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26 May • june 2008 the Physicianexecutive
i n t h i s a r t i c l e …
Traditional medical training may actually impede a
physician’s ability to solve complex problems because
it is based on vertical, linear and traditional thinking.
By James S. Hernandez, MD, MS, and Prathibha Varkey,
MBBS, MPH
Vertical versus Lateral Thinking
Leadership
Physician leaders operate in a realm of uncer-
tainty and guide complex adaptive health care systems.
Managed health care, compensation-based guidelines
and the need for cost-effective systems fueled the neces-
sity to deliver value-based, high-quality patient care.
The need to better understand complex systems is
especially critical in light of the magnitude of medical
errors as noted by the Institute of Medicine.1 The challeng-
es faced in today’s health care organizations are immense-
ly complicated, which often necessitate sophisticated and
non-linear thinking and solutions.
Does medical training impede the ability of physicians
to resolve leadership challenges? Traditionally, physician
leaders have depended on reasoning and logical/sequen-
tial thinking to solve organizational problems.
As described by Hauser, this process usually consists
of “thinking that proceeds in a stepwise fashion applying
specific rules in order to reach a definite goal.”2 It is linear
and left-brained, selecting only what is relevant and “cor-
rect” to achieve a goal. This traditional way of thinking is
referred to as “vertical thinking.”3
Much of the time that is spent in undergraduate
and graduate medical education cultivates this form of
Vertical vs. Lateral Thinking
Vertical Thinking Lateral Thinking
Linear
Yes No
Pattern
Develop an existing pattern Restructure an existing pattern
Direction
Stepwise and methodical Multidirectional and creative
Uncertainty Tolerated
No Yes
Rewards for
Depth of knowledge Breadth of knowledge
Restricted by relevant information
Yes No
Novel approaches welcomed
No Yes
Table 1
the Physicianexecutive May • june 2008 27
bound by logic, external demands or
goals. It does not follow the linear
direction of vertical thinking and
it is not confined to left-brain
dominant thinking.
While vertical thinking
seeks to develop an existing pattern,
lateral thinking seeks to restructure
the existing pattern. Lateral thinking
is a step-by-step method of creative
thinking with prescribed techniques
that can be used consciously.
As opposed to vertical thinking,
lateral thinking tries to identify
different directions of solving a
problem. It is not sequential, it is
thinking. Vertical thinking rewards
the depth of our knowledge. We
believe that it produces physicians
who are capable of making correct
decisions under ambiguous cir-
cumstances, leading to the rigorous
development of analytical, sequen-
tial thought processes that enable
literature-supported, evidence-based
decisions. This process of reason-
ing often serves well for scien-
tific research and for the further
advancement of the medical and
scientific disciplines.
On the other hand, “lateral
or horizontal thinking” often used
by successful leaders demands a
breadth of knowledge and skills that
requires an understanding of com-
plex systems.3 This form of creative
thinking incorporates reasoning and
imagination. By adding imagination
to reasoning abilities, new ideas are
born. This form of thinking is not
Examples in a Spectrum of Vertical and Lateral Thinking
Figure 1
Standardization
of a Practice
Instituting an
Electronic Medical
Record
Implementing a
Quality Program in
a Clinic
Developing
Disruptive
Innovations
Traditional Medical
Training
Requires Mostly
Vertical Thinking
Requires Mostly
Lateral Thinking
By adding imagination to reasoning
abilities, new ideas are born.
28 May • june 2008 the Physicianexecutive
Jim Hernandez, MD, MS, FCAP, is an
assistant professor of laboratory medi-
cine and pathology and chair of the
division of clinical core laboratory ser-
vices, department of laboratory medi-
cine and pathology. He is the course
co-director for the department's lead-
ership and management program. He
is based in Rochester, Minn., and can
be reached at hernandez.james@
mayo.edu
Prathibha Varkey, MD, MPH, MHPE,
is an associate professor of pre-
ventive medicine, medicine, and
medical education and the program
director of the preventive medicine
fellowship at Mayo Clinic. She is
based in Rochester, Minn., and can
be reached at varkey.prathibha@
mayo.edu.
References
Corrigan J, Kohn LT, Donaldson MS. 1. To
Err Is Human: Building a Safer Health
System: Washington, DC: National
Academy Press, 2000.
Hauser MJ, Feinberg D. Problem solving 2.
revisited. J Psychiatr Nurs Ment Health
Serv. 15(10):13-7 Oct. 1977.
de Bono E. Creativity and quality. 3. Qual
Manag Health Care. 2(3):1-4, Spring 1994.
Passi GR. Lateral thinking in clinical 4.
practice. Indian Pediatr. 35(9):867-9,
Sept. 1998.
Hutchens D. 5. Introduction to the Emerging
Principles of Complexity Theory
Woodburn L. Stop leading? 6. Hosp Health
Netw. 78(6):94 June 2004.
Innes AD, Campion PD, Griffiths FE. 7.
Complex consultations and the ‘edge of
chaos’. Brit J Gen PRac 55(510):47-52, Jan.
2005.
often resort—at least at the start
of their leadership career—to this
approach to solve complex business
and operational concerns.
Such thinking may result in
potentially significant failures, low
employee morale and financial loss-
es for the organization. Training in
systems thinking, complex adaptive
systems, quality process improve-
ment and leadership are some of the
ways to mentor new physician lead-
ers to cultivate lateral thinking.
It is entirely possible that there
is a spectrum of thinking from almost
pure vertical thinking to almost pure
lateral thinking and that our solutions
will depend on the nature of the prob-
lem in a complex system.
`We suggest that effective leader-
ship in complex health care systems
will require both traditional/vertical
medical training and lateral/complex
thinking strategies to optimize effec-
tiveness as physician leaders.
If physician leaders fail to ade-
quately and systematically develop
and implement lateral thinking skills
in problem solving, they may fail to
solve complex systems issues ade-
quately and effectively.
Systematic training in the appli-
cation of lateral thinking and com-
plexity theory may assist physician
leaders early on to develop effective
innovative solutions to complex
challenges in the evolving health
care system.
not restricted by relevant informa-
tion, and it does not have to be
correct. Uncertainty and novel
approaches can be terrifying to phy-
sician leaders who have been rein-
forced to find the “right” answer and
to succeed all the time.
Some of the techniques of lat-
eral thinking include challenging
labels, search for alternatives, frac-
tionation, exposure from other fields
and reversal.4
Challenging labels requires
reframing and questioning the root
causes of the problem to be solved.
A search for alternatives helps
leaders go beyond the apparently
obvious solutions, akin to generating
a differential diagnosis for a disease.
Fractionation involves the tech-
nique of breaking a complex prob-
lem into discrete subsets, and expos-
ing novel solutions or a bundle of
solutions to the issues at hand.
An exposure from unrelated
fields can aid creative problem
solving by using best practices in
other fields such as mathematics,
engineering and informatics.
Some of the concepts of lat-
eral thinking parallel the complexity
theory,5 which states that complex
adaptive systems, composed of a
network of agents, have significant
interaction among its various building
blocks. Hence, small changes within
or outside the system can lead to
major changes to the overall team,
while large changes can make very
little difference. 6
As physician leaders, the focus
in such complex medical systems is
to define the vision of the organiza-
tion in order to enhance the pro-
ductivity of front-line microsystems,
rather than to try to plan out their
every little strategy.7
Traditionally, institutions turn
to the most skilled clinicians and
researchers to fulfill leadership roles.
Since these physician leaders usu-
ally use vertical reasoning in their
previous endeavors for success, they
