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[00:00:00] Dr. Sharp: Hey, y’all. Welcome back to The Testing Psychologist podcast. I’m Dr. Jeremy Sharp. This is the podcast where we talk all about the business and practice of psychological neuropsychological assessment.

Glad to have you back with us today.

I’m excited about the episode today. I’ve had the opportunity to interview my good old friend, Dr. Rob McNamara. Rob and I went to graduate school together. He was one of the first people I met when I moved out to Colorado back in 2003, and we’ve maintained a really strong friendship over the years. I’m just honored to have him here to talk about the professional side of things.

Rob will be talking with us all about capacity and decision-making assessment in a hospital setting, which is really interesting and not something I knew a lot about but he had an unorthodox path to getting where he is at.

Rob is a [00:01:00] licensed clinical psychologist in Virginia. He got his doctoral degree from Colorado State, and like myself, he did his pre-doctorate internship at the Thomas E. Cook Counseling Center at Virginia Tech. He currently practices with the Carilion Clinic and he’s an assistant professor with Virginia Tech Carilion School of Medicine, department of psychiatry and behavioral medicine.

Rob has clinical and research expertise in many areas specifically substance use prevention and treatment. He’s done a lot over the course of his career. And like I said, took a little bit of an unorthodox path to his current position which we’ll get into a little bit.

I hope you enjoy this conversation with Rob in a relatively little-known area of assessment, at least for me.

If you need CE credits for your license renewal, which for us is [00:02:00] coming up in about three weeks at the time of this recording, the Testing Psychologist podcast is available for CEs. You can go to athealth.com and search for The Testing Psychologist and get CE credits for listening to a podcast that you already listened to. It’s very cool. So, check that out.

Without further ado, here’s my conversation with Dr. Rob McNamara.

Hey everybody. Welcome back to The Testing Psychologist podcast. I’m Dr. Jeremy Sharp. Like you heard in the introduction, I am so glad today to be talking to my dear old friend from graduate school, Dr. Rob McNamara. [00:03:00] Rob and I did it the same year, the same cohort from Colorado State University. He moved back to the East Coast. He is now a licensed clinical psychologist at Carilion Clinic and an assistant professor at the Virginia Tech Carilion School of Medicine which is awesome.

Rob is going to talk with us all about assessment in the medical setting. It’s a really interesting job he’s got going on.

Before we dive into that, Rob officially, welcome to the podcast.

Dr. Rob: Thanks, Jeremy. Happy to be here. Good to be with you again. Good old friends, for sure. 

Dr. Sharp: I know. It’s fun.

Dr. Rob: It’s good.

Dr. Sharp: Yeah, for sure. I was thinking, it’s rare that we see each other in person. It’s maybe once a year, maybe once every two years. So any opportunity to jump on and do a little video chat and talk business it’s great. [00:04:00] Thanks for being here. 

I know that you have just been an employee of the medical school and in your position, there’s some sort of disclaimer that we need to give.

Dr. Rob: Yeah, absolutely. I just wanted to make clear in terms of the information that I’ll discuss today; any opinions that I expressed, I’m just speaking on behalf of myself as a licensed clinical psychologist here in Virginia as opposed to speaking on behalf of the hospital or the medical school.

Dr. Sharp: Okay. All right. Now that we got that out of the way.

Dr. Rob: Thank you. Yes.

Dr. Sharp: I’ll be very clear about that.

Dr. Rob: Yes.

Dr. Sharp: I think we got a lot to tackle today. I would love for you to describe your journey to where you are today-how have you moved from graduating to what’s going on right now?

Dr. Rob: Yes. Training at Colorado State in the counseling psychology program, we had a really nice balance of getting [00:05:00] assessment training and getting good clinical therapeutic training and a lot of opportunities to do different work with children, adolescents, college students, and adults. A lot of us, including yourself and myself, did work in college counseling at the Colorado State University Counseling Center.

That wasn’t intentionally my path of going in terms of going to graduate school, going to an internship, but I really enjoyed the work and found it interesting and personal and professional coming together. I ended up at Virginia Tech, at their counseling center for an internship.

It was a wild experience. I was there the year after the shootings happened. I essentially coming on to internship right when all the students were coming back. And so that was quite an interesting time because the students and the university were really going through a [00:06:00] lot of transition, a lot of trauma, a lot of changes. With all of that said, it made for a very challenging experience, but a wonderful one too; one that really kept me interested in college counseling and saw a different aspect of what college counseling could be.

So, I did that year, and following that went down to Wake Forest University and was in their counseling center for a while. After I did that for a few years, which was another great experience, I tried to divert off because I’ve always had this interest in research and dipping my foot into that world and decided to take two years and move back up to Roanoke to Virginia Tech, where I did some research for two years. And that was pendulum swinging too far in the other direction, from college counseling, and ended up swinging back to college counseling where I did some more administrative work both at Wake Forest and then the University of North Carolina Wilmington.

Roanoke has always been a [00:07:00] place where I am right now that I’ve loved, my wife, her family is from here. We had two children. I wanted to get back to this area. I moved back into this world of the hospital setting. And now I identify as more behavioral health work including these capacity valuations which were an add-on to this job because I started with the intention and do this work of, I work in pain management, doing assessment and psychotherapy, and the same with cardiopulmonary rehab.

