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Diagnosis is Situated

  • 1.  Diagnosis is Situated

    Posted 08-24-2020 12:28

    Diagnosis is Situated – A New Perspective


    A just-released special issue of Diagnosis examines diagnosis from a new, very unique perspective  - as a 'situated', social activity. And yes, situativity  was a new word for me too  ;<)


    You can find the special issue here.   All articles are free, open access.  Details on a situativity Twitter chat  -9 PM Eastern on September 15th , and a journal club, October 13, 3-4 PM Eastern, will follow.


    Using this lens of social cognitive theory, diagnosis involves not just the clinical reasoning process, but all our interactions with the world around us that play into this.  Context is key, and observation of diagnosis in practice is the major research approach used to study the process.

    The special issue includes 21 articles, and a set of wonderful illustrations by Michelle Daniel and colleagues.  Other highlights include:


    • An introduction and overview by guest editors Eric Holmboe and Steve Durning. 
    • A very special editorial essay by Pat Croskerry on the importance of context and critical thinking in diagnosis.  If you enjoy Pat's writings, don't miss this one.
    • My own editorial on the significance of situativity and observational techniques for advancing our field


    Some of my favorite articles also include:

    • A case report of a patient with COVID-19 infection by James Boyle and colleagues that illustrates some of the many environmental factors that influence diagnosis (like having to use a disposable stethoscope !)
    • A summary perspective by Merkebu and colleagues:  "Situativity: A family of social cognitive theories for understanding clinical reasoning and diagnostic error".  If you only have time to read one article on situativity, this is it. 
    • Novel thoughts on assessment from a situativity perspective by Joe Rencic and colleagues
    • A research paper from Alan Schwartz and colleagues using direct observation by standardized patients of depression identification – a real eye opener.


    Please share these articles with your colleagues and share your thoughts here:


    • What do you think about this new framework for examining the diagnostic process?
    • What are the implications for future research?
    • What are the implications for clinical practice?



    Mark L Graber, MD FACP

    Co-Editor-in-Chief, DIAGNOSIS

    Founder and President Emeritus, SIDM

    Professor Emeritus, Stony Brook University, NY

    Work   607 305-0050

    Cell      919 667-8585

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  • 2.  RE: Diagnosis is Situated

    Posted 08-25-2020 13:08

    Thanks, Mark!  

    This sounds fascinating.  I have downloaded the whole issue and am eager to read this new issue of Diagnosis.  Also, for future spelling bees, I will definitely need to know how to spell "situatuity" and use it correctly in a sentence!  Also, from what you've mentioned before, I am interested in understanding how Radiology might be a unique example of this, so maybe you address that in your editorial.

    Thinking about these concepts kind of reminds me of the discussion that Dr. Bimal Jain and I had last month on this forum - specifically about how Bayesian reasoning is SUPER-important for Radiology as we narrow our range of differential diagnoses to explain what we are seeing on images, but that Bayes theorum may not be so applicable to the internist trying to establish a "final" diagnosis for an individual patient, and thus needing a higher degree of confidence that the diagnosis is correct (and not merely more likely than other possibilities).  Perhaps this concept of "situated" diagnosis might be the bridging concept that can unify our two worlds

    All the best,


    Michael A. Bruno, M.D., M.S., F.A.C.R.  
    Professor of Radiology & Medicine

    Vice Chair for Quality & Patient Safety

    Chief, Division of Emergency Radiology

    Penn State Milton S. Hershey Medical Center
    ( (717) 531-8703  |  6 (717) 531-5737

    * mbruno@pennstatehealth.psu.edu  


  • 3.  RE: Diagnosis is Situated

    Posted 08-26-2020 18:22
    I have read the papers regarding the role of situativity in diagnosis with great interest and find them to provide a lot of food for thought. Here are my thoughts after reading these papers.
    1. It is argued in these papers if I understand them correctly is that social (environmental) factors such as context etc. should (and do) influence a physician's thought process (cognition) in performing diagnosis in improving diagnostic accuracy.
    2. It is important, I believe, to have an idea of what the thought process is in performing diagnosis. In my view, this process consists of 'suspect and test' whereby a disease is suspected from a presentation, formulated as a diagnostic hypothesis which is evaluated by performing a test. This is the method we are taught in medical school and use in practice with a high degree of diagnostic accuracy (85 to 90 percent).
    3. Situativity presumably helps by providing clues so that we can suspect a disease which we may not have suspected otherwise. This may include suspecting a disease with an atypical presentation. This i all for the good and highly desirable.
    4. But the relevance of certain concepts included in situativity, to diagnosis is questionable. The main such concept, in my view, is that of DPT (dual process theory).
    5. DPT with its System 1 and 2 thinking is based on observation and experiments on ordinary persons (man in the street) who are not trained in any particular method of reasoning. For example, testing does not play a role in checking an opinion in day to day reasoning.
    6. Physicians , on the other hand, are trained to check their opinion (hypothesis) by testing. Thus whether they formulate a hypothesis fast by System 1 or slowly by System 2, it is not accepted as a diagnosis till it has been tested and confirmed. Fast or slow thinking in diagnosis depends, I believe, on expertise. For example, my thinking is fast, I believe, during diagnosis in my speciality, pulmonary disease, and much slower, say in hematology.
    7. I like the emphasis on observation in situativity in learning about diagnosis. I wish observation is employed to learn as well about the method of diagnosis in practice. For example, observation in all published diagnostic exercises in real patients indicates that the prescribed Bayesian method is not employed in diagnosis. For example, a prior probability is not interpreted as prior evidence (degree of belief) and a disease is not inferred from a posterior probability generated by combining a prior probability and a likelihood ratio in these exercises. In my view, this observation should have some effect in altering prescription of the Bayesian method for diagnosis.
    These papers are important as they open a window on interaction between social environment and a physician's cognition (thought process). Ultimately a diagnosis is made by a physician's cognition. It is important therefore we learn more about a physician's cognition to improve diagnostic accuracy.

    Bimal Jain MD
    Northshore Medical Center
    Salem MA 01970

  • 4.  RE: Diagnosis is Situated

    Posted 08-26-2020 19:28
    While I applaud your use of social context in affecting diagnoses, I note that to a sociologist this is like discovering gravity 300 years after Newton.  Medical sociology has over 2000 papers on this topic going back to the turn of early century.  The previous century. 

    best wishes

    Ross Koppel


    Prof. of Biomedical Informatics, Perelman Sch of Medicine.

    Senior Fellow, Wharton's Leonard Davis Institute of Healthcare Economics;    

    Senior Fellow, Center for Public Health Initiatives, Perelman Sch of Medicine; 

    Adjunct Professor (full) Sociology Department;    

    Affil Prof of Medicine, Perelman Sch of Medicine;  

    Prof. of Biomedical Informatics, SUNY@Buffalo    


  • 5.  RE: Diagnosis is Situated

    Posted 08-27-2020 15:33

    Thanks Ross – Maybe we should titled the special issue "Lost and Found" – its true that some of the elements falling under situativity have been around for a long time, but they haven't been part of the mainstream discussion.  Time to re-visit and re-invigorate this field !




  • 6.  RE: Diagnosis is Situated

    Posted 08-27-2020 20:21
    Of course.  The effort is important...critically so....and must be encouraged.  I'm not sure about the value of giving it a new name...but if it helps.... Great