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Letters
The cover article in our Fall issue—about a family physician who struggled for years with the increasing burden of regulatory and payment-related paperwork before finally giving up solo practice—struck a chord with readers. We heard from a former coworker of Tim Shafer's, a former patient, a couple of other private practitioners, and even an English professor, who found the story "heart-wrenching." And that wasn't the only feature in the last issue that moved readers to write in. We also got letters about alumnus Bob Rufsvold's experiences in Ethiopia with Médecins Sans Frontières and about DHMC's first-in-the-nation Center for Shared Decision Making.
Kindness and compassion
I was very surprised to see Dr.
Tim Shafer on the cover of the
Fall issue of Dartmouth Medicine. I used to
work with him at Grace Cottage
Hospital in Townshend, Vt., so
of course that was the first story I
turned to.
The article was written superbly and enlightened me about rural private medical practice. I really had no grasp of the complexities and struggles that are involved in meeting the needs of the patients, the practice, and the government.
Yet despite all of these headaches and tribulations, I recall many good times working with Tim. I owe him thanks from the bottom of my heart for the help and support he gave me during my nursing career at Grace Cottage Hospital. I think back with to all the knowledge I gleaned from him.
One of the best things I worked on with Tim was the creation of an ACS [acute coronary syndrome] policy and procedure protocol, which we drafted with the assistance of DHMC. Because of that effort, the second night the protocol was in effect we saved a life. This is something that I will always cherish.
Because of Tim Shafer and all the other dedicated doctors, nurses, and staff members who work there, Grace Cottage is an outstanding little hospital.
My mother also had a very special place in her heart for Tim. He was always her Tim and no one else's. She talked often of his kindness and compassion to her, and of the wonderful care he provided her as a patient and as a friend.
Many thanks for the enlightening article.
Margo Boyd
Jamaica, Vt.
Not a clock-watcher
When I saw the cover of the Fall
issue of Dartmouth Medicine,
I said to myself, with a great
sense of bittersweetness, "That's
my doctor!" Though Tim Shafer
has actually not been my primary-care practitioner for several
years now, due to distance, he
was my doctor and my friend for
almost 18 years. I still think of
him as my doctor and suppose I
always will.
So of course I read the article with great interest, and I must say that in all the years I was his patient I had no idea that any of this financial struggle to create a "Care Package" was going on—because, as Tim's wife, Deb Luskin, writes in the article, his patients were never treated any differently than they had been. If it is possible for me to have gainedmore respect for thisman, this father, this husband, and this doctor, I have.
I remember going to his office feeling that I needed to see him urgently, and he always made time for me. Having to sit for 45 minutes to an hour past my appointment time never bothered me because I knew he was giving someone else his precious time, listening intently to that patient. No matter how long it took, I knew when it was my turn to see him that he would give me as much time as I needed, too. He never looked at his watch and he never sat in front of a laptop typing while patients were talking with him. He always looked at his patients as they were speaking, which gave him so much insight into what was really going on in their lives. This is something that is sorely lacking in today's doctors, in my opinion.
Tim often had medical students working with him. I always felt hopeful that somewhere in this world would be a few new doctors who understand that laptops and HMOs and how many patients you can fit into a day are not what is really important.
I miss him.
Cheryl Taylor
Canaan, N.H.
A great narrative
I enjoyed the wonderful article
by Deborah Lee Luskin about
Tim Shafer in the Fall issue of
Dartmouth Medicine. I empathize
with them, recalling with
fondness the nice relationship I
had with patients but cringing
about the unpleasant administrative
and financial burdens. I,
too, became an employed physician
in 1991, but my health
forced me to retire in May 2007.
The patients were what made it
all worthwhile.
I note with awe the retirement at age 55 to 60 of college classmates who went into business and finance. Theymay have homes and toys I can only dream about, but I get to live where they like to visit—not too bad.
I commend Tim on his impressive career and Deborah on writing a great narrative and supporting the office for so long.
Warner Jones, M.D.
North Springfield, Vt.
A way to go it alone
I was terribly saddened by the
commentary within "Care Package,"
as it sends the message to
our younger physicians that solo
private practices are no longer
possible.
The truth is anything but that. Speaking as a solo physician whose office is much like the one described in the Editor's Note in the same issue, "Revisiting Vinyl" I have avoided HIPAA entirely by remaining small and by not having any electronic transfers of information. And I've avoided billing problems by simply collecting payment at the time of service, by not accepting any insurance or joining any managed care panels, and by keeping my fees reasonable.
My patients know what day I'll be at the office and simply show up. I stay until I'm finished and the waiting room is empty. Patients are thrilled with the ease of access, I'm happy because I'm not wasting anyone's time (my own included), and satisfaction on both sides is high.
The American Medical Association offers all member physicians a catastrophic insurance coverage program that serves me well and is inexpensive.
Placing a professional into an employment situation means that professional decision-making becomes biased by the needs or desires of the employer. Just as an example, the decision of DHMC to have a policy that applies to all employees regarding pharmaceutical company freebies means that the professionals employed there no longer get to use their own professional judgment regarding that domain.
