Ordering Tests in the United States and England

To the Editor.—  In the article by Epstein et al¹ in the Oct 5 issue of The Journal, two important factors were not mentioned by the authors in their discussion of their results.The disparity in test-ordering behavior between the two groups might not be nearly so large if the comparison were made between more nearly comparable groups. British general practitioners might be considered much more comparable with American general or family practitioners than either group is with American internists. The comparison between board-certified internists in the Boston area and board-certified family practitioners in the central United States might also show a rather wide disparity.The second factor is one that is woven into the fabric of American medical education. The term rule out has been used so commonly that it is even a basis for hospital admission (as in "R/O MI [myocardial infarction]"). Any medical student or resident