Oximeters

robert bell rmsbell200 at YAHOO.COM
Mon Feb 5 18:04:51 UTC 2018


Thanks Edward,

Good points.

Do you know of any studies that are currently being done to look at the accuracy of, BP readings from different devices and the different ways a BP is taken, different stethoscopes (with different user hearing), reducing radiological errors, reducing laboratory errors, etc. etc. Are these routinely published?

Do litigation overtones hinder this kind of research? Is that why the autopsy disappeared? How do we handle that?

Osler was right!

We have a long, long way to go before we have good, more accurate information that in turn improves the current accuracy of the diagnostic process. 

Rob Bell
> On Feb 4, 2018, at 2:55 PM, Edward Winslow <edbjwinslow at GMAIL.COM> wrote:
> 
> It seems that this thread has gotten a little off track from accuracy of Oximeters. There were many great points made. One that seems to have been missed was that a single  point measurement isn't of as much value as noting changes, that might indicate something may need to be done.
> 
> We have now gotten into the question of diagnosis in clinical medicine. I mean to note that clinical medicine encompasses lab testing, but also so much more. I too believe that the beginning of the diagnostic process should begin with the very first part of the clinical encounter - the "Chief Complaint", followed by a thorough history of the illness.  At one time, my partner and I came up with some components that should in most cases be a part of the description of a symptom. Much of this was from what we were taught over 50 years ago:
> Quality of the symptom
> Severity and timing along with how the symptom limits the patient.
> Location and radiation
> Chronology
> Modifying (aggravating and relieving) factors
> Associated Symptoms
> Patient Attribution - "what do you think might be wrong, what frightens you?"
> I haven't seen an H&P recently with all of these "Sacred Seven" addressed. I believe, as did Osler, that listening to the patient will many times allow her/him to tell you what is wrong. 
> When we try to do tests without knowing about what we are testing to define, we won't do as good a job for our patients as we might.
> 
> I believe, as did the National Academies publication in 2015 (Fig S-1 and others), that the beginning of the diagnostic process depends on getting  the right information from the clinical encounter. I'm not sure that this hypothesis is testable, though.  We would need a reliable "gold standard" against which to judge the diagnostic process (did I hear someone whisper, "What happened to the autopsy?")
> 
> 
> On Sun, Feb 4, 2018 at 9:47 AM, Robert Bell <0000000296e45ec4-dmarc-request at list.improvediagnosis.org <mailto:0000000296e45ec4-dmarc-request at list.improvediagnosis.org>> wrote:
> Dear David and others on this thread,
> 
> I would have thought that in medicine nearly every supportive test, evaluation we use has a number of things necessary to make them as accurate as possible, be it a lab test, radiological evaluation, physical examination, patient history, etc. And with some things we do we may not have well worked out the best way to do things to achieve accuracy. That surely is the evolutionary way of medicine. The one comment I would add is that change is all far to slow. I have been mentioning this about this for 35 plus years and little has happened. Yes, we do have different types of BP machines, but which is the best? And nothing seems to well substitute for the many recommendations to obtain an accurate BP measurement.
> 
> It seems we are still evolving. As this is such a big part of what we do, it would seem that there should be a high powered Think Tank group overseeing the topic, and perhaps even others, and making appropriate recommendations from time to time. But right now it is a disaster with I suspect thousands/millions of mis-diagnoses being made each year in the US alone.
> 
