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An implementation strategy to improve the guideline adherence of insurance physicians: an experiment in a controlled setting
© Zwerver et al; licensee BioMed Central Ltd. 2011
- Received: 7 June 2011
- Accepted: 21 December 2011
- Published: 21 December 2011
The aim of this study was to investigate the efficacy of a newly developed implementation strategy for the insurance medicine guidelines for depression in the Netherlands. We hypothesized that an educational intervention would increase the insurance physicians' (IPs) guideline adherence in a controlled setting.
Forty IPs were allocated in a randomised controlled trial (RCT) to an intervention group (IG) (n = 21) and a control group (CG) (n = 19). The IG received tailored training in applying the guidelines for depression, while the CG received an alternative programme. Baseline (T0) and follow-up (T1) measurements were conducted before and after the intervention within a period of two weeks. The intervention consisted of a workshop in which the evidence-based theory of the guidelines was translated for use in practice, with the help of various tools. The IPs had to write a case-report on the basis of video cases, two before and two after the training. Specially trained and blinded test IPs judged the case reports independently on the basis of six performance indicators. Primary outcome measure in the controlled setting of the trial was guideline adherence measured by six performance indicators on a scale of one to seven. Secondary outcome measure was knowledge of the guidelines for depression. Analyses were performed using Linear Mixed Models, and ANCOVA.
We found significantly higher scores in the IG than in the CG at T1 for both outcomes. The interaction effect (standard error; p-value) of group crossed with time was 0.97 (0.19; p < 0.0005) for guideline adherence in the controlled setting. The group effect at T1 for the knowledge test was 0.86 (0.40; p = 0.038).
The newly developed implementation strategy for the insurance medicine guidelines for depression improved the guideline adherence of the trained IPs in disability assessments of clients with depression when performed in a controlled setting. Furthermore, the trained IPs showed gains in knowledge of the guidelines for depression.
Trial registration
Netherlands' Trial Register NTR1863.
- Randomise Control Trial
- Implementation Strategy
- Control Setting
- Work Disability
- Knowledge Test
The implementation of guidelines, together with the difficulties and barriers that might occur when evidence-based medicine has to be translated into a physician's daily practice, has been the subject of various studies [1–4]. Results have suggested a sizeable gap between the ideal and the actual performance of physicians in the application of guidelines [5], and explanations for this gap have emerged. In existing studies, barriers to effective guideline implementation have been analysed at the level of the patient, the physician, and the healthcare organization [1, 3, 4]. In this study, we put the focus on the physician's guideline adherence. Our aim is to investigate in a controlled setting the influence of a newly developed implementation strategy on the adherence of the insurance physician (IP) to the depression guidelines. IPs evaluate the disability claims of employees, which is of great societal and financial importance; they write their assessments in a medical work disability report and the benefit level of the employee is defined on the basis of that report. We chose to study the insurance medicine guidelines for depression because depression accounts for a substantial and increasing proportion of long-term disability claims; this corresponds with worldwide trends that show that depression is expected to be one of the leading causes of disability-adjusted life years in 2020 [6, 7].
We questioned whether the usual implementation of the guidelines for depression could be improved. After research, in which we used the Intervention Mapping method, we developed a newly implementation strategy for these guidelines [8]. It was found that this implementation strategy should include an interactive educational training and tools for IPs, with the aim to teach and facilitate IPs to apply these guidelines [8].
This aim is challenging because it means overcoming potential barriers such as negative aspects of physicians' behaviour in the adoption of guidelines. One of the summary points mentioned in an overview of reviews concerning the gap between research and practice is that passive dissemination of guidelines is generally ineffective [9, 10]. Nevertheless, change in the behaviour of physicians was found for certain educational interventions, while in other more formal types of medical education there was no evidence of change [10]; interactive sessions that enhance participant activity and provide the opportunity to practice skills for instance were found to result in changes in the physician's performance [11]. In the development of our strategy, we took these findings into consideration by consulting educational experts and by assessing the needs of the IPs [8]. The IPs wanted tools such as a checklist or a guideline summary card to facilitate the use of guidelines in practice. The experts expected a multifaceted strategy with interactive educational sessions and the practice of skills to be most effective. After taking these findings into account, we developed an implementation strategy and evaluated its efficacy by setting up an randomised controlled trial (RCT) in which we compared implementation of the guidelines using this strategy with the usual levels of implementation in the Netherlands [12, 13]. Primary outcome measure was the guideline adherence of the IP in a controlled setting, leading to the research questions: Does training IPs in applying the guidelines for depression improve their guideline adherence in the work disability assessment of clients with depression in a controlled setting? Additionally, does the strategy improve their knowledge of the guidelines for depression?
The Medical Ethics Committee of VU University Medical Center approved the study design and the Netherlands Trial Registration accepted the RCT: NTR1863.
To determine the efficacy of training IPs in applying the guidelines for depression, we conducted an RCT in which we compared the intervention implementation strategy with the usual methods of training IPs by measuring their performances in disability assessments of clients with depression. The intervention was a training programme designed for IPs in which they learned to apply the guidelines for depression. This programme, together with the baseline and follow-up measurements, was integrated into a four-day postgraduate course located at the Netherlands School of Public and Occupational Health (NSPOH). At the NSPOH, we created a controlled setting in which we carried out the RCT. While the intervention group (IG) was trained in applying the guidelines for depression, the control group (CG) received an alternative programme of training in motivational interviewing that did not conflict with the intervention programme. The RCT took three days within a period of two weeks in March 2009. After the RCT had been ended, for reasons of recruitment and equal treatment for both groups, the CG received the same training as the IG, while the IG received the alternative programme; this was planned as the fourth day of the course, which was held three months later at the end of June 2009. At the NSPOH, we managed to create a laboratorial setting where we could measure each IP's work disability assessments of clients with depression played by actors on video. The training programme was developed for use in practice.
Study population and recruitment procedure
In January 2009, IPs working at the Dutch National Institute for Employee Benefits (the Institute) were invited to attend a postgraduate course in applying disability assessments of clients with depression in the period from March to July 2009. The Institute is responsible for evaluating disability claims of employees. The inclusion criteria were being registered as an IP or still following the post-academic colloquium on insurance medicine and conducting disability assessments of clients as commissioned by the Institute. Participation was voluntary. The NSPOH was responsible for enrolling participants in the course during the period January to March 2009. Written informed consent was obtained from the participants of this study, when they entered the course.
Allocation and blinding
The IPs who participated in the postgraduate education programme were individually allocated in order of registration to the IG or to the CG by means of a random-sequence table. To prevent an unequal allocation across both groups, the participants were stratified before randomisation on three prognostic factors: age, gender, and registration as an IP. The randomisation and stratification procedure was executed by a research assistant. After the stratification and randomisation procedure, the dates for the RCT were planned in cooperation with the NSPOH. Participants were assigned to either the IG or the CG by the research assistant, while the assignment was communicated to the participants by the NSPOH. Participants who were not available on the planned dates were excluded from the trial. The participants were blinded for the complete trial, including baseline, intervention or usual implementation programme, and follow up. The participants were informed about the fact that the course was part of a research project, but they were not informed about the design and were blinded for the type of group they participated in. Contamination between groups was not possible due to the design of the trial. The researchers were blinded for the collection of data. The data were coded by an independent research assistant.
