observed as they cope with preparing grant applications, writing scientific papers, and meeting deadlines.

I wish her all the best as she pursues her determinedly nonscientific course!

Constance Brinckerhoff, Ph.D.
New London, N.H.

Brinckerhoff is DMS's Nathan Smith Professor of Medicine and of Biochemistry and the associate dean for science education.

Repudiation and reconsideration
It was with great pleasure that I read the latest issue of Dartmouth Medicine—especially the engaging essay by Marjorie Dunlap, about her repudiation of her parents' careers in science.

Even I am reconsidering my intention to pursue a scientific career after reading that she "equated a career in science with stress, overwork, and paper shuf- fling." I am also curious as to who Marjorie was commenting on in line two!

Seriously, it was a great article —her parents must be proud.

Giles E. Duffield, Ph.D.
Hanover, N.H.

Duffield is a research associate in the genetics department at DMS.

Generally speaking
Dr. Jonathan Ross asks in your Spring issue, provocatively, if generalist medicine continues its decline, "Who will be connected to the patient through wellness and illness?"

One answer, meant in no way to be self-serving, is us—we chiropractors, acupuncturists, naturopaths, etc.—the burgeoning ranks of alternative medicine practitioners. Patients crowd our offices for the 30- to 60-minute consultation they cannot dream of getting with an M.D. A 1994 New England Journal of Medicine study established that 12% of Americans came to us and that out-of-pocket payments to us equaled noninsurance payments to all U.S. hospitals. The figures have undoubtedly risen since.

These two recent essays prompted reflection—and rebuttal—from readers.

I realize this is not the answer Dr. Ross hoped for. (Disclosure: He is my mother's physician, and she lauds him to the skies.) The idea of "alternative generalists" —for that is what we are—must scare conscientious M.D.'s who question competency and scopeof- practice, and anger avaricious ones. In part, this sea change has come about by default, for the reasons Dr. Ross listed. But there are other factors. Here is an incomplete list:

Personal contact: Our methods require us to listen to, be with, and often touch patients. No nurse, no accounting department intervenes. Like all family practitioners, we live and work in the communities we serve. I take care of the grandchildren of those who began with me 30 years ago. In that same period, my patients have seen dozens of M.D.'s who cannot possibly be attuned to their evolving personal and family histories. Even low-income patients—a third of my practice—prefer our sliding scale to medical roulette.

Insurance influence: Few of us work under the yoke of managed care. We don't need to play the volume game to offset fee reductions. This means more time per patient. An M.D. friend told me the oncologist he refers to is obliged to see 26 advanced cases in four hours. How sad!

Cost: Our professions did not promise, nor do most of us seek, six- or seven-figure incomes. We are willing to work for less. Indifference: Patients are if not infuriated, at least frustrated by such

lines as "We'll only call you if the test is positive" or "Don't call unless it gets worse."

Arrogance: No one is immune to this ill, but U.S. medicine has taken it to breath-taking heights. Susan Sontag's Illness as Metaphor quotes a doctor who said: "When I can't find what the patient's problem is, I assume he doesn't have one." Many alternative precepts run to the contrary: "What the patient feels and thinks is as important as the diagnosis," for example.

A personal story summarizes what drives people crazy about modern medicine. I once had to beg a Spanish-speaking family to return their grandfather to County Hospital, where he had been diagnosed with leukemia. They refused: "We only want you." The grandfather was pale and trembling—from illness or fear or both. I said I'd request his lab reports, hoping the hard facts would force them to obtain care. When I called County, I was told, "There was a mistake on that case. We mixed up his lab work with someone else's. He doesn't have leukemia."

Knowing many M.D.'s, I have no illusions that the rest of the profession is any more sanguine than Dr. Ross about the medical nightmare unfolding in this country. It may soon blow up in the public's and the government's face. Perhaps that will induce reform. In the meantime, we alternative practitioners are not going away. Medicine is free to continue treating us with its usual conceit: ignore us; dismiss our results as anecdotal; badmouth us in the press; and condescend to patients about us.

Or we can start to really talk with each other. I cast my vote for dialogue. But if we ever actually meet face to face to share knowledge and experience, may it go better than an address I was invited to give at the University of Michigan Medical School 30 years ago, when the professor who preceded me at the mike announced that he'd mark down the grade of anyone who dared to stay and listen to me.

Frederick R. Campion, D.C.
South Pasadena, Calif.