So, I have those two clinics in the morning and in the afternoon and then the capacity evaluations come as they do and I’m the main consultant for those evaluations. So even though it’s just this 20% of my job, it’s really, for me, the most fascinating part of it, because it really gives me an opportunity to see a different side of the work that we can do as [00:08:00] psychologists, as opposed to the run of the mill therapy counseling and assessment. It’s a very unique situation.

So that’s hopefully not the too-long-winded path that I’ve taken.

Dr. Sharp: No, it’s perfect. I really did want to talk about that because I think like yourself, and like a lot of folks out there, I think, I didn’t take that traditional path to be a neuropsychologist or really have that in mind going into an internship or even post-doctorate. I think it’s important to highlight that you can end up in assessment-based positions, or positions with a fairly decent assessment component even if you didn’t do that classic post-doctorate training.

Dr. Rob: Yeah. I think that’s a really good point, too. And as you’re talking, I’m just thinking to myself how at any point in your career, we have such a good base in our training and our experience that [00:09:00] so much of our knowledge and our skills are translatable to different areas. There’s not a whole lot of retooling that you have to do with time.

If you’ve done a lot of different types of therapy and assessment, nothing is so completely out there unique that we can’t slip in and have a lot of knowledge of how to just jump in and take forever. But as I came on, the psychologist that was here before me was really good about taking me under his wing for some training and getting me up to speed on it. And then I hit the ground running after that.

Dr. Sharp: Nice. I’m curious about this interview process because the position that you’re in now seems at least from the outside vastly different than that college counseling center experience. I’m curious when you made that leap, how did you even present your CV differently? I mean, how did you get your foot in the door at a hospital [00:10:00] coming from the counseling center primarily?

Dr. Rob: Good question. And one of the big gaps that I left out in terms of what happened in my training, because I’m so focused on the clinical, was my research training. You and I shared a lot of that background in terms of interest in substance use, prevention and that such work. From that work that I did in graduate school, and then when I worked at Wake Forest in the counseling center, I also hooked in with their public health sciences department and did some research with them.

So, I began to identify myself not just as a psychologist and a practitioner, but as a behavioral health-minded psychologist. And so, when I heard about this job, especially when I thought about pain management and opioid use and just other addiction problems that go along with that at times, and cardiopulmonary rehab, just this strong identity with cognitive-behavioral work, and [00:11:00] not necessarily that the substance use component ties in there, but all these pieces pulled together in my own identity and sold it as that because I think that there’s just so much of those different facets of my training that come together to make me prepared for this work.

So, I looked at all those experiences and crafted a nice letter after a lot of thought, but I just sold myself as just somebody with this expertise in substance use prevention, motivational interviewing, and I thought about, wow, that could really work with pain management folks and cardiopulmonary rehab. I think that’s so translatable to a lot of different populations in terms of behavioral change and getting people to just live their lives differently in a way that’s more in line with their values and that they want to be pursuing.

You take all these pieces funnels down and it ends up where I am [00:12:00] right now. And it’s interesting because there’s been a lot of changes in my career but this one is where I definitely feel good about where I am and I’m pretty certain that’s going to stay here. I like the trajectory at this point.

Dr. Sharp: Sure. Well, maybe that’s a nice segue to talk about what you are actually doing day to day right now. Can you walk me through a typical day or week, maybe in your job? And of course, we’ll highlight the assessment component as we go on.

Dr. Rob: Sure. I think that’s a good place to jump into the assessment. But I’ll start with talking about the psychotherapy clinics. First thing in the morning, I go into the pain management clinic where I’m embedded right in that clinic. We have currently 2 MDs, some neuro practitioners, and a large team of nursing staff and support staff.

What I do there is I do more traditional psychotherapy with pain management patients. So the clinicians there just refer me people, [00:13:00] and this could be just about everybody, that they think could benefit from some behavioral means of managing their pain. But they’re really attuned to folks that have already identified problems with depression, anxiety, and post-traumatic stress to try to really help people get a hold of both managing the pain and the mental health component as well.

And simultaneously, a lot of cognitive behavioral techniques can help people manage both of those things. We can bounce back and forth and I really tailor it to each individual person I see. For a period of time, I was doing some group work too, where it was more based on a lot of the cognitive behavioral therapy for chronic pain. The VA has a nice manual but I adapted for group setting  and paired it down. I really enjoyed doing that and the patient seemed to really like that too. So different a variety of things that I do there in my clinic.

[00:14:00] The cardiopulmonary clinic is another psychotherapy-based clinic where people are generally post heart attack, stents, major heart surgeries, or people with just ongoing pulmonary concerns, or COPD these kind of problems. Helping them transition and adjust after these major events a lot of the time, or helping normalize depression and anxiety after a heart attack. I mean, people sometimes feel so out of place or they feel like there’s something wrong with them because there’s a lot of depression after a heart attack. And just really that makes a lot of sense, right?

Of course, you’re feeling down, your body is going through this horrible trauma and you have to adjust your life. And now there’s this fear and worry, like every little change that you’ve noticed in your chest is going to set off these alarms and especially people with pacemakers and others, when they have implanted devices, there’s anxiety around that. There’s a bunch of different [00:15:00] things that can go on that people just are trying to get support for. And of course, like anything else, some people with preexisting depression and anxiety concerns, and then they have these medical concerns. A lot of variety of people are coming in for services in that territory.