Measurements and data collection
Data were collected at the location of the NSPOH where the course took place. At baseline and at follow up, each IP assessed the disability of two clients, played by actors, who were presented separately on video. The actors played clients with depression that were reconstructed after real cases. The actors played their roles on the basis of extensive scripts, with room left for improvisation. Thereby, the actors realistically represented actual clients with depression. The videos showed the disability assessment encounter of a client and an independent IP (not a participant in the RCT), who was briefed to perform the assessment in complete accordance with the guidelines for depression. The decision phase of the assessment was not shown on the video. The IPs wrote their medical work disability reports immediately after watching each client on the video. All the medical work disability reports were collected during the RCT. Furthermore, each IP's knowledge of the guidelines for depression was measured at the start and at the end of the intervention and the control programme with the same set of knowledge questions.
Subjects of performance indicators for the guidelines for depression
Correct diagnosis
• DSM-IV criteria for depressive disorder
Determination of severity of the disorder
• Source: medical examination or e.g., information of curative physician, HRSD
• Relation between severity of the disorder and the limitations
Origin, course and prognosis of the disorder
• Risk factors for depressive disorder
• Course of depressive disorder
• Substantiated prognosis of depressive disorder
• Presence or absence of co-morbidity
• Influence of co-morbidity on prognosis and limitations
Evaluation of care and cure
• Level of information about claimant and medical treatment
• Action for required information if necessary
• Reasons for stagnation in recovery of functioning
• Medical treatment related to rehabilitation
Assessment of work limitations
• Work limitations related to the severity of depressive disorder
• Work limitations substantiated to insurance medicine standards
The secondary outcome was the IP's knowledge of the guidelines for depression, which was measured with a knowledge test. The knowledge test was developed on the basis of the guidelines for depression. This test was piloted by two independent IPs, who were researchers from other research groups and not involved in our project. In the final version, the test consisted of 10 propositions derived from the guidelines to be scored true or false. Sum scores were calculated immediately before and after the intervention or control programme.
Judgement of the medical work disability reports with PIs by test IPs
After the RCT was completed, the medical work disability reports of all participants were measured with PIs at baseline and at follow up by three pairs of senior test IPs. These test IPs had received separate training in which they learned to measure medical work disability reports using the PIs. Each medical work disability report from each participant from the RCT was judged blind by one pair of test IPs, which produced the PI scores per report. In cases of disagreement in the pair of Test IPs about a certain PI score, a consensus procedure was followed, resulting in one PI score. We measured the guideline adherence by the scoring of the six PIs as a scale. Taking into account the distance between the NA scores and A scores within the PIs, and the differences across the PIs, the scores were recoded in the following way to form the scale: (NA1 = 1), (NA2 = 2), (NA3 = 3), (NA4 to NA7 = 4), (A1 = 5), (A2 = 6), (A3, A4 = 7). A more extensive explanation of the scale and its reliability with two test IPs is published elsewhere [14].
Intervention implementation strategy
The implementation strategy was developed on the basis of a needs assessment carried out by IPs and of semi-structured interviews held with psychiatrists, researchers, IP trainers with experience in post graduate education, and the psychiatrist who was member of the board that drew up the guidelines for depression. In this needs assessment, the needs of the IPs concerning the implementation of the guidelines were investigated. Their needs and the recommendations of the other experts were integrated into the intervention strategy using Intervention Mapping [11]. This intervention strategy consisted of a specific training programme for IPs in which they learn to apply the guidelines for assessing depression. Several evidence-based tools were developed to serve this goal intended to improve the applicability of the guidelines. Realistic cases of clients with depression presented at a video screening were used to enrich the training. Learning objectives for the IPs were: to use the tools for the improvement of their diagnostic skills, to improve their performances in the work disability assessment of clients with depression, and to write their findings and conclusions down in well-argued medical reports. The aim was to bring the IPs' reports more in concordance with the guidelines, i.e., transparent, more evidence-based, and well-argued conclusions of clients' limitations in working ability. The participant's self-activation was stimulated in an interactive learning process with feedback given by the trainers. Two of the authors (FZ and JRA), both IPs themselves, were involved as trainers in the intervention programme. Appendix 1 gives an overview of the intervention programme.
Sample size and measures
Sample size estimation was based on the minimum desirable change in the primary outcome that is the least sensitive, i.e., the NA/A-score of the guideline adherence. For detecting a difference of 25% in the proportions of adequate scores between two independent groups, with a power of 80% and an alpha of 0.05 (two-sided), we needed 20 IPs in each arm of the RCT. Given the fact that each IP made two cases at baseline and at follow up and each case was scored with six PIs, each IP produced 12 NA/A-scores at both baseline and follow up.
Statistical analysis
The baseline characteristics of the IPs in the two groups (CG and IG) were compared using crosstabs (Chi-square) for the categorical variables and independent T-test for the continuous variables.
Univariately, the outcome measures were analyzed with T-test for the scale scores of the PIs and the sum scores of the knowledge test. These tests were paired for the difference between T0 and T1 per group (CG or IG), and independently for the difference between groups (CG and IG) at T0 and T1. For the binary outcome measure, the differences between the groups (CG and IG) at the two time points (T0 and T1) were analyzed with crosstabs (Chi-square).
The scale outcome variable of the PIs (1 to 7) was analyzed using linear mixed models. Besides the effect of group, time, and their interaction effect on the outcome variable (the scaled PI score), we also corrected for the possible effects of the case, of the pair of test IPs, and of the kind of PIs per case on the PI scores of the participants. In our model, fixed effects were: intercept, group (CG, IG), time (T0, T1), pair of test IPs (1, 2, 3), group*time, case (B, C, D, E) within time, and PI (1 to 6) within case within time. Besides these fixed effects, a random coefficient for the intercept with as 'subject' the IPs (1 to 40) was calculated to account for possible clustering of the scores at IP level.
The binary outcome variable for the PI-score NA versus A was analyzed using Generalized Estimating Equations (GEE) with a logit link function, and with the same fixed effects as was the case in the linear mixed models analysis of the scale outcome variable, and for subject effect the IPs (1 to 40). Ancillary analyses were performed, using the differences in the estimated marginal means, to analyze the influence of case, pair of test IPs and PIs on the proportion of adequate scores.
For the knowledge test, the sum score of good answers per group before and after the training was calculated and analyzed using ANCOVA, with the sum score of the knowledge test at T1 as dependent variable and the sum score of the knowledge test at T0 and group as independent variables.
In the multivariate analyses possible confounding effects of background variables--of which the baseline characteristics of the IPs in the two groups (CG, IG) were significantly different--on the outcome variable were taken into account, i.e., a change of the coefficient of the variable group of 10% or more. If so, a possible interaction effect of this confounding variable with the variable group on the outcome variable was analyzed as well. All analyses were performed using SPSS 15.02.
