Bedside diagnosis

Peggy Zuckerman peggyzuckerman at GMAIL.COM
Thu Feb 21 05:10:53 UTC 2019


Why doesn't this begin with an annual measurement of the level of hearing
in doctors using stethoscopes?  This may impell a few to recognize that one
can lose hearing over a period of time, and be completely unaware of it,
and also that that there are hearing devices...etc.
Peggy Zuckerman
www.peggyRCC.com


On Wed, Feb 20, 2019 at 8:54 PM ROBERT M BELL <
0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:

> Thanks Tom,
>
> Are there studies comparing different groups of HCPs looking at say high
> frequency hearing loss vs normal hearing in a group of same year residents?
> And, then do the same study without and through clothing.
>
> Do the radiologists, ED physicians and others have a rough idea of how
> often physicians are incorrect with their physical exams including
> stethoscope use.
> From my perspective the stethoscope is a misleading instrument.
>
> I am sure bias is important, but I think with bias issues it will take
> forever to get unanimity on the best ways to change practice and save lives.
>
> By focussing on all the things around us and tidying those up there is a
> good chance that we could start saving lives fairly soon. Particularly with
> dynamic leadership.
>
> And if you did some basic studies that show the benefits and lives saved
> we could start saving lives even quicker quickly - particularly if we did
> it the Pronovost way!
>
> Dr. Hoffer pointed out how badly doctors did with cardiac auscultation. So
> there is one reporter!
>
> Are there enough similar stethoscope studies that could be used together
> to get a better idea of how inaccurate the stethoscope is in certain hands
> and ears?
>
> Rob Bell
>
> On Feb 20, 2019, at 8:30 AM, Tom Benzoni <benzonit at GMAIL.COM> wrote:
>
> Dr. Bell:
> We do have the data, we just don't use it properly.
> Nor do we recognize it's value.
> I'd recommend John Brush's *The Science of the Art of Medicine*
> I own few physical books (Kahneman, Groopman, Gawande among them) and this
> book has taken up residence on my shelves.
> (I have a few hundred years of reading electronically, though...)
>
> E.g., a test for a serious disease is very sensitive (no false negatives)
> but at the cost of false (+) of 5%. The disease incidence in the population
> studied is 1:1000. You patient is (+). What is the likelihood they have the
> disease in question?
> This is a 6th grade algebra question. It just looks hard.
>
> I think the real problem is cognitive biases; we have the data but
> disregard it because of confirmation, recency, availability,
> representativeness, etc.
> I teach at a med school and can't get traction on inserting a workshop
> here; blind spot bias?
> (Funny thing, I get a lot of requests from EMS for a talk on cognition;
> maybe because they suffer direct consequences of bad decisions.)
>
> tom benzoni
>
>
>
> On Wed, Feb 20, 2019 at 9:06 AM Robert Bell <rmsbell200 at yahoo.com> wrote:
>
>> Thanks Tom,
>>
>> Why do we not know the accuracy in different groups of the most
>> frequently used diagnostic test in medicine.
>>
>> The stethoscope has been around for 200+ years!
>>
>> What are the obstacles?
>>
>> Rob
>>
>> On Tuesday, February 19, 2019, 11:43:23 AM MST, Tom Benzoni <
>> benzonit at GMAIL.COM> wrote:
>>
>>
>> This interests me.
>> I use an electronic stethoscope with Bluetooth capability.
>> This is great to share sounds with students and residents which their
>> young ears don't discern.
>>
>> I find, however, what is between the stethoscope ear pieces is much more
>> important.
>> That's where the age issue comes to fore.
>> The knowledge in a head that's "seen 3 of these" is not measured.
>> So I'd approach decisions not based on evidence with the same reticence
>> we'd show following any guidance not based on, well, evidence. Do you
>> really know what you think you know?
>> Do we ascribe  ordering too many CTs for PEs that aren't there to youth
>> and inexperience, requiring corrective action?
>>
>> tom benzoni
>>
>> On Mon, Feb 18, 2019, 23:16 Peggy Zuckerman <peggyzuckerman at gmail.com>
>> wrote:
>>
>> How hard would it be to get someone to attach a stethoscope to an iPhone
>> with a good little microphone.  And what happens to the older doctor whose
>> hearing is slowly diminishing...does he not miss more and more things?  Any
>> studies on this?
