Semantics and the $28 Million Unnecessary Test

MRI LumbarThere’s been an awful lot of Internet hullabaloo about “unnecessary testing” lately. The Choosing Wisely program keeps trying to assert that we should not perform any “unnecessary” tests. Recently, a paper was published in the Journal Academic Emergency Medicine alleging that “overordering of advanced imaging may be a systemic problem” since many emergency physicians believe that such testing is “medically unnecessary.” The paper was based on surveys that were presented to emergency physicians and the work was at least partially funded by the Veterans Administration and the National Institutes of Health — which should be considered a conflict of interest. After all, don’t the entities that pay for the testing stand to gain to gain the most from limiting “unnecessary” testing?

But now that the paper has been published, the media has been whipped up into a frenzy, stating that doctors admit they perform “unnecessary” testing and are single-handedly bankrupting our medical system.
Consultant Magazine has an article stating that “ordering unnecessary imaging tests ‘may be a systemic problem.’”
NewsMax Health states that “97% of ER docs order unneeded tests out of malpractice fears
HealthLeaders Media trumpets that “97% of ED physicians order unnecessary imaging tests
Even Time Magazine has a headline stating that “your doctor likely orders more tests than you actually need.”
However, I’d bet my white coat that if you asked any of the study authors or any of the authors of the articles in these prestigious magazines what the definition of an “unnecessary test” was and how to prospectively determine whether or not a test is “unnecessary,” they would all look at you with blank stares and shrug their shoulders.

Unfortunately, defining the term “unnecessary” is more difficult than it seems. The American Heritage Dictionary defines “unnecessary” as being “not necessary.” In turn, “necessary” is defined as being “needed or required.” “Needed” is defined as “A condition or situation in which something must be supplied in order for a certain condition to be maintained or a desired state to be achieved.” This definition gives us a little bit of help, but is still vague as it applies to medical care. When discussing advanced medical imaging, a necessary test would be that which must be performed so that a “certain condition can be maintained or a desired state can be achieved.” Ruling in or ruling out a disease process would seem to fit that definition.

Based on the paper’s abstract, it appears that almost 500 emergency physicians were given a survey and 97% of them stated that at least some of the advanced imaging studies (CT scans and MRIs) they personally ordered were “medically unnecessary.” In other words, the researchers took a politically charged statement and, using a fallacy of definition, created a statistic which is in itself both untrustworthy and sensationalistic. Rent-Purchase
The questions used in the survey aren’t available. If you want to look at them, you can “rent” the article for $6 or you can splurge and purchase the article for $38 – neither of which I’m planning to do. However, consider the questions that would be raised if the researchers asked 500 people whether they were “good parents” and then published a study saying that, based upon survey data, bad parenting did not exist in the United States. Or consider a study asking doctors if they acted in “professional manner” and then declaring that unprofessionalism does not exist in medical care because 97% of doctors answered “yes.” Those studies would get laughed out of Medline because it is easier to see the bias in asking people ambiguous questions when the terms of the questions haven’t been defined. That’s why I’m very surprised that some of these authors would put their names behind a paper with such dubious conclusions.

Shortly after the JAEM paper was published, Lenny Bernstein then published an article in the Washington Post noting that patients with low back pain who were first sent for MRIs instead of first going to physical therapy paid an average of almost $5000 more for their medical care. The reason was apparently that MRIs tended to show all kinds of “benign changes” in the patient’s backs. The article is based on a study in the Journal “Hospital Services Research.” Again, it will cost you $6 to rent or $38 to own this piece of research. It would be nice to know whether or not the authors, two of whom were physical therapists and one of whom was a researcher in “Clinical Quality and Outcomes Research”, discussed whether there were any adverse outcomes associated with proceeding directly to physical therapy as opposed to obtaining advanced imaging. It is difficult to draw any conclusions from the abstract other than physical therapists are advocating more physical therapy for low back pain.

Finally, also published right around the same time as the above two articles, there was an article in the Los Angeles times noting how Kaiser Permanente was ordered to pay a young woman more than $28 million after delaying an MRI that could have detected an aggressive cancerous tumor. According to the article, the patient was 17 years old and experiencing severe lower back pain. She and her mother repeatedly requested an MRI of her lower back, but the patient was instead told that, at 125 pounds, she had too much “belly fat” and needed to lose weight. After three months, Kaiser ordered the MRI and found a large fast-growing cancer in her pelvis. Ultimately, the patient required amputation of her right leg, removal of half her pelvis and part of her lower spine in order to remove the tumor. The patient’s lawyer argued that her leg and pelvis could have been saved had the MRI been performed and the cancer diagnosed earlier. Kaiser argued that the cancer was already so large that the patient would have lost her leg even if they had ordered the MRI sooner.

