This is not my coinage. It was coined by an orthopedic surgeon at the Hospital for Sick Children, a real character, a great orthopedic surgeon, and, incidentally, a Brit, I think by his accent and by his "unconventional" approach. He describes a long, winding, painful voyage taken by the medical system which begins when an abnormal test result (often not even indicated in the first place) comes back from the lab. A slightly elevated SGOT (AST), for example. More tests are done, then xrays, then scans, then, who knows, maybe even a liver biopsy. And the child (it is a paediatric hospital) came for a broken arm! This is described (not using the same terms) in a not too bad movie of the 70's, I believe, with George C. Scott called "The Hospital". Medically, it was very accurate. It starts off very funny, but then fades. Anyhow, when Scott, the attending, asks, during morning rounds, who this new patient is, he is taken aside by the resident, and told that the man had a routine insurance physical. They found some protein in his urine, and then a whole bunch of investigations began, which ended with a kidney biopsy. The man bled after the biopsy and is now in coma after going into hypovolaemic shock. The biopsy was normal (or maybe my memory made that bit up). But it is so true. Unfortunately, the way physicians are trained, there is little hope for improvement. In a residency programme you are rarely chewed out for tests you do do, even if they are unnecessary. The smart resident will say, I was trying to rule out.... But you get chewed out all the time for not doing tests. And clinical skills are just out the window. The test is everything. No one knows how to feel the baby's belly to feel a pyloric tumour--do the ultrasound. I tell medical students that visible jaundice is usual, and should be considered normal in exclusively breastfed babies even to 6 or 8 weeks of age in some cases, sometimes even longer. It is our bottle feeding mentality which makes us think it is not normal. But if a 3 week old with obvious jaundice is brought to your office, how do you know this is not *direct* hyperbilirubinemia. They almost always answer "Do a blood test"? This is your question for the day, Lactnetters. How do you know the baby does not have direct hyperbilirubinemia, rather than the usual indirect *normo*bilirubinemia (higher than the lab's normals) of the normal exclusively breastfed baby? Jack Newman, MD, FRCPC