Our covers seem to be coming in for comment of late. The cover story in our Summer issue sparked a couple of letters—as well as, according to one of those letter-writers, a number of dinnertable discussions about its subject matter. And the cover of our Spring issue got a reader guessing about the identity of the patient pictured in the painting featured there.
Fair and balanced
Jennifer Durgin's cover story on cancer screening, in the Summer issue of Dartmouth Medicine, was masterful. It is probably the most accurate and balanced article most any of us in the field have ever seen written on this complex topic. Her article has been the centerpiece of many a dinner discussion during the past few months, both at DHMC and around the country.
I'm sure it was not easy so fairly presenting such a balanced perspective. The fact that both sides probably felt Durgin went too far in presenting the other side's position probably means she got it just about right. It's sort of what [DMS outcomes research pioneer] Jack Wennberg and his colleagues at the Foundation for Shared Decision Making went through during the development of their shared decision-making tapes for patients in the 1990s.
Again, my congratulations on this really important article on such a complex issue.
Michael Zubkoff, Ph.D.
Zubkoff is the chair of DMS's Department of Community and Family Medicine, as well as a professor of economics and management at Dartmouth's Tuck School of Business and codirector of Dartmouth's M.D.-M.B.A. program. He was the subject of the "Faculty Focus" profile in our Spring 2005 issue.
Both sides now
Thank you for the cover article "Screening for Cancer: Are We Hunting Too Hard?" by Jennifer Durgin in the Summer 2005 Dartmouth Medicine.
Since its inception in 1992, the New Hampshire Breast Cancer Coalition has called for honesty and clarity about the bene- fits as well as the limitations of mammography screening for breast cancer.
Slogans like "Early detection is your best protection" oversimplify a complex disease and mislead many women into believing that if they have this test, they will not die of breast cancer.
Women need evidence-based information about breast cancer screening. Anyone who is considering whether or not to have routine mammograms would be well advised to read this article. Furthermore, it should inspire all of us to move forward from the debate about screening to determining what causes breast cancer and how best to treat it.
Nancy A. Ryan
Ryan is chair of the New Hampshire Breast Cancer Coalition, a grassroots advocacy organization.
I see you?
Here is yet another letter regarding the cover feature about ICUs in the Spring 2005 Dartmouth Medicine. I was absolutely convinced that the patient depicted in the painting on the cover was my father-in-law, Guy White. He was the victim of a hunting accident in which both eyes and the bridge of his nose were shot out. Another bullet entered his right upper arm, shattering the bone. In the painting, the patient's eyes and nose are bandaged and there is an IV line in his left arm.
However, a caption on page 45 says that the photo on which the painting was based was used in an exhibit in 1957. But the hunting accident occurred in November 1959. Is it possible the date of 1957 is incorrect?
Dr. Brewster Martin of Chelsea, Vt., administered first aid at the scene and Guy was transported to Mary Hitchcock, where I know he was a patient in the Special Care Unit. He was 55 years old at the time of the accident and lived to be 86.
It has been in the back of my mind to write, but we did not have the wet spring here that was mentioned in your Summer issue as a possible cause of all the letters that you had already received about the ICU article!
Barbara Huckins White
The ICU photo that White refers to—on which the painting featured on our Spring cover was based—was included in a newspaper clipping dated 1957, so there appears to be no doubt about its vintage. White is a 1959 graduate of the Mary Hitchcock Memorial Hospital School of Nursing—which, as it happens, is the subject of a feature in this issue.
I enjoyed the "Facts & Figures" box about surgical gloves in your Spring 2005 issue, for a reason that will be obvious from the recollection which follows.
In the spring of 1968, I was an intern assigned to the cardiothoracic surgery service at Mary Hitchcock Memorial Hospital. My assignments one day included interviewing and examining a new inpatient, an elderly man whom I'll call Mr. Jones, who was accompanied by his wife. The interview proved to be intriguing and priceless.
Mr. Jones was the owner of a golf course that had gained worldwide renown when Dwight D. Eisenhower used it to retreat from his presidential duties. It was also famous throughout New England for the unique greens grass developed and marketed by Mr. Jones.
