Program Profile: West Los Angeles VA Medical Center

WEST LOS ANGELES VA MEDICAL CENTER

AITCN Program Contact:  Charles Hinkin, Ph.D., ABPP-CN

Neuropsychology Experiences Offered:

Neuropsychology Track / Major Area of Study (At least 50%)
Neuropsychology Emphasis (30% to <50%)
Neuropsychology Experience (>20% to >30%)
Neuropsychology Exposure (20% or less)

Resources / Links:

An overview of relevant Information regarding the internship training program at the West Los Angeles VA Healthcare Center follows. Additional information can be found at the following website:  http://www.psychologytraining.va.gov/westlosangeles/

Brief Description of General Internship:

The Psychology internship program at the West Los Angeles Healthcare Center has been accredited by the American Psychological Association since 1979. It is a generalist program based on the scientist-practitioner model, the core concept of which is the understanding and application of scientific research to the practice of clinical psychology. Of the 37 clinical psychologists on staff at the West Los Angeles VA Healthcare Center, 25 provide clinical supervision in the Training Program.  All psychologists on staff are licensed, are from APA-accredited  doctoral programs in clinical or counseling psychology, and have completed an APA-accredited predoctoral internship.  Many hold clinical and academic appointments at local institutions, including the University of California, Los Angeles, the University of Southern California, and Fuller Graduate School of Psychology.  Psychologists at the West Los Angeles VA occupy a variety of roles in both inpatient and outpatient medical and mental health settings, with several staff members involved in program leadership positions and the majority working in interdisciplinary settings with allied mental health care professionals. Supervisors represent a wide range of theoretical orientations, including cognitive-behavioral, behavioral, integrative, and psychodynamic. In addition to the clinical internship, the Psychology training program provides training for 4-6 practicum students each year, most of whom are from local doctoral programs.   In addition, we have four postdoctoral fellows in four clinical tracks: Geriatric Neuropsychology, Health Psychology-Integrated Care, Polytrauma Psychology, and Trauma.  Interns will have the opportunity to work closely with practicum students and fellows.

Brief Description of Neuropsychology Training:

The APA-accredited internship training program at the West Los Angles VA Medical Center provides a multitude of clinical and didactic neuropsychological training opportunities.  The program closely adheres to the recommendations of the Houston Conference on Specialty Education and Training in Clinical Neuropsychology.  While this internship is generalist in nature and ensures that interns receive adequate breadth of experience, trainees who desire more in depth, focused training in neuropsychology can easily devote 50+% effort towards neuropsychological experiences.

The Neuropsychology Program, headquartered in the Neuropsychology Assessment Laboratory, is affiliated with the Medical Center’s Neurobehavioral Unit and the Neuropsychology Postdoctoral Training Program at UCLA. Typically, interns seeking intensive neuropsychological training will devote an entire three-month rotation to this track, though on rare occasions an intern who has already obtained a wide array of non-assessment experience will be allowed to stay on for a second rotation. Additional training in neuropsychological assessment can be obtained on a number of other rotations including the Polytrauma Program/Traumatic Brain Injury (TBI) Program, Ambulatory Care, the Domiciliary, GEM/GRECC (Geriatric Medicine), Geropsychology, and Health Psychology.  If so desired, interns who wish to maximize their training in clinical neuropsychology can structure their training year to obtain neuropsychological experience and supervision on all four quarterly rotations throughout the year.  Interns will be exposed to patients with a wide variety of neurological disorders including Alzheimer’s disease, vascular dementia, traumatic brain injury, substance-induced cognitive disorders, toxic/metabolic encephalopathy, seizure disorder, major psychopathology, and subcortical dementias such as Parkinson’s disease and HIV-associated neurocognitive disorder.  From a theoretical perspective, interns will be primarily exposed to a hypothesis testing/process approach to neuropsychological evaluation.

Neuropsychology Supervision:

Supervision is provided by a nine neuropsychologists, four of whom are board certified in clinical neuropsychology by the American Board of Professional Psychology.

