Cold comfort for ICU patients
I thoroughly enjoyed the article in your Spring issue on the origins of intensive-care units.

I was a neurosurgery resident at Hitchcock in the 1950s and have many memories of Dr. Mosenthal's revolutionary concept of placing all acutely ill hospital patients in one location. Hypothermia was thought back then to be beneficial in treating brain problems, such as from trauma or a ruptured aneurysm. So during the winters of 1956 to 1958, we placed such patients in a separate room on the ICU and left the window open; the nurses became very adept at keeping patients' body temperatures close to 90 degrees by raising, lowering, or closing the window. I doubt this accomplished much, but it made for chilly rounds.

I also enjoyed John Sibley's sketches, which I had not seen before. John and I were residents at the same time, and he was also at Dartmouth in 1982, the year I returned as a visiting professor of neurosurgery. We both found no comparison to the ICU we had known 25 years earlier.

David M. Barry, M.D.
Housestaff '56-58
Stuart, Fla.

Where's Wendell?
I wonder if you have any information about the individuals pictured in the painting on the cover and on page 40 of the Spring Dartmouth Medicine. The article mentioned Dr. Mosenthal but not the other people in the picture.

I currently take care of the gentleman to the left of the bed. His name is Wendell Cherrier and he is from Windsor, Vt. He is a retired nurse who worked at Dick's House [the Dartmouth College infirmary] for 35 years, and before that for 10 years at Mary Hitchcock Hospital.

John D. MacDonald
Windsor, Vt.

We have, in fact, learned the names of everyone except the patient in the photo from which the cover painting (reproduced above) was made—thanks to a newspaper clipping featuring the photo. They are, from the left, Mary Thomas, an aide; Wendell Cherrier, then an orderly; Dr. William Mosenthal, then a surgeon; Janet Wenzell, R.N.; and Dr. George Cole, an intern. We still don't know the exact date the photo was taken, however. It was sometime between 1955, when the unit was created, and 1957, when the photo was used in an exhibit.

Medicine cum heart (and harmonica)
The article by John Radebaugh, "House Calls with John" [Spring 2005], is awesome, courageous, inspiring, visionary, and told with wonderful humor and wit! My medical education and training coincided with several points in his career; the article brought back memories of Rochester, Brawley, the Imperial Valley in the summer of 1970, and a month I spent with him in Fresno in 1975. I loved the story about the woman with the pseudopregnancy. But I never knew he'd started his career in Maine, and I'd forgotten about the harmonica he always carried.

Throughout the piece, he put into words exactly the ideals that inspired me and others to enter the profession of medicine—the compassion, the curiosity, the advocacy for patients, the outreach and partnering with them on their "home" turf, and, ultimately, the quest for peace and social justice that is at the heart of the medical profession. Or at least should be.

Richard A. Aronson,
M.D., M.P.H.
Augusta, Maine

Aronson is medical director of the Maine Bureau of Health's Division of Maternal and Child Health.

At patients' beck and call
What a delight to read the entire Spring issue of Dartmouth Medicine—especially "House Calls with John." Just as there are books celebrating The Joy of Cooking and The Joy of Gardening, Dr. Radebaugh should be encouraged to write The Joy of House Calls.

I was fledged in 1949 as an M.D. from Harvard Medical School—poor training for someone who wanted to be a family physician and make house calls. My mentor wanted me to do a fellowship and be a gastroenterologist, but I resisted and never regretted being the only LMD (local M.D.—a disparaging term in the '40s) allowed to practice for 37 happy years at the lofty Massachusetts General Hospital. I even sewed up lacerations on occasion (unheard of for internists) and rode in ambulances to the emergency ward.

One house call in particular delighted me. A friend of my inlaws had what sounded on the phone like nothing more than a heavy cold. Please would I drop by on my way home to see "Uncle Bobby"? I was greeted at the door of quite a fine home by Bobby's wife, who asked if I could first help her. She held a rattrap in her hand and asked me if I would bait it for her—which I dutifully did, seeing myself as "the compleat physician."

Uncle Bobby was just fine, though I may have prescribed some medication to persuade him he really was sick.

The next day a second call came. Uncle Bobby was no better; would I stop by again? True to my calling, I did. His wife again said she had an unusual request: Please would I remove a dead rat from the trap? I did! Uncle Bobby was, again, just fine and pleased to see me. The socially registered of Chestnut Hill continued to think well of "the compleat physician."

Like Dr. Radebaugh, I never wore a white coat either on house calls or within the great MGH, though my peers wore them—all the way down to their knees! I always felt it created a psychological gulf between doctor and patient, although my daughter, a resident at your magnificent hospital, disagrees. As a doctor, one should, as Rudyard Kipling put it, be able to "walk with kings—nor lose the common touch." I am now 85 years old and loved every minute of my career, especially the house calls, and I love every issue of your excellent journal.

John W. Keller, M.D.
Nahant, Mass.

