Fwd: PDF - www.pnas.org

HM Epstein hmepstein at GMAIL.COM
Wed Aug 31 16:36:27 UTC 2016


That's an excellent question, Peggy. (And an elegant response to the
"ulcer" doc.)

OK, I'm defining it, for the purposes of my book, the way most *patients*
would define it: seeing a second physician of the same area of
specialization (and to me that includes GPs) to help shed light on what the
next step should be. One is either uncertain about the Dx they've been
given, or haven't gotten a Dx at all, or the treatment isn't working, or
the Dx treatment plan requires a big decision (money, pain, serious risks,
or it's just plain scary), so they go to another doctor in that specialty.
The universe of second opinions lies outside the source of the expert's
contact info, whether they ask their GP for a name, or a friend who had the
same Dx or check Yelp.

However, I'm *not* defining it as seeing a specialist recommended by the
gateway physician, internist or GP after a round of tests indicates an
issue. To me that's the normal diagnostic pathway many insurance companies
require, i.e. your annual checkup's EKG indicates a potential problem so
you're sent to a cardiologist or your child stops growing so you given an
appointment with an endocrinologist.

How do physicians define it?

Best,
Helene

hmepstein.com
@hmepstein <https://twitter.com/hmepstein>
Mobile: 914-522-2116

On Wed, Aug 31, 2016 at 11:04 AM, Peggy Zuckerman <peggyzuckerman at gmail.com>
wrote:

> One of great difficulties in understanding this data is to know how one
> defines 'second opinion'.  When I was found to have a large kidney tumor
> and not a 'scabbed-over' stomach ulcer, I did not request the doctor
> suggest I get a second opinion.  I just found an oncologist with expertise
> in kidney cancer.  If a patient realizes that his doctor is not doing a
> good job, rarely does the patient want to take the advice of the
> discredited doctor to help find a second opinion, in my experience.  Is
> this a 'second opinion' or simply shifting to a new doctor?
>
> The only follow up by my 'ulcer' doctor to me was to ask for a payment of
> the last appointment fees.  I declined, not very politely, to that request.
>
> Peggy Zuckerman
>
> Peggy Zuckerman
> www.peggyRCC.com
>
> On Tue, Aug 30, 2016 at 11:54 PM, HM Epstein <hmepstein at gmail.com> wrote:
>
>> I found articles on the topic in PubMed but most aren't available to read
>> full text without a subscription. A recent study was  [J Cancer Res Clin
>> Oncol. 2016 Jul;
>> "Is there evidence for a better health care for cancer patients after a
>> second opinion? A systematic review."] The abstract's results section
>> wasn't very helpful:
>>
>> *"Depending on the study, between 6.5 and 36 % of patients search for a
>> second opinion, due to a variety of reasons. Changes in diagnosis,
>> treatment recommendations or prognosis as a result of the second opinion
>> occurred in 12-69 % of cases. In 43-82 % of cases, the original diagnosis
>> or treatment was verified. Patient satisfaction was high, and the second
>> opinion was deemed as helpful and reassuring in most cases. Yet, data on
>> patient-relevant outcomes or on the quality of the second opinion are
>> missing." *
>>
>> Perhaps if I could see the charts there would be more helpful data, but
>> there's a pay wall even for healthcare journalists.
>>>>
>> Best,
>> Helene​
>>
>>
>> hmepstein.com
>> @hmepstein <https://twitter.com/hmepstein>
>> Mobile: 914-522-2116
>>
>> On Wed, Aug 31, 2016 at 12:16 AM, <Michael.H.Kanter at kp.org> wrote:
>>
>>> great questions.  I dont know the answers to any of these.  Part of the
>>> barrier of getting second opinions besides the need for second opinions not
>>> being recognized is the cost which can be born either by the patient or the
>>> delilvery system but is not trivial.
>>>
>>>
>>> Michael Kanter, M.D., CPPS
>>> Regional Medical Director of Quality & Clinical Analysis
>>> Southern California Permanente Medical Group
>>> (626) 405-5722 (tie line 8+335)
>>>
>>> Executive Vice President,
>>> Chief Quality Officer,
>>> The Permanente Federation
>>>
>>> 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:        HM Epstein <hmepstein at GMAIL.COM>
>>> To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>> Date:        08/29/2016 12:02 PM
>>> Subject:        Re: [IMPROVEDX] Fwd: PDF - www.pnas.org
>>> ------------------------------
>>>
>>>
>>>
>>> Michael:
>>> You wrote, "Frequently, in practice getting a second opinion is NOT a
>>> routine and so the second opinion approaches the case very differently as
>>> he/she knows someone is questioning the diagnosis.  Of course, if a second
>>> or third opinion is the routine, this is not the case."
>>>
>>> Does anyone have statistics on how often a patient gets a second
>>> opinion? I would think it varies by specialty. Also, I expect those with a
>>> diagnosed illness seek second opinions more often than those without.
>>>
>>> Plus a little wishful thinking: I would love to see a study comparing
>>> use of second opinions between patients who are told their tests are
>>> negative and still have symptoms vs. those who don't. (Even that group can
>>> be broken down between patients who never had symptoms and those whose
>>> symptoms dissipated when told their test results were clean.)
>>>
>>> Thanks.
>>>
>>> Best,
>>> Helene
>>>
>>> *-- *
>>> *hmepstein.com* <http://hmepstein.com/>
>>> *@hmepstein*
>>> *Mobile: 914-522-2116 <914-522-2116>*
>>>
>>> *Sent from my iPhone*
>>>
>>>
>>>
>>> On Aug 29, 2016, at 10:37 AM, Ely, John <*john-ely at UIOWA.EDU*
>>> <john-ely at uiowa.edu>> wrote:
>>>
>>> 0.01 = 1%
>>> 0.01 x 0.01 = 0.0001 = 0.01% (not 0.001%)
>>>
>>> 0.01=1%
>>> 0.001=0.1%
>>> 0.0001=0.01%
>>>
>>> At least I think that’s right.  It actually took me a little while and
>>> my calculator to figure it out.  Embarrassing.  Apart from the math, I
>>> don’t think this would work because those 1% from the first radiologist
>>> will be tough cases and the second equally skilled radiologist won’t have
>>> the same 1% error rate for tough cases.
>>>
>>> John Ely
>>>
>>>
>>>
>>> *From:* Mark Graber [*mailto:mark.graber at IMPROVEDIAGNOSIS.ORG*
>>> <mark.graber at IMPROVEDIAGNOSIS.ORG>]
>>> * Sent:* Monday, August 29, 2016 7:31 AM
>>> * To:* *IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG*
>>> <IMPROVEDX at list.improvediagnosis.org>
>>> * Subject:* Re: [IMPROVEDX] Fwd: PDF - *www.pnas.org*
>>> <http://www.pnas.org/>
>>>
>>> Second opinions are an attractive intervention to help reduce diagnostic
>>> errors, but will require a LOT more study to understand when and how to go
>>> this route for maximal benefit and value.  As a start, second (and third,
>>> etc) reviews seem to be an ideal answer for all the diagnoses that depend
>>> on visual findings, including imaging, pathology and cytology-based tests.
