I listen to books while driving. Given the amount of time that I spend driving, I listen to many books. While I usually listen to fiction (especially mysteries), today I started listening to a non-fiction book – The Long Tail. Recently the Health Care Blog had an interesting entry about the long tail and medicine – Healthcare and The Long Tail – Searching for help when you’re on the wrong-end of the curve
In a recent THCB post, author Maggie Mahar writes that “Ambiguity haunts medical care”. She goes on to quote Dr. Atul Gawand “Uncertainty is the core predicament of medicine . . . the thing that makes being a patient so wrenching, being a doctor so difficult and being part of a society that pays the bills so wrenching.”
It’s important to note that for a great many cases, ambiguity is not really an issue. This is because the distribution of medical ailments follows a curve very similar to Chris Anderson’s The Long Tail, with a great many common blockbuster ailments stacked up high on the left-hand side of the curve. For those not familiar with the Long Tail, Anderson describes how Amazon, Netflix, and other online retailers sell lots of the usual blockbusters, but actually derive more total volume from 100s of thousands of niche products. In healthcare, it is the left side of this distribution curve which inspires (for better or worse) Wal-Mart, Target, and others to offer “Doc In A Box” services – Allergies, Bladder Infections, Bronchitis, Ear Infections, Pink Eye, Sinus Infections, and a full battery of vaccines – all served up for a fixed price while you wait.
On the right hand end of the curve though, the NIH Office of Rare Disease classifies over 6,000 conditions, each afflicting fewer than 200,000 Americans. Along this part of the curve, things do indeed get very ambiguous in a hurry “ both for patients and physicians. Specialization is a response to this range of ailments (nichefication in Anderson’s terms), and brings physicians repeated cases of a particular nature “ giving them the confidence that they can routinely diagnose and treat a high percentage of these patients. However, even within a particular specialty area, cases will naturally follow a distribution curve from typical to atypical. Unto themselves “ atypical cases are just that “ one of a kind aberrations that force physicians to go outside their typical comfort zone of diagnosis and treatment. For each individual physician, these atypical cases feel like the exception rather than the rule. What the Long Tail suggests though, is that taken in their entirety, these rare cases actually compromise a large percentage of all medical cases. In fact, over 25 million Americans suffer from a rare condition.
In academic medicine we try to make sense of the long tail. We physicians have a great challenge. When patients present with routine complaints, we have to quickly know whether the patient fits the left hand side of the curve, or the right (long tail) side. Our challenge is in knowing when the patient does not fit routine.
The best physicians understand this concept. They work hard to avoid “premature closure” in diagnosis. Retired Doc wrote about this phenomenon last year – Medical errors and role of premature closure
The authors state that defective knowledge as a cause of error was rare and more commonly reflected problems with synthesis of available information.This refers to a formulation of how humans solve problems namely by searching for an explanation that best fits and then the search stops. Physicians at all levels of training and experience do this.
Are there take-home messages here? With premature closure, the suggestion is to make a conscious effort to not completely stop after you reach a diagnosis but ask ” what alternatives should be considered?” This could be done initially and from time to time as the clinical case plays out. Some times things seem so obvious we do not do that but that practice seems like a good mental back up mechanism to minimize errors.
We cannot provide enough attention to the long tail of medicine if we do not give physicians enough time to think. Currently many physicians limit their thought processes because of time constraints.
Given that the long tail is very important (as The Health Care Blog describes), we must work to prevent long tail mistakes. Long tail mistakes are costly (both in terms of money and health). We probably should more systematically determine those costs. I am finding the book fascinating. Understanding the concepts are important if we want to understand quality health care.