Admittedly, it is difficult to determine whether care was appropriate based upon an incomplete clinical picture, but I think we can safely assume that the patient falls into the “don’t image” guidelines that ACEP has created for the “Choosing Wisely” initiative (see guideline #8).
Note that the Choosing Wisely guidelines for acute low back pain are different than the low back pain “red flags” that are traditionally considered an indication for diagnostic imaging. This patient had at least two “red flag” symptoms.

The Kaiser case also raises an issue as to whether or not the jury award was unreasonable and based upon emotion rather than based upon the patient’s injuries. However, consider that the award must provide for lifelong care of a young adult who had to have her leg amputated, half of her pelvis removed, and part of her spine removed. She’s going to require quite a bit of care and is going to go through a lot of suffering for the rest of her life. This case took place in California where there are caps on the “suffering” or “non-economic” portion of the damages. We don’t know how much of the award was based on future medical care and punitive damages (neither of which are subject to the caps) versus noneconomic damages which would be capped at $250,000. If the patient was able to introduce evidence that Kaiser had a pattern of engaging in denial of care to increase profits as the article suggests, punitive damages would be more likely to be imposed.

The thing I found most interesting about the Kaiser case was that Kaiser did not argue that the MRI of the young patient’s lumbar spine was an “unnecessary” test. Nobody in the comment section of the article argued that the MRI was an “unnecessary” test, either. Why? Because the results of the test were positive and anyone who argues that a test is “unnecessary” when it shows gross abnormalities needing immediate therapy would be viewed as an idiot. Had the exact same MRI in the Kaiser case been normal, everyone would have rolled their eyes, shook their heads, and proclaimed what a waste of money it was to perform the test. However, because the MRI was grossly abnormal, the consensus is instead that the test was not only “necessary”, but that it should have been performed much sooner.

This concept underscores why the JAEM article is so misleading. The authors don’t adequately define the terms on the surveys that they provided and, as a result, the conclusion they base on those ill-defined terms do not pass scrutiny. When we define the utility of a test by that test’s results, we engage in medical mumbo-jumbo which neither improves the health of patients nor improves the practice of medicine.

It sure makes for some great “unnecessary” headlines, though, doesn’t it?

Healthcare Update Satellite — 03-04-2015

Homeless North Carolina VA patient comes into the ED to be evaluated for the sores on his feet. His shoes are falling apart. Nurse Chuck Maulden bandages up the patient’s feet and then gives the patient the brand new Nike sneakers off of his own feet. Chuck then works the rest of his shift in a pair of shoe covers and doesn’t say anything about it. Only way that people found out was because the patient’s family called to say thank you. We need more people like Chuck.

I’m not aware of too many uses for virtual reality in medicine, but this seems to be a good one: seeing what it’s like to suffer from schizophrenia. Imagine being cooped up in an elevator with strangers staring at you and voices telling you “you will fail”. The author of the article wore the VR headset only briefly, but noted that after he removed the headset, “the feeling of discomfort lingered.”

Long Island woman fights to keep database about NY physicians online. It is scheduled to go offline due to lack of funding. “Choosing someone because they were nice just didn’t work anymore.” Just think, you can always rely upon the accurate and reliable data from Press Ganey and /sarcasm.

Long Island town demanding that nearby hospital construct an emergency department in its town. Hurricane Sandy destroyed the prior hospital in 2012. Commenter to the article notes “Everyone wants the luxury and availability of a hospital but fails to support it financially. Don’t be like Long Beach or your hospital will also be Long Gone.”
Spot on, ma’am. Spot on.

I suppose this explains why I never see any parents of newborn children coming to the emergency department with strokes. Sleeping more than 8 hours per night associated with almost a 50% increase in stroke risk.

Woman complains to TV station because Florida’s Gulf Coast Medical Center emergency department is close to maximum capacity, and her 87 year old father had to sleep in the hallway. News flash, lady: Emergency departments are crowded all over the country. However, Florida doesn’t have enough doctors because of the miserable environment Florida has created for its medical providers. Remember the amendment to Florida’s Constitution revoking the licenses of doctors who had three malpractice cases against them? You reap what you sow.