Those are my two clinics. And then the medical decision-making capacity which is the focus of what we’re doing today, those like I said, I’m the main person that does these for the hospital. I have 2 folks that back me up when I’m out of the office on vacation, but primarily, if one comes through it’s mine, and I cover every day that I’m in the office. And just like any other medical consultation service, it’s a huge question mark.

There could be days in a row when I don’t see any patients. There can be one day where within an hour I get a few consultations and these are pretty in-depth consultations. From start [00:16:00] to finish, we’ll generally take about 90 minutes to two hours. And I know a lot of folks in the psychology world thinking about assessment, well, that’s not a lot of time. For this medical world where things are moving quickly, that can be a lot of time to dedicate. What I normally do is I try to find periods of time during each day where I will have two hours to do that if one comes through. Because they just come through when they do, I can never really fully plan my day.

With all that said, it’s just a very dynamic day. I think that’s probably the way to put it. Sometimes they can be very stressful trying to just fill holes and gaps because as we talk further, I mean, as I get into the nuts and bolts, the whole process, there’s a lot of things that need to happen from start to finish where I sign this note and it’s ready to go- including talking to a variety of different people, attending physicians, [00:17:00] social workers, and case managers, reviewing the chart, and then actually seeing the patient. And folks are in the hospital there, I can go to the room and they can be out for a scan or just asleep and they’re not able to raise. A lot of hiccups along the way can happen.

Dr. Sharp: Oh yeah. I’m just thinking about all those different scenarios. It’s not like someone presents to your office and they’re like, okay, I’m ready to do this assessment now.

 So, walk me through the logistics a little bit. Can you get called for these consults at any point during the day, do you have to drop everything and go do them, or can you schedule them later in the day or how does that generally work?

Dr. Rob: That’s a really good question. Between 8:00 and 5:00, I’m on call for these capacity evaluations. The beauty of this job, I don’t like being on call, especially after hours, but I have no after-hours calls. So it’s nice because it [00:18:00] makes for a crazy day between 8:00 and 5:00, but at least it’s predictable that I will be dealing with things at those hours.

Generally, when a normal capacity consult comes through, I have 24 hours to respond, essentially to complete that evaluation. From time to time, there will be what they call stat consults, where there will be a very urgent situation where they need me to do the evaluation. Now, generally speaking, these consults aren’t emergent in that way. There are other ways to manage medical emergencies. And I won’t get into that.

So, even if I get one of those calls, most of the time I can talk to the treatment team about, well, you can do X, Y, Z, and then I can get over there in four hours to see the patient because if it’s urgent medical care and emergent, they generally have some leeway to just treat the patient without having me intervene. And other times there’s medical holds and things like that that they can do if a patient’s trying to get out of the [00:19:00] hospital and they don’t think it’s safe for them to go and they don’t really understand the consequences of leaving the hospital.

Most of the time, I would say 95% plus of the time, they’re predictable. I know if they come in, I have that 24-hour period to complete them. So, it’s not too urgent and overwhelming. But one of those calls when they do come through when it’s, I need you to come over within the next hour or two, that can be difficult in terms of shuffling around the schedule and making everything happen.

Dr. Sharp: Oh, I can imagine. My gosh. Maybe we could back up just a little bit and maybe you’re going to get to this, but just to define what you mean when you say medical capacity evaluations. What is that all about? What are you actually evaluating for? What scenarios demand them?

Dr. Rob: Within the hospital context, there are two major things that I do. When we talk about medical decision-making [00:20:00] capacity, that word capacity, what that really means is there’s some medical treatment that’s being offered to a patient and capacity is do they have a solid grasp of understanding what that treatment is? And can they use rational reasoning of risks and benefits to make a logical decision considering consequences that might happen, to decide whether they want that or not? And that will be anything from they may need a feeding tube to be put in, or this may be a major surgery or ongoing cancer treatment, or a lot of the time I get these calls based on discharge. And that’s a pretty common one.

For example, somebody that may be experiencing dementia wants to go back home, but the team is obviously concerned maybe about their physical safety but certainly about whether they can [00:21:00] do the day-to-day keep themselves going and not leave the stove on or have any of those other incidents. A lot of the times the patients will clearly, as we all would just say, I want to go home. I want to go back home. That’s where I love to be. It’s safe or not safe. It’s what I love to do. And everything that I have is there. And I just want to be there.

But by all accounts from everybody that’s involved in their treatment, it’s just not a safe place to be. So, a skilled nursing facility, for example, might be the recommendation. So, I would evaluate patients around whether they can understand what would happen, what are the risks if they go home, what are some of the benefits of going to a place like a skilled nursing facility and talk them through that process.

Dr. Sharp: I got you. You’re not necessarily evaluating their skills or cognitive. Well, I don’t want to say that because you kind of are, but it’s not necessarily their skills, [00:22:00] adaptive ability, or anything like that. It’s more like decision-making. Can they even manage?

