Successful Private Practice in Neuropsychology and Neuro-Rehabilitation: A Scientist-Practitioner Model

Successful Practice in Neuropsychology and Neuro-Rehabilitation

A Scientist-Practitioner Model

Second Edition

Mary Pepping, Ph.D., ABPP-CN

University of Washington School of Medicine, Seattle, Washington

Pepping and Barber Corporation, Sandpoint, Idaho

Table of Contents

Cover image

Title page

Copyright

Dedication

Foreword to the Second Edition

Preface

Chapter 1: The Challenges of Practice in Neuropsychology: Overview of Key Issues and Effective Solutions

Abstract

Pros and Cons of the Institutional Setting

Maintaining High-Level Skills

The Interdisciplinary Network

Do Not Go Gently into That Research Decline

Creating Educational Opportunities

Productively Managing Anxiety: Income

Protectively Managing Anxiety: Malpractice

Personality Factors in Private Practice

Ego Needs and Decreased Prestige

Ongoing Consultation: Are You Willing to Seek It? The Buck Stops Here

Chapter 2: Other Potential Indignities

Abstract

No Paid Sick Leave or Holidays

No Additional Reimbursement for Professional Fees

No Guaranteed Salary or Health-Care Benefits

Overhead Expenses

Billing, Collections, and Taxes

Chapter 3: The Good News

Abstract

Integrating Skills and Interests in Patient Selection

Creating the Optimal Schedule

Design Your Own Contracts

Setting Your Own Fees

Determining Salary

Choosing Your Own Support Services

Office Location, Space, and Atmosphere

Developing Your Own Letterhead and Brochures

Personalized Report Formats

Test Selection

Tax Advantages

Chapter 4: Getting Started: Practical Preliminary Questions

Abstract

Are You Experienced Enough to Be on Your Own?

Individual or Group Practice

Interdisciplinary Practices

Full-Time or Part-Time Private Practice

Consultation or Supervision Practices

Teaching

Medical–Legal Work

Neuropsychological Evaluations and Expert Witness Work

Hospital and Clinic Affiliations

University or Medical School Positions

Adjunct Appointments

Part-Time Clinical Faculty

Chapter 5: A Practical Guide for Opening Your Business

Abstract

Don’t Burn Bridges

Clinician, Know Thyself

A Moveable Feast: The Menu of Practice Options

Maintain a Part-Time Practice with Your Previous Employer

Developing a Safety Net: Starting with a Group

Offering Contract Services to Inpatient Rehabilitation Units

Offering Contract Services to Private Clinics

Membership in Managed Care Panels

Obtaining Adjunct or Clinical Teaching Appointments

How to Determine Fair Fees

How to Find Good Help

Developing a Business Plan and Practice Management Statistics

Chapter 6: Marketing and Other Matters

Abstract

First: The Other Matters

Next: The Marketing Piece: The Introductory Letter

Develop Seminars and Workshops

Give Guest Lectures

Offer a Memory Course to the Public

Contact Local Physicians and Fellow Neuropsychologists

Contact Independent Nurse Case Managers

Contact Private Vocational Firms

Attend Weekly Hospital Teaching Rounds

Supervise Residents, Interns, and Postdoctoral Fellows

Obtain Graduate Student Help for Research

Conference Participation: Yours and Other Related Professions

Publish

Final Comment

Chapter 7: Creative Approaches to Financial Issues

Abstract

Next Steps

Trading Consultation Time for Office Space

Sharing Testing Materials

Advice on Billing and Collections

Obtaining Basic Data from Your Patients

Obtaining Insurance Authorization

Contract and 50% Down for Private NPE

ICD-9 and CPT Codes

How to Bill and Collect for Legal Work

Reduced Cost Malpractice Insurance

Contract Assistants

Tax Deductions, a Good Accountant, and Type of Business

Chapter 8: Medical–Legal Work

Abstract

The Problems with Legal Work

True Believer Polemics in the Absence of Strong Scientific Data

Integrity and Reputation—Are You a Plaintiff or a Defense Expert?

