Rising health care expenditures have led to numerous cost-control proposals. An examination of the ethical questions surrounding the role that physicians play in the control of health care costs suggests that unilateral rationing decisions by individual physicians at the bedside are morally unacceptable. Such decisions are arbitrary, ineffective in redistributing health care resources, and formally unjust. Restrictive gatekeeping (the creation of financial incentives for physicians to limit care given to individual patients) also seems unacceptable because of its morally significant effects. First, it disguises the role of those actually responsible for cost-control decisions; second, it routinely creates a "moral stress test" by forcing physicians to act in ways that are contrary to their own interests in order to serve the needs of patients; third, it undermines the trust between doctor and patient; and fourth, it rations by class of persons rather than class of technology. In contrast, a morally sound system would attempt to control costs by honestly informing patients and assigning responsibility justly, would encourage physicians to act in the interests of patients, would foster trust, and would recognize the great importance of equal treatment for all patients. Such a system would depend on input from an informed public and would apply equally to all members of society.

The insulin-like growth factor (IGF) family of peptides, binding proteins, and receptors are ubiquitous and important for normal human growth and development. Modern techniques including specific radioimmunoassays, radioreceptor assays and recombinant DNA technology have improved our understanding of the role of IGFs in growth and development. In addition to enhancing our understanding of normal physiology, these techniques assess changes in these hormones, binding proteins, and receptors in pathologic conditions including growth retardation, acromegaly, malnutrition, diabetes, and malignancy. Further, these studies have led to improvement in the assessment of responses to certain therapies used in the treatment of these diseases and may lead to improvements in these therapies.

To review the methods used for preoperative cardiac risk stratification of patients having peripheral vascular surgery.

To estimate the prevalence of objectively proven thrombotic complications in antithrombin-III-deficient persons.

Membranous nephropathy is a worldwide problem that accounts for about 20% of the cases of the adult-onset nephrotic syndrome. This disease places many patients at risk for both end-stage renal failure and the complications of hyperlipidemia. Immune-mediated injury to the glomerular capillary wall in patients with membranous nephropathy is characterized by subepithelial immune complex formation and generation of the membrane attack complex of complement. Glomerular capillary hypertension, hyperlipidemia, and possibly cytokines could contribute to the glomerular sclerosis seen in the advanced stages of the disorder. In some cases, production of pathogenic antibody can be suppressed by treating the underlying condition. The mechanisms of action of immunosuppressive agents are being investigated and treatments are being tested in clinical trials to optimize the balance of efficacy and toxicity. Alternate-day treatment with corticosteroids is often recommended for nephrotic patients with idiopathic membranous nephropathy, but this approach has not been proved beneficial. Ongoing studies are evaluating whether cytotoxic drugs or cyclosporin A combined with prednisone is more effective than treatment with corticosteroids alone. Lipid-lowering drug therapy is warranted in cases of the persistent nephrotic syndrome to avert the cardiovascular sequelae of hyperlipidemia.

To determine the appropriate patients, methods, and timing for screening for diabetic retinopathy.

Although the treatment of hypertension has increased markedly during the last decade, many patients have been left undertreated, including many of the disadvantaged, the elderly, and those at relatively high overall risk for cardiovascular disease. A rapidly growing number of patients, however, are being exposed to overtreatment with resultant interference with their quality of life and potential hazards to their health. These include patients who are diagnosed and treated without adequate documentation of the presence of persistent hypertension, patients who are not appropriately managed with nondrug therapies, and patients who are given inappropriate and overly aggressive drug therapies. Better recognition of the frequency and potential hazards of overtreatment is needed so that more appropriate goals of antihypertensive therapy can be established and maintained.

To review the physiologic basis for normal and abnormal vagal reflexes arising from the pharynx, larynx, and esophagus, as well as the relevance of vagal reflexes to the pathogenesis of such clinically common cardiorespiratory responses as bradycardia, tachycardia, dysrhythmia, coronary angiospasm, bronchospasm, laryngospasm, prolonged apnea, and singultus (hiccups).

