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We feel very lucky to have readers who take the time to share comments, reactions, and recollections sparked by what they read in our pages. As well as readers who let us know when we, ahem, err—as is the case in the first letter below. Happily, our fact-checking process means that very few mistakes slip into print. But once in a while we prove that we're only human. Humanity is important in covering medicine as well as in practicing it . . . right?
Here a billion, there a billion
I read your Winter 2007 article about Jack Wennberg with great interest. I recall his revolutionary ideas well from my time as a DMS student in the early 1980s. I have often found his principles about variation in medical practice useful inmy role as medical director of our physician organization, in discussions with both doctors and payors.
I did note one small typo in the piece. One of the people who was quoted referred to health care as being a $2-billion industry. That should have read $2-trillion! But who's counting? (I am a huge fan of Dartmouth Medicine, by the way.)
Richard Parker, M.D.
Clearly, we weren't counting. We apologize for the error, which reminded us of Senator Everett Dirksen, who in the 1950s reportedly said, "A million here and a million there, and pretty soon you're talking real money." Parker is medical director of the Beth Israel Deaconess Medical Center Physician Organization. We appreciate his noting the error, which, as it happens, we caught before the issue was mailed—but after it was printed, so too late to fix at a cost our budget could bear (it being a few bucks shy of even a measly $2 billion). But we did fix it in our online edition.
Father knows best
I plan to forward a copy of your Winter 2007 article on Jack Wennberg to all my family members. I have a multiyear project organized to convince my adult children never to agree to a surgical procedure without first considering conservative alternatives and without getting a clear idea of the likelihood of a successful outcome from the surgical procedure.
Your article just may convince my kids that their dad's advice is worth taking—at least on health issues.
James W. Ryan, M.D., D. Phil.
Dartmouth College '57
I enjoyed the reminder of my DMS days in the Winter 2007 cover article recognizing Jack Wennberg and his pioneering work in small area variations analysis. This tribute to Dr. Wennberg resonated with me, since I credit (blame?!) my exposure at DMS to him and his work for helping to inspire me to try the then-outlandish idea of combining careers in surgery and outcomes research.
And I can't help pointing out—given the emphasis in his work on the relationship between geography and medical care—an ironically and humorously appropriate juxtaposition: the issue with Dr. Wennberg on the front cover had a real estate ad on the back cover that declared the importance of "location, location, location"!
David W. Levine, M.D.
Jousting with windmills
I was much taken by the fine article in the Winter 2007 issue about Jack Wennberg's career. I have known Jack and admired his beliefs, convictions, imagination, and dogged persistence ever since he was involved in the Regional Medical Program (RMP) at the University of Vermont.
In the 1970s, he was an administrator with access to money, and we local M.D.'s were supplicants in need of help. Those of us then practicing in the backwoods of New Hampshire and Vermont were desperate for help—any help—to improvemedical facilities and services.
So, being a jouster with windmills, I suggested to Jim Russell, a resident at Hitchcock in '53-54 and later an internist in solo practice in St. Johnsbury, Vt., and Harry McDade, also a '53-54 Hitchcock resident and later a surgeon in Littleton, N.H., that the area would be best served by one multiservice hospital and clinic, centrally located somewhere in the geographic triangle bordered by Lancaster and Littleton, N.H., and St. Johnsbury, Vt. Such an arrangement would greatly improve and expand the limited and redundant services available in the seven small hospitals that then served Cooes County in New Hampshire and Essex County in Vermont.
Jim and Harry liked the idea, and the three of us decided to approach the RMP for help. We learned that Jack Wennberg was its nearest representative, so we went to many meetings in various locations, including at the regional center in Boston, which was dominated by a skilled and officious bureaucrat.
As you might guess, all we needed (but didn't have) was infrastructure, concrete plans, political savvy, and clout—not to mention money. The RMP was our hope for the latter, and that's how we got to know Jack. He eventually realized, I guess, that he, too, was jousting with a lesser windmill and directed his energies to other, more challenging windmills. I suspect that the RMP ended up being what Kurt Vonnegut would have classified as a "granfalloon." Nothing ever came of our idea, but Jack ended up as a realistic visionary.
