Can a VA psychologist or psychiatrist produce reliable and valid results when conducting six C&P exams per day? (Hint: No.)
VA compensation and pension examinations for PTSD and other mental disorders lack adequate reliability1 and validity2 for several reasons.
Not providing C&P psychologists and psychiatrists enough time to conduct a thorough, evidence-based assessment of PTSD leads to less accurate (valid) and less consistent (reliable) results.
1. Lexico.com, "reliability n. – 1.1 The degree to which the result of a measurement, calculation, or specification can be depended on to be accurate."
2. Truman Lee Kelley, Interpretation of Educational Measurements, (Yonkers-on-Hudson, NY: World Book, 1927), 14 ("The problem of validity is that of whether a test really measures what it purports to measure...").
The Department of Veterans Affairs' C&P Service Clinician's Guide3 provides the following recommendation:
14.6 What is the recommended time allotment for completing examination?
This guideline is designed to enhance the objectivity, reliability, and accuracy of PTSD examinations conducted in compensation and pension settings.
Although the administration of the recommended assessment instruments requires additional clinician time, it is expected to result in improved quality and increased veteran satisfaction.
Approximately three to four hours are required to conduct a comprehensive initial compensation and pension examination for PTSD.
This includes 90 minutes for interview assessment of trauma stress exposure and PTSD symptoms plus an additional hour to complete other portions of the examination.
An additional 1.5 hours is required for review of psychological testing materials and preparation of a report of findings.
3. Majorie Auer et al., C&P Service Clinician's Guide, ver. 3.0, ed. Lewis R. Coulson (Washington, D.C.: Department of Veterans Affairs, 2002), 209–210.
But consider the following job announcement4 on USAJobs.gov for a C&P Psychologist:
The Compensation and Pension (C&P) Psychologist functions as the full-time mental health examiner for compensation and pension examinations.
As such, the incumbent will perform all the duties necessary for high quality, timely completion of the mental health examinations assigned for initial, review, or increase C&P evaluations.
It is expected that up to six examinations (i.e. face-to-face appointments with the patient) will be completed in a day, with the psychologist expected to review the Claims file, medical record, and associated background materials, perform the examination of the patient as requested by Newark Regional Office of Veterans Benefits Administration (VBA), and complete documentation of the examination by dictation or by typing within 24 hours.
4. Job Announcement Number: BH-15-JL-1320141-BU; Vacancy Identification Number (VIN): 1320141; East Orange, NJ - Open Period: 05 FEB 2015 to 27 FEB 2015. See also Job Announcement Number: KT-15-IJS-1400279-R19; Control Number: 403030500; Vacancy Identification Number (VIN) 1400279; Fayetteville, AR - Open Period: 05 MAY 2015 to 28 MAY 2015.
Six exams in one eight-hour day, presuming the psychologist has other duties and is allowed to take a couple of bathroom breaks, means about one hour per exam.
Can these C&P psychologists conduct a reliable and valid PTSD C&P exam in one-third to one-fourth of the time recommended in VA's own guidance?
One hour per exam not only contradicts VA's own guidance, VA has never conducted program evaluation studies, genuine quality assurance reviews, or empirical research to determine if one-hour exams produce accurate results.
Consequently, if VA declared that one hour per exam leads to reasonably reliable and valid results, their assertion would constitute mere speculation.
Of course, they cannot conduct reliable and valid C&P exams in one hour.
C&P psychologists and psychiatrists need adequate time to conduct quality PTSD evaluations, as a VA-requested study5 by the National Institute of Medicine pointed out 12 years ago:
The key to proper administration of VA’s PTSD compensation program is a thorough compensation and pension (C&P) clinical examination conducted by an experienced professional. ...
Many of the problems and issues identified by the committee in previous chapters (of the xxx-page report) can be addressed by consistently allocating and applying the time and resources needed for a thorough PTSD C&P clinical examination ... [which would] facilitate:
- more comprehensive and consistent assessment of veteran reports of exposure to trauma;
- more complete assessment of the presence and impact of comorbid conditions;
- the conduct of standardized psychological testing where appropriate;
- more accurate assessment of the social and vocational impacts [occupational impairment] of identified disabilities;
- evaluation of any suspected malingering or dissembling using multiple strategies including standardized tests, if appropriate, and clinical face-to-face assessment;
- more detailed documentation of the claimant’s condition to inform the rater’s decision (and thus potentially lead to better and more consistent decisions) ....
5. Institute of Medicine, PTSD Compensation and Military Service, (Washington, DC: National Academies Press, 2007), 204–205.
This is an updated version of "Six Exams Per Day", which I published on 9 Jun 2015 on my discontinued blog (ptsdexams.com). The original post is archived at https://perma.cc/WM2V-RFKQ .
Auer, Majorie, Troy Baxley, Lewis R. Coulson, Joseph Enderle, and Carol McBrine. C&P Service Clinician's Guide. Version 3.0. Edited by Lewis R. Coulson. Washington, D.C.: Department of Veterans Affairs, 2002. https://perma.cc/KY9E-TUCB
Institute of Medicine and National Research Council. PTSD Compensation and Military Service. Washington, DC: National Academies Press, 2007.
Kelley, Truman Lee. Interpretation of Educational Measurements. Yonkers-on-Hudson, NY: World Book, 1927.
Oxford University Press. Lexico. https://www.lexico.com/en/definition/reliability
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