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.