[AVAPL Members] Re: avapl members Digest V1 #109
- From: "Padin, Edgardo (VHACLE)" <Edgardo.Padin@xxxxxx>
- To: <members1@xxxxxxxxx>
- Date: Tue, 28 Sep 2010 10:52:52 -0400
From the looks of this e-mail string, we continue to want to dialogue
around this issue. I do believe it is extremely important, and will
continue to be so as psychotherapy interventions become the central
skill set of Psychologists. As Psychology Leaders in the VA, we must be
at the forefront of helping to establish guidelines and criteria for
what is "acceptable" evidence based practices within the VA. AVAPL can
certainly help with this through promotion of dialogue on criteria sets,
perhaps even having one of our conferences dedicated to these issues. I
hope the AVAPL Conference Agenda Committee looks at this as a
possibility, given the amount of interest this issue has generated among
members.
-----Original Message-----
From: avaplmembers-bounce@xxxxxxxxxxxxx
[mailto:avaplmembers-bounce@xxxxxxxxxxxxx] On Behalf Of Roth, Shanan L
Sent: Tuesday, September 28, 2010 9:37 AM
To: members1@xxxxxxxxx
Subject: [AVAPL Members] Re: avaplmembers Digest V1 #109
I couldn't agree more with Russell's statement about EBP, RVU's, and
Productivity Incentives.
In light of my previous comments about the paucity of good empirical
evidence in utilizing EBPs with patients with TBI, and the number of
patients that VA has with co-morbid PTSD and TBI, I am concerned that
this may impact how we do psychotherapy with TBI patients (or patients
with other co-morbid medical disorders), for which there may be a great
need to individually tailor the psychotherapy due to specific patient
deficits (cognitive or otherwise).
Shanan L. Roth, Psy.D.
Clinical Neuropsychologist
VISN-17 TBI Point of Contact
VISN-17 Polytrauma Network Site
Dallas VA Medical Center
Office: (214) 857-0534
Pager: (214) 759-3836
Assistant Professor
Department of Psychiatry
UT Southwestern Medical Center
-----Original Message-----
From: FreeLists Mailing List Manager [mailto:ecartis@xxxxxxxxxxxxx]
Sent: Saturday, September 25, 2010 12:05 AM
To: avaplmembers digest users
Subject: avaplmembers Digest V1 #109
avaplmembers Digest Fri, 24 Sep 2010 Volume: 01 Issue: 109
In This Issue:
[AVAPL Members] Re: How to Improve the Implementation of
Evi
[AVAPL Members] Re: How to Improve the Implementation of
Evi
----------------------------------------------------------------------
Subject: [AVAPL Members] Re: How to Improve the Implementation of
Evidence-Base
Date: Fri, 24 Sep 2010 12:08:23 -0400
From: "Padin, Edgardo (VHACLE)" <Edgardo.Padin@xxxxxx>
------_=_NextPart_001_01CB5C02.B6B88432
Content-Type: text/plain; charset="us-ascii"
Content-Transfer-Encoding: quoted-printable
Almost as if you have questions about the sanctity of the RCT Model?
=20
From: avaplmembers-bounce@xxxxxxxxxxxxx
[mailto:avaplmembers-bounce@xxxxxxxxxxxxx] On Behalf Of Tan, Gabriel
Sent: Thursday, September 23, 2010 1:14 PM
To: members1@xxxxxxxxx
Subject: [AVAPL Members] Re: How to Improve the Implementation of
Evidence-Based Psychotherapy in the VA
=20
I concur with the points brought out by Kathy. I believe the
scientist-practitioner tradition should guide our decisions along with
the RCT model currently so popularly held as sacrosanct by many. =20
=20
From: avaplmembers-bounce@xxxxxxxxxxxxx
[mailto:avaplmembers-bounce@xxxxxxxxxxxxx] On Behalf Of McNamara,
Kathleen M.