Participant flow
Baseline characteristics
Baseline characteristics of insurance physicians in control group (CG) and intervention group (IG)
Baseline characteristics
CG (n = 19)
IG (n = 21)
Mean (sd) or percentage
Age in years
50.5 (6.7)
51.1 (6.2)
Weekly working hours
31.8 (9.9)
31.1 (9.2)
Years working as physician
21.7 (6.4)
23.5 (5.1)
Registered as insurance physician
Years working as insurance physician
15.4 (8.1)
15.6 (7.9)
Intensity of kind of professional activities
4.1 (0.8)
3.9 (0.8)
Number of clients with depression assessed per month*
9.3 (5.6)
5.3 (3.7)
Assessment time for depressed clients (minutes)
136.3 (62.3)
153.7 (48.4)
Assessments under the new disability act
Employee of the Institute
Attitude to guidelines in general (Scale 9 to 45)
30.8 (5.4)
31.7 (6.8)
Attitude to the GD (Scale 9 to 45)
31.8 (4.1)
33.9 (6.2)
Intention to use the GD (Scale 10 to 50)
34.5 (5.5)
35.0 (6.0)
Use (self-reported) of the GD (Scale 1 to 5)
3.1 (1.2)
3.0 (1.1)
Outcome measures control group (CG) and intervention group (IG) at T0 and at T1 and p-values between-group differences at T1
Guideline adherence IPs to GD
(19 physicians)
(21 physicians)
228 scores
252 scores
- Mean (SD) PI-sumscores (1-7)
3.6 (1.9)
3.3 (1.9)
3.8 (1.9)
4.4 (1.6)
p < 0.0005
- Adequate scores (%)
p < 0.0005
(17 physicians)
(21 physicians)
Knowledge test IPs on GD
- Mean (SD) test scores (0-10)
5.1 (1.2)
5.1 (1.3)
5.5 (1.4)
6.3 (1.2)
p = 0.006
Results of the Mixed Models analysis of the primary outcome guideline adherence in a controlled setting.
Estimated means
Interaction effect (se)
PI-scale score
(1 to 7)
0.97 (0.19)
p < 0.0005
Results of the Ancova analysis of secondary outcome knowledge
Estimated means
Knowledge Test Sum Score (0 to 10)
Group effect (se)
0.95 (0.36)
0.86 (0.40)
The bivariate analyses of the data showed significantly higher scores for the IG at T1. The paired T-Test of the PI score between T0 and T1 was not significant for the CG (p = 0.092), but was significant for the IG (p < 0.0005). The unpaired T-Test of the difference between CG and the IG was not significant at T0 (p = 0.32) and significant at T1 (p < 0.0005). The crosstabs revealed similar results for the (percentages of) Adequate scores (See Table 3).
The unpaired T-test of the second outcome, the knowledge of the IPs of the guidelines for depression, showed no significant differences between groups at baseline (p = 0.28) and was significant at follow up (p = 0.006). The paired T-test between baseline and follow up was not significant for the CG (p = 0.84) and significant for the IG (p = 0.017)
The multivariate analyses of the data resulted in statistically significant differences between groups for the IPs' performances on applying the guidelines for depression. The mixed models analysis produced a significantly higher score at the PI-scale score, i.e., guideline adherence, for the IG compared with the CG, accounted for possible effects of variables at different levels such as the pair of test IPs, the case or a certain PI used within a case (see Table 4). The GEE analysis, which also accounted for the effect of the same variables at the various levels, showed similar results for the binomial PI score (results not shown here). The estimated marginal means of the guideline adherence (NA/A score) per PI and per case showed that the trained IPs (IG) performed significantly better at each PI and at both cases at follow up (results not shown here).
The ANCOVA analysis of the secondary outcome knowledge test sum score produced significantly higher scores for the IG compared with the CG. The results of the ANCOVA analysis had to be adjusted for the confounding variable 'mean number of clients with depression, assessed by an IP per month' (see Table 5).
Main findings and interpretation
Due to the newly developed implementation strategy, gains in guideline adherence and knowledge were obtained in the controlled setting of this study. The results of the knowledge test between the groups at follow up were significant, although the difference was smaller than that for guideline adherence.
In the controlled setting of this study, trained IPs performed their work disability assessments more in concordance with the guidelines than did those from the CG. It appeared that the trained IPs produced significantly more adequate scores in all six PIs. With these scores they distinguished themselves from the CG in each of the main points of the guidelines, as measured by the PIs at follow up.
After adjustment for confounding, the result of the knowledge test showed a smaller positive effect for intervention. A logical explanation for this is that fewer gains in knowledge of the guidelines can be achieved, due to the intervention, by IPs who are already more familiar with the disorder, suggesting that the greater the number of clients with depression an IP assesses per month, the more their knowledge of this disorder increases. Given the outcomes of the CG, it should be remarked that we found no indications for a learning effect from the measurements (assessing the work disability of the clients), because the guideline adherence in the CG seemed to decrease slightly in the follow-up measurement.
The scores of correct answers on the knowledge test were rather low for both groups at baseline and at follow up, but increased significantly for the IG compared with the CG at follow up. However, having knowledge of the guidelines does not imply application of the guidelines in practice. Guideline adherence as a concept should be regarded as behaviour involving more than knowledge. Furthermore, the main goal of training was that the IPs practised their skills in applying the guidelines, and not specifically that they improved their knowledge; the improvement in knowledge can be considered as a desirable side effect of the training.
Strengths and limitations
The strength of this study was that the intervention implementation strategy was developed on the basis of the needs of IPs and the opinions of experts [11]. Another strong point was that we were able to measure quality with a valid and reliable instrument, the developed PIs [14]. In the analyses, we accounted for the possible effects of factors at different levels on the outcomes, such as the influence of the case, the pair of test IPs, and the PI itself. The results were confirmed in each of the different types of analysis. The design of this RCT, in which four different clients were each simultaneously assessed by groups of IPs, provided results that allowed us to draw sound and specific conclusions concerning the efficacy of the intervention. The developed implementation strategy improved guideline adherence in a controlled setting.
However, this design had limitations as well. We could not evaluate the effectiveness of the implementation strategy in practice, and thus the results of this study cannot be directly translated into practice. For practical reasons, we had to conduct the RCT in a fixed laboratorial setting. In this RCT, the disability assessments were performed under specific conditions: the clients were presented on a video screen, the participating IPs could not speak to them but had to assess their disability based on the information presented by the actor playing the client on the screen. Nevertheless, this RCT was based on and translated from the situation of IPs working in practice, and thereby offered us the optimal conditions for studying the efficacy of our newly developed implementation strategy. Another limitation of this study is the short time line of the RCT. This RCT contained one follow-up measurement, so that long-term effects of the training could not be evaluated; however, the justification for this short time line in the design of the RCT was the risk of contamination between groups i.e., the possibility that the CG may be contaminated by the IG in the period after the IG had received the intervention programme. We therefore planned the intervention programme immediately after the follow-up measurement of the CG, making contamination of the CG by the IG impossible. The overall time interval between the start and the end of the RCT was no more than two weeks. By shortening the timeline of the trial, we limited the risk of influences from outside the laboratorial setting. Furthermore, selection bias of the IPs who participated in this study is possible since they participated voluntarily.
Comparison with literature
The effectiveness of continuing medical education with the aim of stimulating physicians' guideline adherence has been evaluated for clinical care, primary care, and occupational healthcare [5, 16–19]. The resulting overview was that most effects could be expected from multifaceted interventions characterized by mixed educational programmes with an active role for the physicians. Although in this RCT, where guideline adherence increased from 51% to 71%, this expectation was confirmed for the field of insurance medicine, our implementation strategy still has to be evaluated in practice where there may be more barriers to implementation than the physician's behaviour. Two primary care studies concerning multifaceted interventions in the implementation of guidelines did not demonstrate any increase in guideline adherence in practice [18, 20]. In another study in primary care, multifaceted intervention strategy only modestly improved implementation of guidelines for low back pain [21]. The overall adherence rate to 70 guidelines in primary care within a period of 10 years was 67% [2]. For mental health disorders the figures of guideline adherence were even lower. In occupational healthcare, guideline adherence of 39% was found for mental health problems [22], while in primary care guideline adherences for depression and for anxiety disorders of 42% and 27%, respectively, were reported in a cross-sectional study [23]. Our findings showed that with a multifaceted strategy for a mental health disorder such as depression sizeable gains in guideline adherence could be achieved in a controlled setting. We can add to the conclusions of another insurance medicine study [24], in which it was found that a workshop improved evidence-based skills and self-efficacy, that an evidence-based medicine approach can be successfully adapted to the field of insurance medicine.
