Matters both very modern (the greening of health care) and timeless (the mentors who make medical students into doctors) caused our readers to pick up their pens over the last few months. Well, figuratively speaking. A couple of the letters here, including the first one below, were actually penned on paper and arrived by post. But the vast majority of our mail nowadays, not surprisingly, comes in electronically. Yet however you write us, we appreciate your insights and observations.
As a trustee of the New London Hospital—a member of the Dartmouth-Hitchcock Alliance—I have become an avid reader of Dartmouth Medicine.
It is a remarkably good general-readership publication and consistently hits the topics and issues that make a difference in medical advances. As such, it's a great help to laymen such as myself who struggle to stay current with local, regional, and national health issues.
Nice work. Keep it up. You have readers out here!
New London, N.H.
Putting green in perspective
Sharon Tregaskis's cover article on green hospitals in your Summer issue was a well-written and thorough treatment of a complicated topic.
From my perspective, as a national green and healthy building consultant, I amheartened to see what an incredible job Dartmouth is doing for their staff and patients. It is truly exemplary work that shows a real commitment to your mission and values.
The rest of the issue was also very interesting—you are to be commended on a job well done.
Jan D. Stensland
Brewster Martin, an icon of medical care in Chelsea, Vt., recently passed away. Brewster had no formal ties to DMS or DHMC, yet he was one of the most formative figures in my medical education, key to my sense of what it means to be a physician.
In the fall of 1990, as a first-year medical student, I was assigned to Brewster as my community physician mentor; I was to spend an afternoon every few weeks with him, to see what doctors really did. I still remember my first drive from Hanover to Chelsea. Traveling from the Upper Valley to the shire town of Chelsea seemed more than just a matter of miles; there was a different perspective and sense of time in this lovely valley.
With my white coat and new stethoscope, I took on my new role in Brewster's office—eager observer. I did my first physical exam and read my first EKG and chest x-ray in Chelsea. After a while, I was seeing patients and presenting them to Brewster. I marveled at how much he knew about his patients—all of them. It was if he had heard their whole story already. Eventually, I realized that he knew them so well because he had delivered many of them and seen them grow up around him.
As fall segued into winter and then spring, I continued my forays to Chelsea—drawn as much to Brewster as I was to feeling like a doctor.When it came time to find a summer job, I asked Brewster if he'd take me on for a few months. I felt like a character in a John Irving novel. I secured a small grant from DMS to cover part of my keep, and Brewster helped out a bit, too, so I could pay the rent and buy gas.
Our relationship deepened, and I realized my summer was really an apprenticeship; even more than the clinical skills I was learning, I treasured his tales, hints for better living, and insights about life.
On our lunch breaks we'd make house calls in his pickup truck. We saw homebound elders, people he wanted to check on, and people so poor they literally had dirt floors.
I vividly remember one afternoon being called out to a barn where an elderly man had gone crazy and was threatening everyone. When no one else dared to intervene, Brewster stepped in and reassured the man with a measured voice and tender hand gestures, like a whisperer calming a wild horse. The man was covered in filth and was totally delirious; I had never seen such fear and wildness as filled his eyes.
After the man calmed down, Brewster pulled over a large basin and filled it with warm water; right there in the barn, we took his clothes off and bathed him. We dried him off, and his wife brought some clean clothes. His emaciated form was lost in the worn shirt and trousers that had once fit him well.
In later years, I would describe this sort of appearance as cachexic; the man was likely in a late stage of cancer that had metastasized to his brain. But at the time it was something else, something much more meaningful. We carried him to the house and put him to bed, and he slept for the first time in days. The next day he died.
In the ensuing years, whenever I have driven through Chelsea, past that barn, I've recalled Brewster's tender words and actions, his place in the community. I am confident that I was a witness to something I may never see again and certainly to someone I will never forget.
Edward J. Merrens, M.D.
