A question - the primary complaint

robert bell rmsbell200 at YAHOO.COM
Sat Nov 25 23:18:36 UTC 2017


Hello all,

I agree with Melanie. 

So what is the way forward? What about triaging the main problems and divvying up some of the work to other organizations. Could that work, particularly if there were time related goals?

There would then be a coordinated do something positive effort.

And I think Improvedx could take the lead.

Is there a Nobel prize there for the asking?

Rob
> On Nov 25, 2017, at 9:31 AM, Powell, Melanie A <Melanie.A.Powell at medstar.net> wrote:
> 
> To Bob's point - 
>  
> I think we have to do both at the same time. Fixing the big things (payment models, EHR compatibility, health exchanges, open notes) shouldn't preclude smaller tests of change and educational initiatives around the diagnostic process - those small changes are what help providers and patients navigate clinical encounters on a daily basis in the system we have right now.
>  
> There are a number of excellent initiatives in place (like the SIDM patient toolkit and Kaiser Permanente Southern California's SureNet Program) to help mitigate challenges like the one's I outlined in my previous post. The National Academy of Sciences Report on Improving Diagnosis in HealthCare propelled the issue forward. The SIDM coalition represents hundreds of thousands of providers and has government agency partnership. The national dialogue around diagnostic error (with patients at the center of this process) is becoming part of every day life - this is how we shape the legislative agenda and impact regulations. 
>  
> Although many of the interventions and educational initiatives we're planning now may ultimately be unnecessary or obsolete, it's challenging not to take action in the meantime and continue these discussions around improving the diagnostic process, especially if it can impact patient safety. 
>  
> Melanie Powell, MD/MPH
> Fellow, MedStar Institute for Quality and Safety
> (c) 410-688-5216
> Website: http://www.medstariqs.org/ <http://www.medstariqs.org/> 
>  
> From: robert bell [0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG <mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>]
> Sent: Friday, November 24, 2017 9:40 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] A question - the primary complaint
> 
> Melanie Powell gives a totally different perspective on the art or science of diagnosis. Well done!
> 
> How can we ever hope to do a good job with diagnosis with all the hindrances Melanie mentions. 
> 
> I have mentioned before that it seems foolish to focus on better diagnoses when the support systems, including laboratory, radiology, the electronic records, Melanie’s list etc., etc. can be inaccurate or lead to inaccuracies. 
> 
> Just accepting the status quo seems almost criminal. 
> 
> I have mentioned before the stethoscope accuracy/inaccuracy problem in experienced/inexperienced, deaf, and the differing groups of Health Care providers. We know nothing about this. 
> 
> And don’t get me started on BP measurements!
> 
> Let us first get all or at least some of these things sorted out at he same time as improving diagnoses or even before. Please let us put the Horse before the Cart.
> 
> We do not even know what standard errors (an estimated 60% of the pie) do to the diagnostic process. Should we get on top of those errors first or at the same time?
> 
> The ice on the lake is far too thin right now for us to safely ever think about fishing!
> 
> Robert Bell, M.D.
> 
> 
>> On Nov 24, 2017, at 12:31 PM, Powell, Melanie A <Melanie.A.Powell at medstar.net <mailto:Melanie.A.Powell at medstar.net>> wrote:,  
>> Hello all,
>>  
>> This has been a really excellent thread and one that resonates with me not only as a Family Medicine doctor who struggled with time management and confidence in my clinical skills and diagnostic reasoning throughout residency, but as a daughter, granddaughter, sister and niece who continues to experience the impact of our health system's failures (insurance, health administration, health education, and individual provider behavior) on people I love. I have seen both my colleagues and patients/family members disengage with the system, either because of burnout, loss of trust, or annoyance with incorrect charting/billing or delay in care/communication. It feels like a crisis of some sort is upon us.