>>> I'm just guessing that 50 years from now, cancer cytologies will all be
>>> read by teams of people.
>>>
>>> In general medical practice, the story is a little different.  In
>>> theory, if the error rate after a single reading is 1%, that could be
>>> reduced to 0.001% by a second reading by an equally skilled clinician.
>>> But, if a patient only pays attention to the second opinion, the error rate
>>> doesn't improve at all.  Another factor that degrades the potential
>>> improvement is that most people with a 'normal' reading from the first
>>> clinician won't bother to get a second opinion (which would pick up most
>>> false negatives).  The math on that gets a little complicated, but is
>>> explained here:  Lindsey PA, Newhouse JP. The cost and value of second
>>> surgical opinion programs: a critical review of the literature. J Health
>>> Polit Policy Law. 1990;15(3):543-570.
>>>
>>>
>>> Mark L Graber MD FACP
>>> President, SIDM  *www.improvediagnosis.org*
>>> <http://www.improvediagnosis.org/>
>>>
>>> <image001.png>
>>>
>>> On Aug 29, 2016, at 12:01 AM, *Michael.H.Kanter at KP.ORG*
>>> <Michael.H.Kanter at kp.org> wrote:
>>>
>>> I found this article really interesting.  I think there are some
>>> significant limitations though.
>>> 1)  it was confined to situations in which all of the information was
>>> made available to the physician (s) to make a diagnosis.  This works for
>>> images best but in most situations the physician when less than certain can
>>> get other information.  Perhaps more clinical information, lab tests, ect.
>>> Even in interpreting images, physicians can get more views or images prior
>>> to making a decision.  None of this was available in this study so the
>>> generalizability to the real world  is somewhat limited.
>>> 2)  I would agree with Linda in that having a dichotomous outcome is
>>> also a bit artificial.  Physicians can have an uncertain diagnosis and do
>>> close follow up.
>>> 3)  Not having discussion among the differing opinions is also
>>> artificial.  Ideally, in practice if there was a difference of opinions,
>>> there should be a discussion as to what each physician is thinking and
>>> why.  Of course, in some settings this may not occur as when a second
>>> opinion is obtain in a totally separate institution so the lack of
>>> discussion among the physicians in this study may reflect much of current
>>> practice.
>>> 4)  Frequently, in practice getting a second opinion is NOT a routine
>>> and so the second opinion approaches the case very differently as he/she
>>> knows someone is questioning the diagnosis.  Of course, if a second or
>>> third opinion is the routine, this is not the case.
>>>
>>> Overall, though, this article addresses the really important issue of
>>> how to aggregate different opinions and use the collective wisdom of the
>>> crowd.   I think more study is needed but this forms the basis of a
>>> theoretical framework that deserves more study.
>>>
>>>
>>> Michael Kanter, M.D., CPPS
>>> Regional Medical Director of Quality & Clinical Analysis
>>> Southern California Permanente Medical Group
>>> (626) 405-5722 (tie line 8+335)
>>>
>>> Executive Vice President,
>>> Chief Quality Officer,
>>> The Permanente Federation
>>>
>>> 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:        "Linda M. Isbell" <*lisbell at PSYCH.UMASS.EDU*
>>> <lisbell at psych.umass.edu>>
>>> To:        *IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG*
>>> <IMPROVEDX at list.improvediagnosis.org>
>>> Date:        08/25/2016 09:03 AM
>>> Subject:        Re: [IMPROVEDX] Fwd: PDF - *www.pnas.org*
>>> ------------------------------
>>>
>>>
>>>
>>>
>>> * Caution: *This email came from outside Kaiser Permanente. Do not open
>>> attachments or click on links if you do not recognize the sender.
>>>
>>> ------------------------------
>>>
>>> Hi Mark and others -
>>> Ok I'll take stab at this...
>>> Yes, this is a complicated piece methodologically and statistically, but
>>> the implications you suggest (Mark) below are generally correct.  It is a
>>> great paper and one that I am sure psychologists especially like, but I
>>> think there are some important caveats to keep in mind if you were to apply
>>> in practice.  I'll describe them below and also try to elaborate some on
>>> the methods/stats as I understand them.
>>> First, be careful not to draw wide-ranging conclusions about how this
>>> might actually work in practice - that is, these were independent judgments
>>> from a group of doctors (for whom there were meaningful individual scores
>>> of diagnostic accuracy available) who diagnosed and rated their confidence
>>> for each of many images for which there were correct/known diagnoses (101
>>> radiologists for the mammograms, 40 dermatologists for the skin images) -
>>> images were divided into different groups for different docs so not
>>> everyone rated all of them (due to the large number I'm sure).  No one ever
>>> communicated with anyone.  Following each diagnosis, docs rated their
>>> confidence.  Virtual groups were created by randomly sampling up to 1000
>>> groups for each of the two types of images (breast and skin) AND for each
>>> of three different doc group sizes (2 v. 3 v. 5 doctors).  So, what they
>>> did is essentially create a bunch of randomly selected groups of doctors
>>>  by repeatedly sampling from their "population" of doctors/diagnoses (for
