It is 3 a.m. on a Saturday morning when a 20-year-old man presents to the emergency department complaining of abdominal pain. The pain began gradually around noon, but is now “pretty bad.” He has vomited once and feels mildly nauseated. He noticed he felt warm but hadn’t taken his temperature. He has no history of previous medical problems or surgeries. He does not smoke, drink alcohol, or use drugs. His family history is noncontributory. His physical exam is unremarkable except for the abdomen, where he has tenderness and guarding in the right lower quadrant. The patient has an elevated white blood cell count and fever of 38.5°C. The surgery consultant is called and listens to the description of the situation. The consultant requests that a CT scan be ordered to confirm the presumptive diagnosis of appendicitis, and asks to be called with the results. How should the emergency physician respond?

Stewardship is defined as “the conducting, supervising, or managing of something[, especially] the careful and responsible management of something entrusted to one’s care.”¹ Our patients’ health, along with a variety of health care resources, is entrusted to our care. These resources include material things, such as beds, tests, and medications, as well as people, including technicians, nurses, and physicians. A paper explicating the American College of Emergency Physicians’ policy statement on stewardship of finite resources states: “Stewardship thus requires, at a minimum, an effort to prevent wasteful consumption of health care resources.”²

Identification of waste is not as simple as it may sound, however. In the case described in the introduction, would a CT scan be wasteful? This study may in fact confirm the diagnosis of appendicitis, and ordering it may enhance the professional relationship with the surgical colleague. (It may also give the surgeon a few extra hours of sleep.) But is a CT scan needed to confirm this diagnosis?

On the negative side of the ledger, the test has both financial and nonfinancial costs. It will expose the patient to potentially unnecessary radiation, his surgery may be delayed, and he may be utilizing resources another patient may need. What if imaging for a patient arriving with an acute stroke is delayed because this patient is in the CT scanner? The true cost of this CT scan could include not obtaining

imaging for the acute stroke patient within the time window for thrombolytics. So although it may be an exaggeration to say that the CT scan has no value, its limited value in this situation does not seem to justify the more significant financial and health costs.

If resources were unlimited, or costs were very low, emergency physicians could afford to use them to achieve even marginal benefits. The nation’s health insurance system, however, insulates physicians and patients from the full costs of care provided and received. Patients and providers expect comprehensive health care, even if the treatment lacks evidence, but they don’t expect to pay for it. The ongoing national debate about health care reform has drawn increasing attention to the high cost and inefficiency of our health care system.

The United States spends more money per person on health care than any other nation, and by a large margin. What do we get for the vast amount of money we spend on health care? The data show that spending more on health care does not lead to better health. The United States ranks 45th in infant mortality out of 224 countries and has just the 49th highest life expectancy.3 Singapore, with the lowest infant mortality, just 37% of that in the United States, also has a life expectancy more than 3 years longer. Even residents of Bosnia and Herzegovina, just 10 years after a major conflict, have a longer average life expectancy than residents of the United States.³

Abundant evidence from other nations suggests that the United States can do a much better job of providing good health care at lower costs. Arguably, therefore, physicians’ duties of stewardship should include not just omitting wasteful care (that is, interventions that have no value whatsoever), but also not providing care with costs that exceed its value. These more complicated stewardship judgments, however, require identification and evaluation of the positive and negative consequences of resource use.

Emergency physicians need good data about the consequences of different interventions that enable judgments of their comparative effectiveness. These kinds of data can form the basis for clinical practice guidelines.

Some health systems are already improving the combination of science with good patient care.⁴ For example, the Intermountain Healthcare system headed by Dr. Brent James has shown great progress. With top physicians getting together to develop guidelines, mortality for surgical procedures and hospitalized patients has been reduced.

Accepted practice changes over time. Rectal exams, once thought to be a requirement in the diagnosis of appendicitis, have been determined to be neither sensitive nor specific to the diagnosis.⁵ Abdominal CT scans have excellent sensitivity and specificity, but are not without complications, especially when done as contrast studies. Delaying surgery in a patient with peritoneal signs to get a confirmatory CT is hard to justify clinically. Acting as a good steward both of the patient and of health care resources, therefore, the emergency physician in the case described in the introduction should respond to the surgeon that additional testing will cause unnecessary delay and radiation exposure.

Good stewardship involves giving up some customary practices and opening up to new ideas (which just might not be all that new). No individual physician can be expected to have all the medical knowledge and skills backed by all the research and know all projected resource availabilities. What we can do is become the best doctors possible, use our knowledge and skills to the best of our abilities, and listen when well-researched guidance is offered. Doctors can learn to be good stewards and still provide excellent, personalized care.

References

1. Merriam-Webster online dictionary. Retrieved on Sept. 3, 2010 (www.merriam-webster.com/dictionary/stewardship).
2. American College of Emergency Physicians. 2007. Resource utilization in the emergency department: The duty of stewardship (www.acep.org/content.aspx?id=29930).
3. U.S. Central Intelligence Agency. CIA World Factbook. 2010 (www.cia.gov/library/publications/the-world-factbook/index.html).
4. Leonhardt D. Making health care better. New York Times, Nov. 8, 2009, p. MM31 (www.nytimes.com/2009/11/08/magazine/08Healthcare-t.html?r=1&pagewanted=1&hp).
5. Brewster GS and Herbert ME. Medical myth: A digital rectal examination should be performed on all individuals with possible appendicitis. West. J. Med. 2000;173(3):207-8.

Dr. Hall-Boyer is an employee of Sutter Emergency Medicine Associates working at Memorial Medical Center in Modesto, Calif. She is a member of ACEP’s Ethics Committee.