There are certainly some low-risk patients who can go home after a simple, brief, and relatively inexpensive evaluation. Everyone else needs more. And it’s my responsibility to identify the cut-point. Sometimes it’s not straightforward. I have a conversation with the patient about my risk analysis. Some patients are worriers and very nervous even about fairly low-risk situations. They are afraid to go home from the hospital without a higher level of diagnostic certainty. And I respect that.

Other patients are skydivers. They want to stay in the hospital as much as I want to go to … oh, pick something, because whatever I pick (say, Wagnerian opera), I’ll offend somebody who likes it. “Doc, your best guess is that it’s probably not my heart? That’s good enough for me. I’ll call my doctor Monday and then she and I will decide about further testing.”

Recently one of the emergency medicine residents I supervise had a patient with chest pain. The initial results came back, and we agreed the patient should stay in the hospital overnight for further evaluation.

The resident called the hospitalist – an internal medicine specialist whose practice consists of taking care of hospitalized medical patients – and found that the hospitalist thought the patient should be discharged. But he came to the ED, saw the patient, and arranged for him to stay the night and have further testing. He gave the EM resident a copy of a paper published in a major journal on this very subject, to support his opinion.

Last week we had Journal Club, that monthly gathering at which we discuss important papers from medical journals that might have implications for the practice of our specialty. This particular resident and I quickly agreed that we should include this paper. By now you can tell that, after my first quick read, I was rubbing my hands with glee. It was the worst paper I’d ever read on the subject.

Let me reiterate: I am an enthusiastic proponent of the cost-efficient practice of medicine. The percentage of our Gross Domestic Product that we spend on health care is now in the high teens. At the beginning of my career it was in the low teens. The upward slope cannot go on indefinitely. We have to find ways of getting better health outcomes for less money. And I believe we can do that. But we have to be smart about it. I volunteer for the job of deciding what’s smart.