Another look at Questions regarding Radiologists and Imaging

Ted.E.Palen at KP.ORG Ted.E.Palen at KP.ORG
Wed Mar 23 18:50:25 UTC 2016


In my experience most PAC systems that radiologist use to accept images 
and use for reading images are not integrated with the electronic medical 
system that was used for ordering the image study in the first place. 
Radiologist have told me that they do not have the time (or inclination in 
a production environment) to access the EMR to look at the clinical data.
They only have the data that was included in the original order request 
that was transmitted the PACs with CPT code for the order.  The additional 
issue is that if the ordering physician actually includes extensive 
clinical information in the order so that the radiologist does not need to 
access the EMR for additional information, some interfaces between the EMR 
CPOE system and the PAC system are not very good.  The PACs clinical 
information field does not have the same data structure as the EMR CPOE 
and as a result the PAC system may truncate the clinical information that 
was entered into the EMR CPOE.

We need much better data transmission standards and interoperability 
standards.





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From:   "Swerlick, Robert A" <rswerli at EMORY.EDU>
To:     IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Date:   03/23/2016 12:34 PM
Subject:        Re: [IMPROVEDX] Another look at Questions regarding 
Radiologists and Imaging



I agree that a better outcome is more likely with additional information 
from the treating clinician. I suspect much of this information is already 
within the medical record within the clinician's note. The lack of risk 
factors for ischemia was likely in the assessment and plan of the 
evaluating clinician.  Do radiologists actually look at the notes written 
in the EHR when they evaluate images?

When I do an evaluation of a patient sent to me from one of my colleagues 
in another department, I feel obligated to read their notes. When a 
radiologist reads an image of a patient where they have access to the 
notes of the referring physician, do they generally feel that same 
obligation if they have access to read them?

Bob

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: Wednesday, March 23, 2016 10:14 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Another look at Questions regarding Radiologists 
and Imaging 
 
Tom,
 
What a wonderful story!  That's the way all of us--radiologists and 
non-radiologists alike --  should practice medicine!
Sadly, your incident is a rarity.
 
Lenny Berlin
 
Date: Wed, 23 Mar 2016 07:55:40 -0500
From: benzonit at GMAIL.COM
Subject: Re: [IMPROVEDX] Another look at Questions regarding Radiologists 
and Imaging
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

A note from yesterday on how this idea is used.
This a is a case report only, n=1.

Older female presented with abdominal pain, epigastric, crampy/burning, 
maybe left>right.
Occurs after eating, getting worse the last few weeks. 
Attendance to ED/A&E prompted by a particularly bad episode that left her 
faint, diaphoretic, nauseated without vomiting.
Basically benign prior history for 70+.
Labs normal.
Exam non-concerning fro peritonitis.
Requested CTA; ? was mesenteric ischemia.
(Usually, docs just click the button that says Abdominal Pain for Reason; 
that's sufficient to satisfy the payers.)
I didn't train that way.
I wrote the rads a note that I was concerned about mesenteric ischemia but 
was flummoxed by her lack of vascular risk factors.
Rads called back that, due to that note, he looked for and found high 
grade obstruction from arcuate ligament syndrome with downstream 
hyperemia. No necrosis.

Basically, simple communication made a difference.

This is not astounding, but the very ordinariness  was striking.

tom

On Tue, Mar 8, 2016 at 12:10 PM, Bruno, Michael <mbruno at hmc.psu.edu> 
wrote:
Hi all,
 
Great discussion! 
 
As a practicing academic radiologist focused on quality and process 
improvement and a person actively engaged research directed toward error 
reduction in radiology, I also have some thoughts to share on the topic of 
Radiologist errors.  Our interdisciplinary, multi-institution research 
group based here at Hershey is very focused on understanding the roots of 
radiologist errors, especially perception errors (the most common type). 
This has become a major focus of our work here at Penn State Hershey, and 
has grown directly out of our process improvement efforts.  See the 
attached review our group published late last year (note to David Myers: 
as 1st author I give SIDM permission to share this PDF on the listserv). 
As Lenny noted, our specialty is committed to reducing our collective 
error rates, which have been a very tough problem—a needle that hasn’t 
been moved since the 1930’s when Garland published his first papers on the 
topic.  (And no, it didn’t make Dr. Garland popular among his fellow 
Radiologists at the time!)
 
