IMreasoning

 

Conversations to inspire critical thinking in clinical medicine and education

 

Welcome to IM Reasoning with your hosts Dr. Art Nahill and Dr. Nic Szecket, two general internists with a passion for teaching clinical reasoning. Join us for case discussions, conversations and interviews that explore issues important to medical students, trainees and practitioners of clinical medicine, with a special focus on clinical reasoning, the once-mysterious process behind the remarkable abilities of the master clinician.

ASHM_DiagnosticError_RegoFlyer_A4_2PP_WEB

61 Comments

  1. HI Art and Nic

    I love the site – great idea and interesting and stimulating topics.

    regards

    Margaret

    Reply

  2. Are you interested in patient experiences?
    I am an RN/patient who developed a problem which no doctor was able
    to correctly diagnose or treat (fortunately a PT knew what was going on).
    17 months of misdiagnosis! Bursitis, tendonitis, hernia of the tensor fascia lata,
    were some misdiagnoses. One doctor thought the bump had always been there, but I’d just never noticed it. He was wrong too.

    I don’t want to see this happen to other patients. I’d like to see us educate ourselves, then our patients. Had I been so educated at the time of surgery,
    I could have prevented this from happening altogether. If you want to know more, I will share it with you. Just let me know. Sue

    Reply

  3. Art and Nic
    I’m a Paediatrician from Australia with an interest in diagnostic error. Well done for your podcasts. I’m back at SIDM this year and would like to catch up if possible

    Reply

  4. Many thanks for this site, and especially for the podcasts.
    RE the definition of diagnostic error – the importance of checking the diagnostic impression against the patient’s experience of the illness can’t be overemphasized. But perhaps the definition would better include a qualifier, like “appropriate” communication, to the patient. There are always some patients for whom too much information, or too much too soon, can itself be an error, can exacerbate the illness, can create a new diagnosis…

    Reply

  5. Just listened to your last two episodes back to back. Love this series, and especially fellow geriatrician David Sprigg’s interview, his support and openness with other doctors is inspiring.
    Having a play with Human Dx app, has a way to go yet but very exciting potential.

    Reply

    1. Thanks Jackie for the words of encouragement. We love these episodes too! I think you will also enjoy an interview we just recorded with Tony Fernando, psychiatrist, about compassion in health care. That will be episode 12, after another “stump the chumps”. Spread the word!

  6. Very cool podcast. Cheers. Any chance you will interview John E Brush Jr about his book ‘The Science and Art of Medicine: A Guide to Medical Reasoning’?

    Reply

  7. Brings back fond memories of General Medicine. Amongst the tsunami of patients admitted on take, the most challenging and perplexing (but also the most fun) was the patient who didn’t fit into any particular diagnostic category and needed some inventive detective work and outside-the-box thinking. Good on you!

    Reply

  8. Hi guys – I don’t know whether I am the only surgeon listening to your podcast but I am finding it fascinating.

    1. It would be great to hear about the other types of cognitive biases and how they affect decision making.

    2. You focus (not unsurprisingly) on diagnostic reasoning but not therapeutic or interventional reasoning. RACS runs this course (http://www.surgeons.org/for-health-professionals/register-courses-events/professional-development/clinical-decision-making/) to address these issues but it’s often said that there is a fundamental divide between “how physicians think” and “how surgeons think”. Does this really exist and if so why? I’d love to hear an ED physician or a surgeon on the show to talk about this.

    3. Much of diagnostic medicine is focussed on classical syndromes and presentations. Every specialty has syndromes and disease patterns which are gradually being re-defined as knowledge becomes available. Some traditional syndromes are now being recognised as consisting of many subtypes, some of which belong in a different clinicopathological family, which can explain why traditional treatments are variably effective and also dramatically alters the prognosis and management (eg some types of epilepsy, rheumatological disorders). How can we make management decisions when coping with diagnostic uncertainty, or even the uncertainty that our diagnostic framework is correct?

    4. Lastly – Hi Jackie!

    Reply

  9. Love the podcasts – been binging on the series after discovering them a couple weeks ago. I’m currently in a masters program in med ed and am considering a thesis about how to build systems for diagnostic feedback to allow deliberate practice for junior faculty as they strive to improve and grow in their reasoning, physical exam, and procedural skills. You’ve teased such an approach during your show and I’m excited to hear what you’ve learned.

