President's Message

Working Smarter with Pareto’s Principle in Pediatric Pain Medicine

Dr. KunduBy Anjana Kundu, MBBS, MD
Dayton Children's Hospital
Dayton, OH

As we wrap up 2017 and prepare to welcome another year, I find myself in planning mode. Granted, not all of my plans always materialize, but it does allow me to focus more at work. Hard work and directed activity as defined by our training programs, have been the hallmark of physicians' lives. However, this can pose a challenge when we first embark upon our journey beyond training, transitioning into new faculty or independent practitioner roles, and have to define these goals ourselves. 

As physicians, we go through very rigorous training schedules, challenging situations, evolving concepts and witness the real impact of our decisions and actions on people and their lives. This is even more difficult when our patients are children. We all understand that the human interactions are complex and have an impact on the physical and emotional well-being of all parties involved, be it the patient, their family or their physicians. All the influences we bring to each interaction, verbal and non-verbal, affect the outcomes for our patients, our colleagues and ourselves. Therefore any tools that can help us plan and prepare for these encounters, enhance our productivity, ease our burdens and increase our satisfaction, are worth exploring.

We can generally agree that there are some universal laws and common truths that have very broad applications. Pareto’s Principle is one such popular concept that is applied widely in the business and management world, and is touted to govern the general functioning in the world surrounding us.  Many of you may know this as the “80-20 Rule” as in 80 percent of effects always come from 20 percent of the causes.

Pareto’s Principle, named after a 19th century Italian economist, Vilfredo Pareto, was proposed upon his observation that 80 percent of the land and wealth in Italy was owned by 20 percent of the people. He also went on to observe this in his own garden, where he noted that 80% of the peas were produced by 20% of the plants.  Although, this principle was first applied in economics, it has since found applications in business, management and a whole host of different arenas including healthcare.

You can also see examples of the Pareto’s principle all around you, in nature and in society; 80 percent of traffic occurs on 20 percent of roads, 80 percent of a company’s profits come from 20 percent of their products, 80 percent of the work is done by 20 percent of the people. In some cases the scale may be skewed to 90-10 or more, but as a broad concept 80-20 is cited as a pretty universal phenomenon.

So how does this apply to pediatric pain medicine?

Think about your work carefully and you’ll see examples of this all around you:

  • 80 percent of your clinical challenges, efforts or time during rounds is credited to caring for 20 percent of your patients or what we sometimes refer to our “challenging patients”. 
  • When providing clinical care, you use the same 20 percent of the information learned during training, 80 percent of the time or for 80 percent of your patients.
  • 80 percent of your satisfaction at work comes from 20 percent of your interactions.
  • 80 percent of calls and pages originate from 20 percent of your patients or nurses. It may even be the same 20 percent of complaints/symptoms that are the cause of repeated calls on different days or different patients.
  • 80 percent of the complaints are related to 20 percent of same issues or colleagues.
  • The reverse is also true when 80 percent of a team's success or praise can be attributed to the work of 20 percent of the team.

As disheartening as these statistics may appear, they are not reasons to turn our backs on pediatric pain and bolt as fast and as far away as we can. Instead, we can use them to our advantage, to better understand our patients, and our work and potentially improve productivity and satisfaction.

We can reverse the equation to work in our and our patients’ favor, when we place our focus on evaluating the situations such as those listed below, and plan our actions accordingly.

  • Which 20 percent of patients are going to take up 80 percent of my effort?
  • What small (20 percent) action NOW, would address those issues responsible for the 80 percent of calls/pages later?
  • What 20 percent of information do I want to emphasize most, so that my patients get the most from their visit?
  • Which 20 percent of issues generate most of the QI presentations?
  • Which 20 percent of colleagues are responsible for 80 percent of what makes my work environment enjoyable?
  • Which 20 percent of my time is giving me 80 percent of my job satisfaction?
  • Which 20 percent of work-related issues are responsible for 80 percent of my job dissatisfaction?

Of course, this 80-20 rule may not be an absolute fit for everything, but it does provide a starting point to assess where we should direct our efforts to optimize outcomes. This could function as a guiding principle in clinical care and during discussions with patients regarding the use or elimination of a particular medication, treatment modality, procedure or lab test. It may also be used as a communication tool with handoffs for complicated patients so that we deliver the most relevant information.

With an increasing incidence of burnout amongst physicians, a better understanding and consistent application of the Pareto Principle may prove to be an effective tool for enhanced resilience and a better integration of our work and personal life by evaluating what provides us the most satisfaction and what presents the most challenges for us in our work environment.

I would even venture to say that understanding and application of Pareto’s Principle can be transformative, not just in our work but also our personal lives.

Taking this one step further, I would encourage all of you to consider how 20 percent of your work, contribution or engagement in SPPM can enhance the knowledge, profile and mission of your Society to provide better care for children in pain!

I wish you a wonderful Holiday season and a successful 2018!

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