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Vital Signs

A changing of the guard (and the name) at CECS

By Jennifer Durgin

In the early 1970s a young epidemiologist, Dr. John Wennberg, noticed something strange happening to children's tonsils in Vermont. In one town, 70% of children had had their tonsils out by the age of 12 due to tonsillitis. In a neighboring town, the tonsillectomy rate was only 20%. What was behind this dramatic variation, he wondered. The cause, to his surprise—and the disbelief of nearly everyone else—was the preferences of individual physicians.

In the nearly 40 years since, Wennberg and his colleagues at Dartmouth have demonstrated again and again that where patients live often determines the amount and kind of health care they receive. "Geography is destiny," Wennberg is fond of saying. In 1988, he founded the Center for the Evaluative Clinical Sciences (CECS), which has grown to be a national research and policy powerhouse.

Now, at age 73, Wennberg is stepping down as the director of CECS and passing the torch to Dr. James Weinstein, a professor and chair of orthopaedics at DMS and a convert to Wennberg's teachings. At the same time, CECS is being reborn as the Dartmouth Institute for Health Policy and Clinical Practice. More than just a name change, this restructuring recognizes the national and international impact of the research conducted at CECS.

Role: Though he's relinquishing the director's role, Wennberg will continue to hold the Peggy Y. Thompson Chair in the Evaluative Clinical Sciences and to be active in the Institute and its work, including the Dartmouth Atlas of Health Care. Launched in 1996, the Atlas documents geographic variations in care and outcomes across the U.S. It has

One thing that didn't change was the initials of the program's director—its founder, Jack Wennberg, left, has been succeeded by Jim Weinstein, right.

consistently shown that more spending and more services are not associated with better outcomes. In fact, patients in high-cost, high-care areas tend to fare worse than those where more conservative care is the norm.

Another focus for Wennberg has been involving patients in treatment decisions. In 1989, with Dr. Albert Mulley, a Harvard faculty member and a DC '70, he created the Foundation for Informed Medical Decision Making. (For more on patient decision-making, see "Making Choice an Option".)

Dictum: Wennberg's dictum that "more care is not always better care" is one that Weinstein, the new director, clearly embraces. Weinstein left an endowed professorship at the University of Iowa to come join Wennberg's team in 1996.

Since then, Weinstein has founded the DHMC Spine Center, as well as the first-in-the-nation Center for Shared Decision Making, both national models for informed patient choice. He is the principal investigator for the $21-million Spine Patient Outcomes Research Trial—the first large, randomized trial of the efficacy of various back surgeries—and he is also editor-in-chief of the journal Spine.

Reform: "More than anyone, he understands how our research can be applied in the real world to improve patient care, reform our health-care system, and produce a new kind of health-care leader," Wennberg said ofWeinstein in an announcement of the changes. And Weinstein observed that "we all stand on the shoulders of those who came before us, and I am proud and honored to stand on the shoulders of Jack Wennberg."

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