Sent: Thursday, September 23, 2010 4:53 AM
To: Lemle, Russell; members1@xxxxxxxxx; VHA Psychology Postdoctoral
Training Directors; VHA Psychology Internship Directors; VHA National
Psychology Chiefs; members1@xxxxxxxxx
Subject: [AVAPL Members] Re: How to Improve the Implementation of
Evidence-Based Psychotherapy in the VA
=20
Aloha, All -
I have been following the very cogent responses to Russell's
initial e-mail on this topic, and have very much appreciated the depth
of the discussion from many of you. As those of you know who have heard
me speak on this issue at the Leadership Conference and at the
Convention VACO Meeting, I am less concerned about the fact that we are
advocating for evidenced-based treatments (though I wish we were
discussing evidenced-based practice), and much more concerned about the
issues which others have also raised in this discussion since Russell's
posting: (1) transparency and the selection process for inclusion of
the limited treatments which are explicitly named in the Uniform MH
Services Handbook, and (2) implementation, more generally. The first
point on the limiting of those treatments which are explicitly named at
this time again reached a level of concern for me as I was reviewing
literature for the completion of a chapter I am writing for a book on
Veterans Health Care, with a particular focus for my invited chapter
being ethnic, racial and cultural factors in health care for veterans.
The process of reviewing the literature pointed to the obvious fact that
we have a peer-review process for journal publications that intends to
provide us with the most scientifically sound evidence for various
psychological issues - with treatments being among the issues in those
refereed journals. The review also highlighted the fact that the
literature contains many studies which are examples of the differences
across minority groups in the treatment provided, as well as the
response to treatment. So, the question raised in this e-mail
discussion about how these particular treatments were included and
others are not is a critical one for those of us in the practice arena
to address. I consider the question a little more broadly: why any
particular treatments were named as opposed to a more general principle
being stated which would allow practitioners to base their practice (not
their "treatments") on sound psychological tenets, seeking evidence
which supports their practice (so the language about evidence-based
would be explicitly included), and allowing the treatment to be
patient-centered (which also should be explicitly stated) in the way
that the IOM and the APA Reports indicated. With regard to the
differences already noted in the literature for minority groups, the
evidence is clearly not complete and not in published (refereed) form
yet on the named treatments, and the National Center for PTSD - Pacific
Islands Division has a number of very significant research studies
on-going in this area. So, I am looking forward to our discussion
during the call this morning (afternoon for East Coast). =20
The implementation concerns remain significant areas about which the
Psychology Leadership in the field need to be providing input and
feedback to VACO. I noted that Toni mentioned that the Handbook was
undergoing revisions, and I hope that our call today addresses the
language will be included so that there is a clearer statement of how
the intent of having practice be based in psychological evidence can be
achieved. I look forward to hearing how the input from the various
meetings and phone calls will be incorporated into the revision process.
While the above issues would have priority, at some point (in a
future call would be fine) it would be great to hear how VACO has
followed up to work with APA President Carol Goodheart's Task Force
working on her Presidential initiative on Outcomes, what is being
discussed in that Task Force and how the VA's input is being received.
Dr. Goodheart's invitation to have a representative from the VA working
with that group is such a great opportunity to show that VA Psychology
has much to offer and is often on the forefront of research such as
this!
I am eager to hear our discussion today, and again hope that the
concerns about transparency and implementation of a broader concept of
evidence-based practice are addressed.=20
Aloha. =20
=20
From: Lemle, Russell=20
Sent: Monday, August 02, 2010 11:22 AM
To: 'members1@xxxxxxxxx'; VHA Psychology Postdoctoral Training
Directors; VHA Psychology Internship Directors; VHA National Psychology
Chiefs; V21SFC Psychologists
Subject: How to Improve the Implementation of Evidence-Based
Psychotherapy in the VA
=20
How to Improve the Implementation of Evidence-Based Psychotherapy in the
VA: Increase Transparency, Equitability and Efficacy
=20
Since the San Antonio VA Psychology Leadership Conference in May, there
have been a series of email exchanges about the direction of
evidenced-based psychotherapy in the VA. I would like to further that
discussion and raise several critical issues.
=20
The utilization of EBPs within the VA is an unquestionably important
goal. However, I am gravely concerned that some of the methods for
reaching that goal are taking us in the opposite direction - i.e. toward
the curtailment of VA clinicians' ability to choose from the broad array
of effective evidence-based interventions. The difficulty started when
the Uniform Mental Health Services Handbook embraced a narrow, limited
subset of VA-preferred evidence-based psychotherapies (without revealing
the criteria for their selection). The Handbook conveyed the implication
that these specific treatments were the only ones that satisfied the
standard of being "evidence-based."=20
=20
More significantly, a new VA policy -- RVU Productivity Incentives -- is
being deliberated that would discourage the use of non-sanctioned
treatments, including efficacious ones. From what I understand, this
plan will grant clinicians 25% greater workload credit for rendering a
VA-preferred psychotherapy than for rendering another psychotherapy of
the same duration. If you use VA-preferred psychotherapies, you reach
your annual productivity quota much quicker. That buys you time to do
other activities and as someone with higher total workload numbers, you
will be evaluated as being "more productive." Using other evidence-based
treatments will result in having to work additional hours to attain your
quota.