Dr. Rob: That’s exactly right. I will get calls sometimes where there’s a vague question of whether a patient is safe at home. And that’s not something that I will evaluate. I understand where they’re coming from, but the treatment team often will include an occupational therapist and a physical therapist. They can really talk about what their capabilities are.

So, I am doing, and I think what I’ll do is just maybe run through from start to finish in a minute what this looks like, but I am doing some cognitive assessment, because I want to understand attention, language, visuals spatial, executive functioning, not as the main component of saying a patient can make a decision or not, but that gives me a really strong idea of how impaired they are cognitively. And then I’ll go into the [00:23:00] actual evaluation of their decision-making.

I usually do the Montreal Cognitive Assessment tool. I get 10 minutes snapshot of where they are cognitively. Again, that’s not the primary part of the evaluation, but it really gives me a sense of how well people are doing. And there are some good studies out there. The mini-mental status, is not directly comparable to the MoCA, but in some ways, we could use those as two pieces to look at, but many mental statuses and using that as a predictor of whether a patient has the capacity or not.

There’s some good literature out there about cutoff scores and things like that. But again, those assessments are just secondary to the solid interview that you have to do to really understand if a person knows that particular decision that’s ahead of them.

Dr. Sharp: Okay. Well, maybe we can just dive in and walk through the [00:24:00] process from start to finish. So you get those calls, like, Hey, we need a capacity evaluation.

Dr. Rob: Yes. And if I’m not clear, please just interrupt and let me know because it’s such a normal part of my day-to-day that I run through it and may not be following clearly. The first thing that I do is, through our electronic medical record system, I get a consult order. First and foremost, what I do is I call the attending physician most of the time, sometimes there are residents involved or nurse practitioners or PAs.

And a lot of times I’ll contact those folks because for example, with surgery, you have a lot of PAs and nurse practitioners that are doing the day-to-day management of the patient, and a lot of times they have a better idea of what’s going on with the patient at the moment. But I really like to get the attending on the phone too, because I like to have that one-on-one [00:25:00] discussion about what’s going on because when I get the order, I do get a lot of information about what their concern is, what their question is, and whether they believe the patient has the capacity or not. But that brief 2 to 3-minute phone call really solidifies the information that’s in there. And I can feel like I’m ready to go in and talk with the patient.

But after I talk with the attending, what I’ll do is I do a thorough record history review looking for if it’s related to discharge, did occupational therapy and physical therapy see that person, what are they recommending, and looking for social work notes and case management notes about their conversations with the patient about going to the facilities. And I’ll look in the notes for if it’s related to treatment, did the team talk directly with the patient about what they’re recommending and how did the patient react? How did they seem to understand and grasp the [00:26:00] information that was shared? And there’s a variation with each treatment team. Sometimes the records can be very clear and detailed and that’s great. And other times not so much. So it’s good to just have those ones on one conversation with people to fill in any holes that seem to be missing.

Dr. Sharp: Let me ask two questions. Is it easy to get physicians on the phone? That seems hard.

Dr. Rob: It varies. Within the hospital, we have a call system. What I do is at my desk, I just pick up the phone and I hit zero and I get somebody on the phone immediately and I say, we page this position. Then they page them. Most people call me back immediately. Some people there may be a lag time if they’re in another meeting or whatever, but generally, within 5 minutes and worst case. Well, I shouldn’t say the worst case, but some of the worst cases are 15 minutes, but sometimes I have to page again just to try [00:27:00] to get them on the phone. But that all depends on my urgency in trying to get over there. How quickly do I need to get them? Because if I have other things going on, you can be patient, but yeah, people are generally very responsive.

And I think that one of the things about the medical world is with these consultations, it’s often a hospitalist who is managing the care for the patient, the central hub of all these consultants. They know that they’re asking me to come do some work for them just like they would a nephrologist or anybody else. So they want to make that as expedient as possible. They can just move forward and move on to the next thing. But it’s unlike psychology, and I think most folks know this, but the medical world is just like bam, bam, bam. Everybody wants to do things quickly, and have these consultations happen quickly and those conversations are often quick and fast.

And if we were to sit down and talk about a case, a client that we were working with, we might spend 45 minutes and get really nowhere. [00:28:00] But with physicians, 2 or 3 minutes, you’ve got to get every essential detail because it’s just a different mindset in terms of the care that’s being given. That was a weird thing to adjust to because I’m not by nature one that’s just trying to do that quickly and been in the world of being a therapist and being that was a tough change, but adjusted quickly.

Once I get all that information, I usually take some notes that I take with me to the room just about identifying what medical problems the patient has, especially their current problems, what medications they’re taking, and why they’re in the hospital, and what the recommendations are. I jot those down on a piece of paper because when I’m doing my interview with a patient, I want to get a sense of whether can they tell me what’s wrong with them. Can they tell me what medical problems they have? Can they tell me what medicines they’re taking or are they just like, I don’t know, somebody else gives them to me and that’s [00:29:00] often the case or for some folks.

When I get actually over to the hospital, well, what I do is I usually check in with a nurse first thing, just to see, because they’ve probably been the most recent person to touch base with the patient within the last 5 to 10 minutes. How’s the patient been doing? And it’s nice if I get people that have consistently been with a patient, for example, for a week or so, because they may have seen some changes; are we looking at some deficits because of delirium or is this really more of an ongoing neurocognitive problem? Or maybe it’s withdrawal from substance or whatever else.

