Campion is a doctor of chiropractic. His mother, Nardi Reeder Campion, is a former member of the Dartmouth Medicine Editorial Board—and the author of an essay in this issue (see here).

Making a difference
The eloquent appeal in your Spring issue by Dr. Jonathan Ross, for the retention of the generalist, may fall on deaf ears. There is an old expression that "it's different at Dartmouth." I wish this were so. Most longtime DHMC patients have noticed the problems that result from the lack of continuity in patient care. This is most obvious when one physician is your primarycare physician, another the "hospitalist" who sees you as an inpatient, and another a specialist or surgeon. One can wait hours or even days for them to communicate with each other. They never see the whole picture.

Dartmouth-Hitchcock can still make a difference, both in practice and training, but it takes courage on the part of hospital and clinic administrators to do so. Patients need to make themselves heard, but unfortunately even at the friendly Dartmouth- Hitchcock Clinic they do not know how.

Jon H. Appleton
White River Junction, Vt.

Appleton is the Arthur R. Virgin Professor of Music at Dartmouth. We offered Jonathan Ross an opportunity to respond to the points made by both these letter-writers, and he replied as follows: "I appreciate both written responses to my essay in Dartmouth Medicine; they complement many oral comments I've heard from students, housestaff, faculty, and patients. There is no doubt that a chord was struck—everyone has felt, directly or indirectly, the loss of continuity and accessibility in health care.

"Whether alternative medicine practitioners can adequately fill that gap is doubtful, despite their provision of many desirable practices. And as frustrating as it is in our own backyard, I continue to be proud of my DHMC colleagues, who strive to practice a quality of medicine that most other regions in the country would be grateful to approach. My sense is that Dartmouth- Hitchcock once again has a chance to lead in the renaissance of the best in medical care, by answering the plaintive cry of so many: 'Where is my doctor?' I continue to be hopeful that the expectations of our patients, which have at times strongly influenced the course of medical care, will, in this instance, force the profession to rescue care from the increasingly fragmented model so dominant today."

A DMS alumnus shares here some ruminations sparked by this article.

A rich resource
I enjoy every issue of your fine magazine and was especially delighted to see the article in your Spring issue on Dr. Rich Rothstein's latest work [on perfecting robotic-assisted incisionless surgery]. He was my primary doctor when I lived in Hanover, so I know how fortunate Dartmouth is to have him on the faculty and performing such great work.

Keep up the excellent work.

John L. Gillespie, DC '54
Boothbay Harbor, Maine

Name-dropping
I enjoy receiving Dartmouth Medicine and always look to see if there is anyone I know mentioned in it. In the Winter 2004 issue, I noticed an interview with Joan Crane Barthold, M.D. I wonder if she grew up in Plymouth, N.H., and if her parents were doctors. If I'm correct, she is from a wonderful family and is following in her parents' footsteps in serving others—and the surgical suite at Speare Memorial Hospital in Plymouth is named in her father's memory.

It's nice to come across acquaintances as well as read all the articles. In the same issue was a story about Ethan Bennett Gagne, who died only a few days after his birth. It reminded me of our son, Raymond, who was diagnosed in 1981 with a brain tumor. Dr. Peters at Plymouth made the diagnosis and sent Raymond to Dartmouth for testing, where we had Dr. Saunders and his team, who all were very nice. I was a patient at Dartmouth myself as a child; I had nephritis and was sent to the old hospital for tests. I remember looking out at a lovely sunrise.

DHMC is a wonderful place, expanding

and reaching out to the community. I'm so very glad there's a place like it nearby.

Fay Gray
Rumney, N.H.

A consequential matter
I was interested in your Winter 2004 article about the DMS faculty member who was involved in the withdrawal of the anti-in- flammatory drug Vioxx. I believe the Vioxx story is a perfect example of the law of unintended consequences.

Treating inflammation has been one of the major tasks of medicine since ancient times. The problem has persisted, so makers of medications continue to come up with all manner of new drugs. Studies in the 1880s showed that aspirin was benefi- cial against inflammation, and later research showed benefits from antipyretics (anti-fever drugs), analgesics (anti-discomfort drugs), and anti-inflammatory drugs. These all became known as "aspirin-like," and the term non-steroidal anti-inflammatory drug (NSAID) was first used (for phenylbutazone) in 1949. The mechanisms of these drugs were all found to involve activity of the enzyme cyclooxygenase (COX), which mediates the synthesis of endogenous prostaglandins. Yet we still don't completely understand how NSAIDs curb inflammation.

In 1992, a new enzyme, cyclooxygenase- 2 (COX-2), was cloned from human and animal sources. COX-2 levels rise in the presence of inflammation. Prostaglandins are also involved in inflammation and form a group of fatty-acid derivatives called prostanoids. Once the existence of two different cyclooxygenases was known, it was theorized that NSAIDs' anti-inflammatory effects were due to inhibition of COX-2, and the unwanted side effects to inhibition of COX-1. This concept then led to the development of anti-COX-2 drugs —Vioxx, Celebrex, and others.

The use of these drugs skyrocketed. But as more and more people used them, and more years of patient-use experience accumulated, researchers began to pay attention to some precautionary notes in a 2001-02 article on COX-2 inhibitors in the Therapeutics Letter. The widespread use of these drugs demonstrated the law of unintended consequences (first discussed by Robert Merton in 1936).

When one bumps against a wall of evidence not perceived in advance, it is always sobering. In today's responsibility-oriented climate, adverse outcomes can be devastating. Soon there were reports of an elevated risk of cardiac events in patients taking COX-2 inhibitors. The risk