Laudable approach
I read the article "House Calls with John" with keen interest, for I remember when our family doctor made house calls. My mother did not drive and my father used our car to commute to his work as a police officer. Public transportation in our farming community was poor. Our Dr. Lundberg made his hospital rounds first thing in the morning, then did house calls, and later held office hours in the afternoon—so I am somewhat familiar with the subject.

"House Calls with John" is well written and contains numerous true-life examples of real house-call experiences in a variety of venues across the country. Dr. Radebaugh has had several careers of medical practice and recounts them in a pleasant, easily read style to make the case for house calls in any general medical practice.

Dr. Radebaugh's recounting of the importance of house calls should resonate in the minds of many of your professional readers, including medical students. Not every medical doctor will subscribe to Dr. John's somewhat philanthropic approach to his various practices over the years, but it is laudable and should remind all physicians of the value of house calls. I mentioned the article to a family physician I know, and he scoffed at the idea, claiming that making house calls is a highly inefficient approach to medical practice. He claimed that anyone who is so sick as to want a house call belongs in a hospital. Of course I didn't argue but I'm aware that he was looking at it strictly from the point of view of the physician's time and not from the viewpoint of the patient in need of qualified attention. Besides, he did not address the questions of where is the hospital, how does the patient get there, and at what cost to the medical care system.

Our Dr. Lundberg mentioned above, after a normal retirement, lived to a good old age in quite comfortable circumstances, so I don't think we can assume that making house calls equates with physician poverty.

Herbert K. Seymour
Falmouth, Maine

Grace note noted
I enjoyed the article "House Calls with John" by Dr. John Radebaugh. I played in a recorder group with him before he retired to Maine. He clearly made good use of his musical talents during his career. I can't evaluate his approach to medicine, not having a medical background myself, but if I were a patient I'd be thrilled to find a doctor so attentive to my needs.

Burton Bickford, DC '44
White River Junction, Vt.

Peripatetic passion
I am a faithful reader of Dartmouth Medicine and was delighted to find the article by John Radebaugh in your Spring issue. He (with his wife, Dottie) was a neighbor at Dartmouth's Sachem Village in the early 1950s, when we were both interns at Hitchcock. I have wondered where his career took him. Now I know. He's certainly had a peripatetic existence and a career driven by honesty and compassion, which comes as no surprise to anyone who has known him.

Though my almost-stay-put career looks dull by comparison, I had a great time, too, and hope I also made a difference. Like John, I learned early on the value of house calls. The norm when I began practice was that after hospital rounds, the morning was for house calls. Morning office hours were many years in the future. I bought a geodetic survey map to find the back roads. In those days, there was no charge for mileage and you could carry pretty much what you needed in your black bag.

I was glad to learn that John came full circle and ended his career back in Hanover. I might have wound up there, too. I stayed on at Hitchcock after internship for another year of general practice (GP) residency. There was no such official program, but John Milne and William Wilson had told me I could devise my own program. Sam Doyle, a 1950 graduate of DMS, was initially going to join me, but he was seduced by John Murtagh into ear-nose-throat (ENT) medicine. John tried to recruit me, too, so that was the first instance when I might have stayed in Hanover. But I was determined to be a GP. I divided my year in quarters and assigned myself to relevant faculty in ENT, orthopaedics, medicine, and anesthesia. Obstetrics was an add-on; I went to Providence Lying-In Hospital for that.

I must have seemed like a fifth wheel to the Hitchcock clinicians, but they were all very gracious and I really had good training. I was asked to stay on by both the neurosurgeons and the orthopaedists, but I persisted with my plan to be a GP. After I'd gotten my practice started, Rodger Weismann, a vascular surgeon, asked if I'd be interested in starting a family practice department. It was a tempting offer, but I was too happy where I was and again declined.

I enjoyed my career immensely—first as a GP in Exeter, N.H.; then in emergency medicine in Wilmington, N.C.; and for the last few years at an urgent care center. I finally quit at age 69. In retrospect, the way I structured my residency year was prophetic. Or maybe my career developed the way it did because of my training. Who knows? In any case, I loved it all.

Jerome T. Nolan, M.D.
Housestaff '52-54
Wilmington, N.C.

Important articulation
I recently read a wonderful article in Dartmouth Medicine concerning the lifework of Dr. John Radebaugh.

It is encouraging to read how one person had such an impact in many underserved areas of our country and beyond. Dr. Radebaugh is obviously committed to patient care—care of the entire patient, including physical, social, and emotional needs and more. It was truly refreshing to read this article.

Inasmuch as Dr. Radebaugh clearly has an important story to tell, I wonder if there is a way that his life story can be told in detail. Does Dartmouth have a way of connecting him with an agent or publisher?

A few years ago, DMS honored Dr. Radebaugh by naming its student community service award in his honor, so clearly the institution sees his work as significant. Moreover, I feel certain that Dartmouth recognizes the impact made on the world at large by Dr. Radebaugh's willingness to testify about the needs of migrant workers and others. If someone at Dartmouth can take the time to pursue his story in detail, it would be a great service.

