Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Robert M Centor rcentor at UAB.EDU
Mon Jan 12 18:24:37 UTC 2015


Data and experimental results would be almost impossible to collect.

Patients experience discomfort in different ways – because humans are complex biological organisms.  Two patients can give very similar histories and have different underlying disease.  Two patients can have the same disease and yet provide very different histories.  Sometimes experienced observers obviate the need for “experimental results"
--
Robert M Centor, MD, MACP

Chair ACP Board of Regents
Regional Dean, UAB Huntsville Regional Medical Campus
301 Governors Drive
Huntsville, AL 35801

Office: 256-539-7757
Fax: 256-551-4451

Professor, General Internal Medicine
UAB
FOT 720
1530 3rd Ave S
Birmingham, AL 35294-3407
Office: 205-934-3007

From: Alan Morris <Alan.Morris at IMAIL.ORG<mailto:Alan.Morris at IMAIL.ORG>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Alan Morris <Alan.Morris at IMAIL.ORG<mailto:Alan.Morris at IMAIL.ORG>>
Date: Monday, January 12, 2015 at 11:02 AM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

We all have opinions, of course.  Do any have data/experimental results to offer in this discussion?
Alan

From: Albert Wu <awu at JHU.EDU<mailto:awu at JHU.EDU>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Albert Wu <awu at JHU.EDU<mailto:awu at JHU.EDU>>
Date: Monday, January 12, 2015 at 9:37 AM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

A long as we are piling on, I’m in Bob’s camp

If algorithms are going to work they still need to be delivered by Lisa Rosenbaums (great piece!)

Best regardsAlbert

Albert W. Wu, MD, MPH, FACP
Professor and Director
Center for Health Services & Outcomes Research
Johns Hopkins Bloomberg School of Public Health
624 N Broadway Room 653
Baltimore MD 21205
(410) 955-6567 / fax (410) 955-0470
Mobile (410) 978-1539


From: <Thomas>, Eric Thomas <Eric.Thomas at uth.tmc.edu<mailto:Eric.Thomas at uth.tmc.edu>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Eric Thomas <Eric.Thomas at uth.tmc.edu<mailto:Eric.Thomas at uth.tmc.edu>>
Date: Monday, January 12, 2015 at 11:26 AM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

As long as we are taking sides :) , I’ll also side with Bob and Ed.  Ed’s bridge analogy is good.  With patients you almost never have a clear view of all the facts.  This is especially true in primary care, less so in some subspecialties.  So although medicine can benefit from more standardization I am skeptical that history taking can be rule-based.  Partly rule-based yes, but ultimately there is a degree of subjectivity, complexity, misinformation, misunderstanding, and “art” that occurs between a doctor and patient that defies logic.

I never cease to be amazed by the way patients describe how they feel, how they are selective about information they provide me, how they understand what is wrong and why….the list goes on and on.  I rarely have all the “facts” and a rule-based tool to collect the facts would only take me a few steps in to this maze.  And by the way, I don’t find this maze frustrating, I find it endlessly rewarding to try and understand my patients and to help them.

I think Lisa Rosenbaum’s recent essay in the New England Journal helps illustrate part of this complex nature of patient-doctor communication by providing a rich and fascinating glimpse into patient beliefs about taking medicines for heart disease: http://www.nejm.org/doi/full/10.1056/NEJMms1409015?query=featured_home

Best,

Eric

Eric J Thomas MD, MPH
Professor of Medicine
Associate Dean for Healthcare Quality
Director, UT Houston-Memorial Hermann Center for Healthcare Quality and Safety
The University of Texas Medical School at Houston
6410 Fannin UPB 1100.44
Houston, TX 77030
713-500-7958
www.utpatientsafety.org<http://www.utpatientsafety.org/>
https://twitter.com/EJThomas_safety







From: Hoffer, Edward P.,M.D. [mailto:EHOFFER at MGH.HARVARD.EDU]
Sent: Monday, January 12, 2015 6:03 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Indeed, as an MIT grad who planned to be an engineer, I must side with Dr. Centor.  If you are tasked to build a bridge, virtually all of the parameters are defined. The bridge will go from A to B [unless perhaps it is in Alaska  :)], it will carry vehicles of up to X tons with a fudge factor for truckers who disobey posted limits; the average and maximum recorded wind velocity are known, etc.