Potential War of the Clinical and Legal Worlds

Subtle Influence and Examiner Drift

Inadvertent Promotion of a Litigious Zeitgeist

The Benefits of Forensic Work

Chapter 9: Consultation and Supervision Practice

Abstract

Clinical Psychologists, Primary Care Physicians, Nurse Practitioners, Physician Assistants, and Neurology or Rehabilitation Nurses

Neuropsychologists Who Wish to Augment Their Training

Therapists in Social Work, Counseling, or Pastoral Counselors

Rehabilitation Therapists, Occupational Therapists, Physical Therapists, Speech Pathologists, Vocational Counselors, Rehabilitation Specialists, Recreational Therapists, and Case Managers

Consultation with Psychologists Preparing for Licensure

Chapter 10: Psychometric Concerns

Abstract

The Interview: Who Should Be Present and Why?

The Collateral Interviews: When, Why, and with Whom?

Preparing the Patient to Be Tested

Test Selection

Selective Additional Testing: Divided by Specific Areas of Concern

Evaluating Personality in Neuropsychological Assessment

Cross-Cultural Issues

Use of Psychometrists

Report Formats

Review of Test Results

Dictation Versus Typing it Yourself

Dissemination of Reports

Preservation of Testing Files and Raw Data

Chapter 11: Treatment Practices for Neuropsychologists

Abstract

Your Training Background and Future Training Needs

What Kind of Practice do you Want?

Other Parts of Good Clinical Practice Development: Outpatient Psychotherapy

Establishing Short-Term and Long-Term Groups

Individual Treatment in a Neuropsychology Practice

Billing and Reimbursement Issues

Other Practice Options: Employee Assistance Program Contracts

Other Practice Options: Case Management Services

Chapter 12: Nuts and Bolts of Your Evaluation Practice

Abstract

Referrals

Educating Referral Sources

Purpose of Testing

Mechanisms of Feedback to Referral Sources and Patients

Insurance Preauthorization of Services

Timely Billing and Collections

Chapter 13: Neuro-Rehabilitation Program Treatment: Principles and Process

Abstract

Introduction

What Is Milieu-Based Treatment?

The Value of Work in the Lives of Humans

Why Is the Traditional Versus the Milieu-Based Rehabilitation Distinction Important

What Is Traditional Outpatient Rehabilitation?

Why Is Milieu-Based Treatment Needed for the Medium-Severe?

Guiding Philosophy and Principles of the Milieu Model

Some Implications of Psychological Factors in Evaluation and Treatment

Practical Considerations for Neuro-Rehabilitation

Key Practical Program Components

Fundamental Relationship Between NPE and NRP Treatments

How Can the Milieu-Based Model Be Modified for Your Practice?

Chapter 14: How to Design and Implement a Cognitive Group

Abstract

Introduction

Which Patients?

Basic Clinical Rules and Procedures

Basic Billing and Documentation

One Model for Cognitive Group Treatment

Chapter 15: The Value and Use of the MMPI in Neuropsychological Practice

Abstract

Introduction and Background

Challenges to Providing Balance: Identifying Personality Strengths

MMPI Profile Case Examples

Chapter 16: Designing and Implementing a Clinical Neuropsychology Fellowship

Abstract

Introduction

Design of the Fellowship: Three Key Components

Implementation of the Key Components

Training Content to Meet General Knowledge Requirements for Our Fellow

Specific Skills to Master per Houston Guidelines

Our Practice and Training Components

Organizing the Training Schedule

Feedback from the Fellow After Return to Active Military Service

A Final Word on Selection of Trainees

A Final Comment on How to Make This Happen in Your Locale

Supervisor Time Required for Fellowship Training

Chapter 17: Research as a Daily Reality

Abstract

What Are Your Research Interests?

Grants

Conference Presentation

Journal Articles

Chapters

Journal Groups

Collaborations

Chapter 18: Summary and Conclusions

Abstract

The Importance of Relationships and Mutual Best Interest

What Sort of Work Do You Want to Do?

Where and How Do You Want to Begin?

What are the Best Ways for You to Minimize Costs and Maximize Income?

What Sort of Financial Floor Do You Need?

How Will You Monitor and Promote Growth of Your Practice?

What Do You Do If Plan A Isn't Working as You Expected?

What are Your Short-Term, Intermediate, and Long-Term Goals?

