Original Source Research

“He who can go to the fountain
does not go to the water-jar.”

                                                           —Leonardo da Vinci

I have more respect for Leonardo than for any other curious human I’ve ever heard of. He may have been the most restless investigator of all. Kenneth Clark called him “the most relentlessly curious man in history.” He was also weird, surpassingly weird, in his interests, which were as wide and unexpected as the limits of imagination.

His notebooks were filled with observations, math equations, drawings of sawed-open skulls, of severed arteries, of water eddies, of explosions and flying machines, full also of to-do lists that chronicle his boundless curiosity. Walter Isaacson collected some samples from one day’s entry:

Measure Milan and its suburbs.
Get the master of arithmetic to show you
how to square a triangle.
Ask Giannino the Bombardier
about how the tower of Ferrara is walled.
Describe the tongue of a woodpecker.
Ask Benedetto Protinari by what means
they walk on ice in Flanders.
Get a master of hydraulics to tell you how to
repair a lock, canal and mill in the Lombard manner.
Go every Saturday to the hot bath where
you will see naked men.
Observe the goose’s foot; if it were always open
or always closed the creature would not be able
to make any kind of movement.
Draw Milan.
Get the measurement of the sun promised me by
Maestro Giovanni Francese, the Frenchman.”

What I hope you’ll notice and find inspiring is that Leonardo took nothing for granted, cultivated sources that would provide him the information he sought, and prized most of all his own observations or the direct testimony of other keen observers.

Leonardo Water
from Leonardo’s notebook

He went to the fountain,
not to the water-jar.

When Google leads you to a magazine article that says, “The study concluded that the earth is not actually getting warmer,” you’re drinking from the water-jar. You can either trust Coalminer Times, or you can be like Leonardo. Follow the lead back to the fountain. Find the study that did the testing and tracked the temperatures and drew the conclusions. See for yourself what conclusions they drew.

Are they the same conclusions Coalminer Times reported them to be? Who conducted the study? Who financed it? Was it someone interested in tracking the earth’s temperature? Or was it someone interested in promoting coal?

If the study turns out to be a collection of other people’s opinions, you’ve found the tank from which the jars were filled. Keep looking. The world is full of water tanks and water jars tainted with water from suspect sources. And very few fountains.


Isaacson, W. (2018). Leonardo Da Vinci. New York: Simon & Schuster Paperbacks.


Riddles About Riddles

Just one last word before I go.

I wrote these jokes to make a point.

Version 1
—Knock knock.
—Who’s there?
—Death who?

Version 2
—Knock knock.
—Who’s there?
Death who?
—Ultimately, it makes little difference in what form death arrives or by what name we call it. We all go one way or another and while there may be more dignity in some manners of demise, more time to prepare, or less suffering, the ultimate destination couldn’t be more similar: gone and gone and gone forever.

For me, they’re both funny (for you, maybe neither), but for different reasons. Version 1 is funny because it’s quick to point out a universal absurdity. Version 2 is funny because it gets the tone of a knock-knock joke so spectacularly wrong.

In Version 1 we laugh at ourselves for caring what kind of death is knocking. In Version 2 we laugh at the form the joke takes. I think that makes Version 2 a meta-joke, a joke about jokiness.

But that wasn’t my point.

My point was there is usually a way to say what you mean that is perfectly appropriate to your intentions, sometimes more than one, but always many, many, many, many, many ways to get the tone all wrong and spoil the effect you were going for, usually by falling for ready-made language or by overwriting what could be written simply.

My point is that when the chicken crosses the road “to get to the other side,” we laugh at the well-made joke. We laugh at how badly the joke gets it wrong when the chicken crosses the road “to find itself in sudden and much-valued possession of some other-sidedness.”

Which sort of jokes are you writing (Version 1 or Version 2)?

Which sort of jokes are these?:

—How many licensed electricians does it take to screw in a lightbulb?
—Just one.

—How can you tell the difference between an oral thermometer and a rectal thermometer?
—The taste.

Exercise for the Leave a Reply fields below:
Write a joke that gets the tone so wrong that it either dies on the spot or is funny precisely because it upends our expectations.

And if you can’t do that in the time available, just share a good (or amusingly bad) joke.

Course Evaluations, Please

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Your instructor has not been informed of the recipients of this message; only that it has been sent to the students who have yet to complete the course evaluation.

Thank you.

Stephen Hawking Was Wrong.

I shared this post with you today in class before I found this perfect expression of why we can always say with confidence that “the scientist was wrong.”

The opening joke (attributed to Albert Einstein) tells the whole story.

How to Demand Your Readers’ Attention.

This is a post in progress.


Grade Levels 2

Recently I wrote two sentences in preparing a post I never published called  “Counterintuitive Econundrums.” Reading them back, I realize they contain roughly the content value of a paragraph each. They’re not perfect sentences, but their advantages over the paragraphs they represent make them excellent models of writing that earns better grades.

An econundrum—combining the words “ecology” and “conundrum”—is a counterintuitive example of a supposed bit of “green” technology or practice that turns out to be less ecologically friendly than it seems.

Example 1

My favorite econundrums puncture the inflated claims of greenness too often made by commercial operations determined to sell us something they pretend has big environmental advantages.

This sentence packs a lot of material and delivers it in a steady stream that needs no punctuation. Commalessness is not a requirement of good writing, but sentences that charge resolutely toward their conclusion without deviating can gain a lot of momentum and arrive like a freight train. Let’s unpack the sentence into its component claims. Here’s the paragraph the sentence replaces:

Commercial operations are in business to sell us something. Because they know a large percentage of consumers are more likely to buy something that is kind to the environment than a similar but planet-killing product, they promote their products as green. Often they exaggerate the environmental friendliness of their products to trick us into making purchases that don’t really benefit the planet. Econondrums sometimes puncture the inflated claims of the companies that exaggerate their environmental benefits. Those are my favorite econonundrums.

