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Jack Wennberg Has Battled Uncertainty in Medicine—And Foes of His Findings— for 35 Years

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Jack Wennberg Has Battled Uncertainty in Medicine—And Foes of His Findings— for 35 Years Jack Wennberg has battled uncertainty in medicine—and foes of his findings— for 35 years. His weapons have been intellectual bravery and a dogged sense of doing the right thing. Now hailed nationwide for his iconoclastic ideas, he has just stepped down from leading the troops he assembled at Dartmouth. By Maggie Mahar or half a century,” Dr. John Wennberg declared in a 1977 issue of Pediatrics, “the tonsil has been the target of a large-scale, un- ‘Fcontrolled surgical experiment—tonsillectomy.” Jack Wenn- berg had just taken the pin out of a grenade—and he knew it. With the phrase “uncontrolled surgical experiment,” he acknowledged what few doctors at that time would admit: they operated on people with- out knowing, with certainty, whether the procedure would do the pa- tients any good. And in this case the patients were children. During the 1930s and 1940s, half of the nation’s children had their tonsils removed, but “since World War II,” Wennberg reported in that article, “opinion has swung away from mass use” (emphasis added). By 1973, he added, only 25% of the nation’s children were undergoing the procedure. (Nevertheless, though its popularity had ebbed, ton- sillectomy remained the second most common procedure in the Unit- ed States, after circumcision.) The word “opinion” in that passage is jarring. What could Wenn- Recently named the most influential health- berg mean? After all, by 1977 medicine was firmly established as a sci- ence. Wasn’t it? Surely doctors would not subject millions of children policy researcher of the past 25 years, Jack to a painful and potentially risky operation unless they had solid evi- Wennberg took a lot of barbs early on for his dence that the surgery was truly needed. work on geographic variations in health care. Not according to Wennberg. With a boldness that is surprising, ILLUSTRATIONS BY BERT DODSON even today, he went on to compare doctors to meteorologists: “Pedi- Mahar is currently a fellow at the Century Foundation, where she writes and blogs (see www.healthbeatblog.org) about health care. She is the author of the book Money-Driven Medicine: The Real Reason Health Care Costs So Much (published in 2006 by HarperCollins) and has worked for the New York Times, Barron’s, and Bloomberg. This is her third feature for Dartmouth Medicine; she wrote in the Spring 2007 issue about the impact the Dartmouth Atlas of Health Care has had on the national health-policy BRAVEHEART debate and in the Fall 2007 issue about DHMC’s Center for Shared Decision Making. 30 Dartmouth Medicine—online at dartmed.dartmouth.edu Winter 2007 Winter 2007 online at dartmed.dartmouth.edu —Dartmouth Medicine 31 Wennberg at that time lived on the line between Stowe, Vt., and Wa- geons and hospital beds—and how much surgery the residents of that terbury, Vt. His children went to school in Waterbury, 10 miles down community received. More surgeons and more beds equaled more pro- the road, but had the family lived about 100 yards father north, they cedures. Put simply, supply seemed to drive demand. would have been in the Stowe school system. When he looked at the Four years before his article appeared in Pediatrics, Wennberg had health-care data for the two towns, he realized that 70% of the Stowe published, in the journal Science, his first study about geographic vari- children had had their tonsils out by the time they were 15 years old, ations in health care. There, he and his coauthor, Dr. Alan Gittelsohn, as opposed to only 20% of those in Waterbury. Were his kids in dan- established a firm connection between the supply of health-care re- ger of being undertreated? Or were the children of Stowe being sources in a community and how much care its citizens received. At overtreated? the same time, they acknowledged that they could not say which rate “The communities were very similar,” Wennberg explains, recall- of care represented “a better allocation of resources.” For a given ing his surprise at the finding. “It was implausible that the need for surgery, it was not clear whether patients in communities where sur- tonsillectomies varied by that degree.” geons were in relatively short supply received too little care, or In Pediatrics in 1977, he noted that physicians defended geograph- whether those in areas with a surfeit of surgeons got too much. ic variation as “inevitable” in cases where there is “professional uncer- Few studies had been done “comparing outcomes under controlled tainty” and physicians “do not know which level of use is ‘appropri- circumstances,” Wennberg explained at the time. Sadly, the situation ate.’” Wennberg was not satisfied with the explanation: “This defense, hasn’t improved much. “Jack’s first paper in Science was so on target,” while