Practical Ways to Vary Your Practice

Periodic or Long-Term Contract Work

Clinical Faculty Appointments

Be Alert to Clinical, Teaching, and Research Opportunities

Enjoying Your Practice

Appendices

Appendix A

Appendix B

Appendix C

Appendix D

Appendix E

Appendix F

Appendix G

Appendix H

Appendix I

Appendix J

Appendix K

Abodes

Note-Taking Strategies (Cognitive Group)

Appendix L

Appendix M

Appendix N

Appendix O

Appendix P

Appendix Q

Appendix R

Index

Copyright

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Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

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Dedication

Dedicated to my husband, Joseph Barber, and to the Neuro-Rehabilitation Program team at University of Washington Medical Center

Foreword to the Second Edition

The world of neuropsychology and the world at large have changed in many ways in the 11 years since the first edition of this book was published. Within neuropsychology, a wide range of topics continue to evolve from the newly understood chronic traumatic encephalopathy in some professional football players to the fuller explication of neuropsychological difficulties for people with multiple sclerosis or chemotherapy effects for people with cancer. As a specialty profession, we continue to update our core tests, refine brief screening instruments and work diligently to elucidate brain–behavior relationships as they uniquely affect each person yet are characteristic of human function.

There have also been great strides in science and technology, including an impressive array of new capabilities in brain imaging techniques as well as the delineation of the human genome and such advances as targeted genetically related treatments for some cancers.

We are also in many ways a more closely connected global community than was true even 11 years ago, with events in one country or economy having far greater impact on other countries and economies than was appreciated in 2003. This closer connection is complex. It includes exposure on a daily basis though graphic news accounts to the details of terrorism, genocide, famine, disease, mass murders, environmental degradation, and the many other forms of human suffering, most of it at the hands of other humans.

Some of this occurs in our own countries, some in the countries of friends and colleagues throughout the world. It all forms a steady thrum of underlying stress present in all of us, if we take the time to pay attention, rolling like a deep river under the surface of our daily lives.

Yet it is this higher degree of interconnection, interdependence, and awareness that has allowed each of us to be reminded of the importance of each single life, to identify with people of every race, ethnic group, country, and condition, as they seek to survive, and if possible, find a better life for themselves and their children. On a scientific and academic professional level, the greater interconnections of this smaller world yield much better appreciation of, and involvement with, the work of our peers in the many countries of the world. This includes the people and places where neuropsychology and neuro-rehabilitation are employed.

On a clinical level, this awareness of each individual's potential contribution can lead to a redoubling of our efforts to fully understand and assist each person referred to us for care. For me personally, it comes down to this: I can’t singlehandedly stop famine or murder or the melting of the polar ice cap in the service of a better world. However, I can provide the kind of thorough analysis of a given person's neuropsychological evaluation results that can lead to an improved life for that person in the world, in the larger context of effective treatment.

It is this purpose and rationale that has led to this Second Edition of my 2003 book on private practice in neuropsychology. This time, there is an expanded focus, first upon neuropsychology in the private practice and the institutional work domains and second upon neuro-rehabilitation as it may be best carried out in each of those settings by a team of interdisciplinary clinicians. This Second Edition contains three new chapters: on Neuro-Rehabilitation, on the MMPI in clinical practice, and on the design and delivery of a clinical neuropsychology fellowship.

By way of relevant historical review: In 1993, after many years of work in institutional settings, I decided to enter private practice and to become fully self-employed. Although I had a general sense of what would be required, it was only in the day-to-day implementation of myriad clinical and business details (as well as in trying to maintain some teaching and research interests) that I learned first-hand what might constitute a good practice model.

At the end of 1999, an unexpected opportunity arose to direct a neuropsychology service and an outpatient neuro-rehabilitation program in an academic medical center. Part of the reason I was recruited was my history as a private practitioner who knew how to build and operate a successful neuropsychology practice. The teaching and clinical research I continued during those private practice years were also a good fit for the Clinician-Educator faculty position the university was seeking to fill. Prior interdisciplinary neuro-rehabilitation experience rounded out the fit.

I have recently returned to private practice in a consulting role, both for clinical consultation and for medical-legal cases, while shifting to Professor Emeritus in my academic life. With a well-developed appreciation for both practice settings, it is my intention for this 2nd Edition to fulfill four specific roles for the reader:

(1) Continue as an updated practical guide for understanding and meeting the requirements of effective self-employment as a neuropsychologist in the scientist-practitioner framework.

