But the point seems to be that patients will make the best decision based on the evidence they have at hand. If they are not making the best decision, based on the doctor’s greater command of greater data, then isn’t the role of the doctor to educate and share that evidence?

You can’t blame patients for wanting the best care available based on the evidence they have at hand, while at the same time not sharing all the evidence at hand.

That’s what…self-serving? self-absorbed? condescending?

That is not criticism. It’s a statement of fact, and until we learn to work together with respect instead of pointing fingers, we aren’t going to do things any better.

Just my two cents (and I have plenty more if you want to hear it. )

“For children under 2, if there is normal mental status, no scalp swelling, no significant loss of consciousness, no palpable skull fracture, and no behavioral changes (as reported by a parent), and if the injury occurred in a nonsevere way (something other than a car crash), it is safer to skip the CT scan.”

If anything in the patient’s history, presentation or physical exam deviates from these criteria (i.e. bleeding disorder, “looks bad”, focal neurological signs, etc.) than a CT would be warranted and a doc who didn’t order it would be remiss in his responsibility to the patient (and liable if a bad outcome occurred). Doctors would never be FORCED to use a guideline in all circumstances. In just the same way as guidelines cannot exist without clinical judgement, clinical judgement really can’t exist without evidence to guide it.

The thing is…and this is the part where I’m sure to lose you…most patients do not have a unique characteristic that sets them apart from the 10,000 other people in the study. Most kids fall off their bike, don’t lose consciousness or vomit, have normal exams, look fine, have normal vitals, and aren’t on blood thinners or have a bleeding disorder. In other words…for the vast majority of patients presenting with a given symptom (in this case 99.9%), they are, for the purposes of triage and diagnosis, enough like the many other people presenting with the same problem, that guidelines are useful. As long as the child did not have some identifiable characteristic that rendered the guideline inappropriate, the doctor, who did not order a CT in that one patient, should not be sued for the bad outcome. Like I asked, if you know a way to identify the 0.1% without scanning everyone (which, I would argue, is much less individualized than following guidelines) I would like to know – but it’s not going to be some “unique” feature that only an astute clinician can identify. This may work on “House, M.D.”, but not in the real world.

Bottom line…what you say is true, and this is the reason most guidelines are very specific as to which patients they apply to. In fact, many guidelines (such as the Fleischner Criteria for Lung Nodules or the Consensus Statement on the Management of Thyroid Nodules, to use two radiology examples, include in the algorithm itself some caveat about high risk factors or other clinical features which would render the criteria moot).

You may still not like evidence-based medicine even after all of this but just so you know – next time you go to a doctor and he orders some test or prescribes a certain drug, it’s because there’s a compilation of EVIDENCE out there in the literature GUIDING the BASIS for that decision. That is, if he’s a good doctor.

I don’t think physicians can be excused by a practice guideline for missing something right under their noses.

“Would anyone here take $1,000 (ballpark CT scan cost) to join a pool of 1,000 people in a death-row lottery?”

A lot of people see this debate in these terms–high financial costs vs. safety.

I think it is the physician’s job to point out that their is skin in the game on both sides. 1,000 CT’s may find one clinically invisible bleed (which often would not actually be fatal). But how many cancers would 1,000 CT scans cause? How many benign abnormalities might be mistaken for problems and lead to risky surgeries?

The people who write these recommendations study these risks intently. We aren’t talking about a benign thing when we irradiate the brain of a 4 year-old. Not only may low-yield CTs cost money but lives.

The skin game cuts both ways. Unfortunately everyone has a tendency to accept risks while doing something big and invasive that they would never accept while doing nothing. Both physicians and patients have a dangerous bias toward “doing something” rather than waiting, even when waiting to see is the best decision.

Head CTs is only one example. Look at the massive prescription of antibiotics for flu-like symptoms if you really want to see this bias in effect.

Texas physician growth trails it’s population growth. Is it surprising that there are more physicians in states with a growing population? What it is surprising, if you think tort reform works, is why California is the second highest source of physicians moving to Texas.