=20
In my view, Productivity Incentives -- like some of the other methods of
promoting EBP in the VA -- take us on an errant course. They purposely
aim to increase the use of the few VA-preferred psychotherapies and curb
all other approaches, including those with a strong evidence basis. Yet,
it is clear from the research that there are many treatments beyond the
officially sanctioned ones that are equally effective -- and sometimes
superior -- for alleviating the target disorders and problems. In
addition, attending to clinician and patient factors in treatment
selection is well known to improve outcomes. When we can choose from a
wider selection of psychotherapies, we are able to provide the most
effective treatment for our patients. This was the conclusion of the
APA's Task Force on Evidence-Based Psychotherapy.
=20
I therefore propose that VACO champion the use of all evidence-based
psychotherapy approaches and then let clinicians use their clinical
judgment as to which treatment would be most effective. Four particular
actions would enable that to occur:
1. VACO should make transparent the specific "evidence-based"
criteria that were used to select the UMHS handbook psychotherapies and
disseminated roll-outs (e.g. ACT, CBT, CPT, IBCT, PE, etc.). =20
2. This criteria should be equitably applied to all psychotherapies.
VACO should inform the field that every treatment -- whether or not
mentioned in the UMHS Handbook -- that meets this standard would be
explicitly endorsed as an equally suitable "Evidence-Based
Psychotherapy."
3. "Fidelity to Evidenced-Based Psychotherapy" and "Access to
Evidence-Based Psychotherapy" should be assessed for all psychotherapy
treatments that meet the criteria, not just for disseminated treatments.
4. Productivity incentives should be applied far more broadly than
just for using VA-preferred psychotherapies. =20
I hope that these suggestions prompt continued dialogue about how VACO
can promote the full armamentarium of evidence-based approaches. =20
=20
Russell Lemle, PhD
Psychology Director, San Francisco VA Medical Center
=20
=20
=20
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<div class=3DWordSection1>
<p class=3DMsoNormal><span style=3D'color:#1F497D'>Almost as if you have
=
questions
about the sanctity of the RCT Model?<o:p></o:p></span></p>
<p class=3DMsoNormal><span =
style=3D'color:#1F497D'><o:p> </o:p></span></p>
<div>
<div style=3D'border:none;border-top:solid #B5C4DF 1.0pt;padding:3.0pt =
0in 0in 0in'>
<p class=3DMsoNormal><b><span =
style=3D'font-size:10.0pt;font-family:"Tahoma","sans-serif"'>From:</span
>=
</b><span
style=3D'font-size:10.0pt;font-family:"Tahoma","sans-serif"'>
avaplmembers-bounce@xxxxxxxxxxxxx =
[mailto:avaplmembers-bounce@xxxxxxxxxxxxx] <b>On
Behalf Of </b>Tan, Gabriel<br>
<b>Sent:</b> Thursday, September 23, 2010 1:14 PM<br>
<b>To:</b> members1@xxxxxxxxx<br>
<b>Subject:</b> [AVAPL Members] Re: How to Improve the Implementation of
Evidence-Based Psychotherapy in the VA<o:p></o:p></span></p>
</div>
</div>
<p class=3DMsoNormal><o:p> </o:p></p>
<p class=3DMsoNormal><span style=3D'color:#1F497D'>I concur with the =
points brought
out by Kathy. I believe the scientist-practitioner tradition should =
guide our
decisions along with the RCT model currently so popularly held as =
sacrosanct
by many. <o:p></o:p></span></p>
<p class=3DMsoNormal><span =
style=3D'color:#1F497D'><o:p> </o:p></span></p>
<div>
<div style=3D'border:none;border-top:solid #B5C4DF 1.0pt;padding:3.0pt =
0in 0in 0in'>
<p class=3DMsoNormal><b><span =
style=3D'font-size:10.0pt;font-family:"Tahoma","sans-serif"'>From:</span
>=
</b><span
style=3D'font-size:10.0pt;font-family:"Tahoma","sans-serif"'>
avaplmembers-bounce@xxxxxxxxxxxxx =
[mailto:avaplmembers-bounce@xxxxxxxxxxxxx] <b>On
Behalf Of </b>McNamara, Kathleen M.<br>
<b>Sent:</b> Thursday, September 23, 2010 4:53 AM<br>
<b>To:</b> Lemle, Russell; members1@xxxxxxxxx; VHA Psychology =
Postdoctoral
Training Directors; VHA Psychology Internship Directors; VHA National
Psychology Chiefs; members1@xxxxxxxxx<br>
<b>Subject:</b> [AVAPL Members] Re: How to Improve the Implementation of
Evidence-Based Psychotherapy in the VA<o:p></o:p></span></p>
</div>
</div>
<p class=3DMsoNormal><o:p> </o:p></p>
<p class=3DMsoNormal><span style=3D'color:#1F497D'>Aloha, All =
–<o:p></o:p></span></p>
<p class=3DMsoNormal><span =
style=3D'color:#1F497D'>
