too much of a good thing case study

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Methylmercury is an environmental toxicant that has been shown to cause neurologic damage in both children and adults if ingested in sufficiently high quantities. Poisoning outbreaks in Japan and Iraq have revealed serious effects on developing fetuses at levels far below those that produced clinical signs or symptoms in the mothers. Therefore, health guidance values for methylmercury, such as the chronic oral minimal risk level (MRL) of the Agency for Toxic Substances and Disease Registry, have been set by governmental agencies at levels that would protect fetuses. Since adults are less sensitive than fetuses, chronic intakes within an order of magnitude of the MRL generally have been considered to represent no health risk to otherwise healthy adults. The present report of suspected mercury intoxication in a 53-year-old female suggests that some individuals might be susceptible to adverse health impacts of methylmercury at intakes just 7 to 15 times the MRL.

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Too much of a good thing is wonderful? A conceptual analysis of excessive examinations and diagnostic futility in diagnostic radiology

• Scientific Contribution
• Published: 12 February 2010
• Volume 13 , pages 139–148, ( 2010 )

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• Bjørn Hofmann 1 , 2  

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It has been argued extensively that diagnostic services are a general good, but that it is offered in excess. So what is the problem? Is not “too much of a good thing wonderful”, to paraphrase Mae West? This article explores such a possibility in the field of radiological services where it is argued that more than 40% of the examinations are excessive. The question of whether radiological examinations are excessive cries for a definition of diagnostic futility. However, no such definition is found in the literature. As a response, this article addresses the issue of diagnostic futility in five steps. First, it investigates whether the concept of therapeutic futility can be adapted to diagnostics. A closer analysis of the concept of therapeutic futility reveals that this will not do the trick. Second, the article scrutinizes whether there are sources for clarifying diagnostic futility in the extensive debate on excessive radiological examination. Investigating the debate’s terms and definitions reveals a disparate terminology and no clear concepts. On the contrary, the study uncovers that quite different and incompatible issues are at stake. Third, the article examines a procedural approach, which is widely used for settling controversies over utility by focusing on the role of the professionals. On scrutiny however, a procedural approach will not solve the problem in diagnostics. Fourth, a value analysis reveals how we have to decide on the negative value of excessive examinations before we can measure excess. The final and constructive part presents a definition of diagnostic futility drawing upon the lessons from the previous analytical steps. Altogether, too much radiological examination is not a good thing. This is simply because radiological examinations are not unanimously good. Excessive radiological examinations can be defined, but not by one simple general and value-neutral definition. We have to settle with contextually framed value-related definitions. Such definitions will state how bad “too much of a good thing” is and make it possible to assess how much of the bad thing there is. Hence we have to know how bad it is before we can tell how much of it there is in the world.

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There are studies of specific examinations with certain modalities, e.g., MRI of the knee joint, that show that over 75% of the examinations are unnecessary (Hanger 2005 ). See also (Robling et al. 2002 ).

For specific references to the debate, see below.

For other uses of “overuse” see (Villforth 1979 ; Shapiro et al. 1999 ; Abd El Bagi et al. 1999 ; Hage 1996 ; Guadagnoli et al. 2001 ; Fisher et al. 2003 ; Fuhrmans 2005 ).

For other uses of “unnecessary examinations” see (Jonsson et al. 1978 ; Gibson 1987 , Rosen 1985 ; Whittaker 1987 ; Burwood 1989 ; Bransby-Zachary and Sutherland 1989 )

For other uses of “inappropriate” see (Leape et al. 1990 ; Oakeshott et al. 1994 ; Armstrong 1999 ).

More subtle reasons for excessive health care, such as increase in diagnostic sensitivity due to improved diagnostic technologies, resulting in increased prevalence of disease, and lowered treatment threshold (Black and Welch 1993 ; Fischer and Welch 1999 ) have not been included. That is, the highly relevant, but far too extensive, debate on medicalization has been left out of this study. The same goes for the debate on defensive medicine (defensive radiology) and self-referral (Fenton and Deyo 2003 ). The reason is that the debate on defensive radiology has a particular terminology addressing the intensions of the examinations directly. The issue is included, however, in the moral aspect discussed in this article. Furthermore, the interesting debate on inadequate requests is not addressed, as only a fraction of inadequate requests would lead to futile diagnostics.

The term “excessive examinations” may serve as a generic term to denote all the (six) aspects of “too much” imaging, and “diagnostic futility” more specifically in line with the term “futile treatment” as discussed above to discuss the usefulness of a diagnostic service.