Not wanting anyone else to make professional decisions for me, whether I happen to agree or not, I choose to keep my medical practice in my own hands.
Stuart Gitlow, M.D.,
M.P.H., M.B.A.
Woonsocket, R.I.
Gitlow holds an appointment as an adjunct instructor in psychiatry at Dartmouth Medical School.
Heart-wrenching portrayal
"Care Package" by Deborah Lee
Luskin was a heart-wrenching
story in its portrayal of the devastating
effects of federal legislation
on a rural medical practice.
Reeling from one blow after another—managed care, HIPAA,
CLIA, EMTALA—the "mom
and pop doc shop" that she and
her husband ran was finally
forced to close.
It was not a happy story, but it was a true story; the details of the struggles she described speak volumes about health-care delivery in the U.S. today. What we value most when we are ill—a focus on the treatment plan and on the healing process, and personalized and empathetic care—is undermined today by the proliferation of paperwork and the limits placed on providers.
This story both moved and frightened me. Thank you for publishing it.
Mary Buchinger Bodwell
Boston, Mass.
Bodwell is an assistant professor of English atMassachusetts College of Pharmacy and Health Sciences.
Insidious effects
As a friend of Dr. Bob Rufsvold's,
I was glad to read the article
about his time in Ethiopia [see
"Being Present" in the Fall 2007
issue of Dartmouth Medicine]. I'm pleased
to know that through his article,
many people are being educated
about the practice of medicine in
the Third World. And about the
insidiousness of the way the dam
is threatening the grazing lands
of the indigenous people of
Ethiopia's Afar region. Dr. Paul
Farmer's work in Haiti with Partners
in Health offers similar insight
into medical caregiving in
this sort of situation.
I was glad to read recently that Médecins Sans Frontières, the organization with which Bob worked in Ethiopia, has developed a peanut paste that is better at helping nourish starving people than the milk products that have been commonly used in the past—for they depend on a clean water supply. There is no substitute for water. In fact, it may represent the limit of sustainable development, since 80% of disease and death in the developing world is due to the absence of a safe water supply. Ground water depletion and contamination are perils that we must make strong laws to prevent.
Yet little by little, headway is being made. I believe this is a time in which cross-cultural experiences and these sorts of reflections have never been more needed. Each hand that touches another makes a difference. To know that what we do matters is essential. I loved the thought at the end of the article—that just "being present" may be enough.
Martina Nicholson, M.D.
Santa Cruz, Calif.
Narrative masterpiece
The article "Being Present" by
Robert Rufsvold in the Fall 2007
issue of Dartmouth Medicine
is a masterpiece of narration, by
a physician whom I knew well
during his time as a family practitioner
in Lyme, N.H. What a
pleasant surprise it was to see
him involved with Médecins
Sans Frontières in the Afar region
of Ethiopia—probably one
of the poorest regions in the
world, with only one medical facility
serving a region as large as
the state of Colorado.
The article reveals Dr. Rufsvold's deep empathy for the plight of the region's starving people—victims of chronic drought as well as of a plan to build a dam that will offer no succor to the Afar but will only benefit sugarcane growers whose products will provide biofuel for military purposes.
I was truly moved as I read of his efforts to provide care for over a hundred patients a day in temperatures of up to 120 degrees. Even an ordinary upperrespiratory infection could be life-threatening for these nomadic herders, and two out of five infants did not survive to their fifth birthday.
He realized that he could make only a small dent in the problems of these wonderful people, but he concluded that merely being there, fully there, was enough—though humbling to the extreme. It was the most taxing work that he had ever done, to face the impossibility of eliminating such suffering. I express my admiration to him for contributing his expertise in an effort to offset, to the extent that he could, the hopelessness of the situation.
To quote from the poem with which he ends his article: "What if we could simply live this experience, / place our hand on the door, / and before entering say, 'Use me. / Help me to do good work today.'"
I hope that Dartmouth Medical School—and Dr. Rufsvold's article—can inspire other graduates to serve in the needy areas that are all too numerous worldwide. Such service is welcomed by the recipients and rewarding for those who serve where they are most needed.
Dartmouth Medicine has done a great service by publishing this article (as well as "Care Package" by Deborah Lee Luskin in the same issue; that article, too, is an excellent description of a service opportunity thatmay inspire a few DMS graduates).
John Radebaugh, M.D.
Falmouth, Maine
Radebaugh is an associate professor emeritus of community and family medicine at DMS. An article in the Spring 2005 issue of Dartmouth Medicine explores his own efforts to serve needy populations, from migrant farmworkers to Biafran refugees.
Evidentiary finding
I think that Maggie Mahar's article
in your Fall issue, "Making
Choice an Option," is extraordinarily
well-written. She outlined
clearly and accurately the work
at DHMC's Center for Shared
Decision Making, in terms of its
ethicalmotivation, its conceptual
and empirical basis, and its
practical strategies for providing
patients with high-quality, evidence-based, balanced decision
support and decision aids in
close-call, preference-sensitive
situations.
Thank you for publishing this fine article. I plan to use it in my graduate teaching at the Dartmouth Institute for Health Policy and Clinical Practice.
