Hurt makes us human

Thank you for publishing Mary Daubenspeck's journal ["One More Byline," Fall 2004]. As one of her caregivers during the final months of her life, I found the piece very painful to read, for it brought back difficult memories, but I loved her beautiful writing and loved the opportunity to remember her.

Her brother Andy was absolutely right in his remark at the end of the article that Mary never accepted her death—but my hope for her is that she made peace with it in the end. She just loved life too much to let go; as much as it hurt for those who cared about her to see her struggle at the end, I respected her for her beliefs.

That respect, and her memory, still inspire me as I care for my patients. Palliative care has shaped me, and continues to do so, both personally and professionally. There are a handful of special patients in the careers of all caregivers whom we keep close long after they die because they change us forever—and Mary was one of those for me. Part of the challenge of getting through these difficult deaths is finding some meaning in the midst of all of the hurt.

Again, thank you very much for sharing this piece—for the reminder that it is the ability to feel hurt that makes us human.

Karen Skalla, M.S.N., A.R.N.P.
Brownsville, Vt.

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Required reading

I want to thank you for sharing Mary Daubenspeck's diary with your readers. It should be required reading for all oncologists and physicians dealing with lifelimiting illnesses. Most important would be her January 22, 2001, entry describing her feeling of liberation after she decided to stop aggressive treatment of her cancer: "My new life is heaven on earth."

After 30 years in medical oncology, I have spent the last five years doing hospice and palliative medicine. Over and over in my practice, I hear patients say the same thing and then go on to die before they can receive the full benefit of hospice care.

Although in many instances aggressive high-tech therapy to the very end is patients' choice, I feel physicians need to be more realistic about the possible benefits of these treatments, so perhaps more quality time, without the toxicities of therapy, is available to patients. The comment of Daubenspeck's physician on January 19—"if I were a member of his family he'd refuse to give me more chemotherapy" —was well put but perhaps could have been said months earlier.

Hopefully the presence of Dr. Ira Byock at Dartmouth will further promote the cause of palliative medicine, both locally and nationally.

Allen D. Ward, M.D.
Dartmouth College '61
Hyannis, Mass.

A feature in this issue, beginning on page 43, highlights Byock's work.

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Helpful and moving

As an interfaith chaplain at Central Vermont Medical Center, I would appreciate being added to your mailing list. On several occasions, our hospital president, Daria Mason, has shared her copy of Dartmouth Medicine with me. I have found useful, helpful, and moving information in each issue I've had the opportunity to read.

The Fall issue contained several helpful items, as well as two very emotionally moving pieces: "One More Byline" by Mary Daubenspeck and "Broken Bodies, Broken Souls" by Emily Transue. I intend to share both articles with the members of our palliative-care committee, the staff in our psychiatry unit, and our physicians at a CME luncheon I am responsible for.

Thank you very much for the opportunity to receive my own copy of the magazine.

Linda F. Piotrowski
Barre, Vt.

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Relevant experience

I happened to see your Fall issue at our local library, and I found Mary Daubenspeck's diary of her experience with cancer very relevant. I am a psychiatric nurse practitioner at the VA Medical Center in Manchester and have worked in hospice and palliative care. I have read Dartmouth Medicine in various waiting rooms for years, but this article prompts me to ask to be put on your mailing list. Thank you.

Sherry Kahn
Hudson, N.H.

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Game plan

Mary Daubenspeck, the author of one of the features in your Fall issue, was my sister-in-law (her oldest brother, Joe, is my husband). I found reading her words poignant, gut-wrenching, uplifting, sad, memorable . . .

Mary has been in my life since the day I was born. We played together as children; back then, who ever imagined that we would "cancer" together as adults? We spent the bulk of Mary's last years playing a game that we called "Gag—you're it!" We wondered which of us would emerge the winner but all the time prayed for a tie. (Humor—it's all about humor!)

Mary had joint surgery at an earlier age than I did, but our cancers crossed paths—pulling us together spiritually, albeit banishing our childhood innocence. During Mary's remissions, she supported me through a dozen osteoarthritic breakdowns, including a very nasty multiple corpectomy that left my "hipbone connected to my neckbone." (Humor—it's all about humor!)

