Letter from Dr. Clayton Reynolds to Dr. Steven Gold

Dr. Steven Gold is the author of "The Magic of Praxis"


I love recounting the origin of the word concept processor and the theory of the 3 Rs. My experience with the process of chart review for quality led to my formulation of the theory of the 3Rs. Richard remembers the day in 1999 when I met him for dinner at Denny's Restaurant in Northridge, Ca. I had alerted him a few days prior, that I was not going to leave the restaurant until I really understood what he meant by the statement: A clinical practice guideline and a query are the same thing and what Dr Allan Wenner meant by the corollary: a query is a clinical practice guideline in reverse.

In the intervening days, I had occasion to finish my ad hoc study on Hypertension care and my monthly presentation to the members of the Department of Ambulatory Care. It was at the latter meeting when one of the nurse practitioners said: How could you expect us to follow those guidelines- on management of hypertension- when we didn't know there were going to be any guidelines? We didn't know someone was going to review our charts. Not only did we not know about the requirement for documentation, you weren't even here when we handled those cases that you reviewed. My reply was simple and unadorned: I didn't expect you to follow those guidelines, I made them up for the chart review. But now that I know where the deficiencies are, I do expect you to follow the documentation guidelines.' I then struck me (the Eureka moment we all want to have at least once in our lives) that a chart review for quality and a query were the same thing. I was telling them: A clinical practice guideline and a query are the same thing and, by implication, a query is a clinical practice guideline in reverse . To myself I then added the truism: A clinical practice guideline and a query differ only in their time sequence.

Richard, having tried repeatedly to explain his version of the statement: A CPG and a query are the same thing, was delighted that he didn't have to explain it once again. As you know it took another 9 years before I felt comfortable releasing the theory of the 3Rs in written/publishable form.

As mentioned at the end of our discussion today, I will renew my acquaintance with the Query capabilities of Praxis and let you know when I'm ready to give another tutorial!!. Meantime, send me whatever information you have on the current status of PQRI and NCQA. Be explicit as you can, about the need for CPGs.

Also, I will explore the technology of the Reply or Response (the 4th R) within the CPG program and let you know its implications.

If I develop CPGs for Diabetes and other diseases, would you be a potential customer? What would be a reasonable annual subscription fee, in your opinion?

Best regards,



Practice Medicine the way it was meant to be.

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