> I definitely believe in a culture of excellence as Tom strongly supports - but where does time factor in?
> 
> Rob Bell
> 
> Sent from my iPad
> 
> On Feb 1, 2018, at 8:45 AM, David Katz <d.katz at MAIL.UTORONTO.CA <mailto:d.katz at mail.utoronto.ca>> wrote:
> 
>> Wouldn’t an easier way to fix this problem be to reduce the number steps needed to accurately check the BP?
>> Do we really know if all 11 steps are necessary?
>> I find it hard to believe that there are more steps to checking a blood pressure than items on a central line checklist.
>> What is important is not that we achieve a specific number. What is important is that we all do it the same way. Any procedure that includes 11 steps, with some of them being so mundane, is going to lead to wide variety in practice.
>> 
>> 
>> David Katz MD FRCPC MSc
>> Adult Critical Care Medicine
>> Internal Medicine
>> 
>> On Jan 31, 2018, 9:49 PM -0500, hszerlip at gmail.com <mailto:hszerlip at gmail.com> <hszerlip at GMAIL.COM <mailto:hszerlip at gmail.com>>, wrote:
>>> Unfortunately most clinicians also 
>>> Fall short in taking BP. As our colleagues in other countries have learned, BP is best taken automatically after the patient has been allowed to relax and without a clinician in the room. 
>>> 
>>> Harold Szerlip, MD
>>> Director, Nephrology Division 
>>> Baylor University Medical Center, Dallas
>>> Sent from my iPhone
>>> 
>>> On Jan 31, 2018, at 4:40 PM, robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG <mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:
>>> 
>>>> Thanks Tom,
>>>> 
>>>> I checked on the JAMA Med Student blood pressure report - pretty awful. Here is the link to the JAMA network summary.
>>>> 
>>>> https://jamanetwork.com/journals/jama/article-abstract/2653029?redirect=true <https://jamanetwork.com/journals/jama/article-abstract/2653029?redirect=true>
>>>> 
>>>> Only 1 out of 159 medical students scored 100% on all elements of the BP challenge. Of the 11 elements the average score for all students was 4.1!
>>>> 
>>>> What does that say about the State of the Medical Industry!
>>>> 
>>>> Yes, it may be worse for the average HCP. I would be interested to know what it would have been at foreign medical schools.
>>>> 
>>>> I agree with the idea of focussing on the small things first to establish a culture. However I do think that culture needs some direction from above. 
>>>> 
>>>> And with bottom line concern that is not always possible.
>>>> 
>>>> Would it be worthwhile to triage the main problems and focus on them with or without help from other societies?  If we do not do this what will happen?
>>>> 
>>>> Will more people be placed on BP medicines when they do not need it, with this adding to the errors in diagnosis? 
>>>> 
>>>> Thanks again for your fine replies.
>>>> 
>>>> Rob
>>>> 
>>>> 
>>>>> On Jan 31, 2018, at 10:19 AM, Tom Benzoni <benzonit at gmail.com <mailto:benzonit at gmail.com>> wrote:
>>>>> 
>>>>> I'd focus on the rampant, low-level, constantly-tolerated, worked-around errors.
>>>>> These create an atmosphere wherein errors are ok.
>>>>> Given human behavior, "We're ok with doing small jobs badly; we want big jobs done right."is the philosophy of failure.
>>>>> Big jobs are based on small jobs.
>>>>> 
>>>>> It's also simple math: the result of any process cannot be more precise than the least precise of its components. (There are myriad sayings: weakest link, slowest runner, etc.)
>>>>> 
>>>>> Excellence built into the system percolates up; it cannot drizzle down.
>>>>> 
>>>>> tom
>>>>> 
>>>>> On Wed, Jan 31, 2018 at 9:58 AM, Robert Bell <rmsbell200 at yahoo.com <mailto:rmsbell200 at yahoo.com>> wrote:
>>>>> Dear Tom,
>>>>> 
>>>>> Thanks - appreciate your illuminating comments/thoughts. If all errors, including diagnostic, are at times inter-related how does the diagnostic error movement move forward? Focus on the commonest problems/combinations or focus on those that produce the greatest damage? Or all. A massive big challenge.