I have been following the very cogent responses to Russell’s =
initial
e-mail on this topic, and have very much appreciated the depth of the
discussion from many of you. As those of you know who have heard =
me speak
on this issue at the Leadership Conference and at the Convention VACO =
Meeting,
I am less concerned about the fact that we are advocating for =
evidenced-based
treatments (though I wish we were discussing evidenced-based practice),
=
and
much more concerned about the issues which others have also raised in =
this
discussion since Russell’s posting: (1) transparency and the
selection process for inclusion of the limited treatments which are =
explicitly
named in the Uniform MH Services Handbook, and (2) implementation, more
generally. The first point on the limiting of those treatments =
which are
explicitly named at this time again reached a level of concern for me as
=
I was
reviewing literature for the completion of a chapter I am writing for a
=
book on
Veterans Health Care, with a particular focus for my invited chapter =
being
ethnic, racial and cultural factors in health care for veterans. The =
process of
reviewing the literature pointed to the obvious fact that we have a =
peer-review
process for journal publications that intends to provide us with the =
most
scientifically sound evidence for various psychological issues – =
with
treatments being among the issues in those refereed journals. The
=
review
also highlighted the fact that the literature contains many studies =
which are
examples of the differences across minority groups in the treatment =
provided,
as well as the response to treatment. So, the question =
raised in
this e-mail discussion about how these particular treatments were =
included and
others are not is a critical one for those of us in the practice arena =
to
address. I consider the question a little more broadly: why
=
any
particular treatments were named as opposed to a more general principle
=
being
stated which would allow practitioners to base their practice (not their
“treatments”) on sound psychological tenets, seeking =
evidence which
supports their practice (so the language about evidence-based would be
explicitly included), and allowing the treatment to be patient-centered
=
(which
also should be explicitly stated) in the way that the IOM and the APA =
Reports
indicated. With regard to the differences already noted in the =
literature
for minority groups, the evidence is clearly not complete and not in =
published
(refereed) form yet on the named treatments, and the National Center for
=
PTSD
– Pacific Islands Division has a number of very significant =
research
studies on-going in this area. So, I am looking forward to our =
discussion
during the call this morning (afternoon for East Coast). =
<o:p></o:p></span></p>
<p class=3DMsoNormal><span style=3D'color:#1F497D'> The =
implementation
concerns remain significant areas about which the Psychology =
Leadership
in the field need to be providing input and feedback to VACO. I =
noted
that Toni mentioned that the Handbook was undergoing revisions, and I =
hope that
our call today addresses the language will be included so that there is
=
a
clearer statement of how the intent of having practice be based in
psychological evidence can be achieved. I look forward to hearing
=
how the
input from the various meetings and phone calls will be incorporated =
into the revision
process. <o:p></o:p></span></p>
<p class=3DMsoNormal><span style=3D'color:#1F497D'> =
While the
above issues would have priority, at some point (in a future call would
=
be
fine) it would be great to hear how VACO has followed up to work with =
APA
President Carol Goodheart’s Task Force working on her =
Presidential
initiative on Outcomes, what is being discussed in that Task Force and =
how the
VA’s input is being received. Dr. Goodheart’s =
invitation to
have a representative from the VA working with that group is such a =
great
opportunity to show that VA Psychology has much to offer and
=
is
often on the forefront of research such as this!<o:p></o:p></span></p>
<p class=3DMsoNormal><span style=3D'color:#1F497D'> I
=
am eager to
hear our discussion today, and again hope that the concerns about =
transparency
and implementation of a broader concept of evidence-based practice are
addressed. <o:p></o:p></span></p>
<p class=3DMsoNormal><span =
style=3D'color:#1F497D'> Aloha.
