Frequent undertreatment of analgesic-responsive acute pain and chronic cancer pain persists, despite intensive efforts to provide clinicians with information about analgesics. A set of background factors must be addressed in interventions to improve pain treatment: Traditional patterns of clinician and patient interaction on the ward, quality assurance, and drug regulatory practices do not support prompt recognition and treatment of pain. Possible interventions to modify these patterns of daily practice include monitoring and displaying patient pain ratings routinely, making available educational tools to assist optimal drug ordering, encouraging patients to communicate about unrelieved pain, reviewing quality assurance of pain treatment regimens, increasing behavioral research into analgesic prescribing, and selectively modifying narcotics regulatory practices.

To evaluate evidence that concurrent infection with human immunodeficiency virus (HIV) alters both the natural history of syphilis (by increasing the frequency of early neurosyphilis) and the response to penicillin.

No prospective, randomized clinical trial comparing coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, and conservative therapy has been reported. To address when revascularization is indicated, we constructed a decision analytic model. Our model incorporates procedure-related mortality and morbidity, coronary artery disease-related mortality, and the benefit of revascularization. We determined the quality-adjusted life expectancy and expected costs for each strategy. Our model suggests that angioplasty is a reasonable alternative to bypass surgery in patients with favorable lesions if angioplasty would provide a comparable degree of revascularization. Our model predicts that patients treated with angioplasty will have more revascularization procedures than will patients treated with bypass surgery but predicts that both treatments will cost the same over the typical patient's lifetime. In many patients with severe angina or documented ischemia, angioplasty is indicated for stenosis of a single artery. In patients with two vessel disease that is amenable to angioplasty, angioplasty may be a reasonable alternative to bypass surgery. Even in patients whose three vessel disease can be completely revascularized by angioplasty, bypass surgery, although relatively expensive, is slightly better than angioplasty. In patients with three vessel disease and comorbidities that increase operative risk, angioplasty may be a reasonable alternative to either bypass surgery or medical therapy.

Many patients think that there are shortcomings in the ethical dimensions of patient care, and research supports their view. In this issue of Annals, Erde suggests that physicians' incomes should depend on patients' assessments of their ethical behavior in much the same way that waiters' incomes depend on patrons' tips. Although Erde's solution is satiric, the problem is a serious one. The experiences and perspectives of patients regarding their own illness are undervalued by physicians. A truly patient-centered care demands that physicians elicit, understand, and respond to patients' perspectives. Tying physicians' pay to measurements of patient satisfaction is unlikely to dramatically improve the ethical quality of patient care as long as attention to the patient's perspective is seen as peripheral to "good medical care." Rather than relying on a single, easy "fix," we must re-examine all of professional development and practice. We need to choose persons for medical careers who will find patient-centered care rewarding; we need to provide such persons with training and socialization that underscores the value of personalized medicine; and we need to build institutions and systems that facilitate and reinforce patient-centered practice. The best ways to achieve these objectives are as yet unclear, but if we, as physicians, are offended by Erde's "modest proposal," then we must respond by proposing and implementing our own ideas about how patient care can become more humane.

Several current and proposed structural features of medical reimbursement are intended to alter the behavior of health care providers. I propose adding a structure to make physician behavior more ethical. The structure's design would be complex, but its core would be reminiscent of how a patron tips waiters. My proposal would apply the truism that society's reward systems should foster rather than undermine social goals. This idea draws on features of medicine's social background and on a theory of behavior. It challenges the taboo against the physician's financial interests being clearly present in the doctor-patient relationship and it challenges the overly pure characterization of medical ethical dilemmas that currently dominates. Detailed sketches of necessary mechanisms, such as anonymous forms for patients to complete, are offered, and connections to the insights of George Bernard Shaw are made.