To let me know that she had some medical background, Mrs. Jones mentioned that she had been a nurse prior to her marriage. She said she had worked as the personal nurse for a neurosurgeon at Johns Hopkins, one Harvey Cushing, M.D.
"Have you heard of him?" she asked.
"Yes, I have," I replied, trying to subdue my exuberance and maintain my fledgling professionalism. Dr. Cushing was merely the most famous neurosurgeon in history, and there I was listening to his very engaging nurse!
Then she told me about the gloves. Surgical gloves were not routinely used in the early 20th century. During her duties, she developed a nasty rash on her hands. Dr. Cushing diagnosed it as contact dermatitis from chemicals in the operating room.
He then got in touch with an acquaintance of his in Akron, Ohio, a Mr. Goodrich, and asked if he could make some rubber gloves for his nurse. Soon the gloves arrived and the dermatitis disappeared.
So, in one brief interview, I had intimate brushes with the lives of four of the most successful men and one of the nicest ladies who lived in the 19th and 20th centuries.
The Joneses also related several other interesting anecdotes during that interview, but they do not pertain to surgical gloves. It was a very special event in my career.
Don E. Cloys, M.D.
I was fascinated by the Spring 2005 "Grand Rounds" essay by Jonathan Ross, M.D., one of my mentors from DMS.
I also worked during my DMS years with Dale Gephardt, M.D., an internist in Windsor, Vt. Dale was a true generalist as defined in the essay. He provided continuous, comprehensive, personalized care. As we drove through Windsor on our lunch break, he could tell me stories about the people we saw in town, his patients. He knew them that well!
I envisioned myself working like Dale. I did my residency in primary care at the University of California at San Francisco because residents there spend 50% of their time with outpatients (I now spend more than 95% of my time with outpatients).
I opened a solo practice in San Luis Obispo, Calif., in 1998. My wife grew up here and we wanted to move here. The two group practices in town weren't hiring then, but luckily my father- in-law, Frank Collie, M.D., has been a Dale Gephardt in San Luis Obispo for over 30 years. He had room in his building, so we decided to share some employees and it has worked.
Like Gephardt and Collie, I strive to be an internist providing continuous, comprehensive, personalized care. I learn more about how to do that every year. What do I hear from my patients? They left their last physician because they never saw her or him. They could see only the nurse practitioner or physician assistant. Rarely was it the same person twice. They left a big group practice because they could never get hold of their physician on a "crazy" phone system. They want me to know who they are, to know a bit about their life. They frequently come to me after seeing a specialist because "you're my doctor and I'm not doing anything unless you agree." They (usually!) value my opinion. They trust me to provide palliative care during terminal illnesses.
I spend a fair amount of time on unreimbursed work: reviewing studies ordered by specialists or calling specialists to coordinate my patients' care. I do this because they are "my" patients. I am their advocate, someone armed with medical knowledge and knowledge of the medical system. I do this because they have trusted me with their care and I feel responsible for helping them. I dictate a list of medications for my geriatric patients, because I realize they are more likely to foul it up without a list. I make house calls.
I feel the care I provide could be better. I feel like a little island at times and wonder how other solo practitioners do it. Is the small-office care I provide better or worse then the care in a big system like Kaiser or the VA? Do automated triage, computerized reminders, tracking of outcomes, or use of a limited formulary help patients more than I do? If I tried to track my own outcomes, would it produce useful information? Do nurse practitioners or physician assistants (I don't use either) provide the same kind of care I do? Do they save money or cost more for our health-care system (i.e., order more unnecessary tests) than I do?
Why don't more physicians want to do what I do? I don't think the lifestyle demands of providing continuous, comprehensive, personalized care have to be as big a barrier as many medical students perceive. I work pretty darn hard (though not the crazy hours of some specialists), and I make a respectable salary (though nowhere near what many specialists make). But I feel lucky to be doing something I enjoy. I am fortunate to have 10 other internists in my call group. What makes my life as an internist crazy is that my income is directly tied to how many patients I see. To earn my respectable salary, I have to see more patients than I'd like on many days. Better reimbursement for what I do would help draw more medical students to generalist care. So, too, would changing the mindset whereby generalist medicine is referred to by specialists as a "dumping ground."
