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David Goodman, M.D.: Counting all doctors
Five minutes after his parents brought him to the hospital in Colebrook, N.H., the two-month-old baby's heart stopped beating. He was fighting Haemophilus influenzae type b, a leading cause of bacterial meningitis in children under five years old. Dr. David Goodman and a team of nurses stabilized the baby, then bundled him into an ambulance for the two-and-a-half hour ride to Mary Hitchcock Memorial Hospital.
The year was 1984. Goodman was fresh out of residency and working with the National Health Service Corps as the sole pediatrician for all of Coos County—1,800 square miles in the wilds of northern New Hampshire. He saw patients from throughout the county—in the clinic, in the emergency room at Colebrook's Upper Connecticut Valley Hospital, at the local school, and in the county jail. What he remembers most clearly, though, is that long ride with that very sick baby.
After loading the equipment he'd need—an infant warmer, a monitor, and an intravenous (IV) pump—Goodman and one of the nurses climbed into the old ambulance. Searching around inside, he discovered that it had only two electrical outlets. He needed three.
Goodman pauses as he tells the story, leans forward, and says with quiet intensity, "Two out of three. Which one do you choose not to use?" He quickly decided not to plug in the IV pump, hoping the fluid delivery could be achieved through gravity alone. He knew, however, that getting a reliable flow without a pump would be hard, especially in an infant. On top of that, the infant warmer was old and not working properly. Half an hour down the road, the baby's heart stopped again. The ambulance rushed to nearby Lancaster Hospital, but it was too late. They could not resuscitate him this time.
"A complete tragedy," says Goodman, who later was asked by the parents to be a pallbearer at their baby's funeral.
Yet out of this tragedy came two good outcomes. Goodman worked with the hospital in Colebrook and the local community to raise $9,000 for a new infant warmer. And the next year, when the first vaccine for Haemophilus influenzae type b (Hib) became available,
the manufacturer donated enough to immunize every 18- to 36-month-old child in the hospital's service area. "I feel very confident that we had 100% participation," says Goodman. Today, an improved Hib vaccine is routinely administered to infants aged 2 to 15 months.
Goodman loved being a rural doctor, but his practice in Colebrook didn't fill up as fast as he had expected. He realized that many families still took their children to a pediatrician in St. Johnsbury, Vt., an hour and a half away. He began to wonder about the importance of the local supply of physicians in a rural area and the relationship between physician availability and patients' perceptions of access, their use of health-care services, and their health outcomes.
He had a chance to explore these ideas further when he joined the DMS faculty in 1988 as an assistant professor of pediatrics. Soon after he arrived, he began doing health outcomes research with John Wennberg, M.D., director of the Center for the Evaluative Clinical
Sciences (CECS), and Elliott Fisher, M.D., a prominent health-services researcher at CECS. CECS provided fertile ground for Goodman to explore his questions about physician supply and patient access. And he appreciated Wennberg's intensity and mentorship; Wennberg, Goodman says, is "very, very good at picking out ideas that are most important from those that are merely good."
Goodman went on to earn a master's degree at CECS in 1995, and in 2003 he became the director and teacher of one of the program's courses, Advanced Methods in Health Services Research. He has also established himself as a leading expert on physician supply and the relationship between regional physician capacity and health outcomes. He has published numerous papers on these topics; has given presentations all over the U.S. and in Australia, Canada, and the United Kingdom; and has been a planning committee member and speaker for the International Medical Workforce Conference.
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Matthew Wiencke is the assistant editor of Dartmouth Medicine magazine.