Hilary A. Llewellyn-Thomas, Ph.D.
Lebanon, N.H.
Llewellyn-Thomas is a professor of community and family medicine at DMS and codirector of the Center for Informed Patient Choice at the Dartmouth Institute forHealth Policy and Clinical Practice (formerly the Center for the Evaluative Clinical Sciences).
Tributary follow-up
Reading the tributes to Dr. Brewster
Martin, one of the North
Country's stalwart family doctors
[see the Letters section in the
Fall 2007 issue], put
me in mind of Dr. Israel "Dinny"
Dinerman of Canaan, N.H. He,
along with Dr. Bill Putnam of
Lyme (who has been mentioned
in these pages many times), was
seen in the halls of Mary Hitchcock
Memorial Hospital now
again when I was a resident
there, visiting patients and attending
rounds.
"Dinny" wasn't a mentor for me. We didn't have mentors in the 1950s. But my residency advisor, Dr. John Milne, thought it might be instructive for me to sit in for a real general practitioner. Dinny wanted to attend a medicalmeeting, so sometime during the last months of my residency I was dispatched to Canaan as a locumtenens, to fill in during his absence.
I moved into Dinny's house and sat behind his desk during his office hours. Motherly Mrs. Dinerman fed me my meals, and the office staff held my hand.
Instructive isn't the right word for the experience. It was both sobering and terrifying. Right there was where I learned that the average patient coming in to a family practice office didn't suffer from the exotic diseases that I was prepared to pounce upon triumphantly, but seemed to have incomprehensible complaints. It was a great relief when all someone wanted was a prescription refill. Somehow I managed to get through the week, however, with subtle prodding from the office nurse.
My one masterstroke, I had thought, wasmaking a house call on a small child with pharyngeal exudates whom I treated for tonsillitis. When I later related the incident to Dinny, he said, "Interesting. I didn't think one saw tonsillitis under the age of five," or some such age, thus bursting my bubble.
Sitting behind my own desk a few months later, and remembering my locum experience, I wondered if I was really prepared for practice. But the one principle I took away with me from Canaan was that if you really listened carefully enough to patients, you could ferret out what it was that had brought them in and make them grateful so that they might think you knew what you were doing.
Jerome Nolan, M.D.
DHMC Housestaff '52-54
Wilmington, N.C.
A solon's story
I write to commend one of Dartmouth's
extraordinary medical
students, Lisa Merry. I had the
occasion to meet her in September,
when I managed to wreck
my motorbike on the edge of
Route 12A. I was pretty shaken
up after flying through the air
and landing on my helmet.
Lisa appeared very shortly after the accident, announced that she was a second-year medical student, and asked if I was okay or in need of any assistance. I thanked her and asked her for help with my injuries.
It's not that she bandaged me up very efficiently, which she did, or that she offered to take me to the emergency room after I decided I didn't need ambulance transport. What most impressed me was the determination she made that she was going to look after me until I was home and okay. She stayed with me at the DHMC emergency room, where I was wonderfully treated, and then took me back to Cornish. She took care of me.
I realize how rare it is to find that kind of commitment offered by one stranger to another on the side of the road. Lisa gave me her help freely and with great kindness. I am happy to share how moved I was by what she did. I sometimes wonder if we as a culture maintain a group of core values that are worthy. I don't have an answer yet to the large question, but I know that Lisa Merry has those values.
I extend my thanks to Dartmouth Medical School for having such a wonderful student close at hand.
Senator Peter Hoe Burling
Cornish, N.H.
Burling represents District 5 in the New Hampshire State Senate.
It's all in the IT
I read with interest Kelley
Meck's article "Who would import
RICE to Vietnam," in your
Summer issue. I was
intrigued because of the article's
title and because I am Vietnamese.
I live in Dallas now, and importing
rice to Vietnamwould be
like importing heat to Texas.
I believe that RICE [which stands for "remote interaction, consultation, and epidemiology"—a Dartmouth-based effort to link rural clinics with urban hospitals in Vietnam using smartphone technology] will produce beneficial results for the people of Vietnam. Furthermore, I do believe that information technology is a constructive way to facilitate the health care there.
I am really interested in the progress of this project.
Hue Dao
Dallas, Tex.
We've got you covered
My husband and I get your magazine
in the mail and enjoy reading
it, cover to cover, each time.
I wonder if you can add my
mother, who lives in California,
to your list of subscribers? (She
isn't computer savvy, so reading
it on the internet isn't possible.)
She is 84 years old and dealing
with some medical issues. I sent her a copy of
"Making Choice an Option," from your Fall
issue, and she found it very interesting.
Thank you for publishing such a relevant and informative magazine!
Karen Norris
Augusta, Maine
Something for everyone
I have been reading Dartmouth Medicine
for many years and enjoy it very much. I
check it out from my local library. There are
always many interesting and informative articles—something for everyone, scientists
and laypeople alike.
Would you add my son's name to your mailing list? He is on the faculty at a pharmacy college in Virginia and will appreciate the magazine even more than I do.
Patricia Lee
Temple, N.H.
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