>>  
>> I appreciate the various viewpoints and affirm that they all play out every day in a primary care office (likely any health care setting across the country). I struggled in the past when, after meticulously planning out visits based on the documented "primary complaint", I discovered that we weren't going to focus on the list of preventive measures I wanted to discuss, but on a completely different list of concerns that the patient had been worried about for a number of months or years, but for a variety reasons did not address (i.e. financial issues, transportation issues, symptoms weren't severe enough, etc. etc.). I used to become very frustrated by this pattern and deployed a number of strategies to help the visits run more smoothly to avoid running late (I often found myself 60-90 minutes behind schedule after trying to cover mine and the patient's concerns in a single visit) - all of which were either recommended or supported by senior faculty:
>>  
>> 1. Inform the patient of the reason for the scheduled visit (e.g. preventive care) and that we could pick one additional complaint to review, but that he/she would have to return within the next month to discuss the rest of their concerns. This was widely recommended to me as a time management technique during visits. 
>>  
>> 2. Offer the patient a choice of a preventive visit or problem-focused visit and recommend that the patient return within one month for a preventive visit. Again, a widely recommended strategy. Within this strategy, the patient would also be urged to choose no more than 3 complaints for a problem focused visit. 
>>  
>> 3. Do a truncated preventive health review and review of acute concerns. Perform a focused physical exam. Order all necessary tests and perform follow up over the phone for test results and additional complaints. This is my strategy now.
>>  
>> I find that my day goes better if I do the third option, but my patients are more satisfied if I throw out my own agenda prior to the visit and start with a standard line: "What do you want to talk about today? What concerns do you have?" The patient completely owns the visit. At the end I provide a caveat (if indicated) that there will be a follow up phone call, that we may need additional tests, that I may need to seem them back in the office for additional evaluation or refer to a consultant, and that I need to know if anything changes for better or worse so we have all the information we need. I still run behind (15-30 minutes is almost never enough time for active listening, documentation, examination, counseling, and check out), perform at least 2 hours of over the phone care a day, and have patients leave without being seen because I take more time with others before them (which is definitely a negative consequence of having to schedule 10-12 primary care patients within a 3 hour window).
>>  
>> I don't need to tell anyone on this thread that healthcare in the United States is complicated. With fractured and imperfect EHRs I do not always get consultation notes, records from previous physician's offices after transfer of care, lab/radiology/pathology results before I see a patient in the office. Often, without this information I am unable to form a plan of care that satisfies either of us. Additionally, without an accurate problem list I can't bill appropriately. Tests I may want to get during a visit may be billed unnecessarily to the patient because I cannot say for sure whether he/she has diabetes (even thought it was reported by the patient and they were prescribed anti-diabetic medications by a previous provider). This causes delay in care, return visits, etc. etc. 
>>  
>> Until we as providers have perfect information (all patient records integrated into one system, patient access to their own health data so they can produce it for the physician to review during the visit without having to request access to records) and support patient engagement in their own care (by actively listening, being flexible with our agenda, etc.) visits will continue to be disjointed and require follow up testing, referrals, etc.
>>  
>> A good example of this happened during an office visit last week with a new patient who presented for transfer of care from another facility because she was referred for repeat testing, multiple specialist evaluations, and brought back to her doctor's office without any satisfactory answers about a health care problem she was experiencing. We did not talk about any preventive measures and I did not have any access to her records. Ultimately, I was unable to provide much care for her during the visit except to refill select medications and a refer her for home physical therapy that she badly needed. From a quality metric standpoint, the visit was a failure (BP was high, without recent labs I didn't want to adjust medications and didn't want to overtest in case records revealed she had labs done within the past 30 days); however, from a patient engagement standpoint it was a great success - she was extremely gracious and finally felt heard.
>>  
>> Balancing the two is the great struggle we face now. I don't think physicians want to do this badly, I think there isn't a perfect model for how to do it well. Further, despite the move towards value based payments, we are still very much a pay for performance system with salaries dependent on RVUs (procedures, level of thinking during a visit, etc.). Currently, there isn't a payment model that facilitates (not just incentivizes or penalizes, which MACRA does) patient-centered care and diagnostic uncertainly. This group makes me hopeful that both will exist soon. 
