program's emphasis on shared decisionmaking. "As an orthopaedic surgeon, I often didn't feel that my patients were getting the information they needed to make their decisions," says Weinstein. "They were talking to me, but maybe that wasn't good enough, because I was a surgeon and surgeons do what surgeons do. Maybe they weren't getting a fair shake.
"When it came to risk," he continues, "I knew that many of my patients were thinking, 'I trust my doctor. He is so good that nothing bad will happen tome.' I wanted to say, 'Wait. Stop. This is important. You could die. You could get an infection.'"
Wennberg recognized Weinstein's concern for patients and deep interest in the same questions he himself was drawn to. "When I was there" at Dartmouth, Weinstein remembers, "Jack said, 'You know, you should stay here.'" But Weinstein had an endowed chair and an established practice in Iowa. So he went back.
Weinstein also had a sick daughter, who had been diagnosed with leukemia when she was one. "By this time she was eight or nine, and she was pretty sick," he recalls. "When I returned to Iowa, I was asking myself, 'What am I doing with my life?' Given what was going on in my daughter's life, I was pretty unsettled in my own life. My wife was unsettled." And, Weinstein adds, "when we got back to Iowa I missed the intellectual discussions that Jack stimulated."
So, in 1996, Weinstein turned his back on tenure, abandoned his endowed chair, followed his instincts, and returned to Dartmouth. "CECS and Dartmouth-Hitchcock . . . made me an offer so that I could still practice," he recalls. Before long, he was asked to start a Spine Center at DHMC, which became a demonstration project for CECS's
"In the basic sciences, you have discussion and debate. Why not in medicine?," asks Wennberg. "We need to be continually evaluating what we are doing over time. 'Why are we doing this? What is the evidence that it is working?'"
precepts. It offered a chance to coordinate patient care and outcomes research from the ground up, to directly compare the effectiveness of various treatments. "I said, 'Orthopaedists and neurosurgeons should work together, with primary-care doctors, and actually collect data on how our patients are doing,' " Weinstein says. Even then, even at Dartmouth, he met with some resistance. "We're too busy," some doctors said. "This is going to interfere with my practice," others complained.
But Weinstein was undeterred. "My daughter's experience in [the] health-care system had been pretty chaotic," he recalls. "There were errors; she was given the wrong drugs; there were complications from chemo and they were not well explained. So I really didn't mind the
noise about the effect on their practice. I was concerned about the effect on the patient."
By this time his daughter was very sick once again. In 1997, a year after his return to Dartmouth, his daughter died. She was 121/2 years old. "This really tested my spirit," Weinstein says. "Either you withdraw and go into your hole, or you draw on it for strength. She had become my hero," he continues. "She never complained about anything. She had suffered a lot for a long time while we had pushed on from one experimental treatment to another experimental treatment. And the doctors would say, 'This is the protocol. This is what we do next.' I wouldn't want my daughter to have been with us for one day less, but . . . " His voice trails off.
One can only imagine the agony for Weinstein—who had always worried about overtreating his patients—at being forced tomake treatment decisions for his daughter. Impossible decisions, given the paucity of information about risks, benefits, and options. When doctors say "This is the protocol," they are simply stating "This is the way we do it." Not why. Not whether they know why.
"After my daughter's death,"Weinstein goes on, "my wife and I felt an obligation to try to make it better for other people. . . . So I didn't give up practicingmedicine. I didn't want to losemy chance to change the world of medicine from within.
"And then I was asked to become the chair of the orthopaedics department—something I hadn't expected. It gave me a chance to advocate for the changes I wanted to make."
What did he change? "Everything," says Weinstein, suddenly grinning with enthusiasm. He began by connecting the department's teaching and research missions with its clinicalmission. "Part of the problem with geographic variation in