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