Another look at Questions

Peggy Zuckerman peggyzuckerman at GMAIL.COM
Sun Jan 10 23:13:44 UTC 2016


To complete the very recent email:
Some patients will be anxious, others will not, but all have a right to
those results, and their emotional responses are their own.

Back to some preparation of the patient and explanation/resource about
those tests.
Peggy Zuckerman

Peggy Zuckerman
www.peggyRCC.com

On Sun, Jan 10, 2016 at 3:11 PM, Peggy Zuckerman <peggyzuckerman at gmail.com>
wrote:

> It is quite possible to educate patients with the kind of data who
> describe.  Being told in advance that  an elderly person has a greater
> likelihood of a higher or lower creatinine is normal is probably helpful.
> And if the patient is anxious and wonders if there is a need for more
> tests, the physcian can surely educate the patient--though a bit late--that
> this or that reading is quite normal.  Of course, it is not the patient
> that 'orders' the tests.
>
> Some patients will be anxious, others will not, but all have the right to
> those test results, and their +
>
> Peggy Zuckerman
> www.peggyRCC.com
>
> On Sun, Jan 10, 2016 at 11:33 AM, hszerlip at gmail.com <hszerlip at gmail.com>
> wrote:
>
>> One of the problems with giving patients all their lab results is that
>> oftentimes labs that are "abnormal" gave no clinical significance and only
>> will result in patient anxiety and likely ordering of more tests. A
>> creatinine of 1.1 in an 81 year old female will have an eGFR of 47. This
>> will often result in an unnecessary consult to a nephrologist.
>>
>> Sent from my iPhone
>>
>> On Jan 10, 2016, at 12:26 PM, Michael.H.Kanter at KP.ORG wrote:
>>
>> This is really complicated issue in my view.  Some of my thoughts.
>> 1) all results should be given to patients based on ethical grounds.
>> Sadly, this does not happen consistently.  In terms of reducing diagnostic
>> errors informing patients of all results likely will help prevent some labs
>> from get overlooked.  Having said this,  in our most recent study on
>> abnormal creatinine values not getting acted on, many not acted on had the
>>  results given to the patients via our patient portal and yet they were
>> still not acted on.  Our study was not designed to test whether patients
>> using our portal that sends them virtually all lab results decreased the
>> rate of failure to act on labs but I can state, that even when patients are
>> given the abnormal results, a sizable number still do not get acted upon.
>> So informing patients of test results is the right thing to do but likely
>> wont prevent all errors in not following up abnormals.
>> 2)  there is harm that can occur when patients are informed of abnormal
>> tests in the form of unnecessary stress or concern over the implications..
>> This potential harm needs to be considered PRIOR to the physician ordering
>> the test though.  An example may be lung cancer screening where if one
>> orders a CT to screen for lung cancer, there is a significant risk of
>> finding an incidentaloma that may requiring follow up and create a great
>> deal of patient anxiety.  This does not mean one never order a CT scan to
>> screen for lung cancer in appropriate patients but on that  the potential
>> psychological harms are concidered as part of the risk/benefit prior to
>> ordering the test.   Once it is ordered, results need to be given to the
>> patient.
>>
>> Michael Kanter, M.D., CPPS
>> Regional Medical Director of Quality & Clinical Analysis
>> Southern California Permanente Medical Group
>> (626) 405-5722 (tie line 8+335)
>> THRIVE By Getting Regular Exercise
>>
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>>
>>
>>
>>
>> From:        robert bell <
>> 0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>
>> To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>> Date:        01/09/2016 10:23 PM
>> Subject:        Re: [IMPROVEDX] Another look at Questions
>> ------------------------------
>>
>>
>>
>> Thanks Dr. Strull,
>>
>> Does anyone know how frequently lack of call back/communication with the
>> patient occurs in ambulatory practice for both positive and negative test
>> results? I understand that it is not uncommon to call back only positive
>> results - is that appropriate?.
>>
>> If the figures are relatively high it would seem *not* to warrant any
>> restriction on the patient knowing immediately the results are available.