Medicine was, in the past, about caring for people regardless of their means. In the fastpaced, technological society of the last 25 or so years, it is important to know that there are still individuals who have committed their lives to serving those who might not otherwise receive care or be heard. Dr. Radebaugh's story causes one to reflect on that fact and on the direction of medicine today. It is a story that needs to be heard.

Sarah D. Krug
Royal Oak, Mich.

There is no office at Dartmouth with an official mission such as Krug describes, but Dartmouth Medicine has been pleased to offer Radebaugh some advice on publishers—and pleased (though not surprised) by the response to his article.

Distilled spirits
Thank you for distilling and publishing "House Calls with John" in your Spring issue. Its author, John Radebaugh, is my brother. He has been trying for some time to find a publisher for a booklength version of his life story, and the article's appearance has raised his spirits. At the same time, it presented a compelling overview of my brother's struggles, dedication, and accomplishments. What an inspiration to students and other healthcare professionals as a role model of commitment to the underserved. (Following his example, I was a public-health nurse.)

Thank you again for sharing his story—and for mentioning the important role played by his wife, Dottie.

June Radebaugh Hall
Lexington, Mass.

Rueful recognition
I was delighted, on many levels, to read Marjorie Dunlap's essay —"Whither genetics?"—in the Spring 2005 issue.

First, I enjoyed it because my husband was Marjorie's guidance counselor at Thetford Academy. I immediately showed the piece to him so he could share a measure of pride in what she's done since high school.

Second, I appreciated her graceful writing style and gentle humor—the piece was exceedingly insightful and well-written for someone still just a first-year college student.

And third, as one of her parents' DMS faculty colleagues, I can—ruefully—identify with the stresses she has 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.

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.

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 page 32).

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 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 of these adverse events seems to be only about 1.9%, however, and only with long-term use. Nevertheless, there has been a huge decrease in the use of COX-2 inhibitors and a return to more basic treatments.

It was also known as early as 2002 that there was a family of bioactive products, resolvins, produced from omega-3 fatty acids by aspirin. These compounds, which are involved in anti-inflammation signaling, were thus of interest in the treatment of inflammation. New evidence about aspirin's role in triggering potent anti-inflammatory actions was reported in 2004; this article also speculated that COX-2 inhibitors could block the synthesis of resolvin. Once again, the law of unintended consequences is at work, for anti-COX-2 drugs appear to inhibit this natural anti-inflammatory mechanism.

Further work is being done on resolvin, and it's likely to lead to well-controlled clinical trials and perhaps commercial production of synthetic human resolvin. However, until that time, patients suffering from inflammation can take advantage of the knowledge that if your diet is high in omega-3 fatty acids, you can add aspirin and produce resolvin to treat inflammation. How much aspirin must be taken to get the desired anti-inflammatory response? No one knows, yet. However, I myself take two tablespoons of flax oil morning, noon, and night at the time of major meals, plus one regular (325 mg.) aspirin tablet at these same times. This routine controls my joint discomfort due to arthritis just as effectively as Vioxx or Celebrex. This is only an uncontrolled, one-person result, but it may be worth others' consideration. I would also caution that aspirin at these dosages can have adverse gastrointestinal effects, so preventive measures against that problem must be taken.

This small saga shows that the mechanisms of this machine we live in—the human body—are very complex, and the introduction of any chemical to treat a medical condition can have unintended consequences.

Michael J. McKeown, M.D.
DC '58, DMS '59
Hillsboro, Ore.

Author! Author!
I very much enjoyed John Morton's excellent article about his open-heart surgery ["Heart Of An Olympian," Fall 2003].

In 1970, I had the good fortune to serve in Vietnam with then-Captain Morton, who was our team leader. I will always be grateful for the opportunity to meet, serve with, and learn from this gifted, dynamic, and inspirational man. He led by example, and one of the most valuable examples he set for me was the value of sustaining a positive attitude and sense of humor, even under the austere and sometimes scary conditions under which we operated in Vietnam. Over the subsequent years, whenever I have faced the various challenging situations that life brings, I have instinctively thought back to Captain Morton and his incredible spirit, confidence, and optimism to bolster my own courage and will to succeed.

John Morton is a great human being. I was not surprised to read of his spectacular achievements since his army service.

CSM (Ret.) Gary Boone
Fayetteville, N.C.

Touched by Tanzer story
I read with melancholy the article in your Summer 2003 issue about Dr. Radford Tanzer, a member of the DMS faculty who was for the last year of his life the holder of the Boston Post cane. [The article explains a tradition dating back to 1909, when Edwin Grozier, the publisher of the Boston Post, distributed goldtopped ebony canes to 700 towns in New England, to be presented to each town's oldest citizen.]

I was especially touched by the story because I am Edwin Grozier's great-grandson.

Theodore G. Grozier
Hanover, N.H.

Grozier is, as it happens, a student at Dartmouth's Tuck School of Business and Thayer School of Engineering. And there's a further "rest of the story": Tanzer's widow, Sheila Harvey Tanzer, wrote a feature for the Winter 2004 issue of Dartmouth Medicine, eloquently detailing her husband's choices at the end of his life.