(2) Examine features of private practice design and application that can be brought to bear on institution-based practices and vice versa. This 2nd Edition will speak more specifically to ways in which a greater degree of creativity, flexibility, and individual practice freedom can be possible, even within the institutional setting.

(3) Expand exploration of career options for psychology graduate students, interns, and postdoctoral fellows who might find it helpful to learn more details about private practice as well as clinical practice in interdisciplinary medical settings than may be available to them within the walls of their graduate programs.

(4) Psychologists of all stripes, whether neuropsychologists or clinical psychologists, as well as other treating therapists and rehabilitation clinicians, are likely to find portions of this book that could be implemented to maximize quality of work life and patient care options.

This book reflects my beliefs and approaches to the topics of neuropsychological practice and neuro-rehabilitation, in both private and institution-based settings. I have tried to make those beliefs explicit and reference some of the information upon which they are based. There are many additional valuable viewpoints. I encourage you to find and consider them in your reading, conference attendance, and work.

Three caveats are the following:

1. This book is not intended as a primer on how to become a neuropsychologist. Those criteria are well documented in the National Academy of Neuropsychology (NAN) definition of neuropsychologist; in the requirements for candidacy for neuropsychology diplomates via ABPP (American Board of Professional Psychology: Clinical Neuropsychology) and ABCN (American Board of Clinical Neuropsychology); and in the APA (American Psychological Association) Div. 40 (Neuropsychology) and Houston Guidelines regarding necessary training to become a neuropsychologist.

2. Neither is this book intended as a primer on how to create or conduct a forensic practice. While the medical-legal work described here can be an interesting, challenging and satisfying source of work, the skills, training, and experience required go beyond the intent of this book.

3. While I include such topics as billing processes, procedural coding advice, diagnoses useful for neuropsychology, and potential tax deductions and other business matters, these represent my opinions and are never to be construed as legal advice. You need to determine what is appropriate for your practice and assure yourself it conforms to local, state, provincial requirements, and national requirements that govern your business.

One of the most important things I have learned over the past 33 years in both institutional life and private practice is that regardless of our work setting, we have more freedom to craft a practice that works well for us than we may think we do. Although some jobs do not lend themselves to the flexibility I advocate, it is also true that those of us with a particular kind of work ethic may find it difficult to consider the kinds of modifications that would make our lives better. This may be for fear of being perceived as less than productive, as not carrying our weight, or as somehow not being fully up to the task of chronic overwork.

There is a funny (and I don't mean humorous) unspoken competition in many institutions about who is toughest when it comes to bearing unreasonable demands and a subtle pecking order based on those principles. So, you may have some decisions to make about your own quality of life and career. To borrow a phrase from Winnicott, you can be the good enough neuropsychologist and find that a sufficiently meaningful, satisfying, and remunerative goal.

You can also play a satisfying role in evaluation, treatment, teaching, training, and research projects, in both the private and institutional setting. You can maximize what is positive about each, and reduce what is negative about each form of employment. It is the intent of this book to assist you in that process.

Finally, while this book necessarily reflects my US-based training and practice, it remains instructive for all of us as neuropsychologists and neuro-rehabilitation clinicians to explore the work of our international colleagues. It may be a journal article regarding a study in Bolivia (Chestnut et al., 2012) looking globally at the comparative use of intracranial pressure monitors. It might be an international conference talk held on community-based rehabilitation programs in Australia (Ponsford, conference presentation, Vipiteno, Italy, 2004). You might attend a department meeting where a visiting rehabilitation physician from India (Dr. Raji Thomas, personal communication) describes the nature of inpatient and home-based rehabilitation care in her country. It is a much smaller and better-integrated world of international study, cooperation, and care in neuropsychology and neuro-rehabilitation than was true 11 years ago. It is also stimulating and valuable to seek out this information to expand our own knowledge and refine our own techniques.

In closing, some direct expressions of appreciation are in order. I thank the members of my family, friends, teachers, mentors, trainees, patients, and colleagues who have been instrumental in my personal and professional development. I also thank Zoe Kruze, the Acquisitions Editor, who first contacted me regarding the writing of this 2nd Edition and oversaw the proposal approval process. These thanks further extend to Nikki Levy, Publisher at Academic Press and Elsevier Science, who initiated my 2003 book process and carried this 2014 2nd Edition throughout the writing process to completion. Barbara Makinster, Senior Editorial Project Manager, provided specific needed support to us yet again as did Senior Project Manager, Caroline Johnson.