Definitions that address utility much resemble those of therapeutic futility, although this debate is seldom referred to. Some definitions comprise the probability of achieving a goal, and the uselessness of doing so. E.g., unnecessary examinations are defined as those which are “clinical unhelpful in the sense that the probability of obtaining information useful to patients management is extremely low” (Roberts 1991 ; Royal College of Radiologists Working Party 1991 ). This makes them subject to the same challenges as are “quantitative futility” and “goal futility” (discussed earlier).

Although many of the aspects fuelling the concern for excessive examinations are related to safety, it appears that few definitions (explicit or implicit) reflect this. This may be because there is a widespread agreement on the aspect of safety, while utility based conceptions of excessive examinations appear to be more controversial, and in need of explicit definitions. However, the heated debate on radiation protection indicates that this is not the case. Moreover, at the basis of utility based definitions we may find reference to risk, e.g. when weighing benefits against risks.

One may of course argue that an analysis of definitions is in vain as the definitions, especially in reports or guidelines of (inter)national regulatory bodies, are so general and so vague that they are of no analytical interest. However, many of the definitions reviewed stem from the literature on down to earth practical diagnostic imaging. Besides, if the definitions are poor or vague, they are useless, and will fuel rather than settle debates.

Furthermore, low acceptance rate of guidelines challenges the foundation of guidelines in (professional) virtue ethics: how can guidelines be based in the role of the medical (radiological) profession, when there is low adherence?

We should differentiate between radiologists, referring GPs, self-referring specialists, other referring specialists. However, for the scope and purpose of this study the professionals will be treated as a group.

This curtails a more elaborate axiological analysis. However, an all encompassing axiological study is beyond the scope of this article, and due to the lack of consensus on the various kinds of values, it suffices here to refer to categories of values that have been acknowledged since Platao’s Republic , where he (in 357) distinguishes between goods valued for their own sake and not for their consequences (intrinsic), goods that are valued for their consequences only (instrumental), and goods that are valued both for their own sake and for their consequences (intrinsic and instrumental). The analysis could of course have been performed with von Wrights varieties of goodness, or in terms of a more nuanced variety of extrinsic values, such as inherent, contributory, indicative, relational, and instrumental values.

This is also more in accordance with what Mae West is supposed to have said. http://www.brainyquote.com/quotes/authors/m/mae_west.html

It may be unnecessary to point out that this definition may be controversial.

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Acknowledgments

I am thankful to professor Thomas Pogge and colleagues at the Section for medical ethics at the University of Oslo who have commented on an earlier version of this paper. I am also thankful for inspiring comments from participants at the 21st EUROPEAN CONFERENCE ON PHILOSOPHY OF MEDICINE AND HEALTH CARE in Cardiff (15.08.2007–18.08.2007) for comments on a related paper and to two anonymous referees.

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Hofmann, B. Too much of a good thing is wonderful? A conceptual analysis of excessive examinations and diagnostic futility in diagnostic radiology. Med Health Care and Philos 13 , 139–148 (2010). https://doi.org/10.1007/s11019-010-9233-8

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Summary: Use all sorts of resources for learning your target language: newspapers, vlogs, novels, short stories, comments sections, advertisements, grocery lists—anything!

Going by the book is one of the biggest mistakes you can make while learning a foreign language.

The textbook can give you all the essential building blocks, but it can’t take you much farther.

Have you ever heard the people speaking in the audio files accompanying English textbooks? They’re speaking perfectly correct English, but they sound a bit forced and awkward at times. That’s because they’re reading a script designed for learners. It’s easy on the ears, and great for becoming familiar with the basics of language, but you’ll probably never hear a native speaker who talks quite like that.

Slang, idioms, jokes, regional dialects, pop culture references…they usually can’t be learned from standard textbooks. To really understand native speakers, you must learn casual language.

This doesn’t mean that you shouldn’t use textbooks at all. Some of them are worth trying, and one can find many reasons to use modern textbooks : They’re well-designed, they provide useful content and a road map for learning, they give lots of practice opportunities and they usually offer audio components.

FluentU takes authentic videos—like music videos, movie trailers, news and inspiring talks—and turns them into personalized language learning lessons.

You can try FluentU for free for 2 weeks. Check out the website or download the iOS app or Android app.

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Summary: Find materials about subjects that interest you. If you’re an accountant, that might be accounting statements from a large foreign company, or if you’re an art aficionado, read the latest museum exhibition guides in their original language.

Some learners aren’t super passionate about languages, and instead consider reaching fluency just another task to complete. It’s just another task on a life list, bucket list or resume building plan. There are a couple of noteworthy problems with this:

• It’s very difficult to pinpoint the exact moment you reach fluency, so you may never be able to check the “task complete” box.
• You don’t know a language just because you score all A’s and 100’s on your exams.
• You need to find some personal motivation coming from within to really master a language without ever losing focus.