Practice implications
The educational intervention was evaluated in this study with the participation of a limited group of IPs. Now that the efficacy of this training has been shown in the controlled setting of this study, distribution to other IPs is recommended. Though this training was developed for the guidelines for depression, with adjustments it could be used for the implementation of other insurance medicine guidelines as well. The results of the developed implementation strategy did not show evident barriers at the level of the physician. Potential organizational barriers, such as available time for a physician to apply guidelines in practice, could not be investigated in this RCT. However, this training programme can be seen to suit the needs of physicians and their employers, because its implementation requires the investment of only one day of the physician's time, while the return proves to be relatively high. The RCT was carried out in a controlled setting for practical reasons (i.e., to have groups of IPs assessing the same videotaped clients simultaneously), but the implementation strategy (the training programme with evidence-based tools) itself is ready to be carried out in the real world setting. Finally, clients are expected to benefit from 'guideline proof' assessments, because the quality of these assessments is higher.
In this study, the efficacy of a newly developed implementation strategy for the insurance medicine guidelines for depression was evaluated in an RCT. In a controlled setting, the implementation strategy did improve the guideline adherence of IPs in the disability assessments of clients with depression and gains in knowledge concerning the guidelines were achieved. Though the guideline adherence of the trained IPs increased sizeably under the specific conditions in this study, it is yet not known whether these effects will be retained in the long term. Therefore, further research on the long-term effectiveness of this educational intervention is needed. This educational intervention is suitable for practice, because it combines a high success rate with low investment as the training takes only one day of the physician's time.
Appendix 1. Intervention implementation
Intervention goals
To improve the IP's knowledge and skills and self-efficacy in applying the guidelines for depression. Practice reinforcement of the IP's assessments of clients with depression.
Learning objectives for the participating IPs
Learn to perform disability assessment in concordance with guidelines for depression.
Learn to apply tools to recognize depression and to assess the working ability of claimants with depression.
Learn to base conclusions in the disability assessments on convincing arguments.
Learn to write powerful, more transparent reports.
Intervention content
Explanation of the evidence based content of the guidelines for depression by an IP trainer.
Translation of the guidelines for depression by IP trainer into six main elements, which are relevant for use in daily practice of the IP: diagnostics DSM IV, severity of the disorder, course, risk factors, co-morbidity, judgement of treatment and therapy, assessment of work ability.
Disability assessment of a client with depression presented on video.
Writing assessment report on the client with depression.
Educational strategy
Course manual:
Learn objectives, list of used literature, suggestions for further reading.
The complete guidelines of depression in book format.
Resume of the common principles of reasoning and in particular applied for the guidelines for depression (with practical examples).
Tools with the aim of making the guidelines easier to use in practice: desk mat, summary with main elements from the guideline/evidence based medicine, checklists, Hamilton Depression Rating Scale [15]
Handouts of presentations by psychiatrist and the trainer IP.
One-day training:
Debriefing from the baseline measurements.
Taking a knowledge test concerning the guidelines for depression.
Inter-active presentation by the trainer IP concerning the guidelines for depression. The trainer translates the guidelines into the insurance physician's daily practice.
Client with depression played by an actor is presented on video to the group.
Workshop with IPs in subgroups learning to use practical tools for the assessment of the client with depression. Presentations of the findings per subgroup to the complete group, with feedback from the IP trainer. Modelling of written arguments in the assessment reports about the client with depression by the trainer IP.
Evaluation of the training and taking the same knowledge test as at the start of the training.
IP-Insurance physician
The authors wish to thank the IPs who participated in this research. The Research Center for Insurance Medicine AMC-UMCG-UWV-VU University Medical Center, in Amsterdam, is a joint initiative of the Academic Medical Center (AMC), the University Medical Center in Groningen (UMCG), the Dutch Institute for Employee Benefit Schemes (UWV), and the VU University Medical Center (VUMC). This trial was funded by the Dutch Institute for Employee Benefits Schemes and the Netherlands' School for Public Health. FZ, JRA, and AJMS are (partially) funded by UWV. The study sponsor had no role in the study design, in the collection, analysis or interpretation of the data, in the writing of the case reports, or in the decision to submit the paper for publication. The design of this study was laboratorial and for data collection fictitious but realistic case-reports were used. Consequently, the Medical Ethics Committee agreed with the design.
The full trial protocol can be accessed at the webadress of the Netherlands' Trial Register (NTR): http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1863.
Authors' Affiliations
- Grol R, Grimshaw J: From best evidence to best practice: effective implementation of change in patients' care. Lancet. 2003, 362: 1225-30. 10.1016/S0140-6736(03)14546-1.View ArticlePubMedGoogle Scholar
- Grol R: Successes and failures in the implementation ov evidence-based guidelines for clinical practice. Med Care. 2001, 39: 46-54.View ArticleGoogle Scholar
- Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PAC, Rubin HR: Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999, 282: 1458-65. 10.1001/jama.282.15.1458.View ArticlePubMedGoogle Scholar
- Grol R, Wensing M: What drives change? Barriers to and incentives for achieving evidence-based practice. MJA. 2004, 180: 57-60.Google Scholar
- Davis D, Thomson O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A: Impact of Formal Continuing Medical Education: Do Conferences, Workshops, Rounds, and Other Traditional Continuing Education Activities Change Physician Behaviour or Health Care Outcomes?. JAMA. 1999, 282 (9): 867-874. 10.1001/jama.282.9.867.View ArticlePubMedGoogle Scholar
- Bijl RV, Ravelli A, van Zessen G: Prevalence of psychiatric disorder in the general population: results of The Netherlands Mental Health Survey and Incidence Study (NEMESIS). Soc Psychiatry Psychiatr Epidemiol. 1998, 33 (12): 587-9. 10.1007/s001270050098.View ArticlePubMedGoogle Scholar
- Murray CJ, Lopez AD: Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study. Lancet. 1997, 349: 1498-1504. 10.1016/S0140-6736(96)07492-2.View ArticlePubMedGoogle Scholar
- Zwerver F, Schellart AJM, Anema JR, Rammeloo KC, Van der Beek AJ: Intervention mapping for the development of a strategy to implement the insurance medicine guidelines for depression. BMC Public Health. 2011, 5:11: 9-View ArticleGoogle Scholar
- Berkhof M, van Rijssen HJ, Schellart AJ, Anema JR, van der Beek AJ: Effective training strategies for teaching communication skills to physicians: An overview of systematic reviews. Patient Educ Couns. 2010,Google Scholar
- Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA: Closing the gap between research and practice: an overview of systemic reviews of interventions to promote the implementation of research findings. BMJ. 1998, 317: 465-8. 10.1136/bmj.317.7156.465.View ArticlePubMedPubMed CentralGoogle Scholar