Example 2

Electric cars make me furious, for example, because their manufacturers pretend exhaust pipe emissions are the only measure of a car’s environmental impact, conveniently ignoring the damage done to the planet to produce the electricity in the first place, a huge percentage of which is lost to transmission before it ever starts the car.

The sentence is a little long and might be better phrased, but as it stands it’s certainly not as clumsy at the version it represents, which takes way too much space to spell out the same claims:

Electric car manufacturers claim that their cars cause less environmental damage than cars that burn gasoline. They support that claim by measuring the amount of environmentally-damaging exhaust that gasoline engines emit when they’re driven. While they are correct in saying their cars don’t emit gasses, they are wrong to claim that exhaust gasses are the only way to measure environmental impact. The electricity required to power their cars is not environmentally clean because it can’t be produced in the first place without damaging the planet in some way; what’s more, a huge percentage of the electricity generated at power plants is lost in the miles of transmission wires from the plant to the charging station before it ever gets into the car. Therefore, claims that electric cars are cleaner than gasoline engine vehicles make me furious.

I invite you to respond here if this is helpful, or if you feel the need for additional samples, better models, or even revised versions of your own paragraphs before or after you’ve posted them. If I can model better writing for you, I’ll be happy to try.

Visual Rewrite Advice

Draft Version of First Second

0:00-0:01 Ad opens on a porcelain tea-kettle in the shape of a cat’s head, mostly white but with blue on the outside of the head, brush strokes made to look like hair and small blue flowers on the spout and top of the kettle. The cat’s eyes have been given a more human look, seemingly looking up at its’s holder as if to say my contents are good. It has a small, round pink nose and thin pink lips. The cat is being held buy well manicured handsthe holder must have just left the nail salon. The background is distorted as to not distract us from the kettle cat. But you can make out a possible shelf with other small items. The overall image is bright and clean.

Revision Advice

[I’ve highlighted some grammar and punctuation problems, Username.]

That’s a beautiful description of an opening image, Username. I wonder now what you conclude from looking at it. The trick of the Visual Rhetoric is two-fold. 1) Describe the Visual; 2) Explain the Rhetoric.

That tea-kettle is SOMEBODY’S taste. Perhaps not yours or mine.

  • To admirers, it’s a find.
  • To the vast majority of viewers, it’s an object of amusement at best, scorn at worst.

We don’t want to judge the person who is lovingly handling it, but we do wonder what they could possibly find desirable about it. Does any of that cross your mind when you watch the first second?

SOMETHING crossed your mind. Whatever that SOMETHING is that presented itself to your consciousness IS THE RHETORICAL VALUE of the image.

  • Is this a thrift store item?
  • Is the admirer trying to save money on housewares?
  • Or is it an antique item that might be worth thousands of dollars (not more desirable per se, perhaps, but maybe a good investment).

Those newly-manicured nails.

  • Do they say: “I shop at thrift stores so I can afford expensive manicures”?
  • Or do they say: “I can afford both expensive manicures and costly antiques”?
  • Or do they say: “I do my own nails so I can afford to shop wherever I want”?

The odds are pretty good this is not an ad for kitty-kettles, so there’s something other than a commercial message being delivered in this first second.

The director did EVERYTHING for a reason. Why did she make these first-second choices?

Please comment below if you now understand the two components of the Visual Rhetoric Task.

  1. Visual
  2. Rhetoric

Wield Your Statistics

They’re tools.

Statistics without direction and velocity are useless. They’re a bag of balls, or a rack of bats, blunt as a hockey puck or flabby as an under-inflated football. Pick your own silly analogy, but remember this: having them is pointless if you don’t know how to use them.

We all handle them differently.

Batting Stance

Among the many approaches for handling statistics, you’ll find one that makes you comfortable, but some essentials are common to all good writers: they face forward, adopt a comfortable stance, stare down the opposition, deliver with confidence, and know how to use spin.

My number is a good number.

Readers need to be told how your number compares to the range of possible numbers. The statistic by itself means nothing until you place it into context.

Half Glass

  • A full 50%
  • As high as 50%
  • Has improved to 50%
  • Proud to announce we have achieved 50%
  • At 50%, the perfect balance

My number is a bad number.

Except for experts in the field of your endeavor, your readers are at your mercy to interpret the value of the numbers you share. They count on you to guide them to an understanding of the importance of the evidence you present.

Half Glass

  • A mere 50%
  • As low as 50%
  • Has sunk to 50%
  • Regret to admit we have achieved only 50%
  • At 50%, an awful compromise

Real-life example.

Michelle Obama on her book tour is talking frankly about infertility. The news announcer putting Obama’s miscarriage and subsequent worries into context shared these facts:

  • Approximately 10% of American women between 18 and 45 who attempt to conceive, experience infertility to some degree.
  • The percentage is higher for African-American women.

I have no idea whether those numbers are higher or lower than I should have expected, and the announcer was no help. She could have used the statistics in any of several ways to help me understand.


Find the useless sentence.

Though these sentences are contradictory and entirely fictional, each serves a rhetorical purpose. Find the useless sentence and pledge to purge any like it from your work.