California hospital’s emergency department volume up 7% after Obamacare implementation. Our hospital’s ED volume is up 15%. According the article, Obamacare advocates say that ED numbers would decrease once people received insurance. Now they’re walking it back, citing studies that the decrease in emergency department use only begins to show up at 1 year after insurance enrollment. They’ll be sure to measure and report on the new numbers … just after the next election.

Patients gone wild. Louisiana’s own Patricia Munzey arrested and charged with assault and battery of emergency personnel after she threatened to “slap and kill” ED staff and then kicked a nurse in the face when she was trying to bandage the patient’s injury.

More patients gone wild. Pennsylvania patient William Whitmoyer gets brought to emergency department and threatens to come back to hospital with gun and “make hamburger meat” out of everyone in Geisinger Medical Center. Upset over administrator making $5.6 million. Because the threat of violence caused alarm and was an inconvenience to staff, he was arrested and charged with disorderly conduct and with making terroristic threats.

Quite an interesting idea circulating on Reddit: People waiting in the emergency department for a someone else to be treated should be encouraged to donate blood.

Interesting infographic on the shelf life of multiple foods. According to the comments, though, it seems to create more questions than it answers. Some people are claiming that eggs can be left out on a shelf for a year without spoiling if they aren’t washed. Not sure I’d be the first to try a year old omelette.

Healthcare Update Satellite — 02-10-2015

Home remedy for lice kills a 1 year old child. Headline is a little misleading, though. Family members put mayonnaise all over the child’s scalp to suffocate the lice. No the child didn’t die from mayonnaise poisoning. The child died because the family members put a plastic bag over the child’s head and the bag slipped down over her face and suffocated her. Sad story.
The article links to another story about how 84% of lice in the US have a gene mutation making them resistant to OTC medications such as permethrin. I didn’t know that little factoid.

Another new one on me … Tightie Whities could be lowering your sperm count. The article links to this study on French men whose sperm was found to be of worse quality and whose sperm counts decreased significantly after wearing tight underwear for 15 hours a day. I thought it was just because they were French. OK OK I’m kidding. Also, riding a bike for 12-16 hours a week and growing older than 40 also cause deterioration in sperm and lower sperm counts according other studies cited in the article.

Need an investment? Buy as many Nicorette lozenges as you can find. Glaxo has apparently stopped producing the lozenges due to “quality control issues” and now buyers can’t find them anywhere. They’re currently selling for three or more times their retail price online. Even if the Nicorette gum tastes terrible, just chew a piece of gum and mix it with a piece of different gum.

This explains a lot. Al Qaeda Claims Responsibility For Patient Satisfaction Surveys.

“The doctors and nurses had no backbone to stand up to our sham company, the government and insurance companies forced our meaningless data down their throats, and the patients became captains of the ship. It became, quite literally, inmates running an asylum. Patients got more tests, more cancers, more drugs, more prescriptions, more addictions, and higher mortality. Here is the best part – the US Government, American taxpayers, and insurance companies are funding it all!”

Woman treated with fecal transplant for persistent clostridium difficile infection. Prior to the transplant, she weighed 136 pounds. Sixteen months later, the patient had gained 35 pounds and was unable to lose the weight even with a supervised protein diet and exercise regimen. The fecal donor, the patient’s daughter, was “healthy but obese.” Another instance raising the question whether the food that we eat makes us gain weight or whether the bacteria in our systems are primarily responsible for weight gain. Or perhaps the food that we eat alters the bacterial flora in the intestinal microbiome and affects our weight.

$17.5 million settlement after Kentucky’s TJ Samson Community Hospital ordered to pay $18.27 million in a jury verdict for a child who suffered brain injury at birth. Obstetrician who delivered baby was cleared of liability.

Regulating ourselves to better health care. National Practitioner Data Bank now requires state health profession regulatory boards to swear that they have submitted all reportable actions in a timely manner and expands audits of board actions to make sure that no physicians slip through the cracks.

Michigan man arrested for dialing 911 more than 100 times in one month. Initially says nothing and hangs up. Then when deputies stopped responding to the location, he began pretending that he had labored breathing. Finally made a call stating that he was hurt and needed help. When police triangulated the cell phone signal and knocked on doors throughout the trailer park, they found the suspect with 6 or 7 cell phones and a police scanner. He admitted to making the calls out of “drunken boredom” and was arrested.
Just think … if he just called 911 and went to the emergency department 100 times in a year, nothing would happen and he would get thousands of dollars in medical care.