>>
>> Rob Bell, MD
>> On Jan 9, 2016, at 3:04 PM, William Strull <*William.Strull at KP.ORG*
>> <William.Strull at KP.ORG>> wrote:
>>
>> I whole-heartedly concur with Peggy's request for  "Giving immediate and
>> unfettered access to the patient about his testings,"  with a slight caveat
>> of delaying release of abnormal results for 24-48 hours to allow for the
>> physician to provide comments or interpretation.  As a primary care
>> physician myself, I have been doing just that since the 1980's, initially
>> sending hard-copy results with my comments by snail mail, and in the past
>> decade by releasing results with my comments through the patient portal in
>> the EMR on a routine basis.  I do think it important for the clinician to
>> provide comments and interpretation whenever possible, along with the full
>> report of the lab or imaging results.  In my experience, patients
>> appreciate comments from the physician, and have themselves often noted
>> abnormalities in the report for which further discussion or other follow up
>> was indicated and sometimes very appropriate.  And I agree with Peggy that,
>> even if the physician is not available to provide comments, the full
>> results should be released to the patient.
>> To paraphrase the title of a play, Whose *results*are they anyway?
>>
>>
>> * William Strull *MD
>> Medical Director, Quality and Patient Safety
>> * Kaiser Permanente*
>>
>> * The Permanente Federation, LLC*
>> One Kaiser Plaza, 23B
>> Oakland, California 94612
>> 510-271-5987 (office)
>> 8-423-5987 (tie-line)
>> 510-271-6642 (fax)
>> 415-601-6013 (mobile phone)
>>
>> Debra C. Costa (assistant)
>> *debra.c.costa at kp.org* <debra.c.costa at kp.org>
>> 510-271-6031
>>
>> * NOTICE TO RECIPIENT:*  If you are not the intended recipient of this
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>>
>>
>>
>> From:        Peggy Zuckerman <*peggyzuckerman at GMAIL.COM*
>> <peggyzuckerman at GMAIL.COM>>
>> To:        *IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG*
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> Date:        01/09/2016 01:34 PM
>> Subject:        Re: [IMPROVEDX] Another look at Questions
>>
>> ------------------------------
>>
>>
>>
>> Dear Steve and others interested in this reporting topic,
>>
>> Re the alleged 'harm' that knowledge of the findings might have to a
>> patient:   The harm or potential harm to the patient has alerady been done
>> by that which was found in the report.  The tumor was already there, the
>> anemia well-established, the rib already fractured, all of which may be
>> seen as the harm.  The patient actively seeking and cooperating in being
>> imaged or taking a test has acknowledged the potential for discovery of a
>> problem, and his desire to understand that. The reporting of data actively
>> sought cannot be harmful in itself, even if the expected finding is not
>> demonstrated and an "incidental finding" is shown. Why then would either
>> the simple data points or the more interpretative report be construed as
>> having harmed the patient?
>>
>> As we diagnose more diseases through genetic and/or genomic analyses, we
>> will hear that there is no need to report to the patient those findings
>> which lack "actionable targets".  In effect, the physicians says that there
>> is evidence for the cause for your illness, but I have no medication or
>> treatment. Thus, I shall remain silent.
>>
>> This approach is unethical at the very least.  The physician supporting
>> this says that the diagnosis must be withheld from the patient because
>> he--not all physicians--is unaware of a solution to the problem presented.
>>  This damages the patient. With this knowledge, he may approach another
>> physician, whether then or at another time when that target becomes
>> 'actionable', or provide that info to others, family members, researchers
>> or he may simply choose to ignore that information.  That is a decision to
>> be made by the patient, not the physician or the medical system.
>>
>> Changes in federal law have made invalid those state laws which prohibit
>> patients from receiving their blood lab tests directly, which will
>> certainly be a precedent for assuring that all such medical data cannot be
>> withheld from the patient.
>>
>> Giving immediate and unfettered access to the patient about his testings,
>> with or without the interpretation of those findings is a fundamental step
>> in minimizing diagnostic error.
