That sort of stuff. It’s got three questions on anxiety, two questions on somatic stuff, sleep, et cetera. So it’s very broad.
And then the whole idea is if they pop up as positive [00:21:00] on any one of those, you do a follow-up Level 2 measure, theoretically, that’s how it’s supposed to work. I don’t know that I’m exactly using it that way but I use it as a really broad screener so that I can see areas that I need to ask more about, does that make sense?
Dr. Sharp: Yes.
Dr. Serena: So I think that that is it. 1, 2, 3, 4, 5, boy. I feel like there’s one other thing that I send. I have six documents that I send out to every patient, that PHQ, oh yeah, the DSM thing, informed consent, the GAD, and yeah, no, that’s it.
Dr. Sharp: Okay. So they get the packet. Let’s assume they fill that out ahead of time and then they come in.
Dr. Serena: Oh, and sorry. The one last thing is my intake information. So I have my own document that’s, I have a different one for therapy, then I have for pain, [00:22:00] then I have for bariatric. And so that one is all of my general questions plus my signatures that whatever letting me build their insurance company. There’s incorporated into that a little ROI to their bariatric doctor and to primary care. Plus, I ask them to write out their weight loss history on that document. So that’s out there.
Dr. Sharp: Got you. Nice. Pretty thorough.
Dr. Serena: Yeah, it is. It’s interesting because this is what I use now that I don’t use the MBMD as much and I’m still pretty happy with it. I keep going back and forth being like, oh, am I not doing enough testing to be legit or not?
Dr. Sharp: And that’s fine.
Dr. Serena: But then I was reading up and interestingly, the interview that I give counts as well because it’s considered a structured interview. [00:23:00] That’s the biggest thing that I did when I mostly dropped the MBMD is beefed up my interview further. I’ve based it on the Boston Bariatric Interview, which is a standardized interview for bariatric stuff.
So I based it on that. It’s not exactly that because I’ve augmented it in a few places, that sort of thing. So I’m doing also that structured interview for my interview then.
Dr. Sharp: Oh, okay. Got you. So that happens when they come into the office.
Dr. Serena: That’s right. So then they come into the office, and hopefully, they’ve done their paperwork. If they haven’t, then I hand it to them and they do it there and then I meet with them. I tell them I’m going to ask them a ton of questions and I’m going to be typing. I’m typing throughout the entire interview. I mostly have the vast majority of the report written through the course of that two-hour interview. I’m typically interviewing for two full hours.
Dr. Sharp: So here’s my question, Serena. I admire that 100% and I have no idea [00:24:00] how you do it because when I try to, so I type my notes during the interview. That’s fantastic. I cannot seem to craft meaningful sentences while I’m also trying to take notes from listening to somebody talk. I can’t write it in the final form that I would publish in the report. So did you find some amazing way to do that or are you just a genius or how does that work?
Dr. Serena: What’s interesting is, the final thing that’s my words, that part I am writing after they leave, but that’s just the final paragraph, that’s summary and recommendations. I don’t even feel bad being template-driven with that. I do write stuff extemporaneously related to that, but there are a lot of people that deal with very similar stuff. So I’m okay pulling the same language for some of that.
So I do write that but that typically [00:25:00] takes me about 5 to 10 minutes at most. The rest of it, like I said, it’s a very structured interview. I’m writing their answers to the questions. I don’t have to do that much thinking, if you will.
So I’m asking them, for example, okay, what do you typically eat every day for breakfast, lunch, and dinner? I’m just typing what they’re telling me, not verbatim. I’m digesting it a little bit but I’m mostly writing what they’re telling me. I’m writing their responses to my questions because that’s how the Boston Bariatric works, is it’s a bazillion question and you’re writing, a lot of times verbatim, actually, their responses to those.
Dr. Sharp: Okay. Got you.
Dr. Serena: I don’t have to do that much digesting as they talk. It’s much more what they’re telling me. Another real trick is when I’m doing the [00:26:00] interview in Spanish and I have to be typing the report in English simultaneously, I do that fairly regularly and boy, does that make my brain work?
Dr. Sharp: Oh, I bet. We forgot to mention that other superpower that you have, which is that you’re largely bilingual, for a clinical purpose.
Dr. Serena: Yeah, well, it’s interesting. I do these evaluations in Spanish all the time. The one that I cannot manage is I can’t manage to do the interview in sign language and type at the same time. So when I have someone who is going to do sign language for, if I need to be typing the report, if we’re doing that sort of interview, I have them bring an interpreter for that one session because I can’t sign and type. I can’t do it. I’m not that good. I type in English and I speak in Spanish and it works out.