Neuropsychology Supervisor:
Charles H. Hinkin, Ph.D., ABPP-CN
Director, Neuropsychology Service

Additional Clinical Supervisors for Neuropsychological Assessment:
Steven Castellon, Ph.D.
Fred Kornfeind, Psy.D.
Mona Lam, Ph.D.
Anna Okonek, Ph.D.
Sheryl Osato, Ph.D.
Tara Victor, Ph.D., ABPP/CN
Stacy Wilkins, Ph.D., ABPP/CN
Michelle Zeller, Psy.D, ABPP/CN

Neuropsychology Didactics:

1. Neuropsychology Case Conferences
2. Weekly neurosciences lectures at the UCLA Semel Institute
3. Weekly Neurobehavior seminars presenting research and clinical data on neurobehavioral syndromes and cases highlighting unusual disorders
4. Memory Disorder and Neurobehavioral Clinics
5. Clinical pathology (i.e., brain cutting) conferences.

Neuropsychology Training Objectives:

The training objectives for interns in the Neuropsychology Program are to become familiar, at an introductory level, with knowledge of brain-behavior relationships, to establish a beginning level of competence in neuropsychological practice, to reach an intermediate level of understanding in interpreting research approaches and findings, and to become aware of the emotional consequences of neuropathology and of appropriate methods of psychological intervention. A wide array of research opportunities is also available on this rotation.  Intern involvement can range from attending laboratory meetings to preparing conference presentations or papers for publication.

By the close of the rotation interns will be adept at test administration and scoring. Supervision will largely focus on honing skills in interpretation, differential diagnosis, and patient feedback.  Interns who complete the Neuropsychology rotation will be well-prepared to pursue postdoctoral training. Given the close ties between our VA internship and the UCLA postdoctoral training program in neuropsychology, over the last 20 years an average of one to two interns has been accepted into the UCLA postdoctoral fellowship each year.

GOALS

REQUIREMENTS

1. To improve knowledge of brain-behavior relationships. Particular emphasis will be placed on functional neuroanatomy, integration of neuroimaging and neurological data, and normal and pathological neurocognitive and neuropsychiatric function.

1. Attend Neuropsychology Case Conferences.

2. Focused readings in neuropsychology

3.  Participate in the optional weekly Neurobehavior Clinic and the UCLA Neuropsychology Seminars when possible.

4. Attend Clinicopathologic Conferences (i.e. brain cuttings) when possible.

2. To identify and diagnose basic neuropsychological disorders. Particular emphasis will be given to the more prevalent age-linked dementias such as Alzheimer’s disease and vascular dementia, as well as the neurocognitive disorders that are over-represented in the VA patient population (e.g. brain injury)

Administer and interpret at least 12-18 comprehensive neuropsychological test batteries.  Additionally, briefer, focused inpatient evaluations will be conducted as warranted.

3. To write neuropsychological reports at a level commensurate with a non-specialist psychologist.

Write at least 12-18 comprehensive neuropsychological test reports.

4. For interns desiring a career in neuropsychology, to provide the training and experience needed to be competitive candidates for postdoctoral fellowship.

In addition to the clinical and didactic experiences enumerated above, interns anticipating a career in neuropsychology will also be expected to seek involvement in other professional activities such as research, participation in lab meetings, and attendance at scientific conferences.

Setting:

The VA Greater Los Angeles Healthcare System (GLA) is the largest and most complex integrated healthcare facility in the Department of Veterans Affairs.  It consists of a tertiary care facility (West Los Angeles VA Healthcare Center), three ambulatory care centers, and 10 community-based outpatient clinics.  GLA provides comprehensive ambulatory and tertiary care to Veterans in five counties in Southern California, with 801 beds, over 5,000 employees and an annual operating budget of over $770 million.

In fiscal year 2011, GLA provided medical and mental health services to over 83,000 Veterans residing in the primary service area, including Los Angeles County, which has the largest concentration of Veterans of any county in the United States.  It provides a full spectrum of primary and tertiary inpatient and ambulatory care services, including acute, sub-acute, rehabilitation, extended care, mental health services, telehealth, and home healthcare. GLA is one of 21 national Polytrauma Network Sites (PNS) that serves Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OI/OND) Veterans with complex medical and psychological injuries, including traumatic brain injury. To find out more about GLA, please go to http://www.losangeles.va.gov/index.asp.

