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.