Dr. Sharp: Oh my gosh. Okay. Well, suffice it to say that’s incredible.
Dr. Serena: Just to walk you through the rest of what happens here is I interview them and for some people, it’s way [00:27:00] shorter. If they have a really short psychiatric history, my interview may be a lot shorter. If they have an extensive psychiatric history, it’s longer.
If it’s a failure, then it’s longer. I find that when I deny someone, it could easily take me twice as long to do the interview and the write-up than when I pass someone because when I deny someone, I want to document very well why I’m denying them because I do get grievances regularly. When I deny people, people complain, that’s part of the business. So I want to make sure it’s really well documented why I’m denying them.
And when I get denials, I spend way more time with the patient giving feedback to explain, here’s why I’m denying you, here’s what I need you to do before you get evaluated again. So denials take a million times longer. Anyway, in general, I go through the majority of the new reports, probably two-thirds of it at least, is typically all on eating behaviors. Then I do look at their psychiatric history and their current psychiatric functioning, and social support.
And [00:28:00] then at the end I’ll say, okay. I’m just going to put in a few things from what you filled out and I point to their packet and that’s where I sit there and real quick, literally while they’re sitting there, I score everything that they filled out and I pop that information into my template in terms of, okay, here’s how they did on these different measures.
And then sometimes I’ll have some follow-up questions based on some of the things that they mentioned on the testing. And then I sum up and I make real quick notes as to what I’m recommending or what the concerns are, but I do that throughout the interview. So as I’m going through the interview, when there’s an issue that I’m like, oh, that’s going to come up on my summary, or that’s going to be something we need to discuss here, I highlight it in the computer.
And so as I’m going through and doing my final summary with the patient because I give them feedback right then, as I finish, I write in and I say, okay, I’m going to sum up for you and I’ll tell them whether they passed or failed and I’ll tell them what [00:29:00] I need them to do. And so I scroll backward through this big eight-page thing that I’ve done and look at all the highlighted areas and I incorporate all of those into my feedback.
Dr. Sharp: You’ve new feedback right there?
Dr. Serena: I do.
Dr. Sharp: You’ve done enough of these, you’ve seen the patterns, you know right in the moment what you’re going to say and you can just tell them.
Dr. Serena: Typically, yes. I summarize what I’m looking for and I usually say I’m looking for three things; I’m looking for how they’re functioning in terms of their mental illness issues and I say, just having some issue with depression, anxiety, or whatever. I’ve had schizophrenic people whom I’ve passed and given clearance to. So having mental illness is not the issue but if that’s there, I want to make sure it’s well managed, well treated, and the person’s engaged in appropriate treatment and the symptoms are not so severe that they’re going to get in the way of them being [00:30:00] successful after surgery. So I’m looking at that.
And then I’m also looking at how well they understand what they’re getting into because I’m essentially quizzing them on what they know about the surgery and post-surgical life throughout this questionnaire that I’m going through with them. And so I say, that’s another thing I’m evaluating is whether you understand what you’re getting into and that sort of thing.
And then I say, probably the biggest thing I’m looking at is have you shown that you can make changes to what you eat? Because the surgery will never change what you put in your mouth. You have to be the one to do that, and you have to do it before surgery. So you have to have already dealt with that, and have already made these really good changes to what you’re doing, and you have to prove that to us, and that’s why I go through and do this whole huge questionnaire about what you’re eating, and what changes you’ve made on this program, and how much you lost with that, blah, blah, blah.
We need to know that you can make those changes and that you have made them in preparation for surgery because one of the biggest predictors of post-surgical success is being able to lose weight [00:31:00] before surgery, which I know sounds counterintuitive, because like, wait a minute, aren’t we giving people the surgery because they’re not able to lose weight? But in reality, a better candidate for surgery is typically someone who can lose weight but has trouble keeping it off, or they can make all the changes they need to make and they still don’t lose weight.
And I see this regularly, I see people that have made the changes they need to and for a variety of issues, some of them medical, they’re still not losing weight. They’re following the diet they’re supposed to be following, they’re still not losing weight. They will still typically pass. So that’s the biggest reason that people don’t pass.
I was looking through as I was going through, I said, I was looking at my statistics for over the past year, and for interest sake, I found that I did 101 bariatric evaluations in 2017. Of those, I completely failed 12 of [00:32:00] them and 5 of them got conditional passes where I would say, okay, I’m giving you conditional clearance. That is, you can do the surgery. You do not have to be re-evaluated but prior to surgery, you must complete this and show documentation that you’ve completed it.