  1. Modern medicine and Americans’ overall health have reduced the infertility rate to 10% for American women, though sadly the rate is higher for African-Americans.
  2. Shockingly, the infertility rate for African-American women between 18 and 45 is higher than for women in many of the wealthiest African countries.
  3. The infertility rate has skyrocketed to 10% for all American women 18 to 45, even higher for African-Americans.
  4. 10% of American women between 18 and 45—more for African-Americans—who attempt to conceive, experience infertility to some degree.
  5. Though African-Americans lag behind by a few points, American women who wish to become pregnant have achieved a remarkable 90% fertility rate.


Argument and Rhetoric are inseparable

Despite my pretense that they can be graded as separate categories, Argument and Rhetoric are as inseparable as fist and fingers. Just as I can’t describe a fist without speaking of tightly curled fingers, I can’t describe Rhetoric without explaining how it persuades readers to accept an argument. Even so, I try to grade the fingers and the fist.

The Style Aspect of Rhetoric

Example 1

Uncorrected Drafts suffer from imprecise language that inhibits interpretation.

[When read aloud, the following paragraph sounds like mostly comprehensible conversational speech, but viewed on paper, it is peppered with grammar trouble and peculiar phrasing that make comprehension very difficult.]

The NPR broadcast was very interesting and what surprised me is how the claims were accurately correct in my opinion. I would have never thought of how money can change so drastically in time. In the past, we were exposed to using gold as a currency, then to paper bills and now an electronic transaction. In today’s world, society does claim to use paper bills and coins for small matters, but at the same time we already progressed, using digital cash. A prime example, paying bills, in which society pays bills using a computer and that consist only information it’s seems surprising to know now how easily any amount of a transaction can be paid off or transferred. There is no physical money being involved. The closest idea that I can think of using paper would be is sending checks through the mail, but that’s highly rare nowadays.

[The highlights indicate every phrase that needs to be corrected. Red and purple are not particularly significant, but two colors are needed to call out individual phrases.]

Corrected Drafts make clearer statements that are easier to interpret.

The NPR broadcast was very interesting, and what surprised me was that the claims were correct in my opinion. I never realized that money had changed so drastically over time. In the past, we used gold as a currency, then paper bills, and now electronic transactions. Today, although we claim to use paper bills and coins for small matters, we have already progressed to digital cash. We pay our bills by computer; those transactions consist of information only. At any time, all or part of a bill can be paid off or transferred without any money being involved. The only way we use paper now is to send checks through the mail, but that’s highly rare nowadays.

Rhetorically Effective Drafts persuade readers to accept a premise.

The NPR broadcast told the story of money correctly. I was surprised to learn that money had changed so drastically over time. In the past, we used gold as a currency, then paper bills, and now electronic transactions, each time using a more abstract version of barter. Today, although we claim to use paper bills and coins for small matters, we have mostly eliminated those last physical objects in favor or digital cash. We pay our bills by computer using information only, nothing physical. At any time, all or part of a bill can be paid off or transferred without any paper or metal currency at all. The only way we use paper now is to send checks through the mail, but that’s increasingly rare.

Rhetorically Effective Arguments prove more complex theses.

The NPR broadcast told the story of money correctly. It illustrated that money, already an abstraction, has grown increasingly more abstract, as have our lives in general. Before money, we traded cows for corn, but transactions were limited to what one trader had that another trader wanted. With the advent of gold as a currency, trade flourished because the gold could represent cows or corn or any other valuable commodity. It was an abstraction, a symbol of needs fulfilled. Next paper bills, with no inherent value, represented gold. Now electronic entries in a bank branch database represent dollars, each step more abstract than the previous. Today, we don’t trade, use gold, or for the most part use currency: we pay our bills by computer using information only, nothing physical at all. Like the work we do (which increasingly is not physical labor but mental exertion) it’s no coincidence that our cows are also now abstractions. The closest we get to the animal is the shrink-wrapped meat ground and extruded so that it no longer looks like anything that lived.

Example 2

Uncorrected Drafts suffer from imprecise language that inhibits interpretation.

Money, money, money. The extremely complex and arguably fictional foundation of our economy. I always wondered growing up how did a piece of paper with some inscriptions and fancy images become the social fabric of our world? When you put a U.S dollar bill side by side to monopoly money you understand that one is worth something and the other isn’t. Although, monopoly money like “real” money is simply paper from our trees. Therefore, we must question, why is money valuable? Pre Colonial era we traded among each other valuables in which each person needed. We valued precious and rare metals or jewels such as diamond, gold and silver. We valued goods as currency and only cared about items which every colony needed. If a man had a pig but needed a cow he would search for that person that needed a pig and had a cow. This exchange of goods made perfect sense and never involved a paper bill and a complex system of valuing that bill. Money in its self has no real value to it, it isn’t rare and its not pretty. We the people make money valuable, we make the value “real”, but should we?

Corrected Drafts make clearer statements that are easier to interpret.

Money, money, money: it’s the extremely complex and arguably fictional foundation of our economy. I always wondered growing up how a piece of paper with some inscriptions and fancy images became the social fabric of our world. Even a child who puts a U.S dollar bill side by side to Monopoly money can understand that one is worth something and the other isn’t, even though “real” money—like Monopoly money—is simply paper from our trees. Is it because one is issued by the US government and the other by the Parker Brothers Company that makes one of them valuable? In pre-colonial times, we traded among each other valuables which every person needed. We valued precious and rare metals or jewels such as diamonds, gold, and silver. We valued goods as currency and only cared about items which every colonist needed. If a man had a pig but needed a cow, he would search for the person who needed a pig and had a cow. This exchange of goods made perfect sense and never involved a paper bill or a complex system of valuing that bill. Money in itself has no real value to it; it isn’t rare, and it’s not pretty. We the people make money valuable. We make the value “real”; but should we?

Rhetorically Effective Drafts persuade readers to accept a premise.

