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FACTS & FIGURES By air and by land DHART celebrates its 10th birthday sary Pap tests. If a hysterectomy

DMS researcher CO was done because of cancer, RUM PHOTOGRAPHY documents incidence Sirovich adds, having a regular of needless Paps Pap is still a good idea. But most hysterectomies are not cancer re- Ten million women who have lated. For these women, testing had hysterectomies are tested cells from the vagina, in lieu of each year, needlessly, for cervical the absent cervix, tells nothing. cancer. In most hysterectomies, Vaginal cancer is very rare, and the cervix as well as the uterus is the Pap smear was not designed surgically removed. “It doesn’t to find it. make sense to screen a woman Practice: “The interesting ques- for cancer in an organ that she tion to ask,” Sirovich says, “is It used to be called the Dartmouth-Hitchcock Air Response doesn’t have,” explains Dr. Bren- how did this practice evolve? I Team. It’s still northern New England’s only medical flight da Sirovich, an assistant profes- don’t know. In medical school, service, but now DHART stands for Dartmouth-Hitchcock sor of medicine at DMS. we were taught to do vaginal Advanced Response Team and two high-tech ground vehicles The test for cervical cancer is smears on women who had had augment the service’s two helicopters. Here’s a numerical look the Pap smear, in which a few hysterectomies. It didn’t make at DHART’s impact (“calls” are requests for service; weather or cells from the cervix are scraped sense to me, but when you’re in simultaneous calls can keep them from being completed): off and examined under a micro- training a lot of things don’t scope. Since the test was invent- make sense.” ed in the 1940s, the incidence of 7/1/1994 Sirovich and Welch, who are cervical cancer has greatly de- Date that DHART service began part of the Outcomes Group at clined. Yet for a woman without the White River Junction, Vt., a cervix, the Pap has no value, as 7 VA Medical Center, published guidelines issued in 1996 by the their findings in the Journal of the Minutes after the service started that the first call came in U.S. Preventive Services Task American Medical Association. Force pointed out. 473 / 320 Afterwards, Sirovich was inter- Logic: Yet despite their intu- viewed by more than 20 news itive logic, those guidelines have Number of flight calls / completed missions in 1994-95 outlets, including the New York been ignored. Sirovich and Dr. Times and the Associated Press. H. Gilbert Welch, a professor of 1,709 / 851 She also appeared on NBC’s To- medicine at DMS, analyzed data day Show, National Public Ra- Number of flight calls / completed missions in 2003-04 on 187,670 women who’d had dio, and CNN. hysterectomies. Their source was News: “We can be a little opti- the Behavioral Risk Factor Sur- 820 / 679 mistic,” she says, “that the pub- veillance System, an annual tele- Number of ground calls / completed missions in 2003-04 licity will make a difference, that phone survey conducted by the the awareness of both doctors Centers for Disease Control and 20 and women was raised.” The Prevention. “We looked at Pap Number of DHART staff members in 1994 feedback she’s received suggests smear screening before and after that “both parties think the oth- the 1996 guidelines came out,” 42 er one is not willing to give up Sirovich says. “The rate didn’t this practice that has become so change. It was absolutely flat.” Number of DHART staff members in 2004 universally accepted.” Doctors, She and Welch estimate that she explains, feel “it’s hard to do nearly half of the 21 million U.S. 12,885 / 8,087 less. Once people have come to women who have had hysterec- Total calls / completed missions since 1994 accept an intervention, it’s hard tomies continue to get unneces- to take it away. And screening

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JON GILBER New students bring vestigating the effects of Ginkgo earned a bachelor’s degree from biloba in preventing or delaying Columbia University.

T FOX wealth of experiences the onset of dementia in elderly Four of the ’08s are enrolled as they begin at DMS participants.” in the M.D.-Ph.D. program— Others wrote humorously of two in microbiology and two in With interests encompassing al- their roundabout journeys to pharmacology-toxicology. pine skiing, hiking, rock-climb- DMS. Irvin Sanchez was born in Other programs: The doctoral ing, swimming, logging, and kay- rural Puerto Rico, and, “after a programs in the biomedical sci- According to DMS’s Brenda Sirovich, aking, Dartmouth’s 84 first-year three-year stop at Fort Buchanan ences welcomed 45 other new some 10 million women a year who M.D. students would surely do in San Juan, where I learned to candidates—35 in microbiology, don’t need a Pap test get one anyway. well in an episode of Survivor. speak English, I moved with my six in pharmacology and toxicol- What they’ve survived, how- mother and brother to Dallas, ogy, and four in physiology. for cancer is apple pie. It has this ever, is a rigorous medical school where I ran into the first cowboy And 61 new students entered intrinsic value. Doctors aren’t application process. The new store I could find—yee-haw!” the programs of DMS’s Center willing to risk losing a patient’s students, who were selected from Sanchez later moved to the At- for the Evaluative Clinical Sci- trust by stopping it.” about 5,000 applicants, have a lanta suburb of Peachtree City, ences—18 M.S. students, 40 Another factor, says Sirovich, mean undergraduate grade point “land of golf carts and Delta pi- M.P.H. students, and three Ph.D. may be “report cards” by health- average of 3.7 in nonscience lots,” and earned a degree in mi- candidates. maintenance organizations. The courses and 3.6 in the sciences. crobiology from the University Yet regardless of which pro- Pap is one measure of high-qual- They represent 60 undergradu- of Georgia. “My personal interest gram they are entering, the new ity care for women. “To the ate institutions and 31 states, for learning about new cultures, students, like Jessica Walls, seem HMO,” says Sirovich, “the best and 13 were born outside the people, and ways of life,” he said, to be enthusiastic about being at doctors are the ones with the U.S.; 58% are women, 42% are “is matched only by my love for DMS. “My combined experi- highest number of Pap tests.” But men, and over 25% are of color all things baked, especially bread ences,” she wrote, “leave me in- report card databases often don’t or international students. —Atkins Schmatkins.” spired and excited for the won- note hysterectomies. But the numbers tell only Rigors: For some students, the derful years that lie ahead.” Finally, doctors worry that part of the story. The brief auto- path to medical school involved Matthew C. Wiencke without the pull of a yearly Pap, biographies the ’08s wrote to in- rigors far beyond those of the ap- women may not come in for a troduce themselves to each oth- plication process. Deogratias Ni- Below, team-building exercises like this checkup. “It’s something to keep er reveal a wide range of experi- yizonkiza, who grew up in Bu- are part of the orientation-week activi- in mind,” Sirovich concedes, ences. The class includes a rural rundi and started medical school ties for the first-year M.D. students.

“but if it’s worthwhile to see your engineer who worked in the Hi- there, wrote, “I was doing a clin- T doctor every year, it’s not worth- malayas, an oceanography in- ical clerkship in a hospital with while to spend all your time get- structor, a military police officer 750 beds, where 70% of the RA HEBER

ting an unnecessary Pap smear who served in Bosnia and Croa- patients were infected with MEDO and discussing it. There are a lot tia, a registered Maine guide, and HIV/AIDS, TB, and other op- of patient-driven issues that 11 EMTs. One student was a portunistic infections.” But Niyi- could benefit from having more Peace Corps volunteer in Nepal zonkiza had to flee Burundi dur- time addressed to them. and another was the in-country ing a period of political genocide Time: “We are not advocating coordinator of NASA’s Large and made his way to the U.S., stopping Pap smear screening for Scale Biosphere-Atmosphere “homeless, speaking not a word women who have a cervix,” she Experiment in Amazonia. of English,” but still hoping to emphasizes. “We just want to Many, like Laura Shiveley, complete medical school. After make the practice more rational. have research experience, too. volunteering at a hospice and a As doctors, we want to use our She majored in biology at the nursing home, learning English, resources better—and our main University of California at Davis and working to support the rest resource is time.” and after her graduation was “a of his family while they were still Nancy Marie Brown postgraduate researcher . . . in- in refugee camps, he eventually

4 Dartmouth Medicine Fall 2004 vitalsigns

Study of innovative first of its kind, the study now of the electromagnetic spectrum, gives the investigators essential these modalities detect differ- breast-imaging methods data on tissue characteristics in ences in a tissue’s electrical prop- gathers benchmarks non-cancerous breasts of varying erties—its permittivity (its ca- JOSEPH MEHLING age and composition, thereby pacity to store an electrical Three out of four women who providing baseline information charge) and conductivity—and undergo a breast biopsy turn out for future studies of these tech- in its light-scattering and -ab- not to have breast cancer. But niques. sorption properties. Certain tis- one out of four asymptomatic The researchers hope that sue characteristics can indicate if Radiologist Steve Poplack, left, and en- breast cancers is not detected by these new techniques will “im- cancer is present or not. For ex- gineering professor Keith Paulsen, mammography. Although star- prove characterization of breast ample, NIR spectroscopy, which right, are collaborating to find more ef- tling, these are not new findings. disease,” says Poplack. “If some- measures light scattering and ab- fective alternatives to mammography. They are, however, the impetus one has a lump or a mammo- sorption, allows researchers to behind growing national and in- graphic abnormality, [the hope is map the total hemoglobin con- order to judge the sensitivity of ternational research that’s aimed that] we could say that based on centration and saturation in a the modalities. “We can estimate at finding more accurate meth- these alternative exams there’s section of tissue. This is of “par- that reasonably well,” says Paul- ods to detect and diagnose breast no chance there would be breast ticular clinical interest,” states sen. “But in this next round, we cancer. cancer here and therefore it does the Radiology article, since high want to do more accurate so- “Unfortunately, what often not need to have a biopsy.” And hemoglobin concentration is as- called registration between the gets quoted to the public is that beyond the prospects for better, sociated with angiogenesis in a alternative images and . . . con- mammography is 90% sensitive more accurate detection of can- tumor—the process by which it ventional imaging.” This will al- and we can find a cancer that is cer is the opportunity to learn develops blood vessels to feed its low for refinement of the equip- the size of a head of a pin, which more in general about breast dis- voracious appetite. ment before the next tests. is true in certain people,” says ra- ease, breast structure, and breast Clinical trials: The initial clini- Poplack and Paulsen are also diologist Steven Poplack, M.D., function. cal trials of NIR, EI, and MI ap- nearing completion on another who is codirector of breast imag- Unlike mammography, NIR, pear promising. The research study of 150 women. Half of the ing/mammography at DHMC. EI, and MI do not involve ioniz- team has already encountered women have breast abnormali- But, he adds, “that’s not the ing radiation—which in theory some subtle breast cancers that ties and are slated for biopsies, whole story. . . . [Mammography] may harm the breast, though no are “very conspicuous” when us- while the other half, of corre- does have downsides, and it has studies have shown this conclu- ing one or more of the new sponding ages and breast densi- room for improvement.” sively. (A fourth method, mag- modalities. But many larger trials ties, are a control group. These New types: For the past five netic resonance elastography, is will be needed to determine results should indicate whether years, he and Keith Paulsen, also being explored by the re- whether the techniques have sig- there is a difference in the way Ph.D., a professor of engineering, search team but was not includ- nificant value in breast cancer the techniques work in diseased have been examining three new ed in this study.) detection and diagnosis. and in healthy breasts. types of spectroscopic breast “We don’t really know if ra- Paulsen notes that one of the The team hopes, says Pop- imaging—near-infrared (NIR), diation at a very low level . . . challenges facing the group “is lack, in five years to be able to electrical impedance (EI), and truly causes cancer in the that the mammogram is done in make “some pretty definite rec- microwave imaging (MI). Their breast,” explains Poplack. “We a completely different geometry.” ommendations about which of most recent paper, of which think that it might, and I should Mammography requires com- these modalities, either alone or Paulsen was the principal author, add that the risk-benefit of mam- pression of the breast, whereas in combination, should be tried appeared in the May 2004 issue mography is far in favor of doing the new procedures do not (and in a multi-institutional trial as of Radiology. mammography. But, having said that’s a plus, since the compres- the next big step.” Poplack and Paulsen’s team that,” he adds, “it would be nice sion is very uncomfortable for For the time being, their most collected data for each imaging to have an option where you many women). But that means recent published study remains a technique from 23 women who didn’t have to expose the breast researchers must calculate how “small step but an important had no clinical or mammograph- to ionizing radiation.” regions of the breast correspond step,” adds Paulsen. ic findings of breast cancer. The By operating in other regions among the various procedures in Jennifer Durgin