After six long months, I finally shed my collar. Life was good! Little did I know that just two short weeks later, my annual mammogram would find invasive breast cancer. The first person I called after Joe was Mary. I mean, really—it's all about the game. I was "it." What she said to me that night was: "If I could, I would take it from you and add it to my collection!" (Humor—it's all about humor!)

Her support kicked into high gear when I had a nine-hour bilateral mastectomy and reconstruction—followed by chemo and shopping for new bras. Mary being Mary, she fully understood my sick enthusiasm for explaining to everyone how my "abs" had become my "pecs." (Humor—it's all about humor!)

But (there's always a but . . .) Mary got sick again. Mary was now "it." When I stood in her hospital room during her last days, she held my hands and cried, "Cindie, this could be the end of the game." I knew then that I was going to win. But I never knew that winning could hurt so much.

Now, every time I hear Mary's wind chimes outside my window, every time I climb into her beloved Z3 next to Joe and go for a ride, every time I talk to one more scared soul who thinks her life is over because she has breast cancer, I remember the game. I won for a reason—so I can teach others how to move around the board successfully, feeling good about who they are and determined about where they're going. Cancer is not a death sentence. We might not all survive it, but I do believe that Mary's dying and my living can only offer promise. Win or lose, we're all in this game together.

Cynthia E. Smith-Daubenspeck
Marysville, Pa.

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Got it right

It was a pleasure to see Timothy Takaro in print again [Takaro, a 1942 DMS graduate, was the author of a feature in the Fall 2004 issue titled "The Man in the Middle," about Dartmouth College alumnus Basil O'Connor's role in the creation of the polio vaccine]. I knew O'Connor slightly, and Tim got it right.

Colin B. Holman, M.D.
Dartmouth College '39
Mercer Island, Wash.

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Polio connections

Your Fall issue had an interesting profile by Timothy Takaro of Basil O'Connor. In portraying O'Connor's adroitness in achieving headlines and public support for the anti-polio effort, Takaro omitted one typical O'Connor touch—the fact that the public announcement of the successful results of the Francis polio vaccine field trial was scheduled deliberately on April 10, 1955, the 10th anniversary of the death of Franklin D. Roosevelt.

It is also worth noting that the October 13, 2004, issue of the Journal of the American Medical Association features (on pages 1749-51) an editorial titled "Poliomyelitis in the United States —The Final Chapter?" by your own John Modlin, Dartmouth's chair of pediatrics (and one of my first medical students here at Duke).

Samuel L. Katz, M.D.
DC '48, DMS '50
Chapel Hill, N.C.

Katz is himself a noted figure in the history of infectious disease. An emeritus professor of pediatrics at Duke, he began his career in the lab of Nobel Laureate John Enders, whose work had been instrumental in developing the polio vaccine. And Katz's many honors include the 2003 Sabin Gold Medal, presented by the Albert B. Sabin Vaccine Institute in memory of the developer of the oral polio vaccine.

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And more connections

I was in the final stages of editing a limited-edition book on the 420 recipients of the Dartmouth College Alumni Award, for presentation in December to all living recipients of the award, when I came across the Fall 2004 issue of Dartmouth Medicine. I was pleased to read there the great story on Basil O'Connor, DC '12, the founding president of the March of Dimes. Not only was he a recipient of the College's Alumni Award, but, as it happens, he's one with whom I had a personal connection, as I was involved in raising funds for the March of Dimes many decades ago. In fact, I highlighted him in my book, which features alumni in classes from 1894 to 1977.

Although my book contains several other images of Basil, I was particularly taken with two of the photos in your article—the one of him with the 1954 March of Dimes "poster girl" and the one of him with General George Patton. You would not necessarily know this, but one of Patton's senior aides was another Alumni Award recipient and possibly Dartmouth's most-decorated veteran of World Wars I and II—Harry Semmes '13. I suspect there was a tie between Patton, O'Connor, and Semmes at the time the Patton-O'Connor photo was taken—but that is for another story . . .