You can’t just study for the test. Fluency doesn’t come until after you’ve put your language skills into action, spoken with natives for hours, listened to native speakers intently and followed their directions. You also need to learn the culture behind the language to a certain extent, or you’ll find a large gap between you and natives while communicating.

Not to mention, you have to constantly be updating your language knowledge. Languages change and develop all the time. Don’t miss a chance to learn the culture of those people whose language you learn, chat with your native speaker friends, watch movies, listen to songs, travel to countries and interact with locals.

Summary: Seek out teachers and fellow students who learn like you like to learn and build a learning community, in real life or online.

This may be the most common mistake made by language learners. They rely on whatever course they’re taking, whether they’re taking it through a college, university or institute online, at home or abroad. This “reliance” comes in two forms:

• Relying on the course to give you all the material and exposure you need to learn.
• Holding the course or teacher responsible for your successes and failures.

When you learn a language, it’s good to have a teacher who will help and support you, but it doesn’t mean he or she can do everything for you. Teachers guide you—they can’t inject the language straight into your brain. It’s only you who’s responsible for your learning.

If you feel like the books and materials your school gives you aren’t effective or sufficient on their own, find a different textbook or other language learning materials to accompany the coursework. If the coursework doesn’t target your preferred learning style, learn how you learn best on your own time. If you learn best through music or visual cues, but simply don’t get enough of that in class, take care of yourself at home later.

Don’t only do your homework, study for tests and call it a day. Read and listen to your target language every day, communicate in it, go to language exchange clubs, make friends with native speakers and seek out new articles, blog posts, YouTube videos and more in that language. Become ravenous. Consume as much of the target language as you can on a daily basis.

Ask your school to assist you where needed, manage your emotions and try to stay motivated and optimistic.

If you don’t study properly and perform poorly on tests, take responsibility for this. If you ace all the reading and writing assignments but can’t speak without a heavy accent, then take responsibility for this and double up on speaking practice. The teacher and coursework can only get you so far.

Take these tips to heart and I think you’ll find your language learning journey moves faster than you ever thought it could. It’ll also be more fun!

If you dig the idea of learning on your own time from the comfort of your smart device with real-life authentic language content, you'll love using FluentU .

With FluentU, you'll learn real languages—as they're spoken by native speakers. FluentU has a wide variety of videos as you can see here:

FluentU App Browse Screen.

FluentU has interactive captions that let you tap on any word to see an image, definition, audio and useful examples. Now native language content is within reach with interactive transcripts.

Didn't catch something? Go back and listen again. Missed a word? Hover your mouse over the subtitles to instantly view definitions.

Interactive, dual-language subtitles.

You can learn all the vocabulary in any video with FluentU's "learn mode." Swipe left or right to see more examples for the word you’re learning.

FluentU Has Quizzes for Every Video

And FluentU always keeps track of vocabulary that you’re learning. It gives you extra practice with difficult words—and reminds you when it’s time to review what you’ve learned. You get a truly personalized experience.

Start using the FluentU website on your computer or tablet or, better yet, download the FluentU app from the iTunes or Google Play store. Click here to take advantage of our current sale! (Expires at the end of this month.)

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9 places to nosh on bagels in southern Maine

From old-school spots to foodie favorites, there's a 'hole' lot to try.

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Bread and bagels at The Works Cafe in downtown Portland. Photo by Aimsel Ponti

From New York-style boiled bagels to Montreal-inspired wood-fired ones, there’s lots of great bagels in southern Maine and several shops have the accolades to back that up.

In 2023, Bon Appetit named bagels from Rose Foods and Rover Bagel among the best in the country.

Two years before that,  Food & Wine Magazine put Rover, Forage and Scratch Baking Co. on its list of best bagels in the U.S.

Whether you like yours toasted with cream cheese or as the bread for your breakfast sandwich, you can find plenty of styles and flavors from Biddeford to Brunswick.

BEACH BAGELS

The offerings at Beach Bagels include a French toast and marble bagel, and the cream cheese menu comprises spreads like strawberry, olive and honey walnut. Along with breakfast sandwiches, Beach Bagels has hearty breakfast options like omelets and pancakes. Best of all, you’re steps away from a beach stroll. Just don’t let the seagulls steal your bagel. Advertisement

WHEN: 7 a.m. to 3 p.m. daily WHERE: 34 Old Orchard St., Old Orchard Beach. beachbagels.yolasite.com ______________

Dutchman’s opened in 2022 as a pop-up housed at Nomad pizza in Brunswick’s Fort Andross building. It’s since become a permanent fixture there and uses the pizzeria’s wood-fired ovens to bake its bagels. The hand-shaped, honey-boiled bagels come in plain, roasted garlic, poppy and a bagel-of-the-day flavor.