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Doctors’ Office Building contains more space ASHBURN and appealing features ALL: MARK W After more than three years of planning, construction, and an- ticipation, the new DHMC Doc- tors’ Office Building opened to the public in August. The 160,000 square-foot ad- dition, together with the new 90,000 square-foot East Mall, which connects the new facility to the old, boasts an abundance of natural light, stunning works 1 2 of art, much-needed new space, and many functional details. For example, a sound-deadening structure known as a “cloud” floats above the service desks in the relocated DHMC Pharmacy to provide more privacy when patients order medication. Larger: The new exam rooms are about 10 percent larger and incorporate accent walls painted in soothing colors instead of the standard institutional off-white. And lower counters at reception desks and enlarged waiting areas aim to accommodate wheel- chair-bound patients. 3 4 The most appealing features lie on the sixth floor, the new home of the pediatric specialties and the Children’s Hospital at Dartmouth (CHaD) Outpatient Center. Adorned with holo- grams, kaleidoscopes, and bright- ly colored glass fish dangling from the ceiling, the sixth floor feels more like an interactive children’s museum than a pedi- atric clinic. To the right is a photograph- ic sampling of the new space. Jennifer Durgin 5 6

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BIRD-WATCHING AT DHMC hen Laurance Rockefeller died at age 94 in July, he mer- W ited a full-page obituary in the New York Times. It de- scribed his illustrious family (including his late brother Nelson, a 1930 graduate of Dartmouth College and vice president un- der Gerald Ford). It noted Laurance’s suc- cessful career in finance. And it detailed the philanthropic causes to which he was devot- ed—including conservation and ecology. What the Times didn’t mention was an es- pecially creative gift that he made to DHMC upon the opening of its Lebanon campus in 1991: 47 framed Audubon prints of birds of North America. It 7 wasn’t the gift’s size that set it apart—Rockefeller and his wife, Mary, gave large sums to any number of causes, including oth- 1 Patients who need assisted parking 8 ers at Dartmouth. It was its inventiveness. The new building’s can drive right up to the entrance of the soaring spaces and wooded setting were a perfect foil for the new Doctors’ Office Building. 2 Inside, striking images—a yellow-crowned heron, a white ibis, a barred a dramatic three-story mobile by Seat- eagle. And the gift grafted the Rockefellers’ concern for nature tle artist Koryn Rolstad softens the and love for art onto their interest in the Upper Valley—where stairwell linking levels four, five, and Mary Rockefeller had deep family roots on land that is now the six. 3 Six panels of translucent odds and ends inspire children in the CHaD Marsh-Billings-Rockefeller National Historic Park. Outpatient Center to play “I Spy,” while Thousands of patients, visitors, and staff walk past DHMC’s 4 binoculars stimulate their curiosity in Audubon prints every day, but probably few realize that they’re the world outside. 5 & 6 Expanses of the real thing—the work of noted naturalist John James Audu- windows, sage-green accents, and light- bon himself. Or that they’re there to be enjoyed by all thanks ly stained wood trim help unite the new to the generosity of another noted nature lover. A.S. East Mall with the natural landscape surrounding DHMC. 7 A massive yet 9 warm architectural space, the East Mall connects the new clinical offices with the LOTS OF BIKES AND BANANAS existing outpatient clinics, the inpatient ometimes, a few numbers tell the whole story. Here are some towers, the Cancer Center, and the still- under-renovation Emergency Depart- S from the 23rd Annual Prouty Bike Ride and Fitness Walk, ment. The Norris Cotton Cancer Center, a benefit for Dartmouth’s Norris Cotton Cancer Center: 1,087 featuring a 100,000-square foot addi- (people who biked or walked in the event); 820 (bikers); 306 tion that opened in late 2003, includes (bikers who did the full 100-mile course); and 205 (volunteers). 8 a redesigned Garden of Hope, pro- Then there’s the donated food that fueled the effort: 1,000 viding a quiet place for healing and re- (bananas); 750 (apples); 2,900 (chocolate and energy bars); flection. 9 The new parking garage, 2,500 (bottles of water); and 3,050 (burgers and sand- right next to the Doctors’ Office Build- wiches). And of course there are the results: 52,250 ing, accommodates 540 vehicles and (miles covered); 62 (teams entered in someone’s provides patients with convenient access memory or honor); and 101 (sponsors and donors). to their appointments. Upon completion Not to mention 362,000 (dollars raised). of the Emergency Department expan- sion in October, 10 the new East En- But the most important numbers are these: 132 (Norris Cot- trance will offer a comfortable waiting ton researchers); 194 (clinical trials run under Cancer Center area and an easily accessible pick-up auspices); and 3,300 (new patient visits annually) A.S. and drop-off site for patients. 10

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LAURELS FOR THE MAGAZINE “Student for a Day” “Suddenly medical school seemed a lot less intimidating,” artmouth Medicine was the recent recipient of two na- program hopes to said Keene State student Allen D tional awards in the Association of American Medical Col- recruit rural physicians Wellington. Less intimidating, leges (AAMC) Awards for Excellence Competition. perhaps, but very busy. Like real A feature by Associate Editor Laura Stephenson Carter ti- When three undergraduates medical students, the visitors tled “Puzzling Over Medical Mysteries” received the AAMC’s from New Hampshire state col- hurried from rounds at DHMC highest writing award in the General Staff Writing category— leges were invited to be Dart- in Lebanon to classes on the the Robert G. Fenley Award of Excellence. An mouth “Medical Students for a DMS campus in Hanover and DARTMOUTH MEDICINE A Magazine for Alumni and Friends of Dartmouth Medical School and Dartmouth-Hitchcock Medical Center Summer 2003 inside look at the Department of Medicine’s Day,” they discovered that med- back to Lebanon for afternoon weekly M&M, or morbidity and mortality con- ical school was not as scary as clinics. UNH student James ference, it was the cover article in the Summer they’d expected it would be. Wylie shadowed an ophthalmol- 2003 issue. The AAMC judges called the story Now there’s a good chance that ogist, who let him look into pa- “a fascinating look at physicians working togeth- they’ll apply to medical school. tients’ eyes and then explained An inside look at how doctors puzzle through medical mysteries er to figure out a vexing case.” This is the second And, as an added bonus, they what he was seeing. Steve Skin- award for the article, which won a Will Solimene may choose to practice medicine ner of Plymouth State enjoyed Award for Excellence a few months ago from the New England in rural areas that are desperate- going on rounds with the inter- chapter of the American Medical Writers Association. ly in need of physicians. nal medicine team. “We all met In addition, the magazine as a whole received an Award of Studies have shown that stu- in front of each patient’s room Distinction in the AAMC’s External Audience Periodicals cat- dents from state institutions are and discussed the patient, then egory. The judges commented that “it’s interesting to see that more likely to enter rural prac- entered the room and checked such a variety of content is put together so professionally for the tice than students from private up on the patient,” he explained. small cost.” Both awards will be presented at the AAMC’s an- colleges, according to Donald Wellington attended rounds and nual meeting in Boston in November. A.S. Kollisch, M.D., and Susan Lin- clinics in psychiatry. sey, M.A., codirectors of DMS’s While seeing patients was a Rural Health Scholars Program, A DIFFERENT KIND OF CAMP which prepares medical students to be leaders in providing med- n early August, 15 New Hampshire high schoolers gave up a ical care to rural and underserved I few precious summer days to attend the first annual Dart- populations. They dreamed up mouth Health Careers Camp. There were no s’mores or sing-a- the “Medical Student for a Day”

longs, but the participants enjoyed the four-day camp all the initiative as a way to entice qual- YING SQUIRREL GRAPHICS FL same. It featured tours of DHMC and its research labs; talks by ified students in the state college specialists in family medicine, epidemiolo- system to consider attending gy, radiology, and nursing; and a picnic medical school. The participants where campers got a chance to mingle with came from Keene State, Ply- Dartmouth medical students. mouth State, and the University Donald Kollisch, M.D., an associate pro- of New Hampshire (UNH). fessor of community and family medicine, Observe: Several DMS Rural received a particularly warm response from the teens for his talk Health Scholars—medical stu- about rural health-care careers. “They were able to relate to dents who are interested in rural that and see the promise in that,” says second-year DMS student health care—hosted the visitors, Stewart Mackie, who organized the camp under the auspices of who got to observe doctor- the New Hampshire Area Health Education Center (AHEC). patient interactions at outpa- Increasing awareness about careers in health is one of AHEC’s tient clinics, accompany physi- primary goals. Over the next year, AHEC officials will also help cians on rounds at DHMC, at- The DMS Rural Health Scholars at left the campers work on their college applications. J.D. tend classes, and spend time with showed a good time to the visiting small groups of medical students. “medical students for a day” at right.

8 Dartmouth Medicine Fall 2004

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new experience for the visitors, Palladium coils show the classes didn’t seem all that different from the undergraduate promise in treating courses they’re used to. “The cancer of the prostate depth that the class went into Cyber noms de plume reveal a sense of humor did not seem like it was hard,” or better or for worse, e-mail is the modus operandi of com- Prostate cancer, like many can- said Skinner, who attended a lec- F munication these days. But that doesn’t mean electronic cor- cers, can be treated with surgery, ture on infectious diseases and respondence has to be void of personality. Consider the e-mail chemotherapy, radiation, or var- sat in on some small problem- aliases that the following DMS faculty have chosen for com- ious combinations thereof. The solving groups. municating within the Dartmouth e-mail network: implantation of “seeds”—small The Dartmouth students radioactive particles—into pros- Allergist Harold Friedman, M.D., acquired his nick- pointed out, however, that while Happy Hal: tate tumors is one common and name during his residency at the University of Michigan, where each lecture isn’t that difficult to often effective treatment. he was a self-professed “charter member of the ‘Walking De- comprehend, there is a lot more But a new twist—quite pression Club.’” Today, Friedman, an associate professor emer- Twist: material to learn in medical literally—improves on the con- itus of medicine, admits to cracking the occasional smile. school than in college. “You cept of delivering radiation in- have to find a way to keep it all EoE, Q: “‘EoE’ stands for ‘Expert on Everything,’” says Timothy ternally by using a coil instead of in your head,” Rural Scholar Quill, M.D., a professor of anesthesiology, “a title conferred by seeds. It targets the radioactivity Christine Castro advised during my wife. I think she was being sarcastic, but I sort of liked the more precisely and thus delivers a debriefing session at the end of implication anyway.” Quill also goes by “Q,” after the James more to the tumor and less to the day. Bond character Q—the ultimate gadget guy. surrounding tissues. The device But most of all, the was developed with significant Balance: The mantra for triathletes is swim-bike-run. visitors were impressed with how Swimbikeraptor: input from Dartmouth investiga- Though a devoted triathlete, Anna Adachi-Mejia, Ph.D., a re- friendly the DMS students were tors, and DHMC patients were search coordinator in pediatrics, would rather bike than run, so and how they seem able to bal- the first anywhere to receive the she’s adjusted the usual slogan. “The word raptor makes me ance work with play. “There was new coils. think of adventurous high-flying energy,” she says. Her moun- clearly a great deal of cama- The implantation of conven- tain bike, Velociraptor, provided the inspiration. raderie among students,” said tional seeds involves placing ra- Wellington. “They were tossing SkyNMR: Jeffrey Dunn, Ph.D., an associate professor of radiolo- dioactive palladium seeds in a Frisbees, playing wall ball, and gy, doesn’t like “living as a mole in a dark tunnel,” a reference hollow hypodermic needle. Un- shooting hoops. My conception to the fact that many radiology facilities are underground be- der local or spinal anesthesia, the of medical school life was one of cause of the shielding they require. But Dunn managed to get needle is inserted in the perineal all business and no play, but here DHMC’s nuclear magnetic resonance (NMR) equipment lo- area, the space between the anus were students taking time away cated on the seventh floor of Vail. “The system is sited higher and the scrotum, and positioned from the library and the labora- off the ground than any other that I know of,” he says. “It’s clos- as carefully as possible using tory to enjoy a beautiful day with er to the sky, so we called it ‘SkyNMR.’” transrectal ultrasound and fluo- friends.” roscopy visualization. Then the In an attempt to escape a “chronically low” self-es- DMS student Castro agreed, Massimiliano: seeds are “planted” in the target teem and the burden of a “short, unusual, and perhaps even saying the premeds seemed “sur- area. Scans are taken both before somewhat odd name,” Roy Fava, Ph.D., a research associate prised about how active med stu- and after implantation to con- professor of medicine, created an alter ego, Massimiliano. The dents are outside the classroom firm that the seeds have been name was borrowed from a concert pianist in Ravello, Italy. with things like volunteering correctly placed. “But it doesn’t seem to have changed a thing!” laments Fava. and outdoor activities.” This internal approach to de- Kollisch and Linsey plan to Yet whether they’re inspired by irony, innovation, or an alter livering radiation is called host Medical Students for a Day ego, these and other cyber noms de plume suggest that a sense brachytherapy; the radiation is several times during the coming of humor is alive and well at DMS and DHMC. delivered continuously, over a academic year. Jennifer “Junipertrails” Durgin prolonged period of time, in Laura Stephenson Carter close proximity to the target tis-

