"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"I hear and I forget. I see and I remember. I do and I understand." - Confucius
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"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
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" The best test of a person's character is how he or she treats those with less power." - Bob Sutton
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"Those are my principles, and if you don't like them - well, I have others." - Groucho Marx
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"The difference between genius and stupidity is that genius has its limits." - Albert Einstein
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"It is hard enough to remember my opinions, without also remembering my reasons for them" - Friedrich Nietzsche
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"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
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"This ain't no party, this ain't no disco, this ain't no fooling around." - Talking Heads, Life During Wartime
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"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
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"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
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"An idealist is one who, on noticing that a rose smells better than a cabbage, concludes that it will also make better soup." - HL Mencken
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"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
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"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow
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Workouts by month - Goal 200 from 11/1/09 through 10/31/10
The ACP Advocate Blog by Bob Doherty: "There once was a man named O'Bama ..." http://ow.ly/1nUH3 - HCR limericks and a cold one for BobMarch 18, 2010 5:24
http://ow.ly/1mYi7 - ABIM MOC program - two differing viewpoints - you can guess my voteMarch 16, 2010 5:06
RT @yejnes: My thoughts on the annual exam, etc., final letter ACP Internist, March 2010 http://bit.ly/9FNcXn wel-stated & importantMarch 15, 2010 12:47
A note to the professors, from the "real" world, on the use of ICDs in a fee for service community... http://ow.ly/1jaPy - great postMarch 13, 2010 2:19
RT @paulinechen: New "Doctor and Patient"; Learning to Keep Patients Safe in a Culture of Fear http://nyti.ms/bYA14V - blog post comingMarch 12, 2010 1:35
RT @tom_peters: @kevinmd Spoken like an MD. - true primary care is very complex - it is not simple care -March 11, 2010 12:43
RT @efalchuk: Seriously, what is Nancy Pelosi Talking About? http://bit.ly/9sHSc2 #healthreform #hcr #healthcare think Dazed and ConfusedMarch 10, 2010 7:53
Obama Says Health Overhaul Should Trump Politics - http://nyti.ms/bwKRyo - and he is correctMarch 8, 2010 7:28
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).
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).
2 Responses to My grand rounds – the key slide
Joseph Nicholas, MD, MPH
July 10th, 2008 at 8:23 am
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.
pcb
July 10th, 2008 at 8:53 am
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).