making a correct diagnosis. I always made a point of greeting my patients in the waiting room, since their initial body language often gave important clues about their problem. Likewise, I never reviewed any outside records until after I had visited with the patient in order to remain unbiased. Reaching a correct diagnosis after taking a history in an obscure case always gave me great satisfaction.
Sadly, with the advent of managed care, the time allowed for me to spend with each patient became severely limited. Much of the pleasure of my practice started to disappear.
As a result of these time constraints, I feel the quality of patient care has been significantly diminished. It is virtually impossible to establish good rapport and ask all the right questions in less than an hour with most patients. Unfortunately, our new physicians are influenced by these time restrictions as well, and their skills in history-taking will be limited. Thus they have come to rely more on testing rather than on listening.
William G. Chaffee, M.D.
Paradise Valley, Ariz.
Where there's smoke . . .
I was very interested in the item about smoking in your Summer issue. It brought back several recollections for me.
I entered DMS in September 1957, and in our second week of school we were introduced to talking with patients at Hitchcock—scared though we were. Our residents sent us each to talk to a patient, then we discussed the cases in
the hall afterward with the other three to five students in our group and the resident overseeing us.
"My" very first patient was a 41-year-old Italian-American who had jumped ship in Boston as a teenager and eventually become a citizen with a thriving business and family. He worked hard, skied in the winter, swam in the summer—and smoked three packs a day.
From his symptoms—a persistent cough and loss of appetite and stamina—I suspected cancer despite his age and said so to my resident. The resident told me the patient had inoperable lung cancer; recent British and U.S. research, he added, had shown that a "10-pack-year" history was enough to suggest a diagnosis of lung cancer in those with vague lung complaints, even if they were relatively young. This patient lived just long enough to see his eldest child graduate from junior college.
Nine years later, in 1966, I was a flight surgeon in the U.S. Air Force (USAF), working in the USAF surgeon general's office. I was asked to oversee the Air Force anti-smoking program—the first one in the Department of Defense. Based on 10-year-old data by Dr. Kenneth Cooper and others, we knew that a pilot who'd smoked a single cigarette an hour before takeoff would show the biological signs of someone 4,000 feet higher than his aircraft. This was due to carbon monoxide tying up the hemoglobin to such a degree that the individual was temporarily functionally anemic—a particularly hazardous situation in high-performance aircraft, especially on night flights.
The Army and Navy were not happy with our anti-smoking program, for the cigarette break was considered sacrosanct as a morale-booster in the military.
Smoking was also a politically sensitive issue for the USAF, as most of our bases were in tobacco states because the weather there was conducive to flying year-round. The USAF surgeon general was blasted by legislators from tobacco states, but we stuck by our guns and won the battle, at least within the Air Force. Even so, our pilots often asked us M.D.'s why, if what we told them about cigarettes was true, the U.S. Public Health Service said nothing on the subject. A few years later, they came around.
I hope you'll allow me one more recollection: Dot Stone, my first-grade teacher in Lebanon, N.H., where I grew up, warned us that smoking was "bad for your wind." That hit home to those of us little boys who dreamed of being athletes at Lebanon High School.
I share all this now because I remain appalled that themedical profession hasn't fought hard enough to educate political and educational officials—as well as those who really "teach" the young via TV, movies, and ads—about the hazards of smoking. Perhaps today's medical students can take up the cause.
Amos R. Townsend, M.D.
Of primary importance
The article in your Summer issue on the White River Junction VA Medical Center's