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

Charlene Weir charlene.weir at UTAH.EDU
Mon Jan 12 18:40:42 UTC 2015


Yes - I very much sense that in my work. The conversation is co-constructed with the patient and doc creating common ground, negotiating shared goals and always interpreting (or misinterpreting ) each other.

Sent from my iPhone

> On Jan 12, 2015, at 11:24 AM, Robert L Wears, MD, MS, PhD <wears at UFL.EDU> wrote:
> 
> I have to strongly agree here.  A history is not a collection of facts, but a narrative 
> co-constructed by doctor and patient (and often, family).  It's much more akin to interpreting 
> literature than it is to following an algorithm.
> 
> And it's never 'complete'.  In any communication, there are always more possibilities than 
> can be realized; something is always left out, something else also could have been said.  
> 
> bob
> 
>> On 12 Jan 2015 at 16:26, Thomas, Eric wrote:
>> 
>> 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
>> 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.IMPROVEDIAGN
>> OSIS.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]
>> Sent: Sunday, January 11, 2015 4:47 PM
>> To:
>> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGN
>> OSIS.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.IMPROVEDIAG
>> NOSIS.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.IMPROVEDIAG
>> NOSIS.ORG>"
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAG
>> NOSIS.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.IMPROVEDIAG
>> NOSIS.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.IMPROVEDIAG
>> NOSIS.ORG>"
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAG
>> NOSIS.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.IMPROVEDIAG
>> NOSIS.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.IMPROVEDIAG
>> NOSIS.ORG>"
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAG
>> NOSIS.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_pqCD9hKx9JgXN1VapJQ8JVoF8oW
>> H1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22G
>> Ct9UyBm2n32bIF4mnkdSNOw4yDnw&s=DXLacY0AzLQC9QIBcXYKUCxiHDXjqLlf_E7VbQz
>> I8sU&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_pqCD9hKx9JgXN1VapJQ8JVoF8oW
>> H1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22G
>> Ct9UyBm2n32bIF4mnkdSNOw4yDnw&s=DXLacY0AzLQC9QIBcXYKUCxiHDXjqLlf_E7VbQz
>> I8sU&e=>
>> 
>> From: Jason Maude
>> [mailto:Jason.Maude at ISABELHEALTHCARE.COM<mailto:Jason.Maude at ISABELHEAL
>> THCARE.COM>] Sent: Wednesday, January 07, 2015 4:39 AM To:
>> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGN
>> OSIS.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=ht
>> tp-3A__www.isabelhealthcare.com_&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1Va
>> pJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffq
>> JNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=tmxUA8BuP9Z9n9MUk8j2fGTa3Ama
>> qNSxJOuyDvfX3Ps&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.IMPROVEDIAG
>> NOSIS.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.IMPROVEDIAG
>> NOSIS.ORG>"
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAG
>> NOSIS.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.ht
>> ml?_r=0<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.nytime
>> s.com_2015_01_05_opinion_doctor-2Dshut-2Dup-2Dand-2Dlisten.html-3F-5Fr
>> -3D0&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg
>> 9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mn
>> kdSNOw4yDnw&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>
>> 
>> [cid:image002.png at 01CF4E6D.0D6442B0]
>> 
>> *****E-Mail Confidentiality Notice*****
>> This message (including any attachments) contains information intended
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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.IMPROVEDIAGN
>> OSIS.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.IMPROVEDIAGN
>> OSIS.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/v
>> 2/url?u=http-3A__bjgp.org_content_65_630_e49&d=AwMFAg&c=4sF48jRmVAe_CH
>> -k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=R16GG-MhGQFeEbiQbUUeP30HTmJHZlqL3XxjDP
>> QtyXcSwB0zl0UIXhhofztdrEG1&m=eGvrWf26LmmmVkGW0vnRf9XeztEuR6JjBE8n1vgrI
>> vU&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=ht
>> tp-3A__www.isabelhealthcare.com_&d=AwMFAg&c=4sF48jRmVAe_CH-k9mXYXEGfSn
>> M3bY53YSKuLUQRxhA&r=R16GG-MhGQFeEbiQbUUeP30HTmJHZlqL3XxjDPQtyXcSwB0zl0
>> UIXhhofztdrEG1&m=eGvrWf26LmmmVkGW0vnRf9XeztEuR6JjBE8n1vgrIvU&s=rZEhyq7
>> LgURp9ngavWrjRLodS2ccXYnsmuk6_HzmETc&e=>
>> 
>> 
>> ________________________________
>> 
>> Address messages to:
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>> scripts_wa-2DIMPDIAG.exe-3FINDEX&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1Va
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>> JNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=PZfvD_8JJDPZKWiA5uMLl1QtjDNY
>> zREU_Zggjmg5FzI&e=>
>> 
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis
>> in Medicine
>> 
