The work featured in the cover article of our Spring issue came in for kudos but also caught some brickbats. That's nothing new for the featured researchers, however—they're used to criticism of their counterintuitive findings about patterns of health-care usage.

The proselytizer
Congratulations to Maggie Mahar for her superbly written article, "The State of the Nation's Health." With great clarity, she described the pioneering work of the Center for the Evaluative Clinical Sciences. She has ably demonstrated the power and impact of the efforts of Drs. Wennberg and Fisher in reforming our badly broken system of healthcare services.

The day after I read her article, I incorporated it into a course I teach to undergraduates at the University of Central Florida. Most of the 44 students quickly understood the significance of regional variations and what they mean for American health care. I hope our elected leaders will rapidly arrive at the same understanding.

Charles Pierce, DC '58
Winter Springs, Fla.

The barrister
The article in the Spring issue by Maggie Mahar, on the work being done by Drs. Wennberg and Fisher, was excellent and gave praise where praise certainly is due. Their work has shed a whole new light on the quality of medical care, and, given the quality of their methods, their results are not questioned.

I see the issue of health-care quality from a very different perspective. As a trial lawyer, I have been representing both patients and providers in many different types of litigation for more than 30 years, and I concur in the observations made by Jack and Elliott about variation in the cost and quality of care. I would take it one step further—to variation in the quality of medical education and training.

We're always glad to hear from readers about matters pertaining to medicine at Dartmouth or to the contents of past issues of Dartmouth Medicine. Letters to the editor may be sent to DartMed@Dartmouth.edu. Letters may be edited for clarity, length, or the appropriateness of the subject matter.

The medical establishment would have the American people believe that all doctors are essentially equal, all are well trained, and all are capable of delivering care consistent with applicable standards. I have practiced in a number of states in my career and I know this not to be the case. In some jurisdictions, the historic and sociological development of the population creates a citizenry which accepts average to poor care because (1) the people providing it don't know any better, and (2) the people receiving it don't know any better.

There are hospitals and training programs in this country that are abysmal. There are medical school graduates who don't match anywhere and wind up at a hospital/residency of last resort, and no one seeks to improve that situation. States that do not have a strong tradition of excellence in public education often have publicly funded medical schools that are well behind the curve as far as attracting superior students and providing education and training above the merely passable.

Perhaps the next step in getting to the root of the cost and quality differentials between the different states might be aided by comparing the quality of the training programs and individuals practicing in those states.

Lee J. Dunn, Jr., J.D.
Boston, Mass.

Dunn, an adjunct associate professor of community and family medicine at DMS, both teaches and practices medical law.

The prognosticator
I read with great interest the article "The State of the Nation's Health" in the Spring 2007 issue of Dartmouth Medicine. Drs. Fisher and Wennberg have indeed established, defined, defended, and developed the evaluative principles of health care within Dartmouth's Center for the Evaluative Clinical Sciences (CECS). Their efforts have faced and overcome many professional and political impediments.

I would like to offer some comments on the evolution in the cost of medical care. I am a 71-year-old retired physician, and my father was secretary-treasurer of the American Medical Association for several years. Thus I grew up with discussions of the socioeconomic forces in medicine. My own career began at Dartmouth and Harvard, included several years as a physician in the U.S. Navy, training in ob-gyn at the University of Chicago, then several years of academic practice in Chicago.

In 1972, I joined a multispecialty group in rural Oregon. This transition—from being paid a salary to think and innovate to being paid to perform procedures—was brutal. Actions, not ideas, are reimbursed on the front lines of medicine.

From then until my retirement in 1997, I observed ever more sophisticated and complicated carrot-and-stick controls on health-care costs. The business side of medicine is like any other business. There is a cost of doing business—paying