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During the latter half of the 20th century, estrogen therapy was administered to prevent otherwise healthy girls with tall stature from becoming tall adults by inhibiting further linear growth. We explore how decisions to treat tall girls with estrogen were influenced by both scientific knowledge and sociologic norms. Estrogen therapy represented the logical application of scientific knowledge regarding the role of estrogen for closure of the growth plates, but it also reflected prevailing societal and political beliefs about what it meant to be a tall girl. We discuss the rise and fall in popularity of this therapy and suggest that insight into the present-day treatment of short stature can be gained by comparing the use of estrogen therapy for tall girls with the use of growth hormone therapy for short boys. We suggest that this case study illustrates how scientific knowledge is always created and applied within a particular social context.

Who are you? What is your role in the medical setting? What is your professional status? Who am I? This last question may be answered easily by looking to the end of this editorial, but when we meet face-to-face, knowing the answers to questions such as these usually requires some other source of information. Alas, too often even today, some patients (and one fears some health professionals as well) answer these questions with reference simply to cues such as class, race, and gender, leading to unfortunate mischaracterizations—not all women in the hospital corridor are nurses or social workers, for example. A name tag can indicate an unknown person's professional identify and status. A name tag (often with a picture ID) also serves a security function by indicating that the person belongs in the setting. A name tag used for this purpose primarily answers the question “Does this person really work here?” As both status and security markers, name tags are worn in a variety of settings, from zoos to factories to airports. But perhaps nowhere are they so important as in health care, where people—our patients—are at their most vulnerable: ill, afraid, in pain, partially clothed (or not at all), often separated from their friends and family, and implicitly obligated to follow the instructions of the professional staff. Who is the person coming in the door? That question is often answered by their name tag. What, precisely, do name tags tell us about the person? Well, for one, the person's name. But let us hope that we are past the days when a patient might refuse to be cared for by someone only because his name is “O’Connor” and not “Gottlieb,” or vice versa. Obviously, name tags in the medical setting are intended to convey more than names. They also serve as role markers, although in fluid settings such as the hospital ward any of a wide range of professionals might assume the role of “blood drawer.” More than merely marking a role, the name tags also indicate where a person exists in the professional hierarchy of medical workers. That standing may then be read as a marker of that person's professional status. The article by Silver-Isenstadt and Ubel in this issue examines precisely how U.S. medical school and hospital administrators label medical students. The basic idea behind this article was brilliant in its simplicity, proving (once again) that insightful research can be done without an army of research assistants or a 4.2-gigabyte hard drive. The authors wrote to all medical student campuses in the United States asking for photocopies of the name tags worn by medical students and received a response from 78%. Their findings are simple and striking—almost half of the respondents used some formulation other than “medical student” to describe the status of their students. (Full disclosure caveat: My university prints “Medical School” on the name tag, a choice not discussed in the article. I do not know if we responded to the survey.) Terms used around the country other than “medical student” include “student physician,”“student doctor,”“MD student,” and, my personal favorite, the letters “MD” in large type followed, in much smaller type, by “Prog.” (The authors do not state the meaning of this abbreviation—I assume it means “Program.”) Not content with simply documenting the variation in labels, the authors then went on to find out what these terms mean to the most important set of readers: patients. They selected outpatients expected to wait at least 30 minutes for their appointments. (I was appalled but not surprised to hear that it was seemingly easy to identify such patients.) The authors asked the patients to rank order the various descriptors from the least medically experienced to the most medically experienced. Perhaps not surprisingly, these patients assumed that people labeled as “medical students” have less experience than people labeled with other descriptors such as “student doctor,”“student physician,” and “MD student.” Methodologic quibblers might question the convenience sampling technique used by the authors, but I doubt even quibblers believe one would find a different response from a larger and more systematically obtained sample. Faced with the results of this study, we can no longer pretend that all the various terms used on name tags mean the same thing to patients. Identifying medical students with any term other than “medical student” is, as the authors suggest, obfuscation. By the standards of contemporary America, to obfuscate intentionally or to dissemble outright (a nice word for “lie,” which is probably more appropriate) in ways that imply (or state) that medical students are physicians is blatantly unethical. Program leaders doubtless claim to hold honesty as a (nearly) absolute rule. If they intend to deceive vulnerable patients who enter the walls of the medical center seeking care, one must wonder why. I suspect that the rationale is based on the belief that overstating medical students’ status will more likely get patients to accept care from medical students. The study shows clearly that such deception works, that the use of obfuscatory descriptions does, in fact, change how patients perceive the medical qualifications of their caregivers. Is such an approach necessary? It is not at all clear that most patients will refuse to be seen by medical students. Many patients understand the societal need to train physicians. Many others will be appropriately reassured when the student's well-supervised role in the system is explained. Patients admitted to teaching hospitals may understand that team members are at various stages of the educational process, carrying out their tasks under the supervision of those with more experience and status. They may perceive a team of caregivers, believe that it is headed by a person of superior ability, treat the internal structure and machinations of that team as irrelevant, and trust either those people or, more likely, the institution, to ensure that the team is competent and behaves in the patient's best interest. If so, there would be little reason to hide the fact that there are medical students on the team. Indeed, patients may be as happy (or more happy) to receive the calm, unhurried ministrations of a fourth-year medical student as they would be to be attended to by a harried, cross-covering intern. The question of how patients feel about being seen by medical students lies beyond the scope of the article in this issue, but it is a question worthy of empirical research. I also question the “hide the medical student” approach from a matter of public policy. It is better for people who pay for much of medical education to see and to understand precisely where and when it is going on. Assuming, for the sake of argument, that the medical education system will run more easily from the educator's perspective if patients do not fully understand that they are being seen by medical students, is obfuscation what we want? Should we accept and support a system that continues to perpetuate historical inequalities reminiscent of the older days of medical education, in which patients—poor, often people of color—accepted being “guinea pigs” to obtain free health care? Do we want to teach our students that their best interests are served by hiding their identity? I hope not. There are reasons for specific concern about the few medical student name tags that included the letters “MD” in the text. Many of our patients would find it difficult to read a name tag. Some are illiterate, others have impaired vision, and a considerable proportion of patients seen in teaching institutions fall into one (or both) of these two groups. It is likely that such patients will recognize the initials “MD,” yet be unable to read the accompanying text. Patients reading this name tag could reasonably assume that they were being seen by an MD, even when they were not. If we want patients to trust us, we must be honest with them. If we are not, patients are likely to distrust the educational system in all its aspects. How do faculty describe the people they teach? Do we say, “I’m off to give a lecture to student physicians”? How do these students describe themselves? Do they say, “I’m a student doctor”? Or “I’m an MD student”? I think not. No, we teach “medical students,” they refer to themselves as “medical students,” and that is how they ought to be identified to patients. All U.S. medical students ought to have name tags that read “Medical Student.” According to this study, slightly over half of U.S. campuses already do. The rest ought to do the right thing as well.