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experimentally by DMS faculty Two DMS researchers ject.) While the FDA expressed members Jack Hoopes, D.V.M., strong interest in Schwartz and Ph.D., and David Gladstone, establish and endorse Woloshin’s proposal, the agency Sc.D.—RadioMed finally settled drug information box wanted to know if patients could on a coil made of palladium. understand and make use of effi- The device looks like a very “The clams were the only ones cacy data. fine wire but is actually a micro- that benefited from my arthritis,” Box: To answer the FDA’s in- coil. According to Hoopes, says the clam digger in a Vioxx quiries, Schwartz and Woloshin “Coils had two potential advan- advertisement. collaborated with Dr. H. Gilbert This fluoroscopic image shows a pros- tages over seeds: greater stability The first page of the magazine Welch, a DMS professor of med- tate implanted with palladium micro- after placement in the tissues ad is a splash of color. The flip icine, to adapt three real-life ad- coils (the fine gray lines)—a brand new and improved dosimetry from side, however, is a sea of black- vertisements for the drugs Vioxx, technology developed at Dartmouth. the long strand versus that of a and-white text, known as the Pravachol, and Plavix. They small sphere.” “brief summary,” detailing the changed the names of the drugs sue. External radiation, by con- Testing: First, extensive testing side effects of the drug (the and created two versions of each trast, is delivered in short bursts, for safety was done in animal brand-name version of rofecox- ad—one with a benefit box and at much higher doses, daily over models. Hoopes says that dogs ib). Even if average consumers one without it. (See below for a period of several weeks. suffering from enlargement of read and understood this sum- the pseudonymic Vioxx ad and In brachytherapy, however, it the prostate were chosen. “Pure- mary, they would still not gain a information box.) is hard to position the radioac- bred beagles have a prostate realistic sense of how well the The efficacy data for each in- tive source to both maximize ra- much like humans,” he says. drug works, according to Drs. formation box was gleaned from diation to the tumor and mini- The human first patient re- Lisa Schwartz and Steven Wolo- the randomized trials conducted mize the exposure of adjacent ceived an implanted coil in May shin. They are both DMS associ- to gain FDA approval of the normal tissue. And even with 2004, and four of the procedures ate professors of medicine based drugs. After viewing each ver- the best positioning techniques, have been done since then. at the VA Medical Center in sion, participants were asked to there is always some uncertainty DHMC is still the only institu- White River Junction, Vt. rate the effectiveness of the drug; about the precise placement of tion in the world using the new “[Direct-to-consumer drug they were also asked how useful the seeds; for example, the pro- microcoils. The coils’ availabili- advertisements] talk about bene- and understandable they found cedure results in some swelling of ty, however, limits the number of fits in these vague ways, but it’s the benefit box. In addition, par- the prostate gland, which can patients who can receive them rare that you’ll find data,” ex- ticipants’ ability to understand change the geometry of the seeds for the time being, for they must plains Schwartz. “If you do find the facts in the box was evaluat- relative to the tumor. And even be produced in an experimental data, it’s rare that it’s in a bal- ed with a test. if the seeds are placed precisely reactor in Belgium. RadioMed anced, understandable format. The results were dramatic— in the beginning, they have a has plans to build a reactor in the How can you decide whether it’s tendency to migrate within the United States, but that solution worth exposing yourself to prostate tissue over time. Still, is several years away. harms, if you don’t know what there is a far smaller risk of dam- Future: Also in the future is you are getting?” age to the urethra, rectum, and testing of the coils with other For the past few years, the bladder with brachytherapy than cancers; as is the case with seeds, husband-and-wife research team with external radiation. it is likely that palladium coils has been urging the FDA to ask So a Boston medical-device can be used to treat tumors in or- pharmaceutical companies to in- company called RadioMed Cor- gans other than the prostate. clude efficacy data—information poration recently decided to see When that happens, DHMC is about a drug’s benefits, not just if there was a better internal op- ideally positioned to carry for- its side effects—in all printed tion than seeds. The firm turned ward both the experimental and direct-to-consumer ads. (See the to DMS to help it develop the the clinical evaluations of these Spring 2002 issue of Dart- concept. From an array of possi- new applications. mouth Medicine for details of ble shapes—many of them tested Roger P. Smith, Ph.D. their earlier study on the sub-

10 Dartmouth Medicine Fall 2004 vitalsigns FL 93% of respondents preferred the bo, they underrated that one- Faculty members YING SQUIRREL GRAPHICS benefit box to the “brief summa- percentage-point difference, not ry,” and 95% to 97% answered recognizing that the drug actual- join the ranks the test questions accurately. But ly reduced deaths by 25%. of the “retired” perhaps the most intriguing find- “The paper by Woloshin and ing was that the box changed colleagues makes some intrigu- What do a psychiatrist, a pathol- participants’ perceptions of how ing suggestions,” wrote Pat Kelly, ogist, an anesthesiologist, and a well a drug works. a vice president of Pfizer, in an biochemist have in common? Lower: “Perceptions of drug ef- opinion piece in the same issue They are DMS’s newest emeritus fectiveness were much lower for of Health Affairs. “But it also faculty members and are now Emeritus status means no more paper- ads that incorporated the benefit shows that many consumers lack embarking on one degree or an- work for psychiatrist Silberfarb, above. box than for ads that did not,” the context required to judge if a other of retirement. wrote Schwartz and Woloshin in medicine that reduces overall Peter Silberfarb, M.D., chair of Vermont Institute of Natural their article, published as a Web mortality over five years from 4% psychiatry from 1984 to 2003, Science, and the Norwich, Vt., exclusive by the journal Health to 3% is a medical miracle or a joined the faculty in 1973 after Conservation Commission. Affairs. For example, the per- waste of money.” completing his residency in psy- Walter Noll, M.D., a patholo- centage of participants rating Interpret: Schwartz argues that chiatry at DHMC. In 1974, he gist, is widely known for his re- Vioxx as “extremely or very ef- lay individuals can and will be became the first psychiatrist in search in diagnostic molecular fective” dropped from 65% to able to interpret such data, if the U.S. to work full-time for a genetics and predictive gene 28% after they saw the benefit- they are exposed to it. “When cancer center. He cofounded the testing. Less well known may be box version of the ad. “The pres- [the nutrition facts label] came field of psycho-oncology, the his work on a task force that re- ence of the benefit box also out, a lot of people wondered study of the emotional effects of organized DHMC’s pediatric ser- caused many more respondents whether people could make cancer and its treatment, and vices and invented the acronym to correctly rate the effectiveness sense of this information,” she made many contributions to the CHaD for the Children’s Hospi- of [Vioxx] as being ‘about the says. “There has to be a learning literature on the subject. tal at Dartmouth. same’ as that of ibuprofen,” the curve,” she insists. He’s past president of the Before coming to DMS in authors continued. So which is worse: overesti- American Board of Psychiatry 1973 to run the Clinical Chem- But Schwartz and Woloshin mating or underestimating the and Neurology and of the Amer- istry Laboratory, Noll ran a U.S. noted that participants failed to benefit of a drug? “It’s hard to ican Association of Chairs of De- Army research lab in Bangkok. understand the significance of know which direction is more partments of Psychiatry, and past In 1985, he established DHMC’s certain data. For example, when harmful,” says Woloshin. “The chair of the National Psychiatry Molecular Genetics Diagnostic study respondents looked at the idea here is to help [people] get Match Review Board. Laboratory. His work in molecu- 3% mortality rate in people tak- accurate estimates.” During his tenure, DMS con- lar genetics was stimulated by his ing Pravachol, a cholesterol-low- The team presented its find- tracted to supply psychiatric care interest in a family affected by fa- ering drug, and the 4% mortali- ings to the FDA in September to the New Hampshire psychi- milial thyroid cancer. ty rate in people taking a place- 2003, but the agency has taken atric hospital, the state prison In “retirement,” Noll is serv- no steps to incorporate drug ben- system, and the Augusta Mental ing as medical director and vice Everything in the ad at left is real ex- efit data into direct-to-consumer Health Institute in Maine. And president of medical services at cept the name of the drug. Two DMS ads nor to conduct a national on Silberfarb’s watch, the sec- Myriad Genetic Laboratories in researchers would like to see the infor- test of the more detailed drug in- tions of behavioral medicine, Salt Lake City, Utah. He still has mation box below be a part of such ads. formation box that Schwartz and sleep medicine, child psychiatry, a home in Etna, N.H., however, Woloshin originally proposed. and neuropsychiatry-imaging be- and gets back to the Upper Val- So the pair are making plans came nationally recognized. ley as often as he can. to conduct a larger study on their He plans to continue his re- Kenneth Travis, M.D, an anes- own, while also doing their best search in psycho-oncology and thesiologist, was in private prac- to raise public awareness about spend more time working for the tice in Massachusetts before the issue. conservation nonprofits he loves coming to DMS in 1992. He Jennifer Durgin —the Nature Conservancy, the trained under several legendary

