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
For half a century," Dr. John Wennberg declared in a 1977 issue of Pediatrics, "the tonsil has been the target of a large-scale, uncontrolled surgical experiment—tonsillectomy." Jack Wennberg 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 without knowing, with certainty, whether the procedure would do the patients 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, tonsillectomy remained the second most common procedure in the United States, after circumcision.)
The word "opinion" in that passage is jarring. What could Wennberg mean? After all, by 1977 medicine was firmly established as a science. Wasn't it? Surely doctors would not subject millions of children to a painful and potentially risky operation unless they had solid evidence that the surgery was truly needed.
Not according to Wennberg. With a boldness that is surprising, even today, he went on to compare doctors to meteorologists: "Pediatricians have been the weathermen in the change of clinical climate, pressing for reduction in use of tonsillectomy in their journal articles.
"Among a sample of California physicians, the offspring of pediatricians underwent fewer tonsillectomies than the children of other types of physicians. Unless, as seems highly unlikely, the children of pediatricians are healthier than the children of other physicians, this
seems to reflect specialty-related differences in opinion on the value of tonsillectomy."
There is that word "opinion," cropping up once again. In themeantime—this was the really strange part—Wennberg had discovered that tonsillectomies were much more common in some communities than in others. But why?
Geography is destiny
In the early 1970s, when Wennberg began puzzling over tonsillectomies, he was working at the University of Vermont as the director of the state's Regional Medical Program. The role involved studying the health-care system and analyzing how resources were used in different parts of the state. What he found, as he combed through hospital discharge data, was wide variation in how
doctors practiced in communities right next to each other.
In the case of tonsillectomies, the research struck home. Literally. Wennberg at that time lived on the line between Stowe, Vt., and Waterbury, Vt. His children went to school in Waterbury, 10 miles down the road, but had the family lived about 100 yards father north, they would have been in the Stowe school system. When he looked at the health-care data for the two towns, he realized that 70% of the Stowe children had had their tonsils out by the time they were 15 years old, as opposed to only 20% of those in Waterbury. Were his kids in danger of being undertreated? Or were the children of Stowe being overtreated?
"The communities were very similar,"Wennberg explains, recalling his
Mahar is currently a fellow at the Century Foundation, where she writes and blogs 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 Harper Collins) 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 debate and in the Fall 2007 issue about DHMC's Center for Shared Decision Making.
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