>>  
>> I'm wondering what other providers do to navigate the "multiple primary complaints" and what patients do when providers push back - any thoughts? Should we even document a primary complaint, or just walk into each visit with an open agenda? Would this allow providers to be more open-minded in their clinical reasoning? Is it reasonable to expect resolution of a problem within a 20 minute office visit without expectation of a follow up visit or additional testing/medication trials? Is it safe?
>>  
>> Melanie Powell, MD/MPH
>> Fellow, MedStar Institute for Quality and Safety
>> (c) 410-688-5216
>> Website: http://www.medstariqs.org/ <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.medstariqs.org_&d=DwMF-g&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=Qo6TafT5V-QOIW0iyBYTO3I9cCWfv7o8vZ51RcdbyGI&s=iuisJPN04MvND9jOiiPRads90U5aBD2Moani0xNnKz8&e=> 
>>  
>> From: K D [kvdavis at COX.NET <mailto:kvdavis at COX.NET>]
>> Sent: Wednesday, November 22, 2017 8:02 PM
>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> Subject: Re: [IMPROVEDX] A question - the primary complaint
>> 
>> Interesting... as Arizona is ranked 2nd worst state to practice medicine in...
>> 
>> https://www.medscape.com/slideshow/best-places-to-practice-2017-6008688#29 <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.medscape.com_slideshow_best-2Dplaces-2Dto-2Dpractice-2D2017-2D6008688-2329&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=PeG3Ej5EHINo-1mxU2AUuD_Rm8af1ellT5QOOp7SHT8&e=>
>> 
>> The times I have contacted my state board (including the state nursing board, whose "oversight" of nurse practitioners appears beyond their capacity), I was informed the board does not have the capacity or manpower to follow up...
>> 
>> The reality of practicing medicine in the US now is wholly dependent upon bureaucratic baggage from both government and for profit entities who have patient care at the bottom of their priority lists. 
>> 
>> If you're not cynical, you are not paying attention.
>> 
>> > On November 22, 2017 at 1:56 PM Michael Grossman <Michael.Grossman at MIHS.ORG <mailto:Michael.Grossman at MIHS.ORG>> wrote:
>> > 
>> > 
>> > Dr Benzoni, your message is probably true in many states. In Arizona physicians are instructed to notify the state licensing board if there is overt suspicion of inadequate medical care being provided by another licensed physician. This allows the board to do a confidential review of said physician all done anonymously . You receive a message from the board and a thank you. But no revelation of their findings. This also applies to observed errant behavior. 
>> > In my experience this has worked well
>> > More states should institute this. 
>> > 
>> > Michael Grossman, MD,MACP
>> > Professor emeritus university of Arizona College of Medicine
>> > 
>> > > > Sent with Good (www.good.com <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.good.com&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=rH5dG9WvBDyLsq0xnTt4JRjSpyiHOZ4q3yX2Ea11foE&e=>)
>> > 
>> > 
>> > -----Original Message-----
>> > From: Tom Benzoni [mailto:benzonit at GMAIL.COM <mailto:benzonit at GMAIL.COM>]
>> > Sent: Tuesday, November 22, 2016 01:51 PM US Mountain Standard Time
>> > To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> > Subject: Re: [IMPROVEDX] A question - the primary complaint
>> > 
>> > Ms. Zuckerman:
>> > 
>> > 
>> > We in practice do indeed know who are the incompetent physicians among us.
>> > 
>> > And you (plural, society) have decided that we are not to say anything.
>> > 
>> > 
>> > You see, to speak up is to risk losing all in a court of law, which expresses the will of the people.
>> > 
>> > There is no protection for whistle-blowers.
>> > 
>> > 
>> > So until this is fixed, incompetent practitioners will continue to be big profit centers.
>> > 
>> > (You can generate a lot more bills off a botched procedure than an expertly done one.)
>> > 
>> > 
>> > Cynical? I don't think so. I think it exposes the system operating as designed.