    You should also think about having Lisa Sanders, MD, from Yale onto the show. She writes the diagnostic dilemma series in the New York Times and her book Every Patient Tells a Story is a great read that overlaps with your areas of interest.

    I’m also wondering about where medical subspecialties fit into the framework, as our differential diagnosis process is more narrowed. In my experience over the years reasoning and differential discussions tend to be seen through the generalist lens, but as a cardiologist, I’ve always been curious if there is a twist on the discussion when we are confined to a single organ system.

    Reply

    1. Thanks Alex for the comments and suggestions. Still working on the “automated diagnostic feedback tool” (ADFT – just made that up…). Actually, we plan to call it “diagKnowsis”. We’ll keep you updated on progress. We’ll definitely look into Dr. Sanders and her series!

  10. Really enjoyed your podcast on feedback. I’m a nurse in a surgical stepdown unit in Missouri, but my previous training was in photography where critiques and feedback were a constant. The info on feedback gave some much needed insight and I look forward to trying to use it with the students I precept.

    Reply

    1. great. Thanks for your comments Zac. Very happy you found it useful. I love this idea of “coaching”. i now pre-empt feedback/evaluations to my juniors telling them that I intend to be pedantic. My job is to watch them carefully, identifying anything that could make their performance better the next time…and tell them.

    1. Hi Marie. As it happens I had read that article! It was a great depiction and analysis of this almost unconscious practice in med ed.
      I think you’re on to something with “embracing uncertainty” IN FRONT of the patient… This ties into the IOM’s recent position paper on diagnostic error, where there was a big emphasis on “patient engagement” as one of the important strategies to reduce diagnostic error. I personally “think out loud” with my team in front of the patient, as we deliberate on their differential diagnosis. This gives them a peek into our clinical reasoning. Occasionally, they pipe in with a comment like, “Nah, that doesn’t sound right…”. A powerful moment in the diagnostic process…

  11. Hi. Greetings for Newmarket, Ontario, just a few km’s north of Nick’s old stomping ground. I’m a UofT grad and an ex-Sinai guy, too, Nick. Just stumbled upon your podcasts. Excellent stuff. Brings me back to the days of morning reports downtown! So, while I started listening to your show because of the diagnostic error material (a la Mark Graber), I really like your Stump The Chump more than anything. I give you a lot of credit for going through the process on the web. I remember how anxiety-provoking it was to speak up at morning report as a trainee, as a chief resident, and then as a staff doc! I’ve already used some of what I’ve learned on your show to enhance my residents’ experience here at Southlake Regional Health Centre. Keep up the great work! Many thanks.

    Reply

    1. Thanks Barry. Its great to hear you enjoy the podcast and find it useful! We had heard from others as well that Stump the Chumps is the highlight. We’ll try to do it more frequently.

  12. Hi Art and Nic,

    Great podcast. Really improved my commute to work. We’ve posted links on our website and twitter feed.

    A little suggestion if I may? I’d love to hear you interview Dr Gordon Caldwell who shares a lot of interests with you. He’s done loads of work on reducing errors on ward rounds, using checklists, reducing distractions, making care more patient-centred. He’s published some fascinating stuff. He’s also done some great stuff on CPR. A couple of his lectures are on youtube.

    I’m reluctant to put his contact details on this open forum, but he’s very active on twitter @doctorcaldwell and would respond to a direct message.

    Thanks again,
    Alex

    Reply

    1. Thanks Alex for the suggestion and the endorsement. We will definitely look into it.

  13. Hi Art and Nic,
    I stumbled upon your podcast (saw it on Tony Fernando’s Facebook feed, of course!) and wanted to say that I’m thoroughly enjoying it. I was once a house officer at Auckland Hospital, who wrote poetry (and Art was kind and polite enough to read some of it). Your podcast brings back good memories of general medicine at ACH. I’m now about to finish training in neuropsychiatry in Australia, and have a keen interest in clinical reasoning, and in particular the use of technology to aid diagnosis, and guide treatment decisions. It’s great to see physicians from Auckland setting up such a great podcast – keep up the good work!

    Reply

    1. Thanks for your comment Dhamindhu. and for the vote of confidence. Hopefully you’ve had a chance to listen to episode 19 where we introduce the work of Larry Weed. Next up is an interview with the man himself and further discussion about the use of technology to aid diagnosis.

