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rent, paying staff, buying equipment and supplies, etc.—and an income from the business. Just as in any business, profit depends on controlling the costs of maintaining and repairing the "machines" that produce the "product" and maximizing the price of the "product."

I learned soon after going into private practice that payment for my efforts was based on my rural location—that a similar service provided by an equivalent "repair unit" (doctor) in an urban area was reimbursed at a higher rate. I also learned an arcane set of rules governing payments. For example, if I observed a cervix with an instrument called a colposcope while evaluating the cervix for possible conditions requiring repair, I would be paid a reasonable fee only if I removed a sample of cervical tissue and sent it for biopsy; I received less than 20% of that fee if I did not do a biopsy. I also learned terms such as "full-risk capitation," "third-party agreements," and "adjustments and write-offs." And many more.

Such is the arcane medicoeconomic system that CECS is trying to fix. My guess is that we will end up with all the "repair units" under one large umbrella—call it socialized medicine if you want—so the costs of maintaining all the "service units" (patients) are standardized.

The "repair units" in this system have historically operated under a code of conduct known as the Hippocratic Oath—one of whose precepts is Primum non nocere—"First do no harm." But after the evolution to the new system that I suspect we are headed for, I fear their motto will be Primum non redundo—"First do not do too much."

Michael J. McKeown, M.D.,
DC '58, DMS '59
Portland, Ore.

The unpersuaded
I, too, have enjoyed the increasing prominence of Dartmouth researchers in the national media, as described in the Spring 2007 cover feature—but I think a dose of real-world medicine might alter the conclusions Drs. Wennberg and

This feature in the Spring issue—on research from Dartmouth that is changing the national health-policy debate—impressed, intrigued, and irked readers.

Fisher draw about the roots of regional disparities in health care. They take great pains to document that a disproportionate amount of services are provided in areas overstocked with physicians and hospitals, and then blithely jump to the conclusion that it is this supply that drives up the demand.

Of course, correlation is quite different from causation. Several alternative explanations for this correlation leap to mind. The most obvious is that different patient populations might be more demanding of sophisticated services. While it is not popular to suggest that ethnicity could be an intervening variable, I do not think it a coincidence that Northern New England and the North Central States, home to hardy Yankees and stoic Scandinavians, respectively, stand out as low-demand states. I suspect patients there might not be as quick to request fancy tests and MRIs as wealthy retirees in the Sunbelt.

Yet the researchers summarily dismiss this possibility with unfounded, inflammatory statements like "People don't just go out and get care . . . the financial incentives point providers in that direction."

The team also discounts the impact of malpractice concerns on this issue by saying that eliminating this factor would decrease spending by "only" 5% to 9%. Inexplicably, they prefer to ignore this amount (which is in fact a huge sum of

money) in their search for a single explanation for excess spending—greedy doctors and hospitals.

Interestingly, two additional variables that CECS does not examine are explored in the same issue of Dartmouth Medicine. Maria Ceyala's research demonstrates that both distance from health care facilities and bad weather reduce patients' pursuit of more sophisticated care. The Dartmouth Atlas map reinforces her findings. High demand for services predominates in densely populated states (New York, New Jersey, Pennsylvania) and those whose population is concentrated in large metropolitan areas, while the Great Plains and Rocky Mountain states stand out for their lower demand.

I heartily agree with Fisher and Wennberg's assessment that perhaps one-third of health care dollars are wasted—but not by avarice. I choose tests without regard for how I might benefit from them, and I believe the great majority of physicians do the same. We resent the implication that doctor greed is at the root of the cited disparities. I suggest the researchers do a better job at ferreting out the other, more real causes. At DMS, even 30 years ago, my friends and I would speculate about where all these arrogant, "me-first" doctors we read about were coming from. It couldn't be any of us! Doctors in this regard are like congressmen: the ones you know are great; it's all the others who are doing the bad stuff.

As an aside, I'm a major fan of Dartmouth Medicine, with its pleasing but not flashy layout, spectrum of issues covered, and discreet ads.

S. R. Fahey, M.D., DMS '72
University of Maryland Health Center
College Park, Md.

We invited Drs. Wennberg and Fisher to respond to the points made in this letter. They wrote: "We appreciate Dr. Fahey's interest in our work and agree about the importance of distinguishing association from causation. But it is also important to distinguish the causes of health-care

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