>> > 
>> > "Every system is precisely designed to achieve exactly the results it gets." (Berwick) (as nearly as memory can pull out) 
>> > 
>> > 
>> > tom benzoni
>> > 
>> > 
>> > On Tue, Nov 22, 2016 at 2:06 PM, Peggy Zuckerman <peggyzuckerman at gmail.com <mailto:peggyzuckerman at gmail.com>> wrote:
>> > 
>> > 
>> > As a patient who was misdiagnosed with a non-existent stomach ulcer, despite a pathology report countering the diagnosis, and later found to have a large and metastatic kidney cancer, I am likely biased in my response.
>> > 
>> > I feel that until patients are empowered to have immediate access to all their data as soon as it is produced, there will not be real improvement as to diagnostic errors. The unprofessional actions of the doctors or the cognitive errors can be counter-balanced by the engagement of the patient in the process. As a minimum, we patients will not be mistaken for our sisters-in-law with the same name, or be given a medication to which we are allergic, and we will be able to provide relevant tests from an earlier appointment and clarify the medications we are taking compared to those which have been prescribed to us.
>> > 
>> > Of course, we also have the right to assume--wishing it were the case--that the unprofessional and just plain incompetent doctors will be outed by the good guys. Still waiting.
>> > 
>> > Peggy
>> > 
>> > 
>> > Peggy Zuckerman
>> > www.peggyRCC.com <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.peggyRCC..com&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=h7XnwzW6o_bFX8kud7D6pWSsVCDD-DpEdAfJxe1KNls&e=>
>> > 
>> > 
>> > On Tue, Nov 22, 2016 at 8:40 AM, Amy Reinert <amy.reinert at gmail.com <mailto:amy.reinert at gmail.com>> wrote:
>> > 
>> > 
>> > Art, 
>> > Thank you for your response, and your excellent points about medical technology. I do agree with them.
>> > 
>> > Perhaps my point was not clear enough. If the physician is one of those who maintains a consistently suspicious, rather than interested, view of patients; if she is one who brushes off complex cases by telling the patient "it's all in your head," won't look past his initial bias, or is otherwise disinclined to be professional, then none of the great tools made available to physicians will help. In order for these wonderful tools to provide the support that they can offer, the physician must first use the tool. This is part of the problem-- physicians who brush off patients for whatever reason, never taking the time to run proper tests or do a proper exam. These are not the ones who will use technology to aid in answering patient questions. 
>> > 
>> > I would bet that most physicians are willing to use the tools some of the time. Unfortunately, what I am learning through my preliminary research is that there seems to be a large enough population of physicians who do not behave professionally with all of their patients all the time that it seems we need to acknowledge that egregious or careless physician behavior exists, and it is important to consider the degree to which it affects misdiagnosis. It is difficult to measure what goes on during the one-one encounter in the exam room, so it is difficult to measure just how large a problem it is. I suspect that it is quite large, though, due to the volume of patient reports of rude, dismissive, aggressive, and in a few cases, criminal behavior that takes place in the exam room. Unfortunately, the doctors write the notes, so they make the only official record of the visit. That presents a problem of power dynamics. So, as I stated in my first message, I have been working on a research design to quantify the problem so that it can be addressed.
>> > 
>> > I do believe that most physicians are sincere in their desire to be healers, and do their best in systems that do not support them. However, physicians are human, and some behave badly toward their patients, or at least some of their patients. Some of these probably know that they are doing this, but I suspect many don't. So, in the interest of taking action to improve diagnosis, I believe this is one issue that needs to be explored and better understood so that it can be resolved. The physician-patient encounter is the foundation of diagnosis.
>> > 
>> > I welcome continuing dialogue on this issue. 
>> > 
>> > All the best,
>> > Amy
>> > 
>> > A.D. Ruzicka, Ph.D.
>> > 
>> > 
>> > 
>> > 
>> > On Tuesday, November 22, 2016, Art Papier <apapier at visualdx.com <mailto:apapier at visualdx.com>> wrote:
>> > 
>> > 
>> > Disclosure: I am the CEO of VisualDx (and a practicing physician).
