at the end of the article—that just "being present" may be enough.

Martina Nicholson, M.D.
Santa Cruz, Calif.

Narrative masterpiece
The article "Being Present" by Robert Rufsvold in the Fall 2007 issue of Dartmouth Medicine is a masterpiece of narration, by a physician whom I knew well during his time as a family practitioner in Lyme, N.H. What a pleasant surprise it was to see him involved with Médecins Sans Frontières in the Afar region of Ethiopia—probably one of the poorest regions in the world, with only one medical facility serving a region as large as the state of Colorado.

The article reveals Dr. Rufsvold's deep empathy for the plight of the region's starving people—victims of chronic drought as well as of a plan to build a dam that will offer no succor to the Afar but will only benefit sugarcane growers whose products will provide biofuel for military purposes.

I was truly moved as I read of his efforts to provide care for over a hundred patients a day in temperatures of up to 120 degrees. Even an ordinary upperrespiratory infection could be life-threatening for these nomadic herders, and two out of five infants did not survive to their fifth birthday.

He realized that he could make only a small dent in the problems of these wonderful people, but he concluded that merely being there, fully there, was enough—though humbling to the extreme. It was the most taxing work that he had ever done, to face the impossibility of eliminating such suffering. I express my admiration to him for contributing his expertise in an effort to offset, to the extent that he could, the hopelessness of the situation.

To quote from the poem with which he ends his article: "What if we could simply live this experience, / place our hand on the door, / and before entering say, 'Use me. / Help me to do good work today.'"

I hope that Dartmouth Medical School— and Dr. Rufsvold's article—can inspire

DMS alumnus Bob Rufsvold wrote in the Fall 2007 issue about his experiences with Médecins Sans Frontières in the drought-stricken Afar region of Ethiopia.

other graduates to serve in the needy areas that are all too numerous worldwide. Such service is welcomed by the recipients and rewarding for those who serve where they are most needed.

Dartmouth Medicine has done a great service by publishing this article (as well as "Care Package" by Deborah Lee Luskin in the same issue; that article, too, is an excellent description of a service opportunity thatmay inspire a few DMS graduates).

John Radebaugh, M.D.
Falmouth, Maine

Radebaugh is an associate professor emeritus of community and family medicine at DMS. An article in the Spring 2005 issue of Dartmouth Medicine explores his own efforts to serve needy populations, from migrant farmworkers to Biafran refugees.

Evidentiary finding
I think that Maggie Mahar's article in your Fall issue, "Making Choice an Option," is

The impact of shared decision-making on individual patients and, potentially, on the health-care system was the subject of this feature in the Fall 2007 issue.

extraordinarily well-written. She outlined clearly and accurately the work at DHMC's Center for Shared Decision Making, in terms of its ethical motivation, its conceptual and empirical basis, and its practical strategies for providing patients with high-quality, evidence-based, balanced decision support and decision aids in close-call, preference-sensitive situations.

Thank you for publishing this fine article. I plan to use it in my graduate teaching at the Dartmouth Institute for Health Policy and Clinical Practice.

Hilary A. Llewellyn-Thomas, Ph.D.
Lebanon, N.H.

Llewellyn-Thomas is a professor of community and family medicine at DMS and codirector of the Center for Informed Patient Choice at the Dartmouth Institute for Health Policy and Clinical Practice (formerly the Center for the Evaluative Clinical Sciences).

Tributary follow-up
Reading the tributes to Dr. Brewster Martin, one of the North Country's stalwart family doctors [see the Letters section in the Fall 2007 issue], put me in mind of Dr. Israel "Dinny" Dinerman of Canaan, N.H. He, along with Dr. Bill Putnam of Lyme (who has been mentioned in these pages many times), was seen in the halls of Mary Hitchcock Memorial Hospital now again when I was a resident there, visiting patients and attending rounds.

"Dinny" wasn't a mentor for me. We didn't have mentors in the 1950s. But my residency advisor, Dr. John Milne, thought it might be instructive for me to sit in for a real general practitioner. Dinny wanted to attend a medical meeting, so sometime during the last months of my residency I was dispatched to Canaan as a locumtenens, to fill in during his absence.

I moved into Dinny's house and sat behind his desk during his office hours. Motherly Mrs. Dinerman fed me my meals, and the office staff held my hand.

Instructive isn't the right word for the experience. It was both sobering and terrifying. Right there was where I learned