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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."

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.

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.

I taught at Augsburg College in Minneapolis from the fall of 1960 through the spring of 1962, while I finished my doctorate in experimental psychology at the University of Minnesota, across the Mississippi River from Augsburg. Paul Batalden was one of my students, and we developed a nice friendship—something I always tried to do with exceptional students. Paul was indeed an exceptional student, one of several I enjoyed at Augsburg.

Sadly, I lost track of him and most of the others. I happened to see his mother's obituary in the Duluth paper and saw that Paul was a doctor in New Hampshire. I asked my daughter to see if she could contact him; she was not able to make a connection then, but that's why she gave me your magazine with the story about him and his work.

After eight more years of college teaching and administration at the University of Minnesota at Duluth, I became a management consultant in Grand Rapids, Mich. I worked largely with manufacturing organizations in the automotive industry and became familiar with the principles involved in the microsystems approach applied by Deming to auto companies and now by Paul Batalden to health care.

I am proud to have been his teacher, if only for a short time.

Kenneth De Young
Sparta, Mich.

It ain't broke at DHMC
For over three years, my husband and I have made many visits to DHMC with our 43-year-old disabled daughter. She has seen a number of your doctors for some of the many problems caused by the rare disease she has, mucolipidosis III. Throughout her life we've visited many hospitals, so it is natural for us to make comparisons. We have all been more than pleased with the quality of care at DHMC, as well as with the positive and caring attitude we have seen in everyone in its employ. In fact, we've joked that we wish all facilities had the same happy pills they must pass out at DHMC every morning!

Now comes the Summer issue of Dartmouth Medicine, with an article explaining what we have experienced! "What System?" by Doug McInnis enlightened us. The DHMC system works very well indeed!

Besides passing the system on to other facilities, how about letting state and federal agencies know your secret? We can just imagine how much less stressful all our lives would be if every system operated like DHMC.

I always look forward to picking up the latest issue of Dartmouth Medicine, filled with interesting articles. I'd love to get it at home, so please add me to your mailing list.

Denise Crompton
Gilford, N.H.

Hive of intellectual activity
Some years ago, my wife and I visited relatives in Hanover and admired the Dartmouth campus—but without fully realizing the intellectual activity behind its elegant walls. I recently had an opportunity to read Dartmouth Medicine and was impressed by the high standard of research being conducted there.

I am a retired orthopaedic surgeon, having given up the last of my medical activities last year. My father was also a doctor, having graduated from medical school in 1905. Between us, we were in practice for a century. My father's early transport was by pony and trap; he saw his first automobile, a steam-driven vehicle, in 1908. When he began his career, there were only a handful of remedies with any impact on disease and almost all of them, except the newly discovered aspirin, were of herbal origin.

Your Summer issue highlights some of the amazing developments that have taken place since then. New therapies and surgical procedures have created universal problems of cost control. Dr. Paul Batalden's clinical microsystem concept is an interesting attempt to tackle this problem. But as some diseases come under control, new ones, like AIDS, have emerged—a process excellently reviewed in Laura Carter's article. A possible advance in the treatment of prion disorders is described, as well as a new approach to Parkinson's disease. I wonder what the next century will bring.

My other interest is early bird painters, particularly John James Audubon. I believe your library is fortunate to have an original set of his Birds of America. Edinburgh is, as I write, in the midst of an annual festival that attracts a host of visitors from all over the world. One of the exhibitions this year is "Audubon's Adventures in Edinburgh." I wonder how many of your readers know that he spent nearly three years in Edinburgh during a series of visits between 1826 and 1839? During that time, the first of his engravings were made and his Ornithological Biography was written, with the assistance of Edinburgh natural historian William MacGillivray. Audubon acknowledged that without the support he received here, his work "might like an uncherished plant, have died."

John Chalmers, M.D.
Edinburgh, Scotland

Not only does Dartmouth College own a set of Audubon's engravings, but DHMC's corridors and waiting areas are graced with 47 framed Audubon originals; they were a gift upon the 1991 move to the Lebanon, N.H., campus from the late Laurance and Mary Rockefeller.