  14. I would like to commend you both a really enjoyable and educational series of podcasts. I have found them all so interesting. Don’t lose the momentum- keep it up!
    It’s made me a better doctor

    Reply

  15. Hi Art and Nick

    I’m a General Medical Registrar at North Shore Hospital, a recent convert to IM Reasoning. Just thought I’d let you know that I am thoroughly enamoured with your podcast series.

    I’ve spent an entire week of to-from-hospital commuting bingeing on serial episodes, and am now totally hooked (sometimes doing gratuitous laps around the block to finish an episode!). The diagnostic reasoning stuff is brilliant: I don’t think metacognitive strategies, or the art of self-reflection; are nearly well-enough emphasised in undergraduate (or indeed post-graduate clinical) medical education. [Nor, of course, are the medical humanities, or empathy and compassion, or self-care and collegiality, or communication skills]. I’ve had an entire week delightedly analysing the cognitive idiosyncracies of our PAWR-reasoning… amazing what a sleep-deprived, flat-white-buzzing brain will do to save cognitive energy!

    Thank you whole-heartedly for a medical podcast which acknowledges the physician as a Person as opposed to a diagnostic machine.

    Some fantastic recent articles you may enjoy:

    http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
    (Atul Gawande on the epidemic of overdiagnosis, and the where-to-from-here)

    https://www.theguardian.com/books/2016/apr/22/literature-about-medicine-may-be-all-that-can-save-us
    (on medicine in literature, writing being my other main passion: and featuring many of the most inspiring contemporary medical minds)

    http://www.nejm.org/doi/full/10.1056/NEJMp1603934
    (a rather-lovely personal piece from the NEJM).

    These aren’t necessarily podcast-fodder, but just lovely mindfood for physicians everywhere, and pieces I thought you might enjoy.

    Keep up the good work, you eloquent souls: I’m a huge fan.

    Kate.

    Reply

    1. Kate, thank you for your encouragement. Art and I really enjoy making these podcasts. Its certainly the best part of my day, on those too-few-days that we get to work on this… It makes us so happy that you enjoy the episodes.
      Thanks as well for the links. I will have a read right now! We are always looking for ideas for more episodes. Good stories lend themselves very well to an audio podcast. I am not sure what kind of writing you do…but I had a thought that you could write a piece that we could read for the listeners (or you could even come over to read it yourself…)
      Cheers, Nic

    2. Hi Kate. Art here. I too share a passion for writing, mostly poetry. I’d love to hear about your writing and how it informs what you do as a clinician!

  16. Dear Art and Nic,

    I rarely write fan mail, but had to share my delight at having recently discovered your podcast. I have binge listened my way through most of the episodes and thoroughly enjoyed them all. You have found the sweet spot – demonstrating a near perfect balance between the informative and authoritative , and the entertaining and self-deprecating.

    I am am Australian GP, medical educator and writer. My deep interest in teaching clinical reasoning stems largely from my role as a Royal Australian College of General Practitioners (RACGP) examiner and Censor. One of the three RACGP Fellowship exams for GPs in Australia is called the Key Feature Problems (KFP) exam. The KFP is a short answer written exam designed specifically to test clinical reasoning. It has the highest failure rates of any of the GP Fellowship exams (usually 40-50%) and many candidates find it the hardest of the three Fellowship exams to get through.

    As a Censor, one of my jobs is to give feedback to failed candidates. While exam technique and knowledge gaps are undoubtedly factors for many, time and time again I see doctors with good clinical knowledge but poor clinical reasoning (memorisers, not thinkers). They tend to find it difficult to assess patients in the context of the scenario given and to identify the key features/critical steps.

    Given the sheer number of doctors who fail the KFP (several hundred every six month exam cycle) and the mere handful of us who are giving feedback, extended one-on-one remediation is impossible. From here on in I intend to recommend your podcast as a KFP study plan essential – both for those intending to sit the exam for the first time, and for those who plan to re-sit.

    I will also recommend it more broadly as it is relevant to all of us!

    Thank you again for such a wonderful resource.

    warm regards
    Genevieve

    Reply

    1. Hi Genevieve, thanks so much for you lovely feedback. It sounds as though your role as an examiner for the College is a very challenging one. It’s difficult enough to give meaningful, transformative feedback to ONE individual you have worked with, let alone to many you probably don’t know who have failed an exam! I don’t envy you at all.
      Nic and I are glad you find the podcasts useful, and if they can be useful to struggling junior doctors, so much the better!
      By the way, what kind of writing do you do?