Genetics and Medicine in the United States, 1800-1922. By Alan R. Rushton. Johns Hopkins University Press: 1994. Pp. 209. $45, £37.

To the Editor. —Dr Ramsey and his colleagues 1 are to be congratulated on an elegant study of peer ratings of physicians' humanistic qualities and communications skills, and Dr Petersdorf 2 nicely outlines potential problems that could arise if we try systematically to implement a professional associates rating questionnaire. But before implementing such methods, we need to establish that they can answer the relevant questions. The questionnaires measured very well what physicians thought about other physicians, and compared those findings with what nurses thought about those physicians. But for communications and humanistic skills, the important issue is what patients think about their physicians. Certainly, it is far easier to rely on peer assessment than patient assessment. This may be appropriate for measuring some characteristics of how physicians interact with their patients. In terms of technical abilities, physicians may be able to judge their peers quite well. But their ability is

The history of clinical preventive medicine has been shaped by the interactions of biomedical knowledge and sociopolitical forces. In the late nineteenth century, medical thinking shifted from the belief that diseases were caused by general bodily imbalances to the belief that diseases were caused by specific agents, and that they might be amenable to specific preventive and therapeutic approaches. During the twentieth century, preventive medicine moved from advocating a public health, community-based approach toward preventing specific diseases in individual patients. The establishment of preventive medicine as a discipline has been fostered both by recent concerns that medical care emphasizes cure, rather than care, and by efforts to reduce health care costs.