>> Peggy Zuckerman
>> www.peggyRCC.com <http://www.peggyrcc.com/>
>>
>>
>> On Mon, Feb 18, 2019 at 3:41 PM ROBERT M BELL <
>> 0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:
>>
>> Thanks David,
>>
>> Excellent piece, thanks for sending - history and examination are so
>> vitally important. The comment of "fighting through two gowns was
>> interesting."
>>
>> I would think that SIDM alone, or maybe in collaboration with others,
>> could do wonders for medicine by defining the accuracy of the stethoscope
>> among HCPs with differing skills, experience and hearing loss.
>>
>> I would also predict that the results and recommendations would be pretty
>> mind blowing!
>>
>> Rob Bell, M.D.
>>
>> On Feb 18, 2019, at 2:45 PM, David L Meyers <dm0015 at COMCAST.NET> wrote:
>>
>> A very interesting article on some realities of beside medicine, raised
>> by Rob Bell and others on the listserv in the past.
>>
>> David
>> David L Meyers, MD FACEP
>> Society to Improve Diagnosis in Medicine
>> Listserv Moderator/Board member
>> www.improvediagnosis.org
>> Save the Dates: Diagnostic Error in Medicine Conference (DEM2019),
>> November 10-13, 2019 at Hyatt Regency Washington, DC (Capitol Hill)
>> AusDEM2019, April 28-30, 2019; Melbourne, Aus
>>
>>
>> https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2724394?guestAccessKey=a76c424d-dd3d-4d63-8ed8-70af67b2ca89&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=021819
>> <
>> https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2724394?guestAccessKey=a76c424d-dd3d-4d63-8ed8-70af67b2ca89&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=021819
>> >
>>
>> The “Hemolyzed” Physical Examination—Situational Challenges to Accurate
>> Bedside Diagnosis
>>
>> A page comes in from downstairs—another admission. A 41-year-old postal
>> worker in bed 22, presented with severe back pain and needs pain control
>> and a physical therapy evaluation. Three weeks ago, he was lifting a box
>> when he felt a sharp pain in the middle of his lower back. The pain has not
>> decreased, despite his taking naproxen around the clock. I look at the
>> vital signs: temperature, 99°; pulse, 92 bpm; pressure, 140/90 mm Hg;
>> respirations and oxygen saturation, normal. Nothing stands out as I click
>> through the laboratory results.
>>
>> I look for this patient among the closely spaced cots in the emergency
>> department. Before I can find him, I see another man in bed 18 whimpering
>> in pain. I look at the cluster of computers where the nurses are charting;
>> his nurse gives me a nod—“I know. I’m coming.” In bed 21, I recognize a
>> woman behind a bilevel positive airway pressure (BiPAP) mask. She smiles
>> weakly. In bed 22, the patient shivers under a blanket.
>>
>> Another page comes in for another admission. I will call back as soon as
>> I finish here.
>>
>> The patient tells me that he has been shivering like this on and off for
>> several weeks. However, what bothers him most is his back, and he worries
>> he might lose his job if he does not get better. I gather some more history
>> and move on to the examination. He looks tired, but his eyes, hands, nails,
>> and teeth look healthy. His neck veins are normal. His lungs are quiet but
>> clear—I think. I move on to listen to his heart, fighting through 2 gowns
>> and an undershirt. I settle, trying to at least flatten any folds out of
>> the way. I do not hear much, and I close my eyes to try to focus. I am
>> struck by how much noise surrounds me. The cacophony of alarms, the BiPAP
>> machine for the other patient, a patient with delirium yelling out to no
>> one in particular. I open my eyes. He is shivering again—my cue to move on.
>> His belly is soft, and his back is tender over the mid lumbar spine and
>> surrounding muscles.
>>
>> Another page, another admission. I quickly put in orders for the patient
>> and go to see the other patients—I am now 2 behind.
>>
>> Three hours later, I write my admission notes for this patient. Physical
>> findings: “Lungs—diminished breath sounds, otherwise clear. Heart…” I
>> pause, trying to remember what I had heard. Nothing echoes in my mind. I
>> rub my eyes and look at the corner of the screen. It is almost 3:00 am. “JV
>> [jugular veins] flat. RRR [regular rate and rhythm], no MRG [murmurs, rubs,
>> or gallops].”