- Davis DA, Taylor-Vaisey MLS: Translating guidelines into practice. A systemic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. Can Med Assoc J. 1997, 157: 408-16.Google Scholar
- Health Council: Assessment, treatment and counselling. Medical responses to sickness absenteeism en occupational disability. 2005, The HagueGoogle Scholar
- Health Council: Insurance Medicine Guidelines for Depression. 2006, The HagueGoogle Scholar
- Schellart AJM, Zwerver F, Anema JR, Knol DL, Van der Beek AJ: Development and reliability of performance indicators for measuring adherence to a guideline for depression by insurance physicians. Dishabil Rehabil. 2011Google Scholar
- Hamilton M: A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960, 23: 56-62. 10.1136/jnnp.23.1.56.View ArticlePubMedPubMed CentralGoogle Scholar
- Smits PBA, Verbeek JHAM, Van Dijk FJH, Metz JCM, Ten Cate ThJ: Evaluation of a postgraduate educational programme for occupational physicians on work rehabilitation guidelines for patients with low back pain. Occup Environ Med. 2000, 57: 645-646. 10.1136/oem.57.9.645.View ArticlePubMedPubMed CentralGoogle Scholar
- Coomarasamy A, Taylor R, Khan KS: A systemic review of postgraduate teaching in evidence-based medicine and critical appraisal. Med Teach. 2003, 25 (1): 77-81. 10.1080/0142159021000061468.View ArticlePubMedGoogle Scholar
- Forsetlund L, Bradley P, Forsen L, Nordheim L, Jamtveldt G, Bjorndal A: Randomised controlled trial of a theoretically grounden tailored intervention to diffuse evidence-based public health practice [ISRCTN23257060]. BMC Med Educ. 2003, 3: 2-10.1186/1472-6920-3-2.View ArticlePubMedPubMed CentralGoogle Scholar
- Sanci LA, Coffey CMM, Veit FCM, Carr-Gregg M, Patton GC, Day N, Bowes : Evaluation of the effectiveness of an educational intervention for general practitioners in adolescent health care: randomised controlled trial. BMJ. 2000, 320 (7229): 224-30. 10.1136/bmj.320.7229.224.View ArticlePubMedPubMed CentralGoogle Scholar
- Walldorff FB, Almind G, Mäkelä , Moller S, Waldemar G: Implementation of a clinical dementia guideline. A controlled study on the effect of a multifaceted strategy:. Scand J Prim Haelth Care. 2003, 21: 142-147. 10.1080/02813430310005136.View ArticleGoogle Scholar
- Engers AJ, Wensing M, Van Tulder MW, Timmermans A, Oostendorp RAB, Koes BW, Grol R: Implementation of the Dutch Low Back Pain Guideline for General Practitioners: a Cluster Randomised Controlled Trial. Spine. 2005, 30: 595-600.View ArticleGoogle Scholar
- Rebergen D, Hoenen J, Heinemans A, Bruinvels D, Bakker A, van Mechelen W: Adherence to mental health guidelines by Dutch occupational physicians:. Occup Med. 2006, 56: 461-8. 10.1093/occmed/kql042.View ArticleGoogle Scholar
- Smolders M, Laurant M, Verhaak P, Prins M, Van Marwijk H, Penninx B, Wensing M, Grol R: Adherence to evidence-based guidelines for depression and anxiety disorders is associated with recording of the diagnosis. Gen Hosp Psych. 2009, 31: 460-469. 10.1016/j.genhosppsych.2009.05.011.View ArticleGoogle Scholar
- Kok R, Hoving JL, Verbeek JH, Schaafsma FG, Smits PBA, Van Dijk FJH: Evaluation of a workshop on evidence-based medicine for social insurance physicians. Occup Med. 2008, 58: 83-87. 10.1093/occmed/kqm151.View ArticleGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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The Novel
Writing a novel is a work of inspiration and this novel by MG Singh fills that genre. I am told the novel was written many years back but was kept pending as the author never thought it good enough for publication. Having got hold of a copy I am impressed with the book. For a first timer, it is good and well written. There is a lot of action, killings, and the most important part is that the book is laced with oriental erotica.
The novel is published by Notion Books an Indian publishing firm from Chennai and overall as far as esteem value is concerned the book is well presented with a glossy cover that will attract readers.
The book is on sale on-line in both paperback forms, as well as a kindle e-book.
The Plot
The novel is set in the period when the British empire was on its last legs and as a parting shot had decided to divide India into two by creating Pakistan. This was a tumultuous period in Indian history and forms the background of the novel.
The hero is a Muslim Pathan tribesman who is benevolent, educated and above all a great warrior. The novel delineates his love affair with the daughter of a British major of the Indian army and subsequent affair with Anglo- Indian girl. In all this mayhem there are excellent erotic passages, as well as action. The hero kills with compunction, but he is just and fair . The author presents a feud between him and a Punjabi Muslaman who wants to drive the Hindus out of Punjab.
There is plenty of action and the reader can be spellbound in case he likes tales of love and adventure.
The author
MG Singh is an early retired officer of the IAF. He took up writing a few years back and has written over 7000 articles on the net. In addition, MG is a prolific short story writer and has published over 60 short stories in various magazines.
MG is presently a corporate advisor and "The Romance of the Frontier' is his first novel. MG has drawn heavily from his experience in the services for this novel. He also has a strong connection with Punjab and thus has first-hand accounts from his grandfather about the tumultuous period of the partition of India which forms the backdrop of the novel.
MG is fond of golf and writing and is a specialist on military matters.
Last Word
Considering that it is the first book, I feel it's a commendable piece of work. However one wonders if all the gory violence depicted is really required in the novel. In addition, MG could well in his future books try and join up some disjointed parts. Probably he will iron out the problems in the next book.
The book runs into 252 pages and does a picture of that turbulent time. The backdrop of a sizzling love adds to the allure of the novel. It's a good tale and well presented. It's also a tribute to the language of English which is now part of India, making it the biggest English knowing nation in the world. At a conservative estimate over 350 million Indians are well versed in this language. India has produced a number of top writers like Salman Rushdie and Kushwant Singh and this book will add to the repertoire of English literature published in India.

subset: commoncrawl


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Diotasoft is a French start up company, created in 2009, which provides breakthrough Augmented Reality (AR) solutions for major industrial groups in the automotive, aeronautics, and other industries.
Diotasoft employs a team of 12+ specialists consisting of software engineers, programmers, graphics designer and a dedicated salesforce.
Since 2011 Diotasoft has been financing a CEA (Commissariat à l'Energie Atomique, €4.7b budget, 15k+ employees) laboratory responsible for the development of complex tracking algorithms. This partnership gives Diotasoft the exclusive rights to commercialize a very advanced tracking algorithm, which allows for a greater, more realistic user experience in the fields of
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Our unique combination of proprietary software and hardware enables us to provide marker-less, high definition, photorealistic AR solutions that are unmatched in the market.
For more information about Diotasoft visit their website.


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On Mother's Day weekend we celebrated my baby girl's 2nd birthday! Ah…I can't believe she's officially two now! I'm still amazed at how fast she's grown. It's difficult to grasp and most certainly bittersweet, but I've loved every moment of watching her blossom and reach new milestones. I wouldn't trade it for the world.
Her actual birthday fell on Mother's Day this year (such a special gift), so we planned the Minnie Mouse festivities for the day prior. It was a quaint little party, with tons of pink, and ombre accents, but not too over the top in terms of character details. Definitely more subtle and understated, but just perfect for our sweet mimi.