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/<https://urldefense.proofpoint.com/v2/
>> url?u=http-3A__www.improvediagnosis.org_&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx
>> 9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj
>> 0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=bAODY6fB9g6C7LWuO1dM
>> Oq-kCaS1chnRmoZIPB84Ccc&e=>
>> 
>> ________________________________
>> 
>> Address messages to:
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>> ediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1&d
>> =AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_K
>> FlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw
>> 4yDnw&s=dOhlPiskz90C5VJLnsvmaQOlIvElFHTIcmerOzwGElg&e=> or send email
>> to:
>> IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-S
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>> 
>> Visit the searchable archives or adjust your subscription at:
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>> scripts_wa-2DIMPDIAG.exe-3FINDEX&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1Va
>> pJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffq
>> JNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=PZfvD_8JJDPZKWiA5uMLl1QtjDNY
>> zREU_Zggjmg5FzI&e=> Moderator:David Meyers, Board Member, Society for
>> Improving Diagnosis in Medicine
>> 
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/<https://urldefense.proofpoint.com/v2/
>> url?u=http-3A__www.improvediagnosis.org_&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx
>> 9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj
>> 0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=bAODY6fB9g6C7LWuO1dM
>> Oq-kCaS1chnRmoZIPB84Ccc&e=>
>> 
>> 
>> ________________________________
>> 
>> Address messages to:
>> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGN
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>> ediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1&d
>> =AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_K
>> FlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw
>> 4yDnw&s=dOhlPiskz90C5VJLnsvmaQOlIvElFHTIcmerOzwGElg&e=> or send email
>> to:
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>> 
>> Visit the searchable archives or adjust your subscription at:
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>> scripts_wa-2DIMPDIAG.exe-3FINDEX&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1Va
>> pJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffq
>> JNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=PZfvD_8JJDPZKWiA5uMLl1QtjDNY
>> zREU_Zggjmg5FzI&e=>
>> 
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis
>> in Medicine
>> 
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/<https://urldefense.proofpoint.com/v2/
>> url?u=http-3A__www.improvediagnosis.org_&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx
>> 9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj
>> 0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=bAODY6fB9g6C7LWuO1dM
>> Oq-kCaS1chnRmoZIPB84Ccc&e=>
>> 
>> ________________________________
>> 
>> Address messages to:
>> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGN
>> OSIS.ORG>
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>> To unsubscribe from IMPROVEDX: click the following link:
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>> ediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1&d
>> =AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_K
>> FlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw
>> 4yDnw&s=dOhlPiskz90C5VJLnsvmaQOlIvElFHTIcmerOzwGElg&e=> or send email
>> to:
>> IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-S
>> IGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
>> 
>> Visit the searchable archives or adjust your subscription at:
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>> urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_
>> scripts_wa-2DIMPDIAG.exe-3FINDEX&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1Va
>> pJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffq
>> JNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=PZfvD_8JJDPZKWiA5uMLl1QtjDNY
>> zREU_Zggjmg5FzI&e=>
>> 
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis
>> in Medicine
>> 
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/<https://urldefense.proofpoint.com/v2/
>> url?u=http-3A__www.improvediagnosis.org_&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx
>> 9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj
>> 0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=bAODY6fB9g6C7LWuO1dM
>> Oq-kCaS1chnRmoZIPB84Ccc&e=>
>> 
>> ________________________________
>> 
>> Address messages to:
>> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGN
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>> To unsubscribe from IMPROVEDX: click the following link:
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>> ediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1&d
>> =AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_K
>> FlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw
>> 4yDnw&s=dOhlPiskz90C5VJLnsvmaQOlIvElFHTIcmerOzwGElg&e=> or send email
>> to:
>> IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-S
>> IGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
>> 
>> Visit the searchable archives or adjust your subscription at:
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX<https://
>> urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_
>> scripts_wa-2DIMPDIAG.exe-3FINDEX&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1Va
>> pJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffq
>> JNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=PZfvD_8JJDPZKWiA5uMLl1QtjDNY
>> zREU_Zggjmg5FzI&e=>
>> 
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis
>> in Medicine
>> 
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/<https://urldefense.proofpoint.com/v2/
>> url?u=http-3A__www.improvediagnosis.org_&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx
>> 9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj
>> 0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=bAODY6fB9g6C7LWuO1dM
>> Oq-kCaS1chnRmoZIPB84Ccc&e=>
>> 
>> ________________________________
>> 
>> Address messages to:
>> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGN
>> OSIS.ORG>
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>> To unsubscribe from IMPROVEDX: click the following link:
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>> ediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1&d
>> =AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_K
>> FlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw
>> 4yDnw&s=dOhlPiskz90C5VJLnsvmaQOlIvElFHTIcmerOzwGElg&e=> or send email
>> to:
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>> 
>> Visit the searchable archives or adjust your subscription at:
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>> scripts_wa-2DIMPDIAG.exe-3FINDEX&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1Va
>> pJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffq
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>> zREU_Zggjmg5FzI&e=>
>> 
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis
>> in Medicine
>> 
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/<https://urldefense.proofpoint.com/v2/
>> url?u=http-3A__www.improvediagnosis.org_&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx
>> 9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj
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>> Oq-kCaS1chnRmoZIPB84Ccc&e=>
>> 
>> ________________________________
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>> To unsubscribe from IMPROVEDX: click the following link:
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>> ediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1&d
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>> scripts_wa-2DIMPDIAG.exe-3FINDEX&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1Va
>> pJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffq
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>> zREU_Zggjmg5FzI&e=>
>> 
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis
>> in Medicine
>> 
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/<https://urldefense.proofpoint.com/v2/
>> url?u=http-3A__www.improvediagnosis.org_&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx
>> 9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj
>> 0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=bAODY6fB9g6C7LWuO1dM
>> Oq-kCaS1chnRmoZIPB84Ccc&e=>
>> 
>> The information in this e-mail is intended only for the person to whom
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>> ________________________________
>> 
>> Address messages to:
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>> To unsubscribe from IMPROVEDX: click the following link:
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>> ediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1&d
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>> IGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
>> 
>> 
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis
>> in Medicine
>> 
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>> 
>> 
>> 
>> 
>> 
>> 
>> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
>> Medicine
>> 
>> To unsubscribe from the IMPROVEDX list, click the following link:<br>
>> <a
>> href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=I
>> MPROVEDX&A=1"
>> target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.ex
>> e?SUBED1=IMPROVEDX&A=1</a> </p>
>> 
> 
> Robert L Wears, MD, MS, PhD
> University of Florida      Imperial College London
> wears at ufl.edu        r.wears at imperial.ac.uk
> 1-904-244-4405 (ass't)      +44 (0)791 015 2219
> The pen is mightier than the pencil.
> 
> 
> 
> 
> 
> 
> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine
> 
> To unsubscribe from the IMPROVEDX list, click the following link:<br>
> <a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
> </p>






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