I greatly admire and secretly envy his accomplishments. I suggested to a friend still practicing medicine in a small town in New Hampshire that she should seek out the article. I added that I believe Jack deserves a Nobel Prize. I truly do believe that.
Robert W. Christie, M.D.
Housestaff '51-53 and '55-57
Beltway insiders, listen up
I read the article on the evolution of outcomes research in your Winter 2007 issue—every word of it. If only the folks in Washington, D.C., would do the same, and then pick up on the work from DMS and run with it.
Needs in our own backyard
As a strong believer in Jack Wennberg and his campaign to improve medical care, I liked your last issue.
The biggest problem in medicine is rural medicine. Doctors, too often, are attracted to urban practices, perhaps for monetary gain, silly social ideas, or whatever. It's fine to supply aid to needy countries, but there is a great need at home, too. Rural medicine is badly in need of some help.
Rowland French, M.D.
A valid observation
For a number of years I have been sent Dartmouth Medicine, free of charge. Please accept my thanks for the subscription. Your publication has added greatly to my reading pleasure. It is my favorite periodical. On the day that Dartmouth Medicine arrives, I cannot attend to other tasks until I have read the magazine from cover to cover. I have gained so much new information from the various articles.
In the Winter 2007 issue, I was particularly interested in the well-written story by Maggie Mahar concerning the life and contributions of Dr. Jack Wennberg. I am so glad his hard work and insights have been validated. Often those with great talent and brilliant ideas are not acknowledged during their lifetimes.
I am pleased to have the opportunity to read about all the people, places, and programs that make up DMS and DHMC. It makes me feel a firsthand connection to your great medical center and medical school.
Painter's point of view
The Winter issue of DM was, as always, fascinating. I think the staff has long since achieved the right balance between serious subjects and a dash of humor. Honestly, I can't imagine a more informative, well-edited magazine; the magazine's talented editors and writers richly deserve every award they get.
There's one element of the issue that calls for particular comment. I can't think when I've seen a more marvelous portrait than the one of Jack Wennberg. It's a rendering that, as a longago pastel painter of children, I find incredibly well done. And it's in perhaps the trickiest medium—watercolor. I hope the original is someplace where it will be widely appreciated.
That portrait (reproduced above) was the work of noted artist Bert Dodson, whose work first appeared in these pages 20 years ago—in our Spring 1988 issue. Happily, his watercolor of Jack Wennberg will indeed be hung in a spot where it can be appreciated, as it's been acquired by the Dartmouth Institute for Health Policy and Clinical Practice, which Wennberg founded.
I just finished "Braveheart," about Dr. Wennberg. What an excellent piece—hats off!
My colleague and I have spent over 30 years combined in health-care outcomes management, asking these same questions. For example, we have seen physician after physician continue (even today) to order wet-todry dressings for chronic wounds, a practice that results in delayed healing, increased pain, increased costs, and poorer outcomes. Yet physicians still order these dressings ad nauseam.
When we ask nurses to collaborate with physicians to improve wound care, many simply say, "We just follow the physicians's orders."
I once got up the courage to ask a physician in Houston why these dressings are still ordered—even though the Agency for Healthcare Research and Quality has been sending out the message since 1994 that they do not yield better outcomes (except, of course, in cases of short-term debridement, when the practice is "appropriate medical care"). He looked at me with a thoughtful expression and said, "Well, Melinda, I guess it's just a habit"!
We who are responsible for developing programs to improve health outcomes certainly do have our work cut out for us to get folks on board with something other than "habits." I only wish that most physicians felt the same enthusiasm.
Melinda Huffman, M.S.N.
Huffman is a disease management/ outcomes specialist with Miller and Huffman Outcome Architects, L.L.C. She is not related to the writer of the next letter.
Calling Norman Rockwell
I very much enjoyed the description in the Fall 2007 issue by Editor Dana Cook Grossman of her childhood doctor's office. She could just as well have been describing my dad's office in Ravenna, Ohio. He, too, took no appointments, just calling "Next." He charged only $2.00 to $5.00 per visit (often including medications) and when he began in practice had office hours every day, including Saturday and Sunday!