England experiments with using private pharmacists providing medical treatment to patients with minor injuries and ailments. Emergency department patients are offered the option of waiting to see the physician or of seeing the pharmacist instead. So far, patients have given “extremely positive feedback” on the process.
Next up: Colonoscopies by college biology majors.
I’ve said before that I think we should deregulate the practice of medicine so that anyone can treat anyone for any medical ailment.

Amazing. And amazingly priced. Cell phone attachment allows patients to be screened for HIV and syphilis using a drop of blood. The devices cost $34 and are 96% accurate. Hat tip to Instapundit for the link

Should testosterone be as tightly regulated as it is? This article calls testosterone the “drug of the future” and compares its use to estrogen – which isn’t a controlled substance. One person interviewed for the article noted that “almost everything we treat in medicine is age-related. Aging is related to bad eyesight, bad hearing, bad joints, bad hearts, bad blood vessels, and cancer. We treat all of these without trying to minimize or diminish them that they are age related.” Why pick on testosterone use?

Damn. Boyfriend secretly records himself having sex with his 17 year old girlfriend. Video “somehow” gets uploaded to internet. Girlfriend finds out about it and becomes furious. She followed him into a bar, called him a “dog” in front of his friends, then dumped battery acid all over his lap. Boyfriends penis “will never work again” and he’ll have to urinate through a tube for the rest of his life.

Healthcare Update Satellite — 02-03-2015

Thanks for the patience in putting up with my lack of regular posting. Life has been challenging lately. Still working on it.

When government pays for your care, government may try to force its values on you. Learning-disabled mother of six children in England deemed at “grave” risk if she has any more children. Now the government wants to forcibly remove her from her home and sterilize her. A lawyer representing the woman stated that sterilization was “therapeutic.”

This process will come to medicine sooner than you think. Just watch. Uber drivers now get to rate their passengers after a ride. When passengers get lower scores, some drivers no longer want to deal with them and they have to wait longer for a ride. “1 star for passengers does not do them any harm. Sensible drivers won’t pick them up, but so what?” One expert interviewed for the article stated that “It’s inevitable that these review systems are coming. What I’m worried about is whether they’re accurate enough. Otherwise, we’re going to get a disinformation economy.” The disinformation economy is already happening with doctors via Press Ganey and its ilk. Wait until it happens with patients and they can’t find a physician willing to care for them. Then watch it happen to hospital administrators as the ratings follow them around after they destroy the morale at one hospital and try to bring their destructive ways to another facility.

What’s the sex position most likely to cause a man to have a penile fracture? Cowgirl, baby. Cowgirls are twice as likely to cause penis fractures than the boring missionary position.

Think you’re doing yourself a favor by purchasing those herbal supplements at health food stores? About 80% of the time you’ll be wrong. When the NY Attorney General investigated supplements such as ginkgo biloba from retailers GNC, Target, Walgreens, and Wal-Mart, only 5 of 24 contained the actual ingredients by DNA testing. The others contained either unrecognizable DNA or DNA from a different plant. Even more worrisome was that 5 of 24 impostors contained either wheat or beans, putting people with allergies to those products at risk.

Because we don’t have enough clipboards walking around hospital hallways … Studer Group being acquired by Huron Consulting Group in $325 million deal to create a consulting operation with more than 1500 employees.

Fascinating article on a topic that isn’t really discussed. What should people do when they hear voices? Some experts recommend talking back to them. Reading the stories about people suffering from this problem really opened my eyes. It’s one thing to have a patient tell you they’re hearing voices. It’s another thing to read about patients who go into detail about what the voices are saying and how the voices affect every aspect of their lives.

Woman develops toxic shock syndrome, develops liver and kidney failure, falls into a coma and deteriorates to point that family planned to meet with doctors to take her off of ventilator. Four hours before the family had their meeting, the patient woke up. Kidney and liver function improved. Now she’s eating and undergoing rehab. I’m happy for the patient and her family, but I’m worried about the precedent that the story sets. Will families of all terminally ill patients in comas now expect the same to happen to their family members?

Back in December, Dr. Wes Fisher did an investigation into the ABIM Foundation, Choosing Wisely, and the ABIM Foundation’s $2.3 million condiminium with regard to Maintenance of Certification requriements. He ripped the ABIM Foundation for waste, hypocrisy, and corruption.
Today, the ABIM Foundation admits “we got it wrong” and announced fundamental changes to its MOC Program.
The power of the well-written word should never be underestimated.
Great job, Wes!