      Art

  17. Thanks so much for replying, Art,

    I have been avidly plugging your podcasts, including on a very active doctors-only Facebook Group for Australian and NZ GPs called “GPs Down Under” which has over 3200 members. You now have lots of new fans!

    I will certainly continue to recommend them to those sitting GP Fellowship exams as a fantastic way of getting to better understand clinical reasoning concepts.

    I really like the mix of topics and formats in your podcast episodes. Stump the Chumps and Cognitive Autopsy are my favourites and I would love to see more of both formats. I particularly liked the episodes on Feedback, Compassion and the Second Victim also.

    Keep up the wonderful work!

    Genevieve

    PS: Thanks for asking about my writing. Over the years I’ve dabbled in a variety of genres: playwriting, short film, musical theatre (co-wrote “GP the musical”), columnist (for the medical newspaper, Australian Doctor and others), and a novel. Nowadays my writing is mostly work-related, but I occasionally post on my rather neglected blog, https://genevieveyates.com/

    Reply

  18. Hello Art and Nic,

    I’m a GP registrar working in Canberra, Australia and I’ve been using my half hour commute over the past couple of weeks to listen to many of your podcasts. Thank you for your time and energy and good humour, I’m really enjoying them.

    I have a comment / question about the content in one of the early podcasts – about framing biases and how they impact on the lives of junior doctors. It has been my experience as a junior (intern, resident) that, while working in ED or on the wards that, in order to “sell” the patient to a particular speciality for consults or to take over care it’s often necessary to consciously emphasise particular aspects of the case to even get the registrar to see the patient. We all knew the “nice” registrars that would help us with questions / uncertainties over the phone, and we also knew those that simply acted like “walls” unless you could convince them very rapidly that they needed to see a patient. I guess this isn’t really a cognitive bias on the part of the junior in that it happens quite consciously(!), but I worry about the impact on patient care, the effect of priming the registrar and on whether it unnecessarily compromises care because it “fixes” a diagnosis too prematurely. I see it as consequence of system problems, really, involving patient handover practices, workload and time constraints.

    Do you have any advice for juniors in how to approach day to day ward work that requires patient handover to seniors from other teams, and are there any system changes that might help solve these issues? For example, at one hospital here in Canberra the majority of ED patients go directly to a general medical ward prior to then going under a sub-speciality. I see the benefit of this as having a general physician care for them for a period of time prior to sub-specialties being involved.

    I just re-read that last part and I’m sorry it’s so long-winded! I blame the late hour.

    Thanks again for your great podcast and all the best.

    Steve

    Reply

    1. Thanks Steve. An excellent observation that we can all relate to. It is true, and in some ways unfortunate that we feel we have to “embellish” the case in order to gain the attention of the service we are consulting. It becomes a fine balance between, achieving your goal of having the service review your patient, and not “over-biasing” the recipient of the handover.
      The classic case is Radiology; how do you convince the radiologist that it is worth scanning your patient? Well, you might emphasise the abdominal pain, even though you felt that it was not really the main feature of the symptoms. You then may have to de-bias the radiology report if it doesn’t match the clinical picture…
      Consulting services like it when you have a good idea about the diagnosis, because this is less work for them. Who wants to hear, “please come and solve this complete mystery. I have no idea what’s going on.”? Instead, I would suggest that in your handover you postulate the diagnoses that you are considering that justify you phoning them, and then highlight the features of the case that you think don’t quite fit. This forces the consulting service to actively consider the inconsistencies. That’s one thought anyway. How do you deal with this?
      Nic

  19. I’m a hospitalist and clinical faculty at New York Medical College/Westchester Medical Center, in the suburbs of New York City. I was privileged, twice this year, to meet Dr. Jeff Wiese from Tulane in New Orleans. Jeff lectures often on clinical reasoning. I strongly recommend his book “Teaching in the Hospital,” which provides both a framework for thinking and teaching, and a series of Socratic dialogs specifically designed to make learners think about their processes.