>>>>> 
>>>>> Rob
>>>>> 
>>>>> 
>>>>> Sent from my iPad
>>>>> 
>>>>> On Jan 31, 2018, at 8:04 AM, Tom Benzoni <benzonit at gmail.com <mailto:benzonit at gmail.com>> wrote:
>>>>> 
>>>>>> Dr. Bell:
>>>>>> It's not well known, and is a double tragedy.
>>>>>> Clinicians get beat up over endangering a patient when there was no expectant danger.
>>>>>> This has the odd effect of causing interventions when none is warranted and making people less cognitive/aware.
>>>>>> The way I know it is not well known: Hospitals have pages long protocols for procedural sedation, many written, in my not-very-humble opinion, to protect margins, and i've never seen this error discussed. (Don't make them aware; it's a marker I use for situational awareness.)
>>>>>> 
>>>>>> You've only scratched the surface of errors in BP readings. JAMA had a recent paper discussing med student errors in measurement.
>>>>>> Fortunately, they didn't study attendings or nurses in practice; it would have been worse.
>>>>>> And nowhere so I see awareness that automated cuffs do not measure BP; they find first turbulent flow (approximately MAP) then, using proprietary algorithms, calculate a systolic and diastolic. Find that method in AHA guidelines?
>>>>>> I helped write, many years ago, the original ACEP guidelines to NOT normalize/treat asymptomatic BP elevations found in the ER. (Full-on discussion behind that one separately.)
>>>>>> 
>>>>>> If we tolerate this low level error systematically, how can we expect to address the large/few errors?
>>>>>> High frequency-low consequence errors are arguably of greater import than low frequency-high consequence ones; driving to the airport caries greater risk of death than the flight itself.
>>>>>> 
>>>>>> tom
>>>>>>  
>>>>>> 
>>>>>> On Tue, Jan 30, 2018 at 10:21 PM, Robert Bell <0000000296e45ec4-dmarc-request at list.improvediagnosis.org <mailto:0000000296e45ec4-dmarc-request at list.improvediagnosis.org>> wrote:
>>>>>> Thanks Tom,
>>>>>> 
>>>>>> That is something to consider. How many HCPs know about that? 
>>>>>> 
>>>>>> What about, Ipsilateral sphygmomanometer cuff - oximeter reading error!!
>>>>>> 
>>>>>> And do not get me started on the frequency with which blood pressures are taken with the wrong sphygmomanometer cuff size, and through clothing (some times thick). 
>>>>>> 
>>>>>> I have in my postings to the list here always been interested in the level of error in the things we do to help us with diagnoses. I strongly believe that we need, to not only be improving our diagnostic abilities, but also work to improve the errors of support tools at the same time. Both need to be worked upon to get to our goal of significant reductions in diagnostic error. That could be done with partnering with another society or societies, more dedicated to standard errors, with time related goals to help get there soon.
>>>>>> 
>>>>>> Robert Bell
>>>>>> 
>>>>>> On Tuesday, January 30, 2018, 2:57:56 PM MST, Tom Benzoni <benzonit at GMAIL.COM <mailto:benzonit at GMAIL.COM>> wrote:
>>>>>> 
>>>>>> 
>>>>>> Orthopedic changes do not effect them.
>>>>>> Skin thickness does not but we don't use these over callused areas.
>>>>>> They can read black skin. Melanin has a different spectral absorption.
>>>>>> Very cold extremities where the capillary beds are clamped down can cause erroneous readings as can patients in extremis from end-stage myocardial disease...but don't need a pulse ox there.
>>>>>> An interesting error source comes from blood pressure cuffs. Because the cuffs are usually set to automatic, intermittent low readings occur not from the patient but from temporary occlusion of the artery by the cuff if on the ipsilateral arm. If you're not aware of this error source, you can think the patient on whom you're doing a procedure is in trouble when they're fine. And you might terminate the procedure or make an unnecessary intervention on a well person.
>>>>>> What is that type of error?
>>>>>> 