Fall 2004 Dartmouth Medicine 11 signsvital

figures in anesthesiology and res- Cancer biologist and lab with ability but is clearly very piratory care at the University of green . . . to watch them grow Virginia and Massachusetts Gen- cancer survivor is scientifically over the next sev- eral Hospital. He contributed to named to Carroll Chair eral years, to the point where describing the association of up- they understand the details of

per airway obstruction and pul- Nancy Speck, Ph.D., has studied their project probably better YING SQUIRREL GRAPHICS monary edema in children and the biological mechanisms of than you do.” She especially en- FL focusing attention on the aging cancer for years. She has men- joys mentoring women because Nancy Speck, second from right, was re- anesthesia workforce. tored many young cancer re- of the tough choices women sci- cently appointed to Dartmouth’s James His retirement plans include searchers. She is associate direc- entists have to make when bal- Carroll Professorship in Oncology. hiking, biking, and visiting fam- tor of basic sciences at DHMC’s ancing career and family. ily. He is an amateur photogra- Norris Cotton Cancer Center. “[Nancy] arrived at a crucial they are,” she says. “It has cer- pher and writer, too. “I keep And she is herself a cancer sur- moment in my career, when the tainly made me more dedicated pecking away at a short-story se- vivor. All those threads of her decision to go for it, ‘it’ being an to the Cancer Center.” quence for the grandchildren,” life came together with her ap- independent position as a scien- Speck has also made many he says. He also serves on a task pointment on July 1 to Dart- tist, had to be made,” says Uni- contributions in the administra- force on aging for the American mouth’s James J. Carroll 1948 versity of Oxford researcher tive realm. She cochaired the Society of Anesthesiologists and Professorship in Oncology. Marella De Bruijn, Ph.D., who committee for the recent Cancer hopes to teach part-time. Being named to an endowed first met Speck at Erasmus Uni- Center expansion, chaired the Oscar Scornik, M.D., Ph.D., a chair is one of academe’s highest versity. Speck was studying committee for wet-lab space al- biochemist, began his career in honors. Speck, who has been on hematopoietic stem-cell emer- location in the addition, and is the 1960s at the National Re- the DMS faculty since 1989, is gence in mouse embryos as a the founding director of the search Council of Argentina, known internationally for nam- Fogarty Fellow, and she encour- Cancer Mechanisms Research then did a postdoctoral fellow- ing and describing core-binding aged De Bruijn to come work in Program at Norris Cotton. ship at Harvard under noted bio- factors, as well as for more recent her lab at Dartmouth. “What in- She has received numerous chemist Mahlon Hoagland, work with hematopoietic stem- fluenced me most was, I think, national honors and grants, in- M.D. When Hoagland became cell development and mutation. the personal exchanges we had cluding a prestigious Leukemia chair of biochemistry at DMS in Hematopoietic stem cells are about her own career and how and Lymphoma Society grant. 1968, he convinced Scornik—by precursor cells that develop into she succeeded in her work.” She also helped her department that time back in Argentina—to blood cells. Mutations within Genes: Trained as a basic sci- secure a National Institutes of take a job at Dartmouth. Scornik these cells, as a result of mutated entist, Speck did not intend to Health predoctoral training has been at DMS ever since. genes and altered proteins, can become a cancer researcher but grant, a benchmark of quality in His research has focused on cause some types of leukemia. stumbled into the field when the graduate programs. protein synthesis and the regula- In addition to contributing to two genes she was studying were A graduate of Western Mary- tion of protein content in mam- the study of leukemia, Speck’s re- found to have a direct link to hu- land College, now McDaniel malian cells. His lab’s studies of search on gene mutations has man cancer. Basic scientists of- College, and of Northwestern ways to minimize the require- provided strong supporting evi- ten view clinical science as a bit University, Speck trained as a ments of dietary protein in mice dence for the hypothesis that mundane, Speck admits. postdoctoral fellow at the Mass- have implications for humans in hematopoietic stem cells devel- But her perspective changed achusetts Institute of Technolo- situations when food is scarce or op from endothelial cells. dramatically in 2001, when she gy’s Whitehead Institute before when protein intake should be Speck is also devoted to shar- was diagnosed with breast cancer joining the DMS faculty. restricted, as in kidney or liver ing her love for the lab with oth- and experienced the anxiety and Endowed: The Carroll Profes- disease. ers. Her passion for mentoring fear that accompany such a diag- sorship was endowed in 1979 in Scornik will keep teaching young researchers is evident nosis. “When you are in the po- James Carroll’s memory by his and writing but isn’t sure what from the way her eyes light up sition of being a patient and re- Dartmouth College ’48 class- else he’ll do—yet. “It’s too early when she talks about her gradu- liant on the information that’s mate Samuel Noble. Speck is the to be more specific,” he says. ate students. “I love it,” she says, gained from those trials, you third incumbent in the chair. Laura Stephenson Carter when a student “comes into the come to realize how important Jennifer Durgin

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Voices are raised Highlights from the Class Day Addresses in celebration of graduating students Judah Folkman, M.D. which is most important from our patients. They Julia Dyckman Andrus Professor of Pediatric Surgery and have taught us about their diseases, they have “The one voice missing is that of Professor of Cell Biology at Harvard Medical School shared their stories of illness, they have sat be- the people whom we will serve From now on, patients will continue to be your fore us naked physically and emotionally and some day soon,” said M.D. grad- teachers. . . . There is a debt that we owe our pa- asked for our help. We carry each of their stories uate Gary Maslow during his tients for our education. . . . How does one give with us, somewhere beneath the breast pocket of Class Day speech. So he supplied back to one’s patients? Well, first by trying to be- our white coats. It is what is inside these stories the missing voice by reading come the best physician or and relationships that is important. aloud a letter from grieving par- medical professional you can. What is inside our white coats is ourselves, ents whose daughter had died in . . . One sure way to achieve our minds, and our bodies, which have been DHMC’s Pediatric Intensive this is to find a mentor, as soon trained over these past few years to carry out the Care Unit. They thanked Mas- as you can. . . . Secondly, a lit- work of medicine. low and others for “kind words,” tle later in your development, “cheerfulness,” and “time spent try to become a mentor your- Margaret Ann Crane-Godreau at just being there in support to self. . . . And then when you DMS 2004 Ph.D. Graduate in Physiology all of us.” become really good at something—whether it’s Our nation has an aging population and there is Those voices—Maslow’s and a central intravenous line or diagnostic under- political pressure to change the way we deliver the parents’—were among the standing—try helping others to achieve the and pay for medical services. Also, there is pres- many heard on Class Day, held same expertise. . . . Finally, you know, I’m sure, sure to reduce the cost of medical care. We are on June 12. Dean Stephen Spiel- how important it is to avoid destroying a pa- challenged by emerging dis- berg, M.D., Ph.D., welcomed the tient’s hope. Physicians have such power to de- eases such as SARS and Ebola graduates and their families and stroy hope without even being mindful of it. . . . and by the worldwide HIV friends to the event. Keynote And for those of you who will do research pandemic, with its social and speaker Judah Folkman, M.D., . . . remember that it is you who will arm your economic consequences. . . . who has made significant discov- fellow clinicians with new ways to relieve suf- In contrast to these chal- eries in angiogenesis, reminded fering and with an increased understanding of lenges, we have technology, students that patients would be the scientific basis of medicine. medications, and insight that their most important teachers. might have seemed more like science fiction a Maslow talked of the white coats Gary Maslow relatively short time ago. We have a real that symbolized what he and his DMS 2004 M.D. Graduate prospect of personalizing patient care, where classmates had learned. And The white coat is important to our teachers. . . . practitioners will have detailed genetic infor- graduate student speaker Mar- Their white coats were symbols of their compe- mation providing insights into the metabolism garet Ann Crane-Godreau spoke tence, but what they taught me was not so much and physiology of the individual patient. Such of how well Dartmouth had pre- about the power of the coat as new technologies will allow physicians to tailor pared students to meet the chal- a symbol, but instead about treatments with far greater precision than is pos- lenges ahead. (Excerpts from the the value of what was inside sible today. Funding is increasingly available for three main speeches are in the —both inside their hearts and integrated investigations, supporting multi- adjacent box.) inside their heads. disciplinary teams . . . of physicians, researchers, Later, the voices of DMS fac- It is what is inside the public-health workers, and educators. . . . We ulty members announced the white coat that counts, name- will face challenges and over the course of our names of this year’s degree can- ly ourselves, all of our experi- collective lives, will make thousands of decisions didates: 49 M.D.’s; 27 Ph.D.’s ences, what we have learned here on these hal- that will influence the lives of individuals and, plus two M.S.’s in the biomed- lowed grounds. . . . We have also learned that in some cases, perhaps whole nations. ical sciences; and 20 M.S.’s, 32 M.P.H.’s, and one Ph.D. in the

Fall 2004 Dartmouth Medicine 13

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evaluative clinical sciences. Then came the presentation of the student awards. Symeon Student Prizes & Awards Missios earned the Dean’s Medal as the M.D. graduate with the Dean’s Medal Department of best overall record of achieve- Symeon Missios Medicine Award ment, and Sergio Quezada was Emily Demetriou awarded the John W. Strohbehn John W. Strohbehn Medal for Excellence Medal for Excellence in Bio- in Biomedical Research Merck Manual Awards medical Research. All the stu- Sergio Quezada Todd Burdette, Angela Sanchez dent prizes presented during graduation week are listed in the Department of Anesthesiology Outstanding Arthur Naitove Surgical Scholar Award adjacent box. Graduating Student Award Danielle Adams Kirsten Redborg Teachers: Students handed out American Academy of Neurology Prize some awards, too. The Basic Sci- Saul Blatman Award for Excellence for Excellence in Neurology ence Teaching Award went to in Maternal and Child Health Fremonta Meyer anatomy professor Matthew Sarah Pitts Heintzelman, Ph.D.; the Clini- New England Pediatric Society Award cal Teaching Award to general Harte C. Crow Award in Radiology Gary Maslow internist Roshini Pinto-Powell, Leila Khorashadi M.D.; and the Thomas P. Almy Department of Psychiatry Award for Excellence Housestaff Teaching Award to Dartmouth-Mosenthal Surgical Society in Clinical Psychiatry chief surgery resident Christo- Danielle Adams, Todd Burdette, Gary Maslow pher Alessi, M.D. In addition, Jason Kemp, Symeon Missios the College’s honorary-degree John F. Radebaugh Community Service Award recipients included Janet Row- French Distinguished Student Award in Pathology Andrew Smith ley, M.D., known for her work on Joren Keylock leukemia and lymphoma. Rural Health Scholar Awards As Class Day came to an end, Dr. Freddie Fu Orthopaedic Surgery Jason Kemp, Victoria Martin, the deep, rich voice of Dart- Medical Student Award Gary Maslow mouth language professor John James Ames Rassias sang the Hippocratic Hilda Weyl Sokol Award Oath in Greek. And in closing, American Medical Women’s Association Leigh Strauss Dean Spielberg led a chorus of Glasgow-Rubin Achievement Citations Rolf C. Syvertsen Scholars voices as the M.D. candidates re- Sarah Pitts, Fremonta Meyer, Danielle Adams, Joren Keylock, cited the oath in English. Danielle Adams Fremonta Meyer, Simeon Missios, Still, the voices of those par- Good Physician Award Sarah Pitts ents who wrote Maslow echoed Leigh Strauss silently with a message for all the Leonard Tow Humanism in Medicine Award graduates: “When we think of Hitchcock Foundation Student Research Prize of the Arnold P. Gold Foundation you and your future that you’ll Gary Maslow Gary Maslow have in the medical field, we know that many lives will be Julian and Melba Jarrett Memorial Prize John and Sophia Zaslow Prize touched by your life because of Wendy Osterling Jason Kemp the caring way you have in con- necting with people. Continue Frederic P. Lord Award in Anatomy Douglas P. Zipes, M.D., Research Prize in Medicine on. You’re doing a great job!” Joren Keylock Robert Nutt Laura Stephenson Carter

14 Dartmouth Medicine Fall 2004 vitalsigns

Cancer Center hosts visitors from top German cancer center

YING SQUIRREL GRAPHICS In June, a group of renowned German cancer scientists made a ALL: FL visit to Dartmouth’s Norris Cot- ton Cancer Center. The group had been charged with establish- ing Germany’s first comprehen- sive cancer center (CCC), and they’d selected Norris Cotton as their model. The visitors represented two 1 2 organizations: Deutsches Krebs- forschungszentrum (DKFZ), an internationally recognized re- The sun shone on 1 Wendy Osterling search institute, and the Univer- and 130 other DMS graduates as 2 sity of Heidelberg, one of the Dean Stephen Spielberg presided over his first Class Day. Among the proud oldest and most highly regarded grads were 3 Katie Chatfield, 4 Mar- German universities and medical garet Thompson, 5 Nesochi Igbokwe, 6 schools. Their aim in forming a Brian Livingston, and 7 Chunbai Zhang. CCC is to provide a kind of on- cological patient care new to Germany and a new foundation for translational research—cre- ating a partnership under one roof between DKFZ and the uni- versity medical center. Objectives: According to Dr. Mark Israel, Norris Cotton’s di- 3 4 5 rector, the visit had two objec- tives: to show the Germans how an American cancer center is or- ganized and where the areas of greatest challenge are, and to be- gin the process of building per- sonal interactions between lead- ing scientists there and investi- gators and physicians here. “We’re expecting a lot to come out of this,” said Israel at the end of the Germans’ visit. “Numerous e-mail addresses and telephone numbers have been exchanged. That was really my 6 7 goal—not only to help them, but

