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section in this issue. See here for an example of his way with words in verse rather than prose.

Sensitive stories
I really enjoy your magazine and always learn something new when I read it!

For example, it was so interesting to read about the life of a resident; the article had good layout, interesting photos, and enough information.

Thank you also for publishing the personal stories of cancer researcher Nancy Speck's experience as a cancer patient and of writer Nancy Graff's struggle with chronic depression. We can all learn from articles like these and become more aware and sensitive. I am grateful these two individuals were willing to share their thoughts with all of us.

Paula Reynolds
Morrisville, Vt.

Dazzling photographs
I very much enjoyed the Fall issue of Dartmouth Medicine. Hilary Ryder is my daughter, so it was thrilling to see her on the cover [reproduced above]. What a wonderful story on her 24-hour day—I saw her in a new light and was dazzled by your photographer's success at capturing her concentration. I now have a new appreciation for the work Hilary and all physicians do!

Susan Furste
Wellesley, Mass.

Longitudinal learning
We enjoyed reading the Fall 2005 article titled "24 Hours on Call," about second-year resident Hilary Ryder.

Although we will be accused of being "old school" in our approach to medical education, both of us are impressed that most of the didactic teaching that the resident received occurred before 3:45 p.m. and seemed less instructional in its clinical aspects than the oneon- one contact that happened urgently in the later hours with students, attendings, and patients.

We are aware of the current concern regarding the number of hours a resident is permitted in a week and the fear of

A day on call for the resident pictured on our Fall cover drew several letters.

clinical errors. If we may be so bold, we would like to quote from a book written about Dr. Eugene Stead, who trained a previous DMS dean, Dr. Andrew Wallace. The excerpt refers specifically to the
issue of becoming overtired in medical training.

From Bloomfield's And the Pursuit of Healthcare: "'All of us had, or developed, this incredible fealty toward Dr. Stead. . . . Dr. Stead's pronouncement that there was no way to learn about disease other than by seeing patients is now falling on deaf ears. We were overworked but never overtired. I believe that patients are going to suffer in the long run because internists are simply not going to be knowledgeable enough to care for them the way we learned to.

"'Did we ever make mistakes? I honestly don't think so. . . . The system just didn't allow that to happen because every move of every student was watched over by [the residents], [the chief resident], and Dr. Stead. . . . There was just no room for errors. . . . Dr. Stead simply willed it so. . . .' Arthur Finn, M.D., [Former] Professor of Medicine and Physiology, UNC-Chapel Hill, North Carolina."

We believe—even though this is
unpopular with current residents—that there is an advantage in caring for

patients and learning clinical medicine after hours—even beyond 24 hours!

Robert Bloomfield, M.D.,
DC '73, and Elizabeth
Gentile, P.A.-C.
Winston-Salem, N.C.

Questioning the regime
Please enlighten me as to how sleep deprivation, caffeine hype, work overload, and spotty food intake by residents ("24 Hours On Call," Fall 2005) enhance the quality of health care.

How does it add to the acuity of mind necessary for the very serious decision-making residents must handle from minute to minute and patient to patient, even including a code blue? Is anyone, having gone through 30 hours of such a regime, in any condition to take to the road and drive home?

Ginger Lamontagne
Stratham, N.H.

We asked Dr. Worth Parker—who in his role as director of graduate medical education for DHMC oversees all the residency programs, to respond to the points raised in these last two letters. He replied as follows:

"I appreciate the comments by Ms. Lamontagne, as well as those of Dr. Bloomfield and Ms. Gentile. DHMC takes very seriously its responsibility to ensure that our residents are following the ACGME duty hours requirements put in force in July 2003.

"The article in Dartmouth Medicine's Fall 2005 issue presents a realistic picture of the present training situation for residents in internal medicine. The pace of inpatient medicine is undeniably hectic. We are currently looking at several alternative models of delivering education, through the process of patient care, that would limit the hours worked to less than what was depicted in this article. So the picture will look different in the near future.

"The real, ongoing challenge for medical educators is to produce physicians with the skills to manage acutely ill patients over a three-year course of training that includes fewer hours than residents historically have spent at the bedside."

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