Red Flags, Yellow Flags, Blue Flags, Black Flags


This page was originally posted on September 21, 2006. It has been the most viewed page on this blog. Updated February 22, 2013.  

The other day a student asked me where the phrase “red flag” originated. He had also heard of yellow flags, and suspected that there were other colours of flags to indicate barriers to recovery. Well, we looked in various glossaries of medical and medical education terms, without success. So I e-mailed Dr. Shawn Thistle, and, sure enough, he helped. It is difficult to find where these terms originated (try Googling blue flags!) and Dr. Thistle thinks they may just be part of every doctor’s vocabulary. (Ever since I wrote the title above, I can’t get Dr. Seuss’s One fish two fish red fish blue fish out of my head.)


Red flags/clinical red flags (biomedical factors) ~
These help identify potentially serious conditions, and are often listed in practice guidelines. Here is a description from Chapter 13 of the
Clinical guidelines for chiropractic practice in Canada [Glenerin Guidelines]:
The main focus for the prevention of complications is the recognition of well-known and established indicators or “red flag” signs and symptoms which may require careful assessment and reassessment, changes in treatment plan, or other appropriate action, such as emergency care or referral to another health care specialist. Ignoring these “red flag” indicators increases the likelihood of patient harm. 

Yellow  flags/clinical yellow flags (psychological or behavioural factors/predictors) ~
These indicate psychosocial barriers to recovery. Here is a definition from

New Zealand acute low back pain guide: incorporating the Guide to assessing psychosocial yellow flags in acute low back pain:
Yellow Flags are factors that increase the risk of developing or perpetuating long-term disability and work loss associated with low back pain … Before proceeding to assess Psychosocial Yellow Flags it is important to differentiate between acute, recurrent and chronic presentations. Evidence suggests that treating chronic back pain as if it were a new episode of acute back pain can result in perpetuation of disability. 

Blue flags/occupational blue flags (social and economic factors) ~
These refer to conditions in the workplace that may inhibit recovery. Examples are
monotony, low degree of control, poor relationships or high work demands. 

Black flags/socio-occupational black flags (occupational factors) ~
These are also used for workplace issues, but refer to organizational issues such as financial reliance on disability benefits, workers’ compensation issues, or employer attitudes to the sick worker.


Helliwell PS, Taylor WJ. Repetitive strain injury. Postgrad Med J 2004;80(946):438-43.See An Approach to Diagnosis
Main CJ, Williams AC.  ABC of Psychological Medicine. Musculoskeletal pain. BMJ 2002;325(7363):534-7.

Click on the image below for The clinical flags approach to obstacles to recovery from back pain and aspects of assessment.

From:  Main CJ, Williams AC.  ABC of Psychological Medicine. Musculoskeletal pain. BMJ 2002 Sep 7;325(7363):534-7. PMC version

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The Future of Medical Education in Canada

There needs to be a radical new approach to the training of doctors – with more emphasis on patient-centred care, preventive health care and working in teams with other health professionals, according to a much-anticipated new report. — from The Globe and Mail, January 29, 2010: MD schools call for radical rethink of doctor training

This is the report that was endorsed by all 17 Canadian medical schools:
Association of Faculties of Medicine of Canada (AFMC). The Future of Medical Education in Canada: A Collective Vision for MD Education. Ottawa: AFMC, 2010.

Just as Abraham Flexner’s report did 100 years ago, The Future of Medical Education in Canada (FMEC) project looks at how the education programs leading to the medical doctor (MD) degree in Canada can best respond to society’s evolving needs. In turn, the FMEC project is rooted in the Association of Faculties of Medicine of Canada’s (AFMC’s) articulated social accountability mission for medical schools.

The 10 FMEC recommendations for MD education are, according to this report,  “grounded in evidence and emerge from a broad and rigorous consultative process”. They are:

1. Address Individual and Community Needs
2. Enhance Admissions Processes
3. Build on the Scientific Basis of Medicine
4. Promote Prevention and Public Health
5. Address the Hidden Curriculum (influences affecting the nature of learning, professional interactions and clinical practice)
6. Diversify Learning Contexts
7. Value Generalism
8. Advance Inter- and Intra-Professional Practice
9. Adopt a Competency-Based and Flexible Approach
10. Foster Medical Leadership

These recommendations are accompanied by five enabling recommendations that will facilitate the implementation of the FMEC recommendations:
A. Realign Accreditation Standards
B. Build Capacity for Change
C. Increase National Collaboration
D. Improve the Use of Technology
E. Enhance Faculty Development