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CLINICAL OBSERVATION

n this section, we highlight the human side of What’s the last book you read? Iclinical academic medicine, putting a few The Fellowship of the Ring, also to create this personal con- questions to a physician at DMS-DHMC. the first book in Tolkien’s tact that would lead to future Lord of the Rings trilogy. My sons have interactions.” Charles Carr, M.D. become obsessed with the story, and The visit was a tightly sched- Associate Professor of Orthopaedic Surgery that has sparked my interest in it. uled two days of presentations, Carr, a graduate of both Dartmouth College and discussions, tours, and group DMS, joined the faculty in 1989. He is medical di- What’s your favorite nonwork activity? meals. According to Dr. Hans- rector of DHMC’s Sports Medicine Clinic and di- Spending time with my family is number one, Ulrich Kauczor, head of DKFZ’s rector of the orthopaedic residency program. His and playing golf is number two. radiology department, the visit clinical interests include arthroscopy, knee and was a success. “It was wonderful. shoulder disorders, and trauma. What about you might surprise most people? Very busy. We learned a lot I think people are surprised that I’m a southern about how the comprehensive What made you decide to specialize in orthopaedics and, Californian. I’ve been told that I act more like cancer center is set up. Most im- in particular, sports-related injuries? a native New Englander. portant for us was to see how you Orthopaedics offers the physician a sense of are trying to initiate the collab- quick gratification compared to other special- Of what accomplishment are you most proud? oration between clinicians and ties. And sports- My number-one accomplishment is raising three research scientists.” medicine patients kind, caring children with my wife, Carol. Protocols: Dr. Volker Diehl, the are very motivated acting head of the new CCC, to recover quickly What bores you? noted that currently in Germany from their injuries Filling out insurance and disability forms. each researcher has his or her so they can return own protocols. “I think for the to their sport. I What is stressful for you? sake of the patients, it is ex- have a great deal of Taking exams and speaking in front of large tremely important to have com- respect for physi- groups. mon protocols so the patients get cians who care for the best treatment,” he said dur- patients who are Are there any misconceptions that you find people have ing the visit. “People here [in the chronically ill or about your specialty? U.S.] like to work together. That have incurable diseases. It would be very difficult Sports medicine is sometimes seen as a “glam- is not true in Germany.” for me to be a bystander to irreversible diseases. our” specialty. People think that sports medicine Diehl has known Israel for We’re fortunate in orthopaedics that we don’t physicians primarily take care of the acutely in- some years and has visited Dart- have to deal with that form of illness very often. jured, elite, competitive athlete. But that’s only mouth before. It was Diehl’s de- a small part of what we do. Most of our patients cision to use Norris Cotton as a Did you play sports yourself growing up? are middle-aged weekend warriors or people model. “We are enchanted by I played football, baseball, track, and golf all with chronic overuse problems that require non- the friendliness and the high sci- through high school. At Dartmouth, I was on operative treatments. We spend most of our time entific standard,” he noted. “We the varsity track team. taking care of the bumps and bruises and muscu- are very happy to be here.” loskeletal aches and pains that everyone gets. The visit concluded with If you weren’t a physician, what would you like to be? closing presentations over a I wanted to be a veterinarian. If I had become a Is there anyone who was a mentor for you? working lunch. While the group vet I would have probably chosen to care for Leland “Pete” Hall, who was chief of ortho- munched on cold cuts and salad, large animals rather than just family pets. paedic surgery when I was at DMS and during Dr. Andrew Gettinger, whom Is- my residency. He is now retired and remains ac- rael introduced as the inspiration What’s the last movie you saw? tive in department conferences. He was enthu- and brains behind DHMC’s elec- I have three sons—ages 8, 13, and 15—so I get siastic about and truly enjoyed his profession. I tronic patient information and to go to a lot of action movies with them. The hope I can remain as committed to the field and record system, gave the group a last one that I saw was Spiderman 2. as excited about the care of patients as he was. virtual tour of these systems. “The information needs to be

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JON GILBER care—including “HELLO, DOLLY!” AT DHMC central monitor-

T FOX ing of data, inter- he’s known as the “fairy grandmother” of Dartmouth-Hitch- disciplinary tu- S cock Medical Center’s Pediatric Intensive Care Unit mor boards, and (PICU), but she prefers to remain anonymous. Communicating centralization of through Elizabeth Stanton, a lawyer in the DHMC risk man- information and agement department, the PICU’s fairy grand- counseling. The mother handcrafts dolls for sick girls who are concept of shared having an especially difficult time. Several German visitors listen intently as white-coated DMS faculty members Jay Buckey, right, and Eugen Hug, governance, not- “Last week, we gave a doll to the sister of a left, explain the integration of hyperbaric and radiation ed Wiestler, will young patient who died here,” says Stanton. therapies at Dartmouth’s Norris Cotton Cancer Center— perhaps be their Since the dolls are typically given to patients, one example of work at a comprehensive cancer center. toughest sell. As Stanton had called the doll maker to ask if she Israel gave advice could give one to a sibling. “I knew her answer available where it’s needed,” said on how to structure the gover- would be an enthusiastic ‘yes,’ and the very Gettinger, noting that most nance of this new entity, Wiest- next day there was a new, beautiful doll sitting physicians use laptops to enter ler moved boxes around on his on my chair.” and retrieve data. German heads electronic organizational chart. Over the last couple of years, the unknown benefactor has nodded vigorously. “There is fierce competition for provided more than a dozen dolls, each of which has individu- How expensive are the com- funding,” explained Wiestler. alized hair and skin coloring and elaborate handmade clothing puters, they wanted to know, and “Forging collaborative partner- and accessories to match the season. “She is the kindest, sweet- how do you control access? Get- ships will not in all cases be est, most accomplished woman,” says Stanton of the doll mak- tinger responded that the system easy.” er. “Our fairy grandmother embodies the generosity of spirit— was restricted by an internal “First we want to bring the the very heart—of who we are at DHMC.” J.D. name-recognition device. “Ah, partners together,” said Dr. Josef like an internal firewall,” said Dr. Puchta, administrative chairman Otmar Wiestler, chair of the of the DKFZ management board. TOUCHED BY MEDICINE DKFZ management board. “Ex- “Maybe in a few years we will actly,” responded Gettinger. In come under one legal structure.” hen medical student Sai Li decided to launch a student- the international language of “I think you’re destined for W run DMS literary magazine, he had no idea it would de- computers, jargon such as “fire- success,” commented Israel. velop into a project that almost no other medical school was do- wall,” “reboot,” and “IP” needed “We will do it. That’s for ing. With a large staff of his fellow ’06s, Li has edited, designed, no translation. sure,” asserted Puchta. and published a magazine called Lifelines. It contains submis- Knuckles: As Gettinger con- “We have learned a lot,” sions from people whose lives have been cluded his presentation, the vis- added Wiestler. “I think in the touched by medicine—students, caregivers, itors rapped their knuckles ap- not-too-distant future, we should patients, and patients’ families. preciatively on the table—a tra- have you in Heidelberg.” As “As you flip through Lifelines,” says Meghan dition in Germany. Wiestler shut down his Power- McCoy, the artwork editor of the publication, Israel then invited Dr. Wiest- Book, the Americans initiated a “you are greeted with poetry and stories that ler to give an overview of the round of enthusiastic knuckle- examine life in all its forms as well as illness.” progress to date in Heidelberg. rapping. For example, the issue contains a short story Wiestler pulled out an Apple “This is something we should describing a DMS student’s memorable but dif- PowerBook and fired up a Pow- borrow,” declared Ralph Cza- ficult experience caring for a patient on a rotation in Germany. erpoint presentation entitled chowski, the director of financial “The spirit of both the patient and the student really permeates “Comprehensive Cancer Center services for Norris Cotton, as the through you after you read it,” says Li. —NCT Heidelberg.” visitors and their hosts filed nois- To obtain a copy of the first issue, or for more information At the core of their venture ily from the room. about the project, e-mail [email protected]. M.C.W. is interdisciplinary oncological Katharine Fisher Britton

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INVESTIGATOR INSIGHT

n this section, we highlight the human side of What’s the last book you read? DMS is a finalist for Ibiomedical investigation, putting a few ques- Sweet Thursday by John Steinbeck. tions to a researcher at DMS-DHMC. national community What kind of music do you enjoy? service recognition Bill Roebuck, Ph.D. I don’t listen to much music, but lately I’ve been Professor of Pharmacology and Toxicology listening to the Johnny Clegg Band, a South Minutes before this year’s Class and Adjunct Professor of Environmental Studies African group. Day celebration was to begin, Roebuck joined the faculty in 1979 after completing Dean Stephen Spielberg, M.D., a four-year research fellowship at DMS. He studies If you could travel someplace you’ve never been, where Ph.D., got word that DMS was the role of aflatoxin in causing liver cancer and would it be and why? one of three finalists being con- teaches medical students as well as an undergradu- Greenland would be one location. The coastal sidered for a national award— ate course on global public health. lands are lush with vegetation, the sea is full of the Outstanding Community life, and there is a big sky—one is not hemmed Service Award of the Associa- How did you decide to become a scientist? in by tall trees. Nature is mostly in control, and tion of American Medical Col- I did not decide to become a scientist, rather it humans have to adapt to the ways of nature. leges (AAMC). He quickly re- just happened. In college, I enjoyed chemistry vised his welcoming speech so he and biochemistry and was very interested in What are the greatest frustration and the greatest joy in could share the good news with agricultural issues. In the late 1960s and early your work? the assembled multitude. 1970s, the so-called green revolution was in full The greatest joy is easy—having a manuscript Site: Soon after, the AAMC tilt. It looked as if hunger might really be elim- accepted for publication, followed by seeing it in began scheduling site visits to inated from the world. In graduate school, op- print. The frustration is the slow pace at which the finalists. In July, it was DMS’s portunities opened quality experiments can be completed. turn. Three representatives from to combine these the organization spent a whirl- interests with the Do people have misconceptions about your field? wind day at DMS hearing pre- field of toxicology Toxicology is the study of the adverse conse- sentation after presentation and to contribute quences to an organism that has been exposed to about student-run community to public health. a particular chemical or chemicals. It is very service projects; making a visit to hard for people to understand that it is the dose, the Good Neighbor Clinic, the What advice would you or amount of chemical to which one is exposed, local free clinic in White River offer to someone that determines if a toxic event occurs. The dose Junction, Vt.; and meeting with contemplating going is the difference between a drug and a poison, or people from several community into your field? a chemical with no adverse effect and a terrible agencies. Learn as much toxin. We all understand this from chemical re- Spielberg told the AAMC chemistry and biology as possible. Find an area lationships of which we have personal knowl- guests that he was impressed by in which you can become an expert, and then edge—such as coffee and the jitters. But it’s not DMS’s community service pro- work very hard at becoming a generalist. common for people to use this principle in ex- gram before he even accepted pecting adverse chemical actions for the wide the position of dean last year. “I If you weren’t a scientist, what would you like to be? range of substances—such as drugs, pollutants, saw here at Dartmouth, embed- Engaging in this fantasy today, I should love to and natural toxins—to which we are exposed. ded in the psyche, a sense of be a teacher in some small village somewhere community outreach,” he said. “I off the beaten path—oh, perhaps in the Cana- Do you always have a working hypothesis in the lab? wanted to be a part of that.” dian Arctic. Engaging in this fantasy on anoth- Yes, I do. Sometimes the hypothesis is finely de- “We’ve intentionally tried to er day, I might wish to be a photographer col- veloped and carefully constructed and at other embed community service in our lecting images of less-traveled lands. times it is much more general. It is the expecta- culture,” noted Joseph O’Don- tion of an experiment that is critical for me. nell, M.D., director of communi- What’s your favorite nonwork activity? However, I try not to become too attached to ty service programs. He loves to Without a doubt sea kayaking. My favorite des- any particular hypothesis such that I cannot re- talk about the wonderful volun- tination is the Arctic, especially Hudson Bay. ject it or make a new or modified hypothesis. teer work that DMS students do.

