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YESTERDAY afternoon, just after I had finished with my last patient, a man burst into my office. Gasping for breath, he pleaded, "This is an emergency! Please see me immediately!" Before I could reply, he collapsed into my chair and began his tale of woe. "My name is William Wallaby. I'm a 45-year-old internist, and I'm sick. I don't sleep well. I can't concentrate anymore. Worst of all, I'm really starting to doubt my skills as a doctor." Dr Wallaby's only other complaints were headaches and low back pain. However, he admitted to overeating, cigarette smoking, and ocassionally excessive drinking. He exercised rarely, spent little time with his family, and almost never saw his friends. Suspecting that Dr Wallaby was depressed because of his work, I asked him to tell me about his life as a doctor. "After I graduated from medical school," he replied, "I did my time in

Efforts to teach and evaluate humanistic qualities in physicians in residency training are marred by ambiguous goals. The humane physician can be characterized by four distinct qualities: technical competence, humanistic attitude, knowledge of humanistic concepts, and humanistic behavior. Education in the humanities can foster humanistic attitudes, but it cannot promise to lead to changes in behavior. Likewise, although formal training in communication teaches the skills necessary for humanistic behavior, without an understanding of humanistic concepts these skills may not serve medical or moral ends. Evaluation of the humane physician must also include modalities that test attitude, knowledge, and behavior. Testing one characteristic does not ensure competence in other areas; knowledge of the requirements for informed consent, for example, does not guarantee one's ability to discuss this concept effectively with patients. In this article, we suggest ways to combine the humanities and communication skills in the clinical setting and we emphasize both the training and the evaluation of humane physicians.

TODAY physicians accept machines as a desirable part of medical practice and use them to care for patients throughout the United States. Such was not always the case. Medical technology has been widely used only since the early 20th century. 1,2 Many turn-of-the-century machines found their way into the growing number of hospitals. 3-5 Perhaps the machines that had the greatest impact were those that revealed parts of the human body previously hidden from view, such as the x-ray machine, or made visible otherwise imperceptible actions of the body, such as the electrocardiograph. This article examines how the x-ray machine became a part of routine patient care at the Pennsylvania Hospital, Philadelphia, between 1897 and 1927, and compares that process with the introduction of the electrocardiograph. It differs from most previous historical analysis of medical technology by focusing on how these instruments were actually used, not on how they were

This memorial volume, tracing the development of current concepts of tuberculosis, contains 18 short articles commemorating the centenary of Robert Koch's discovery of the tubercle bacillus. Topics include epidemiology, microbiology, surgical and medical treatment, along with more broad and speculative essays. The authors are physicians, some of whom have been instrumental in the development of the fields they discuss. This personal involvement leads to intimate knowledge of the field but from a single perspective and with relatively little historical analysis. Superb photographs and roentgenograms, illustrating surgical treatment in the early 20th century, enhance the visual appeal. This book will make interesting reading for physicians or medical students interested in a brief summary of the development of current tenets in tuberculosis. It would also guide anyone interested in pursuing a more detailed study of the history of the past century of medical approaches to tuberculosis, and it deserves more attention from

The meaning of American cardiology has been transformed over the past century. During that time, cardiology has been defined by several organizations: by the American Board of Internal Medicine through subspecialty certifications; by the two major American cardiology societies, the American Heart Association and the American College of Cardiology; and by the four major cardiology journals. These organizations have sometimes cooperated, sometimes competed. Cardiology has also had to negotiate relationships with several external interest groups, including pediatrics, surgery, hospitals, and internal medicine. Throughout the 20th century, the word cardiology has had no meaning save its definition within a larger web of organizations, relationships, and ideas. The meaning, like the meaning of all specialties and subspecialties, is historically mediated and constantly changing.

Excerpt To the editor: In analyzing the relative impact of medical journals, Dr. Garfield gave greater weight to articles that had more than 1 author than he did to those with a single author (1). ...

WELCOME to the University Hospital outpatient department. We'd like to take a few minutes to orient you to the clinic, and to make your rotation here more rewarding by pointing out some of the differences between inpatient and outpatient medicine. During the next few years, outpatient medicine will become increasingly important. Because hospitals are so expensive, they are being used less often for extensive inpatient evaluations. As a result, medical care has tended to move here, to the outpatient clinic, where care will continue to be less expensive for most illnesses in which there is an option, even if—as many expect—prospective payment or capitation is widely adopted for use in the outpatient clinic. But both medicine and patients have much to gain by this shift. Outpatient medicine has the potential to be more effective in improving people's health than inpatient medicine. It is where most patients see doctors and where

• To identify how nurses and physicians perceive ethical problems in clinical medicine, we conducted structured interviews with 26 nurses and 24 physicians who work in acute-care units. Both groups thought that they frequently encounter ethical problems, although there was significant variation within each group about how often members of each group perceived such problems. Members of the health-care team often disagreed about ethical decisions. Nurses often described conflicts with physicians, but physicians rarely recognized disagreements with nurses. Clinical ethicists need to be aware of this heterogeneous perception in order to communicate effectively about ethical problems. ( Arch Intern Med 1986;146:577-578)

In Reply.— We thank Dr Ellis for his supportive comments, although we should point out that internists have long recognized the imnortance of the ambulatory or, as Dr Ellis puts it, the "vertical" patient. 1 Perhaps the newly institutionalized discipline of general internal medicine will help medical educators clarify how best to teach physicians to practice all types of medicine in the outpatient setting.