Editorial Note: The Clinical Practice Subcommittee of the College's Health and Public Policy Committee undertook development of "Guidelines for the Physician Expert Witness" in order to encourage broad physician participation in providing this much-needed assistance to the legal system. The College believes that more physicians should serve as experts as a component of their professional activities in order to meet the need for medical testimony rather than a few physicians with little current involvement in patient care spending disproportionate amounts of time testifying. The guidelines, adapted from the "Statement on Qualifications and Guidelines for the Physician Expert Witness" by the Council of Medical Specialty Societies (20 March 1989), recommend qualifications for experts and give general guidance.

To examine studies of normal colon and colorectal cancer for evidence that the location of the primary tumor proximal or distal to the splenic flexure of the colon may determine distinct genetic categories of this disease.

The general internist has an important role in the management of head and neck squamous cell cancers. This heterogeneous group of cancers must be accurately diagnosed and staged before planning treatment. Curability is directly related to stage at presentation and, because most patients with such cancers present to internists first, these physicians must be familiar with presenting symptoms and must be suspicious enough to refer patients with symptoms for appropriate evaluation. The work-up of patients with suspected unknown primary cancer presenting as adenopathy is detailed, and the physician is cautioned not to immediately proceed to open biopsy. As many as 10% of such primary cancers remain undetected, although, with proper therapy, the 5-year survival rate for squamous cell cancer of the head and neck is 60%. Those patients cured of head and neck cancer still face significant psychosocial and medical problems, including hypothyroidism, xerostomia, and a 20% rate of second primary cancer. Head and neck cancer is highly preventable; 75% of cases are related to tobacco and alcohol use. Smokeless tobacco has gained popularity among young Americans and is associated with an increased incidence of head and neck cancer at several sites. Education is crucial, and internists must seek strategies to stop patients from using tobacco products. Other etiologic factors include industrial carcinogens, Epstein-Barr virus, and diet. Retrospective serologic and dietary recall studies of vitamin A suggest an etiologic role of diet; vitamin A analogs have been tested in preneoplastic lesions. To reduce mortality from head and neck cancers, the general internist must play a central role in prevention and early detection.

To determine the discriminant accuracy of exercise thallium-201 myocardial perfusion scintigraphy for the diagnosis and prognosis of patients with known or suspected coronary artery disease.

To review the biologic origin, functional characteristics, and current and potential clinical applications of a novel marker of immune system activation, the soluble interleukin-2 receptor (sIL-2R).

To review recent developments of antiretroviral therapy for the acquired immunodeficiency syndrome (AIDS) and related disorders.

To review the recent advances in the biologic and clinical research of chronic lymphocytic leukemia.

Global environmental change threatens the habitability of the planet and the health of its inhabitants. Toxic pollution of air and water, acid rain, destruction of stratospheric ozone, waste, species extinction and, potentially, global warming are produced by the growing numbers and activities of human beings. Progression of these environmental changes could lead to unprecedented human suffering. Physicians can treat persons experiencing the consequences of environmental change but cannot individually prevent the cause of their suffering. Physicians have information and expertise about environmental change that can contribute to its slowing or prevention. Work to prevent global environmental change is consistent with the social responsibility of physicians and other health professionals.

The intricate cause of the aging process in humans and animals, at present a matter of intense speculation, has given rise to many theories. Despite its uncertain cause, aging constitutes the most significant and universal problem confronting physicians today. Age-related physiologic deterioration and age-associated diseases are of immense concern to physicians because of the "old-age boom" anticipated in the first part of the twenty-first century. Biomedical research achievements in the twentieth century have permitted more persons to approach the fixed upper limit of the human lifespan. We discuss the functional decline of the aging heart and the underlying mechanisms of that decline; quantitative and qualitative changes in the immune system; and normal aging of the human brain contrasted to the brain changes seen in Alzheimer disease. With our growing geriatric population, we greatly need to increase our understanding of both the causes of human aging and the goals of gerontology and geriatrics and to expand research into the significant problem of Alzheimer disease.