Let’s improvise the diagnosis. How knowing when to wing it by sticking to the rules can help in the emergency room

January 24, 2017
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For Dr. Gregory House, the popular protagonist of the successful hit TV series, one look  on the fly is enough to make a complex diagnosis. It’s fiction, of course, but maybe one that’s not so detached from reality – and, even more surprisingly, from practices that can enhance what’s offered from medical and health services.

If medical practice has, year after year and worldwide, increasingly taken the form of a highly specialized and highly standardized profession, the art of improvisation – also understood as being receptive to a particular case, reactive in the face of unexpected, attentive to detail – remains an important aspect of the job in emergency units.

The fact that standardization and improvisation, especially in such a delicate area, can work together in a fruitful way seems to be a contradiction: and yet these two attitudes are far from being incompatible, though there is still a lot to be done – by researchers and professionals – to find out how much knowing how to decide and when to act can have an effect in highly structured and institutionally complex environments such as hospitals and specialized clinics.

In a study conducted with an international research team, Luca Giustiniano, professor of Corporate Organization at LUISS University, shows how improvisation operates as a productive element in a strictly controlled work environment like an emergency room. Close on site observation showed how, maybe in a counterintuitive way, the simultaneous absence and presence of improvisation – absent as it is banned by the strict rules and rigid protocol compliance by doctors and nurses; Present as it’s natural brought about by the unpredictable urgencies of patients – has worked as a useful tool for the overall improvement in organizing rescue units.

Providing an example, a positive improvisation ended up being the basis for new, more standardized procedures and work processes. It may sound like a paradox, but it’s also an example of unexpected organizational effectiveness, which can be used as a virtuous example by everyone. Unless you work with Dr. House.


"Improvising Prescription: Evidence from the Emergency Room"