We may never again see the likes of a doctor working with the same office assistant and in the same office, and living in the same home (with the same wife), for well over 50 years. I was a very fortunate lad. My dad finally closed down his office in his 85th year!
I wish now that we had taken photographs of that Norman Rockwell-like setting—including the hard, white exam table and the "pill room." Fortunately, I do still have his big rolltop desk and some of the pictures from the walls of his office.
Thomas A. Huffman, M.D.
DC '48 and DMS '50
The human touch redux
I appreciated Dana Grossman's Editor's Note, "Revisiting vinyl," in the Fall 2007 Dartmouth Medicine—with its reminder that medicine involves humanity as well as technology.
I had the same kind of experience at the doctor's officemany years ago in Germany, where I grew up. And I can still see our family doctor coming into my bedroomwhen I had tonsillitis at age 10. Doctors then gave you the sense that they were personally interested in you.
For some time after that, though, it seemed that technique and theory were getting the upper hand over humanity.
But in the latter years of my work as a nurse (I amnow retired from DHMC), I began to see more emphasis on humanity—in interactions with patients and in the teaching ofmedical students. Dr. Joe O'Donnell especially, in his work with poetry and the arts, is doing much to emphasize the importance of human connections in medicine.
Science is important. But so is the human touch. I now see a renewed awareness of human needs at DHMC, and this comes through very clearly in Dartmouth Medicine.
Down memory lane
Kudos to Dr. Witters not only for his well-written article on Drs. Nathan Smith and Harvey Cushing in your Winter 2007 issue, but also for helping me recapture memories of my studies at Dartmouth and Yale. It was heartwarming to recall the significant contributions made by the two educators who were the subject of his article.
I recently had my prostate resected in a large New York City hospital and felt like a number. How times have changed.
Nicholas Procino, D.M.D., M.D.
Dartmouth College '59
Do I see me?
At my DMS class's 50th reunion last fall, my classmates and I were given, as part of our "goodie packet," a postcard featuring a painting of the intensive care unit at Mary Hitchcock Memorial Hospital.
This is the same painting that was featured in the Spring 2005 issue of Dartmouth Medicine. I'm writing because I believe the person on the far right might be me. [The painting was on the article's opening spread—which is below. The article detailed the history of MHMH's ICU, which, as far as can be determined, was the nation's first multispecialty ICU.]
In the article, the photograph on which the painting was based is identified as having been taken in 1957 or earlier. That date would have to be incorrect if it is me on the right. I was a surgical resident at Mary Hitchcock and the White River Junction, Vt., VA from July 1, 1959, to December 31, 1961, and was chief resident in the final six months of that period under Dr. Bill Mosenthal, who established Hitchcock's ICU in 1955.
I do think it may be me—the hair color, the profile and face, and the glasses, jacket, and ring all fit. In addition, the suggestion of a swelling in the individual's left jaw is consistent with the fact that I had a swollen left submandibular gland.
Could someone on the DM staff see if the date of the photo might be incorrect?
James Cavanagh, M.D.
DC '51 and DMS '52
It would be very satisfying to identify another of the individuals in that image. However, as far as we can determine, the 1957 date is correct, which means the young man on the right must be someone else.
In praise of uniformity
I had time to kill between several appointments at DHMC and luckily was able to while away most of it reading Dartmouth Medicine. (It's an excellent magazine. I enthusiastically echo the subscriber comments that are quoted in the Winter 2007 Editor's Note.)
As I sat there, I was reminded of one area of improvement that I feel could be made at DHMC—and that is to develop a dress code for nurses. While it might be unrealistic to go all the way back to the starched dresses and caps of earlier days (though there are those of us who would love it), there has to be something between that and today's casual, unprofessional, undignified individual statements.
I have felt for quite some time that nurses' appearance falls below that of other health-care professionals. And, as if to spur me on to write this, one of my appointments today began with my being escorted by a nurse wearing a pink, brown, and white print smock atop brown pants. Now I know that "brown is the new black" in fashion, but this was, to my eyes anyway, an ugly, shrill, coppery brown.
But I don't think the point is whether that particular nurse's outfit is tasteful or not; someone might love it. The point is that for everyone who finds an individualistic outfit attractive, there is someone who finds it ugly. That's what happens when any group of professionals, nurses or others, are allowed to decide on their own what is an appropriate fashion statement to make.