18 Dartmouth Medicine Fall 2004 vitalsigns TOUR OF HOPE

“The stories take your breath in the early 1990s. The program away,” he says. pairs medical students with area DMS’s dedication to commu- elementary-school teachers to nity service can be traced all provide age-appropriate health the way back to the School’s education to local schoolchild- founder, Dr. Nathan Smith, who ren. Another important initia- recognized the importance of tive is the Albert Schweitzer Fel- meeting community needs. In lowship, which provides a mech- 1991, the DMS Student Gov- anism for students from Dart- ernment formalized the concept Highhouse (left) is pedaling hard at the head of this practice peloton. mouth Medical School, the Uni- by founding the Community versity of Vermont, and Vermont Service Committee, which still DHMC oncology nurse hits the high road Law School to develop projects exists as a student-run organiza- that address unmet health-care tion that sponsors projects to hey have this great spirit and optimism—a real passion for needs in their communities. meet community health needs, ‘T life,” says Brian Highhouse, a DHMC oncology nurse for the Better: Although the commu- provide community education, past 15 years. He’s referring to his patients, who, he explains, nity service program has been a and promote social justice. In have inspired him to stay in nursing. “I said, ‘Hey! That’s for me! success by any measure, DMS 1995, DMS received the Ameri- I agree. Let’s live every day to its fullest.’” wants to make it even better. Re- can Medical Student Associa- For Highhouse, living every day to its fullest usually involves cently, O’Donnell, student lead- tion’s Paul Wright Award for a bicycle and miles and miles of pavement. In October, High- ers, faculty members, and com- outstanding community service. house will join 19 other experienced cyclists in the Tour of munity advocates undertook a Back then, nearly 80% of the Hope—a 3,500-mile cross-country relay, sponsored by the phar- formal review of students’ com- first- and second-year students maceutical firm Bristol-Myers Squibb, to promote participation munity service experiences. The were involved in one or more in clinical trials for cancer research. Leading the team will be group’s recommendations in- volunteer projects. Today it’s al- six-time Tour de France winner Lance Armstrong, who survived clude improving messages about most 100%. advanced testicular cancer in the mid-1990s. service during the application Endless: The projects are many Along the route from Los Angeles to Washington, D.C., the process, emphasizing communi- and varied: students work in free team will stop at various rallying sites, where team members ty service more at matriculation medical and dental clinics; vol- will share their personal experiences with cancer. Armstrong and orientation, fostering lead- unteer with community agencies will join the team for the start, the finish, and selected segments ership skills, improving faculty such as Planned Parenthood and along the way. The riders, who range from age 32 to 66 and in- mentoring, connecting better to a local home for unwed mothers; clude cancer survivors and caregivers, will ask people to “make community needs, and dissemi- help people with AIDS and vic- the promise.” The promise is a personal pledge, outlined at nating information about the ex- tims of domestic violence; be- www.tourofhope.org, to be proactive about cancer screening, to periences to inspire others. friend children with chronic ill- support loved ones with cancer, to help make cancer a nation- The AAMC’s Outstanding nesses or special needs; teach al health priority, and to consider, if diagnosed with cancer, par- Community Service Award, es- high-school and college students ticipating in a research study. tablished in 1993, recognizes about substance abuse; volunteer “Hopefully, studying new treatments is going to speed the community service programs on wilderness response teams; process toward better treatments and cures. Without [clinical that go beyond the historical role work with underserved popula- trials], we’re not going to make advances,” says Highhouse, who of academic medicine to reach tions internationally . . . has come to understand the importance of such research on a communities whose needs are The list goes on. personal as well as a professional basis. Two years ago, his wife, not being met through the tradi- One of the longest-standing Paulette Buchholz, a dietitian at DHMC, was diagnosed with tional health-care delivery sys- programs is Partners in Health lobular carcinoma in situ, meaning that she has a high risk of tem. The winner of the award Education, which grew from the developing breast cancer. But Buchholz—who is also an avid cy- will be announced at the 2004 vision of former U.S. Surgeon clist—is receiving a new tamoxifen-based treatment, recently AAMC annual meeting in General C. Everett Koop, M.D., tested in a clinical trial, and is doing well. J.D. Boston in November. after he joined the DMS faculty Laura Stephenson Carter

Fall 2004 Dartmouth Medicine 19 signsvital

FOCUS ON RECENT RESEARCH

his section includes brief accounts of se- cerous colorectal tumors, but this is the first ceptors. But the vast ma- T lected Dartmouth research projects on randomized trial to evaluate the effect of jority of metastatic tumors biomedical and health-policy issues. calcium on different types of colorectal le- eventually become resis- sions,” says DMS epidemiologist John tant to tamoxifen and oth- Revealing patterns Baron, M.D., about his recent study with er endocrine therapies, ex- Magnetic resonance imagining (MRI) may DMS graduate student Kristin Wallace. plains Gary Schwartz, M.D., the principal one day play a key role in the early diag- The researchers analyzed data from 913 pa- investigator of the trial. The results of the nosis and treatment of Alzheimer’s disease. tients and found that supplemental calcium study are due out in early 2006. Using repeat MRI scans to track changes in slightly decreased the risk of all types of col- the brains of 90 older adults, DMS re- orectal polyps; the effect was greatest for Unlocking metabolic mysteries searchers, led by Andrew Saykin, Psy.D., the most advanced lesions. The results Thanks to a recent DMS study, energy reg- found a strikingly similar pattern of brain were published in the June 16 issue of the ulation in mammalian cells has become less activity and gray-matter loss in patients Journal of the National Cancer Institute. mysterious. DMS endocrinologist Lee Wit- who have only perceived cognitive deficits ters, M.D., and colleagues at Harvard have and in those diagnosed with mild cognitive Same relief, lower dose shown that a gene known as LKB1 is re- impairment, a precursor condition to Alz- Tacrolimus, a topical, steroid-free ointment sponsible for the activation of an impor- heimer’s. Saykin presented the findings at often used to treat eczema, is effective in a tant cell-energy mediator, AMP-activated the International Conference on Alzhei- lower concentration than is commonly pre- protein kinase (AMPK). AMPK regulates mer’s Disease and Related Disorders. scribed, according to a DMS study. The cellular metabolism and proliferation and ointment, which also goes by the brand protects against cellular death. It has been Structural insight name Protopic, proved successful in adults known that LKB1 is a tumor suppressant, Dartmouth computer scientist Bruce Don- and children ages two and older at only a yet cells lacking LKB1 are more likely to ald, Ph.D., and his students are working to 0.03-percent concentration. The results die. Witters’ team proposed a model to ex- make structural genomics—the study of were presented at the annual meeting of plain this paradox and a way that strategic proteins’ three-dimensional, geo- the American Academy of Dermatology. manipulation of LKB1 and AMPK may metric structures—less onerous. In a report on the study in Dermatology help combat certain cancers and type 2 di- In the Journal of Biomolecular Times, DMS’s Shane Chapman, M.D., the abetes. The work was published in the Pro- NMR (nuclear magnetic study’s principal investigator, said that in ceedings of the National Academy of Sciences. resonance), his team pre- his own practice he used to prescribe 0.1- sented new algorithms that require percent ointment to his patients regardless Helping to stub out smoking less data and deliver more accurate results. of their age or the severity of their condi- Parents, take note: a new DMS study, led Most NMR experiments measure a protein tion. “I suspect a lot of other dermatolo- by pediatrician James Sargent, M.D., shows and report the distances between molecules gists also favor the higher-strength prod- that children whose parents restrict them and the angles of chemical bonds, but can’t uct,” he said, noting that these findings will from viewing R-rated movies are much less indicate which atoms or bonds the mea- allow dermatologists to prescribe the low- likely to try smoking than their peers. In surements correspond to. “It’s a little like er dose with confidence. the study, only 3% of adolescents who were taking all the heights and weights of every- never allowed to watch R-rated one at a cocktail party, but you don’t know A matter of some sensitivity movies had lit up, compared which height goes with which person,” says A Phase I clinical trial at Dartmouth’s Nor- to 14% of those whose par- Donald. The new techniques assign the ris Cotton Cancer Center is testing a new ents let them view such flicks measurements to the correct nuclei, un- drug, gefitinib (also known by the brand sometimes or all of the time. veiling the architecture of proteins more name Iressa), to see if it can restore sensi- For a list of actors who light up and accurately. tivity to tamoxifen in breast-cancer pa- films that glamorize tobacco use, visit tients who have become resistant to the www.scenesmoking.org/whyitsimportant.cfm, Calcium does a colon good popular antiestrogen therapy. For more an American Lung Association site that “Previous studies have demonstrated an as- than 20 years, tamoxifen has been a staple mentions Sargent’s ongoing research. His sociation between calcium intake and treatment for the two-thirds of women new study, which received a lot of press, ap- moderate decreases in the risk of precan- with breast tumors that express estrogen re- peared in the July issue of Pediatrics.

20 Dartmouth Medicine Fall 2004 vitalsigns

Match legislation ical Colleges (AAMC), as well ates to residency programs. Prior programs—maximizing a high as with the Vermont and New to the 1950s, medical students choice for each side. About was championed Hampshire Congressional dele- had to seek out residency posi- 24,000 students from U.S. and from Dartmouth gations, McDougall lobbied for tions on their own, program di- foreign medical schools compete legislation that would exempt rectors often pressured students for some 20,000 positions annu- When a federal class action law- the Match from antitrust laws. to make decisions before they ally; 85% of U.S. medical stu- suit charged that the National Academic medical centers and were ready, and students who dents get into one of their top Resident Matching Program teaching hospitals have relied on “knew someone” were apt to three choices. (NRMP) has been violating an- the Match for over 50 years. land the better positions. Com- In 2002, three medical resi- titrust laws, DHMC’s govern- “If the Match was dissolved mitments were often broken— dents filed an antitrust class ac- mental relations director, Frank . . . was ruled to be an antitrust by students as well as programs— tion lawsuit against seven non- McDougall, set out to help pre- violation,” explains McDougall, resulting in further confusion. profit organizations and 29 serve the system that has long “then we’d have a whole new Choices: Now, after they inter- teaching hospitals, charging that “matched” medical-school grad- system that would cost a whole view at the programs they’re in- the Match violates antitrust laws uates with residency positions at lot of money and not be as effec- terested in, students list their by limiting competition and pre- academic medical centers. tive as the one we have.” choice of programs in rank order, venting medical residents from Working with the American The NRMP, established in and program directors likewise negotiating for higher pay, short- Hospital Association and the 1952, uses a computer algorithm rank the applicants; the comput- er hours, and better working Association of American Med- to match medical school gradu- er then matches students with conditions. Typically, residents

Medical technologist Betty Ward is a walking history of DHMC’s clinical laboratories FL

ne might expect an 80-year-old woman who’s able equipment “is ever so much safer of course.” YING SQUIRREL GRAPHICS O lived her whole life in Hanover and worked at A graduate of the now-defunct Mary Hitch- the same place for 52 years to be misty-eyed about cock School of Medical Technology, Ward has the past. Meet Elizabeth “Betty” Ward, currently served over the years as technical director of the longest-serving DHMC employee: she exhib- MHMH’s clinical lab, as educational coordinator its the laconic speech and telltale “ayuh” of the ar- of the medical technology program, and as an in- chetypal New Englander, but walks faster than she structor in the medical students’ parasitology labs. talks and is not one to glorify the past. Today, she continues to offer informal tutorials for When Ward started working in the clinical medical students and residents who want more labs in 1952, “everyone had to do everything,” she background in parasitology. “Occasionally,” says recalls. “Now we are all departmentalized. . . . You Elmer Pfefferkorn, Ph.D., a longtime professor of don’t come into contact with the other folks in microbiology, “students will find something puz- the laboratory the way you used to.” But, she adds, zling during their microscopy of a clinical speci- “I find it better to be specialized. It’s very difficult men. When I’m puzzled, too, it’s a relief to be able to keep on top of things if you have so many dif- to appeal to a higher authority.” ferent areas you have to deal with.” Ward’s matter-of-fact attitude toward change For Ward, change has been a constant. As has pervades her personal life as well. An avid out- the good humor with which she’s embraced it. For doorswoman who once built her own frame back- example, midway through her career, “we went to pack out of oak and canvas, she says that “when I disposable everything. . . . It took a while to get first started doing backpacking, the pack would used to, like using plastic petri dishes after using weigh about, oh, I don’t know, 48 pounds.” But for Betty Ward goes the distance on these big clunky glass ones. They were always fly- an expedition she was planning in the Big Horn the trail—still with a full pack ing!” Ward laughs as she pantomimes handling Mountains, she notes, “I’m hoping for like 35— at age 80—just as she has for the lightweight plasticware but adds that dispos- or 32 would even be better.” J.D. 52 years in the clinical lab.