Diagnostic acumen
Thank you for "Anatomy of an epidemic" [Summer 2006], about the 25th anniversary of the identification of AIDS. Here is a Mary Hitchcock ICU footnote to your excellent article.

In July of 1981, we admitted a male flight attendant with atypical pneumonia and oral candidiasis. His homeopathic physician in New York City had said fresh air would be good for his shortness of breath, so he visited family in New Hampshire. Ann Collier [a DMS '78, who was mentioned on this page of the feature about AIDS] was the senior resident on the case and had just read the Morbidity and Mortality Weekly Report item mentioned in your article. She correctly suggested a diagnosis of Pneumocystis carinii pneumonia. I believe Ann presented this as one of the first cases of what was later classified as AIDS at the 1982 American College of Physicians meeting. Ann went on to an infectious disease career and is much published in the field.

As I recall—though these details may not be accurate—the patient's initials were the same as the initials of a person in the book And the Band Played On, about the spread of HIV/AIDS. The patient, who flew frequently between New York and Miami, died in the MHMH ICU after weeks of failing to respond to therapy. I was covered with his blood on multiple occasions, from starting arterial and central lines. I was afraid for years to have an HIV test, but fortunately when I did it was negative.

I believe Lin Brown, who is still on the faculty at Dartmouth, was my resident. And I think the other intern on the team was Andy Pavia, who went on to work at the Centers for Disease Control and Prevention.

David Conard, M.D.
Housestaff '81-83
Mill Spring, N.C.

Magnificent legacy
I was interested in the box on page 22 of the Summer Dartmouth Medicine. It quoted a 1963 issue of Hitchcock Highlights newsletter. The change from Hitchcock Highlights in the '60s to Dartmouth Medicine today has been spectacular.

I joined the Hitchcock Clinic (at age 29) in August 1955, as an orthopaedic surgeon with Drs. Staples and Russell. I had completed my military service (in Korea) and was therefore eligible to receive a $7,500 salary in my first year as a member of the Clinic. My wife and I bought a tiny house on Turnpike Road in Norwich, Vt., for all of $18,000.

The friendships and rapport among the Clinic members were incredible. Now I read of those—most since deceased—who brought the Clinic to the excellence of today: Rad Tanzer, John Bowler, Dumps McCarthy, Brian Burke, John Milne, Elizabeth French, and others. They should be remembered as pioneers of health care in Hanover.

It is so gratifying to see that the positive ethic of excellent health care is being promoted so magnificently today.

Robert C. Shoemaker, M.D.
Claremont, N.H.

A tale of two schools
Westshire Elementary School in rural West Fairlee, Vt., is as racially and ethnically non-diverse a place as they come. It is probably a little whiter than the average whiteness of the very, very white state of Vermont. The faculty at Westshire understands both the anomaly this represents and the handicap it imposes upon Westshire students as they begin to confront an adult world enriched and challenged by diversity. Diversity and prejudice are related issues!

On Wednesdays during the past school year, I spent my mornings with eight Dartmouth medical students in the On Doctoring course, and my afternoons with a dozen-plus Westshire third-graders. At the end of the year, an opportunity presented itself to bring the two groups of students together.

Henry Nguyen, who was born in Vietnam and was then just finishing his first year at DMS, joined me at Westshire on May 28. He was greeted enthusiastically by principal Mary Bronga, who gave him a quick tour of our beautiful, pre-K through fifthgrade school.

Ms. Bronga then sat in as the fifth-graders grilled Henry for almost half an hour on his life as a child in Vietnam and on his and his family's adjustment to the challenges of life in the U.S.

Next, Henry joined the third grade, where I was engaged in my weekly reading of the second Harry Potter book. In The Chamber of Secrets, the bigotry of a few "pure-blooded" witch and wizard scholars at Hogwarts plays itself out in their disdain and hostility toward the "Mudbloods" from non-wizarding families. That fiction was not a bad prologue for a visit with someone of quite different ethnicity!