For example, you must complete a minimum of three months of psychotherapy, at least twice a month, that is completing a total of six sessions over three months, and show documentation of that prior to surgery or whatever. So those are conditional clearances, if you will. I will certainly give you recommendations typically.
Dr. Sharp: I guess that was one of my next questions is, does the report also include recommendations in most cases or if they pass, is it just like, okay, you passed?
Dr. Serena: Oh, no, very seldom do I have a clear pass where I’m like, hey, you are a good candidate. That’s rare.
Dr. Sharp: Oh, okay.
Dr. Serena: If I only pass them, I would [00:33:00] be passing less than 10% of my patients.
Dr. Sharp: Okay. So you do offer recommendations often.
Dr. Serena: Oh, very much so. There are some people where I might say, you know what, you’ve done a really good job preparing yourself. You understand the surgery well. You don’t have any major psychiatric issues and your diet is exactly in line with where it should be.
Way to go, the one thing I’m going to recommend is that you go to a bariatric support group after surgery for accountability, and attend every month, even though you’ve lost all your weight, keep going because maintenance is the hard part. So almost universally, I will recommend to everybody that they attend that support group. But that’s the best case scenario is if they have everything in line, I’m going to recommend that but it’s seldom that that’s the case.
Typically, I’m also going to give some specific advice on how they can further refine their diet to prepare themselves for surgery. So I’ll say, okay, you’re doing good. You’ve made this and these changes. From what I’m seeing, here’s the other things that need to change. [00:34:00] They’re not so out of line that I’m going to fail them for that reason but I might say, you’ve done a good job but you probably need to switch away from having oatmeal for breakfast and switch to a more protein-based breakfast.
Or you’re skipping lunch right now, I would recommend that you just have a protein shake because you got to get used to that. So bring a protein shake with you to work and have that for lunch or whatever. So I might give them some advice on how they can bring their diet further in line or sometimes I might say, I’d recommend that you actually start psychotherapy, or I might say, if they, there’s some recommendations that are just like, keep doing what you’re doing. I might say, continue with your current psychiatric care, basically stay on your medicines please and you’ll do okay with that.
I’m always giving them some pretty clear recommendations, and oftentimes they’re fairly dietary based, or a lot of times I’ll say, you’ve been doing really well but you still have some junk food in [00:35:00] your home, and I know you’re saying that you’re not eating it but I need it to be out of the home because you got good willpower right now but willpower comes and goes.
Willpower is a crappy predictor of post-surgical success, and what’s a better predictor are these two big things. One of them is, how well can you plan? This is the best predictor of post-surgical success, is people’s ability to plan their food ahead of time. So I need you to know what you’re eating the next day, have everything you need and have thought that out already.
And environmental management, get the crap out of the house. That’s huge. And so sometimes I’ll talk with them about what needs to leave the house and how they might manage that with family members and that sort of stuff.
Dr. Sharp: Got you.
Dr. Serena: Yeah, there’s a lot of recommendations. My goal isn’t just to clear them or don’t clear them. I want them, even if they get cleared, to walk out of my appointment having a better chance of success than they would have if they [00:36:00] didn’t come to me, if they went to somebody else, for example.
Dr. Sharp: Sure. So let me just run down. I know that both of us are on a little bit of a time crunch so I want to make sure and ask a little bit about the billing and referrals and that kind of thing. So just to be clear, are you doing the MBMD or either, or does the …?
Dr. Serena: I do it barely at this point. I would say, gosh, part of the reason I moved away from it is, one, I wasn’t feeling like I was getting the information from it that I wanted or it just was reduplicating what I was getting an interview. I was like, well, that’s great confirmation but it takes a fair bit of time, and it’s expensive, and I’m not sure I’m getting any additional value from it that makes it worth that cost.
And then the other big issue is that my patients had a hard time completing it. I’m dealing with a lot of patients who have very low educational levels and so MBMD is listed as [00:37:00] 6th grade reading level and up. And that’s actually too much for a lot of people. It’s very burdensome. It’s supposed to take like 25 minutes. I would have people that are just slogging for an hour and a half on this thing. And I question the validity at that point. I really do.
Plus, the other big thing that I wasn’t that thrilled with is the validity measures are too obvious. It’s not like the MMPI, it is hard to lie on. It really is. You’re going to see it. You’re going to see it. Same with PAI. They’re subtle enough that you’re going to get some decent validity measures there.