For uniforms to be professional and dignified and to reflect well on their wearers, they should above all be neutral and, well, uniform—like the white lab coats worn by physicians.
I'd favor a navy blue or dark green top; a white cardigan for cold weather (a variation might be a white top with a navy or green cardigan); white pants; and white clogs, sneakers, or other comfortable, practical, but tasteful footwear.
Perhaps a committee made up of patients and a cross-section of staff could take on the task of researching what's been done in the past as well as whether there currently a dress code for nurses at other medical centers, and then recommending and even designing a new look. If such a committee is ever convened, I'd love to see it include Margaret Spicer, a longtime professor of theater at Dartmouth who is about to retire as head costume designer.
As it happens, Dartmouth Medicine could give such a committee a leg up on researching "Changing Fashions in Nursing Garb"—that's the title of a sidebar to a feature in our Fall 2005 issue about the history of the now defunct Mary Hitchcock School of Nursing—an article that is, coincidentally, the subject of the next letter.
I just read the article in your Fall 2005 issue on the Mary Hitchcock School of Nursing. What a treat. I am a proud 1972 grad of the Hitchcock nursing school. My days in Hanover are some of my happiest memories. I was disappointed, though, that there was no mention in the article of the tunnel system that linked the nursing dorms to the hospital.
I'd love the contact information for the nursing school alumni group. I lost all my yearbooks during a move years ago and have lost touch with virtually all of my classmates. (They knew me as Sydney Ward; Sydney was a nickname I was given at MHMH—that's a story in itself, as is how I finished my last clinical rotation in a walking cast! Oh, what memories!)
Thank you again for a great read. I was excited to find this article. I plan to share it with my husband, which will get me telling stories—including about those tunnels . . .
Mary Ellen Ward Osler
The treasurer of the alumni association for the MHMH School of Nursing is Peter Nolette, today a wound-care nurse at DHMC. He can be reached at PeterRN@Comcast.net.
Reader falls for Fall
I would very much like to receive a copy of the Fall 2007 Dartmouth Medicine. There was an excellent story on Tim Shafer of Townshend, Vt.; he's very well known in this area. In addition, that issue had an article on Elijah Stommel, with whom my late husband had a great relationship while Dr. Stommel was treating him for myasthenia gravis; he, too, is a very caring doctor.
If we have extras of back issues, which we often do, we're happy to send out a copy; feel free to ask. We also have 10 years of back issues on our website—just go to our Past Issues.
Sharing the word
I just finished reading in your Fall 2007 issue the comprehensive and well-written article by Maggie Mahar titled "Making Choice an Option". She described the concept and process of shared decision-making so clearly that I'm sure other readers will pass the word along, as I have.
My husband and I were impressed with the process when he was considering treatment for spinal stenosis. The videos and books we were given clearly outlined the options and their risks versus (hoped for) benefits. I am a health-care professional, but my husband is not; even so, he was able to integrate the information and have an informed discussion with his medical team.
I read your publication whenever we visit DHMC. However, our health is progressing well enough that we don't need to go there as often. Therefore, I would like to be added to your mailing list so I won't miss even a single issue.
Many thanks to DHMC for the great care it provides. And thanks, too, for the wonderful way you communicate it in Dartmouth Medicine!
Hip, hip, hooray for DHMC!
I have had two hip surgeries at Dartmouth in the last six months. I was so pleased with the kindness, caring, and professionalism I experienced in all of my visits and phone calls with the professionals there. I cannot say enough good about your hospital.
Please add me to the mailing list for Dartmouth Medicine. I find it a very interesting and informative publication.
Dartmouth Medicine is a wonderful publication. I have been privileged to be able to read a friend's copy for several years. The articles and information in the magazine are so interesting, and I find the life stories that people share just wonderful. My friend has now moved away. So please, if you would, add my name to your subscription list as soon as possible. Thanks again for such a wonderful and educational publication.
Back on the list again?
Your magazine is great reading and very informative. I used to receive it, but my address changed and I'm afraid I neglected to notify you of my new one.
I'm sure I'll learn better memory skills by being a subscriber again! Please, would you put me back on your mailing list?
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