Decorations included everything from hand-made tassel garland, made with white tissue paper and minnie inspired letter prints in different shades of pink. A simple DIY pink ombre glittered #2, a banner of bows to capture the bowtique feel, glittered mouse and bow confetti, a dress up station with headbands and jewelry and plenty of balloons.
I made the floral arrangements using roses in 3 shades of pink and white from Trader Joes, carnations also in 3 shades of pink, and all white hydrangea. I finished each arrangement with Minnie prints, which I attached to wood skewers.
All of our lunch plates were adorned with the most adorable minnie mouse ears, which I was delighted to find via a free printable from Chickabug! Visit Heather's shop for fabulous prints and paper designs for your upcoming celebrations. Seriously…how cute are these?! Just cut them out, attach with tape and you've got ears! I would recommend printing them on a thicker quality paper.
We kept the menu simple, serving barbecue, teriyaki wings, a fresh quinoa salad, my mom's famous potato salad and many of my daughter's favorite things…chicken sausage, olives and fresh fruit and veggies cut into mouse shapes, using a minnie mouse cookie cutter.
The beverage station featured my homemade watermelon lemonade, and sparkling berry lemonade from Trader Joes. Mix-ins included: Perrier, fresh lemons, mint and raspberries.
For dessert I made gluten-free and dairy-free cupcakes with vegan icing so they were suitable for my daughter who has a dairy and soy intolerance. I actually bought the cake mix (Bobs Redmill) but made one batch of cupcakes and the vegan buttercream homemade, using freeze dried raspberries and strawberries to color and flavor the icing. I topped the cupcakes with royal iced sugar cookie rounds that I cut using a shot glass to mimic the mouse ears, and used a shaped mold to make colored bows out of white chocolate with a little gel food coloring in two different shades to finish each cupcake. The white chocolate bows were the only component that weren't dairy free.
On the dessert table were the Minnie Mouse cupcakes, as well as colored jelly bellys, 3 shades of sixlets, pink ribbon candy and strawberry popcorn. I also made sugar cookies with royal icing which were decorated with the help of my dear sister and good friend the night before! Thanks so much fabulous ladies!
The birthday girl's mini cake was made using the same technique as the cupcakes. I baked 1 cake and cut out 4 rounds using a water-glass. Stacked them, and then my hubby iced them with two different colors of vegan buttercream for the ombre effect. I topped the mini cake with homemade bunting made from minnie inspired prints, ribbon and paper straws, which can be found in the Etsy shop!
A little help from dada to blow out her candles.
In addition to the gift opening and adorable minnie mouse blankie from auntie, other highlights included the little ones sneaking their way over towards the desserts and dessert table. Caught them in the act! How cute are they?!
and here's beautiful big sis! Always ready for the camera.
As the afternoon came to a close, guests were sent off and thanked with Trader Joes brand white Oreo cookies, dipped and white chocolate and topped with sugar pearls aka posh sprinkle mix. So delish! Find the toppings in the Etsy shop with more coming soon!
It absolutely made our day to celebrate with our loved ones and close friends. Our sweet girl couldn't have had a better time! She'll thoroughly enjoy looking back on these moments in the years to come!
All of the details from this special party were handmade with love by yours truly. 5.11.14. We love you to the moon and back sunshine!
Lastly, a mama-daughter shot to celebrate both me and her on Mother's Day!
What a wonderful gift she is!
One party down, now one to go! My oldest will be 5 this summer and has her heart set on a Hello Kitty celebration. Check back soon for more relating to that, as well as the recipe for the homemade delish watermelon lemonade seen in this post. Instant summer favorite!
Thanks for reading and Happy weekend!
This specific Ombre Minnie Mouse celebration was seen first on Posh Little Designs. All Rights Reserved. 2011-2014.
All Images are photographed and owned property of Posh Little Designs. All Rights Reserved 2014.


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Spokane Alliance Accomplishments
- School Bullying: Following almost 9 weeks of work by Spokane Alliance members and allied organizations, the Spokane Public Schools school board voted unanimously to provide a public statement to the community in response to recent bullying.
- The statement included: Reaffirmation of SPS commitment to respect for all students
- Commitment to swift enforcement of harassment, intimidation, and bullying (HIB) policies
- Contact information for those needing to report incidents or concerns
- Context to the divisive year in politics
- Sick, Safe, and Family Leave Campaign: A successful two-year campaign to bring mandatory earned sick, safe and family leave benefits to 40,000 uncovered workers in Spokane. It is a stronger policy than most jurisdictions in the country.
- Developed city-wide policy after a year and half of conversations with over 50 local businesses and nonprofits and hundreds of individuals.
- Held assemblies in front of elected officials with over 650 attendees. Brought over 80 individuals to testify at city council meetings.
- Held press conferences and generated coverage. Published dozens of letters to the editor and op-eds. Delivered over 1000 supportive cards from Spokane residents to City council members.
- Policy will take effect in 2017. Construction workers are exempt. Businesses with 10 or more employees - employees will earn a minimum of 5 days of sick and safe leave. Businesses with less than 10 employees - employees will earn a minimum of 3 days.
- National Recognition: US Senator Patty Murray invited the Spokane Alliance to join her in a joint press conference on paid sick leave, recognizing our local campaign, and announcing her national policy on the same topic.
- Public Safety & Mental Health: Researched and successfully advocated for a Jail Diversion Facility - which moves people in mental health and substance use crises out of jail and into treatment - to be the top priority for the Spokane Regional Law and Justice Council.
- Quality Jobs Spokane Campaign: Building on the Public Facilities District win, took the campaign to another level and developed three Ordinances with city council leaders to:
- Create 15% rate of apprentices on all public works projects over $350K (5% year one, 10% year two, and 15% year three on)
- Codify location for contractors & sub-contractors to be considered evaluation criteria in design-build contracts
- Consider sales tax in determining the lowest bid for the purchases of supplies, materials, and equipment.
Between 11/24/14 - 12/15/14 we turned out 28 Alliance leaders to testify in support of the Quality Jobs Ordinances at the three City Council meetings. On the night of the vote, we turned out over 170 leaders –the largest turnout to any city-council meeting in 2014. Council voted and passed all three city-wide ordinances.
- Action - Inequality For All Film: Co-organized film screening helping to turnout a sell-out crowd of 700+.
- Action - Increasing Our Quality of Life Assembly: Turned out over 215 people to a Summer 2014 action assembly. Secured commitments from religious leaders, business leaders, elected officials and the health department to move Spokane Alliance issue campaigns forward.
- Leadership Development: 16 Spokane Alliance members attended the week long IAF Regional Training, and 39 attended the 2-day local leadership training. Individuals increased leadership skills through holding numerous roles in actions and research team meetings. Built the Executive Team and city-wide Leadership Team.
- City Ballot Feb 2013: Spokane Alliance committed to talk with over 1,300 people to Get Out The Vote (GOTV) in order to support the Library Levy. We reached our commitment and successfully helped pass the Levy.
- Convention Center and Spokane Arena Project Continued: In November 2012, Spokane Alliance made a deal with the Public Facilities District (PFD) to heighten the expectations for the contractor to be hired for this expansion job. The PFD kept the deal. On April 19th, 2013 after the Spokane Alliance interviewed each of the three contractor finalists we identified which contractor we thought would be best for Spokane's families and economy. The PFD worked with us and together we won quality jobs for Spokane residents: Contractors hired locally, utilized a 15% rate of apprenticeship, and gave preference to contractors that bought materials locally. In the end, we kept $38 out of $42 million spent on the project in Spokane.