Despite its importance to all our lives, we have to admit money is a fiction. Children are right to wonder how pieces of paper with some inscriptions and fancy images run our world. They know but can’t grasp why one dollar bill can be traded for candy at the corner store while the other is worth nothing, except in Monopoly. What they do understand is that the houses in Monopoly aren’t real, but the money doesn’t seem so different from the bills we use for groceries. 

In our early history, we traded valuable things directly. If a man had a pig but needed a cow, he would search for the person who had a cow and needed a pig. This exchange of goods made perfect sense but was clumsy and sometimes impossible to manage. Substituting precious and rare metals or jewels for cows and pigs, we were able to trade with everyone, whether they had cows or not. Money in itself has no real value to it, but we agree to make it valuable for convenience. While it no longer represents gold, the money we use today has value only because it is issued by the US government and not the Parker Brothers Corporation.

The Argument Value of Rhetoric

Rhetoric Can Reveal or Hide Arguments

The fact that there is a giant ball of limestone sitting in the middle of the ocean somewhere still being claimed by someone who is deceased is unsettling to me. That is like me having 500 dollars and throwing it in the ocean. When the money washes up onto shore and someone picks it up, it would now be theirs. Nobody can just go pick up the giant ball of limestone and claim it.

This paragraph may contain a valid argument, but the language obscures it. The analogy misses the point of the story of the sunken fei. Nobody will ever retrieve that “money,” but its physical presence or absence is of no longer of consequence to its owner.

Let’s try a different analogy for the limestone disc at the bottom of the ocean. Donald Trump has created a value for his name. Unlike banks that pay huge naming fees to have NFL stadiums named for them, Trump can get developers to pay him millions to attach his name to a project. His name is not an object like the sunken fei. Its insubstantiality doesn’t matter at all. And neither could anybody steal it and be richer. If he’s a billionaire, it’s because he can sell his name for a billion dollars whenever he wants to.

Brevity and Clarity

Don’t Give Readers Time to Disagree

A first draft may contain many capable sentences that make reasonable individual points, but if they don’t transition well from one idea to the next, and if the goal of the argument is not identified in advance, readers are free to follow any path that distracts them and never arrive at the summit you want to guide them to.

1. The value of money is the mental reassurance of wealth.
2. One might question what mental reassurance of wealth has to do with money.
3. Simply it is the way we track value.
4. We are reassured that the money we have can purchase a curtain amount of things.
5. We place a value on money to keep track of things it can purchase.
6. The psychological or economic value of money may change with currency variations, but the money will always be worth something.
7. Over time, America’s relationship with the value of the dollar has evolved.
8. In the early 20th century, it granted a request from the French to convert their dollar assets into gold.
9. Granting that request gave the impression that the US dollar was weak.
10. The French believed that their money was worth more than the U.S. dollar.
11. The French wanted something they thought was worth having, so they asked for gold.
12. Even though the gold was worth no more than the equivalent value in US dollars, the French were not convinced that the dollars were “worth their weight in gold.”

First, combine the sentences for better effectiveness.
[1-6] Money reassures us of our economic wealth. While the volume of goods and services it can buy will change from time to time, knowing that we have enough to meet our needs is reassuring.

Then, provide the needed transition between the sections.
But even money can vary in value compared to other currencies.

Then, combine the conclusion sentences.
[7-12] When the French began to doubt the stability of the value of American dollars, they demanded the US convert their dollar holdings into gold.

Most of your individual claims can be made in a word or two so that the sentences provide their own internal transitions.

Sufficient Scholarship

Example 1

Over-reliance on Personal Perspective

So what makes these pieces of paper we call dollars have value? well because people in society decided to make it have value. This method of currency was created to make the trade of goods easier and faster to manage. After reading “The Island Of Stone Money” one can notice that the inhabitants of Uap had a similar system to the one we use today. Today technology has advanced so much that we can now digitally manage, distribute and hold our money through mobile apps and online websites. whether one prefers using credit cards, Pay Pal or bank apps a physical dollar is a place holder for that digital number on any of those digital outlets. Now comparing Uap’s method to our current method the people of Uap used the stones as their physical placeholder to replace their word. Essentially creating a word for product system. Whilst currently people are using a pixel for product system.

Rhetoric and Scholarship are inseparable in your case, MyStudent. You’re trying to thrive on observation and speculation alone, without bringing any evidence or support from the rich material at your disposal. You cite only the Yap, and you do so in a way that assumes your readers are all familiar with Milton Friedman’s article. They’re not. They haven’t listened to the NPR podcast. They have no idea what you’re talking about. They know only what you tell them. So tell them what you learned and help them understand.


Advertising Failure

Counterintuitivity in Medicine

Advertising Failure

By which we mean: “Announcing Where and When Failure has Occurred as a Method for Reducing Failure.”

The story of Doctor Kim A. Adcock’s approach to solving a problem in the radiology department at Kaiser Permanente in Denver reads like script background for one of those “procedural” TV shows such as CSI. We know who died (far too many) and we know who did it (doctors, sort of) but we’re not sure how to handle the evidence to make sure nobody gets killed next time.

Procedures that seemed reasonable to Kaiser in 1995 because they “had always been done that way,” turned out to be entirely unreasonable, with deadly consequences. And a solution that seemed impossible because of fear, turned out to be the best and most logical of solutions, and has saved countless lives.

Microsoft PowerPoint - EKA.RSNApressimages.2012.10.08.pptxMicrosoft PowerPoint - EKA.RSNApressimages.2012.10.08.pptx

[Caption above and below:Mammography images (from 2010, left; and 2012, right) of a woman in her forties with no family history of breast cancer who missed a year of screening and in the interval developed suspicious right upper out calcifications [ ] and a suspicious mass { }, both of which underwent biopsy, yielding invasive carcinoma.]

