[EXTERNAL] RE: [IMPROVEDX] What a doctor may miss by reaching for the MRI first

Graber, Mark Mark.Graber at VA.GOV
Sun May 25 13:31:14 UTC 2014

Interesting perspective Charlie - thanks.  It reminds me of the point that Gary Klein made at the DEM conference a few years ago: That we'd learn more about improving diagnosis from studying BOTH diagnostic errors AND diagnostic success.  We'd been focusing almost exclusively on the errors up to that point.

Lisa Sanders, in her case reports in the NY Times Magazine, now has hundreds of these 'how it was done right' stories.  I hope someone can try to formally analyze the lessons from these cases at some point.

From: Charlie Garland - The Innovation Outlet <cgarland at innovationoutlet.biz>
Date: Fri, 23 May 2014 13:18:07 -0400
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Lorri Zipperer <Lorri at zpm1.com>
Cc: "mark.graber at va.gov" <mark.graber at va.gov>
Subject: [EXTERNAL] RE: [IMPROVEDX] What a doctor may miss by reaching for the MRI first

Mark, thanks for bringing this intriguing article to the group's attention.  What leaped out at me is the relevance that Polarity Thinking <http://www.polaritypartnerships.com>  (see therin: "What are polarities?") plays in this scenario.  Polarity Thinking (PT), which has been highly impactful in many areas of healthcare, is one form of critical thinking, which reframes one's view of two "opposing" constructs as a polarity to be leveraged, rather than a problem to be solved.  It replaces "either/or" approaches with "both/and" optimization, and converts resources otherwise wasted on opposition and conflict...into energy that instead propels toward a higher (and common) purpose.

The article's contents are reminiscent of a classic polarity: "High-Tech AND High-Touch" (rather than VS.), which has been addressed in multiple domains, and with some notably positive results in measurable systems improvement.  In the domain of diagnostic errors, it is troublesome to read here that "...some experts are skeptical that reviving the physical exam is the best approach in the 21st century," or "...physical exam skills are dismissed as inferior relics of the past..." when there is unique wisdom and value inherent in that (end of the polarity) that a problem-solving only mindset (and consequent policy) might allow to atrophy.  Instead, PT helps identify action steps that leverage the wisdom/value of both poles; as evidenced in Hosamini's reflection, "...a good exam, which is not intended to replace technology, but to guide its use."

The take-away here is that this is merely one of the dozens of important polarities that exist within the realm of diagnostics, and that it may be worth considering how policies, practices, culture, and individual cognition might be improved by a process that begins with examining such conventional dilemmas through a polarity lens, rather than through the conventional "either/or" problem-solving orientation.  This has implications not only for medical practice, but of course for education (initial and continuing) as well.  In my humble opinion, this is a potentially vital message for the ears of any Chief Medical Officer.

For anyone interested in more detail on how PT can apply to this sort of scenario, which might include a deeper elaboration of this article's case references (or those more familiar to your own practice), I would be more than happy to illustrate some of the key dynamics of how these issues might map out.  Feel free to let me know, and I can also connect you with those whose expertise in this approach/domain far exceed mine.



Charlie Garland, President

The Innovation Outlet

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-------- Original Message --------
Subject: [IMPROVEDX] What a doctor may miss by reaching for the MRI first
From: Lorri Zipperer <Lorri at ZPM1.COM>
Date: Tue, May 20, 2014 5:02 pm

Forwarded by the moderator:

With thanks to Dean Sittig for finding it, here's a tantalizing story on re-emphasizing the physical exam in medical training as a critical skill in diagnosis.

Sandra G. Boodman and Kaiser Health News. Washington Post, May 19 2014.


Mark L Graber, MD FACP
Senior Fellow, RTI International
Professor Emeritus, SUNY Stony Brook School of Medicine Founder and President, Society to Improve Diagnosis in Medicine
Phone:   919 990-8497


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