>>> these 6 "conditions" in what can be thought of as a 2 [skin v. breast
>>> images] x 3 [group size: 2 v. 3 v. 5 doctors] design).  So they created up
>>> to 6000 virtual groups (up to 1000 for each) - something I think is really
>>> cool methodologically!   Each doctor got a sensitivity score (that is,
>>> proportion of positive results identified as such) and a specificity score
>>> (that is, proportion of negative results identified as such).  Youden’s
>>> index (J) is an accuracy measure that takes into account both of these
>>> scores and is equal to (sensitivity + specificity) - 1.  The index ranges
>>> from -1 to +1 where a score of 0 means that the proportion of people
>>> identified with the disease is the same regardless of whether they actually
>>> have it or not.  A 1 means the test is perfect (no false positives or
>>> negatives).  For a pair of docs in any given group, a change in J was
>>> computed (ΔJ), which is the difference in accuracy between that pair of
>>> doctors.  So, basically then, when ΔJ is small, that is when docs have
>>> similar accuracy - based on all of the cases they judged).
>>> The "confidence rule" means that the doctor with the most confidence in
>>> his/her diagnosis in any given group "wins" on a specific diagnostic
>>> assessment - and that becomes the outcome/diagnosis for the group (and that
>>> outcome is compared to the diagnosis of the best doctor in the group - the
>>> one with the highest accuracy score based on all diagnoses from all images
>>> rated).  So, regardless of group size, it turns out that if you have a
>>> group of doctors who generally perform similarly well across all of their
>>> diagnostic assessments, then going with the diagnosis in any given
>>> case/image that is associated with doc who is most confident with it will
>>> be best/most accurate.    For groups of 3 or 5 docs, if they have similar
>>> accuracy levels in general, then going with the majority "vote" (diagnosis)
>>> is more accurate than the diagnosis of the single best/most accurate doc in
>>> the group.  As you can see in Figure 2 in the article, if docs aren't
>>> pretty similar in their overall accuracy in a given group, then they are
>>> MUCH better off going with the diagnosis of the best diagnostician in the
>>> group.
>>> SO that's how I read/understand all this.   The tricky part, I think,
>>> about applying this to practice prior to more research is that these were
>>> all independent judgments/diagnoses and accuracy scores were computed for
>>> each doc based on a large number of images that each evaluated.  This is
>>> how it was determined who the docs are that are similar in accuracy to one
>>> another.  In the real world (everyday practice), I am not sure you would
>>> actually know this - would you?  (I'm an outsider here - a social cognition
>>> expert, not an MD or clinician).  I am guessing you have a sense of who the
>>> good docs are who make good judgments, but I wonder how much more info you
>>> need about their general accuracy in order for the effects reported in this
>>> article to emerge in real clinical practice (in a way that is CLINCIALLY
>>> significant and not just statistically significant)?  There is a noteworthy
>>> literature in social psychology that demonstrates that group decisions can
>>> sometimes lead to bad outcomes and in some cases to very good ones - the
>>> trick is to figure out what those conditions are that take you one way or
>>> the other.  If group members can truly add some expertise/understanding to
>>> a problem, outcomes can improve.  However, much work suggests that groups
>>> can lead to situations in which individuals are overly influenced by others
>>> and thinking gets kind of stuck or overly influenced by some ideas that may
>>> well be wrong (which can lead to confirmatory hypothesis testing around
>>> those ideas if people engage in more discussion/thought, and may ultimately
>>> lead to premature closure either with or without the confirmatory
>>> hypothesis testing).  Of course much of this work also has been done with
>>> group discussions and interactions - something that is noticeably missing
>>> in the study reported in the PNAS article (but appropriately, they do note
>>> this in their discussion).
>>> Overall, it seems that in diagnostic decisions that are relatively
>>> dichotomous (as in this article - though I also wonder how many decisions
>>> really are quite this dichotomous??  If there are few, then more research
>>> is needed to see what happens when their are multiple
>>> possibilities/diagnoses/outcomes), these simple decision rules
>>> (majority and confidence rules) could work out well and be relatively
>>> efficient IF one actually knows the diagnostic accuracy of the group
>>> members and knows that they are similarly good.  Personally, I see that as
>>> kind of a big if --- because if you are wrong about this - ugh - these
>>> decision rules lead to MORE error than if you just went with the best doc!
>>> (Again see figure 2).  I guess this is where I wonder most about applying
>>> this in practice.   SO at the moment at least, this research looks very
>>> promising to me for application down the road, but more work would be
>>> needed to get there and feel confident that the rules actually do lead to
>>> fewer errors in practice (and not too more errors....yikes!).  Plus that