Microsoft PowerPoint - EKA.RSNApressimages.2012.10.08.pptxMicrosoft PowerPoint - EKA.RSNApressimages.2012.10.08.pptx

I read this story when it first appeared in 2002 and have cherished its insights ever since. Now 16 years later, I had to go find it to share it with this class. Since reading it, and other stories like it, I cannot look at statistics of any kind without wondering what they really mean. If the crime rate goes down, does that mean there is less crime? Maybe not. It might mean fewer people are reporting crimes.

For example, in New Orleans after Katrina, distrust of the police ran so high most citizens in some neighborhoods preferred to suffer crime in silence than to involve the police. The very first thought that came to my mind listening to that story was, “I’ll bet the crime rate has gone down in those neighborhoods” and not because there’s less crime. The mayor though, and the chief of police, can trumpet those statistics as if they’re doing a better job in those same neighborhoods.

But I digress. Before you read the article, “Mammogram Team Learns From Its Errors,” I want you to make predictions on a variety of factual situations that lend themselves to counterintuitivities. (I’m going to keep using this word until the rest of the world adopts it.)

Open the post Counterintuitive Predictions and react to the 50 claims by making a long Reply below the post. When you finish classifying the 50 claims, try to summarize the article you’ve never read based on the claims you find in the list.

Photo Source: Radiologic Society of North America RSNA

The Article

Against the possibility that we will some day be unable to access the original article at the New York Times, I reproduce here the contents:

”Every mammography program in the country should be doing something like this,” says Dr. Robert A. Smith, the American Cancer Society’s screening chief.

Very few do. In fact, what Dr. Adcock has created is a mirror image of American mammography as usual — an industry that remains deeply troubled 10 years after Congress set out to clean it up through its own experiment in medical regulation.

At the heart of Dr. Adcock’s experiment was his willingness to confront his doctors and focus on their skill in spotting tumors in the swirls and shadows of X-ray film, what experts call the hardest job in radiology. For the government, facing withering resistance from physicians, regulating doctors proved too politically risky. At the very moment in 1995 that Dr. Adcock was beginning to hold his doctors to the statistical fire, regulators were settling for a system that concentrated on the X-ray machines and the images they produced.

In that breach, a yearlong examination by The New York Times has found, the government has fallen far short of its pledge to ensure high-quality mammography for all. Here in Denver, Dr. Adcock has winnowed his team down to a few specialists. By contrast, most of the 20,000 doctors in the United States reading breast X-rays are generalists with limited training and practice in mammography. Many lack the skill needed to do so effectively, yet neither they nor their patients have the tools to find out who is good and who is not.

Keeping score, though, is not simply a matter of identifying and weeding out the worst practitioners. For Dr. Adcock and his admirers, the statistics offer a way to approach a more pervasive, and more elusive, problem that increasingly preoccupies the entire medical profession: the mistakes that, to varying degrees, all doctors make.

At Kaiser in Denver, the statistics anchor a regimen of continuous education that far outstrips the few hours a year the government requires. The Denver doctors are constantly analyzing their errors, searching for those meaningful patterns of shadow that they have missed, perhaps again and again.

The Denver group is not the first to use statistics to track doctor performance. A small but growing number of other mammography programs are beginning to keep score. Several states now publish individual doctors’ death rates for open-heart surgery. But seven years in, the Kaiser mammography group has perhaps gone as far as anyone in creating a statistical system for holding doctors accountable for their work.

Still, even many of Dr. Adcock’s admirers point out that he has achieved his success in the closed and relatively manageable confines of a health maintenance organization. They wonder if it can be replicated broadly, especially since the government has not fulfilled its promise of a national registry of cancer cases. At Kaiser, if a woman receives a breast cancer diagnosis, a doctor can find past mammograms and see if her case was missed. In the world at large, a doctor will often do a mammogram and never see or hear of the patient again.

In the end, though, the most delicate obstacle may be the doctors themselves. Doctors have been pushed a good distance from their traditional pedestals. But few have done so especially happily, and rare is the physician eager for the psychic roughing up that comes when the Denver doctors are forced to confront their mistakes.

Dr. Ken Heilbrunn, a Seattle radiologist who says he admires what Dr. Adcock has done, calls this the ”shame” factor, and manipulating it is the stealth ingredient of the Kaiser method. ”To really improve your skills,” he explains, ”you have to repeat this shameful moment over and over.”

It’s a tricky business, this question of the doctor’s image. Even today, Kaiser is reluctant to advertise its turnaround, and it would share only some data with The Times. Too many people still believe doctors walk on water, one official explained, so how can we brag about making fewer mistakes?

In wielding those mistakes, Dr. Adcock says he pledged from the first to avoid emotions and hold everyone accountable, including himself. After all, he says, ”it is easy for us to delude ourselves about the quality of our work.”

Setting a New Standard

The revolution began with a shot in the dark.

When several physicians complained about an apparent missed case in September 1994, Kaiser dealt with it in a typically ad-hoc way: the radiologist in question was encouraged to have another doctor double-read his films for a while. There was no reason to go further, Kaiser reasoned, since even experts make mistakes.

But soon after, the H.M.O. named a new radiology chief, Dr. Adcock, with a different approach, drawn from his personality and personal experience.

Five years before, Kaiser had hired Dr. Adcock for a variety of X-ray work. He had little grounding in mammography and a cautious, statistical turn of mind not entirely common in a doctor. In fact, he had thought about becoming a lawyer, and in medicine had sought out a specialty about as far removed from patients — and especially, he says, their blood — as possible.