- Action - City Council Candidate Forum: Turned out over 220 people to an October 2013 assembly. Secured commitments from city council candidates on quality jobs, sick leave, the Spokane River, and public safety funding.
Leadership Development
- Developed 32 new leaders through local campaigns and actions.
- Trained 21 Spokane Alliance members in a two-day local Leadership Institute.
- Three leaders attended week-long Regional and National training.
- One leader attended a 3-day training on Transformational Leadership.
- Three new organizations joined Spokane Alliance.
Local Campaigns
- Supporting Local Jobs. Spokane Alliance's Jobs Team led the effort to engage the Public Facilities District (PFD) to make their upcoming expansion on the Convention Center and Arena a truly local project. The PFD will hire local contractors and employees and use a local manufacturer. We supported a modest increase for the hotel/motel tax to directly help fund this Design/Build project. We are still meeting with the PFD board to continue to push for apprenticeship utilization and full family health care.
- Shifting Public Conversation about Spokane's Budget. During the Spokane City Budget process, Spokane Alliance responded to dramatic cuts to city services and jobs. We changed the way people where talking about the budget and shifted the tone of how the budget was covered in the news by:
- Bringing attention to a budget that cuts services and threatens our safety
- Turning out over 60 people to the budget hearings, which is the most people to ever turn out for a budget conversation.
- Engaging citizens in the process when the city was silent.
- Keeping Spokane Beautiful. Spokane Alliance built a public relationship with absentee landlords next to Westminster UCC Church. We asked them to clean up their property. They are acting on our request.
State-Wide Campaign: Washington State Jobs Bill
Spokane Alliance partnered with our sister organization in the Puget Sound, Sound Alliance to pass a $1.1 billion construction bill that is creating over 18,000 jobs in Washington State. It includes $54 million of projects in the Spokane area, such as the rest of the needed funds to complete the WSU Medical School and expand a learning center at our local community college. The bill included money to develop the Centennial Bike Trail, a pedestrian bridge and a number of other local projects. It also included funding for the Community Energy Efficiency Pilot program (CEEP), which has been a primary funding source for Sustainable Works.
Spokane Alliance members played a key role in this campaign. We led strategic efforts by phone banking our membership to educate them about the bill and encouraged them to call their legislators. Our members met with local city and county officials to gain their support. A team of 12 traveled to Olympia to meet with all Spokane County State Representatives. The Alliance organized a press conference/rally with over 100 Alliance leaders and all TV, newspaper, and local radio stations turned out. The Jobs Bill has already made a difference for many of our families who have been put back to work and it has spurred other local investment and development.
Earlier Accomplishments
Spokane Alliance has accomplished a lot since our inception. Please click here to see a list of achievements since our founding.


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Today I wanted to share this lovely photo and the thought behind it, because it encompasses two ideas that I thoroughly believe in. This is taken from A Craft A Day Keeps Boredom Away.
The first is just what the saying says, that One Small Positive Thought In the Morning Can Change Your Whole Day. Even if all you can manage is a teeny amount of positivity, if you can find just one thing to smile about, that will make a difference.
As I talk about in my book "10 Steps to a More Positive You" (which you can get absolutely free by subscribing to our newsletter via the link on the right, or by clicking here), positive thinking is a habit, and the more you do it, the more you practise, the better you get at it, and the easier and more natural it gets. If you can start with finding just a small positive thought in the morning, that is getting you on the road to a more positive day and a more positive life.
The second is another aspect of positivity that I talk about in my book: doing something you love every day. The creator is in the process of making a total of 365 beautiful handwriting pieces – a collection of lovely sayings and quotations all lovingly handwritten in ink. When they are all finished, they'd make a lovely book – a thought for each day of the year.
If you can spend a little time each day doing something you love, that will help you feel more positive about life. If it's something that is also relaxing (which crafts so often are), then even better.
Get our free ebook by subscribing here
©Liz Wootton, 2013. All Rights Reserved.


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text:
Wednesday, July 18, 2018 -- 2:48 AM EST
Bonomo wins $10 million and moves to the top of the all-time money list; Over $2 million raised for One Drop charity.
Read More
Monday, July 16, 2018 -- 3:29 AM EST
Phil Ivey and Daniel Negreanu lurk just behind him at the top of the counts
Friday, October 14, 2016 -- 7:17 PM EST
Alfred Decarolis leads the Big One heading into Day 2
Thursday, July 14, 2016 -- 8:17 PM EST
Kenny Hallaert from Belgium leads, Hellmuth and Hachem bust out, 800 players still alive.
Saturday, July 12, 2014 -- 9:42 PM EST
Lovely ladies, Mark Newhouse, the POY race, and more.
Friday, July 11, 2014 -- 8:54 PM EST
Luck be the ladies, bust be the Champs, and Nice to be five-time casher Ronnie Bardah.
Monday, June 30, 2014 -- 5:08 AM EST
The Brit busted three players to end Day 1 with the only eight-figure chip stack.
Sunday, June 29, 2014 -- 7:27 PM EST
Here are the highlights of the first two levels.
Wednesday, March 19, 2014 -- 12:35 PM EST
This year's Big One for One Drop event has the potential to pay $20 million to first.
Friday, June 28, 2013 -- 4:47 AM EST
The Swedish pro leads the stacked field as they approach the money bubble.
Tuesday, July 31, 2012 -- 2:19 PM EST
The Big One for One Drop Airs In Back-to-Back Episodes at 8 PM ET/5 PM PT.
Wednesday, July 4, 2012 -- 4:33 PM EST
Big One for One Drop Becomes Poker's Most Majestic Moment.
Tuesday, July 3, 2012 -- 6:15 PM EST
Follow the Money - Esfandiari Wins $18 Million and 'One Drop' Championship; Jim Willerson Tops 3,166-Player Field; 3,221-Player Field Down to Two - Jaffe vs. Campelo; Happy July 4th!
Tuesday, July 3, 2012 -- 3:46 AM EST
It's Esfandiari, Rast, Baldwin, Einhorn, Laliberte, Yong, Trickett, and Hellmuth.
Monday, July 2, 2012 -- 10:28 PM EST
Best friends Brian Rast and Antonio Esfandiari vying for the chip lead with 16 left.
Monday, July 2, 2012 -- 6:16 PM EST
Final Table Set for 'Big One for One Drop.'
Sunday, July 1, 2012 -- 4:07 PM EST
'The Big One for One Drop' Makes a Huge Splash.
Saturday, June 30, 2012 -- 12:34 PM EST
Announcing Final Official List of 48 Entrants -- $18,346,773 For First Place.
Saturday, November 19, 2011 -- 4:10 AM EST
A Look Back at the 2011 World Poker Championship From Start to Finish.
Wednesday, July 20, 2011 -- 1:16 PM EST
Seven Different Nations Represented At WSOP Main Event Final Table.
Tuesday, July 19, 2011 -- 6:13 PM EST
WSOP Summer Comes to a Thrilling Conclusion -- Czech Martin Staszko is Chip Leader.
Sunday, July 17, 2011 -- 9:20 PM EST
Entering Day Seven -- Only 57 Players Remaining in 2011 WSOP Main Event Championship.
