Several essays and features in the Summer issue got readers to pick up their pens—or put down their fingers on their keyboards. Five readers commented on the cover feature on microsystems.

A different view
I found Dr. Jay Buckey's essay in the Summer issue, "Taking a long view," somewhat muddled in places and somewhat reminiscent of spin. It is true that many wonderful developments have been instigated and/or supported by military-related need—such as Robbins and Lawrence's construction in 1846 of the armory in Windsor, Vt. (now the home of the American Precision Museum—an organization where I am a volunteer docent), in response to their having been the low bidder on an order of rifles for the U.S. Army. This resulted in their need to successfully complete the system of "interchangeable parts manufacturing" already partially developed by several others. But is that as it should be, or is it merely a symptom of flawed human nature?

If, instead of funding the space effort, we directly funded the many beneficial potential spin-offs, we could do much more work, presumably make much more progress, and at the same time avoid huge amounts of pollution and squandering of natural resources. I am not optimistic that we will soon turn more in that direction, but I feel that an article such as Dr. Buckey's would have been better had it included this aspect and hope.

Roald Cann
Weathersfield, Vt.

Jay Buckey responds as follows: "I want to thank Mr. Cann for his thoughtful response to my 'Grand Rounds' essay. If we did have the foresight to predict beneficial spinoffs, then supporting them directly would be both efficient and rational. Unfortunately, our imaginations often don't reach that far. For example, we know that the internet didn't grow out of an effort to find better ways to market books. My point was that in an economy where success increasingly depends on innovation, it can be fatal to focus too much on immediate results and short-term gains."

We're always glad to hear from readers about matters pertaining to medicine at Dartmouth or to the contents of past issues of Dartmouth Medicine. Letters to the editor may be sent to DartMed@Dartmouth.edu. Letters may be edited for clarity, length, or the appropriateness of the subject matter.

System failure
I very much enjoyed, as I always do, the Summer "Editor's Note." I was moved by the sensitive words about President Freedman. Thank you for remembering him. I'm afraid the contributions by editors to the body of American literature, including graceful writing, are often insuf- ficiently appreciated by the public (although enhancements by the likes of Max Perkins and Harold Ross, with whom my close friend Corey Ford worked, are not!). Keep it up.

In fact, the whole Summer issue is great. I especially relished the feature "What System?" To the points made by author Doug McInnis I'd add two more: (1) that Medicare (or some other single-payor, government-run or -supervised system) be extended to all ages, and (2) that intelligent tort reform be enacted, so physicians would stop feeling compelled to practice defensive medicine—with its overuse of expensive lab testing and excessive subspecialty referrals. I'm certain from my 31 years of experience as an internist that the most efficient and effective—and least costly—way to properly diagnose patients is with a skillful medical history and physical examination. The laboratory is simply a corollary tool, of perhaps 5% worth overall.

These opinions are, of course, neither original nor widely shared. But both those advances would, I'm convinced, save money and improve outcomes—as proven in many other countries and as well documented in McInnis's article. I believe that our non-system is truly the greatest and most immediate crisis in America today. Virtually all of my physician friends agree with these concepts, and I'm personally ashamed to be part of the current terrible—I'll even say obscene—situation.

James W. Hall III, M.D.
DC '55, DMS '56
Central Point, Ore.

Well-tooled
A friend sent me a copy of the article "What System?" by Doug McInnis. It was a great article and had personal significance for me. From 1969 to 1971, I worked for the Illinois Department of Children and Family Services—the state's foster-care placement agency. It was by far the most satisfying and fulfilling of all of the jobs I've had over 40 years. We made a significant impact on the placement of foster children. How? By using many of the same tools that Dr. Paul Batalden has used at Dartmouth.

I've downloaded, read, and analyzed the Microsystem Action Guide and have started to apply it to my primary area of interest—mental health. We've made great strides in physical medicine; now we must make equal or greater progress in mental health issues.

I'd like to be added to your mailing list. While I'm a patient of several doctors at DHMC, I'm fortunately not up there every quarter so I miss some issues.

Bob Gorman
Nashua, N.H.

For more on clinical microsystems, see the Clinical Microsystems website.

A small world after all
Our daughter, Anna De Young, M.D., of Dover, N.H., recently gave me a copy of the Summer Dartmouth Medicine, which featured Paul Batalden and his microsystems team. I was pleased to read about his career and accomplishments in health-care improvement and very interested in his approach.