Science wasn't a medical ical journal, so its reviewers were less likely to be clinicians who might be stung by Wennberg's suggestion that they could be overtreating their patients. Moreover, at Science the author of a study was able to suggest potential reviewers, and Wennberg suggested people who were both prominent and aware of his work. If Science had not given writers that opportunity, it is not clear when Wennberg's work would have seen the light of day.
"The problem is that all of this stuff is so antithetical to the dominant ideology in the medical community—so antithetical that they can't bear to talk about it," Wennberg reflected a few months ago. The fact that he spoke in the present tense suggests that the "dominant ideology" lingers still. But what exactly is that ideology?
"Manifest efficacy,"Wennberg says, smiling. "Everything we do [in medicine] is effective." His smile isn't smug; it's rueful. "It's not just doctors," he adds. "Patients want to believe in manifest efficacy. It places medicine closer to a religion than a science."
Today, "such manifest confidence is grounded in a fervent belief in medical technology,"Wennberg continues. "In the past, this wasn't so important. And it didn't cost so much. But now it's expensive. It's costly not just in dollars, but in the cost for patients." In today's "uncontrolled experiments," patients who undergo surgical treatments run a serious risk of life-changing side effects—in the case of early stage prostate cancer, for instance, incontinence and/or impotence. Urologists may recommend surgery for such patients reflexively, and patients may assume it is their best option. Yet the National Cancer Institute's position is that although "screening tests are able to detect prostate cancer at an early stage, it is not clear whether this earlier detection and consequent earlier treatment leads to any change in the
"The problem is that all of this stuff is so antithetical to the dominant ideology in the medical community—so antithetical that they can't bear to talk about it," Wennberg reflected a few months ago. But what is that "dominant ideology"?
natural history and outcome of the disease."
But patients need to believe, must believe, that whatever treatment they get is effective, Wennberg explains. "At one point, Jack Fowler, the president of the Foundation for Informed Medical Decision Making and a friend from my Vermont days, interviewed patients who had been treated for prostate cancer. . . . They believed their lives had been saved,"Wennberg says. "And so they were bearing the burden of their surgery—and whatever side effects they suffered—very well. That's part of the dynamic that prevents change. The committed patient is committed to the treatment and the ideology. That circle stands in the way of change."
The birth of a skeptic
Jack Wennberg probably brought more
skepticism to his career than most doctors. After earning his M.D. at McGill in Montreal, he did his residency at Johns Hopkins, where he also earned a master's of public health and began a Ph. D. in sociology. "I was interested in social systems and how societies addressed large questions," Wennberg remembers. "At the time, the Vietnam War and the civil rights movement were important drivers in my thinking." His interest in social change translated into a fascination with public health and epidemiology, the root causes of illness, and even the health of the health-care system itself. "I was interested in measuring process, structure, and outcomes," he explains.
From Johns Hopkins, Wennberg headed for Vermont. Back then, "I still believed in the general paradigm that science was advancing and that it was being translated rationally into effective care," Wennberg recalled in a 2004 interview published in the journal Health Affairs. "At that time, economists and sociologists as well as patients and doctors believed . . . that the central tendency of the market was rational. . . . I had read enough sociology and was aware [enough] of the overt and covert functions within systems that I came [to Vermont] armed with some skepticism about human behavior. Having read that literature, I was prepared for interpreting what we found. But I don't think I went into it thinking we would find such a marked variation in medical practice."
If Wennberg was surprised by what he found, others in the medical profession resolutely refused to believe his findings of seemingly arbitrary variations in medical practice—variations driven by little more than the number of surgeons and beds available. Both the 1973 paper in Science and a similar 1977 article published in the Journal of the Maine Medical Association drew fire from critics such as Dr. Francis Moore.
Now deceased, Moore was a professor of surgery at Harvard and the chief of