    Reply

    1. Thanks for the recommendation Randy. Have heard of the book but will definitely have a read.

      Art

  20. Suggestion: when doing Stump the Chumps, please include US values for labs. Those of us listening in the US are completely lost with your SI values…

    Reply

  21. Hi Nic and Art

    Stump the chumps is superb! It’s excellent and fun and also make us easy to memorize the case and the disease. I remember symptoms and signs of AOSD now 🙂 Please kindly do more of these. I love this episode so much plus the jokes 😀 Thanks a million for teaching an interesting case.

    Reply

  22. Hi Dr. Szecket and Dr. Nahill,

    Thanks for the latest episode on the evidence behind various clinical signs, I found it particularly fascinating as I have often wondered about the evidence of a lot of the historic practices that we continue to use.

    Just the other day I put in a request form for a CTPA for a woman in whom I suspected a PE (Wells score = 7) and I wrote on the form “Left leg positive Homan’s sign.”

    I know you said on the podcast “we shall never mention Homan’s sign again,” as I now know that it lacks any clinical utility, however I do believe it can still be useful for young docs to include signs like Homan’s when requesting a scan from a radiologist, especially when it is after hours. As the addition of an associated physical sign (albeit a useless one) may be the added weight we need to get a scan that our seniors are demanding of us.

    The caveat being that the radiologist must not have listened to your latest podcast and see through our non-differentiating clinical signs…

    I look forward to more critical appraisal of physical signs!

    Reply

    1. Thanks Jimmy. Listen, we’ve all been there, late at night, trying to wrangle what we think is best for the patient, using whatever means we have available, INCLUDING useless physical signs (assuming that the person on the other end of the phone doesn’t appreciate the poor likelihood ratios for that sign)! I would argue though that with a Wells score of 7, the pretest probability of PE was already so high the scan just should have been approved- end of discussion!

      Regards, Art

    1. Michael, sorry for the delayed response. So glad you listen to the podcast! Really think your efforts are worthwhile and use your app with students and junior doctors regularly. Keep up the good work!
      Art

  23. Dr Nahil
    I am listening to this great series
    I was your house surgeon 9 years ago in Auckland Hospital I am a rural Gp in Australia
    I find this very very useful
    And very interesting

    Reply

    1. Yes Aseel, I remember you! Glad you’re finding the podcast useful. It’s great fun to produce, it’s really educational for us as well, plus it beats doing ‘regular’ work! Be well.
      Art

  24. Hi Nic and Art

    Just discovered your excellent podcast… somehow managed to evade me despite many shared ideas!
    Will be giving you guys a plug for our education sessions and to the wider audience out there in the ether!
    Great stuff
    Keep it up

    Dr Casey Parker

    Reply

    1. Hi Casey. Glad you discovered us. Had a look through your blog- lots of great stuff there as well. Keep up the good work!
      Art

  25. Nic and Art,

    I am a colleague of Casey’s in Broome and he sent me the link. This is a fantastic podcast, interestingly presented and with what is a novel take, but which resonates so deeply with our everyday experience as diagnosticians in this complex environment.

    Keep it up!

    All best,

    David Berger

    Reply

    1. Wow, Broome sounds like the place to be! Keep up the good work. Glad you find what we do of interest.

      Art and Nic

  26. Hi Nic and Art,
    I’ve recently been listening to your fantastic podcast and really enjoying this. I’m a public health physician who works part time as a supervisor on the Australian Field Epidemiology Program, and part time as a GP registrar and so I have been finding your podcast interesting from both the angle of improving my clinical reasoning, as well as the teaching and training angle. As part of my work on the Australian Field Epi Training program I’ve recently been looking at how we train people in outbreak response, and particularly at aspects of supervision – it’s an interesting area as there are some clear areas of similarity with clinical medicine but also some distinct differences (for example the standard of what constitutes a good outbreak investigator/public health practitioner is generally a lot less well defined than say an internal medicine physician). I ran a workshop on effective supervision last year in Cambodia at a conference for field epi. training programs in the Asia-Pacific region – am now wishing I’d listened to your feedback episodes before doing this!
    In any case, I just wanted to say thanks for your work. It’s a fantastic resource (and highly entertaining) and I’ll continue to avidly plug the podcast to colleagues.
    Cheers,
    Steph

    Reply

    1. Wow Steph, your work sounds pretty amazing. Glad you find some relevance in what we do- it’s really gratifying to hear!

      Art and Nic

  27. Love the show guys. I listen to about 15 or 20 podcasts on a semi-regular basis, and you are one of my favorites (and easily my favorite medical one). I’ll be passing the word on to my colleagues/residents/students to listen.