Starting out at Kaiser, he had dreaded missing too many tumors. ”A good deal of what we do in radiology does not have the same sort of health implications,” he says. ”’With mammography, you’re looking for the opportunity to save a life.”

He devised a personal oversight system, using what are known as medical-outcome data, in which a doctor’s action is tracked to see how the patient fared.

Mammography, he felt, was well-suited to a statistical approach. Unlike, say, hip surgery, with its many gradations of success — is it the ability to walk, or run, with or without a limp? — the equation in mammography is fairly straightforward. The radiologist concludes that a woman appears to have cancer or not, and over time that judgment is proved right or wrong.

If mammography was the ideal medium, Kaiser was the ideal laboratory, since it already tracked its members. So when Dr. Adcock began his new job, he quickly homed in on his suspect employee. The doctor, it turned out, had not missed just one case; he had apparently missed a lot.

In taking the matter to his bosses, Dr. Adcock says now, he realized he was stepping into a running debate. He remembered the furor, and the mixed lessons, of the heart-surgery initiative in New York.

After the surgeons’ scores began appearing, the heart-surgery death rate had fallen by about 40 percent. Dr. Mark Chassin, a former New York State health commissioner, says hospitals were pressed to fix underlying problems. New Jersey and Pennsylvania have since begun their own listings.

Some researchers suggested, however, that other factors might have driven down the death rate. They questioned the soundness of the data. They warned that surgeons might be increasing their scores by avoiding higher-risk patients, a criticism that prompted the state to refine its system.

But where others saw controversy, Dr. Adcock saw opportunity.

”For me,” he recalls, ”it was a feeling of exhilaration that here at last was some aspect of medicine that could be measured and managed.”

He rechecked his numbers, then sat down with Kaiser officials, lawyers and public-relations people. They were worried about many things — negative publicity, malpractice claims, women turning away in skepticism. How many might die because they stopped getting tested?

But there was another danger they could not ignore. The radiologist had read 3,000 mammograms, and if Dr. Adcock was right, a dozen or so women he had said were fine in fact had breast cancer.

Making Tough Decisions

Finding those women was a huge job. The radiologist’s films had to be culled from the files and reread by several doctors.

They concluded that 259 women needed follow-up X-rays. Kaiser brought these women back in, gave biopsies to 30, and in the end, 10 women were found to have cancer, the H.M.O. says.

Word eventually reached The Rocky Mountain News, a local newspaper, which reported it as a front-page medical scandal.

In its defense, Kaiser said it had uncovered the situation through its own detective work. Steve Krizman, who edited the Rocky Mountain News’ coverage and later joined Kaiser as a spokesman, said he was skeptical enough about Kaiser’s assertion to mention it only briefly in the pieces.

”I thought, ‘That’s how they are trying to spin it,’ ” Mr. Krizman recalls.

But if the news media missed the broader story, some of the women involved did not.

At first, Ann Veenstra felt spun when she got a phone call asking if she would mind getting another mammogram. ”I felt something was wrong,” says Ms. Veenstra, an administrative assistant.

It felt especially wrong in her case. The mammogram had been her first, a baseline test at 40; she had not planned another for five years. When she turned up with cancer, she says, ”I was so very angry.”

But Kaiser explained how it had found her cancer, and she realized that after potentially killing her off, the H.M.O. may have saved her. ”After I got over my initial shock and anger, I appreciated that someone was checking and double-checking,” she says. ”It’s unbelievable to me this is not nationwide.”

Missed breast cancer is a leading malpractice complaint. But Kaiser was sued by just one woman, who eventually settled.

The radiologist, Dr. James A. Walsh, was crushed when Kaiser asked him to leave, his former colleagues say. He was 60, with two children in graduate school. ”It was a painful moment,” he said recently.

Dr. Walsh said he felt singled out for undue scrutiny and had been treated unfairly and unprofessionally. He said that an expert had found that only three of the missed cancers could be legitimately blamed on him, and that such an error rate fell within acceptable bounds.

”I think I was right and they were wrong,” he says.

The Kaiser official who headed the Denver affiliate’s quality-control program, Dr. Andrew M. Wiesenthal, says the treatment of Dr. Walsh was ”exceedingly fair.”

”We didn’t take any action until it was patently clear that he didn’t do this very well,” Dr. Wiesenthal says.

The Colorado medical board placed Dr. Walsh on probation, and he eventually moved to North Carolina. He says he attended numerous training programs and is now reading mammograms as a fill-in radiologist in four or five states.

”All the medical staffs I work for have no problems at all with my work,” he says.

Starting Fresh

Even with all the hubbub, Dr. Adcock’s bosses gave him a free hand to dig deeper.

”Jim Walsh was a lovely, lovely guy,” says Dr. Deborah S. Shaw, one of the radiologists on the team. ”But we knew this was the right thing to do.”

Which is not to say that the team did not feel wrenched by the firing, and by all the publicity. The doctors could not help but wonder who would be next.

Over the next few years, several more radiologists were fired or resigned in the face of concerns about their interpretive skill. Then Dr. Adcock spotted an even trickier problem. Nearly half the original 20 radiologists were reading far fewer mammograms than the others. They met the federal minimum of 480 a year, but with the others reading as many as 14,000, Dr. Adcock agreed with experts who say the government minimum is far too low.

Moreover, the low-volume doctors were not accumulating enough data to show if they were good. So he simply assumed they were not, and restricted them to other radiology tasks, like CAT scans.

How did they feel? Rather relieved, it turns out. Dr. John A. Siebert, for one, says mammography was monotonous, particularly since he might screen 200 healthy women before finding one cancer. An instructor once told him to pretend that each X-ray was his mother’s, but that trick, he says, went only so far. ”It’s sort of tedious,” he says. ”You have to sort of slap yourself to look at them.”