>> > 
>> > 
>> > 
>> > Amy,
>> > 
>> > Certainly the drudgery of electronic health information systems have taxed many physicians, interfering in the physician-patient interaction and causing stress, burnout and fatigue. Telemedicine while bringing speed and access to people in remote areas, is certainly not as personal as face to face. There are problems with technology, but we must be careful to not lump “medical technology” into one homogenous bucket as we seek to reestablish a more human physician-patient interaction. Medical knowledge accessed on mobile devices, desktop computers and integrated into the EHR is more efficient and more useful than books down the hallway. Books reduced medical knowledge to averaged summaries of classic presentations, and are limited by space, difficult uniaxial indexing, out of date, and hard to retrieve information. Databases can catalog the spectrum of disease presentation, can be designed to reflect and contextualize information to the unique clinical scenario. Furthermore new relationships will be uncovered in clinical medical medicine because of digital information. Hundreds of thousands of physicians use tools like UpToDate, VisualDx, Epocrates etc and they all prefer these digital medical technologies because they are faster, more comprehensive and more current than what we memorized from on paper. Using the new information toolsh the patient in the exam room enhances the physician-patient relationship in this day and age of patients using WebMD and Wikipedia before they see us. A physician saying something like “I don’t know, let me check my professional database” to a patient instantly communicates to the patient that the physician cares enough to pause and look up information on their behalf. Young physicians, students and residents do not see these cognitive tools as destroying the physician-patient relationship, they see these tools as essential to practice. I caution all on the list to appreciate how varied are the practice patterns, habits and methods of physicians. Physicians (and NP’s and PA’s) are remarkably heterogeneous. Their attitudes and styles are remarkably diverse. Many are using medical technology to enhance the physician-patient relationship. Using evidence at the point of care is a very positive force in healthcare. 
>> > 
>> > Art Papier MD
>> > 
>> > CEO of VisualDx
>> > 
>> > 
>> > 
>> > 
>> > 
>> > From: Hess, Dr. Donald [mailto:dhess at SUSQUEHANNAHEALTH.ORG <mailto:dhess at SUSQUEHANNAHEALTH.ORG>] 
>> > Sent: Tuesday, November 22, 2016 8:10 AM
>> > To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> > Subject: [IMPROVEDX] A question - the primary complaint
>> > 
>> > 
>> > 
>> > Re: Without sick patients, there would be no need for physicians. Therefore, regardless of what changes might be made in software, systems, education, etc., very little progress will be made in diagnostic accuracy until improvements in individual physician-patient encounters are made.
>> > 
>> > 
>> > 
>> > I’ve recently read “The Finest Traditions of My Calling” by Abraham Nussbaum, MD. Here’s a quote: “…modern medicine was born when physicians learned to see like scientists. And I suspect that medicine will advance once more only when physicians change their self-perception again”. He goes on to explore what has happened between patients and physicians over the years, and offers hopeful glimpses into how things might be different. 
>> > 
>> > 
>> > 
>> > Physician-patient encounters have gradually, perhtered by medical technology. They have now evolved into virtual transactions mediated by a disembodied tele-diagnostician. I sometimes wonder, what are the core traditions surrounding the physician-patient relationship? Are they worth preserving? In light of what the practice of medicine has become, is it even possible to preserve them? 
