Another look at Questions

Bob Latino blatino at RELIABILITY.COM
Mon Jan 11 16:27:16 UTC 2016


Thank you Peter for describing your daily, proactive process.

As simply a patient myself, this is the way medicine should be.

You are treating your patients like unique individuals not a number in a patient mill.

I know your patients are appreciative and that is why they come back to you.  They are more prone to trust you as well because you tell the truth (in a very factual, evidence-based and personal fashion) versus what they want to hear.

Form the patient community...thank you!

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com
www.reliability.com

From: Elias Peter [mailto:pheski69 at GMAIL.COM]
Sent: Monday, January 11, 2016 9:17 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Another look at Questions

It isn’t easy and it can’t be done perfectly regardless of how much time one allots.  That said..


  *   My pattern has been ~ 18 patients in an eight hour day
  *   I have learned to say: “We don’t have time to address everything today, so let’s set up another appointment so we can talk about X and do it right."
  *   The smallest slot is 20 minutes, with predominantly 30 minute slots and some 40 minute slots.
  *   I use (insecure) email for considerable conversation with patients.
  *   I spend ~ 60 minutes every morning before I start seeing patients starting the ‘update’ for all the scheduled patients that day, review (and repair when needed) the clinical lists, make sure I understand the reason for the visit (schedule’s notes, triage notes, plan from last visit), look for pertinent data (recent ED visit or consult note), look for services due (mammogram, immunization, surveillance lab…), do homework like assessing NNT or fracture risk or looking up prevalence, sensitivity info), and paste into the note data relevant to the visit (lipid results if on statin, a1c if diabetic).As a result, I do less multitasking during the visit, I miss fewer things, the note is more presentable and usable, and the visit can focus less on housekeeping and more on clinical tasks.
  *   I do most of the visit out loud with the patient, typing as we talk. Some patients like to sit next to me and watch the screen but our rooms are not conducive to this.
  *   I ALWAYS do the assessment and plan out loud, as a collaborative process or negotiation with the patient so it is OURS, not MINE.  We don’t always agree, of course, and then I note both opinions.
  *   The patient leaves with a completed and signed copy of their note and I am finished with each patient before I start the next one.


I am slower than most (but not all) of my colleagues and my productivity is not what my employer often targets, and yes, that has cost me income. So be it. I didn’t become a physician for the money.

At the risk of sounding evangelical, when I started approaching visits as a collaborative process and the note as shared documentation, it changed everything for me - and I hope for my patients.


Peter Elias, MD

On 2016.01.10, at 10:37 PM, Robert Bell <rmsbell200 at yahoo.com<mailto:rmsbell200 at yahoo.com>> wrote:

Is there an accepted number of patients to be seen per hour to allow this kind of excellent contact to occur?

Sent from my iPad

On Jan 10, 2016, at 8:09 PM, Elias Peter <pheski69 at GMAIL.COM<mailto:pheski69 at GMAIL.COM>> wrote:
I want to echo and enlarge upon this.

If the patient thinks that I have done things to them (ordered tests without full explanation, for example) they are far more likely to be unhappy with the results than if the plan (be it testing or NOT testing) arises in the setting of good conversation, good relationship and full disclosure.  If it is OUR decision, not MY decision.

Peter Elias, MD


On 2016.01.10, at 6:02 PM, Stephen I. Lane <Stevelane at LANE-LANE.COM<mailto:Stevelane at LANE-LANE.COM>> wrote:

In all seriousness, I've spoken to medical and nursing groups over the years about communications with patients. I've seen a lot of what seemed to be significantly substandard medical care, and often seen what appears to be heroic and caring providers. I truly feel that even in the most egregious cases, very few patients would even seek out legal counsel if they felt they had a relationship with their physician. I probably turn down 90-99 of 100 people who approach me with cases, and I know they never would have sought my advice if they'd been able to talk to their doctors.  My $.02 is that's where resources are poorly utilized.

Sent from my iPhone




Steve
Please respond to:
Stephen I. Lane
Partner
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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 10, 2016, at 5:57 PM, "hszerlip at gmail.com<mailto:hszerlip at gmail.com>" <hszerlip at gmail.com<mailto:hszerlip at gmail.com>> wrote:
Poor utilization of resources. It would overwhelm the system and lead to testing that is not necessary. Patients often insist on things (eg antibiotics, CT scans)

Sent from my iPhone

On Jan 10, 2016, at 5:48 PM, Stephen I. Lane <Stevelane at lane-lane.com<mailto:Stevelane at lane-lane.com>> wrote:
But shouldn't the patient have the right to decide to consult if the patient deems it necessary? Even if it's just comforting? I just don't see who is hurt by that.

Sent from my iPhone




Steve
Please respond to:
Stephen I. Lane
Partner
<image001.png>
230 W. Monroe  St.,  Suite 1900<x-apple-data-detectors://7>
Chicago, Illinois      60606-4710<x-apple-data-detectors://7>

Office:   (312) 332-1400<tel:(312)%20332-1400>
Facsimile: (312) 899-8003<tel:(312)%20899-8003>
Mobile: (847) 736-7769<tel:(847)%20736-7769>
stevelane at lane-lane.com<mailto: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 10, 2016, at 3:41 PM, hszerlip at gmail.com<mailto:hszerlip at gmail.com> <hszerlip at GMAIL.COM<mailto: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<mailto: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<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto: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 resultsare they anyway?


William Strull MD
Medical Director, Quality and Patient Safety
Kaiser Permanente

The Permanente Federation, LLC
One Kaiser Plaza, 23B
Oakland, California 94612
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8-423-5987 (tie-line)
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From:        Peggy Zuckerman <peggyzuckerman at GMAIL.COM<mailto:peggyzuckerman at GMAIL.COM>>
To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto: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<tel:(312)%20332-1400>
Facsimile: (312) 899-8003<tel:(312)%20899-8003>
Mobile: (847) 736-7769<tel:(847)%20736-7769>
stevelane at lane-lane.com<mailto: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<mailto: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<mailto: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<mailto:Michael.H.Kanter at KP.ORG>
Subject: Re: [IMPROVEDX] Another look at Questions
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<tel:%28626%29%20405-5722> (tie line 8+335)
THRIVE By Getting Regular Exercise

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From:        robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto: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<tel:%28626%29%20405-5722> (tie line 8+335)
THRIVE By Getting Regular Exercise

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From:        robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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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