Others say they had trouble mustering — and holding onto — the intense yet relaxed concentration needed to find the more subtle tumors, what some of the Denver doctors call ”the Zen zone.”

”It was hard for me to get in the groove,” Dr. John W. Grudis says.

Improving Accuracy

In a dark basement room, Dr. Shaw takes a deep breath, clears her mind and begins the hunt for breast cancer. It takes her just minutes to stumble.

She sits facing a large machine shaped like a player piano that holds a reel of mammograms, and when she spins the films of a 55-year-old woman into view, she is riveted to a whitish spot in the shadows.

”This one cluster has my attention,” she says. ”I can’t tell you why, but it looks funny.”

She dictates instructions for the woman to return for further testing. But the biopsy finds only normal cells.

The doctors do not take these ”false positives” lightly, given the physical and psychic pain they can inflict on a patient. But there is a weightier side of the coin, the moment when a doctor finds a tumor that looks as if it has been around awhile. Then the question becomes, was the cancer visible on earlier films? If so, who read them?

”It’s a horrendous experience, just an explosion of emotions at once,” says Dr. Gerald L. Lourie, another team member. ”You know you are either going to be free as the judge says, ‘Not guilty,’ or you look and you know you just missed this one cold.”

What distinguishes the Denver team from most others is its systematic embrace of frequently occurring shame.

Once a year, Dr. Adcock also sends out lists of actual cancers missed, known as false negatives, so the doctors can pull the files and commit their mistakes to memory.

”That’s your boss telling you, ‘These are the ones that weren’t so hot,’ ” says one of the doctors, Richard A. Propper.

Last comes the toughest scrutiny of all. The doctors’ hits and misses and other statistical variables are displayed in brightly colored charts for all to see.

Mammography everywhere is a constant balancing of possible harm: between missing too many cancers and ordering too many needless biopsies. But the Denver doctors say their continuous scrutiny enables them to spot weaknesses in their work before they do inordinate harm.

Over time, they say, they have made an important discovery about why they miss some tumors. Breast cancer has many different shapes on an X-ray: a line of little white dots, perhaps, or a star-shaped blob known as architectural distortion. By testing and keeping score, the Denver doctors found that they sometimes obsessed over one type and neglected the others.

Today, the team’s accuracy is close to what experts say is the best mammography can offer.

Women have been told that mammograms can find 90 percent of breast cancer. But that figure stems from ideal conditions in research, and recent real-world samplings in two states show that doctors are finding just over 70 percent of the cancers in women who get regular exams.

Some clinics are doing much worse. Four of the six busiest centers in a study of screening in North Carolina are averaging about 65 percent. That is, they miss one cancer for every two they find. (Not all missed cancer can be blamed on the doctor; the X-rays might be poorly taken, and many tumors are simply too hard to see.)

The Denver team, stuck near 70 percent before it began its makeover, is now scoring 80 percent. By another measure, it is finding cancers at an earlier stage, allowing for earlier treatment. It did this without increasing the number of women it sends to biopsy. Just as critically, the group says, its team is consistently good, doctor to doctor. Women need not worry about having their X-rays read by a weak member of an otherwise strong team.

What that means, in the simplest terms, is that the Denver doctors are finding about 15 more cancers a year than they would have at their previous accuracy level. (Kaiser says it does not know if that improvement has affected its breast-cancer death rate.) In a country where 192,000 breast-cancer cases are diagnosed each year, that same increase in accuracy could mean finding upwards of 10,000 more annually.

Seeking a Better Way

Dr. Adcock is branching out. He has begun looking at outcome data for other radiology procedures, like breast biopsies, in which doctors can cause bleeding or miss the targeted cells.

And the news from Denver is starting to get around Kaiser’s loose nationwide confederation of H.M.O.’s.

”Kim Adcock is at the cutting edge of everything in radiology,” says Dr. William E. Drobnes of Kaiser’s Maryland affiliate, ”and I’m shamelessly trying to steal this.”

A similar effort is under way in British Columbia, and about 120 clinics in the United States, mostly in North Carolina and New Hampshire, are volunteers in a study designed to help doctors improve their skills.

Still, this is a revolution of small steps. Even at the nation’s leading cancer centers, doctors say they cannot do all Dr. Adcock has done.

Partly, it is that vast and inevitable well of psychic resistance. Equally important, few medical organizations can control information the way Kaiser can, as an H.M.O. that provides all of its patients’ care.

”Everybody would like to do this if they could. It’s a wonderful learning experience,” says Dr. David Dershaw, the mammography chief at Memorial Sloan-Kettering Cancer Center in New York. ”But the search for false negatives is difficult, cumbersome and expensive.”

Sloan-Kettering does track false positives, and Dr. Dershaw says he is confident that his doctors, all trained by him, are highly skilled.

Still, he has never calculated their skill by tracking missed cancers. That would require contacting all the women who got negative mammograms — tens of thousands each year — to see if they later received diagnoses of breast cancer.

”I’ve been trying to reach one woman for three days,” Dr. Dershaw says. ”And I’m trying to give her the results of her biopsy. Just imagine what it would take to reach every woman who comes in.”

In pursuit of a better way, Congress a decade ago ordered the creation of a national cancer registry that radiologists could search for patient records. But the system remains a cumbersome and piecemeal hodgepodge of state archives.

The data are also difficult to interpret, especially for the many doctors reading just a few hundred films a year. Several years’ worth would be needed to be meaningful.