>> > 
>> > 
>> > 
>> > Sincerely,
>> > 
>> > 
>> > 
>> > Dr. Donald Hess
>> > 
>> > 
>> > 
>> > From: Amy Reinert [mailto:amy.reinert at GMAIL.COM <mailto:amy.reinert at GMAIL.COM>] 
>> > Sent: Friday, November 18, 2016 1:24 PM
>> > To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> > Subject: Re: [IMPROVEDX] A question - the primary complaint
>> > 
>> > 
>> > 
>> > In my encounters with misdiagnosed patients, or patients with rare disease or complex problems currently in the (rather exhausting) diagnostic process, this focus on only being able to discuss one problem is a source of patient frustration. Regardless of the physician's reason for stating this limit, patients report feeling dismissed, angry, patronized, disrespected, or disbelieved. Being educated toward some degree of expertise in human behavior, I conclude that it is not the "one symptom focus" that leaves the patients so upset, but rather the way the message is delivered. Simple demeanor in communication. Human beings are not data sets with neat flow charts, nor does each one present in the physician's preferred manner. This is no excuse for not taking the time to listen, using appropriate training to read between the lines, ask follow up questions, and treat the patient with respect. It takes just as much time to behave in this way as it does to behave in a rude, dismissive, or sometimes even aggressive manner. If physicians feel powerless within the various systems influencing medicine, surely the patient encounter is not the place to compensate for that sense of powerlessness by becoming a bully, yet too often, in my research, this seems to be the case. It is a problem that appears to be common knowledge to all but the physicians themselves. Perhaps gallows humor, professional courtesy, or empathy fatigue prevents physicians from identifying others within their ranks that behave inappropriately, or even incompetently, in the one-to-one physician/patient encounter. Based on my research with patients, it is a problem that needs to be addressed. I am currently trying to design a study that will quantify this problem, including the cost associated with repeat visits necessary for correct diagnosis, as well as the social and economic ramifications of leaving persons lingering unnecessarily with advancing disease. Medicine is part of the larger web of society, and it cannot be ignored that what happens in the patient encounter has ripple effects far beyond the individual patient, doctor, or hospital. Still, as a field, medicine seems reluctant to welcome the contributions of relevant expertise from other fields that may help resolve some of its issues. If any of you get ahead of me in carrying out such a study, Godspeed. It must be done.
>> > 
>> > 
>> > 
>> > I have watched discussions in this group for some time with great interest. I've noted the discussions of EHRs, lab problems, diagnostic software, medical education, charts and graphs, etc., with great interest. I've also noticed that the closest the group has come to discussing egregious physician behavior is within the exchanges about cognitive bias that occurred some time ago. I suggest here that it is a much larger issue than might be seen from inside the ranks. Until medicine is willing to integrate awareness of power dynamics, the limits of physician training and consequent limits on appropriate medical conclusions, and social justice into its collective consciousness, I believe that misdiagnosis will continue to be a very expensive and frustrating problem for the rest of society.
>> > 
>> > 
>> > 
>> > Perhaps this statement might come across as unsympathetic to the physician. Perhaps it is. This does not mean that I am not sympathetic the plight of physicians in general. I do respect the demanding work, the fatigue, the problems inflicted by profit focused administrative systems, and abusive patients. Unfortunately, the entire field boils down to the needs of the patient. Without sick patients, there would be no need for physicians. Therefore, regardless of what changes might be made in software, systems, education, etc., very little progress will be made in diagnostic accuracy until improvements in individual physician-patient encounters are made.
>> > 
>> > 
>> > 
>> > Respectfully,
>> > 
>> > A.D. Ruzicka, Ph.D.
>> > 
>> > 
>> > On Thursday, November 17, 2016, Tom Benzoni <benzonit at gmail.com <mailto:benzonit at gmail.com>> wrote:
>> > 
>> > ....should and do are different ideas.
>> > 
>> > 
>> > 
>> > This would be an ideal area for patient involvement.
>> > 
>> > 
>> > 
>> > Tom
>> > 
>> > On Monday, November 14, 2016, Phillip Benton <0000000697ec7b18-dmarc-request at list.improvediagnosis.org <mailto:0000000697ec7b18-dmarc-request at list.improvediagnosis.org>> wrote:
>> > 
>> > We have to have data from that encounter and then outcomes data to know. As for the encounter, EHR should give you all the PHx and FHx without your having to ask again.
>> > 
>> > 
>> > 
>> > Phillip Benton
>> > pgbentonmd at aol.com <mailto:pgbentonmd at aol.com>
>> > 
>> > 
>> > 
>> > 
>> > 
>> > -----Original Message-----
>> > From: robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG <mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
>> > To: IMPROVEDX <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
>> > Sent: Mon, Nov 14, 2016 8:45 pm
>> > Subject: [IMPROVEDX] A question - the primary complaint
>> > 
>> > I have noticed that physicians when seeing a patient in an office setting often focus on the primary complaint with laser like enthusiasm, almost to the exclusion of anything else.
>> > 
>> > I suspect this is mainly related to time restraints.