>>> whole issue of communication between docs seems extremely important for
>>> practice too.
>>> All that said, I like the paper VERY much as an important contribution
>>> to basic research with the strong potential to one day to have applied
>>> implications - but I don't think we are there yet.
>>> Very interested also in others' thoughts,
>>> Linda
>>>
>>> ---
>>> Linda M. Isbell, Ph.D.
>>> Professor, Psychology
>>> Department of Psychological and Brain Sciences
>>> University of Massachusetts
>>> 135 Hicks Way -- 630 Tobin Hall
>>> Amherst, Massachusetts 01003
>>> Office Phone:  413-545-5960
>>> Website:  *http://people.umass.edu/lisbell/*
>>> <http://people.umass.edu/lisbell/>
>>> On 2016-08-23 12:17, *graber.mark at GMAIL.COM* <graber.mark at gmail.com>
>>> wrote:
>>> Thanks to Nick Argy for bringing this article to attention.   The
>>> methods and findings are a bit hard to follow, but if I understand things
>>> correctly, the article finds that diagnostic accuracy can be improved by
>>> second opinions or larger groups if the diagnosticians have similarly high
>>> skill levels, but that accuracy is degraded to the extent that the
>>> variability increases.  I'd really like to hear what others get out of this
>>> paper, because these findings have important implications for
>>> recommendations to move in the direction of getting more second opinions,
>>> or using the new group-based diagnosis approaches.
>>>
>>> Mark
>>>
>>>
>>>
>>> ------------------------------
>>>
>>> Address messages to: *IMPROVEDX at LIST.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*
>>> <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>
>>>
>>> Visit the searchable archives or adjust your subscription at:
>>> *http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX*
>>> <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/* <http://www.improvediagnosis.org/>
>>>
>>>
>>> ------------------------------
>>>
>>> Address messages to: *IMPROVEDX at LIST.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*
>>> <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>
>>>
>>> Visit the searchable archives or adjust your subscription at:
>>> *http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX*
>>> <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/* <http://www.improvediagnosis.org/>
>>>
>>> ------------------------------
>>>
>>>
>>> Address messages to: *IMPROVEDX at LIST.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*
>>> <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>
>>>
>>> Visit the searchable archives or adjust your subscription at:
>>> *http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX*
>>> <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/* <http://www.improvediagnosis.org/>
>>>
>>>
>>> ------------------------------
>>>
>>>
>>> Address messages to: *IMPROVEDX at LIST.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*
>>> <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>
>>>
>>> Visit the searchable archives or adjust your subscription at:
>>> *http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX*
>>> <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/* <http://www.improvediagnosis.org/>
>>>
>>>
>>>
>>> ------------------------------
>>>
>>>
>>> Address messages to: *IMPROVEDX at LIST.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*
>>> <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>
>>>
>>> Visit the searchable archives or adjust your subscription at:
>>> *http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX*
>>> <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/* <http://www.improvediagnosis.org/>
>>>
>>>
>>>
>>> ------------------------------
>>> Notice: This UI Health Care e-mail (including attachments) is covered by
>>> the Electronic Communications Privacy Act, 18 U.S.C. 2510-2521 and is
>>> intended only for the use of the individual or entity to which it is
>>> addressed, and may contain information that is privileged, confidential,
>>> and exempt from disclosure under applicable law. If you are not the
>>> intended recipient, any dissemination, distribution or copying of this
>>> communication is strictly prohibited. If you have received this
>>> communication in error, please notify the sender immediately and delete or
>>> destroy all copies of the original message and attachments thereto. Email
>>> sent to or from UI Health Care may be retained as required by law or
>>> regulation. Thank you.
>>> ------------------------------
>>>
>>> ------------------------------
>>>
>>> Address messages to: *IMPROVEDX at LIST.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*
>>> <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>
>>>
>>> Visit the searchable archives or adjust your subscription at:
>>> *http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX*
>>> <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/* <http://www.improvediagnosis.org/>
>>>
>>>
>>> ------------------------------
>>>
>>>
>>> To unsubscribe from IMPROVEDX: click the following link:
>>>
>>> *http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1*
>>> <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?SUBE
>> D1=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


HTML Version:
URL: <../attachments/20160831/915ecbae/attachment.html>


More information about the Test mailing list