My grand rounds – the key slide


Category : Medical Rants



I will write more about this either later today or tomorrow.

Comments (2)

I think your “long tail” concept is very illustrative and informative. As you stated, physicians often provide great value to individual patients when we keep the long tail in mind. We all can acknowledge this.

There are serious system downsides, though. I would argue, as a profession, we tend to operate on the long tail excessively for patients who are “short tail” patients. The amount of medical testing and treatment we do dwarfs the expected benefit for many patients.

Every renal consult gets a renal US, almost every cardiology consult gets an echo, every ED evaluation of delirium gets a head CT, and most chest pain gets an admission and rule out MI. Certainly we should expect some negative testing to rule out disease, but it is a matter of degree. Coming up with a long differential diagnosis is a valuable skill. Testing each of those hypotheses indiscriminately with expensive medical imaging and blood testing is a failure of judgement. We are way out of step with regional and international spending without any major differences in outcomes. We have problems restricting our workups on many patients who are overwhelming likely to be short tail patients, in an attempt to either a)find a long tail disease or b) avoid a lawsuit.

The balance is the key, but without incentive and/or legal protection to perform judicious testing, we are contributing to the bankrupting of our society, IMHO. And I think the emphasis in our teaching institutions has not been on judicious application of testing, but on thoroughness (with an emphasis on ruling out long tail diseases).

Thanks for sharing your work with us.

well, deciding when to fish for long tail diagnoses and when to stay in the short tail is one of the fundamentals of wise clinical decision making. And it’s very difficult. that’s why we spend 7+ years in training before working independently in making those judgments.

It is unfortunate that there is incentive not to use that judgment in many cases, however, and instead simply “rule out” zebras, no matter how unlikely. (for the reasons mentioned in the comment above).

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