After thinking about this, and I do appreciate Kevin’s insight as well as Laura’s and the rest of the staff’s, what about the simple strategy of stating that ACEP has developed five proposed safe harbors and then submitting those to the media? We would certainly need Laura to craft a great message about how safe harbors are the right thing to do, and we let the other people shoot them down. The worst thing that could happen is that ACEP was proposing cost-saving measures that benefit patients and eliminate unnecessary tests. I think it might be hard politically for ATLA and even consumer groups to say that safe harbor should not exist, particularly if we pick something very simple and straightforward. Emergency physicians determine the standard of care, and there’s no reason why we should not be able to determine what safe harbors should exist in our field. If we can determine what is unethical and egregious testimony, certainly we should be able to agree on some straightforward, simple safe harbors. Jay [Kaplan’s] list and some of our Choosing Wisely submissions might be a good start, but I’d like to do something with chest pain and POLST [Physician Orders for Life-Sustaining Treatment]. I don’t think we do need to make this too complicated. Legislation will take forever and get bogged down, and if it gets close, they may even filibuster it.

—Paul D. Kivela, MD, FACEP, ACEP Secretary-Treasurer

Maybe not safe harbors, but could we have more transparency around what following the guidelines means in terms of risk? For instance, following PECARN [the Pediatric Applied Research Network Head Injury/Trauma Algorithm], 1 in 2,000 kids will have clinically significant traumatic brain injury that will not have been CT’d initially. The “cost” of trying to be perfect is the cost of 1,999 CTs and the subsequent radiation exposure versus the cost of defense/settlement/verdict for the one “miss.”

—William Jaquis, MD, FACEP, ACEP Board Member

Bill,

Excellent points. I think an important educational point for the layperson is that reducing utilization and cost is the right thing to do, but there are two sides of the equation. Albeit a small percentage, some patients who are exempted by the guideline will have a bad outcome due to missed or delayed diagnoses from not ordering the test. When looking at population data, most, if not all, agree that this is the right thing to do. However, applying this to the individual patient encounter is a very different application of the concept. In other words, most laypersons agree this is the right thing to do. However, their opinions may change when they personally will not receive the test and particularly if they ultimately suffer a bad outcome.