Abundant evidence that medicine is in trouble includes serious career dissatisfaction among practicing and would-be physicians as well as steeply declining interest in generalist careers, especially internal medicine. Medicine is threatened by ever-rising health care expenditures and ineffectual but vexing administrative efforts to contain them. Additional problems challenge internal medicine in particular: the clinical complexity of practice, lower income potential, and incomplete clinical experiences for medical students. Yet, in the past 25 years, spectacular advances in science and technology enabled improved patient care and outcomes; more women and minorities entering the profession brought it into better demographic balance; relative physician incomes rose; and access to physician services improved with Medicare and Medicaid and the desegregation of southern hospitals. Despite an unfinished agenda, never before has medicine held so much promise for improving the health of the public. Despite various professional problems, no other career offers the unique blend of state-of-the-art science and humanism that epitomizes internal medicine--medicine's integrating specialty.

Doctors and patients alike are saddened and angered by the distance that increasingly interferes with their interactions. Two complementary strategies may enhance the human quality of clinical care and improve outcomes. First, the doctor and patient can undertake a systematic "patient's review" that addresses seven dimensions of care: 1) respect for patient's values, preferences, and expressed needs; 2) communication and education; 3) coordination and integration of care; 4) physical comfort; 5) emotional support and alleviation of fears and anxieties; 6) involvement of family and friends; and 7) continuity and transition. Incorporating the "review" into the clinical encounter encourages both patient and doctor to confront individual preferences and values and offers patients an explicit framework for participating actively in their care. Second, using survey instruments designed to solicit focused reports from patients that address each dimension of care, doctors can gather aggregate feedback about their practices. Such reports move beyond anecdote and can serve as screening tests that uncover areas in doctors' practices that merit improvement. In addition, patients can join doctors in developing solutions to problems uncovered by patients' reports.

The development of the hospital into a corporation has influenced the care of patients and the work of the professional staff. As a corporate enterprise, the modern hospital has a private agenda aimed at increasing growth and efficiency with an emphasis on technical services, professionals as employees, and patients as customers. These changes have resulted in a decrease in trustee and professional authority and an increase in administrative control. This shift in the control structure has continued in response to the need for accounting and regulation of services and in response to demands for increased growth and efficiency made by an increasingly competitive market environment. Strategies for the reorganization of hospital staff aimed at improving both inpatient and outpatient care are reviewed. The reorganization of the institution and staff, using either a staff group-practice corporation or an administrative staff model, is proposed. Clinicians have new responsibilities for developing collective arrangements for institutional governance, for allocating institutional resources, for providing public accountability regarding the use of these resources, and for defining the missions of care.

To review the literature on the appropriateness of red blood cell transfusion and current physician practice, with emphasis on the physiologic and symptomatic implications of elective transfusion in the treatment of anemia.

To describe five cases of early syphilis with gastric involvement and to review the literature pertaining to this disorder.

To quantitatively assess the efficacy and safety of published randomized trials comparing subcutaneous heparin with continuous intravenous heparin for the initial treatment of deep vein thrombosis.

Substance abuse and impairment are serious societal problems. Physicians have historically had high rates of substance abuse, which has been viewed as an occupational hazard. Most authorities agree that the rate of alcoholism among practicing physicians is similar to that among control populations and that the rates of other substance abuse are greater, although some studies have shown no difference. Data about substance abuse among residents in training are limited but suggest that the use of benzodiazopines is greater than that among age-matched peers, whereas the use of alcohol is similar between the two groups. Medical institutions, including those with teaching programs, have legal and ethical responsibilities concerning substance abuse among current and future physicians. Many training programs, however, do not provide educational programs on this subject, do not have faculty trained in substance abuse medicine, and do not have a formal system to address the problem of residents who are suspected or known to be substance abusers. This position paper examines the extent of substance abuse, including alcohol abuse, among physicians in residency training. It outlines approaches to the problem and delineates responsibilities of institutions and residency program directors. Recommendations are made to establish an informational program and a clearly defined, organized process to address the problems of substance abuse among residents. Careful and humane approaches can be used to identify and treat residents with substance abuse problems and thus allowing them to complete their training as competent and drug-free professionals.

To review the literature on early management of myocardial infarction.

To determine whether published cost-effectiveness and cost-benefit analyses have adhered to basic analytic principles.