Sunday, July 17, 2011 -- 5:54 PM EST
A Look at the 142 Survivors Remaining in the 2011 WSOP Main Event Championship.
Friday, July 15, 2011 -- 5:04 PM EST
2011 WSOP Main Event Down to 378 Survivors, Day Five Coming on Saturday.
Friday, July 15, 2011 -- 10:45 AM EST
853 Survivors -- Players Expected to Play into the Money on Friday.
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Here's the letter and my responses to each point:
In the aftermath of the recent election, we may find ourselves oddly on the defensive regarding our support for the Yes on Proposition 8 cause. Our young people have been especially subject to mean spirited comments by high school friends and teachers. We have nothing to be ashamed of. We did nothing wrong. In fact, we did everything that a civic minded American can and should do. I have put together a few facts that help me to appreciate our position better. For example:
1. Mormons make up less than 2% of the population of California. There are approximately 800,000 LDS out of a total population of approximately 34 million.
2. Mormon voters were less than 5% of the yes vote. If one estimates that 250,000 LDS are registered voters (the rest being children), then LDS voters made up 4.6% of the Yes vote and 2.4% of the total Proposition 8 vote.
And yet the members of our church donated nearly half the money to the cause.
People aren't angry at us because we make up the majority of the people in California who voted yes – they're angry because we bankrolled it. Money talks in politics, as we all know. You could say that without the LDS so greatly invested, this proposition would have lost.
3. The Church of Jesus Christ of Latter-day Saints (Mormons) donated no money to the Yes on 8 campaign. Individual members of the Church were encouraged to support the Yes on 8 efforts and, exercising their constitutional right to free speech, donated whatever they felt like donating.
Actually the Church did, well within their legal limits (something like a little over $2000), but they did donate.
Encouraged? When the Prophet says jump, we ask how high. That's how it is. We follow the prophet or risk being unworthy of many, many blessings like going to the temple. Yes, some people understand the principle of praying to know for yourself, but most consider this a matter of belief vs. non belief.
Flyers were placed in the foyers of ward buildings. Sign up sheets were passed around. Announcements and discussions took up the majority of some class times. Donations were "encouraged" over the pulpit. Some people were strongly encouraged – bishops and leaders alike. I'm glad I wasn't a leader. Makes me wonder if I would've been released from my calling.
That makes some wonder about the tax-exemption thing. I don't think it'll happen. I think the Church flirted with the line, but nothing will happen.
4. The No on 8 campaign raised more money than the Yes on 8 campaign. Unofficial estimates put No on 8 at $38 million and Yes on 8 at $32 million, making it the most expensive non-presidential election in the country.
5. Advertising messages for the Yes on 8 campaign are based on case law and real-life situations. The No on 8 supporters have insisted that the Yes on 8 messaging is based on lies. Every Yes on 8 claim is supported.
And yet…not. I've got all sorts of evidence to the contrary. If they weren't outright lies, they were half-truths meant to deceive and scare people. If you know law, you know loopholes, and that nothing is cut and dry. Context is everything. Look it up.
6. The majority of our friends and neighbors voted Yes on 8. Los Angeles County voted in favor of Yes on 8. Ventura County voted in favor of Yes on 8.
Not as many of our "friends and neighbors" voted as they did back in 2000. About nine percent less. That's a lot of people.
And uh, LA County was 50/50. 16,000 votes separated Yes from No. In a county of millions, that doesn't hold much clout.
7. African Americans overwhelmingly supported Yes on 8. Exit polls show that 70% of Black voters chose Yes on 8. This was interesting because the majority of these voters voted for President-elect Obama. No on 8 supporters had assumed that Obama voters would vote No on 8.
What does this mean? "It's not our fault it passed! Go after the blacks! Go after the Hispanics! The Catholics! Just not us, we don't deserve it!"
You voted for it. You called people, knocked on doors, gave up your life savings in some instances for it. So stand up for it. Be not ashamed. You expressed your right to an opinion, to a vote, to get others to vote - these people are expressing their right to be pissed off. As long as they're peaceful, who cares. And they do want to be peaceful about it - you just always have your idiots on either side.
See response to 7
9. The Yes on 8 coalition was a broad spectrum of religious organizations. Catholics, Evangelicals, Protestants, Orthodox Jews, Muslims – all supported Yes on 8. It is estimated that there are 10 million Catholics and 10 million Protestants in California. Mormons were a tiny fraction of the population represented by Yes on 8 coalition members.
See response to 7.
10. Not all Mormons voted in favor of Proposition 8. Our faith accords that each person be allowed to choose for him or her self. Church leaders have asked members to treat other members with "civility, respect and love," despite their differing views.
And yet I've been chastised for going against the prophet, testimonies have been called into question, various idiots on some discussion boards have declared we should rip up our temple recommends, family and friends can't really look me in the eye anymore, etc.
I don't want to be told how to vote, what to think, what to do or I'll be ex'd, lose my calling, etc. I don't appreciate those regarding the proponents of 8 as the "moral majority." I don't like the Church calling those gay couples who want to marry "selfish."
11. The Church did not violate the principal [sic] of separation of church and state. This principle is derived from the First Amendment to the United States Constitution, which reads, "Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof." The phrase "separation of church and state", which does not appear in the Constitution itself, is generally traced to an 1802 letter by Thomas Jefferson, although it has since been quoted in several opinions handed down by the United States Supreme Court in recent years. The LDS Church is under no obligation to refrain from participating in the political process, to the extent permitted by law. U.S. election law is very clear that Churches may not endorse candidates, but may support issues. The Church as always been very careful on this matter and occasionally (not often) chooses to support causes that it feels to be of a moral nature.
Like Prohibition?
You know what else grates me? A story on The View yesterday recounted about a boy with some problems who nobody wanted to adopt. Finally, a couple who specialized in working with kids like him stepped forward and put in papers to adopt him. His reaction? "Somebody wants me!"
It was a gay couple. You're going to tell me this is immoral and wrong? Tell that little boy that.
And can we quit implying that separation of church and state doesn't exist? No, the phrase verbatim doesn't exist in the Constitution, but the idea is absolutely there. We don't live in a theocracy, and I'd prefer to not live in one right now thankyouverymuch.
12. Supporters of Proposition 8 did exactly what the Constitution provides for all citizens: they exercised their First Amendment rights to speak out on an issue that concerned them, make contributions to a cause that they support, and then vote in the regular electoral process. For the most part, this seems to have been done in an open, fair, and civil way. Opponents of 8 have accused supporters of being bigots, liars, and worse. The fact is, we simply did what Americans do – we spoke up, we campaigned, and we voted.
They spoke out on an issue that concerned them? I know of a handful of people who wouldn't have voted yes, donated, made phone calls, etc. if the Church hadn't made an official plea for its members to do all it could to allow it to pass. Pretty sure there are many more.
And we've been just as awful to the No on 8 people, calling them selfish and abhorrent to God and that giving them the ability to marry would bring down society and the world as we know it. Yeah. They really should just have thicker skin than that.
Neither side was right in calling names. Don't for a second think it was just the No side. We got in the mud, we got dirty, deal with it.
Hold your heads up high – you did a great job on this most important cause. We will have more opportunities in the future to participate in our democratic process. Let's remember the lessons learned and do an even better job next time.
These are my personal opinions and thoughts; any errors are mine and in no way reflect official Church policy or doctrine.
Kevin Hamilton
Thanks, Kev.
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