>>
>> I finish my notes in time for the next admission, a woman with black
>> stools and lightheadedness. Her vital signs are stable after receiving some
>> fluids. I click through her laboratory results. Hemoglobin is a bit lower
>> than her baseline. Chemistry results are normal except that her potassium
>> is 6.3 mmol/L, with a comment that the blood specimen is “grossly
>> hemolyzed.” I order a repeat metabolic panel.
>>
>> On my way to see her, I notice a room on the floor labeled with the
>> patient’s name. I stop in to check on his pain. The medicine has improved
>> his pain, and he is hoping to finally rest, because “it’s so nice and quiet
>> up here.” I look back at the closed door hiding the hallway. It is quiet. I
>> ask the patient if I can listen to him again. He is able to move better and
>> sits up on the edge of the bed. I untie his gowns and apologize for my cold
>> stethoscope on his skin. I hear a systolic murmur over his apex and axilla.
>> It is not subtle. I listen to his lungs again, hearing faint crackles at
>> the left base and right mid lung. I look again in his mouth, at his palate,
>> and see some petechiae.
>>
>> The patient’s echocardiogram the next day shows a large mitral valve
>> vegetation. A magnetic resonance image of his lumbar spine shows
>> osteomyelitis and diskitis as the cause of his pain. He began to improve
>> with antibiotics and supportive care and eventually required a valve
>> replacement.
>>
>> Several recent reviews and commentaries reflect a renewed interest in
>> bedside medicine, including physical diagnosis.1-5 Some reviews remind us
>> that certain aspects of the physical examination are irreplaceable in terms
>> of the information they confer and the human connection they foster with
>> the patient.4 Other reviews are more technical, providing data about test
>> characteristics of specific maneuvers and outlining concepts such as
>> likelihood ratios of examination findings.5
>>
>> An important aspect of physical diagnosis requires more attention—context
>> specificity. When referencing sensitivities, specificities, and likelihood
>> ratios of various examination findings, we should recognize that they are
>> not universal or static. The percentages reported in the literature are
>> averages across hundreds of patients, clinicians, and techniques. Even when
>> the clinician and patient are the same, circumstance can change everything.
>> When the blood sample of my other patient was hemolyzed, I was quick to
>> regard the test as spoiled and repeat it. But the other set of tests—my
>> physical examination of the patient—was also spoiled by noise, distraction,
>> poor positioning, and haste. Only serendipity led me to repeat the physical
>> examination that had been “hemolyzed.” Instead, we should be attentive to
>> situational impediments to accurate bedside test results. Sometimes we can
>> optimize the situation in the moment. Other times we may need to repeat the
>> test under improved circumstances, or we may simply acknowledge that a
>> particular test did not influence the diagnostic process. “JV flat. RRR.
>> Exam for any abnormal sounds limited.”
>>
>> The notion that physical examination test characteristics are variable
>> and dynamic adds to the uncertainty that already challenges clinicians
>> every day. Yet this variability can also motivate us to improve our
>> personal examination skills. The reported sensitivity of a new murmur in
>> the diagnosis of endocarditis may be as high as 85%.6 But what is the
>> sensitivity of murmur for endocarditis through your stethoscope, in this
>> patient, in that moment, under those conditions? And can you improve it
>> instead of settling for a hemolyzed examination?
>>
>>
>>
>> Article Information
>>
>> Corresponding Author: Zaven Sargsyan, MD, Department of Medicine, Baylor
>> College of Medicine, 1504 Taub Loop, 2RM81-001A-F, MS: BCM285, Houston, TX
>> 77030 (zavens at bcm.edu <mailto:zavens at bcm.edu <zavens at bcm.edu>>).
>>
>> Published Online: February 18, 2019. doi:10.1001/jamainternmed.2018.8753 <
>> http://jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2018.8753>
>> Conflict of Interest Disclosures: None reported.
>>
>> Additional Contributions: I thank Chana Sacks, MD, Massachusetts General
>> Hospital, Boston, Massachusetts, and Ricardo Nuila, MD, Baylor College of
>> Medicine, Houston, Texas for reviewing earlier drafts of this article. They
>> received no compensation for their contributions. I thank this patient for
>> the lessons he taught me.
>>
>> Additional Contributions: We thank the patient for granting permission to
>> publish this information.