>>>>>> tom
>>>>>> 
>>>>>> On Mon, Jan 29, 2018 at 11:49 PM, robert bell <0000000296e45ec4-dmarc-request at list.improvediagnosis.org <mailto:0000000296e45ec4-dmarc-request at list.improvediagnosis.org>> wrote:
>>>>>> I was thinking also of the accuracy in elderly patients with osteoarthritis, bent fingers, and soft skin versus hard thickened skin and also the differences with different fingers.
>>>>>> 
>>>>>> Yes, alarms are a problem.
>>>>>> 
>>>>>> Rob Bell, M.D.
>>>>>> > On Jan 29, 2018, at 3:11 PM, Rory Jaffe <rjaffe at CHPSO.ORG <mailto:rjaffe at CHPSO.ORG>> wrote:
>>>>>> >
>>>>>> > Interpretation is a big issue. Pulse oximetry is very insensitive to hypoventilation when a patient is on supplemental O2. Also tends to have lots of false alarms--the default limits are not very usable and ideally, people would use patient-specific alarm limits.
>>>>>> >
>>>>>> > -----Original Message-----
>>>>>> > From: Grubenhoff, Joe [mailto:Joe.Grubenhoff@ CHILDRENSCOLORADO.ORG <mailto:Joe.Grubenhoff at CHILDRENSCOLORADO.ORG>]
>>>>>> > Sent: Monday, January 29, 2018 8:55 AM
>>>>>> > To: IMPROVEDX at LIST. IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>>>>>> > Subject: [No SPF Record] Re: [IMPROVEDX] Oximeters
>>>>>> >
>>>>>> > Pretty accurate in my experience - the problem may be in how this single value is interpreted in the context of the whole clinical picture:
>>>>>> >
>>>>>> >
>>>>>> >
>>>>>> > Effect of Oxygen Desaturations on Subsequent Medical Visits in Infants Discharged From the Emergency Department With Bronchiolitis.
>>>>>> >
>>>>>> > Principi T, Coates AL, Parkin PC, Stephens D, DaSilva Z, Schuh S.
>>>>>> >
>>>>>> > JAMA Pediatr. 2016 Jun 1;170(6):602-8. doi: 10.1001/jamapediatrics.2016. 0114.
>>>>>> >
>>>>>> >
>>>>>> >
>>>>>> > Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial.
>>>>>> >
>>>>>> > Schuh S, Freedman S, Coates A, Allen U, Parkin PC, Stephens D, Ungar W, DaSilva Z, Willan AR.
>>>>>> >
>>>>>> > JAMA. 2014 Aug 20;312(7):712-8. doi: 10.1001/jama.2014.8637.
>>>>>> >
>>>>>> >
>>>>>> >
>>>>>> >
>>>>>> >
>>>>>> > On 1/29/18, 09:49, "Robert Bell" <0000000296e45ec4-dmarc- request at LIST.IMPROVEDIAGNOSIS. ORG <mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:
>>>>>> >
>>>>>> >
>>>>>> >
>>>>>> >    How accurate are oximeters? Are the errors big enough to make wrong decisions?
>>>>>> >
>>>>>> >
>>>>>> >
>>>>>> >    Rob Bell, M. D.
>>>>>> >
>>>>>> >
>>>>>> >
>>>>>> >    Sent from my iPad
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>>>>>> > To unsubscribe from the IMPROVEDX list, click the following link:<br>
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>>>>>> > <a href="https://urldefense. proofpoint.com/v2/url?u=http- 3A__list.improvediagnosis.org_ scripts_wa-2DIMPDIAG.exe- 3FSUBED1-3DIMPROVEDX-26A-3D1& d=DwIGaQ&c=hx0HUg_nG- xRkKlwWZeJFCbvzzw0Ym5DwdL_ 1FKbReI&r= ykcs2wU25yxj5BckI49bSg&m= QIkoLzICpYYYnJV71LxRMewHHWap0B 4fISMAF5CYMLo&s= lyvKwnUZgRPBhfNCIu9JFtzglcSuGj DtA4pR1Q6eZFA&e= <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1&d=DwIGaQ&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=QIkoLzICpYYYnJV71LxRMewHHWap0B4fISMAF5CYMLo&s=lyvKwnUZgRPBhfNCIu9JFtzglcSuGjDtA4pR1Q6eZFA&e=>" target="_blank">https:// urldefense.proofpoint.com/v2/ url?u=http-3A__list. improvediagnosis.org_scripts_ wa-2DIMPDIAG.exe-3FSUBED1- 3DIMPROVEDX-26A-3D1&d=DwIGaQ& c=hx0HUg_nG- xRkKlwWZeJFCbvzzw0Ym5DwdL_ 1FKbReI&r= ykcs2wU25yxj5BckI49bSg&m= QIkoLzICpYYYnJV71LxRMewHHWap0B 4fISMAF5CYMLo&s= lyvKwnUZgRPBhfNCIu9JFtzglcSuGj DtA4pR1Q6eZFA&e= <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1&d=DwIGaQ&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=QIkoLzICpYYYnJV71LxRMewHHWap0B4fISMAF5CYMLo&s=lyvKwnUZgRPBhfNCIu9JFtzglcSuGjDtA4pR1Q6eZFA&e=></a>
>>>>>> >
>>>>>> > </p>
>>>>>> >
>>>>>> >
>>>>>> > To unsubscribe from the IMPROVEDX:
>>>>>> > mail to:IMPROVEDX-SIGNOFF-REQUEST@ LIST.IMPROVEDIAGNOSIS.ORG <mailto:to%3AIMPROVEDX-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>