The MPMT validity measures, it’s practically, I’m not exaggerating much to say they just ask them, are you being honest right now? Are you answering these questions honestly? That’s the validity measure.
Dr. Sharp: Very face valid.
Dr. Serena: So there’s people where I look at them and I’m like, I know that you are bsing me and you’re just saying that you’re answering honestly, but I can tell from the interview that you’re not. [00:38:00] So I’m not giving that the majority of the time at this point.
Dr. Sharp: Okay. That’s good to know.
Dr. Serena: And then billing-wise, I am functioning almost exclusively but not entirely exclusively on case rates. So I have deals with two insurance companies right now that pay me a case rate. So I get the same amount no matter how long the evaluation takes me, no matter how much testing I do or don’t do, I get that same amount.
I originally set that up and it’s more than they were paying their other evaluator. What they did is that, again, they recruited me and said, look, here’s the sort of evaluation we are getting. We don’t like this very much. Can you do better? I looked at what they were getting and it was a one-page thing with no testing at all or maybe like a PHQ, maybe.
And I said, well, look, this is what you’re paying for. They were paying for a single 90791 and that’s it. And I said, look, if you want [00:39:00] more, you need to pay for more. And they said, okay, great. Give us a proposal. Tell us what you want and what would it cost. And I did that and they took it and I’ve had that case rate since then.
And what’s happened then is as I’ve gotten more efficient, it’s better for me because my case rate hasn’t changed. So it used to be that each evaluation took me three hours, now they’re usually done in two, which is great. Just barely started branching out into doing these outcase rates but it’s not as good of a rate of pay at this point. I’m not super thrilled with it.
It’s okay but I don’t need the additional business right now. When I expand and I’m looking at like, hey, I could take even more, I’ll probably do more and more of that because the surgeons that like me want to send me more people. The one that I’ll get a call and they’ll be like, hey, we liked your reports. Can we send you more? What other insurances are you contracted with? Can you do this one? Could we nominate [00:40:00] you to get in with this other insurance? That sort of stuff.
Dr. Sharp: Are you in network with the insurance companies with these case rates?
Dr. Serena: Yes.
Dr. Sharp: Or are these single case agreements?
Dr. Serena: Oh, gosh, if I had to negotiate a single case agreement for each one, that would be incredibly burdensome.
Dr. Sharp: Okay, so you are technically in network and they just give you this case rate?
Dr. Serena: Exactly. So I have the case rate with one of them, I have a general behavioral health contract and I see therapy patients through them as well and I have a separate case rate contract. It triggers the case rate when I bill a certain diagnosis and a certain code. So in this case, it’s like obesity diagnosis and this 90791, those two in combination trigger the case rate and it pulls up case rate instead of my normal behavioral health contract.
The other company I contracted with, I don’t have a behavioral health contract with them at all. I only have a case rate contract, so it’s very specific. I only do evaluations for them [00:41:00] and that’s that.
Dr. Sharp: Oh, that’s fantastic. Well, so it sounds like you haven’t had to do much “marketing” to build a practice like this. You were recruited by insurance to do it.
Dr. Serena: I was recruited by one insurance company that wanted better, more comprehensive evaluations. And that got me started. And then once my evaluations got out to the surgeons, some of them decided that they did not like me because I would deny their patients based on non-psychiatric reasons, there’s some of them that hate that. They’re like, that’s not your job. This person doesn’t have any major psychiatric diagnosis, how dare you deny them?
Some of them deliberately route people away from me and I’m whatever, that’s cool. But several of them really like my reports. And then what happens is the surgeons call me, not them but their staff calls me. I never hear from the surgeons themselves. Their staff calls me and says, hey, we’d like to send you more people, could you tell us what other companies you [00:42:00] take? We saw this report, can you do more? What’s your cash rate? That sort of stuff.
Dr. Sharp: It’s good to hear you say that. Anybody who’s listened to the podcast in the past, I’ve talked so many times about how our reports are one of the best marketing tools that we have. And this is just another case where a report can do the work for you in some ways.
Dr. Serena: It absolutely does. It is the reason I have more and more business. I have people that contact me all the time who say, I saw one of your reports and I really liked it. Can we send you more people? So it does all the work for me, honestly. If I have a good report, then the doctors love it and they want more.
Dr. Sharp: So before we wrap up, do you have any thoughts on, if someone did want to jump into this, has a good history of assessment, and wants to expand:
1. How would they go about getting the training and getting [00:43:00] familiar with the measures they need to and the standards for bariatric evaluations?
