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As F Scott Fitzgerald wrote in the collection of 1936 essays called ‘The Crack Up’,1 ‘The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.’ Likewise, in their 2002 book ‘Built to Last’ regarding the features of sustainably successful organisations,2 Collins and Porras extol the ‘Genius of the AND’ and warn against the ‘Tyranny of the OR’. (For clarity here, they were not referring to the Operating Room.) Collins and Porras suggest, “The ‘Tyranny of the OR’ pushes people to believe things must be either A or B but not both.” All of these authors across different times and sectors are identifying a common human way of thinking. I’ll call this ‘A or B but not both’ approach ‘dichotomous thinking’.
The first goal of this perspective is to consider two different types of thinking that are deeply ingrained in medical reasoning and clinical care—the first of these is ‘dichotomous thinking’ as just defined and the second is ‘deficit-based thinking’. Simply put, deficit-based thinking is focusing on problems rather than on opportunities; metaphorically, the deficit-based thinker sees the hole rather than the donut.3
The second goal of this paper is to examine ways in which these two thinking paradigms help define the time-honoured, effective approaches for clinical reasoning that doctors use as they care for patients. At the same time, I want to highlight a paradox related to these two types of medically entrenched thinking. On the one hand, both dichotomous and deficit-based thinking are very well suited to and, in fact, are critically important for clinical reasoning and for physicians’ clinical effectiveness. On the other hand, both types of thinking can conspire against physicians’ effectiveness as leaders and as …
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