Some clinics are trying other approaches. A few have two radiologists read every X-ray independently; others are using novel computer programs that show promise in seeing some hard-to-find cancers.

Even so, when experts talk about doctors’ skills, the discussion almost always circles back to the conundrum federal officials wrestled with when they wrote the mammography rules a decade ago: How to improve quality without diminishing access to care. If doctors start dropping out of mammography because they score badly in tests or performance audits, where will women go?

The balancing act gets trickier and trickier. New research is stoking concern about doctors’ competency. At the same time comes anguished talk about doctors driven away by skyrocketing malpractice rates and shrinking reimbursement.

To some experts, the solution lies in a radical-sounding reorganization: centralized facilities across the country where large numbers of mammograms would be read by small teams of highly skilled, and presumably enthusiastic, experts. In the future, digital mammography, a recent and still-experimental innovation, could make sending films as easy as e-mail.

Which is remarkably similar to what they do in Denver. Call it the two-step mammogram. Women are still X-rayed at satellite offices, but the films are shipped to the central complex where Dr. Adcock’s six-member team works. This has also meant lower costs for a procedure that many radiologists see as a money-losing obligation.

For now, though, many people are banking on the federal government, hoping it will pay more attention to the doctors.

Legislation moving through Congress to extend the federal mammography rules would have the Institute of Medicine, an independent research group, study several matters, from doctor training to interpretive skill. Breast-cancer screening advocates are quietly pushing Congress to take strong steps, sooner. The American College of Radiology, which accredits the nation’s mammography doctors, says it would support a federal requirement for periodic competency drills.

Many experts, like Dr. Robert A. Schmidt of the University of Chicago, say that only a complete government overhaul can do the job, starting with financial incentives and ending with tools to assess doctor skill.

He is not holding his breath. ”There are lots of arguments you can make in deciding to do nothing,” he says. ”Even with the way mammography is now, you could still say you’re still doing more good than harm.”

Working as a Team

Even Dr. Adcock is wary of having the government police doctors’ performance. ”I could see that being counterproductive,” he says.

On the other hand, left to themselves, it is not clear how many doctors would do what Dr. Adcock did when his data turned on him.

The Denver doctors all have their own reading styles. Dr. Shaw likes to press her red-nailed fingers against the X-rays when she zeroes in on a problem spot. Dr. Geoffrey D. Friefeld burns through films at a torrid two-minute pace.

Dr. Adcock is a fretter. ”Oh boy, I hate it when that happens,” he said one afternoon last summer when he couldn’t make up his mind. ”This one is very hard to let go.”

Then his latest scores came in, and he really started to worry. He was dumping more X-rays into an ambiguous pile, having failed to decide if they showed cancer or not. Holding his charts, he said, ”I look at that and think, my goodness, have I forgotten how to read mammograms?”

He labored over the tougher cases, and even his body language — big exhales and slouching — seemed to show his concern. He thought about the radiologists he had exiled, including Dr. Walsh.

Then his volume began to slip as he spent more time on management duties, and he wondered: If his accuracy slipped, too, would he see it in his data? ”That was the hardest thing,” he says, ”knowing that I might not be able to tell.”

Late last year, his volume slipped below 200 a month, and as his colleagues watched his numbers drop, they feared the worst. If he did not stop himself, Dr. Shaw says, ”I would have had to tell him to.”

On Jan. 1, Dr. Adcock decided to stop reading mammograms. He did not want to burden the team with his workload, since the original group of 20 was down to 6. But he says he had a bigger obligation in bailing out of a task he had come to love: ”I’m protecting the patients against myself.”

Tips on Mammography Clinics

Dr. Barbara Monsees headed the expert panel that helped write the federal mammography rules. But when women ask her where to get a good mammogram, she does not tell them to look for the government seal of approval. ”I tell them to go to a place where people specialize in mammography,” she says.

Comparison shopping for mammograms is not easy. The government does not gather much of the information that experts say women need. Women in rural areas may have to travel long distances to find expert doctors. Some doctors may bristle at being grilled. Even high-technology radiology clinics in fancy neighborhoods may be staffed with doctors who do not have the training, experience or knack to read mammograms well.

Still, Kaiser in Denver is hardly the only place that offers high-quality mammography. Several experts offered these thoughts about how to find one of the others:


Find a clinic where doctors read large numbers of mammograms, far beyond the 480 a year required by the F.D.A.

Insist on having your films read by the ”lead interpretive physician,” who oversees a clinic’s quality controls.

Look for doctors who did fellowships in mammography, or those who spend at least half their time reading mammograms. At the very least, seek out an enthusiast who goes to meetings and perhaps writes about mammography. (They show up on the Internet.)

Look for clinics where two doctors independently interpret every film.

Ask about ”medical audits,” which show if a doctor sends too many women for biopsies.

Use open-records laws to obtain a clinic’s inspection reports, which list violations and chart the image-quality test known as the ”phantom.” Look for a combined score of 12 or more. Beware of citations for equipment failures or missing ”QC,” or quality control records.


Don’t press for an instant interpretation of your films. A day’s delay through ”batch” reading can maximize a doctor’s power of concentration.

Don’t put too much faith in a doctor being board certified in radiology. Many doctors passed before the late 1980’s, when mammography was added to the exam. In any case, the number of practice mammograms on the test does not reflect the rigors of real-world screening.

Don’t judge doctors by the lawsuits they have lost for misreading mammograms. Even the best doctors will miss some cancers.

Don’t put too much faith in promising but still experimental technologies like digital X-ray machinery and computer programs that look for cancers doctors might miss.

Don’t have your mammogram done on Mother’s Day, when many clinics offer free or discounted exams. These programs can swamp the doctors and rush the reading.