>>
>> Peggy Z
>>
>> Peggy Zuckerman
>> *www.peggyRCC.com* <http://www.peggyrcc.com/>
>>
>> On Sat, Jan 9, 2016 at 10:14 AM, Stephen I. Lane <
>> *Stevelane at lane-lane.com* <Stevelane at lane-lane.com>> wrote:
>> I couldn't agree more with Peggy. As an attorney representing patients in
>> medical negligence cases, a common theme to virtually all successful cases
>> has been in a lack of communications. I've never understood the basis for
>> the "Your doctor will tell you" response that is the rule when patients ask
>> for their test results. Surely, giving the results to the patient can't
>> cause any harm, and does bring another possibility for catching a bad thing
>> before it becomes catastrophic. I have no illusion that all patients will
>> understand their reports. But if they're placed in a position to ask
>> someone to explain the results, aren't they better off?
>>
>> On a social note, I'd like to shout out to Lenny, whom I haven't seen in
>> too long!
>>
>> Sent from my iPhone
>>
>>
>> Steve
>> Please respond to:
>> Stephen I. Lane
>> * Partner*
>> <image001.png>
>> 230 W. Monroe  St.,  Suite 1900
>> Chicago, Illinois      60606-4710
>>
>> Office:   *(312) 332-1400* <(312)%20332-1400>
>> Facsimile: *(312) 899-8003* <(312)%20899-8003>
>> Mobile: *(847) 736-7769* <(847)%20736-7769>
>> *stevelane at lane-lane.com* <stevelane at lane-lane.com>
>>
>> Past Member of Board of Directors and Past Chair of the Plaintiff and
>> Consumer Institute of the International Society of Primerus Law Firms
>>
>> Lane & Lane, LLC, a family of trial attorneys dedicated to protecting the
>> rights of those who have been injured through the fault of others.
>>
>> For more information about our firm, please visit our website at
>> *www.lane-lane.com* <http://www.lane-lane.com/>.
>>
>>
>> On Jan 9, 2016, at 11:36 AM, Peggy Zuckerman <*peggyzuckerman at GMAIL.COM*
>> <peggyzuckerman at gmail.com>> wrote:
>>
>> I am a patient who is painfully aware of the number of radiology reports
>> which reference meaningful problems not communicated to the patient, which
>> automatically constitutes a misdiagnosis or error in diagnosis.  In the
>> recent IOM report, the failure to communicate a diagnosis to a patient
>> constitutes a misdiagnosis in itself.
>>
>> This situation can arise from the physician readsthe report only to
>> affirm his suspected diagnosis, and with that being found or not being
>> found, fails to read the entire report.  For example, suspecting a broken
>> rib to explain a nagging pain, and not finding that, the physician may
>> never read that there is a mass on the kidney. With the pressure to limit
>> CTs, the unreported mass will likely not be imaged again for a year or
>> more. The disaster that results from this error is obvious, and sadly, not
>> uncommon with rarer diseases diagnosed incidentally, thanks to imaging done
>> for other purposes.
>>
>> Whereas Dr. Berlin notes that the clinician has the patient.  If the
>> radiologist could rightly fulfill his obligation to the patient, his report
>> would go simultaneously to the patient.  Patients will read the entire
>> report, despite the difficulty they present.  No phrase which includes
>> "mass" or "lesion" will go unnoted to the patient, and as a minimum will
>> open a conversation between patient and clinician.  Naturally, the current
>> efforts by the radiology societies will make the reports more easily read
>> will be welcome to patients and physicians alike.
>>
>> Rarely is it easy to measure the value of finding a tumor earlier than
>> later, or of the cost of treatment given for the wrong disease. Certainly
>> it is possible to determine if a patient has received a report with
>> critical findings by asking the patient, even in a retrospective study.
>> Patients have been 'taught' not to call the doctor's office for a simple
>> blood test and to wait for a call with results, but are not taught that
>> about 15% of problematic tests are not reported.  If there is a similar
>> percentage as to radiology reports, this is a situation quickly corrected.
>>
>> Send the report to the patient directly.  "Nothing about me without me."