Knowledge Translation – CMAJ series

This series began in 2009, when CMAJ was still an Open Access journal.  Link to free full text for Parts 1-5 below at

  • Part 1:
    Straus SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ 2009;181(3-4):165-8.
  • Part 2:
    Brouwers M, Stacey D, O’Connor A. Knowledge creation: synthesis, tools and products. CMAJ 2009 Nov 2. [Epub ahead of print]
  • Part 3:
    Kitson A, Straus SE. The knowledge-to-action cycle: Identifying the gaps.  CMAJ 2009 Nov 30. [Epub ahead of print]
  • Part 4:
    Harrison MB, Légaré F, Graham ID, Fervers B. Adapting clinical practice guidelines to local context and assessing barriers to their use.  CMAJ 2009 Dec 7. [Epub ahead of print]
  • Part 5:
    Wensing M, Bosch M, Grol R. Developing and selecting interventions for translating knowledge to action.  CMAJ 2009 Dec 21  [Epub ahead of print]
  • Part 6:
    Davis D, Davis N.  Selecting educational interventions for knowledge translation. CMAJ 2010 Jan. 5 [Epub ahead of print; subscribers only]

Are doctors whippersnappers?


I just came across this delightful poem, published by Gilda Radner in the November 17, 1988 issue of the New England Journal of Medicine:


Doctors are whippersnappers in ironed white coats
Who spy up your rectums and look down your throats
And press you and poke you with sterilized tools
And stab at solutions that pacify fools.
I used to revere them and do what they said
Till I learned what they learned on was already dead.

Radner G. Doctors are whippersnappers. New England J Med 1988; 319 (2): 1358.

The Cochrane Library is now free for all Canadians!

cclogo.gif  About a year ago, I wrote a blog post entitled Cochrane Library: Free access for all?  Well, this has come to Canada, as a pilot project.  The Canadian Cochrane Network and Centre announced on April 15 that everyone in Canada is now able to access the full contents of the Cochrane Library. From the announcement:

The Canadian Cochrane Network and Centre, in partnership with the Canadian Health Libraries Association, has successfully secured a national license to The Cochrane Library. In essence, the license provides a subscription for every Canadian with access to the Internet to benefit from the immense volume of health information found in The Cochrane Library. Everybody will be one click away from the best available evidence on the effectiveness of treatment procedures including which ones may be harmful.

Access the Cochrane Library at

Neck Pain and the Decade of the Bone and Joint 2000–2010 – Open Access!

The special supplement published in Spine in February 2008 has been republished with permission elsewhere. The European Spine Journal has published the Bone and Joint Decade articles on neck pain as v. 17, Supplement 1. The great news is, the whole supplement is available on PubMed Central.

European Spine Journal Volume 17 (Suppl 1);  April 2008

From the Editorial Preface:
In this supplement of Spine [republished with permission in this supplement], the results of a unique project, The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders, is published. This multidisciplinary, international Task Force, which was formed in 2000, has consisted of an executive committee, a scientific secretariat, an advisory committee together with research associates and graduate students. These groups involved more than 50 people. Committee members were based in 9 countries and represented 14 different clinical and scientific disciplines. Moreover, the Task Force was affiliated with 8 universities and research institutes in 4 different countries. Eleven professional organizations have been non-financial sponsors. Thus, the Task Force represents a unique gathering of international expertise covering all relevant aspects related to neck pain and its associated disorders. The Task Force has made an impressive systematic review of the vast literature in this field and a best evidence synthesis, which has resulted in 21 chapters in this supplement.

“What about the safe surgery checklist?” — Dr. Peter Benton


In January 2009 the New England Journal of Medicine published an article about the World Health Organization’s surgical safety checklist. (See this post for more information.) On March 12, the checklist was a key player in a scene in an episode of ER, and it helped save Dr. John Carter’s life. (See Dr. Peter Benton holding the checklist in the above image; the episode is no longer available for viewing.)

On March 16 this story became big news: ER episode puts safe-surgery checklist on the Hollywood map (Globe & Mail) and the story was picked up widely in the news and in the blogosphere:

“I have to tell you it got to me in a way I never anticipated,” the team’s leader, Atul Gawande of the Harvard School of Public Health, said in an e-mail. “Producing a checklist that could save lives is what we on our team at the World Health Organization spent the better part of two years working to make happen. And underneath it all is a cultural change for surgery exactly like ER depicted on a screen – a change from seeing ourselves as solo agents to effective teams.  But you begin to wonder if anyone is going to get it. What those few minutes showed me is that everyone will.” Download the checklist.

Watch a real surgical team in Toronto use the checklist.