<o:p></o:p></span></p>
<p class=3DMsoNormal><span =
style=3D'color:#1F497D'><o:p> </o:p></span></p>
<div>
<div style=3D'border:none;border-top:solid #B5C4DF 1.0pt;padding:3.0pt =
0in 0in 0in'>
<p class=3DMsoNormal><b><span =
style=3D'font-size:10.0pt;font-family:"Tahoma","sans-serif"'>From:</span
>=
</b><span
style=3D'font-size:10.0pt;font-family:"Tahoma","sans-serif"'> Lemle, =
Russell <br>
<b>Sent:</b> Monday, August 02, 2010 11:22 AM<br>
<b>To:</b> 'members1@xxxxxxxxx'; VHA Psychology Postdoctoral Training
Directors; VHA Psychology Internship Directors; VHA National Psychology
=
Chiefs;
V21SFC Psychologists<br>
<b>Subject:</b> How to Improve the Implementation of Evidence-Based
Psychotherapy in the VA<o:p></o:p></span></p>
</div>
</div>
<p class=3DMsoNormal><o:p> </o:p></p>
<p class=3DMsoNormal><u><span style=3D'font-family:"Times New =
Roman","serif"'>How
to Improve the Implementation of Evidence-Based Psychotherapy in the VA:
Increase Transparency, Equitability and Efficacy</span></u><span
style=3D'color:#1F497D'><o:p></o:p></span></p>
<p class=3DMsoNormal><span style=3D'font-family:"Times New =
Roman","serif"'><o:p> </o:p></span></p>
<p class=3DMsoNormal><span style=3D'font-family:"Times New =
Roman","serif"'>Since
the San Antonio VA Psychology Leadership Conference in May, there have =
been a
series of email exchanges about the direction of evidenced-based =
psychotherapy
in the VA. I would like to further that discussion and raise several =
critical
issues.<o:p></o:p></span></p>
<p class=3DMsoNormal><span style=3D'font-family:"Times New =
Roman","serif"'> <o:p></o:p></span></p>
<p class=3DMsoNormal><span style=3D'font-family:"Times New =
Roman","serif"'>The
utilization of EBPs within the VA is an unquestionably important goal. =
However,
I am gravely concerned that some of the methods for reaching that goal =
are
taking us in the opposite direction – i.e. toward the curtailment
=
of VA
clinicians’ ability to choose from the broad array of effective
evidence-based interventions. The difficulty started when the Uniform =
Mental
Health Services Handbook embraced a narrow, limited subset of =
VA-preferred
evidence-based psychotherapies (without revealing the criteria for their
selection). The Handbook conveyed the implication that these specific
treatments were the only ones that satisfied the standard of being
“evidence-based.” <o:p></o:p></span></p>
<p class=3DMsoNormal><span style=3D'font-family:"Times New =
Roman","serif"'><o:p> </o:p></span></p>
<p class=3DMsoNormal><span style=3D'font-family:"Times New =
Roman","serif"'>More
significantly, a new VA policy -- RVU Productivity Incentives -- is =
being
deliberated that would discourage the use of non-sanctioned treatments,
including efficacious ones. From what I understand, this plan will grant
clinicians 25% greater workload credit for rendering a VA-preferred
psychotherapy than for rendering another psychotherapy of the same =
duration. If
you use VA-preferred psychotherapies, you reach your annual productivity
=
quota
much quicker. That buys you time to do other activities and as someone =
with
higher total workload numbers, you will be evaluated as being =
“more
productive.” Using other evidence-based treatments will result in
=
having
to work additional hours to attain your quota.<o:p></o:p></span></p>
<p class=3DMsoNormal><span style=3D'font-family:"Times New =
Roman","serif"'><o:p> </o:p></span></p>
<p class=3DMsoNormal><span style=3D'font-family:"Times New =
Roman","serif"'>In my
view, Productivity Incentives -- like some of the other methods of =
promoting
EBP in the VA -- take us on an errant course. They purposely aim to =
increase
the use of the few VA-preferred psychotherapies and curb all other =
approaches,
including those with a strong evidence basis. Yet, it is clear from the
research that there are many treatments beyond the officially sanctioned
=
ones
that are equally effective -- and sometimes superior -- for =
alleviating
the target disorders and problems. In addition, attending to clinician =
and