Anyway, many thanks for this fascinating story about a truly great American!

Stephen L. Waterhouse
DC '65, Tuck '67
Hanover, N.H.

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Colored chalk and rubber aprons

I recently came across the fine essay by third-year DMS student Kirsten Andrews ["Anatomy of a dissection," Summer 2002]. I naturally compared her experience with that which my classmates and I had in the summer of 1942. That was when, with the College on a wartime footing, we began our studies at DMS and were plunged into the rigors of human anatomy.

The locale was what we called the "Old Medical Building," constructed in 1811 as the first purely medical school building in America. The anatomy lab occupied a wing that was actually below ground level and had a glass roof like that of a greenhouse. Our anatomy lectures, by Dr. Frederic Lord, were excellent. He was a renowned master of his subject and an artist with colored chalk. Our textbook was Morris's Human Anatomy. The revered Dr. Rolf Syvertsen was in charge of the dissecting room and was omnipresent—to our great benefit. We were 24 in number and had one cadaver for each two students, a ratio unheard of in most schools.

Our first day we approached our task with trepidation, gloved and garbed in rubber aprons. The room reeked of formaldehyde, as all specimens were kept under drapes soaked in the chemical preservative. Our subjects lay face up and were 90 percent male. Each of us had a dissection manual with directions and pictures. I used Cunningham's Dissector and the renowned Spalteholz Atlas, both given to me by my father, who had used them at the University of Edinburgh Medical School. We made our first tentative incisions on an arm according to orders from Dr. Syvertsen, taking turns with our partners between dissecting and reading the books.

Our anatomy course lasted for a full academic year, during which we remained with our original specimens, with few exceptions. After several weeks we relaxed a good deal and in some cases discarded the rubber gloves for the increased efficiency of bare hands. Of course even after a thorough post-class washup, we all carried a strong formaldehyde odor and often noticed people moving away from us on those rare occasions when we went to a movie at the Nugget. We ourselves had long before become immune to the smell.

We were young, so there was a certain amount of levity in the dissecting room. However, Dr. Sy saw to it that our specimens were always treated with great regard. He impressed us early on with the fact that what now appeared lifeless had once been living, breathing humans and deserved our thanks and profound respect. Accordingly, after the course was finished, we all joined Dr. Sy at a private interment where all remains were committed to the grave. Appropriate prayers were said and final thanks were expressed.

In those days, DMS was a two-year school and we all transferred to other medical schools to complete our M.D.'s. Our preparation in the basic sciences was always more than adequate to handle third-year work, but our knowledge of human anatomy was often noticeably superior, thanks to Drs. Lord and Sy.

Charles W. Clarke, M.D.
DC '43, DMS '43
Fair Haven, N.J.

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Of chaos and complexity

As a surgery resident at the University of Illinois, I was fascinated by the novel concept described in Dr. Athos Rassias's essay, "Why chaos matters," in your Spring 2003 issue.

Without a doubt, the idea of a reduction in chaos—or, better yet, complexity—as an underlying mechanism in disease is quite interesting. Fetal heart rate, for example, is controlled by overlapping systems that output a variable pattern. However, when these systems become compromised by lack of oxygen, this pattern disappears and is replaced by a nearly fixed configuration.

But if the hallmark of complex behavior is unpredictability, it would seem that many healthy organs and systems are not all that chaotic, as we are able to make fairly accurate predictions regarding them. For example the indicators we use to assess the normal pancreas are quite constant and hence predictable. If a healthy adult with normal levels of amylase and lipase eats a protein-rich meal, his or her pancreatic exocrine output increases. More importantly, if one avoids the known insults to the pancreas, those normal levels will most likely persist.

In contrast, if one overdoses on fine brews and triggers an attack of pancreatitis, I could not venture to predict the individual's lab values, let alone the outcome of the disease, in spite of great efforts to develop prognostic tools for such a scenario.

