Pediatric appendicitis sits at the intersection of diagnostic urgency and radiation risk — and new qualitative evidence suggests the clinical tools designed to navigate that tension are largely being bypassed in general emergency settings. For the millions of children presenting with abdominal pain each year, this gap has measurable consequences: unnecessary CT scans carry cumulative ionizing radiation exposure during some of the most radiosensitive years of human development.
The study drew on semi-structured interviews with 15 physicians practicing in general emergency departments — settings that serve the majority of pediatric patients in the U.S. but lack the subspecialty infrastructure of children's hospitals. Five recurring themes emerged: ultrasound is frequently unavailable or of limited diagnostic quality outside pediatric-specialized centers; clinicians default to clinical gestalt rather than validated tools like the pediatric appendicitis risk calculator (pARC); existing guidelines feel poorly adapted to resource-constrained general ED environments; shared decision-making (SDM) with families is inconsistently implemented; and institutional factors, including after-hours radiology coverage, heavily influence imaging choices. The net effect is a de facto reliance on CT imaging that formal guidelines actively discourage.
This finding is qualitative by design, meaning it captures perceptions and workflows rather than measuring CT utilization rates directly — a key limitation. Fifteen interviews also represent a modest sample, and selection bias toward more reflective or engaged clinicians is possible. Still, the themes align with a broader body of quantitative literature documenting persistently elevated CT use in non-pediatric EDs. What this study adds is mechanism: it illuminates *why* the gap between guideline and practice persists. The pARC tool, for instance, has demonstrated strong discriminatory performance in prospective validation studies, yet physician familiarity with and trust in such calculators appears low in general settings. This points toward a structural rather than knowledge problem — one that better clinical decision support design and system-level ultrasound access reforms are better positioned to address than individual clinician education alone.