Germane to this discussion: one obvious strategy for error reduction would 
be for radiologists to receive rapid feedback when error occur, which of 
course requires those errors to be discovered.  In this regard, the loss 
of frequent person-to-person interaction between Radiologists and our 
clinical colleagues is a particularly painful one for those of us who have 
practiced Radiology long enough to remember how valuable it was to us. One 
thing that has clearly been lost is the inherently error-correcting 
mechanism of rapid, “formative” feedback from our clinical colleagues, 
which is something we don’t really get from peer review.  That has been a 
major topic of discussion in the American College of Radiology forums in 
which I participate as well, and the ACR has committed resources to 
explore research to detect errors, reduce them, and also reduce patient 
harms that result from our errors, so I can assure everyone on this list 
that these issues are in the forefront for organized Radiology.
 
It has long been a core tenet of Radiology education – which we drill into 
our residents – that the more clinical information we can receive, the 
better.  Since we don’t have enough contact with our clinical colleagues, 
our residents commonly troll the EMR for more clinical/historical details, 
a process which can be tedious and time-consuming.  While there is some 
inherent risk of bias in knowing clinical history that is potentially 
misleading or incorrect (and an argument can be made for reviewing the 
images once first, prior to reading the clinical information, then looking 
at them again after reading it) on the whole, there is little question in 
the mind of any practicing Radiologist that the clinical guidance we 
receive from our colleagues is invaluable, and the more the better.
 
As I mentioned above, the high rate of radiologist errors in practice has 
been a very difficult and seemingly intractable problem for decades. We’re 
attacking this problem aggressively here in the Radiology Department at 
Penn State Hershey from a variety of standpoints: (1) improving the 
quality and clarity of our written and verbal reporting, so that 
actionable information isn’t lost in the noise, (2) improving our 
dialogue/liaison with our clinical colleagues, especially in the Emergency 
Department, (3) taking a hard look at workload and fatigue as a driver of 
error.  This involves mathematically modeling our daily workflows, in 
cooperation with Ph.D. engineering faculty from other Penn State campuses, 
to hopefully be able to adjust our radiologist staffing as nimbly as 
possible to allow radiologists sufficient time to get through the worklist 
without needing to rush on any case to satisfy our growing service 
obligations, and (4) designing basic, hypothesis-driven research to 
understand the underlying drivers of perceptual error and to design and 
rigorously test the effectiveness of strategies to address those 
vulnerabilities.
 
As results accrue on these ongoing efforts, I will report them to this 
group! 
 
All the best,
 

Michael A. Bruno, M.S., M.D., F.A.C.R.
Professor of Radiology & Medicine
Vice Chair for Quality and Patient Safety
Chief, Division of Emergency Radiology
The Milton S. Hershey Medical Center
Penn State College of Medicine
500 University Drive, Mail Code H-066
Hershey, PA  17033

Phone: (717) 531-8703
Fax:      (717) 531-5737

e-mail: mbruno at hmc.psu.edu
 
 


 
 
From: Elias Peter [mailto:pheski69 at GMAIL.COM] 
Sent: Sunday, March 06, 2016 11:26 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Another look at Questions
 
I think, on balance, the studies show more benefit than harm from 
providing clinical information. Specifically, as a PCP, I find that 
providing clinical information to the radiologist has the following 
benefits:
 
The radiologist has the opportunity to check with me and discuss the study 
before it is done, often to suggest an alternative - and better - 
approach.
If the radiologist knows what questions I am asking, it is easier for her 
to answer them.
 
Ideally, the radiologist evaluates the technical adequacy, the radiologic 
findings and the clinical interpretation as separate and distinct 
processes.
 
One could worry about the same phenomenon of premature closure or framing 
bias in my work as a PCP when I take a history and then do an exam and get 
lab.  The history may lead me to examine some areas more carefully, not 
examine some areas at all, and weight different findings differently. the 
same is true when I order lab or other studies.  Using the already 
acquired information to help assign prior probabilities is anecessary, a 
feature rather than a bug.
 
It’s a difficult task and a source of error, though.
 
Peter
 
 
On 2016.03.06, at 9:13 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

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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

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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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