DC '88, DMS '94
Merrens, now chief of DHMC's Section of Hospital Medicine, appeared with Brewster Martin on the cover of the Winter 1991 issue of Dartmouth Medicine, which is reproduced below.
A legend in his own time
Alas, Brewster Martin, M.D., died this summer. He and the rest of the staff at the Chelsea (Vt.) Health Center had a rich relationship with their community. While he had several partners, it was his steady, consistent presence over many years that made him "Chelsea's doctor."
I was lucky enough to work with him both as a medical student and later as a resident. I got to see and hear about a rural Vermont medical practice with hints of the Wild West.
For example, to better understand disease, and with scant access to pathologists, Brewster was given permission by the local undertaker to do unofficial, limited autopsies on his recently deceased patients.
During one 20-mile drive to Barre City Hospital on a January night, Brewster was riding in the back seat of a car with a woman in labor. The future father was intent on his responsibility as driver, on the dark and slippery road. As his patient's labor intensified, Brewster said to the man, "This must look funny." Gripping the steering wheel tighter, the man replied, "Tomorrow I may laugh, but I ain't laughing now."
Brewster taught me to respect and value our local culture. Because rural Vermont is largely Caucasian and English-speaking, it can be easy to overlook the traits that make it unique. The region's agricultural focus, the extremes of the four seasons, and the fragile economy make for a strong tradition of loyalty, independence, and hard work.
He also taught me to use humor liberally and to never underestimate people's wisdom and judgment. He reminded me often that "we don't get older, we get more so." His strong sense of civic duty made him an embodiment of the saying that "one should give more than one takes."
Now, 15 years later, his mentoring has paid off. I, too, practice familymedicine in rural Vermont, am the town health officer, and make house calls. I, too, have babies pee on me. On some days, I give as much medical advice at the post office and local lunch counter as I do at the office. And the best part is that I, too, find myself with front-row seats for the births, deaths, and all the adventures in between that life throws at us.
Stephen H. Genereaux, M.D.
Wells River, Vt.
Genereaux is the medical director of Little Rivers Health Care, Inc., a Federally Qualified Health Center with offices in Bradford, East Corinth, and Wells River, Vt.
A ringing endorsement
I was moved to write after reading about Jim Bell in the Spring issue of Dartmouth Medicine (Bell shared the effect that undergoing cardiac surgery has had on his teaching and practice of cardiology, in a feature titled "The Other Side of the Stethoscope".)
Dr. Bell was my first attending on my first internal medicine rotation when I was a medical student. He was later the attending for my subinternship and my VA rotations as an intern, a second- and third-year year resident, and both years as a cardiology fellow.
Now, 27 years after graduation and 23 years after starting practice as a cardiologist, I often find myself remembering the lessons I learned from Jim. Most of all, it is listening—not just to patients' words but to their emotions, facial expressions, and body language. I learned from him how important it is to make a human connection with those we care for, and I try to practice that every day. This, I find, is what helps me cope with the rigors of caring for patients and families as they attempt to deal with the unfathomable and often tragic situations that life throws their way.
It's hard to believe that Dr. Bell could become an even better doctor than he always was. I regret not being able to see him when I was at DMS for my reunion in 2005; he was and will always remain a steadfast role model and good friend.
Kathy Ryman Dube, M.D.
DMS '80, DHMC Housestaff and Fellow '80-85
Dube is a cardiologist at Kaiser Permanente of Woodland Hills, Calif.
Interest from afar
The article in your Fall 2004 issue about Basil O'Connor mentions the regrettable fact that there is no book about the "Man in the Middle," as your article is titled. (O'Connor, a 1912 Dartmouth College graduate, was instrumental in the development of the polio vaccine.)
Furthermore, the Englishlanguage edition of Wikipedia had no article on O'Connor, although the German edition of Wikipedia did have one. So I started creating an English article, mainly by translating the German one.
It is also mentioned hardly anywhere that O'Connor is one of only two nonscientists (together with FDR) included in the Polio Hall of Fame in Warm Springs, Ga.