We quickly wound up our Harry Potter reading so the kids could interact with Henry. Since the third grade had just finished studying the American Revolution, Henry played Q&A with them, displaying—to the delight of the quite knowledgeable students—a fairly astonishing grasp of the characters (Paul Revere, John Adams, and Nathan Hale among them) whom the class had been studying. Another half an hour zipped by.

Henry was a star—an ambassador for diversity and a role model whom these children of rural Vermont will long remember and whose lessons the Westshire faculty will surely treasure.

James R. Hughes, M.D.
West Fairlee, Vt.

Affecting recollections
I recently came across an article on Dr. Richard Reindollar in your Summer 2005 issue. [The article reported Reindollar's appointment as the chair of obstetrics and gynecology at DHMC.]

I was a patient of Dr. Reindollar's 18 years ago. I had experienced several miscarriages over the period of a few years. Being from a rural area in Maine, I had difficulty in finding a physician who could offer me the most current testing and treatments. I probably suffered the emotional trauma of repeated miscarriages longer than I had to.

I came upon Dr. Reindollar's name in an article he had written and called his office in Boston in desperation. To my surprise, I was able to set up an appointment to see him. I ended up having to make several trips to Boston, a five-hour drive, for the testing and treatment that he recommended. Dr. Reindollar treated me with kindness and skill and worked closely with my local ob-gyn.

As we planned the timing of my next pregnancy, Dr. Reindollar encouraged me by phone as I took the risk to go ahead with another attempt at pregnancy. All along, he kept close contact with me, always returning my phone calls. His knowledge and care enabled me to bring a wonderful, healthy son into the world. Samuel is now 17 years old and a joy in our lives.

Some time later, another young woman in my town told me about her own struggles to become pregnant and the testing and treatments that she was receiving from her local ob-gyn. I was concerned because I had done much reading on infertility and it didn't seem she was getting up-to-date care. I suggested that she try to see Dr. Reindollar, which she did. Dr. Reindollar discovered that she had cancer and recommended a complete hysterectomy. Later, she wrote me a note to thank me for leading her to Dr. Reindollar—who may have saved her life with timely treatment. Happily, this family eventually adopted a healthy baby boy.

I will never forget Dr. Reindollar and his skilled, kind care. I know mine must be just one of the many, many lives that he has deeply affected.

Sarah Wilson
Southwest Harbor, Maine

Nursing a laugh
I've been meaning to send you a note to tell you a funny story. In your Winter 2005 issue, in the "Letters" section, there was a picture of a Hitchcock nursing school class with some letters from graduates of several different classes who all claimed it as their class. [The photo is reproduced above.]

It made me laugh because as I looked at the picture, I was sure I could see myself and some of my classmates in the picture. Of course I knew it wasn't myself or my classmates, because I graduated from All Souls School of Nursing in Morristown, N.J. (the school closed after our graduation in April 1970). But I can see why so many Hitchcock nurses of the same era claimed the picture—we all looked alike then!

In April 2006, I attended my nursing school reunion. I actually brought your magazine with me, and all of my classmates who attended immediately thought it was our class, too. We all had a good laugh. I promised my classmates I'd send you this note.

Gloria Del Grosso
Moorestown, N.J.

Painting piques interest
I really liked the painting by Dr. Lloyd Kasper in "Art of Medicine" in your Summer issue. Where can I see more of his art? And is this painting for sale?

Jan Wesson
New London, N.H.

More of Kasper's work was featured in one of our Summer issue Web Extras. The works in "Art of Medicine" are sometimes available for purchase through the artist. Our web edition often has artists' contact information. Kasper's is here.

Evermore a subscriber
I would like to join the subscriber list for Dartmouth Medicine. Every time I pick up a copy, I am impressed all over again with its good stories, useful information, and heart.

I received the magazine regularly when I worked as director of student disabilities services for Dartmouth College for 24 years, and I find I have missed it since my retirement last year. I was especially moved by "Evermore," Nancy Price Graff's account of her struggle with chronic depression [in the Fall 2005 issue].

Nancy Pompian
Hanover, N.H.

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