When faced with a patient with an undefined illness, you must strike a balance between letting them tell their story and guiding the history when they are clearly going off on irrelevant tangents; you must have or establish enough rapport that they will tell you things that might be embarrassing or uncomfortable; you must know enough to ask about things that have not brought up that are suggested by what they have; you must be able to interpret what they tell you about past medical encounters and tests.  MUCH harder.

Ed

Edward P Hoffer MD, FACC, FACP
Associate Clinical Professor of Medicine, Harvard

From: Swerlick, Robert A [mailto:rswerli at EMORY.EDU]
Sent: Sunday, January 11, 2015 7:59 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

A test to show whether you are correct?

Robert A. Swerlick, MD
Alicia Leizman Stonecipher Chair of Dermatology
Professor and Chairman, Department of Dermatology
Emory University School of Medicine
404-727-3669
________________________________
From: Robert M Centor [rcentor at UAB.EDU<mailto:rcentor at UAB.EDU>]
Sent: Sunday, January 11, 2015 4:47 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"
I must disagree.  The art is in the data collection.  Taking a history is much more complex than asking a list of questions.  Each question has many branch points depending upon how one interprets the words, the body language, and the patient’s context.

I do believe that this process requires artistry.  What am I missing?
==============

Robert M Centor, MD, MACP

Regional Dean, UAB Huntsville Regional Medical Campus
301 Governors Drive
Huntsville, AL 35801

Office: 256-539-7757
Fax: 256-551-4451

Chair, ACP Board of Regents

Professor, General Internal Medicine
UAB
FOT 720
1530 3rd Ave S
Birmingham, AL 35294-3407


From: Alan Morris <Alan.Morris at IMAIL.ORG<mailto:Alan.Morris at IMAIL.ORG>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Alan Morris <Alan.Morris at IMAIL.ORG<mailto:Alan.Morris at IMAIL.ORG>>
Date: Sunday, January 11, 2015 at 10:44 AM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Beo Centor makes the argument that medical diagnosis is “science” plus “art,” and cannot be more like engineering  Science and art are two broad terms that can have multiple meanings, the specific definitions of which determine subsequent argument.  The science of medicine at the patient-clinician encounter is flimsy.  Replicable methods are rarely pursued.  The art of medicine is sometimes uses as a wastebasket for the remarkable achievements of accomplished clinicians (e.g., William Osler) while ignoring his admonition that method is required for all but geniuses.

I believe Dr. Centor has confounded two constructs that are frequently not adequately identified and separated:

  1.  System of interest:   Sick patients are more complex than mechanical or electrical systems.  A patient, for example, is much more complex than an airplane.  This leads many to conclude that engineering solutions, like those in airplanes, cannot be done in medicine.  However, the human decision-maker (and his/her cognitive limitations) is common to both systems.
  2.  Human decision-maker cognitive limits (4±1 constructs in short-term memory before decisions become degraded):  The clinician decision-maker and the pilot decision-maker are both cognitively limited by the same amount – and they are both overloaded by information.  Pilots can enjoy the benefit of autopilot programs, because the engineers have invested the effort to understand the control needs of airplanes.  We can clearly do the same for clinician decision-makers – feasibility is well-established – but the medical community is so married to the “cottage industry” model of the independent clinician decision-maker that we have not invested the effort to establish and scale autopilots for clinicians.
Healthcare challenges require a combination of autopilot and independent clinician decision-maker (cottage industry).  We seem to be making precious little progress with this combination.  I know of no systematic effort to pursue scaling of autopilot programs in medicine.  This may, in part, be what led Eric Topol, MD to claim that medicine is so conservative, its thinking is ossified.

Alan
Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Director of Research
Pulmonary/Critical Care Division
Sorenson Heart & Lung Center - 6th Floor
Intermountain Medical Center
5121 South Cottonwood Street
Murray, Utah  84157-7000, USA

Office Phone: 801-507-4603
Mobile Phone: 801-718-1283

From: Robert M Centor <rcentor at UAB.EDU<mailto:rcentor at UAB.EDU>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Robert M Centor <rcentor at UAB.EDU<mailto:rcentor at UAB.EDU>>
Date: Sunday, January 11, 2015 at 7:59 AM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Bob Latino asks an important question.  To rephrase – why cannot medicine be more like engineering?