I want to just get some more information about what historically has been going on. The nurse is good about that and that’s where I can touch base in person with the social workers, the case managers, and anybody on the unit that’s easily accessible.

I usually will have another brief two-minute conversation just to ask any last-minute questions. And at that point, I just have a ton of data already and [00:30:00] would never do a records review capacity evaluation, but sometimes I may be close enough to have that much information because you can just see it in the chart especially if speech-language pathology, for example, has already maybe seen the patient and done MoCA. I know that their cognition is at this place.

Dr. Sharp: Yeah, I was going to ask if you have all this information before you even meet the patient, well, this is the wrong way to put it, but how much does that evaluation matter? Like, have you already made up your mind or what’s your process then?

Dr. Rob: That’s a tough part of this process- remaining as objective as possible. I think that’s often a challenge in any of the work that we do, especially here though, because one of the things about capacity evaluations is that there are so many people involved. There’s the patient, the family, the physician, the [00:31:00] treatment team, everybody in the treatment team. So, I may get so many varied opinions about how a patient is doing. I have to be aware of everybody’s potential bias there, including my own and through that. If there are any advantages for the family, for example, do they have some secondary gain that could be coming if a patient has X, Y, or Z happening.

So there’s just a lot of things that I’m sorting through in my head and trying be aware of, but not let seep in. And of course, I try to do my best. I’m sure I’m not always doing that because sometimes there are just too many moving pieces. And I do have colleagues that I can bounce these off in those cases where I really am just, my head might be spinning a little bit because there’s so much going on. So, I try to get myself grounded.

But yes, at that point, I am walking into the patient room and I just give them a [00:32:00] really brief overview about why I’m there to see them. It’s a unique situation because I’m not treating the patient. I’m not providing them a service directly in this way. There are a lot of people that I’m serving with these evaluations. So, rather than this “informed consent process”, it’s more just a, Hey, here’s what I’m here to do. Here’s why I’m here.

And I talk about, you’re attending physicians concerned that you may not be able to make decisions on your own, and I’m an objective evaluator. I’m here to ask you some questions, have you do some tasks just to see how you’re doing as far as your decision-making is concerned? I want you to try your best because I’m not part of your treatment. And so if you have the ability to make your own decisions, I want this evaluation to reflect that. But if I agree with your attending that you may have some difficulties, what we’re going to have to do is going to bring in some family members or other people that are important in your life to help you make these choices.

So really just lay it out in simple language [00:33:00] about what is coming. People are really compromised that they look at me and maybe nod their head but I think that the hard part is that in cases like that, it’s a sad thing to see, but it’s clear why this service is there because that person really needs assistance and really needs somebody to help them make their choices. After I go through that, I usually just launch into the MoCA and see if they’re oriented and go through that whole process and understand where they are cognitively.

Dr. Sharp: Can you just for anybody who is unfamiliar with that like myself, for example, despite all the media attention over the last period, just generally speaking, what is the MoCA looking at, and what are the tasks look like?

Dr. Rob: I love the MoCA. I started off doing these with a mini mental status and I thought that was fine, but it also felt a little bit limited in terms of what I [00:34:00] was getting and some other folks that I was working with were using the MoCA and I really liked it. We’re looking at visual-spatial, executive functioning, attention, immediate repetition, and some delayed recall.

It’s about a 10-minute process. There are two paper and pen tasks. The majority of it is… there’s some identification of pictures, me just having them engage in verbal tasks, but you get a 30-point score. And there’s also a blind version, so if people can’t see or they’re having difficulty saying, you can cut that down. They have that normed as well. And they have some nice cutoffs too, if it’s 26 to 30, it’s normal and then they go into the mild, moderate to the severe cognitive range.

And like I was saying before, there are some good studies with the mini-mental status exam about what those scores would and [00:35:00] how they equate with having capacity or not. It gives me a good sense. 

I’ve anecdotally, after doing hundreds of these, I’ve got an idea if you below a certain score, your likelihood of having capacity is very low. But again, I’ve maintained my objectivity and just see that score and then give them their best shot because sometimes I have people that are really close to that severe impairment range as far as cognition and still having capacity. You just never know. It doesn’t happen a lot but it can happen.

So there are those examples, but the MoCA is a great tool and you have to go through training and certification. They’re updating all that now, but I encourage people if they’re listening and not familiar with it to look at it because it’s a nice thing. And I know with the VA, some of my colleagues have talked about using that very frequently for different sources of assessments. I’m sure lots of listeners are using that for various things.

The next part of the assessment is where [00:36:00] I have crafted my own way of doing the capacity evaluation. There are tools out there. There’s one called the MacCAT, which is MacArthur Capacity Assessment, very standardized, but it’s more qualitative in gathering information than you can score.

A lot of what I do, I’m based on that, but I use my own questions because the treatment decisions and the discharge decisions are so often varied. And I like to just be able to mold it to what I’m going into. My questions that I’ve developed, I can use interchangeably with different scenarios.

There are four main components. The first one is just understanding. That’s what we want to look at. So do the patients understand their medical conditions? Do they understand their treatments? Do they understand, for example, what a skilled [00:37:00] nursing facility is that they’re being recommended to go to?

