I first wrote about the long tail in 2006 – Our challenge – the long tail. To remind readers of this concept observe this graph 
Note the short head (in green). The height of the graph represents frequency. The X axis represents possible diagnoses, ranked from most to least likely. This type of curve is also called a Pareto distribution.
I am currently working on a new grand rounds on adult pharyngitis. I plan to focus on the yellow area – the long tail. This area includes the atypical and unusual problems which present as pharyngitis.
The green area in medicine is the common, frequent problems. Most performance measures focus on the short head. Physicians should become comfortable with high quality management of short head problems. However, our value increases dramatically when we recognize that the patient really belongs in the long tail. These patients have the unusual problems, which physicians often miss.
In my grand rounds I will tell several stories of pharyngitis patients who were treated as short head patients, while in fact that had long tail problems. The results of these mistakes are often devastating.
The current "quality movement" focuses predominantly on the short head. Most physicians value those physicians who recognize long tail problems. If you search this blog for the term long tail, you will find several examples of this concept.
Why do physicians make long tail mistakes? First, many physicians live predominantly in the short head, and thus always assume the patient has a short head problem They are usually correct. Second, too many physicians do not teach the long tail clues. Long tail diagnoses require that the physician understand that they are dealing with a long tail problem.
My talk will give some tips for adult pharyngitis. I have heard other physicians use pharyngitis as an example of an easy straightforward problem My talk will try to convince the audience that this "simple" problem carries signficant dangers. I hope that I will convince the audience that every problem that patients have requires careful consideration. We must know the natural history of disease, and understand when the patient’s course varies from that natural history.
We should always beware of the long tail.
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3 Responses to The long tail – implications for quality
The Jobbing Doctor
July 8th, 2008 at 2:24 pm
Elegant, beautifully put, and absolutely vital to understand. This is really the essence of primary care diagnosis, and I always have to ask myself if my diagnosis is right, and (if necessary) go back to the beginning – the history – to check that I have got it right.
This process is important so we do not repeat the mistakes of other doctors.
Another issue is whether this differentiates between clinicians of different levels of intellect, training and skills (doctors vs. nurses vs. health care assistants): I think it does.
pcb
July 9th, 2008 at 8:00 am
I hope you’re planning to summarize your grand rounds here too. Always look forward to your pharyngitis pearls.
pat
July 9th, 2008 at 7:48 pm
Last week I saw two “typical”
pharyngitis patients in an urgent care…one had a peritonsillar abscess and the other had adult epiglottitis and ended up in the ICU. If we hadn’t had a fiberoptic scope handy we may not have found this. This was after seeing thousands of garden variety sore throats. Please email me your grand rounds if you have a chance.