Another look at Questions

Art Papier apapier at LOGICALIMAGES.COM
Mon Mar 14 19:45:06 UTC 2016


Saying "Technology" is like saying it is humid outside when it either is raining or snowing.   Let's make sure we are precise and not vague in this discussion.  Information technology that surfaces the risks and benefits and best evidence to make more accurate decisions is the exact opposite of the overuse, or inappropriate use, of screening labs or diagnostic imaging.  It's fashionable to lump the EHR and CPOE failures into a overreaching technology bucket but other information technologies are widely used and lead to better decisions. The problem of incidentalomas is huge I hope we can focus on this problem at DEM
Art Papier MD
CEO
VisualDx.com

Sent from my iPhone

> On Mar 14, 2016, at 9:44 AM, Leonard Berlin <lberlin at LIVE.COM> wrote:
> 
> Alas, Dr. Swerlick, you are right on target.  Technology is all branches of medicine will indeed make the problem worse.
>  
> Lenny Berlin
> From: rswerli at emory.edu
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG; lberlin at LIVE.COM
> Subject: Re: [IMPROVEDX] Another look at Questions
> Date: Mon, 14 Mar 2016 15:13:33 +0000
> 
> The incindentaloma issue is not confined to radiology. As we apply increased scrutiny to anyone using any number of observational tools, we find variations. For radiology and pathology, the evidence of those variations can be permanent in terms of the stored images or paraffin blocks saved. Increasingly, other exams will create similar permanent records which can be scrutinized retrospectively. We will capture images of skin exams, colonoscopies, and virtually all other exams. What used to get buried within the WNL designation will ultimately reveal huge variations which can and will be captured by sophisticated image capture tools.
> 
> 
> The problem is we do not have a good appreciation for what variation represents just variation without clinical significance and what represents disease or risk for disease. We are reminded consistently of what is missed but cannot get a handle on what is just noise. Any attempt to draw a line between what is actionable and what is "normal" variation will always leave us with some outliers which end up with a bad outcome. Thresholds for action will be lowered in order not to miss subsequent cases, no matter how many harmless incidentalomas need to be acted upon. 
> 
> 
> This is not a problem which technology can solve. My concern is that technology will only make this more of a problem.
> 
> 
> 
> 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: Leonard Berlin <lberlin at LIVE.COM>
> Sent: Monday, March 14, 2016 10:25 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] Another look at Questions
>  
> A great and insightful observation, Tom!
>  
> Obviously, the great majority of malpractice suits filed against radiologists allege a "missed" diagnosis, i.e., a false negative.
> Nevertheless, although rare, an occasional lawsuit alleges a false positive, i.e., the radiologist calls attention to what appears to be a significantly abnormal finding, the patient is treated medically and/or surgically, and it  turns out the finding  was nothing more than a benign variant of normal or other insignificant density.  Indeed, a recent article from the UK reported that 7% of med-mal cases there were due to false positives (I doubt that the figure is that high in the US).  
>  
> However:  a couple of years ago an infant admitted to a Massachusetts hospital with a urinary infection underwent a routine sonogram that "revealed" a lesion in the upper pole of a kidney.  A CT "confirmed" the finding, suggesting a Wilm's tumor.  The surgeon operated, put his hand inside the abdomen and "definitely  felt" the kidney tumor, and did a nephrectomy.  Pathologist found no tumor; just chronic pyeleonephritis.  The lawsuit  was obviously settled out of court.
>  
> Practicing medicine today ain't  easy.......and so it goes......
>  
> Lenny Berlin
>  
> CC: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> From: benzonit at gmail.com
> Subject: Re: [IMPROVEDX] Another look at Questions
> Date: Mon, 14 Mar 2016 10:03:24 -0400
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG; lberlin at LIVE.COM
> 
> Well stated.
> And this then circles back to the question:
> Is a diagnosed incidentaloma an error?
> It is exactly the flip side of a missed actual diagnosis.
> Tom Benzoni 
> 
> Sent from my iPad
> 
> On Mar 14, 2016, at 8:34, Leonard Berlin <lberlin at LIVE.COM> wrote:
> 
> The presence of incidentalomas is one of today's major conundrums, particularly as it relates to radiology.  Because of the marked increase in the number of high-tech imaging (in particular, CTs)  performed currently  and the greatly improved resolution of today's scanners, we are seeing many more incidentalomas  (many articles indicate as high as 50%-60% of imaging  exams)than ever before.   Statistically, the likelihood that a "benign appearing incidentaloma"  is an early carcinoma is no more than 1%.
>  
> What should radiologists do?  If they report every incidentaloma, they are probably subjecting patients to a cascade of  exams and procedures that are not only expensive but that also can lead to complications harming the patient, possibly leading to overdiagnosis and overteatment.  But if radiologists ignore the incidentalomas, a rare patient now and then will suffer a delay in diagnosis of cancer, leading not only to the patient's possible death, not to mention  a malpractice lawsuit.  
>  
>   The AMA Code of Ethics  requires physicians to inform patients of all relevant (italics added) medical findings  and information.  Thus, the real question is:  "Does every incidentaloma constitute relevant information? 
>  
> There is today no consensus  among radiologists regarding whether to, and if so  when and how, to report incidentalomas.  Yes, we do have published guidelines that assist us in determining whether a tiny nodule in the lung, or a small subtle lesion in the kidney, adrenal, liver or spleen, is benign or malignant.  But there is no certainty.
>  
> In summary:  radiologists have to use their best judgment in deciding how to manage incidentalomas.  But the problem of incidentalomas remains one of the  major conundrums and quagmires of modern-day medicine.
>  
>  
> Lenny Berlin
> Radiology Dep't, Skokie Hospital
> Professor of Radiology
> Rush Univ., and Univ Illinois
> Chicago
>  
> Date: Sun, 13 Mar 2016 20:37:15 -0700
> From: 0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] Another look at Questions
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> 
> Thanks Tom,
> 
> Could incidentalomas be ranked from ignore, to full work up needed?
> 
> Also, do radiologists use check lists like pilots in planes?
> 
> Rob Bell
> On Mar 7, 2016, at 3:03 AM, Tom Benzoni <benzonit at GMAIL.COM> wrote:
> 
> 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 
> 
> H.M. Epstein - Writing Portfolio :: Bio
> 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
> 
> Sent from my iPhone
> 
> 
> 
> On Mar 5, 2016, at 8:14 AM, Alan Morris <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] 
> 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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> Robert M. Bell, M.D., Ph.C.
> P.O. Box 3668
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> 
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> To unsubscribe from IMPROVEDX: click the following link:
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> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
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> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> 
> 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:
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> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> 
> 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
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> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> 
> 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
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX 
> 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
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> 
> 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
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX 
> 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
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX 
> 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
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> 
> 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
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> 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
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> 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
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX 
> 
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/ 
> 
> 
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> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> 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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