And then appreciation is the next thing that we’re looking at. Can they appreciate that their condition more at a particular treat for them? Or do they understand? Appreciating various aspects of their care and how it applies to them or how is relevant to them?

And then we get into the reasoning portion after that rational reasoning. This is where I’m always asking whether it’s a discharge decision or a treatment decision. What are the risks of this treatment? What are the benefits of this treatment? What are the risks of going home? What are the benefits of going to long-term care? Talking through risks and benefits and surgery, because sometimes there are some really negative aspects of surgeries that we need to talk about too.

[00:38:00] What I’m doing there is trying to get them to cycle through and talk about a lot of reasoning because I want them to be able to filter through all of that and make a decision and consistently make a decision. That’s the last part. Are they expressing their choice over time consistently?

And that’s an important part because it’s not about, I mean, people will change their mind. I always use the example of palliative care versus ongoing cancer treatment. If somebody spends three days going back and forth and is uncertain one minute, they’re thinking this two hours later, they changed their mind, that’s probably normal. This is a big deal. And a lot of emotion weighing there.

But I want to be able to access their reasoning for going back and forth. And so it was simple or less maybe intense treatments if people are just day to day maybe when the physician comes in, they say, oh, I’ll go to the long term care facility. And then a nurse comes in. They say I want to [00:39:00] go home. Family comes in and just the story changes. And are they playing to that person, are they really just making those statements based on rational reasoning, or do they just go in with whatever is happening at the moment?

That’s where the MoCA is really nice because if somebody’s going through that stuff and I see that they’re cognitively having a lot of difficulties just retaining information and can’t pay attention, and I know that that’s probably related to just that cognitive process being impaired.

Dr. Sharp: That makes sense. Just to clarify, during that portion of the interview, are you actually talking through the treatment options with them and explaining this is a surgery, this is what that means. This is other treatment you might be going through. Do you have to go through that?

Dr. Rob: I do. The key component. One of the major factors that I’ve found to people not [00:40:00] having capacity is poor communication. What I mean by that is I always tell the physicians, I should not be the first person talking to this patient about these treatments. And a lot of times what will happen is you will have somebody that’s clearly just unable to process information.

A lot of times there will be reluctant to try to engage the patient in a conversation about their treatment that they need because the people just don’t feel like they’re going to understand it, but I will say, needs to be the attending or somebody else involved in the treatment, before I get there, I need you to go and talk to the patient about this; explain the treatment, risks, and benefits. They may look at you and not be responsive, but they need to have an opportunity to hear this. Everybody does because you can’t know a lot of these things if you’ve never heard them.

The first part of capacity is that communication has to happen. So with that said, yes, I assure you that that’s happened before I go over to see the patient, but then yes, when I do [00:41:00] go in, I’ll ask directly, what are your medical conditions? What medications are you taking? I talked with your doctor and they’re recommending that you have the surgery. Can you explain to me that conversation that you had with your doctor? How did they describe the surgery? And then I ask questions like, well, from your understanding, why is your treatment team, or why is your doctor recommending this particular surgery for you? And then go into those risks and benefits and that analysis.

And in the end, I always ask you, what do you think is the best option for you? Tell me why that’s the best option for you. And I will touch base a few times, not directly, but maybe more subtly, but just re-asking that question to ask, are they consistently saying that they want to go home, or are they changing as we’re going through these different questions? So it’s an ongoing process and it can be fluid capacity.

[00:42:00] One point that I didn’t make is capacity and competency often get mixed up. When people are talking about what they want, as far as these evaluations, capacity is something that we evaluate as medical providers whereas competency is more of a legal term that the law has to deem somebody to not be competent, but I bring up that difference between capacity and competency because capacity often is something that’s changeable and it can change day to day.

For example, if we have somebody with delirium, they have a urinary tract infection, they’re in a terrible place, 48 hours later, they’re completely back to normal. They didn’t have capacity when they came in, but two days later they do, whereas competency because of the legal process, it’s usually reserved for people that are in terms of intellectual disabilities, that cognitive function being very low, where it’s probably more of a characteristic and more static feature for somebody as opposed to capacity that is going to be a [00:43:00] little bit more potentially changing.

Dr. Sharp: Yeah. I was going to ask how. This just seems very hard from the outside because I’m immediately thinking like, how do you separate capacity from just poor verbal skills or low IQ or some other independent “cognitive issue”? And then there’s always that question like how do you deal with like transient symptoms that may be different tomorrow but today they’re impaired. And maybe those are too big to tackle but those are some of the things that occur to me.

Dr. Rob: Two great points. The first one, I think what we’re getting at is what diagnoses or what problems will people have where they don’t have capacity. Some of the obvious ones are dementia, neurocognitive [00:44:00] disorders, TBI, things that probably are going to be relatively stable or declining. In those cases, it’s pretty clear when you have vascular dementia as a diagnosis, we slip in, do a MoCA then major neurocognitive disorders, pretty clear. And everybody that sees that evaluation will understand that this is probably not something that’s going to change the capacity. We want to keep an eye on it but they’re not likely to improve to a point where they’re going to be able to recover capacity for certain decisions. They could, but it’s not as likely.

