Another look at Questions

Tom Benzoni benzonit at GMAIL.COM
Mon Mar 7 10:03:23 UTC 2016


This is easily the most fraught topic I experience in the ER.

It is crucial we define precisely, from a patient perspective, the meaning
of words and diagnoses.

"Incidentalomas" (finding something that is not bothering the patient) are
a primary reason we are in our current mess.
Many things that are "found" are irrelevant: most "cancers", most PE's,
most chest spots.

Defined from patient perspective, a cancer is some biologic process that is
independent of the patient and will kill him/her before their natural time
or some other process. From a disease-centric perspective, a cancer is a
finding on an XRay or under the microscope. We generally have no certainty
at the individual level that treating a disease-cancer will make any
positive impact on a patient-cancer.

The same is very true of pulmonary embolus and stroke; we have changed the
definition and detection of these disorders, so whether the person in front
of me will accrue benefit (added quality and/or quantity of life) or
experience harm (loss of quality and/or quantity) is increasingly uncertain.

To put it succinctly, if I diagnose a patient with a disease which they
don't have, then lump their statistics in with those who do, the treatment
seems to work better.

Is this misdiagnosis even though I'm administering a treatment? I submit it
is.

tom


On Sun, Mar 6, 2016 at 8:13 PM, Peggy Zuckerman <peggyzuckerman at gmail.com>
wrote:

> Can there not be a creation of bias or limited analysis of the patient's
> images getting the clinical information.  Does the radiologist just focus
> on the ribs when the referring physician suspects a break, and ignore the
> less obvious spot on the pancreas?  In the interest of time, does the
> radiologist find himself confirming or eliminating that presumptive
> diagnoses and missing the 'incidental' finding?
>
> Peggy of the kidney cancer world, with 30+% with such findings
>
> Peggy Zuckerman
> www.peggyRCC.com
>
> On Sun, Mar 6, 2016 at 2:36 PM, robert bell <
> 0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:
>
>> Well said Tom,
>>
>> Another nonsense in medicine where errors abound mainly because of
>> non-communication.
>>
>> There is a clear literature base in the assertion that readings improve
>> with receipt of clinical information.
>>
>>
>> What are we supposed to do with evidence based medicine?
>>
>> Ignore it?
>>
>> Rob Bell MD
>>
>>
>> On Mar 6, 2016, at 11:26 AM, Tom Benzoni <benzonit at GMAIL.COM> wrote:
>>
>> 1980-2 I rotated with radiology.
>> I was taught to read my own films.
>> The rads wouldn't give us rad info without clinical info.
>> I still remember him saying "This is not a game. I'm a clinician. You use
>> a stethoscope, I use an X Ray. We're both here with the same aim, to help
>> the patient. You wouldn't send the patient to cardiology without telling
>> them what the question is. Then don't do differently here."
>> I don't think there was a loss of productivity with these rounds; there
>> is an efficiency in direct communication.
>> There is a clear literature base in the assertion that readings improve
>> with receipt of clinical information.
>>
>> tom benzoni
>> AOBEM, FACEP
>>
>> On Sun, Mar 6, 2016 at 9:35 AM, Elias Peter <pheski69 at gmail.com> wrote:
>>
>>> I would echo that.
>>>
>>> In medical school (early 1970s, University of Rochester, NY) it was
>>> standard to make rounds that included the radiology department where
>>> medical students, residents, fellows and attendings would review the films
>>> and discuss the case with the radiologists. These were real-time mini-CPCs
>>> and very useful.
>>>
>>> In residency, a radiologist (usually Dr. John Juhl) came to our FP
>>> residency clinic once a week with the films that had been done on our
>>> out-patients during the prior week. We reviewed those films with him, our
>>> fellow residents, and the clinical faculty and discussed both the
>>> radiologic and clinical aspects of the cases.
>>>
>>> Collaborative learning.
>>>
>>> Peter Elias, MD
>>>
>>> On 2016.03.06, at 9:58 AM, Koppel, Ross J <rkoppel at SAS.UPENN.EDU> wrote:
>>>
>>> Bob Wachter says the time with the radiologist's was one of the best and
>>> the most informative of his medical school experience.
>>>
>>>
>>> Ross Koppel, PhD, FACMI
>>>
>>> UNIVERSITY OF PENNSYLVANIA
>>>
>>> Sociology Dept;  LDI Senior Fellow, Wharton; &
>>>
>>> Affil Fac. Sch. of Medicine.  Chair, AMIA Clinical Information Systems
>>> Working Group.  Ph: 215 576 8221; Cell 215 518 0134
>>>
>>>
>>>
>>>
>>> ------------------------------
>>> *From:* HM Epstein <hmepstein at GMAIL.COM>
>>> *Sent:* Saturday, March 5, 2016 7:48 PM
>>> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>> *Subject:* Re: [IMPROVEDX] Another look at Questions
>>>
>>> Hi Alan:
>>> What were the Dean of Yale Medical School's objections when you
>>> approached him? What about other medical schools in the US? Does anyone
>>> understand  - or can you enumerate - the reasons for the resistance to
>>> improving the curriculum?
>>> Best,
>>> Helene
>>>
>>>
>>> *--  *
>>> *hmepstein.com <http://hmepstein.com/> *
>>> <http://hmepstein.com/>
>>> H.M. Epstein - Writing Portfolio :: Bio <http://hmepstein.com/>
>>> hmepstein.com
>>> Bio. H.M. Epstein writes about parenting issues, politics and policy,
>>> physical and emotional healthcare, and passions both personal and
>>> professional.
>>>
>>> *@hmepstein*
>>> *Mobile: 914-522-2116 <914-522-2116>*
>>>
>>> *Sent from my iPhone*
>>>
>>>
>>>
>>> On Mar 5, 2016, at 8:14 AM, Alan Morris <Alan.Morris at IMAIL.ORG
>>> <Alan.Morris at imail.org>> wrote:
>>>
>>> We, in the past, made daily (or more frequent) rounds with the
>>> radiologist.  We interpreted the images together.  I also attended post
>>> mortem examinations, and sometimes did dissection myself.
>>> We had much more time for thought and scholarly activities than is now
>>> allowed by the “business” of medicine.
>>> I was not able to convince the Dean of Yale Medical School to consider
>>> decision-support strategies to complement clinician cognitive limitations,
>>> when I attended my 50th Yale reunion.
>>> Best wishes.
>>> Alan H. Morris, M.D.
>>> Professor of Medicine
>>> Adjunct Prof. of Medical Informatics
>>> University of Utah
>>>
>>> Medical Director, Urban Central Region Pulmonary Function Laboratories
>>> 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: "Sanders, Lisa" <lisa.sanders at YALE.EDU>
>>> Reply-To: Society to Improve Diagnosis in Medicine <
>>> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, "Sanders, Lisa" <
>>> lisa.sanders at YALE.EDU>
>>> Date: Saturday, January 9, 2016 at 11:21
>>> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <
>>> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>>> Subject: Re: [IMPROVEDX] Another look at Questions
>>>
>>> Lenny,
>>> I too lament the loss of collaboration between the internist or doctors
>>> of any stripe who is caring for the patient and the radiologist. In my most
>>> recent blog post:
>>> http://well.blogs.nytimes.com/2016/01/07/diagnosis-lisa-sanders-pain-tinnitus-ringing-in-the-ears/
>>> the patient went to three doctors who could not tell him what was wrong,
>>> despite the fact that he had the right tests ordered and that the
>>> radiologist had listed the diagnosis on his very short differential. It was
>>> an unusual disorder and he was an unusual subject so I can imagine that it
>>> was easy to discount such a diagnosis. But would you trust yourself to make
>>> a different diagnosis without at least consulting your own favorite
>>> radiologist? The last physician not only did not recognize the disorder
>>> demonstrated by the CTA but told the patient not to worry about it and to
>>> come back in a year to follow up. Fortunately he didn’t do that and got the
>>> intervention that was needed.
>>>
>>>
>>> Why don’t we talk to the radiologists anymore?  Paying for that time –
>>> as suggested in the NAM report - might make a difference. I certainly hope
>>> so.
>>>
>>>
>>> Lisa Sanders M.D.
>>> Associate Professor
>>> Yale School of Medicine
>>>
>>>
>>> Clinician Educator
>>> Yale Internal Medicine Primary Care Residency
>>> Yale New Haven Hospital, St. Raphael’s Campus
>>> 1250 Chapel St.
>>> New Haven, CT 06511
>>> Office: 203-867-8117
>>>
>>>
>>>
>>>
>>>
>>>
>>> *From:* Leonard Berlin [mailto:lberlin at LIVE.COM <lberlin at LIVE.COM>]
>>> *Sent:* Thursday, January 07, 2016 3:11 PM
>>> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>> *Subject:* Re: [IMPROVEDX] Another look at Questions
>>>
>>>
>>> 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
>>> Subject: Re: [IMPROVEDX] Another look at Questions
>>> To: 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 (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>
>>> To:        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 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 (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>
>>> To:        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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>>> To learn more about SIDM visit:
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>>>
>>> Robert M. Bell, M.D., Ph.C.
>>> P.O. Box 3668
>>> West Sedona, AZ  86340-3668
>>> USA
>>>
>>>
>>>
>>>
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>>> Medicine
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>>>
>>> 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/
>>>
>>>
>>> ------------------------------
>>>
>>> <IMPROVEDX at list.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
>>> <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/
>>>
>>>
>>>
>>> ------------------------------
>>>
>>>
>>> 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/
>>
>>
>> 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:
>>
>> 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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