Patients experience the same disease in many different ways.  They relate different symptoms and have different physical findings and laboratory tests.

The history gives us the greatest challenge.  Patients describe their symptoms in different ways.  Some patients deny their symptoms.  Some patients exaggerate their symptoms.  The great historian needs the art of reading between the lines.  We read body language.  We know when to seek additional information from family members or friends.

If we enter the proper data into our computer (either our biological computer or a program someone else has written) then we often (but not always) get to the correct diagnosis.

Additionally, while some patients follow Occam’s Razor, having a single cause for their symptoms, other follow Hickam’s Dictum (a patient can have as many diagnoses as he/she damn well please).  When patients have shortness of breath, we ask if the heart, lungs, muscles, etc are causing the symptoms.  Many patients have multiple diseases.  Are the new symptoms due to their known diseases or an additional new problem.

I therefore believe the diagnosis brilliance combines the science and the art.  The great diagnosticians spend much time using system 1 thinking and know when and how to proceed to system 2 thinking.  Knowing the textbook is not enough.  We need experience – thus the art.
==============

Robert M Centor, MD, MACP

Regional Dean, UAB Huntsville Regional Medical Campus
301 Governors Drive
Huntsville, AL 35801

Office: 256-539-7757
Fax: 256-551-4451

Chair, ACP Board of Regents

Professor, General Internal Medicine
UAB
FOT 720
1530 3rd Ave S
Birmingham, AL 35294-3407


From: Bob Latino <blatino at RELIABILITY.COM<mailto:blatino at RELIABILITY.COM>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Bob Latino <blatino at RELIABILITY.COM<mailto:blatino at RELIABILITY.COM>>
Date: Friday, January 9, 2015 at 1:51 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

I ask this as a non-clinician, "Should healthcare be more art than science?"

Understanding there are many unknowns in the field of medicine, as there are in science; but with regards to the 'knowns', shouldn't it be more science than art?

I come from the engineering disciplines (so from the left brain world), but with the 'knowns' there is a lot more structure and less variability in the application of the physical sciences in engineering.

With what is 'known' in medicine, why does there appear to be so much variability in 1) what is known (and who knows it) and 2) how it is effectively and consistently applied to the benefit of the patient.

Perhaps a naive question, but nonetheless on my mind as an layman observer:-)

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.reliability.com&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=DXLacY0AzLQC9QIBcXYKUCxiHDXjqLlf_E7VbQzI8sU&e=>

From: David Lawrance [mailto:david.lawrance at gmail.com]
Sent: Friday, January 09, 2015 2:37 PM
To: Society to Improve Diagnosis in Medicine; Bob Latino
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

And, thank goodness, most people seem willing to pay us, again.

At this point it is generally protocol to mention that healthcare is more art than science. I think that is another way of saying that artists are more accident-prone than are scientists.

David

On Wed, Jan 7, 2015 at 6:43 AM, Bob Latino <blatino at reliability.com<mailto:blatino at reliability.com>> wrote:
We never seem to have the time and budget to do things right, but we always seem to have the time and budget to do them again!

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645<tel:1.800.457.0645>
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.reliability.com&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=DXLacY0AzLQC9QIBcXYKUCxiHDXjqLlf_E7VbQzI8sU&e=>

From: Jason Maude [mailto:Jason.Maude at ISABELHEALTHCARE.COM<mailto:Jason.Maude at ISABELHEALTHCARE.COM>]
Sent: Wednesday, January 07, 2015 4:39 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Thanks for alerting us to this article. One of the really positive things about the article is not just the improved care now being given but a great example of the Chief Medical Office and his senior colleagues managing/leading and setting a standard of care. He states in the article "I realize that many colleagues may see methods like ours as too intrusive on their clinical practice and may say that they don’t have the time.” I believe we need to see much more of this in hospitals. Too often, for example, we see DDS viewed as an end in itself rather than a tool to help with setting a standard of care and I think this explains why adoption of these tools is still relatively low.