explaining the past, cannot justify the future,” he declared. “For says Dr. James Weinstein, an orthopaedic surgeon at Dartmouth. “This one thing, the dollar costs of uncertainty are too great.” is what we are working on today.” Weinstein, in fact, heads the largest By then, Wennberg had branched out to study geographic varia- randomized surgical trial ever funded by the National Institutes of tions in the delivery of care in Maine. There, he calculated that in Health—a comparison of surgical and nonsurgical treatments for var- It was his children—specifically their tonsils—from whom Wennberg got his Wennberg is pictured here in 1984, a few years after coming to Dartmouth. communities where few children had their tonsils out, the cost per ious kinds of back pain. And it is Weinstein who has been named to first insight into health-care variations. This photo dates from his Vermont years. capita for tonsillectomy was 85¢. In areas where tonsillectomies were succeed Wennberg as the leader of the people and projects Wennberg Through the decades, the computer has remained his primary investigative tool. popular, the cost per capita was $4.55. “Projected nationally, the low- assembled at Dartmouth. atricians have been the weathermen in the change of clinical climate, rate strategy costs less than $200 million; the high-rate strategy costs ical journal, so its reviewers were less likely to be clinicians who might pressing for reduction in use of tonsillectomy in their journal articles. nearly $1 billion,” he observed. And that was in 1975 dollars. More harm than good be stung by Wennberg’s suggestion that they could be overtreating “Among a sample of California physicians, the offspring of pedia- “But the costs, of course, are not only in dollars,” Wennberg con- But before those people and projects existed, even before Wennberg’s their patients. Moreover, at Science the author of a study was able to tricians underwent fewer tonsillectomies than the children of other tinued. They could also be measured in lives. In Vermont from 1969 arrival at Dartmouth, he began to realize just how much was at stake: suggest potential reviewers, and Wennberg suggested people who were types of physicians. Unless, as seems highly unlikely, the children of to 1973 and in Maine in 1973, “three postoperative deaths followed “Given the magnitude of the variations,” he wrote in 1973 in Science, both prominent and aware of his work. If Science had not given writ- pediatricians are healthier than the children of other physicians, this tonsillectomy,” he wrote. “For so costly a procedure, ambiguity con- “the possibility of too much medical care and the attendant possibil- ers that opportunity, it is not clear when Wennberg’s work would have seems to reflect specialty-related differences in opinion on the value cerning its value will likely become increasingly intolerable.” ity of iatrogenic illness [illness that is caused by medical care] is pre- seen the light of day. of tonsillectomy.” For years, even medical students had recognized the dearth of sci- sumably as strong as the possibility of not enough service and unat- “The problem is that all of this stuff is so antithetical to the dom- There is that word “opinion,” cropping up once again. In the mean- entific evidence behind the procedure. “When I was in medical tended morbidity and mortality.” In other words, in towns blessed inant ideology in the medical community—so antithetical that they time—this was the really strange part—Wennberg had discovered school, I remember one professor—a particularly arrogant Park Av- with many surgeons, the extra surgeons actually might be doing more can’t bear to talk about it,” Wennberg reflected a few months ago. that tonsillectomies were much more common in some communities enue practitioner—asking: ‘What are the indications for a tonsillec- harm than good. The fact that he spoke in the present tense suggests that the “domi- than in others. But why? tomy?’” recalls Dr. James Strickler, who was dean of Dartmouth Med- This is not what Wennberg’s peers in the medical profession want- nant ideology” lingers still. But what exactly is that ideology? ical School when Wennberg joined the Dartmouth faculty. “And one ed to hear. In fact, he almost didn’t get that first paper published. “We “Manifest efficacy,” Wennberg says, smiling. “Everything we do [in Geography is destiny of my more provocative classmates responded: ‘A hundred dollars and tried the New England Journal of Medicine, we tried the Journal of the medicine] is effective.” His smile isn’t smug; it’s rueful. “It’s not just In the early 1970s, when Wennberg began puzzling over tonsillec- a pair of tonsils.’” American Medical Association. We tried all of the medical jour- doctors,” he adds. “Patients want to believe in manifest efficacy. It tomies, he was working at the University of Vermont as the director Wennberg went on to show that tonsillectomies were just one of nals,” he recalls.
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