>>
>> Sincerely,
>> Peggy Zuckerman
>>
>>
>> Peggy Zuckerman
>> *www.peggyRCC.com* <http://www.peggyrcc.com/>
>>
>> On Thu, Jan 7, 2016 at 12:11 PM, Leonard Berlin <*lberlin at live.com*
>> <lberlin at live.com>> wrote:
>> As a radiologist, I'd like to comment briefly on radiologic errors, which
>> admittedly can be problematic.  It is the job of our radiology societies
>>  to  actively work to reduce error rates, and they are trying.
>>
>> But I'd like add the following: the radiologist has the images, and the
>> clinician has the patient; establishing a diagnosis requires collaboration
>> of both (not to mention results of lab and other tests).  If a clinician
>> receive a radiology report that somehow doesn't make sense or fit into the
>> clinician's pre-imaging DD, the clinician should not automatically accept
>> the report.  Call the radiologist and say that somehow the imaging
>> interpretation doesn't seem to fit: ask the rad to take another look at the
>> images keeping in mind  the clinician's doubt. And/or, ask the radiologist
>> to show it to one of his colleagues for a second opinion.   This is
>> certainly not a solution to the overall problem of radiologic errors, but
>> on the other hand every now and then such collaboration will mitigate an
>> error before it harms the patient  and result in a correct diagnosis.
>>
>> Sadly, in this day and age, radiologists don't communicate with ordering
>> physicians as much as they did in the past, and as much as they should
>> today.  That is unfortunate and a shame, but it is a fact.  But in the
>> interest of the patient, there's no doubt that two (or sometimes even
>> three) heads are better than one.
>>
>>
>> Lenny Berlin, MD, FACR
>> Skokie, IL
>>
>>
>> ------------------------------
>> Date: Thu, 7 Jan 2016 08:53:37 -0800
>> From: *Michael.H.Kanter at KP.ORG* <Michael.H.Kanter at KP.ORG>
>> Subject: Re: [IMPROVEDX] Another look at Questions
>> To: *IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG*
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>>
>>
>> In terms of a list of Do's and Dont's this could help.  I think the
>> challenge will be to find Do's and Dont's that are simple enough to
>> describe but at the same time can meaningfully reduce errors.    It is
>> worth exploring though.
>>
>> Michael Kanter, M.D., CPPS
>> Regional Medical Director of Quality & Clinical Analysis
>> Southern California Permanente Medical Group
>> *(626) 405-5722* <%28626%29%20405-5722> (tie line 8+335)
>> THRIVE By Getting Regular Exercise
>>
>> * NOTICE TO RECIPIENT:*  If you are not the intended recipient of this
>> e-mail, you are prohibited from sharing, copying, or otherwise using or
>> disclosing its contents.  If you have received this e-mail in error, please
>> notify the sender immediately by reply e-mail and permanently delete this
>> e-mail and any attachments without reading, forwarding or saving them.
>> Thank you.
>>
>>
>>
>>
>> From:        robert bell <
>> *0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG*
>> <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
>> To:        *IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG*
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> Date:        01/07/2016 07:21 AM
>> Subject:        Re: [IMPROVEDX] Another look at Questions
>> ------------------------------
>>
>>
>>
>> Dear Michael,
>>
>> Some good points.
>>
>> One of my thoughts is that we have the cart before the horse in first
>> focussing on Errors in Diagnosis when something like 60% of errors are run
>> of the mill standard errors. These such as communication problems that are
>> associated with simple things like orders, wrong medications, computer
>> problems, fatigue, education lack, and language problems. If we are truly
>> interested in reducing the death toll and morbidity of Errors in Medicine
>> as a whole should we not go for the jugular, identify the biggest problems,
>> and tackle these collaboratively so that we get a significant reduction in
>> the figures.
>>
>> And that brings up a big issue that first we need to have figures to be
>> able to say if we are making progress. And think of the revolution that
>> will create when we get into litigation and confidentiality discussions.
>> That big question seems to be, can we do anything meaningful in either
>> Standard and Diagnostic Errors without good data?
