A long tail saga

Those who read this blog regularly know that I have written often about the “long tail”. Long tail, practice time, education time

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.

We always run the risk of missing long tail diagnoses. Our challenge is to recognize when we might have a long tail problem. We probably should consider long tail diagnoses a bit more often than they actually present. For those conversant in diagnostic testing, we must sacrifice some specificity to enhance sensitivity.

Most long tail diagnoses can be deduced because the patient does not fit the usual story. This story (thanks to KevinMD for the link) is a classic one – Madison County man gets delayed diagnosis from tick bite.

But that’s all it took, one little tick bite that swelled just a little bit, and turned a bit red in color–to make the 67-year old seriously ill.

He was working in his backyard, just along the edge of the woods back in June.

Gilbert pulled the tick out and didn’t think anything more about it, until a few days later.

“I had a 103-plus fever, chills, shaking,” he said, describing some of his symptoms.

Gilbert went to one Valley emergency room two different times and shared his symptoms and told them he was bitten by a tick days earlier.

“He horse laughed the idea that a tick had anything to do with it,” said Gilbert.

“He said you’ve got a virus, go home and see your family doctor.”

So, Gilbert did. He says his family doctor dismissed his concerns as well.

His physicians missed two long tail clues – the very high fever and the tick bite history. Why might they have dismissed the patient?

Several problems lead to long tail mistakes. Our training should sensitize us to long tail diagnoses. At the risk of insulting other physicians, ER training focuses on the common problems as does family medicine training. We all must gain expertise in caring for the common (or the short head). However, if we do not see enough sick patients in training, then we will consistently miss long tail diagnoses. Those of us who teach must continually remind our learners about the clues to the long tail.

The other possibility for missing long tail diagnoses is lack of time. In order to consider a long tail diagnosis, one must spend the time to think. We all want our physicians to spend time thinking, but the current reimbursement system does not reward time spent thinking. Many ER physicians and family physicians are seeing too many patients each day. If we try to see patients fast, we rarely take the time to reflect on the long tail possibilities.

For those who think that P4P will improve patient care, it will not address this mistake at all. We have no way of capturing missed diagnoses. We have no way to reward excellence in diagnosis.