    Thanks,
    Nick Gowen, M.D.
    Internal Medicine and Pediatrics
    Little Rock, AR USA

    Reply

    1. Thanks for the feedback Nick. Glad you find the podcast helpful and we hope those you recommend us to will as well!

      Art and Nic

  28. Hi Art and Nic,

    I have been listening to your podcast recently and I really love it. I am a last year medical student in Sweden and I am learning a lot and have gotten many new perspectives by listening to your episodes, which I am sure will help me become a better clinician in the future. I especially think your Stump the Chumps episodes are fantastic, it is so helpful to hear how experienced physicians reason about a case.

    I also find your interviews really great and interesting, I am just curious as to why you haven’t interviewed any female physicians yet, is there no female expert in the field of clinical reasoning and education?

    Thanks again for a great podcast!
    Hanna

    Reply

    1. Hi Hanna,

      Thanks for writing to us. You brought up a great point that neither of us had ever noticed. We have not yet had any female physicians on the show! not a conscious decision, just a coincidence. So glad you are enjoying the podcast.
      Art and Nic

  29. Hi Art and Nic. Thank you for an interesting and engaging podcast which I recently discovered when the word of it reached twitter and the FOAMed community there. I was especially pleased about the episode “Myths of the Clinical” exam as I had been thinking that a presentation of Bayesian statistics was missing in the podcast. When doing more rounds of Stump the Chumps an idea could be to more openly mention your gestalt probabilities for the Dx and discuss the likehood ratios for the different tests ordered to improve the reasoning about why this particular test is ordered. Too often in medicine I find that tests and investigations are ordered without considering these aspects and it commonly leads to overdiagnosis and incidental findings that in my mind is an equally large problem in modern medicine as mis- and underdiagnosis.

    Reply

  30. Hi Art and Nic,

    What a fantastic podcast – thank you!
    I recently discovered your podcast through a network of medical professionals on Facebook and I’m so glad I did.

    I am a Psychiatrist over here in Australia but completed my basic medical training at Otago NZ. Listening to your podcast makes me feel more at home and I like that. So great to hear this important work going on there in Auckland and I hope the field of clinical reasoning is expanding across to other main centres of NZ now too.

    Although not a physician, I cannot tell you how much satisfaction and fascination rediscovering general medicine has brought me as I listen to your podcast on my drive to and from work. I can tell you, the art (and science!) of clinical reasoning (especially differential diagnosis generation) has really starting to wane in the field of Psychiatry too. This is I think often-times, as you highlight in one of your episodes, due to the system-driven necessity to record a singular diagnosis for coding purposes so as to meet KPI targets and, in turn, secure funding. This however can be at the expense of carefully considered differential diagnosis generation so important to understanding the complexities of the presentations we see in Mental Health.

    I have already found many ways of applying principles learned (and re-learned) in your episodes to my everyday practice, teaching and supervision, and cannot thank you again enough.

    Cheers guys and keep up the great work!

    Caroline.

    Reply

  31. I am an infectious disease consultant in Seattle. I just listened to your podcast about NEJM clinical reasoning case. Loved the lively conversational format.
    Great job.

    Reply

  32. Hello Art and Nic,
    Here Portuguese medical student studying in the Netherlands. Your podcast is a breeze of fresh air in the medical podcasts community. Love the Stump the Chumps series! It has been one of the most useful podcasts to listen to until now. I have learned a lot. Episode with Gurpreet Dhaliwal was also incredible! Very inspiring person.
    Keep up with the good work.
    Cheers.

    Reply

  33. Dear Art and Nic
    I am a medical educator at James Cook university,involved with training GPs for most of regional Queensland. Your stuff is inspirational ; just the right balance of medicine,brain food and humour.I can’t make it to Melbourne next week,not sure about GPTEC,but am hoping you contact me if you are interested in coming to Cairns +/- Townsville sometime to talk to an audience of GP Medical educators and supervisors.

    Reply

    1. Dear Nick,
      Thanks for your comments. I am sure Art and I would love to make it out to your part of the world for a talk or workshop. Its all about finding time. Is there a forum you had in mind that happens at a particular time? Let’s keep the channel open. imreasoning@gmail.com

Leave a Reply

Your email address will not be published. Required fields are marked *