WHEN: 8 a.m. to 1 p.m. Thursday to Sunday WHERE: Fort Andross, 14 Maine St., Brunswick. dutchmans.me ______________

FORAGE MARKET

Making bagels at Forage Market involves a two-day aging process. The bagels are naturally leavened with wild yeast starter and baked next to a hardwood fire. There are usually five flavors available, including sesame and garlic. Breakfast sandwiches (including vegan options) are available. Forage also has a location in Lewiston. Advertisement

WHEN: 7 a.m. to 1 p.m. Monday to Friday, 8 a.m. to 1 p.m. Saturday and Sunday WHERE: 123 Washington Ave., Portland. foragemarket.com _____________

MISTER BAGEL

There are 10 or so Mister Bagel locations in Maine, including South Portland and Falmouth. It all began with the Portland location, which was the first bagel shop to open in Maine. The late Rick Hartglass started Mister Bagel in 1977, and it is still a family business. Music fans will appreciate the breakfast sandwich menu, which includes The David Bowie (bacon, egg and American cheese), the Jimmy Buffett (egg with roast beef and cheddar) and The Lady Gaga (avocado, salt and pepper, with or without egg).

WHEN: 6:30 a.m. to noon Monday to Friday, 7 a.m. to noon Saturday and Sunday WHERE: 599 Forest Ave., Portland. misterbagelforestave.com ______________

At Rose Foods, the menu varies depending on the day, but there are usually six to eight flavors available. For example, should you pop in on a Friday, you’ll find a poppy and onion bialy (a cousin of the bagel that is not boiled). Rose Foods also makes a number of bagel sandwiches, including the Classic Nova with Nova lox and the Classic Whitefish. Advertisement

WHEN: 7 a.m. to 2 p.m. daily WHERE: 428 Forest Ave., Portland. rosefoods.me

______________

ROVER BAGEL

At Rover Bagel, you’ll find wood-fired plain, poppy, sea salt, sesame and everything bagels available most of the time, and the spread game here is strong with cream cheese options like lemon-thyme-honey cream and chili-garlic.

WHEN: 7 a.m. to 1 p.m. Wednesday to Friday, 8 a.m. to 1 p.m. Saturday, 8 a.m. to noon Sunday WHERE: 10 West Point Lane Suite 10-204, Biddeford (Pepperell Mill). roverbagel.com

______________ Advertisement

SCRATCH BAKING CO.

You haven’t lived until you’ve experienced the line of devoted fans waiting for Scratch Baking Co. to open, especially on weekend mornings. Along with the popular Maine sea salt, plain and other everyday flavors, Scratch has a daily special bagel. There’s honeyed rosemary on Wednesday and jalapeno cheddar on Thursday. Scratch is also famous, at least to locals, for its P-Cheese spread. It’s a pimento cheese recipe made with cheddar, mayo, roasted red peppers and seasoning and was passed down to co-owner and head baker Allison Reid by her grandmother, Mern.

WHEN: 7 a.m. to 1 p.m. Wednesday to Saturday, 7 a.m. to noon Sunday WHERE: 416 Preble St., South Portland. scratchbakingco.com ___________

THE MAINE BAGEL

The Maine Bagel is a drive-thru with several breakfast and other kinds of sandwiches available. With a bagel list that features egg and bialy among the standards, the family-owned spot is the perfect place to stop on your way to Pine Point Beach. The Maine Bagel really shines with a dozen kinds of cream cheese spreads, including raisin-walnut, lox, strawberry, cranberry-nut and bacon-chive.

WHEN: 6:30 a.m. to 2 p.m. Tuesday to Friday, 7 a.m. to 1 p.m. Saturday. WHERE: 117 Route 1, Scarborough. themainebagel.com Advertisement

THE WORKS CAFE

The Works Cafe is an institution on the edge of the Portland’s Old Port. It opened in 1990 as Bagel Works before it changed its name in 2002. The original shop in this regional chain opened in Manchester, Vermont, in 1988, and there are 11 locations around New England, though just the one in Maine. Gone are the ’90s-era banana-walnut bagels and cold pizza cream cheese, but The Works Cafe is still a reliable place to grab a salt, multigrain or cinnamon raisin bagel, among others. The menu also has bowls, sandwiches and smoothies.

WHEN: 6 a.m. to 7 p.m. daily WHERE: 15 Temple St., Portland. workscafe.com

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