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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  • Michael Kirsch, M.D.

    I agree that cost is not a factor as the physician will not be enriched by ordering the CAT scan. However, in cases like this, I suspect that the medical malpractice issue creeps into the decision process.

  • Michael Rack, MD

    not ordering a CT scan of the brain isn’t too difficult of a decision- you can always discuss with the patient/parents that the radiation risk outweighs the possible benefits of a CT scan. But what if a MRI machine is available and the patient asks for an MRI?? Then cost/rationing come into play.

  • andrew tang

    I wouldn’t say it creeps, I’d say it lunges. “Defensive” medicine” is a large and still relatively unrecognized cost in healthcare today. Until this is adressed in some rational way, costs will continue to climb.

  • Anonymous

    If cost is not an issue, get an MRI.

  • jsmith

    I thought standard guidelines (New Orleans, Canadian, etc )do not recommend CT in these cases. What am I missing?

  • what the heck

    The more fundamental question is this: why is an asymptomatic patient in the emergency department?

  • jsmith

    What the heck wins the best comment award.

  • AK

    Forget about the malpractice;
    10-15 minutes to talk to saavy worried parents and child about risk and benefit; Its longer if they arent educated;
    Another 20 minutes (if you are lucky) tracking down the PCP, if you are even kind to do so in a busy ER. What if the PCP disagrees with you? another 5 minutes on the phone
    Another 10 minutes documenting risk/benefits, full, proper neuro exam, this on paper or EMR
    Ordering a Head CT: seconds; CT results come back 30 minutes later; if negative, PCP not called and pt sent home;
    You could have seen 2-3 patients in the mean time.
    I am not an ER doc, but the incentive is too strong to order a CT just based on time alone

  • Heather

    Here in Canada the local health authorities in each province/territory decide the number of MRI and CT scans that will be performed annually based on their fixed budgets.
    Across the country cuts are being made to accommodate budget shortfalls. In September, the Vancouver Island Health Authority (VIHA) in British Columbia cut their MRI scans by 20% (4,400 less) to assist with their budget shortfall of $45 million. The decision not to test is made easy by a government-run health care system but its rationing process results in more difficult choices for Canadian doctors and some deadly results for Canadian patients.

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