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What system?

No one ever sat down and designed the U.S. health-care "system." It simply evolved, in bits and pieces. As it now threatens to crack under its own weight, a DMS faculty member is a leading proponent of the need to stop tinkering and rethink things—from a "microsystem" perspective.

By Doug McInnis

In September of 1955, President Dwight Eisenhower suffered a heart attack. His treatment—the best available at the time—consisted of bed rest, stress reduction, weight control, a low-cholesterol diet, an anti-clotting drug, and a gradual reintroduction of exercise. If a president were to suffer a similar attack today, he would almost certainly receive new cardiovascular plumbing—either catheterization and insertion of a stent (which Vice President Dick Cheney had in 2000) or bypass surgery (which former President Bill Clinton had in 2004). The main difference between the two eras can be summed up in a single word: technology.

Technological advances in cardiovascular care, and nearly every other branch of medicine, have extended countless lives. But those advances have also produced a health-care system that many individuals—and the nation—are having a harder and harder time affording. For example, the cost of catheterization and a stent ($40,200 at DHMC) or bypass surgery ($67,450 at DHMC) could well bankrupt someone without health insurance. Eisenhower's treatment, however, wouldn't have ruined anyone financially.

Health-care spending in the United States—now closing in on 15% of the gross domestic product—continues to boom, and there seems to be no end in sight. But why? The answer lies, in part, in human ingenuity, according to Paul Batalden, M.D., a Dartmouth faculty member who has sought to transform medicine's bloated cost structure for decades.

"If you have the problem of human disease and add to that an engine of scientific creativity and smart researchers, you have a formula for unending spiraling costs," says Batalden, director of health-care improvement leadership development at Dartmouth Medical School. "So we're going to have this problem from this time forward."

But Batalden is not fatalistic about the future of health care, nor is he paralyzed by the seemingly insurmountable task of controlling health-care costs. He believes he's found a way to reduce costs while improving quality and efficiency. His strategy lies in a concept known as the

Before coming to Dartmouth, Paul Batalden practiced pediatrics and was an assistant surgeon general in Washington, D.C.

clinical microsystem. Slowly, clinic by clinic, hospital by hospital, the evidence is growing that the microsystem model may be able to cure American health care.

A clinical microsystem is a fancy term for a relatively simple concept. A microsystem is a frontline unit, the place where patients and care teams meet—such as an outpatient orthopaedic clinic, an operating room, or a chemotherapy infusion suite. It is a group of interdependent people who come together for a common aim. The patient is at the center of any microsystem, but a given patient is not fixed within a single microsystem.

At first glance, it may be difficult to see how such a simple concept could

From 1994 to 1997, using the microsystem approach, the intensive care nursery reduced its hospital-acquired infection rate by about 70% and decreased the mean number of days that infants needed mechanical ventilation.

revolutionize health care, but one needn't look any further than the intensive care nursery at DHMC.

In 1992, Batalden's colleague Eugene Nelson, D.Sc., M.P.H.—the director of quality education, measurement, and research at DHMC—met with neonatologist William Edwards, M.D.—the director of DHMC's intensive care nursery (ICN). They sat down to discuss Edwards's vision for the unit. Edwards wanted DHMC's ICN to be the best in the

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Doug McInnis is a freelance writer based in Casper, Wyo., who specializes in science, agriculture, and business. His work has appeared in publications ranging from the New York Times, to the Corn and Soybean Digest, to the alumni magazine of Oberlin College, his alma mater. He wrote about global health for the Spring 2005 issue of Dartmouth Medicine magazine.

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