>>
>> <>References
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>
>> http://LIST.IMPROVEDIAGNOSIS.ORG/ <http://list.improvediagnosis.org/>
>> (with your password)
>>
>>
>> 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"
>> target="_blank">
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>> </a>
>> </p>
>>
>> *From: *David L Meyers <dm0015 at comcast.net>
>> *Subject: **The “Hemolyzed” Physical Examination—Situational Challenges
>> to Accurate Bedside Diagnosis*
>> *Date: *February 18, 2019 at 4:40:59 PM EST
>> *To: *Society to Improve Diagnosis in Medicine <
>> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>>
>>
>> A very interesting article on some realities of beside medicine raised by
>> Rob bell and others on the listserv in the past.
>>
>> David
>> David L Meyers, MD FACEP
>> Society to Improve Diagnosis in Medicine
>> Listserv Moderator/Board member
>> www.improvediagnosis.org
>> Save the Dates: Diagnostic Error in Medicine Conference (DEM2019),
>> November 10-13, 2019 at Hyatt Regency Washington, DC (Capitol Hill)
>> AusDEM2019, April 28-30, 2019; Melbourne, Aus
>>
>>
>>
>> https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2724394?guestAccessKey=a76c424d-dd3d-4d63-8ed8-70af67b2ca89&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=021819
>>
>> The “Hemolyzed” Physical Examination—Situational Challenges to Accurate
>> Bedside Diagnosis
>>
>> A page comes in from downstairs—another admission. A 41-year-old postal
>> worker in bed 22, presented with severe back pain and needs pain control
>> and a physical therapy evaluation. Three weeks ago, he was lifting a box
>> when he felt a sharp pain in the middle of his lower back. The pain has not
>> decreased, despite his taking naproxen around the clock. I look at the
>> vital signs: temperature, 99°; pulse, 92 bpm; pressure, 140/90 mm Hg;
>> respirations and oxygen saturation, normal. Nothing stands out as I click
>> through the laboratory results.
>>
>> I look for this patient among the closely spaced cots in the emergency
>> department. Before I can find him, I see another man in bed 18 whimpering
>> in pain. I look at the cluster of computers where the nurses are charting;
>> his nurse gives me a nod—“I know. I’m coming.” In bed 21, I recognize a
>> woman behind a bilevel positive airway pressure (BiPAP) mask. She smiles
>> weakly. In bed 22, the patient shivers under a blanket.
>>
>> Another page comes in for another admission. I will call back as soon as
>> I finish here.
>>
>> The patient tells me that he has been shivering like this on and off for
>> several weeks. However, what bothers him most is his back, and he worries
>> he might lose his job if he does not get better. I gather some more history
>> and move on to the examination. He looks tired, but his eyes, hands, nails,
>> and teeth look healthy. His neck veins are normal. His lungs are quiet but
>> clear—I think. I move on to listen to his heart, fighting through 2 gowns
>> and an undershirt. I settle, trying to at least flatten any folds out of
>> the way. I do not hear much, and I close my eyes to try to focus. I am
>> struck by how much noise surrounds me. The cacophony of alarms, the BiPAP
>> machine for the other patient, a patient with delirium yelling out to no
>> one in particular. I open my eyes. He is shivering again—my cue to move on.
>> His belly is soft, and his back is tender over the mid lumbar spine and
>> surrounding muscles.
>>
>> Another page, another admission. I quickly put in orders for the patient
>> and go to see the other patients—I am now 2 behind.
>>
>> Three hours later, I write my admission notes for this patient. Physical
>> findings: “Lungs—diminished breath sounds, otherwise clear. Heart…” I
>> pause, trying to remember what I had heard. Nothing echoes in my mind. I
>> rub my eyes and look at the corner of the screen. It is almost 3:00 am.
>> “JV [jugular veins] flat. RRR [regular rate and rhythm], no MRG [murmurs,
>> rubs, or gallops].”
>>
>> I finish my notes in time for the next admission, a woman with black
>> stools and lightheadedness. Her vital signs are stable after receiving some
>> fluids. I click through her laboratory results. Hemoglobin is a bit lower
>> than her baseline. Chemistry results are normal except that her potassium
>> is 6.3 mmol/L, with a comment that the blood specimen is “grossly
>> hemolyzed.” I order a repeat metabolic panel.