Fall 2004 Dartmouth Medicine 21 signsvital

MEDIA MENTIONS: DMS

mong the people and programs coming in for that was published in the journal’s online edition. A prominent media coverage in recent months Then the device’s manufacturer raised objections earn $40,000 a year and work up was Professor of Psychiatry Matthew Friedman, M.D., about the paper, and the FDA asked the journal to 80 hours per week. Ph.D. When the New England Journal of Medicine to withdraw it. In the August issue of the jour- “The system in place, al- published a study showing that, as USA Today nal’s print edition, the editors refuted the manu- though not perfect, is better than put it, “nearly one out of five facturer’s claim that the paper contained confi- the chaos that existed before,” combat soldiers are leaving Iraq dential commercial information. The controver- according to Peter Chin, M.D., with a mental health problem, sy was then explored in a long feature in the Wall who graduated from DMS in such as post-traumatic stress Street Journal: “The paper concluded that by three 1999, recently completed a resi- disorder,” newspapers nation- years or more after treatment, the mortality rate dency in neurology at the Uni- wide turned for expert com- for patients getting the AneuRx versity of Washington in Seattle, mentary to Friedman, the exec- [stent graft] probably exceeded and is now a Robert Wood John- utive director of the Veterans that for surgical patients. . . . ‘As son (RWJ) Clinical Scholar at Affairs National Center for Post-Traumatic editors, we are responsible for UCLA. Stress Disorder. “Today’s returning soldiers may preserving the rights of authors System: There are, however, recover more easily than Vietnam veterans,” to communicate appropriately some drawbacks to the current continued USA Today, “because the latter were reviewed scientific information system. For one thing, “residents more vilified at home, says psychiatrist Matthew and for preventing corporate in- barely make minimum wage,” Friedman.” He was quoted in the Atlanta Journal- fluence of this process,’ said Jack Cronenwett, a profes- points out Kavita Patel, M.D., Constitution, too: “‘The most disturbing thing, in sor at Dartmouth and one of the editors of the who is also an RWJ Scholar at my opinion, is the stigma, and people who are journal. ‘In this case we were unable to do so.’” UCLA as well as a former presi- most severely affected are the ones least likely to dent of the American Medical seek treatment,’ Friedman said.” The New York As many as 10 million women who have had their Student Association, the na- Times and Wall Street Journal were among the cervix removed are still getting routine Pap smears tion’s largest independent med- other papers seeking his insight. —the test used to screen for cervical cancer. The ical student organization. irony of the finding caught the attention of the But teaching hospitals are “Nothing to cough at” was the headline on a sto- Associated Press, the New York facing a number of financial ry on ABC.com about the “alarming resurgence” Times, the Today Show, and challenges—such as cutbacks in of whooping cough. “Whooping cough, or per- USA Today. Dr. Brenda Sirovich, an Medicare and Medicaid reim- tussis, is a highly contagious bacterial infection assistant professor of medicine bursements, soaring premiums characterized by violent cough- who is based at the VA Medical for malpractice insurance, rising ing fits. . . . ‘Whooping cough is Center in White River Junc- medical costs, and higher patient the only vaccine-preventable tion, Vt., was the lead author of demand for expensive services— disease that has not been com- the paper. Reported USA Today: and are not eager to assume ad- pletely controlled by routine “While these tests are relatively inexpensive, ditional expenses. childhood immunization,’ ac- these women are undergoing uncomfortable ex- Furthermore, a court battle cording to Dr. John Modlin, chair of ams, doctors are being distracted from more im- over the Match could cost tens pediatrics at Dartmouth. And portant matters, and lab specialists are spending of millions of dollars in fees and officials now realize the need for added measures needless time analyzing specimens, Sirovich said.” legal costs, which would be against the disease.” Modlin recently stepped (See page 3 for more on her study.) shared by all academic medical down after many years as chair of the federal Ad- centers and ultimately passed on visory Committee on Immunization Practices. An opinion piece in the Boston Globe questioning to patients and taxpayers. the wisdom of a technological solution for every Legislation: To help the nation’s A faculty member who is coeditor of the Journal medical problem buttressed its argument with re- academic medical centers—in- of Vascular Surgery found himself, and his journal, search from Dartmouth. Dr. Darshak Sanghavi, a cluding, of course, DHMC— in the public eye recently. Here’s what happened: clinical fellow at Harvard, urged expectant moth- deal with the challenge present- Several researchers at the Food and Drug Ad- ers to “decide whether EFM [electronic fetal mon- ed by the lawsuit, McDougall ap- ministration (FDA) submitted a study about a itoring] is right for them” rather than simply ac- proached New Hampshire’s se- stent graft—a device used to treat aneurysms— cepting it if it’s offered. Then he gave a case in nior U.S. senator, Judd Gregg,

22 Dartmouth Medicine Fall 2004 vitalsigns

AND DHMC IN THE NEWS point: “At Dartmouth, for example, re- in an editorial on current federal fiscal poli- the Wall Street searchers had some patients who were con- cies. “The United States currently spends Journal. “The sidering back surgery watch a video about 15% of GDP on staying well, fully six per- results are strik- the operation’s risks and benefits. Presum- centage points more than the average rich ing. Parents really can ably better informed because of the video, economies,” wrote the Post. To support its make a difference,” pedia- the patients had 30% fewer surgeries. That argument that health care presents the trician James Sargent, M.D., the lead author of doesn’t mean that surgery was totally un- greatest opportunity for economic reform, the study, told the Toronto Star. The New necessary—but that education empowers the Post noted that “Elliott Fisher of Dartmouth York Times also reported on people to make personalized choices based Medical School has demonstrated that some a substance abuse sympo- on their own risk tolerance. Similar innov- parts of the country spend twice as much as sium that featured Sargent ative strategies are needed” with EFM, he others per Medicare pa- and research he’s conduct- said. “Otherwise many mothers may choose tient, even after adjusting ing on a similar correlation an ounce of prevention—without some- for regional differences in between movies and alco- times realizing it can cause a pound of hurt.” patients’ health status and hol. “Dr. James Sargent the cost of medical care. . . . said his research shows In June, Dr. Gilbert Welch, a professor of medi- Moreover, Dr. Fisher has that middle school students in Vermont and cine, faced off on NBC’s Today Show against shown that low-spending New Hampshire who watched lots of movie Dr. William Catalona of Northwestern Uni- areas produced health out- scenes depicting alcohol use were more than versity regarding the benefits and harms of comes at least as good as those in high- three times as likely to try drinking than prostate-cancer screening. Welch, the au- spending ones. If all regions could emulate those with little exposure. Although previ- thor of Should I Be Tested the most efficient fifth of the country, the ous studies had looked at whether advertis- for Cancer? Maybe Not and cost of Medicare would fall by 30%.” ing affected teenagers’ drinking behavior— Here’s Why, recommends with conflicting results—no one had ever caution when it comes to In 2001, pediatricians were urged by the looked at the impact of the entertainment cancer testing. Catalona, American Academy of Pediatrics “to relieve industry, Sargent said.” however, advocates wide- needless suffering by better anticipating and spread use of the prostate assessing pain, creating soothing environ- Associated Press reported recently on “a specific antigen (PSA) ments in their offices, and getting parents hormonal disorder that some experts esti- test, which has been shown recently to be more involved,” explained mate affects as many as one in 10 women in less accurate than once thought. “It’s im- a recent story in the Los this country” but that is often misdiagnosed portant that we understand that cancer test- Angeles Times. “A genera- —polycystic ovarian syndrome (PCOS). “It ing in general is a double-edged sword,” tion ago, many health-care affects not only the body’s reproductive Welch said on Today. “Tests like the PSA providers bought into the function, but also many metabolic process- have made us rethink the nature of the word misconception that chil- es. . . . ‘It’s been around for a long time,’ said ‘cancer.’ We all think of cancer as sort of an dren don’t feel pain as Dr. Neal Mahutte, a repro- aggressive disease that will kill you if you’re adults do. But youngsters ductive endocrinologist at left untreated. But there’s another type of deserve—and parents now expect—better, Dartmouth-Hitchcock cancer, small collections of abnormal cells said Dr. Joe Cravero, [director of the PainFree Medical Center. ‘But dur- that will never bother patients in their life- Program at the Children’s Hospital at Dart- ing the last 10 years it’s be- time. And the problem with cancer testing mouth]. ‘There’s no reason a kid needs to be come clearer that this is is we identify and treat these cells and sub- crying and screaming in the hospital,’ he more than a reproductive ject [people] to the dangers of treatment.” said. ‘If you or I come in for an appendecto- disorder.’ . . . According to my, we get the anesthesia we need.’” Mahutte, weight management is often the “The dirty little secret about Social Securi- linchpin in treatment. But he stressed that ty is that it’s too small to transform the fis- A DMS study showing a correlation be- one-size treatment does not fit all: Not every cal future. For all the books and seminars de- tween adolescent smoking and R-rated woman who suffers from the syndrome is voted to the subject, it is a side show” to the movies received sweeping press coverage overweight. Not every woman will benefit growth in the economy and in spending on this summer, including in the New York in the same way from treatment, he said. ‘It’s health care, concluded the Washington Post Times, the International Herald Tribune, and easy to miss the syndrome.’”