2. Do you have any thoughts on how to reach out and market and maybe garner some referrals?
Dr. Serena: It’s hard because I realized that my story of how I got into this doesn’t help many people because I can’t be like, hey, you should get a friend in UM and have them recruit you. That’s not that helpful.
It’s like people who are like, hey, how’d you start your business and be so successful? And they’re like, well, I got this huge loan from my dad. Great. What I would suggest actually is get in network with some insurance companies and then market directly to the physicians and say, hey, I want to let you guys know that I’m doing these evaluations and here’s a sample report that’s de-identified or whatever and I’d love to be able to do your patients. Here’s the people that I’m contracted with, or here’s my cash rate.
I would lean away from cash rates for [00:44:00] most of these patients. They’re oftentimes pretty poor, first of all. And then also if you’re going to do a really good solid evaluation, it’s more expensive, they’re going to be able to get a cheap and crappy one somewhere else. So there’s not good enough competition in that sense. Anyway, I would market it directly to the bariatric surgeons and their staff to say, because they’re always looking for people to refer patients to. I would suggest doing that.
In terms of getting trained, I have trained this one other person who wanted to get into this business. What I had them do is I had them shadow me on some evaluations that shot. I gave them my template and I said, okay, I’m going to be going through and typing. You look through my template as I go through, take notes, see the sort of stuff that I’m writing down, then I’m not writing down. I had them shadow me for several evaluations and then I gave them some reading.
There’s some good articles out there on bariatric assessment and that sort of stuff. And then ideally when you start up, I think it’s great to be able to have some consultation. [00:45:00] So to be able to say, okay, I’ve got my first case today. I’m not going to give them feedback today. I want you to please look over my stuff, see what you think, and then I’ll do the feedback over the phone afterward or something like that or whatever, to have someone who knows what they’re doing discuss the case with you, get a little consultation that way.
Dr. Sharp: Sure. That’s awesome. Well, my gosh, thank you. I feel like you’ve just shared a ton of information with us. I have a decent idea of how I might go about this if I wanted to do that.
If people want to get ahold of you or ask questions:
1. Are you open to that?
2. How will they get in touch with you if they wanted to?
Dr. Serena: That’s a great question. I am open to people asking questions about it. I am just a little slow responding to emails sometimes, but it’s still not horrible. I would say just look me up on Psychology Today and contact me through that. I do respond. It just takes me a bit.
I would say, feel free to bug me. If [00:46:00] you don’t hear a response, send me another message. I’ll get back to you. So feel free to be annoying because I need that. I’m pretty easy to find online that way.
Dr. Sharp: Awesome. Gosh, Serena, thank you so much for your time and for sharing all this information with us. This was really cool and shed some light on an area that a lot of people might be thinking about getting into. Thank you so much for your time.
Dr. Serena: No problem. Thanks a lot.
Dr. Sharp: Bye-bye. All right, y’all. Thanks again for listening to my interview with Dr. Serena Enke. Like I said toward the end of the interview, this was fantastic for me. This is not an area that I know a ton about. So to hear Serena talk about it was enlightening and it’s got me thinking about how to integrate these into our practice.
So just knowing Serena for so many years, I can 100% vouch for the fact that she has done her homework and she is doing things exactly as they should be [00:47:00] done from the clinical perspective. It sounds like she’s got her business practices with it tightened up pretty well as well.
So thanks again for listening, like I said. Would love to have you in The Testing Psychologist mastermind group. If you don’t know much about mastermind groups definitely, check it out.
It’s a laser-focused coaching experience in a group format where each member gets a hot seat experience at least once a month, where we take about 20 minutes to focus specifically on whatever burning questions you have. Everyone in the group is focused on supporting and giving advice and answering your questions. So you get at least one of those a month and you’ll be sitting in a room with about seven other testing professionals. I’ll be facilitating and it’s just a cool experience. I’ve done masterminds myself and couldn’t speak for how powerful they can be.
So if you’re interested at all, go to thetestingpsychologist.com/mastermind. [00:48:00] You can learn more and you can sign up for a pre-mastermind call to talk with me to see if it would be a good fit.
For anyone out there who’s not a member of our Facebook group, please check out The Testing Psychologist Community on Facebook. We’d love to have you. And if you have 20, or 30 seconds, do me a huge favor, go into your podcast app, wherever you get your podcasts, and take just a second to rate the podcast. That helps me to be able to keep doing this and to spread the word to other testing folks.
So I hope y’all have a good week. Take care. Talk to you next time.