>>
>> On my way to see her, I notice a room on the floor labeled with the
>> patient’s name. I stop in to check on his pain. The medicine has improved
>> his pain, and he is hoping to finally rest, because “it’s so nice and quiet
>> up here.” I look back at the closed door hiding the hallway. It *is*
>> quiet. I ask the patient if I can listen to him again. He is able to move
>> better and sits up on the edge of the bed. I untie his gowns and apologize
>> for my cold stethoscope on his skin. I hear a systolic murmur over his apex
>> and axilla. It is not subtle. I listen to his lungs again, hearing faint
>> crackles at the left base and right mid lung. I look again in his mouth, at
>> his palate, and see some petechiae.
>>
>> The patient’s echocardiogram the next day shows a large mitral valve
>> vegetation. A magnetic resonance image of his lumbar spine shows
>> osteomyelitis and diskitis as the cause of his pain. He began to improve
>> with antibiotics and supportive care and eventually required a valve
>> replacement.
>>
>> Several recent reviews and commentaries reflect a renewed interest in
>> bedside medicine, including physical diagnosis.1-5 Some reviews remind
>> us that certain aspects of the physical examination are irreplaceable in
>> terms of the information they confer and the human connection they foster
>> with the patient.4 Other reviews are more technical, providing data
>> about test characteristics of specific maneuvers and outlining concepts
>> such as likelihood ratios of examination findings.5
>>
>> An important aspect of physical diagnosis requires more attention—context
>> specificity. When referencing sensitivities, specificities, and likelihood
>> ratios of various examination findings, we should recognize that they are
>> not universal or static. The percentages reported in the literature are
>> averages across hundreds of patients, clinicians, and techniques. Even when
>> the clinician and patient are the same, circumstance can change everything.
>> When the blood sample of my other patient was hemolyzed, I was quick to
>> regard the test as spoiled and repeat it. But the other set of tests—my
>> physical examination of the patient—was also spoiled by noise, distraction,
>> poor positioning, and haste. Only serendipity led me to repeat the physical
>> examination that had been “hemolyzed.” Instead, we should be attentive to
>> situational impediments to accurate bedside test results. Sometimes we can
>> optimize the situation in the moment. Other times we may need to repeat the
>> test under improved circumstances, or we may simply acknowledge that a
>> particular test did not influence the diagnostic process. “JV flat. RRR.
>> Exam for any abnormal sounds limited.”
>>
>> The notion that physical examination test characteristics are variable
>> and dynamic adds to the uncertainty that already challenges clinicians
>> every day. Yet this variability can also motivate us to improve our
>> personal examination skills. The reported sensitivity of a new murmur in
>> the diagnosis of endocarditis may be as high as 85%.6 But what is the
>> sensitivity of murmur for endocarditis through *your* stethoscope, in
>> *this* patient, in *that* moment, under *those* conditions? And can you
>> improve it instead of settling for a hemolyzed examination?
>> Back to top
>>
>> Article Information
>>
>> *Corresponding Author:* Zaven Sargsyan, MD, Department of Medicine,
>> Baylor College of Medicine, 1504 Taub Loop, 2RM81-001A-F, MS: BCM285,
>> Houston, TX 77030 (zavens at bcm.edu).
>>
>> *Published Online:* February 18, 2019. doi:
>> 10.1001/jamainternmed.2018.8753
>> <http://jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2018.8753>
>>
>> *Conflict of Interest Disclosures:* None reported.
>>
>> *Additional Contributions:* I thank Chana Sacks, MD, Massachusetts
>> General Hospital, Boston, Massachusetts, and Ricardo Nuila, MD, Baylor
>> College of Medicine, Houston, Texas for reviewing earlier drafts of this
>> article. They received no compensation for their contributions. I thank
>> this patient for the lessons he taught me.
>>
>> *Additional Contributions: *We thank the patient for granting permission
>> to publish this information.
>>
>> References
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>
>> ------------------------------
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
>>
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>>
>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>
>>
>>
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>>
>>
>>
>>
>>
>> ------------------------------
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
>>
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>>
>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>
>>
>>
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>>
>>
>>
>> ------------------------------
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
>>
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>>
>>
>> ------------------------------
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
>>
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>>
>>
>> ------------------------------
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
>>
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>>
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
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> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
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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/
>
>
>
> ------------------------------
>
>
> 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:
> http://www.improvediagnosis.org/






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


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