>> > 
>> > However, in the big scheme of things is the past history, family history, drug allergies, etc. etc. that important?
>> > 
>> > In terms of a wrong diagnosis, or bad outcome, is this a small, intermediate or large problem in the number of diagnostic errors made?
>> > 
>> > Rob Bell M.D., Ph.C.
>> > To unsubscribe from the IMPROVEDX:
>> > mail to:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG <mailto:SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
>> > or click the following link: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> > 
>> > Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
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>> > </p>
>> > 
>> > 
>> > 
>> > ________________________________
>> > 
>> > 
>> > Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX 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 <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=EaU2i68jHpk2S3JhM8fpMrn1L9YYBvOy5agpqnnA604&e=> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX> <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=mhYFJLHAkSo89SwgxwNi4EEjp_fbOdxjRQbisz_h_3I&e=> 
>> > Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
>> > 
>> > To learn more about SIDM visit:
>> > http://www.improvediagnosis.org/ <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=43jkrdUr106iy8uhoaBezPfdEX9nJEDPBA6lM6WcPHg&e=> <http://www.improvediagnosis.org/> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=u6Kwlk0QzKr3-YzIh40z8P_COw1o3E6ia1TyccCgG6s&e=> 
>> > 
>> > 
>> > 
>> > ________________________________
>> > 
>> > 
>> > Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto: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 <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=5V3n9f1ytaSPKQbWMZOW2GkF_vkkqnPJLp1JJMn6ZZM&e=> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1> <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=TJgySGxg6leES30PSliMiF4Ke5crSa0HhRI9qa-0ZoM&e=> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG <mailto: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 <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=EaU2i68jHpk2S3JhM8fpMrn1L9YYBvOy5agpqnnA604&e=> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX> <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=mhYFJLHAkSo89SwgxwNi4EEjp_fbOdxjRQbisz_h_3I&e=> 
>> > Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
>> > 
>> > To learn more about SIDM visit:
>> > http://www.improvediagnosis.org/ <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=43jkrdUr106iy8uhoaBezPfdEX9nJEDPBA6lM6WcPHg&e=> <http://www.improvediagnosis.org/> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=u6Kwlk0QzKr3-YzIh40z8P_COw1o3E6ia1TyccCgG6s&e=> 
>> > 
>> > 
>> > 
>> > ________________________________
>> > 
>> > 
>> > Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.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 <mailto: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 <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=EaU2i68jHpk2S3JhM8fpMrn1L9YYBvOy5agpqnnA604&e=> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX> <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=mhYFJLHAkSo89SwgxwNi4EEjp_fbOdxjRQbisz_h_3I&e=> 
>> > 
>> > 
>> > Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
>> > 
>> > To learn more about SIDM visit:
>> > http://www.improvediagnosis.org/ <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=43jkrdUr106iy8uhoaBezPfdEX9nJEDPBA6lM6WcPHg&e=> <http://www.improvediagnosis.org/> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=u6Kwlk0QzKr3-YzIh40z8P_COw1o3E6ia1TyccCgG6s&e=> 
>> > 
>> > 
>> > 
>> > ________________________________
>> > 
>> > 
>> > Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto: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 <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=5V3n9f1ytaSPKQbWMZOW2GkF_vkkqnPJLp1JJMn6ZZM&e=> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1> <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=TJgySGxg6leES30PSliMiF4Ke5crSa0HhRI9qa-0ZoM&e=> 
>> > 
>> > or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG <mailto: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 <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=EaU2i68jHpk2S3JhM8fpMrn1L9YYBvOy5agpqnnA604&e=> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX> <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=mhYFJLHAkSo89SwgxwNi4EEjp_fbOdxjRQbisz_h_3I&e=> 
>> > 
>> > 
>> > Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
>> > 
>> > To learn more about SIDM visit:
>> > http://www.improvediagnosis.org/ <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=43jkrdUr106iy8uhoaBezPfdEX9nJEDPBA6lM6WcPHg&e=> <http://www.improvediagnosis.org/> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=u6Kwlk0QzKr3-YzIh40z8P_COw1o3E6ia1TyccCgG6s&e=> 