Yet how to demonstrate, with research, the value of what an internist can do is incomprehensible to me. How to measure if patients prefer generalist medical care is equally unclear.
So that's the view, from my non-academic generalist shoes, on the interesting questions Jon Ross raised in his essay.
Stephen A. Hilty, M.D.
San Luis Obispo, Calif.
Can those be Kandahars?
The Summer issue of Dartmouth Medicine was another home run—from the Editor's Note, spiced with references from Oprah to Dumas, and the jazzy listing of the issue's contents, all the way to the end.
The feature about Susan McLane really pushed my nostalgia button. She and her twin sister were a fixture on the campus during my years at Dartmouth. And her husband-to-be, Malcolm McLane, DC '46, was just a few years behind me. I got a kick out of the picture of him with his long wooden skis [the photo is reproduced below, on the right]. I remember him and, of course, the twins' father, Dartmouth College Dean "Pudge" Neidlinger. I even thought I recognized the students in the picture of the dean's office [below, on the left] as a pair of Phi Delts—Dick Peebles and friend.
I hope you'll permit me to share a recollection of Dean Neidlinger. Anyone from that era remembers where they were on Sunday afternoon, December 7, 1941, when news of the attack on Pearl Harbor came over the radio. The effect on the Dartmouth community was immediate and extreme. Students by the carful and trainload left Hanover. The campus seemed (was) deserted. Some who remained had their thinking screwed up. Bizarre activities, such as trashing fraternity houses, surfaced.
When word of such an outbreak at the Deke house was received by Dean Neidlinger (who was himself a Deke), he went right down there and forcefully evicted the miscreants. He grabbed them by their scruffs and tossed them, flying, out the front door, according to people familiar with the episode.
One more recollection: The bindings on Malcolm McLane's skis are Kandahars (I think)—a state-of-the-art improvement over the bear-trap bindings with which my hickory-ridge skis (with steel edges) were equipped. When I arrived at Dartmouth, Brooklyn-born and -bred, I'd never been on skis. I was outfitted with ski equipment by John Piane himself, founder of the Dartmouth Co-op. Insurance on the skis was one dollar. It came in handy when one ski "broke" (thank you, bear-traps) in a tumble barely halfway from the Phi Delt back porch to the golf course. Skiing was hard work, especially for a neophyte. But the rope tow up Mount Mansfield beat climbing.
Anyway, many thanks for prompting the memories.
Henry F. Kramer, Jr., M.D.
DC '42, DMS '43
A new twist on the Dartmouth "family"
As the father of a daughter who is about to graduate from Dartmouth Medical School, I have greatly appreciated receiving your magazine for the past four years.
I thought I would share a (very) minor tidbit related to her graduation. Both my daughter, Jaime Walford, and her cousin, Geoffrey Walford, will be receiving their M.D. degrees from DMS. It seems unlikely that cousins would commonly graduate together. We are having our annual family reunion based around the June 11 graduation of these two suddenly prominent members of our clan. Geoffrey is going to Harvard and Jaime to Northwestern for residency.
Again, thanks for your great work. It has been very nice to feel in touch with the Hanover community from so far away.
See here for a Walford family portrait captured during DMS's Class Day.
Exclamation about a periodical
Thank you for the wonderful and high-caliber medical reporting in your publication—Dartmouth Medicine is one of my favorite periodicals. Each issue is even better than the one before, and I read it all!
As a retired member of the cytopathology department, I am especially interested in word about new medical developments.
Dartmouth Medicine magazine is one of the best publications that I have ever read. I am moving from Vermont to Florida and would love to continue receiving it. If you can change my address in time that I may receive the Fall issue in Florida, I would be most grateful. Thank you.
George A. Burrows
South Reading, Vt.
We're happy to keep Dartmouth Medicine coming when readers move—but be sure to let us know your new address, because the magazine comes by bulk mail and so is not forwardable.
Yes, Virginia, there is a DMS
I recently received a copy of your publication and thoroughly enjoyed reading it. As an undergraduate in the University of Virginia's School of Engineering and Applied Science, I would be very grateful if you could add me to the subscription list so that I may continue to read this delightful magazine.
Arash R. Zandieh
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