But then we have things like delirium where yes, it’s potentially very changeable and quickly changeable. The physicians are very good about not calling me in when they know something is just a big delirium blow-up, that’s going to change quickly. They just look a lot of times in those moments they just [00:45:00] provide the treatment that’s necessary and the patients may not even be able to communicate.

Maybe it’s antibiotics. A few days later, they feel fine. Then there was really no need for me to come in at that moment. But sometimes there is a need for me to come in when patients are at a place where they, it might be delirium or something that may be acute withdrawal or something like that. But in those conversations, and sometimes I do document that this is potentially a changeable concern and continue to reevaluate the patient because according to…

One thing that I didn’t mention is with capacity, each state is different in terms of the laws. In the Commonwealth of Virginia, the attending physician has to basically state in the record that the patient does not have capacity. And then they call me in and I’m the capacity reviewer they call it. The second opinion, but you have to have to and for the second opinion, it can be a licensed clinical psychologist or a physician, [00:46:00] we both have to document that the patient doesn’t have capacity. But if a patient regains capacity, a physician that’s treating that patient can at any time just say the patient has regained capacity, do their assessment and documented in the chart.

There are some mechanisms there for people that might have that changeable or more quickly changeable level of capacity. I’m trying to think of other things. I mean, sometimes we have mental health; it could be depression, it could be psychosis obviously, a lot of those problems can come into play. A lot of times that’s interesting and tough assessment because you may have people with severe major depressive disorder, but their cognitive functioning is fully intact.

But there are other things and probably more emotionally related things that are a barrier for them to making appropriate choices and understanding their choices. And those ones are, I shouldn’t say less clean, but when [00:47:00] you get into that emotional aspect, there are some other challenges that come into play of trying to make that appropriate assessment. Those are just two things as far as how we deal with this. And again, if it changes, then the physician can just document that there’s that change and the patient can go about having capacity again. A lot of different diagnoses will come into play that brings people to my consultation service.

Dr. Sharp: Oh yeah. I bet. In my mind, I’m aware that my internal biases, I see these people as being relatively elderly, but I’m assuming that’s not always the case.

Dr. Rob: It’s not always the case. No. I think that that is certainly a good percentage of my people may be 60+. And then [00:48:00] there’s a good range then, 50 to 60. But if you think about things like TBIs, or other substance use problems, sometimes we do get younger people. I’m only serving adults because obviously with children, there’s not really a capacity thing to deal with but we do get people in their 20s and 30s and some younger folks. So it’s a wide range but when it comes to things like placement and facilities, a lot of times that is older adults than I’m working with.

Dr. Sharp: Of course. Before we totally run out of time, it’s flying by, I always have to ask about documentation and reports. Bane of our existence. What does that look like in this position?

Dr. Rob: I have a really [00:49:00] nice template that I use. So that’s helpful. The large majority of what I have to fill in is just to fill in, there’s probably a good solid paragraph of 8-10 sentences. That is me who is writing it, and I’ve tailored that over the years. It’s very expedient because it’s just always helpful to be able to do it quickly. And I say, do it quickly in terms of getting the documentation in, but I’m very careful about the language that I use and how I say things.

I am very careful about reviewing what I put in there because of two things. I want things to be very clear because I know a lot of people are reading this and reading it immediately. There’s not often time to change things. If I didn’t document it the way that I wanted to already a whole treatment team has seen it and gone off of that information. The other part of that is these are highly visible documents outside of the hospital, as far as legal issues are concerned. They [00:50:00] will go for guardianship, for example, they may be called into court for different reasons.

Dr. Sharp: I was going to ask about that. It sounds like a situation fraught with the potential to end up in court.

Dr. Rob: Yes, it is. And having all that tailored so I can get the information in quickly allows me to take more time than I would with any other psychotherapy note, to really be careful about how I’m using my language and what I put in there. And that may be me. That’s partly me and how I do things and more my nature. But I think that it’s for folks doing this, I think it’s a good way to practice just because they are so visible. And there are so many possibilities for these to be critiqued and come into question. And anytime we’re making an opinion, we want to have that good solid data and feel secure with what we’re putting in there [00:51:00] to argue our point.

Dr. Sharp: Well, I wonder if that might be a nice transition to start to wrap up and just ask about how you manage what I would perceive to be challenging emotions of this position, and making what would appear to be pretty serious decisions about people’s lives based on small interactions with them. I know you have a lot of data at your fingertips and it’s a heavy decision, right? Do you ever have to work with that internally?

Dr. Rob: Yeah. It’s a heavy decision. I would say in the majority of these evaluations, there’s not a life or death situation at hand, but there’s somewhere it is, it is literally life or death for these patients in terms of their choices. [00:52:00] That does weigh on you. One way I can talk about it is, a lot of people will say to me sometimes, and ingest, “Oh, you’re coming to take this person’s capacity away.”

Dr. Sharp: Oh, that’s funny.

Dr. Rob: Yeah. The dark world of medicine. I understand where they’re coming from, but my counter to that is like I alluded to before, there are some cases where, and most of the time where it’s just so clear that if I allow this patient to just have their own autonomy by not doing this evaluation appropriately, it’s going to be a bigger mess and a much more difficult for them in their life and potentially risky and dangerous.