patient factors in treatment selection is well known to improve =
outcomes. When
we can choose from a wider selection of psychotherapies, we are able to
=
provide
the most effective treatment for our patients. This was the =
conclusion of
the APA’s Task Force on Evidence-Based =
Psychotherapy.<o:p></o:p></span></p>
<p class=3DMsoNormal><span style=3D'font-family:"Times New =
Roman","serif"'><o:p> </o:p></span></p>
<p class=3DMsoNormal =
style=3D'margin-bottom:12.0pt;text-autospace:none'><span
style=3D'font-family:"Times New Roman","serif"'>I therefore propose that
=
VACO <b>champion
the use of <i>all</i> evidence-based psychotherapy approaches and then =
let
clinicians use their clinical judgment</b> as to which treatment would =
be most
effective. Four particular actions would enable that to =
occur:<o:p></o:p></span></p>
<p class=3DMsoNormal =
style=3D'mso-margin-top-alt:0in;margin-right:0in;margin-bottom:
12.0pt;margin-left:48.0pt;text-indent:-24.0pt;text-autospace:none'><span
style=3D'font-family:"Times New =
Roman","serif"'>1. VACO
should make transparent the specific “evidence-based” =
criteria that
were used to select the UMHS handbook psychotherapies and disseminated
roll-outs (e.g. ACT, CBT, CPT, IBCT, PE, etc.). =
<o:p></o:p></span></p>
<p class=3DMsoNormal =
style=3D'mso-margin-top-alt:0in;margin-right:0in;margin-bottom:
12.0pt;margin-left:48.0pt;text-indent:-24.0pt;text-autospace:none'><span
style=3D'font-family:"Times New =
Roman","serif"'>2. This
criteria should be equitably applied to all psychotherapies. VACO should
=
inform
the field that every treatment -- whether or not mentioned in the UMHS =
Handbook
-- that meets this standard would be explicitly endorsed as an equally =
suitable
“Evidence-Based Psychotherapy.”<o:p></o:p></span></p>
<p class=3DMsoNormal =
style=3D'mso-margin-top-alt:0in;margin-right:0in;margin-bottom:
12.0pt;margin-left:48.0pt;text-indent:-24.0pt;text-autospace:none'><span
style=3D'font-family:"Times New =
Roman","serif"'>3.
“Fidelity to Evidenced-Based Psychotherapy” and =
“Access to
Evidence-Based Psychotherapy” should be assessed for all =
psychotherapy
treatments that meet the criteria, not just for disseminated =
treatments.<o:p></o:p></span></p>
<p class=3DMsoNormal =
style=3D'mso-margin-top-alt:0in;margin-right:0in;margin-bottom:
12.0pt;margin-left:48.0pt;text-indent:-24.0pt;text-autospace:none'><span
style=3D'font-family:"Times New =
Roman","serif"'>4.
Productivity incentives should be applied far more broadly than just for
=
using
VA-preferred psychotherapies. <o:p></o:p></span></p>
<p class=3DMsoNormal =
style=3D'margin-bottom:12.0pt;text-autospace:none'><span
style=3D'font-family:"Times New Roman","serif"'>I hope that these =
suggestions
prompt continued dialogue about how VACO can promote the full =
armamentarium of evidence-based
approaches. <o:p></o:p></span></p>
<p class=3DMsoNormal =
style=3D'margin-bottom:12.0pt;text-autospace:none'><span
style=3D'font-family:"Times New =
Roman","serif"'><o:p> </o:p></span></p>
<p class=3DMsoNormal><span style=3D'font-family:"Times New =
Roman","serif"'>Russell
Lemle, PhD<o:p></o:p></span></p>
<p class=3DMsoNormal =
style=3D'margin-bottom:12.0pt;text-autospace:none'><span
style=3D'font-family:"Times New Roman","serif"'>Psychology Director, San
Francisco VA Medical Center<o:p></o:p></span></p>
<p class=3DMsoNormal =
style=3D'margin-bottom:12.0pt;text-autospace:none'><span
style=3D'font-family:"Times New =
Roman","serif"'> <o:p></o:p></span></p>
<p class=3DMsoNormal><span =
style=3D'font-size:12.0pt'><o:p> </o:p></span></p>
<p class=3DMsoNormal><o:p> </o:p></p>
</div>
</body>
</html>
------_=_NextPart_001_01CB5C02.B6B88432--
------------------------------
Subject: [AVAPL Members] Re: How to Improve the Implementation of
Evidence-Base
Date: Fri, 24 Sep 2010 12:45:06 -0500
From: "Besyner, James K" <James.Besyner@xxxxxx>
------_=_NextPart_001_01CB5C10.3978EA95
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End of avaplmembers Digest V1 #109
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