Hope helps: placebos and alternative medicine in rheumatology.

Most clinicians recognize that emphatic listening is not always enough for patients and that many are comforted by a more tangible sign of help. Pills provide a comforting ritual, and although words should be more important than pills, placebos, rightly given, remind physicians and nurses that we are treating human beings even as they reassure patients that doctors are more than vending machines of techniques. For the physician, there should be no split between mainstream and complementary alternatives, for the benefits of empathy and communication may sometimes prove as great as those from pills and portions.

Teaching gastroenterology in a private outpatient clinic.

In this essay I review how I have taught clinical gastroenterology to residents and fellows and medical students for the past 40 years in an academic private outpatient clinic. Private patients can serve as "teaching patients," even in an ambulatory setting, and even in a managed care environment that encourages productivity.

The Yale-Affiliated Gastroenterology Program: 1965-1995. A community-university model of collaboration.

The Yale-Affiliated Gastroenterology Program (YAGP) originated in 1965 from the informal arrangements of two gastroenterologists, one university based and the other in a community hospital. Conceived at a time when there was little central authority, either on a national or on a hospital/medical school level, its links were forged by the personal relationships of its directors. The process of growth remained informal and flexible enough for the directors to meet the special requirements of their own community and hospital. YAGP provided an important model for improving medical care and education in community hospitals since it addressed personnel needs, contributed to the education of physicians, and fostered clinical research in digestive diseases. YAGP evolved its own standards and its own accreditation mechanism, but faltered when the Accreditation Committee on Graduate Medical Education provided national rather than local criteria. Increased controls by hospitals and medical schools led to more formal ties and programs, and YAGP ceased to matter. Still, there may be lessons from what was in its time an innovation, on a local and state level rather than on a national level.

An internist's approach to acute abdominal pain.

To understand the surgical approach to acute abdominal pain, the internist must be familiar with common presentations of most abdominal emergencies; these emergencies include acute appendicitis, acute gall bladder disease (biliary colic, acute cholecystitis, and acute pancreatitis), ischemic bowel disease and ischemic colitis, abdominal aortic aneurysm, and intestinal obstruction. Nothing compares to experience; this article reviews the salient points that deserve consideration.

Calcium and acid rebound: a reappraisal.

We review acid rebound, the seemingly paradoxical increase in acid secretion resulting from administration of an antacid. Primarily a laboratory observation, the demonstration of the phenomenon was a major contributing factor to the swift, and possibly unjustified, fall from grace of calcium carbonate in the therapy of peptic ulcer disease despite years of apparently successful use. Calcium, as carbonate or other salts, causes an increase in gastric acid secretion owing, at least in part, to direct ionic stimulation. Another possible mode of action involves antral alkalinization with subsequent gastrin release. Other antacids, notably magnesium hydroxide and aluminum hydroxide, may therefore also cause rebound, but the data in this area are less convincing. Despite the demonstration that acid rebound occurs, no one has thoroughly investigated its clinical import. What limited data actually exist suggest no obvious clinically significant deleterious effect from use of calcium carbonate in peptic ulcer. Because of calcium carbonate's excellent acid-neutralizing capacity, its venerable past record in treating ulcer disease, and recent observations that low-dose antacids heal peptic ulcers, it is appropriate to reevaluate acid rebound, to focus on its clinical significance, if any.

What is empathy and can it be taught?

Empathy is the "almost magical" emotion that persons or objects arouse in us as projections of our feelings. Empathy requires passion, more so than does equanimity, so long cherished by physicians. Medical students lose some of their empathy as they learn science and detachment, and hospital residents lose the remainder in the weariness of overwork and in the isolation of the intensive care units that modern hospitals have become. Conversations about experiences, discussions of patients and their human stories, more leisure and unstructured contemplation of the humanities help physicians to cherish empathy and to retain their passion. Physicians need rhetoric as much as knowledge, and they need stories as much as journals if they are to be more empathetic than computers.