My interest in O'Connor arose when I followed traces of Jakob Heine, an orthopaedist who wrote the first clinical report of poliomyelitis and who was born in Lauterbach, Germany, where I live. Heine is also among those included in the Polio Hall of Fame, along with 14 other polio experts.
It was in searching for more information about O'Connor that I came across your article. (And in doing so, I also found and subscribed to your podcasts, which contain interesting information on medical subjects.)
I am 70 years old and was a teacher of English and history at a German gymnasium (high school) in Schramberg. I am interested in all kinds of subjects, especially local history and notable people from here who deserve attention.
Do you happen to know O'Connor's place of death so I can add that to his Wikipedia entry? Many thanks.
According to Dartmouth's alumni records, Basil O'Connor died (in 1972) in Phoenix, Ariz.—a fact Hekler has now added to O'Connor's Wikipedia entry. O'Connor is pictured in the spread to the left—he's on the lower right with a young polio patient; to his left is his former law partner Franklin Delano Roosevelt, and above him is polio vaccine pioneer Jonas Salk.
Article was right on
The article by Jerome Groopman, M.D., "The Right Questions" was enlightening and enjoyable. As a practicing internist and clinical teacher for 33 years, now retired, I found that the medical history was by far the most important factor in 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 theWhite River Junction VA Medical Center's Primary Mental Health-Care Clinic (PMHC)—"Waitless environment is good for mental health"—was of particular interest to me. I am a clinical health psychologist who recently began working closely in this clinic with Brady Cole and Andy Pomerantz (who, with their colleague Debra Scott, just hosted a two-day regional conference on the "White River" PMHC model).
I have worked in a variety of settings over the years and have never seen mental-health assessment and treatment planning offered in such a timely, efficient, and effective manner. Integration models work best in a single-payer system like the VA, which does not separate mental and physical health-care benefits. For integrated models to work outside a VA-style, singlepayer system, the business side of medicine will need to think outside the box and develop new financial strategies.
Mark J. Detzer, Ph.D.
Detzer is an adjunct assistant professor of psychiatry at DMS and a visiting assistant professor of psychology and brain sciences at Dartmouth College, where he teaches two undergraduate courses.
I amlooking for a picture I saw in Dartmouth Medicine—I believe in the Spring 2004 issue; it showed a knee replacement in progress. [The page with this image is reproduced above.]
I read the article in my doctor's waiting room and since then had knee replacement surgery myself. Then this year I had the earlier replacements taken out and new ones put in at DHMC. My surgeon said any removed joints are saved. I would be interested to know why mine lasted only two years. I have had 16 knee surgeries, including four replacements, and I like to stay informed so I can make better choices in the future.
Dartmouth has the world's largest collection of "explanted" orthopaedic devices; many advances in the design of artificial joints have come about from analyzing patterns in their failure.
RICE is nice
I read your article about improving health care in Vietnam and am very interested in the project. I've been to Vietnam a few times and have seen how unprepared the local hospital facilities are. I would like to be involved in the improvement of the country's health care. Who should I contact about RICE?
Hungyen Le Nguyen, DC '09
The DMS project Nguyen refers to—RICE, for Remote Interaction, Consultation, and Epidemiology—is using smartphone technology to link rural clinics in Vietnam with regional hospitals. See "Who would import RICE to Vietnam?.
People are super-nice
My son is doing a fellowship in oncology at DHMC, and I recently had a chance to visit him there. It was my first time in New Hampshire, and I don't think I've ever met as many super-nice people. While I was there, my son let me read his copy of Dartmouth Medicine, which I truly enjoyed. Would you put me on your mailing list?
The reading is good, too
I just had a visitor from California who read your magazine while he was here. He was extremely interested in several of the articles and was very happy to hear he could get on your mailing list.Would you please add him? I have received Dartmouth Medicine for many years and find it excellent reading.
White River Junction, Vt.
We're glad to add interested readers to our mailing list. See the box on page 2 for details.