Fall 2004 Dartmouth Medicine 23

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and asked him to cosponsor same institution or region. In the retroactive protective legisla- mid-1990s, then-DMS Dean tion. Gregg, who chairs the Sen- Andrew Wallace, M.D., chaired ate Health, Education, Labor, a national committee that insti- and Pensions Committee, and tuted an electronic instead of a Massachusetts’s senior senator, paper system for handling the Edward Kennedy, cosponsored residency application process. In an amendment to a major pen- the late 1990s, the algorithm was sion bill that Congress passed tweaked again when it was dis- and President George Bush covered that it was subtly biased signed into law in April. in favor of programs’ choices Provision: Under the amend- Massage is a modality now offered at Norris Cotton Cancer Center. over students’. And last year, a ment, the Match cannot be con- change was made in the length sidered an antitrust violation nor A holistic approach to healing of residents’ workweek, when the can it be used as evidence in an Accreditation Council for Grad- antitrust case. In August, a fed- assage and meditation are not modalities that would jump uate Medical Education mandat- eral district judge in Washing- M to most people’s minds if they were asked to name services ed a reduction in resident work ton, D.C., dismissed the resi- offered by a cancer center. Yet Dartmouth’s Norris Cotton Can- hours from more than 100 hours dents’ lawsuit, citing the amend- cer Center has begun a one-year pilot program to introduce a week in many cases to a maxi- ment’s provision that the Match cancer outpatients and their families to these and other com- mum of 80. cannot be used as evidence in an plementary and alternative medicine techniques. The Haelan Role: Meanwhile, McDougall, antitrust case. Program—the word “haelan” means “to make whole” in Gael- who has received national con- That may not be the end of ic—encompasses a variety of noninvasive procedures that are gratulations for his role in saving the story, though. The New York intended to improve patients’ quality of life and allow them to the Match, is working on a num- Times reported that one of the feel like they are a part of the healing process. ber of other issues—on the fed- lawyers for the residents who The core services of the program so far have been massage eral level as well as in both New brought the suit “said the plain- and mind-body workshops. Massage services are offered (at no Hampshire and Vermont—that tiffs would ‘certainly continue extra charge) to patients in the infusion suite, where chemo- could have substantial financial their fight for fair wages and safe therapy is delivered, as well as in the hematology-oncology and ramifications for DHMC. work hours.’” radiation therapy areas. The first mind-body workshop ran for Still, changes to the residen- Chin and Patel would not be six weeks in the spring and included classes on stress manage- cy system “may cost more in the surprised to see changes that ad- ment and meditation techniques, plus a visit from a Tai Chi short term, but [be] better solu- dress some of the concerns raised master. A second such workshop will run for eight weeks from tions in the long term,” says in the lawsuit. After all, the September through November. Chin, who has experience in Match and residency programs Deborah Steele, the Cancer Center’s patient supportive ser- public policy. He is a member of have undergone a number of vices coordinator, says these classes are different from the drop- the American Academy of Neu- changes since the 1950s. In fact, in cancer support groups that Norris Cotton also offers. “Some rology’s legislative committee; a 1950 graduate of Dartmouth of the dialogue and interaction may be similar to what you he served two terms on the na- Medical School, Harvard pedi- would talk about in a support group,” explains Steele, “but be- tional administrative board of atric surgeon Hardy Hendren, cause you are learning and experiencing techniques and then the AAMC’s student section; M.D., was instrumental in refin- sharing them . . . you walk away with something tangible that and he was one of two student ing the algorithm in the year the you can use.” members on the Liaison Com- Match was inaugurated. The Friends of the Norris Cotton Cancer Center funded the mittee on Medical Education, Changes: The algorithm has Haelan Program’s pilot year. The hope is that the program can the accrediting body for U.S. been modified a few times since, eventually be self-sustaining, with support from some combi- medical schools. including in 1984 to accommo- nation of fees and underwriting, and that services such as yoga “The issue is not going to die date married or partnered stu- and acupuncture can be added. G.C.C. down,” agrees Patel. dents who wished to train in the Laura Stephenson Carter

24 Dartmouth Medicine Fall 2004 vitalsigns MARK CO RLISS New pancreas club is Worthy of note: putting the spotlight Honors, awards, on a challenging organ appointments, etc.

The pancreas, a fist-sized organ Alan Eastman, Ph.D., a professor of tucked behind the stomach, is pharmacology and toxicology, rarely talked about by the lay was elected chair of the 2006 public. People may mention the Gordon Research Conference function (or dysfunction) of on the Molec- their lungs, heart, and intestines. Cynthia Huntington is New Hampshire’s newly named poet laureate. ular Therapeu- But they pay little heed to the tics of Cancer. out-of-the-way pancreas. Dartmouth poet explores illness and self He will also be Its location means that even vice chair for for medical professionals, it’s a he scattered scar tissue that blurs Cynthia Huntington’s MRI the 2005 Gor- challenging organ. At DHMC, T reveals one thing to a radiologist but quite another to Hunt- don Confer- though, the pancreas is not get- ington herself. A professor of English at Dartmouth, she de- ence on the ting overlooked. The Dartmouth scribes the sclerosis—in a poem called “A Picture of My Brain” same topic. Gordon Research Pancreas Club (DPC), a newly —as “where something that is not me / remakes me from with- Conferences, founded in 1931, established collaborative, aims to in.” The poem appears in her newest collection, The Radiant, are a prestigious international fo- improve the diagnosis and treat- which contains poems about multiple sclerosis (MS) as well as rum in which the most well- ment of pancreatic diseases. The about the dissolution of a long marriage. Both subjects, says known scientists in the world DPC was created earlier this year Huntington, address feelings of inadequacy and crisis of identi- discuss their work. Participants by Dr. Murray Korc, chair of ty: “What do you do when all the things you consider to be your come from academia, industry, medicine, and Dr. Hans Fromm, identity are stripped from you?” and government. director of DHMC’s Hepatopan- Huntington, who was named New Hampshire’s poet laure- Michael Whitfield, Ph.D., an assis- creaticobiliary Disease Center. ate a few months ago, has had relapsing-remitting MS for 15 tant professor of genetics, was Consisting mainly of cells years. During relapses, new symptoms appear or existing symp- named a V Foundation Scholar; that make digestive enzymes, the toms become more severe. But the disease can also be inactive the V Foundation for Cancer pancreas also contains cells that for months or years. This unpredictability often leads her to dis- Research was funded in memory produce hormones, most notably trust her own perceptions. of famed bas- insulin. This varied function, as In her poems, however, she has been able to “get past the an- ketball coach well as the organ’s location, com- gle of the personal problem” with her disease and instead ex- Jim Valvano, plicate the diagnosis and treat- plore the question of self—a universal concern. Huntington who died of ment of pancreatic disorders. says people with an illness want to know not just “‘What do I cancer. Whit- “It’s a relatively unique kind of have?’ [or] ‘What can we do?’ but ‘What does it mean?’” field is the situation,” says Korc, a former Poetry is more about asking such questions than answering third V Schol- president of the American Pan- them for Huntington. She is fond of a comment made by crit- ar at DMS in creatic Association, because the ic John Berger, who observed that poems “bring a kind of peace. four years: Lawrence Myers, pancreas “can be affected by so Not by anaesthesia or easy reassurance, but by recognition and Ph.D., was chosen in 2001 and many different conditions and it the promise that what has been experienced cannot disappear James DiRenzo, Ph.D., in 2003. can mask what’s affecting it.” as if it had never been.” When she writes or teaches, Hunting- Michael Sateia, M.D., a professor There are similar groups at ton explains, she considers “how language can work best to give of psychiatry, was elected presi- other medical centers, but “Dart- that shelter to experience, to tend the wounded, as Berger lat- dent of the American Academy mouth is ideal for fostering pro- er says, through presence of awareness and the transformation of Sleep Medicine. grammatic, interdisciplinary in- of form.” She plans during her five-year term as poet laureate to William A. Nelson, Ph.D., an asso- teractions,” says Korc. hold readings and workshops in and out of the state. G.C.C. ciate professor of psychiatry, was Jennifer Durgin recognized by the Veterans

Fall 2004 Dartmouth Medicine 25 signsvital

PAGES PAST n this section, we highlight tidbits from Health Administration with the Ipast issues of the magazine. These mes- in urology. The rankings are establishment of the William A. sages from yesteryear remind us of the pace based on reputation, mortality Nelson Award for Excellence in of change as well as of some timeless truths. ratios, nursing proficiency, and Health Care Ethics. availability of key technologies. Jay Buckey, M.D., an associate From the Fall 1979 issue For the fifth year in a row, professor of medicine, was ap- Exactly 25 years ago, the magazine ran a feature—titled “Horse DHMC was included in the list pointed team leader for the and Buggy Medicine”—drawn from a collection of letters in the of Most-Wired Hospitals and Health Systems Technology Development Team DMS archives. They’d been written during the early 1880s by by Hospitals & Health Networks of the National Space Biomed- a recent graduate of the Medical School, Dr. John Henry, to his and was also listed in the jour- ical Research Institute. fiancée; Henry, who’d been valedictorian of the Class of 1880, nal’s Most Wireless category. Dean Seibert, M.D., an associate had taken over a small-town practice in West Fairlee, Vt., and DHMC received an award in professor of medicine, was se- his wife-to-be was located in Winchendon, Mass. recognition of its excellent organ lected by his alma mater, Albany “September 11, 1881: Last night I was called out to attend transplant results from the Organ Medical College, as the recipient a broken leg about 10:00 in the evening, then routed out at Donation Breakthrough Collaborative. of its 2004 Humanitarian Award. 6:00 this morning to see another patient, and I have just come The American Academy of Geraldine Rubin, M.D., an adjunct in from a case that has kept me since 4:00. Family Physicians presented its assistant professor of pediatrics, “September 18, 1881: My work is getting the best of me. I Program of Excellence Award to the DMS received a Special Achievement have several new cases of typhoid and one of typhoid-pneumo- Family Medicine Interest Group, Award from the American Aca- nia on my hands. Also plenty of others. Last night I did not get for its efforts to stimulate student demy of Pediatrics for develop- to bed till nearly midnight and did not have one spare minute interest in family practice. ment of the New Hampshire either. Today has been the same—I started at 6:30 and rode six A few facts in a piece on page Health Professionals for Health- or seven miles before breakfast and made three or four visits. 11 of our Summer issue bear cor- ier School Nutrition Coalition. “September 25, 1881: I think that I shall get about $100 rection or clarification. The sto- The New Hampshire Pedi- cash for September from all my work—about half of that from ry was about the role played by atric Society presented its Pedi- my monthly payroll and the rest from Dartmouth’s Dr. Benita Walton atrician of the Year Award to my side business. . . . I have got the in the creation of Casting for Re- Charles Cappetta, M.B.B.S., an ad- handsomest set of tooth forceps that covery, a program that runs fly- junct assistant professor of pedi- you ever saw. I had them all nickel fishing retreats for breast-cancer atrics, and its Franklin Norwood plated last week. . . . There are seven survivors nationwide. The name Rogers Award, for contributions pairs, and they are all beauties. of one of Walton’s early Dart- to pediatric causes, to John Brooks, “October 16, 1881: I caught cold mouth supporters was misstated M.D., a professor of pediatrics. last Thursday. Friday I had a hard day’s —it was oncologist Letha Mills, Joyce DeLeo, Ph.D., a professor of work—much more than I wanted. Was M.D., who helped Walton get anesthesiology, received the Dr. Henry, ca. 1880 called up at 6:00 and did not get to bed the program off the ground. And 2004 Dartmouth Graduate Stu- until just past midnight. Yesterday I Walton’s residency at DHMC dent Council Teaching Award. rode all night in the rain, and that didn’t improve my cold. was in general surgery, not plas- Hussein Samji, a fourth-year med- “October 23, 1881: They have kept me too busy for the past tic surgery; she did her plastic ical student, received the Fran- week to give any time to letter-writing—or to anything else, in surgery training in Madison, çois-Xavier Bagnoud Health and fact. I have been about half-killed with work. There has been a Wisc., and Glasgow, Scotland. Human Rights Essay Award for a constant stream of sickness for the last seven days, so much that Finally, Gwen Perkins—whose paper he wrote on the health im- I have been obliged to neglect someone every day. role in gaining support for the pact of incarceration at the “November 6, 1881: I don’t know how much longer I can program from the Orvis sporting United States prison in Guan- manage to exist if this run of work continues at the present goods company was noted in the tanamo Bay, Cuba. rate. I now have 10 cases of fever. . . . One day last week I saw article—“must be considered a DHMC was again ranked and prescribed for almost 50 patients and I guess the average cofounder of the program,” says among the Top 50 Hospitals in the for the past three weeks has been 20 per day. . . . I never real- Walton. We strive hard for accu- nation by U.S. News & World ized before what a dog’s life a physician must lead.” racy (dare we say “reel” hard?), Report—35th in cancer and 39th and apologize for the errors.

26 Dartmouth Medicine Fall 2004