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I was having lunch at Old Town Club, a golf club here in Winston-Salem, and overheard a conversation at an adjacent table. A gentleman of my age asked his clearly older luncheon companion, "Have you received the new book of club rules in the mail yet?" To which the old man replied, "Yes, I did. Quite a volume. Damn. It seems that everywhere you go these days you're being squeezed by rules." And then he added plaintively, "Do you remember when the only rule was that there were no rules?"
There is something about rules that riles physicians. To us rules are often interpreted as coming from people who apparently think they know more than you. They draw up rules because they don't trust you or your judgment.
Physicians much prefer to freelance: exercise their own judgment, depend on their own assessment of needs and requirements. In view of their years of training and personal experience, physicians feel they ought to be allowed to make up their own minds. After all they are the ones responsible for the care of their patients. You have to be there to know what's going on. When the iron is in the fire, the usually anonymous person or persons who drew up these rules is nowhere to be seen.
Rules often seem to have been chosen "out of the blue." To obtain physician "buy-in," rules have to be shown to be effective. Rules should not be the product of personal anecdotes but should arise out of common, shared experience. Rules should be tested and subject to proof. If those affected by the rules see justification in and benefits from application of the proposed rules, they will, at least tacitly if not actively, support their adoption.
Which is not to say there is no place for rules. Some situations seem to beg for rules. Like, "When does a patient require a radiograph after an injury? And what examination should be obtained?" These questions are not easily answered. The answers are bound up in multiple, overlapping considerations—the desire of the physician not to miss any injury, the patient's expectations of and even demand for radiography, and the physician's need to reassure the patient that no injury is present. All of it done in the midst of the ever-present latent fear of medicolegal liability. And lurking in the background these days, the all-consuming cost consciousness of third party payors, the HMOs and insurance plans that are looking for any excuse to deny payment for what they deem to be unnecessary services. It certainly would be nice to have rules to live by under these circumstances.
In fact there are a few such rules available. They are called "decision rules" as described by Tigges and Pitts [1] in the December 1999 issue of the AJR. The best known were promulgated by a group of investigators in Ottawa, Canada. Their purpose was to identify findings on clinical history and physical examination in those who have sustained an ankle injury that points to the need for radiography and, at the same time, eliminate those radiographic examinations that would prove to be unnecessary. The results were published in a series of articles [2,3,4] and have come to be known as the "Ottawa rules." Using the Ottawa selection criteria, examinations were reduced by 30%, resulting in significant savings, and yet, in the hands of these investigators, allowed identification of all significant fractures.
And now in this issue Hanson et al. [5] describe their experience with the use of a clinical decision rule devised to identify those patients with a clinical question of cervical spine injury who should undergo helical CT. Obviously an important topic.
The vexing questions addressed in the article are posed daily in busy emergency departments everywhere. "Should we or shouldn't we do CT? If we don't, what are we likely to miss? And how often are we likely to miss it?"
Hanson et al. [5] propose a prediction rule based on six clinical parameters that identify patients at greater than 5% risk of cervical spine injury. These investigators conclude that the use of this rule allowed them to successfully distinguish between patients with high and low risk of cervical spine injury and that, in low-risk patients, helical CT was of no value and could be safely omitted. This outstanding contribution is certainly worthy of your consideration.
And, of course, it is possible that the work of Hanson et al. [5] may become known as the "Seattle rules." If so, remember you read it here first.
And speaking of first, this month Lane Donnelly [6], in his ARRS Centennial series featuring past articles from the AJR, highlights John Caffey's original 1946 description of the entity that we now know as "child abuse." This truly seminal contribution to the art and science of pediatrics, as well as the practice of radiology, was also read first here in the pages of the AJR.
Now is this a great Journal, or what?
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