>>>>>> >
>>>>>> > For additional information and subscription commands, visit:
>>>>>> > http://www.lsoft.com/ resources/faq.asp#4A <http://www.lsoft.com/resources/faq.asp#4A>
>>>>>> >
>>>>>> > http://LIST.IMPROVEDIAGNOSIS. ORG/ <http://list.improvediagnosis.org/> (with your password)
>>>>>> >
>>>>>> > 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 to Improve Diagnosis in Medicine
>>>>>> >
>>>>>> > To unsubscribe from the IMPROVEDX list, click the following link:<br>
>>>>>> > <a href="http://list. improvediagnosis.org/scripts/ wa-IMPDIAG.exe?SUBED1= IMPROVEDX&A=1 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>" target="_blank">http://list. improvediagnosis.org/scripts/ wa-IMPDIAG.exe?SUBED1= IMPROVEDX&A=1 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1></a>
>>>>>> > </p>
>>>>>> 
>>>>>> To unsubscribe from the IMPROVEDX:
>>>>>> mail to:IMPROVEDX-SIGNOFF-REQUEST@ LIST.IMPROVEDIAGNOSIS.ORG <mailto:to%3AIMPROVEDX-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>
>>>>>> 
>>>>>> For additional information and subscription commands, visit:
>>>>>> http://www.lsoft.com/ resources/faq.asp#4A <http://www.lsoft.com/resources/faq.asp#4A>
>>>>>> 
>>>>>> http://LIST.IMPROVEDIAGNOSIS. ORG/ <http://list.improvediagnosis.org/> (with your password)
>>>>>> 
>>>>>> 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 to Improve Diagnosis in Medicine
>>>>>> 
>>>>>> To unsubscribe from the IMPROVEDX list, click the following link:<br>
>>>>>> <a href="http://list. improvediagnosis.org/scripts/ wa-IMPDIAG.exe?SUBED1= IMPROVEDX&A=1 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>" target="_blank">http://list. improvediagnosis.org/scripts/ wa-IMPDIAG.exe?SUBED1= IMPROVEDX&A=1 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1></a>
>>>>>> </p>
>>>>>> 
>>>>>> 
>>>>>> 
>>>>>> 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 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1> 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 <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 <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 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1> 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 <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 <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 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>
>>>> 
>>>> 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 <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 <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 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>
>>> 
>>> 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 <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 <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 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>
>> 
>> 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 <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 <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 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1> 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 <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/>
> 
> 
> -- 
> Edward B, J. Winslow, MD, MBA
> Home 847 256-2475; Mobile 847 508-1442
> edbjwinslow at gmail.com <mailto:edbjwinslow at gmail.com>
> winslowmedical.com <http://winslowmedical.com/>
> 
> "The only thing new in the world is the history that you don't know"
>        Harry S. Truman, 33rd President of US (1945-1953)
>   
> 
> "... it can be argued that underinvestment in assessing the past is likely to
> lead to faulty estimates and erroneous prescriptions for future action."
>         Eli Ginzberg, 1997
> 
> 
> 
> 
> 
> 
> 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
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> 
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
> 







Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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