It would thus seem that in the case of acute pancreatitis there is actually an increase in complexity, as evidenced by a reduction in predictability. Although this contradicts the idea that disease is brought on by a reduction in complexity, it does not necessarily negate the hypothesis that physiological complexity is lost in a disease state. Maybe normal interactions are halted but overall complexity is increased—either by the emergence of new links between systems or by augmented communication along preestablished paths. The activity of the immune system triggered by acute pancreatitis seems to illustrate this point. But one way or the other, chaos remains.

Thank you for publishing this provocative piece.

Edgar Guzman Arrieta, M.D.
Chicago, Ill.

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Admirable account

I immediately purchased a copy of Constance Putnam's history of DMS as soon as it was available. [A feature in our Summer 2004 issue—"A Question of Balance," about a contentious period in DMS's history in the 1960s—was adapted from this book.] How well does her account of the sorry mess rate? Excellent. It gave me a better view of both sides' stands, as well as admiration for the grace of her writing.

Kenneth W. Cooper, Ph.D.
Riverside, Calif.

Cooper was a professor of cytology and genetics at DMS in the 1960s and is now retired from the University of California at Riverside.

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Powerful lesson

I thought the article by Deborah Schiff in your Summer 2004 issue—" Telling Johnny's Story"—was fabulous! I am a nursing student at Rivier College in Nashua, N.H., and my classmates and I rarely get to see pediatric oncology patients.

This story was powerful and moving. I am going to share it with my fellow nursing students. Some of us are very interested in working at Dartmouth-Hitchcock—especially in pediatrics.

Thanks for this wonderful glimpse into the emotional relationship between the patient and care-providers. It is truly special when you are able to both care for patients in this way and meet their medical needs.

Kellie DeCalogero
Pelham, N.H.

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Rural rotations

I enjoyed the article on the "Medical Student for a Day" program in your Fall 2004 issue and wanted to pass on some information about a rural health opportunity within three hours' drive of DHMC. The Dartmouth- Hitchcock Clinic-Indian Stream in Colebrook, N.H., is a federally designated Rural Health Clinic. All physicians in our clinic are on staff at the local 16-bed hospital, which is designated a Critical Access Hospital.

We have, in the past, had the pleasure of having Dartmouth residents in general internal medicine rotating through our clinic and working with our grateful and needy population. We are preparing to leave the DHMC system, but we intend to strengthen our ties to DMS and to the DHMC family practice and internal medicine residency programs. I encourage Rural Scholars at DMS to contact our clinic if they're interested in working in a rural setting.

Thank you for a great article about the importance of preparing doctors for rural practice!

Christine E. Charman
Colebrook, N.H.

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Second look at smears

Your article about Dr. Brenda Sirovich's study of useless Pap smears in patients with a prior hysterectomy [Fall 2004] was very timely. Unfortunately and interestingly, many women don't remember they've had a hysterectomy—or if they do they can't remember if it was for cancer or not. In fact, many women don't remember if they've ever had an abnormal Pap smear, and many clinicians don't remember or communicate to the laboratory that a patient had a prior abnormal Pap result.

Today, routine Pap smears on the same patient may be sent to different laboratories—depending on the physician or insurance contract—and none of these laboratories may have or receive any information on the patient's gynecological history, previous abnormal smears, or even a history of cervical cancer.

So it's almost meaningless that most if not all laboratories that process Pap smears have built into their quality-control systems patient-history identifiers which target samples from high-risk women to receive automatic double screening or review by a pathologist or both.

Given that one of the top plaintiff lawyers in the country ran for vice president in 2004, I don't think doctors are going to give up doing routine yearly Pap smears on women who have had a hysterectomy—even if we get Hillary-care.

William J. Frable, M.D.
Dartmouth College '56
Richmond, Va.

Frable is a professor of pathology at Virginia Commonwealth University.

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A people place

Dartmouth-Hitchcock Medical Center is my hospital of choice. My respect for DHMC started with my first visit, with Dr. Michael Mayor, when he spent an hour and a half discussing my knee problem.

The same thing happened when I first met with Dr. James Bernat. My latest experience has been with Dr. Franklin Lynch. He, too, takes time to understand his patients. The interest shown by the professional staff is exceptional—especially in light of the financial pressures and impersonal environment in medicine generally. The same applies to all the other staff and administrative personnel I see every time I have an appointment at DHMC.

