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Editor's Note

Seeing, and believing

By Dana Cook Grossman

Research is to see what everybody else has seen," observed 1937 Nobel Laureate Albert Szent-Gyoergyi, "and to think what nobody else has thought." Although the Hungarian biochemist was surely referring to research at the lab bench, his words are a perfect encapsulation of the work of Dartmouth's Jack Wennberg.

Wennberg's research has to do not with cells and molecules but with beds and people. Hospital beds, that is, and the people (doctors, for the most part) who decide if those beds get filled. His research encompasses several related themes, but central to all of them is evidence he's uncovered of astounding variations from one part of the country to another in the use of health-care services.

Actually, it's more than his research now—Jack Wennberg has assembled at Dartmouth a whole constellation of colleagues in the health-care utilization field, has sparked the formation of other such groups all across the country, and, indeed, is recognized as the founder of the entire field.

But it was not always thus. The discipline had its genesis in the early 1970s, when Wennberg was a young epidemiologist. Epidemiologists work with statistics on the incidence and distribution of disease in a population. As he examined reams of figures from the state of Vermont—such as how many kids had had tonsillectomies in a given year, or how many seniors had had electrocardiograms—he saw something more than numbers. He saw patterns, differences disquieting in their magnitude and inexplicable on the basis of health status, from one community to another.

And that was when Jack Wennberg began (to use Szent-Gyoergyi's words) to think what nobody else before him had thought—that maybe this wasn't a case of vive la difference. He dug deeper and demonstrated that the variations were due to uncertainty about the value of many health-care interventions. That doctors' assumptions about patients' tolerance for risk, rather than patients' own preferences, were driving many health-care decisions (doctors who didn't take the time to examine his data didn't like that one). And, most heretical of all, that there is actually such a thing as too much health-care.

How could that be?! Wennberg's findings

were scorned, even ridiculed. Of course having more hospital beds and more doctors would result in a healthier population, people countered. Of course getting people screened more often for cancer and other diseases was a good thing.

But Wennberg (along with an increasing number of like-minded researchers) persisted. His opponents had beliefs. He had data. And more and more data. In 1988, he established the Center for the Evaluative Clinical Sciences (CECS) at Dartmouth. In 1993, CECS launched the nation's first graduate program in health-care utilization, and a year later a doctoral program. In 1994, Jack Wennberg was appointed to the first endowed chair in the U.S. devoted to the field he'd founded—DMS's Peggy Y. Thomson Professorship in the Evaluative Clinical Sciences.

The momentum continued to gather. In 1996, he spearheaded the publication of the Dartmouth Atlas of Health Care, a book filled with maps dividing the country into hospital service regions and comparing costs and numbers of beds, doctors, and procedures across regions. And CECS researchers kept on publishing study after study, including many showing that patients in regions that spend the most on health care have worse outcomes than those in regions that spend the least.

In spite of the counterintuitive findings, and in spite of the fact that CECS's work is complicated stuff to explain, scorn has long since given way to esteem. Today, CECS research is covered regularly in major media outlets. Dartmouth data is cited frequently in Congressional hearings and oped essays. CECS officials routinely deliver keynote addresses at professional meetings. And, slowly but surely, the "house that Jack built" is having an impact on the health-care system.

That impact is the subject of this issue's cover feature. It was written by Maggie Mahar, a Manhattan-based journalist whose work has appeared in the New York Times, Barron's, and Money. She explains why a third of U.S. expenditures on health care appear to be wasted, but why that may offer cause for hope. Talk about counterintuitive!

It took unusual perspicacity to see what Jack Wennberg saw in those Vermont health statistics 35 years ago. But in the decades since then, he's made believers out of a lot of people.

Dana Cook Grossman

Laura Stephenson Carter

Jennifer Durgin

Matthew C. Wiencke

Danielle Thomas, DC '07

Barbra Alan
Nancy Marie Brown
John E. Castaldo, M.D.
Paula Hartman Cohen
James DiClerico
Kristen Garner
Rosemary Lunardini
Maggie Mahar
Ann Patterson
Deborah E. Schiff, M.D.
Parker A. Towle, M.D.
Sharon Tregaskis
John H. Wasson, M.D.

John Bolesky
Ernie Branson
Suzanne DeJohn
Eline de Ruiter
Jennifer Durgin
Flying Squirrel Graphics
Jon Gilbert Fox
Christine Jegan
Joseph Mehling
Daniel McGinley-Smith, M.D.
Lia Rothstein
Rory Tanksley
Keith Weller
Mark Washburn

Kate Siepmann

James L. Bernat, M.D., HS '73-77
Lin A. Brown, M.D., HS '79-85
Theresa Bryant
Todd E. Burdette, M.D., DC '93, DMS '04
Kristen Garner, Ph.D. Student in
  Pharmacology and Toxicology
Nancy Price Graff
Daniel J. Kaser, DMS '09
Claire T. Langran, DMS '09
Katherine J. Little, M.D.
Malcolm W. Mackenzie, M.D. '90
William C. Nugent, Jr., M.D.
George A. O'Toole, Jr., Ph.D.
Drew Remignanti, M.D., DC '75
Jonathan M. Ross, M.D.
Vincent R. Sites, M.D., DMS '65
Nancy A. Speck, Ph.D.
Stephen H. Taylor
John H. Wasson, M.D., DC '67, HS '71-73
Hali Wickner

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