>>
>> I take your point that a large percentage of lab and x-ray reporting is
>> related to diagnosis, but it is also related to monitoring over time -
>> INRs, mammograms, and bone density come to mind. I do not know the
>> monitoring percentage but would guess it is 10 - 20% of the total.  As
>> these two specialty areas are so important to the whole of medicine it
>> would seem that the consortium of specialty societies (that incidentally
>> should have patient representation) could triage the main problems in these
>> areas and collaboratively work on improving them. From what I hear the
>> electronic patient record would be something that should be looked at
>> immediately. If you do not look after the important basic foundations of
>> medicine and the standard 60% of all errors that accounts for the biggest
>> mortality I believe that you are never going to effectively make inroads
>> into the Diagnostic Error piece of the pie.
>>
>> I am sure that with the benefits of technology there are many
>> opportunities to reduce/improve the number of errors in both Radiology and
>> Laboratory pathology.  And yes, you are correct radiology is likely to help
>> make accurate diagnoses sooner than an impression made with a stethoscope
>> (incidentally I have often wondered how accurate, in certain hands, the
>> stethoscope is and have questioned what is its contribution to errors -
>> perhaps it should be triaged close to the top!). But the technological
>> advances in radiology would place it in the forefront for improvement of
>> error rates.
>>
>> So this does not mean that we should *not* be focussing on Diagnostic
>> Errors as we move forward, but strongly believe we should *first* be
>> making sure that the main foundations to diagnosis are as solid as they can
>> be.
>>
>> Yes, specialists with telemedicine links to help in the review process
>> would be a wonderful idea to help with error rates.  And also a wonderful
>> teaching tool to both specialist and radiologist. Could well be tried out
>> with a small study if it is not already being done.
>>
>> One of my thoughts is that in medicine that is structured hierarchically
>> we may not be asking enough questions. Particularly as technology and
>> collaboration is slowly eroding that hierarchy. Questions are often less
>> intrusive and more than anything are creative in group settings. Questions
>> should be encouraged in all meetings if we wish to make quick progress.
>>
>> Do you think that Do and Don’t lists are of value?
>>
>> Thank you Michael,
>>
>> Rob Bell
>>
>>
>> On Jan 6, 2016, at 4:54 PM, *Michael.H.Kanter at KP.ORG*
>> <Michael.H.Kanter at KP.ORG> wrote:
>>
>> interesting thoughts that you wrote below that are very thought provoking
>> as usual.  Maybe I misunderstood but  you make the statement that " I
>> felt that if there is a significant error rate in radiology reports and
>> laboratory tests that this should be addressed first."
>> I personally consider error rates in radiology reports and lab tests
>> within the scope of diagnostic errors and not sure why we would not address
>> this quickly.   I do not believe that anywhere in the IOM report did they
>> suggest otherwise.    In fact, radiology report errors really fall into the
>> class of diagnostic errors related to visual errors and also occur in
>> pathology reports and other areas of diagnosis where the diagnosis is made
>> by visual interpretation of an image.  We recently published a method on
>> how to decrease these for interpretation of retinal photos
>> Visual errors that are based on stored images (as opposed to looking at a
>> skin lesion of a patient) have some advantages in terms of study and
>> performance improvement including
>> 1) they are often stored in data systems for easy retrieval and
>> identification
>> 2)  they can be retrospectively reviewed
>> 3)  one can determine the incidence of diagnosing a disease if the image
>> or image results are stored in a data system and use the variation in
>> diagnosis as a measure of diagnostic error/variability as was done in the
>> attached paper.
>> 4)  Diagnosis based on visual images can be more easily studied because
>>  the variable of data acquisition can be controlled better (that is
>> everyone can look at the same image/data) which is very different than a
>> physical exam or patient history.
>>
>> My point is that it may be simpler to study errors due to visual
>> interpretation of images than other types of diagnostic errors and this is
>> something to consider addressing sooner rather than later.
>>
>> I really like the idea of specialists societies getting involved in
>> diagnostic errors.    Specialists  are likely to see such errors in their
>> practice when referals are sent too late or with the wrong diagnosis.