Your magazine reflects the same concern for people—the personal as well as the clinical and research aspects of the institution. And the articles are well written and interesting.

Joe Kerr
Vergennes, Vt.

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Lens of literature

I am a patient at DHMC, having been diagnosed with multiple sclerosis in 1999. I spend a lot of time at the Medical Center so have become familiar with your magazine, enjoy it very much, and look forward to each issue.

I recently became involved in a project with the DHMC Continuing Health Education Office called the Phoenix Book Group. We plan, starting on January 12, to hold a monthly book discussion group focused on dealing with chronic illness and loss, and finding inspiration through the lens of literature.

In trying to collect potential reading material for the group, I remembered an article in your magazine a few years ago. It was by a man who was reflecting on his cancer treatments at Dartmouth's Norris Cotton Cancer Center. I believe that the construct he used was of the changing of the seasons. If possible, I'd like to obtain a copy of the article. Thank you very much.

David Salvatore
New London, N.H.

The article Salvatore recalls is "The Seasons of Survivorship," by John Milne, from our Summer 2001 issue. Coincidentally, Milne wrote a news article for the "Vital Signs" section in this issue of the magazine—see page 13. More information on the book group Salvatore mentions is available by e-mailing DaveSalvatore@Aldelphia.net.

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A world of opportunity

As a member of the World Health Committee of the Dartmouth Medical School Alumni Council, I would like to make readers of Dartmouth Medicine aware of a Web site that catalogs hundreds of international medical service opportunities. DMS students, alumni, and faculty have always been eager to help improve the quality of life and the delivery of health care in underserved areas of the globe, and this site was created to further foster that interest. It is also available for use by anyone interested in international medical service.

The World Health Committee, chaired by Dr. Chuck Wira, has worked over the last several years to create this comprehensive catalog. It started as a print resource, was updated and expanded, and recently was placed on the Web. The opportunities are currently indexed by country, and the committee plans to expand the site to allow users to search for opportunities by specialty, too.

To get to the site, click here.

Charles Carr, M.D.
DMS '81
Hanover, N.H.

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Photo finish

I noticed with interest the letter from Kay Amsden on page 27 of your Fall issue. I would like to add to her identification of the persons in the photo with Mr. Wilson. In addition to Mr. Amsden, the nurse pictured is Bette Bowler (now Ward). She was temporary director of nursing at that time, which, as Ms. Amsden said, was in the early 1950s.

I enjoy your magazine so much, especially news of those from that time period.

Arline Rich
Enfield, N.H.

Rich is a 1947 graduate of the Mary Hitchcock School of Nursing. The file copy of that photo identified only Wilson; we're delighted to now know the names of all three individuals in the picture (which is reproduced above).

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Right of assembly

The Fall 2004 issue of Dartmouth Medicine was beautiful and contained many interesting stories. However, I was unable to read it in full, as the pages in my copy were not assembled properly. Is it possible to get another copy that is readable?

Dollie E. Ash
Keene, N.H.

With even the best printer, it happens every once in a while that a copy is produced with pages out of order or missing. We're happy to send a replacement copy to any reader who gets a defective one.

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Copy that

Could you please put my name down to receive your excellent magazine? The articles are super. For the last three years I have had occasion to be at DHMC on a regular basis—first as I underwent an operation and then four chemo treatments, and then when my husband was diagnosed with brain cancer. Since I recently had my third cancer-free checkup, and my husband died last May, hopefully I won't be in the hospital to pick up a copy in the near future.

Carol R. Powell
Woodstock, Vt.

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An old friend

I had the pleasure of working at DHMC from 1983 to 1992 (my name then was Pat Wager); when I left, I was director of the intensive care unit. I am now director of the emergency department at St. Luke's Hospital in Boise, Idaho.

I came across a recent issue of Dartmouth Medicine and was happy to catch up on old friends. I'd love to be added to your mailing list. I thoroughly enjoyed my time at DHMC and would like to follow the accomplishments of this great medical center.

Pat Burton, R.N.
Eagle, Idaho