The West Los Angeles VA Healthcare Center, which is the site for this internship program, is the hospital, research, and administrative center for GLA.  It is situated on a 430-acre campus with 149 buildings.  The south campus is primarily devoted to medical/surgical and inpatient psychiatric services located in the main medical center building.  The north campus facilities include two 120-bed long-term care buildings (Community Living Center), a 296-bed Domiciliary, the Mental Health Clinic, substance abuse and PTSD programs, as well as research and administrative offices.  The 496-bed California State Veterans Home,which was completed in 2010, is also located on the north campus.

The West Los Angeles VA Healthcare Center is affiliated with more than 45 colleges, universities, and vocational schools.  GLA sponsors numerous medical residencies and associated health residencies, including dentistry, podiatry, optometry, pharmacy, dietetics, and clinical psychology.  Primary university affiliates include the UCLA David Geffen School of Medicine and the USC School of Medicine.

At GLA there are more than 250 investigators conducting over 700 research projects in all areas of medical and mental health, with total expenditures of $43.7 million in 2011.  GLA has numerous VA and NIH funded Research Centers including: The VA Geriatric Research, Education and Clinical Center (GRECC); the VISN 22 Mental Illness Research, Education and Clinical Center (MIRECC); the Parkinson’s Disease Research, Education and Clinical Center (PADRECC); the VA Health Services Research Center of Excellence for the Study of Provider Behavior; the Center for Ulcer Research and Education and a VA/UCLA Consortium for gastrointestinal research; and the VA/UCLA Center for the Neurobiology of Stress.

The West Los Angeles VA Healthcare Center is located in one of the most culturally diverse cities in the nation and serves U.S. military Veterans who represent a mixture of ethnic, cultural, and individual diversity.  Of the 68% of Veterans who identified their ethnicity when registering for care, approximately 64% identified as Caucasian, 27% as African American, 5% as Hispanic, 4% as Asian, and 1% as Native American.  Our overall Veteran population is approximately 93% male.  Over 41% of Veterans receiving care here are over the age of 65, with 8% under the age of 35 and 31% between the ages of 55-64 years.  Over 14,600 OEF/OIF Veterans have been enrolled at GLA, with over 5,000 in active treatment.  Of this group, approximately 80% are under the age of 30 and 9% are female Veterans.  With regard to socioeconomic status, 57% of Veterans report an annual income of less than $20,000, with 18% reporting less than $10,000 in income annually.

Article Review: Competency Benchmarks

Article Review:  “Competency Benchmarks:  A Model for Understanding and Measuring Competence in Professional Psychology Across Training Levels.”

Nadya A. Fouad, Catherine L. Grus, Robert L. Hatcher, Nadine J. Kaslow, Philinda Smith Hutchings, Michael B. Madson, Frank L. Collins, Jur., Raymond E. Crossman.

Training and Education in Professional Psychology, 2009, Vol. 3 No. 4 (Suppl.), S5 – S26.

Review by Nina Hattiangadi Thomas, Ph.D., ABPP-CN

In the article “Competency Benchmarks:  A Model for Understanding and Measuring Competence in Professional Psychology Across Training Levels” published in the journal Training and Education in Professional Psychology, the authors describe the Benchmarks Document, which outlines core foundational and functional competencies in professional psychology across three levels of professional development:  readiness for practicum, readiness for internship, and readiness for entry to practice.

Meant to serve as a resource for supervisors but also likely to be of great interest to trainees, the Competency Benchmarks Document lists core competencies and behavioral indicators in an effort to provide operational descriptions of the essential components for each level of training.

The workgroup used as a starting point the “Competency Cube” model proposed by Rodolfa, et al. (2005), in which three dimensions of competency intersect:

1.       Functional Competency Domains (e.g., Assessment / Diagnosis / Conceptualization, Intervention, Consultation…)
2.       Foundational Competency Domains (e.g. Professional Practice / Self-Assessment, Scientific Knowledge and Methods, Relationships…)
3.       Stages of Professional Development (e.g. Doctoral Education, Doctoral Internship / Residency, Post Doctoral Supervision…)

The Benchmarks Document Workgroup chose not to address the interweaving of functional and foundation competencies, and additionally focused more directly on preparing for health service practice.  The focus of the Workgroup was on operationally defining each competency.  Each competency was first defined, and then broken into its essential components, with behavioral anchors defined for each essential component that demonstrates the threshold for competent performance at that level of training.