>> > 
>> > 
>> > ________________________________
>> > 
>> > 
>> > Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX 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 <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=EaU2i68jHpk2S3JhM8fpMrn1L9YYBvOy5agpqnnA604&e=> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX> <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=mhYFJLHAkSo89SwgxwNi4EEjp_fbOdxjRQbisz_h_3I&e=> 
>> > Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
>> > 
>> > To learn more about SIDM visit:
>> > http://www.improvediagnosis.org/ <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=43jkrdUr106iy8uhoaBezPfdEX9nJEDPBA6lM6WcPHg&e=> <http://www.improvediagnosis.org/> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=u6Kwlk0QzKr3-YzIh40z8P_COw1o3E6ia1TyccCgG6s&e=> 
>> > 
>> > 
>> > ________________________________
>> > 
>> > 
>> > Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX 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 <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=EaU2i68jHpk2S3JhM8fpMrn1L9YYBvOy5agpqnnA604&e=> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX> <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=mhYFJLHAkSo89SwgxwNi4EEjp_fbOdxjRQbisz_h_3I&e=> 
>> > Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
>> > 
>> > To learn more about SIDM visit:
>> > http://www.improvediagnosis.org/ <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=43jkrdUr106iy8uhoaBezPfdEX9nJEDPBA6lM6WcPHg&e=> <http://www.improvediagnosis.org/> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=u6Kwlk0QzKr3-YzIh40z8P_COw1o3E6ia1TyccCgG6s&e=> 
>> > 
>> > 
>> > 
>> > ________________________________
>> > 
>> > 
>> > Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>> 
>> > 
>> > To unsubscribe from IMPROVEDX: click the following link:
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>> > 
>> > Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=EaU2i68jHpk2S3JhM8fpMrn1L9YYBvOy5agpqnnA604&e=> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX> <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=mhYFJLHAkSo89SwgxwNi4EEjp_fbOdxjRQbisz_h_3I&e=> 
>> > Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
>> > 
>> > To learn more about SIDM visit:
>> > http://www.improvediagnosis.org/ <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=43jkrdUr106iy8uhoaBezPfdEX9nJEDPBA6lM6WcPHg&e=> <http://www.improvediagnosis.org/> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_-253E&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=u6Kwlk0QzKr3-YzIh40z8P_COw1o3E6ia1TyccCgG6s&e=> 
>> > 
>> > 
>> > 
>> > ________________________________
>> > 
>> > 
>> > Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto: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 <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=5V3n9f1ytaSPKQbWMZOW2GkF_vkkqnPJLp1JJMn6ZZM&e=> 
>> > 
>> > or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG <mailto: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 <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=EaU2i68jHpk2S3JhM8fpMrn1L9YYBvOy5agpqnnA604&e=>
>> > 
>> > 
>> > Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
>> > 
>> > To learn more about SIDM visit:
>> > http://www.improvediagnosis.org/ <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=43jkrdUr106iy8uhoaBezPfdEX9nJEDPBA6lM6WcPHg&e=>
>> > 
>> > 
>> > To unsubscribe from the IMPROVEDX:
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>> > 
>> > http://LIST.IMPROVEDIAGNOSIS.ORG/ <https://urldefense.proofpoint.com/v2/url?u=http-3A__LIST.IMPROVEDIAGNOSIS.ORG_&d=DwQFaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=bzfQvFbX-DGLI15CQVkhAVwcVqc3vIixKtMkt86H3Mw&s=5caDkmlIGz8499PW-1U2sqDXD54f4c07EpzB836hsiw&e=> (with your password)
>> > 
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>> > 
>> > Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine
>> > 
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>> > </p>
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>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
>> 
>> To learn more about SIDM visit:
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>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
>> 
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/ <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_&d=DwMF-g&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=Qo6TafT5V-QOIW0iyBYTO3I9cCWfv7o8vZ51RcdbyGI&s=HXLVNAWKod8bH13DWV8jbjar1DL9YJsCvooc3wiE8cc&e=>
> 
> 
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> To unsubscribe from IMPROVEDX: click the following link:
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
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> 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/>






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