>>
>> Michael Kanter, M.D., CPPS
>> Regional Medical Director of Quality & Clinical Analysis
>> Southern California Permanente Medical Group
>> *(626) 405-5722* <%28626%29%20405-5722> (tie line 8+335)
>> THRIVE By Getting Regular Exercise
>>
>> * NOTICE TO RECIPIENT:*  If you are not the intended recipient of this
>> e-mail, you are prohibited from sharing, copying, or otherwise using or
>> disclosing its contents.  If you have received this e-mail in error, please
>> notify the sender immediately by reply e-mail and permanently delete this
>> e-mail and any attachments without reading, forwarding or saving them.
>> Thank you.
>>
>>
>>
>>
>> From:        robert bell <
>> *0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG*
>> <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
>> To:        *IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG*
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> Date:        01/02/2016 04:03 PM
>> Subject:        [IMPROVEDX] Another look at Questions
>> ------------------------------
>>
>>
>>
>> Dear All,
>>
>> I would like to thank all the people on this list who kindly responded to
>> my questions a few weeks back.
>>
>> Since asking those questions I became aware that questions *may* be
>> creative.
>>
>> Does it follow then that statements are less creative. I then thought how
>> does that come about?
>>
>> A question I thought, stimulates listeners and readers to think of
>> various solutions. So from one question you might get many solutions. With
>> statements you would be more relying on the creativity of the writer
>> presenting his or her various ideas and solutions. And these all together
>> may not be great in number.
>>
>> With regard to the medical profession as a whole and people in positions
>> of power in the healthcare industry who can effect change, one can ask do
>> they ask fewer questions for fear of being considered less knowledgeable?
>> So, if this is true, almost by definition, if questions are creative, such
>> decision makers are less likely to be broadly creative, at least initially?
>> There are obvious exceptions. So a  question might be how to better take
>> advantage of the *crowd think*?
>>
>> This all makes an assumption that most things in medicine are complex and
>> that many solutions to an issue may be necessary to arrive at a good
>> solution.
>>
>> The IOM has issued its statement/report on diagnostic errors and there
>> are some good suggestions. I was pleased to see teamwork mentioned first in
>> their solution. Which essentially is an extension of *crowd think*.
>>
>> But the big question is where do we go from here? As you all know I would
>> have preferred standard medical errors to be approached first before
>> diagnostic errors. For example, I felt that if there is a significant error
>> rate in radiology reports and laboratory tests that this should be
>> addressed first. But assuming that we may have the cart before the horse,
>> and I am not completely sure about that, what questions could be asked of
>> the established consortium of speciality societies?
>>
>> Over and above the big structural solutions, what comes to mind for me is
>> that some of these societies have issued Do and Don’t lists for their
>> members.
>>
>> So my new question is, could those lists be looked at and the idea
>> extended to all the specialty societies with the emphasis on reducing
>> diagnostic error?
>>
>> Also, with any statement(s) would it be good to consider asking some
>> questions at the end to stimulate thought?
>>
>> The best for 2016,
>>
>> Robert M. Bell, M.D., Ph.C.
>>
>>
>>
>>
>>
>> ------------------------------
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>> ------------------------------
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>>
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>>
>>
>> ------------------------------
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>>
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>>
>> To learn more about SIDM visit:
>> *http://www.improvediagnosis.org/* <http://www.improvediagnosis.org/>
>>
>>
>> ------------------------------
>>
>> Address messages to: *IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG*
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>>
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>>
>> To learn more about SIDM visit:
>> *http://www.improvediagnosis.org/* <http://www.improvediagnosis.org/>
>>
>> ------------------------------
>>
>> Address messages to: *IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG*
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
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>>
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>>
>> To learn more about SIDM visit:
>> *http://www.improvediagnosis.org/* <http://www.improvediagnosis.org/>
>>
>>
>> Robert M. Bell, M.D., Ph.C.
>> P.O. Box 3668
>> West Sedona, AZ  86340-3668
>> USA
>> Tel: Fax: 928 203-4517
>>
>>
>>
>>
>> ------------------------------
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
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>> *http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1*
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>>
>> or send email to: IMPROVEDX-SIGNOFF-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/
>>
>>
>> ------------------------------
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
>>
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>>
>> or send email to: IMPROVEDX-SIGNOFF-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/
>>
>>
>> ------------------------------
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
>>
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>> or send email to: IMPROVEDX-SIGNOFF-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


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