As a result, the Workgroup defined 15 core competencies, with essential components and behavioral anchors for each essential component at the three levels of professional development (readiness for practicum, readiness for internship, and readiness for entry to practice).  They are as follows:

Core Foundational Competencies:
1.       Professionalism
2.       Reflective Practice
3.       Scientific Knowledge and Methods
4.       Relationships
5.       Individual and Cultural Diversity
6.       Ethical and Legal Standards and Policy
7.       Interdisciplinary Systems

Core Functional Competencies:
1.       Assessment
2.       Intervention
3.       Consultation
4.       Research and Evaluation
5.       Supervision
6.       Teaching
7.       Administration
8.       Advocacy

For example, for the Competency of Professionalism, the Workgroup subdivided this competency into the following essential components:

Professionalism:
a.      Integrity – Honesty, personal responsibility, and adherence to professional values
b.      Deportment
c.      Accountability
d.      Concern for the Welfare of Others
e.      Professional Identity

The essential component is further defined at each level of training, with behavioral anchors for each level of training.  For example, let’s examine the competency of Professionalism, and within that competency the essential component of Accountability.  Here are the essential components and behavioral anchors for each level of training within this essential component.

Professionalism:  Accountability

Readiness for Practicum:
Essential Component:  Accountable and reliable
Behavioral Anchors:
·         Turns in assignments in accordance with established deadlines
·         Demonstrates personal organization skills
·         Plans and organizes own workload
·         Aware of and follows policies and procedures of institution

Readiness for Internship:
Essential Component:  Consistently reliable; consistently accepts responsibility for own actions
Behavioral Anchors:
·         Completes required case documentation promptly and accurately
·         Accepts responsibility for meeting deadlines
·         Available when “on-call”
·         Acknowledges errors
·         Utilizes supervision to strengthen effectiveness of practice

Readiness for Entry to Practice:
Essential Component:  Independently accepts personal responsibility across settings and contexts
Behavioral Anchors:
·         Works to fulfill client-provider contract
·         Enhances productivity
·         Holds self accountable for and submits to external review of quality service provision

In sum, the Benchmarks Document helps to clarify the competencies trainees must have as they gain increasing levels of independence.  Operational definitions will be useful for both supervisors and trainees, in determining areas of strength and weakness and focusing training to ensure achievement of competencies appropriate to the level of training.

The full Competency Benchmarks Document is available as a pdf at the following link:  http://www.apa.org/education/grad/competency-benchmarks.pdf

Related articles of interest:

Rodolfa, E.R., Ben, R.J., Eisman, E., Nelson, P.D., Rehm, L., & Ritchie, P. (2005).  A Cube model for competency development:  Implications for psychology educators and regulators.  Professional Psychology:  Research and Practice, 36, 347 – 354.

Madan-Swain, A., Hankins, S.L., Gilliam, M.B., Ross, K., Reynolds, N., Milby, J., Schwebel, D.C.  (2012).  Applying the cube model to pediatric psychology:  development of research competency skills at the doctoral level.  Journal of Pediatric Psychology, 37 (2), 136 – 148.

Presenting a Clinical Case

by Nina Hattiangadi Thomas, Ph.D., ABPP-CN

Many times in interview situations I have asked an intern or postdoctoral applicant to briefly describe an interesting case they have seen, and have been met either with stunned silence or with a disorganized series of statements that provide little or no insight into the case conceptualization.

The ability to present a case clearly and concisely is a core skill for a neuropsychologist, and one that will be called upon many times in both training and professional practice.  Whether it is a five-minute case description in response to an interview question or a fifty-minute seminar presentation, the guidelines for case presentation are the same.  With a little preparation and practice, being called upon to present a case may be your opportunity to impress.