Swarms of nanobots being used in clinical trials to target 12 types of cancer cells and to repair spinal cords.
I used to laugh at people who worried about government controlling our thoughts by injecting nanobots into our systems. Now I’m stocking up on tin foil to make hats for all my family.

Latest proposed budget includes a $50 million cut to program to help vaccinate un-insured and underinsured patients. However, the budget increases funding by $128 million to provide vaccines free of charge to children under 19 years old.
Of course the free children’s vaccinations will come to a screeching halt when people finally listen to ophthalmologist and Senator Rand Paul who reportedly has personal knowledge of children getting “profound mental disorders” after receiving vaccines.

Great quote from Glenn Reynolds at Instapundit: “ObamaCare — the policy that’s so popular, it never takes effect until after the next election!

Healthcare Update Satellite — 01-19-2015

Penicillin allergy? It’s associated with increased bad outcomes, but not for the reasons you think. The allergies themselves are mostly not allergies. And no, “my mother said I had a rash when I was a baby” isn’t an allergy. However, when compared with patients who don’t have penicillin “allergies”, patients with penicillin allergies have longer hospital stays and are between 14% and 30% more likely to get resistant infections while in the hospitals – possibly because the penicillin “allergic” patients are being treated with much stronger antibiotics that kill off the “good” bacteria in their systems.

Ever wonder why it seems that whenever you call a doctor for a medical problem they tell you to go to the emergency department? Here’s a good reason why: 26 week pregnant patient calls on-call obstetrician with severe abdominal pain and severe headache. On call physician attributes symptoms to a “gastric condition” and that she did not need to come to the hospital. The following day, the patient suffered a stroke. Patient and family sued and were awarded $10.9 million.

Georgia malpractice attorney Wilson Randolph Smith settles case on behalf of his clients, then forges client’s name on settlement check and keeps the money. Tells clients that the case would likely be set for trial later this year. Eventually gets caught and is now cooling his heels in the county jail.

Florida prosecuting pain clinic physician whose prescriptions were associated with three patient deaths. One patient was prescribed 3360 oxycodone pills in the year before his death.

I’m not a big fan of the AMA, but Steve Stack, an emergency physician and president-elect of the AMA is doing a good job at keeping medical issues in the media. I’ve seen multiple interviews pop up in my news feed quoting him on pertinent issues. The latest is about EMRs and “meaningful use.”

Patient writes local newspaper to thank caregivers in emergency department and hospital for providing great care to him. At first I thought this was a great thing and trust me when I say that his letter made an impact on the providers. Then I thought how sad it was that patient gestures like this are so uncommon given the 160+ million emergency department visits each year.

“Glassholes” go into mourning. Google pulling Glass version 2.0 from the market and this Forbes writer Steven Rosenbaum wonders whether Glass will be this decade’s Apple Newton. I sure hope so.

Sad story. Beautiful Ecuadorian beauty queen wins coupon for $1000 worth of liposuction as part of pageant prize. Initially refuses and tries to donate the prize to someone else, but finally talked into procedure after doctor “insists” she have the surgery. She then dies of cerebral edema during surgery. Under Ecuadorian law, doctors may be imprisoned for up to 3 years for medical malpractice.

What happens to patients when one emergency department stops taking ambulance runs? The patients don’t just disappear and the emergencies don’t just vanish. Ultimately they will seek care at other hospitals and ambulances will have to spend more time taking patients to facilities that are farther away. This is just what is occurring in California after Doctors Medical Center stopped taking ambulance runs. Ambulance runs and patient volumes at other facilities increased dramatically. Doctors Medical Center is trying to avoid closing, but is running “deficits because it serves mostly patients of MediCal and Medicare, which provide low reimbursement rates.” Now ambulances and surrounding hospitals will receive the trickle down effect of low reimbursements as the ripple effect spreads throughout the medical system.

Innovation pays off. When researchers were having difficulty culturing any new organisms in labs to try to create new antibiotics, they went au natural. Digging up dirt cultures from one researcher’s backyard, they were able to find 10,000 additional compounds to test against human pathogens. One bacteria from a grassy field in Maine was found to be more effective than vancomycin at killing MRSA and was able to do so at much lower concentrations. In addition, the bacteria so far haven’t developed a resistance to the medication. Just give it some time. Zithromax was a blockbuster antibiotic, too – until most docs started giving it out like M&Ms at a holiday party. Now bacterial resistance to Zithromax is so high in some areas that it is marginally better than a sugar pill.