The list would not be complete without a very heartfelt thanks to my husband, a source of ongoing inspiration, delight, intellectual challenge, and emotional support to me at every phase of this book and in our lives together. As a psychologist, he also provided substantive critique and feedback for the MMPI and the Neuro-Rehabilitation chapters, which are far better as a result of his input. My deep thanks and appreciation also to the outstanding Neuro-Rehabilitation Program team at the University of Washington Medical Center in Seattle. They epitomize the kind of expert, compassionate care described in these pages.

Mary Pepping, Ph.D., ABPP-CN

August 31, 2014

Sandpoint, Idaho, USA

Reference

Chestnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, et al. Global Neurotrauma Research Group. A trial of intracranial-pressure monitoring in traumatic brain injury. The New England Journal of Medicine. 2012;367(26):2471–2481.

Preface

Here is a description of the overall logic and layout of the ensuing chapters:

Chapter 1 is an overview of key issues and challenges inherent in both private practice and institution-based practice with some suggested solutions. Chapter 2 is the equivalent of get out while you still can and goes into some detail about the more harrowing aspects of self-employment versus institution-based employment and how to mitigate those factors in each setting. Chapter 3 provides a further antidote to the difficulties discussed in Chapter 2, by reminding you of all of the many positive features and relative advantages contained within each of those two employment settings.

Chapters 4–6 focus on development of your own unique practice whether private or departmental. In Chapter 4, the initial survey of the various ways you could spend your work time allows you to evaluate and determine what you really like to do. Chapter 5 has practical suggestions on ways to establish your initial practice in a sound fiscal manner and gradually accrue contracts and other sources of paid employment in private practice. This chapter also reviews ways to build a good referral network and evaluation service in an institution. Chapter 6 discusses marketing, including how to take advantage of professional activities you already enjoy and transform them into marketing tools, again, in both the private practice and institutional contexts.

Chapter 7 looks more closely at the expense side of the business and suggests creative approaches to managing costs in each setting.

Chapters 8 and 9 are devoted to special topics (as are Chapters 13–16), looking first at medical-legal work (Chapter 8) and at consulting work (Chapter 9) as interesting sources of income.

Chapters 10 and 11 examine specific neuropsychological concerns, with an emphasis on the interview and testing process in Chapter 10. A review of the clinical nuts and bolts of running an evaluation practice is included in Chapter 11, which covers topics ranging from referral etiquette to billing and collections, including updates regarding ICD-10.

Chapter 13 is a comprehensive but practical description of milieu-based interdisciplinary neuro-rehabilitation program care with examples for implementing and carrying out such a treatment model.

Chapter 14 is devoted to a hands-on discussion of how to develop and deliver a cognitive group to pique your interest about considering group treatment formats as part of an individual private practice. Even people who don't want to have a treatment practice may find the suggestions in Chapter 14 for Cognitive Group of interest. One can use an educational model that is not primarily psychotherapeutic in nature and run particular groups much as a class or course for participants.

Chapter 15 takes a closer look at the MMPI in neuropsychological and neuro-rehabilitation practice, with two detailed case examples of profiles and the associated personality strengths and vulnerabilities to be considered, supported, and treated.

Chapter 16 describes the development and implementation of a clinical neuropsychology postdoctoral fellowship for a military clinical psychologist who wished to acquire neuropsychology specialization.

Chapter 17 describes ways to keep the scientist alive in your self-employment framework via research and publication. Chapter 18 is a final commentary and summary of the ideas presented in this volume.

The appendices were developed (and now updated and expanded) to provide you with practical examples of helpful forms and other information I have used in my practice over these many years. These forms range from consent forms and information sheets for patients to comprehensive report formats and reference sheets for typical Current Procedural Terminology (CPT) codes and diagnostic (ICD-9) codes that are common in neuropsychological practice. In addition, you will find a sample outline and handouts for a cognitive group.

You are welcome to use any and all of the appendix materials, as long as you credit this source for any use of handouts and do not sell or distribute any of the Appendix pages for profit. Please keep in mind that final decisions about codes to use for billing and diagnosis in your practice are fully your decisions, and that in the United States, ICD-9 and/or DSM-V guidelines are your final references until ICD-10 is enacted on October 1, 2015.

