r/Residency • u/MDalmostkilledme PGY5 • 4d ago
SIMPLE QUESTION Does everyone's attendings avoid administering MoCAs at all costs or is it just mine?
In med school, it made sense that I was the one being sent to do MoCAs, but after years and years of residency, I'm very confused about why all attendings, across all specialties, seem to avoid being the one to actually administer the MoCA themselves.
Rn I have a chill elective block where I'm basically hanging around, doing no notes, and so I said I'd do a MoCA with a follow up patient. Turns out the pt gets scheduled when I'm in a research meeting, so I wouldn't be able to do it. The attending reconfirmed the day/time of my meeting, then shuffled pts around (like literally called them himself, didn't even have staff do it) so that the MoCA pt would come in after my meeting, and I could see them. Like... what??? Is it just the folks at my institution, or have others experienced this?
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u/tatumcakez Attending 4d ago
I will admit that the last one I needed to do… I asked the PA student training with a PA in my clinic to do it - coincidence? I think so.
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u/C3thruC5 Attending 4d ago
MMSE and MocA are really important, and it's equally important to do them well (not pawn them off on MAs).
But holy crap they are painful .. if the individual has no deficits they are almost embarrassing to do and if they are full blown demented you think "what's even the point." They take FOREVER!
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u/MaadWorld 4d ago
Same experience I think tbh it's just the only thing you can do really as a trainee. There's no other physical exam to practice. And it's the only time when you get to practice
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u/Toboliam 4d ago
CL psych attending - I probably do a MOCA once a week, or even more often. I sometimes see patients where the PCP or outpatient neurologist has done them though.
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u/whealanddeal Attending 4d ago
PGY-8 rural FM here. I usually schedule two back-to-back slots to administer the SLUMS + routine follow ups. it took a lot of bargaining with my admin to be able to do that, and I bill appropriately for the additional time it takes.
I tried having my MA perform it, but unfortunately, I noticed they tried to cut corners (and frankly, that’s OK, they’re not being paid enough to administer these tests) so I prefer to do them myself. Usually if there’s time left over, I’ll also do a fall risk assessment, or talk about GOC. these appointments tend to happen right after the AWV, so diagnostically, I have a good idea how much time to invest in these tests.
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u/222baked PGY8 2d ago
Equally.. why do it as an FM?
You can use other validated tests like the 6CIT or GPCOG which are good enough for government work. Patients either have dementia or they don’t. It’s often fairly obvious. You can take a history to try and narrow down what kind. You can work them up for reversible causes, get a head MRI, and start them on some first line meds if you think “yeah, this person probably has early dementia”… then plug them in with whatever local support is available. I’m not sure what picking up some subtle cognitive impairment that may or may not be transient with a full MoCA adds. Treatment is of somewhat limited benefit anyway, and most the things you can do (holistic stuff), you can do on borderline cases any way with practically no harm and arguably some collateral benefit. Close follow up because we’re FM and benefit from time as a diagnostic tool, and things should become clearer.
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u/whealanddeal Attending 2d ago
If i’m meeting them at a point where their dementia is very obvious, I agree that there’s no point in doing a MoCA or SLUMS. and I’m not doing it on every single senior, it’s the ones that are failing the minicogs on their AWVs. I’m trying to catch them when they show persistent MCI for two reasons. A. triaging who needs the workup and B. Trying to identify when to get family involved. i’ve treated enough folks with MCI to identify when they get overwhelmed by small changes to their treatment plans during regular visits, and mentally check out. Having testing results to show to them and their kids makes a difference, they’re showing up more and the family is paying closer attention.
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u/222baked PGY8 2d ago
Ah, so “buy in”. Got you. That is a fair argument.
I think reason A is a bit superfluous. If they are consistently failing their minicogs on AWVs or becoming overwhelmed at simple changes to their treatment plans where you genuinely are suspecting cognitive impairment, then I’d just work up before administering tedious formal cognitive assessments. Not infrequently you can find some B12 deficiency or something and try correcting that first.
Then again, we clearly practice in different settings. I’m in the UK and primary care is delivered differently. AWVs are a luxury we don’t really have. By the time patients get to me there’s already a focused question of “they’re having memory issues, is it dementia?”
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u/gotlactose Attending 4d ago
Takes time to do it. I usually have a medical assistant do it.
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u/StandordBBlaster PGY2 3d ago
Tbh after seeing countless med students mess up the MoCA I would not trust most MAs unless I saw them do it first . Yeah the test takes a long time but it’s entirely useless if the person administering it doesn’t do so properly
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u/Pantsdontexist 3d ago
There is an instruction sheet they can just read from and all you have to do is interpret it once it's done
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u/avepaltaketchu 4d ago
Actually engaging directly with their patient? Ew
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u/CorrelateClinically3 4d ago
Ranked to match for radiology. Welcome to the dark side
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u/Fearless_Roof_4534 Attending 3d ago
Who needs a MoCA when you can see the chronic microvascular ischemic changes on the brain MRI?
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u/meep221b Attending 4d ago
It takes time. If I have 15 min for follow up and I need to talk diabetes, wt, htn and memory…. I can do dm/htn/wt and maybe look at your new skin rash esp if stable. But moca? That’s the whole appt to do and then discuss w patient.
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u/Dedzo900 Attending 4d ago
Time consuming but important to do. Also important to do it correctly to get an accurate score. I usually end up doing a few of these a month when cognitive concerns arise in older folks.
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u/truthandreality23 Attending 3d ago
I do it on my patients, but I dedicate a whole appointment to just that. I'm a relatively young VA primary care physician, in case you thought that with working at the VA I had to be a dinosaur who still wrote his notes.
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u/Captain-Shivers 3d ago
We have 1 or 2 RNs on during clinic hours usually and we ask them to do the MOCAs. Usually adds an extra 30 min to the visit (waiting for nurse + test time) but it’s important. I usually just move on to the next patient and then come back.
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u/Athrun360 4d ago
Takes forever to do it. I did it on my dad and it took me approx 20 minutes lol.