I remind myself that when I am deeming somebody to not have capacity, this is a valuable service not because I’m valuable and I’m [00:53:00] providing the service, but it’s something that’s going to help them potentially have a sound mind, come in to work with them to make a decision to help them prolong their life or to end their life or whatever else, but just another rational mind coming together in there to make this choice with them because you can see both sides of it and both sides of it can really look like, oh, that’s tough to go either way.

But I think what it comes down to is just, and I wrestled with that a lot when I started because obviously wasn’t as confident and comfortable with my process but as I’ve done them over the years, it’s like, I always just rest on that that I have this process and I’ve done so many that and again if I get to a place where I’m like, does this person have capacity or not? I’m always picking up the phone and then asking other folks to do these with me to just help talk me through it. And sometimes, as it all I think often is with our [00:54:00] colleagues, the objective person is like, it’s so clear.

I mean, it’s just that our own emotionality gets wrapped up in it. And then we have a rational voice coming through that other line or face-to-face. And it’s like, yeah, that makes a lot of sense when you just have that five minutes or so to bounce that off of somebody. But talking with colleagues about it and doing all the self-care things that we do, whether we’re doing assessment or therapy or whatever else, keeping ourselves exercising and sleeping and eating well and trying to maintain that balance because like any psychology job, that can have a lot of weight to it.

Dr. Sharp: Absolutely. Well, that may be a nice note to close on. Just a reminder. Taking care of ourselves and a reframe too, that it’s not necessarily like you’re taking anything away from these folks, but that you’re perhaps just adding a layer of guidance or [00:55:00] protection even in some cases to make sure that they’re getting what’s best for them treatment wise.

Dr. Rob: That’s right.

Dr. Sharp: I wonder if they’re folks listening and they’re like, Hey, that sounds like a cool job. Do you have any thoughts on moving down that path, any training that might be helpful, or any experiences that could be helpful before looking for jobs or applying for a position like this?

Dr. Rob: Sure. I think if we have any folks listening to this podcast that is at the graduate level, the only place that I’ve found psychologists have had this training is if they’ve gone into hospital settings for their internships. I think it’s really tough to get the experience otherwise, but I have run into two people that have had more of those behavioral health internships and had a lot of consult liaison opportunities within the hospital.

But I do think too if [00:56:00] people are interested, I’m often looking and I’m getting this question, capacity’s not just inpatient. A lot of times people in the outpatient setting and a lot of times I’ll get calls from the doctors that are struggling because they have some in the outpatient setting that they need an evaluation for which I have to put a boundary there because I would just go on forever.

I’d have too much work so I don’t do that, but I know that they are often looking for folks in the community that might do these in private practice. And psychiatrists that do that in an outpatient setting and you can get beyond the medical decision-making into more of the legal forensics. 

So it starts to butt up against that a little bit. But I think it’s more interested in maybe doing it as a little piece of their outpatient consulting service or the assessment service might just try to connect with the hospital, see if there’s somebody doing them that can train them to do it, and then they can have a template for the outpatient setting [00:57:00] because I have some friends that have not started doing it here in Roanoke but are interested in doing it . In the outpatient area, as far as doing it as a service as a psychologist in your own practice, it would be a pretty quick and easy thing to do to add on as a piece of service. And I think it would be a pretty high demand once people discovered that you were doing it based on the number of calls I get for those outpatients.

Dr. Sharp: Oh that’s really interesting. I’m going to be thinking about that. Well, our time has flown by.

Dr. Rob: Yes, it has quickly.

Dr. Sharp: Yeah. Well, I’m always grateful and impressed to chat with you about work stuff . We’re in totally different settings but it’s amazing to hear everything that you’re doing and get a little window into this niche assessment practice that is super interesting.

Dr. Rob: Yeah. Well, likewise, it’s always good to talk with you. I’m glad you invited me to [00:58:00] chat with you. It’s been fun.

Dr. Sharp: Thanks again, y’all for tuning in to this interview with Dr. Rob McNamara. Hope you enjoyed it. I’m going to be thinking about this interview for quite a while honestly, the nuances and layers involved in this type of assessment are so different than what I typically do. So this is super interesting to me.

Like I said, at the beginning of the podcast, if you need CE credits, you can get CE credits for just answering a few questions about the podcast episodes. You can go to athealth.com and search The Testing Psychologist. If you use the code TTP10, you’ll get a discount off your entire order of CE credits, not just the podcast episodes. I hope you can get some of those to renew your license. That’s coming up very soon for us here in Colorado, and maybe for some of y’all as well.

All right y’all, thank you so much again for listening as always. This is fantastic. It still blows my mind that I’m [00:59:00] coming up on 100 episodes and there are so many of you out there who enjoy listening to podcasts about testing. It’s such a funny small little world, but I know there are a lot of you out there who really love hearing about it. So that’s really cool. I love what I’m doing here.

All right. I’ll be back soon. More great interviews coming up. I am talking with the folks from the School Psyched Podcast, which is a really fun conversation. I’m talking with Dr. Julie Cradock O’Leary about the Cradock Test of Shame and shame in general, Aimee Kotrba about selective mutism, and all sorts of other great interviews. So stay tuned, subscribe if you haven’t already, and take care. Bye, bye.

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