Chapter 1

The Challenges of Practice in Neuropsychology

Overview of Key Issues and Effective Solutions

Mary Pepping, Ph.D., ABPP-CN

Abstract

Would you like to maximize what is best about your practice setting and manage its difficulties?

For example, in the institutional setting, you typically have a dependable salary and benefits and an array of system supports, including testing equipment, office space and furniture, help with triage and scheduling, and a billing and collections department. However, you may also have very little choice about the nature or location of your office, the patient groups that you will see, or the number of evaluations or treatment patients you are required to schedule each week.

In private practice, you have the ability to choose your office location and set your own schedule with respect to days for clinical work, paperwork, research, or teaching. You decide which patient populations you wish to see, set your own fees, and you keep what you collect. However, you also bear all of the financial responsibility for your practice. You may not have clinical coverage available when you need to be out of the office. If you are in solo practice, you may be somewhat isolated.

Whether you are institution-based or in private practice, or some combination of each, this chapter can help you begin to create a more satisfying practice by integrating the advantages of each setting.

Keywords

Institutional setting

High-level skills

Interdisciplinary network

Educational opportunities

Income

Malpractice

Personality factors

Ongoing consultation

Pros and Cons of the Institutional Setting

One of the major challenges in a scientist–practitioner model of private practice is to preserve what is best about the academic and clinical aspects of full-time institutional work, while reducing the less attractive features such employment can bring.

On the positive side of the ledger, institutions such as hospitals, clinics, or universities typically provide an array of supports for their professional staff. This usually includes a regular salary, office space, transcription support, scheduling help, at least some built-in referrals from other departments, and billing and collections personnel. Paid sick leave and vacation days are typical, while retirement benefits and perhaps some financial support for continuing education may also be part of the package. In addition, one may have on-site opportunity for grand rounds or other in-service training. Regular contact with like-minded colleagues can provide very helpful interpersonal and professional support and stimulation.

On the negative side of the ledger, one may be subject to a very high and unreasonable workflow of patients that the institution has made a commitment to serve, but for whom sufficient clinical personnel have not been hired. You may have very little control in the patient selection process (e.g., if patients are part of that system and need to see a neuropsychologist, you will see them). You may also be subject at times to the political vagaries of poor administrators or supervisors, to bureaucratic inefficiencies that affect daily quality of work life, or problematic support staff. And there may not be a fair linkage between your level of productivity and your salary, nor, perhaps, room to grow and advance within your profession.

At those times, the joys of private practice exert a strong pull. These include designing the type of practice you want, e.g., evaluation only, evaluation and treatment, medical–legal consultation, and part-time teaching as part of the mix. It includes a choice about which days of the week you work, and other aspects of your schedule. You are free to decide when to take vacation, or to schedule personal appointments at convenient times. Ironically, in my private practice years I also found it far easier to protect large blocks of time for record review, test data review, report preparation, journal reading, and various writing and research projects than has ever been true in the institutional setting. I also had more space in which to work than the typical institutional office provides.

And how about the less desirable aspects of private practice? For me personally as a neuropsychologist I did not have as extensive a range of complex neurological cases in my years of private practice as I was able to see in the academic medical setting. While I was able to pull from several diagnostic groups by working on contract in a medical center combined with my own private referrals, I was still missing some major evaluation groups, e.g., people with brain tumors. I was also not an integral part of a neuro-rehabilitation team. By working as a contract consultant for a private rehabilitation company I had weekly or biweekly discussions with their key clinicians and neuro-rehab teams, but it was a periodic consultative rather than integral daily clinical role.

In the scientist–practitioner model for private practice in neuropsychology, you can create a career life that incorporates some of the best features of each world: the institutional and the self-employed. This approach allows for an ongoing refinement of your activities, in a manner that hopefully avoids or reduces some of the more egregious effects of bureaucracies and institutions and that offsets some of the negative aspects of private practice.

One way to maximize what institutions have to offer is to select an institution and department that you like and to negotiate a part-time contractual relationship with them (see Chapters 4 and 5 for more details). In this manner, you may be able to see patients who would not typically come to your private practice, but whose neurologic problems may be of great interest to you. You can also charge an hourly fee to the facility for your time and let them handle billing and collections. You are also more likely to remain somewhat free of institutional politics, i.e., you show up to see your patients, conduct the evaluations, and provide results and referrals. It is only when changes in referral patterns or billing practices are threatened that you may need to take a more active role in problem resolution with regular staff.