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During the early twentieth century American physicians considered several different ways to identify medical specialists. The first autonomous specialty board was incorporated in 1924, and over the next few decades the board system became the accepted system for credentialing specialists. In 1936 the American Board of Internal Medicine (ABIM) became the twelfth specialty board. It was intended to recognize only a few outstanding internists, for the ABIM's founders believed that general practitioners should continue to deliver the vast majority of care. However, World War II greatly increased the importance of the ABIM and of the specialty boards system. The army medical services emphasized the importance of board certification, thus encouraging physicians to receive residency training and to sit for a specialty board. After the war, the expanding VA hospital system provided them a place to do so. Specialty training and board certification became the norm, not the exception. Also, the national exigencies of World War II forced Congress to devise a new system to distribute federal funds for biomedical research to universities. That system, continued as the National Institutes of Health, supported the subsequent growth of internal medicine in general, as well as its subspecialties. Both the ABIM and the other specialty boards were formed at a particular time and place in response to the specific interests of individuals and organizations, and their histories reflect both the ideals of their founders and the long-term structural effects of war.

In 1917, the Bureau of Labor Statistics surveyed 11,946 white households nationwide, recording demographic variables and yearly expenses on physicians, medicines, nurses, and hospitals. There was significant variation in these medical expenses among the nine census bureau regions. Using a multivariate analysis, we demonstrated that some of the variation could be explained by household variables, such as household income and size, some of the variability could be explained by the availability of physicians and hospital beds, and some could be explained by interactions between the different types of health care. However, after accounting for these possible explanatory variables, significant regional variation remained. We conclude that regional variation in health care expenditures is not new, and that studying how regional variation has changed during the twentieth century is likely to help explain why that variation exists today.

One of the most significant changes in US hospitals over the past decade has been the emergence of hospitalists as key providers of inpatient care. The number of hospitalists in both community and teaching hospitals is growing rapidly, and as the field burgeons, many are questioning where hospitalists should reside within the academic medical center (AMC). Should they be a distinct division or department, or should they be incorporated into existing divisions? We describe hospital medicine’s current trajectory and provide recommendations for hospital medicine’s place in the AMC. Local social and economic factors are most likely to determine whether hospital medicine programs will become independent divisions at most AMCs. We believe that in many large AMCs, separate divisions of hospital medicine are less likely to form soon, and in our opinion should not form until they are able to fulfill the tripartite mission traditionally carried out by independent specialist divisions. At community hospitals and less research-oriented AMCs, hospital medicine programs may soon be ready to become separate divisions.

SummaryWe describe a patient with sarcoid meningitis and hydrocephalus who improved rapidly after initiation of oral prednisone therapy, but who later decompensated acutely and required an emergency ventriculoperitoneal shunt. Hydrocephalus associated with neurosarcoidosis may progress despite steroid treatment, even when symptoms have improved. If hydrocephalus associated with neurosarcoidosis is treated with corticosteroids and without a shunt procedure we suggest that the corticosteroids should be continued at high doses for a prolonged period.

During the early twentieth century, orthodox American medicine incorporated the ideas and the ideology of the natural sciences, marking the beginning of a relationship that has continued to the present day. Medical schools started to devote ever-increasing hours to science, particularly physiology, and physicians began to perceive their task as the application of clinical science.1 In this chapter I explore the historical justification for physicians’ perception of physiology as a natural science valuable to medicine. In so doing I focus on the question: When, and how, did practicing American physicians come to see the physiology of the heart as clinically useful?