The decision not to test is often the more difficult choice

Ordering that head CT scan is the easy way out.

In a piece from Newsweek (via Bryan Vartabedian), Yale emergency physician Christopher Moore details a common scenario: should he order a CT scan in an asymptomatic 15-year old who was hit in the back of the head while playing soccer?

Dr. Moore encapsulates his thought process: “In a case like this, evidence shows the chance of a life-threatening injury is vanishingly small. [But] since we’re dealing with radiation, a CT scan isn’t harmless: some estimates put the long-term risk of cancer death from a single CT as high as one in 1,000—a risk that’s greater in younger patients who have longer to live.”

Cost doesn’t factor in the decision making process. There is no mention of “rationing.” The doctor is simply weighing the marginal benefit of ordering the scan versus the radiation exposure the teen will receive.

Simply ordering the scan is the path of least resistance. As Dr. Vartabedian notes, “Testing is easy. Exercising the judgment to not perform tests takes insight, experience, and confidence.”

Discussing the pros and cons with patients and their families, and coming to a shared decision – the way it should be – is difficult, and all the incentives within our health system are stacked against going down that route.

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