Maintaining High-Level Skills

When opportunities for continuing education are not built into your daily routines (such as stopping by grand rounds, weekly brain cuttings in neuropathology, listening to the neuroradiologists debate the merits of particular imaging approaches, or neuroanatomic details of an interesting case), you need to find solid and creative ways to fill this gap. Neuropsychologists must not neglect to update and expand their knowledge in the areas of neuroanatomy, neuropathology, and basic neurobehavioral issues associated with various diseases and syndromes once they have graduated from formal training. Although annual professional conferences and journal articles help, there is nothing like observation and discussion with expert colleagues to promote new growth in our own neuronal systems.

You may need to expand or supplement your reading of professional journals and develop a regular journal club meeting with colleagues. These activities can expose you to new knowledge and help ensure that you regularly hear informed perspectives on professional matters. Two helpful avenues for ongoing development of your skills include reviewing specific cases with other neuropsychologists who may have special areas of interest or developing an ongoing consultation relationship with a more experienced neuropsychologist.

Attending local meetings of your community's neuropsychology and neurology society meetings can be an excellent source of up-to-date clinical and research information and a potential source of referrals. These two groups can be particularly important for neuropsychologists, who need to be at the top of their form with respect to specific testing knowledge and broader neurobehavioral issues. The latter includes adequate understanding of the disease or injury from a medical standpoint, especially as it is likely to affect neuropsychological functions. There are also workshops, conferences, new books, and new test training opportunities. Although one may need to be selective, sharing the cost and use of these resources can be a very helpful approach in private practice. Books and test materials may be loaned to colleagues in similar circumstances. For some conferences, you and your colleagues may decide to rotate attendance, with the attendee bringing back specific ideas, reprints, and tapes to share.

It is important to acknowledge that scientist–practitioners in private practice are often caught between their training needs and the time and cost associated with leaving one's practice to pursue such opportunities. When we fly to a conference, give a talk, or attend a workshop, we not only bear the full training expense, but we must also continue to cover our rent and other overhead, while not earning any income during the time we are away. I am not sure if that constitutes a triple whammy, or merely a double whammy, but it is one of the more challenging aspects of self-employment.

Fortunately, a sole proprietor can keep an income stream flowing by hiring neuropsychologists to conduct evaluations in your absence, in a manner prenegotiated with some of your referral sources (see Chapter 7). And, if one implements some of the cost-sharing ideas described above for continuing education needs, you will find a stimulating and satisfying mix of information that doesn’t break the bank in the process. Finally, the heightened awareness, thoughtfulness, and energy that private practitioners must invest in their own training can produce a level of development in one's own craft not always found among personnel more safely ensconced in an institutional setting.

The Interdisciplinary Network

For me, the most difficult aspect of private practice was the absence in my daily practice of an established and mature team for the comprehensive interdisciplinary evaluation and treatment of neurologically compromised patients. Such a team typically includes speech language pathologists, occupational therapists, physical therapists, vocational rehabilitation counselors, social workers, recreational therapists, clinical psychologists and neuropsychologists, and rehabilitation medicine physicians. The absence of this kind of team was especially problematic for my patients of working age. For them, well-integrated team treatments are often critical if they are going to resume competitive employment and reestablish a more normal life of work, love, and play.

My neuropsychological evaluations documented the patient's cognitive, emotional, characterologic, and neurobehavioral disturbances and strengths. I also made recommendations for further work-up by other disciplines as appropriate for my evaluation patients. If the patient needed only a single service or treatment, it was a relatively simple matter to refer them to a good clinician.

It was otherwise a source of concern and frustration to witness the piecemeal and poorly integrated help some patients wound up receiving because they needed several different kinds of therapy and their various practitioners were scattered throughout the city. There was often no clear case manager and no good forum for effective communication among those providers.

Perhaps this varies significantly from city to city throughout the United States and Canada, or it may be different in other countries. In America, it seems relatively easy to find similar practitioners self-employed together (e.g., physicians, psychologists, neuropsychologists, speech pathologists, or vocational counselors), but more difficult to find self-employed interdisciplinary groups who provide comprehensive outpatient neuro-rehabilitation services. (An important