You probably won’t be surprised to learn that most of the patients we worry about turn out not to have heart disease as the cause of their symptoms. That’s what happens when you try to make sure you aren’t missing anything. The more diligently you pursue the goal of catching every potential life-threatening problem (thus avoiding the “false negative” result of your evaluation), the more false positives you are going to get: we were worried about your heart, but all of the tests are normal, so we’re now as certain as we can be that it’s not your heart.

The perfect strategy for evaluating anything would have no false negatives and no false positives. Unfortunately, that doesn’t exist.

You probably also won’t be surprised to find out that there is pushback. All of this evaluation, and especially some of the more sophisticated testing, costs money.

If you are a legislator, a regulator, a bean counter, or for any other reason interested in controlling health care expenditures, you are going to take a hard look at a part of the health care system that devotes significant resources to a specific patient population and seems to have a “low yield” relative to dollars spent. An editorial in the New England Journal of Medicine last year said this:

“The underlying assumption … is that some [more definitive] diagnostic test must be performed before discharging these low-to-intermediate-risk patients from the emergency department. This assumption is unproven and probably unwarranted.”

‘I’m the one who has to separate the high-risk patients from the rest and then decide what to do with the low-risk and the intermediate-risk patients.’

Now, I’m as much of an enthusiast as anyone I know for the cost-efficient practice of medicine. And so I’m torn between two impulses here: the first impulse is to agree with an editorialist who clearly shares my bias in favor of a cost-efficient approach. The second impulse is the one that always seizes me, making me rub my hands with glee, any time I find that one of the world’s most prestigious journals has published something stupid. Remember, I’m a critic. And this statement is most assuredly stupid.

Guess who has the job of “stratifying” risk in this patient population? Yes, ‘tis I, your faithful editor. I’m the one who has to separate the high-risk patients from the rest and then decide what to do with the low-risk and the intermediate-risk patients. And so I read the journals, always looking for the best strategy.