Long tail, practice time, education time

I continue to obsess over the long tail concept. As I finish listening to Chris Anderson’s book, I ruminate on the concept. For those who want to sample the ideas, this article preceeded his book – The Long Tail. One important idea that he presents is the Pareto principle.

The principle was suggested by management thinker Joseph M. Juran. It was named after the Italian economist Vilfredo Pareto, who observed that 80% of income in Italy was received by 20% of the Italian population. (Since J. M. Juran adopted the idea, it might better be called “Juran’s assumption”.) The assumption is that most of the results in any situation are determined by a small number of causes. This idea is often applied to data such as sales figures: “20% of clients are responsible for 80% of sales volume.” Such a statement is testable, is likely to be approximately correct, and may be helpful in decision making. Richard Koch has written extensively on how to apply the principle in all walks of life.

I suspect that most medicine follows this principle (obviously we must consider the 80/20 concept as a general concept and not obsess over the exact numbers). Thus, most patients present with common problems which come from a small percentage of possible problems.

Our challenge, as physicians, is to know when we no longer reside in the “short head” of the above curve, i.e., when we have to consider the “long tail”. I believe that long tail excellence requires two factors, adequate time for thinking and adequate time for learning. Earlier this week, another blog commented on this problem – Cutting Off the Long Tail. The author wondered whether:

The problem with long-tail events is that they are difficult or impossible to prepare for. Assuming these are the sorts of things that require prepration and training (for instance, studying up on medical diagnoses and stockpiling supplies to treat them – as opposed to merely stocking books in a bookstore which any clerk can then sell) you can’t make ready for all possible long-tail events because there are simply too many possible ones, of which only a few will actually occur to you personally. Doctors must concentrate on the diagnoses they are likely to see; it is humanly impossible for them to learn everything necessary about every possible one they could see. (There is a line in William Nolen’s celebrated The Making of a Surgeon in which he comes out with some obscure diagnosis for a difficult case, and the attending physician tells him “Learn all you can about appendicitis, Nolen, and leave the dum-dum fever to the experts.”)

I disagree with this formulation. Excellent physicians make long tail diagnoses regularly. I have made diagnoses for which I did not have prior knowledge. What I did have was a sense that I needed to continue to pursue.

I wrote about this concept a couple of years ago – Keeping our minds open.

When a patient presents with worsening symptoms and a presumed diagnosis, we err if we do not rethink the situation. Several times this month we had patients “billed” with one diagnosis, but our clinical acumen allowed us to make a correct and different diagnosis.

Physicians err when they do not think. We must keep an open mind. I like to recall Peter Falk’s Columbo routine – you know the one where he is leaving the room, pauses and turns, and says, “You know, something is bothering me …”

We must have that instinct in medicine. When all the pieces do not fit, then perhaps we need to reinterpret the data. This past month we did so several times – to the patients’ benefit.

One of my colleagues calls this phenomenon “marrying a diagnosis”. She cautions that we should marry a diagnosis reluctanly – she prefers flirting or even having an affair with a diagnosis. We should continue to avoid premature closure until we have enough assurance that we can safely marry the diagnosis.

I have blogged several times now about the unfortunate young woman who had Lemierre’s Disease. As I speculated yesterday, the physicians did have a clue that they should entertain a long tail diagnosis –

Perhaps the two previous experiences were just warm-ups for my oldest daughter’s experience and ordeal with Lemierre’s Syndrome. She had been seen by three doctors: two office visits and one emergency room visit, before she was on her way toward the diagnosis of a serious medical condition.

Almost every physician will treat a sore throat as a simple complaint on the first visit. The patients who get admitted often have several visits to physicians prior to presenting with a serious problem. This phenomenon is not restricted to sore throats. The patients that I see in the hospital often have previous medical encounters. Too often the physician has not considered that they were entering the long tail (sounds a bit like entering the Twilight Zone).

One reason for these errors is insufficient time. We pay physicians by the encounter. Thus, decreasing the length of that encounter is financially motivated. The more patients that we see, the more money we make. Thus, too often we take short cuts. Our reimbursement system does not value spending an appropriate time with a patient. This problem is not unique to the US health care system.

Another potential problem for the future is insufficient training time. Retired Doc wrote about this concept eloquently earlier this week – Practice,practice, practice-will current house officers have time to do that?

I wonder if the current generation of internal medicine house officers will have enough time in their training to practice enough.With my generation’s training (graduation in 1965) we had more time.Counting my two years of pulmonary fellowship, it was ten years from the year I entered medical school.Now someone can complete the IM program ( assuming no fellowship) in as little as 7 years from med school entry. In addition, there is less time per week with the current rules limiting time in the hospital and more material placed into the training requirements that takes away from doctor patient time ( e.g. quality training, cultural competency and my favorite “systems based practice”).

Some leaders want to shorten training. If one considers only the test, shortened training would work. In fact, many interns could pass the board exam.

However, developing medical wisdom or clinical instincts takes time. Having worked with residents for 30 years, I know that 3rd year residents have superior clinical instincts to 2nd year residents. One feature of clinical instinct is knowing when you are entering the long tail.

Experience expands your knowledge of long tail presentations and diagnoses. We need to see many patients to develop these instincts. Book reading and lectures help, but are not sufficient. We must examine patients and hear patient stories (morning reports, case conferences, CPCs) in order to expand the area under our knowledge curve.

The long tail presents one of most important challenges. Our patients need us to know the short head and know when they do not fit into that part of the curve.