Regards
Jason

Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886<tel:%2B44%201428%20644886>
Tel: +1 703 879 1890<tel:%2B1%20703%20879%201890>
www.isabelhealthcare.com<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.isabelhealthcare.com_&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=tmxUA8BuP9Z9n9MUk8j2fGTa3AmaqNSxJOuyDvfX3Ps&e=>

From: <Bruno>, Michael <mbruno at HMC.PSU.EDU<mailto:mbruno at HMC.PSU.EDU>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, "Bruno, Michael" <mbruno at HMC.PSU.EDU<mailto:mbruno at HMC.PSU.EDU>>
Date: Tuesday, 6 January 2015 20:23
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Greetings IMPROVEDX List-serve colleagues, and Happy New Year!

Thanks to Jason and Thomas for starting this years’ discussion.

The attached article appeared in the Sunday New York Times.   I thought it was relevant to our group’s discussion.

http://www.nytimes.com/2015/01/05/opinion/doctor-shut-up-and-listen.html?_r=0<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.nytimes.com_2015_01_05_opinion_doctor-2Dshut-2Dup-2Dand-2Dlisten.html-3F-5Fr-3D0&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=2uw5_WOXY2z3jGuLeqU94nbxI5Ghil9R6C2EkpAv5t8&e=>


All the best,

[Description: Description: Description: \\hersheymed.net\files\Staff\M\mbruno\Signature2.gif.gif]
Michael A. Bruno, M.D., F.A.C.R.
Professor of Radiology & Medicine
Director of Quality Services & Patient Safety
The Milton S. Hershey Medical Center
Penn State College of Medicine
500 University Drive, Mail Code H-066
Hershey, PA  17033

Phone: (717) 531-8703<tel:%28717%29%20531-8703>
Fax:      (717) 531-5596<tel:%28717%29%20531-5596>

e-mail: mbruno at hmc.psu.edu<mailto:mbruno at hmc.psu.edu>

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From: Carroll, Thomas [mailto:Thomas_Carroll at URMC.ROCHESTER.EDU]
Sent: Tuesday, January 06, 2015 1:44 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] "Early diagnostic suggestions improve accuracy of GPs"

Interesting.  My question would be how this would translate to the real world.  In this artificial environment we know whether or not the “correct” dx is in the list of suggested dx’s.  That would not be the case in the real world.

Thomas M. Carroll M.D., Ph.D.
Assistant Professor, General Medicine & Palliative Care
University of Rochester
thomas_carroll at urmc.rochester.edu<mailto:thomas_carroll at urmc.rochester.edu>
Pager 5-1616 #3872
Tel: 585-275-7424<tel:585-275-7424> (General Medicine Office)
Tel: 585-273-1154<tel:585-273-1154> (Palliative Care Office)
Tel: 585-341-6775<tel:585-341-6775> (Resident Practice, Highland Hospital)

From: Jason Maude [mailto:Jason.Maude at ISABELHEALTHCARE.COM]
Sent: Tuesday, January 06, 2015 1:25 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] "Early diagnostic suggestions improve accuracy of GPs"

This is very interesting study just published in the British Journal of General Practice which also highlights the potential value of patients using symptom checkers and handing the results to their doctor at the start of the consultation. This would get over the current technical challenges of a system automatically producing a differential from more complex cases with multiple symptoms.

http://bjgp.org/content/65/630/e49<https://urldefense.proofpoint.com/v2/url?u=http-3A__bjgp.org_content_65_630_e49&d=AwMFAg&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=R16GG-MhGQFeEbiQbUUeP30HTmJHZlqL3XxjDPQtyXcSwB0zl0UIXhhofztdrEG1&m=eGvrWf26LmmmVkGW0vnRf9XeztEuR6JjBE8n1vgrIvU&s=uIrQIXl54eDZI6b32fN7ALZnLQKX_yTntnGzo_z3mD0&e=>

Regards and Happy New Year to the group.
Jason

Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886<tel:%2B44%201428%20644886>
Tel: +1 703 879 1890<tel:%2B1%20703%20879%201890>
www.isabelhealthcare.com<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.isabelhealthcare.com_&d=AwMFAg&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=R16GG-MhGQFeEbiQbUUeP30HTmJHZlqL3XxjDPQtyXcSwB0zl0UIXhhofztdrEG1&m=eGvrWf26LmmmVkGW0vnRf9XeztEuR6JjBE8n1vgrIvU&s=rZEhyq7LgURp9ngavWrjRLodS2ccXYnsmuk6_HzmETc&e=>


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