Voodoo priests on the frontline of Haiti’s mental health care where there are currently about 10 psychiatrists for a population of 10 million. Yup. Pretty soon this will be about all that most patients will be able to get from their Aetna and United Health Care “Affordable Care Act” plans.

How Can You Be Sure?

“How can you be sure?”

That question stopped our discussion for a second.

During some down time, several nurses and I were talking about childhood coughs. Her 6 month old child had just started daycare 2 weeks ago and has been coughing ever since. The child was put on amoxicillin and then Zithromax by her pediatrician but … [GASP] … her cough wasn’t getting any better. The nurse thought her child had pneumonia.
“What should she be taking now?”
I was in a particularly snarky mood, so, with a smirk, I said “probably vancomycin … maybe add gentamycin just for the gram negative coverage, too.”
“I’m being serious. She’s not getting better with antibiotics.”
“BINGO! That’s because she has a virus infection and antibiotics don’t kill viruses any more than RAID kills dandelions.”
“But a virus infection isn’t going to last for two weeks.”
“Neither is bacterial pneumonia. The fact that she isn’t getting better with antibiotics should tell you that she has a chest cold. It’s a virus.”
“How can you be sure?”


There’s just no good response to that question. The truth is that we can’t be “sure” that there isn’t a bacterial infection present. We can’t be “sure” she didn’t aspirate a foreign body. We can’t be “sure” that she doesn’t have tracheomalacia. There is just no way that we can ever give a Flo’s Progressive Insurance 100% guarantee that a given set of symptoms is being caused by a given disease process and nothing else. The problem is that often patients expect this kind of diagnostic accuracy and get upset when there’s a misdiagnosis. Unfortunately, medicine is an inexact science at best. One of the things that I always found ironic is that many patients and even some medical experts expect doctors to “prove” their diagnoses do exist or to “rule out” other diagnoses by showing that those diagnoses couldn’t possibly exist. However, in court, when a doctor is accused of wrongdoing, an expert is required to testify to “a reasonable degree of medical certainty” which in most cases means that something is “more likely than not.” In other words, court testimony demands only 50.001% certainty while clinical practice often demands a much higher level of certainty.

Our discussion transitioned from snark to reality.
“Most of the time you can’t be ‘sure’ of a medical diagnosis – especially a diagnosis with a symptom as vague as a cough.”
“Well patients want certainty. If I bring my child to the doctor, I want to KNOW what’s wrong, not get some wastebasket diagnosis like a viral infection when my baby could have pneumonia.”

I nodded my head. Then I went to the cafeteria to get some lunch and I mulled that last statement while walking down the hall. How could I explain the concepts of pre-test probability and futility without getting too far into the weeds? The runny cottage cheese at the salad bar gave me an idea.

I got back to the ED and asked the nurse
“Have you ever given your child poisoned food?”
“Of course not.”
“But how can you be sure? How do you know that the formula doesn’t have contaminants in it – like that Chinese infant formula contamination back in 2008?”
“That’s completely different from diagnosing pneumonia.”
“True, but it’s the same concept. We assume that a healthy-appearing child with a runny nose and cough in the middle of winter has a head cold the same way we assume that the food we eat is not contaminated. If there are signs of complications with a coughing child, we may do further testing to see if there are other problems. If there are signs of food spoilage, we may choose not to eat the food.”
“Not the same thing.”
“Hear me out. We naturally eat food without examining it much because the likelihood of it being poisoned is quite small. However, if we wanted to be “sure” that the food wasn’t contaminated or poisoned, then we could do a bunch of microbiological testing before we eat every bite to make “sure” that the food wasn’t poisoned. But because the likelihood of poisoning is so small, all of the expenses of the extra testing probably would be a waste of money.”
“Not the same.”
“Even worse, if we do a bunch of testing on a well-appearing child with a runny nose and cough, there may be some complications from the testing or complications/side effects from the treatment for a disease that may not be present. People can get resistant infections or bad diarrhea from antibiotics for a “pneumonia” that was over-read on a chest x-ray.”
“I’ll say. My daughter has had diarrhea for a week.”
“Exactly my point. She’d probably be doing better with nasal saline, suction, and perhaps some … OTC cough medications” – a cringeworthy concept for most pediatricians.

I was convinced I had prevailed in our little discussion until she asked “Can children take Levaquin?”
“Only for bacterial infections.”
“But …”
“No. Just no.”