1.  Include relevant information

Every case description should start out with basic relevant information.  “The patient was a six-year-old female with a history of spina bifida presenting for difficulties with early reading skills…”  Many times I’ve seen an individual launch into test results, and I’ll have to back them up and ask, “How old was the patient? What was his or her medical condition?”  The results are certainly interesting and I can understand the urge to jump right to them, but a brief concise description of demographic and medical information is necessary context.

This skill will also serve you well in your professional career.  In communicating with busy medical professionals, it is always helpful to start out with, “Dear Neurologist:  As you may remember, John Smith is a 10-year-old boy seen by you over the last year for management of treatment-resistant seizures…” as opposed to stating, “I am writing to you regarding John Smith…” and forcing the physician to refer back to the medical record for context.

2.  Don’t include irrelevant information

As important as including the relevant facts is excluding the irrelevant facts.  Often individuals seem to get mired in the details of a patient’s history.  It may be important to document in the report that the patient is allergic to strawberries and once broke his pinky finger, but unless it has direct relevance to the concerns at hand or your conceptualization, these facts are best omitted in a brief case presentation.  If the patient is a typically-developing teenager whose uncle is left-handed, this information can be omitted.  If, however, the patient is a toddler with unclear hand dominance and a strong family history of left-handedness being considered for right hemispherectomy — this fact is now important.

3.  Describe brain-behavior relationships

APA Division 40 defines clinical neuropsychology as a specialty “…dedicated to enhancing the understanding of brain-behavior relationships and the application of such knowledge to human problems.”

Developing an understanding of brain-behavior relationships is at the core of training in neuropsychology, and case presentations are perfect opportunities to demonstrate this understanding.  When conceptualizing your case, be sure not to just describe the pattern of neurocognitive strengths and weaknesses, but also to make clear statements about how these strengths and weaknesses correspond (or conflict) with known medical concerns.  For example, “the patient’s weaknesses in expressive language are highly consistent with the identified left frontotemporal seizure focus.  Weaknesses in attention may be related to seizure occurrence, side effects of antiepileptic medication, or the strong family history of attention problems.”  Not all individuals will have a significant medical history or localizing concern, but if not you should be prepared to answer questions about what brain regions may be involved based on the pattern of findings.

4.  Brush up on the medical condition at hand

No one expects you to become the world’s leading expert in a given medical condition overnight, but if you know you are presenting about a particular medical condition you should at least have a familiarity with important aspects of the condition, particularly factors relevant to neuropsychological outcome.  Presenting a case of spina bifida?  Know that level of lesion, presence of hydrocephalus, and number of shunt placements / failures / revisions are all important factors for cognitive outcome, and be prepared to provide that information for your case.

5.  Don’t hunt for zebras

“When you hear hoofbeats, think horses, not zebras.”  This medical aphorism encourages individuals to consider high base rate level conditions before rare ones.  Although rare cases are certainly interesting and memorable, don’t worry if you haven’t run across one of the ten individuals with Crisponi Syndrome, or a notable case of pure word deafness.  The point of a case presentation is to inform and to demonstrate your thinking, and you can be just as successful in providing a well-formulated description of a child with learning disability as you can one with maple syrup urine disease.

6.  Don’t get defensive

Once again, the purpose of a case presentation is to demonstrate how well you can “think through a case,” and part of that involves flexibility and being able to adapt your thinking to new information.  Not to mention that, as fellow neuropsychologists, cases are all very interesting to us and we may be not so much challenging your conceptualization as we are becoming drawn into the case and thinking it through ourselves.  Try not to consider any additional questions or alternate theories posed as a criticism of your abilities.  If you presented a case of slow recovery from concussion and are asked about the role depression might play in hindering recovery — even if it didn’t occur to you before, consider it now.  Even if you may not have the information at hand, you could say, “That’s a good point.  Her mood appeared positive and her family endorsed no concerns about mood, however we do routinely administer the BASC-2 questionnaire, and therefore it might be helpful to look back at that data.”

To sum up, there’s no need to feel “on the spot” when called upon to present a case.  A little preparation in advance, and you’ll be able to demonstrate your developing skills as a neuropsychologist in training as well as in your future professional career.