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Honoring John E. Wennberg

November 06, 2013
Lebanon, NH

By Steve Bjerklie
Photography by Mark Washburn

Among many other pursuits and interests, Elliott Fisher, MD, MPH, and John (Jack) Wennberg, MD, share a love of cross-country skiing. Soon after Fisher arrived at Dartmouth – "When I was looking for a place to do research after I completed my training, I looked at Dartmouth because he was here" – they began skiing together, enjoying long trips into the snowy, scenic New Hampshire woods and mountains. On one trip, Jack's boots were wearing out and causing him problems on steep slopes. So Elliott switched boots with Jack, and they made it back to the car just fine. Later, Jack returned the boots to Elliott – sprayed with gold paint.

"It was through gestures like this – and a warm welcome to newcomers – that he created the sense of community here that we hope to carry on," said Fisher.

As director of The Dartmouth Institute for Health Policy and Clinical Practice, Elliott Fisher heads the organization that Jack Wennberg founded 25 years ago, in 1988. "Jack fundamentally changed the way we think about health care. His work on variations led to the insight that we lacked adequate evidence about the outcomes of common treatments — and led to the creation of the field of comparative effectiveness research," said Fisher. "The research also revealed that clinical decisions often failed to take account of what mattered most to patients, research that led directly to the establishment of shared decision-making as an ethical and clinical imperative. And his work on the key role of supply in determining utilization rates led directly to insights on the importance of overuse and over treatment as key problems in health care."

These and Wennberg's many other accomplishments in medicine at Dartmouth have led the college to establish the John E. Wennberg Distinguished Professorship, endowed by 25 donors, many of whom are health care leaders. An endowed professorship is the highest honor awarded by Dartmouth to a faculty member at The Dartmouth Institute. The establishment of the Wennberg professorship is timed to commemorate the 40th anniversary of the publication of his seminal Science journal article detailing variations in the delivery of health care.

"Jack has been a true pioneer, with all the courage and fortitude that implies," said Dr. Jim Weinstein, CEO and president of Dartmouth-Hitchcock. "He saw, 40 years ago, what people have onlybegun to come to grips with in the last few years: that our health system was illogical, often irrational, and driven by the wrong incentives. In the 1990's, he proposed the Randolph (VT) Project, which would have essentially been one of the earliest ACOs. It was based on all the ideals we now recognize are at the root of sustainable health care: the health of the population; value— through shared decision making and a focus on quality; and new payment models that allowed for shared savings based on value, not volume. Just think where we'd be today as a nation if we'd listened to Jack."

"Jack has done so much," said Dr. Weinstein, who added, "His intellectual contributions are enormous and of course, his early on-the-ground work, looking at regionalvariation in tonsillectomy, prostate cancer,mastectomy and other elective surgeries, was groundbreaking."

Wennberg's introduction and integration of shared decision-making into clinical practice ranks as one of his most significant ongoing achievements, Dr. Weinstein noted. "We know today, based on Jack's workand our own experience at D-H with the first-in-the-nation Center for Shared Decision Making, that patients, when well-informed, make very different choices about their care. Thirty percent of patients, once they go through the process, change their initial treatment choice. The result is better clinical outcomes, better patient satisfaction, and less decisional regret."

A testament to D-H's commitment to Wennberg's vision of health care is the fact that more than 100 TDI graduates are among the D-H clinical and quality staff. One of those is Dale Collins Vidal, MD, section chief for plastic surgery at D-H and director of the D-H Comprehensive Breast Program. She called Jack Wennberg her "personal hero," noting that his work "changed forever how we understand medical practice" in this country.

"He revealed extensive variations in treatment choices across the U.S.," she said. "Moreover, he has shown that these variations cannot be explained by differences in the patients, but track more closely to local and regional practice patterns. This suggests that in many, many areas of medicine, we do not have enough evidence to reach a consensus about an optimal approach for the treatment of a given condition."

She first learned about Wennberg's research when she was a resident in the mid-1990s."It was because of Jack that I came to Dartmouth in 1995, and I received my master's degree in Outcomes Research from his Center for Evaluative Clinical Science in 1998. In the ensuing 15 years, I have had the opportunity to work with him on a number of projects involving shared decision making and informed patient choice," she described. "Jack was kind enough to fund from his own reserves an important research project on a women's choice for the treatment of early stage breast cancer. This project was one of the first to measure the quality of a patient's decision using the metrics of knowledge about the treatment choice and how the patient's individual values related to the treatment choice."

The Wennberg professorship will provide its honoree a financially stable platform from which to pursue research and teaching without concern for finding continuous sources of grant funding. According to the College's announcement of the honor, the distinguished professorship will be awarded to one of the most senior professors at TDI to support his or her work as well as the dissemination of The Institute's work in order to inform health policy reform and advance health-care research and evaluation.

Elliott Fisher called Jack Wennberg "my most important mentor and colleague by far."

"Meeting Jack changed my life," said Weinstein, who added, "I was very happy at the University of Iowa, had an endowed Chair, and was very involved in research and clinical practice. But I knew we could make the system better. Going through the MS program at CECS (now TDI) excited my imagination, strengthened my resolve, and inspired me to a whole new level of actively seeking change and improvement in health care delivery. When Jack asked me to come back to Dartmouth for good and help him take shared decision-making from research concept to reality, I couldn't resist. The Spine Center, the Center for Shared Decision-Making, SPORT clinical study, the High Value Healthcare Collaborative — all came out of working with Jack.

"I don't think the importance of Jack as a mentor and intellectual leader can be overstated."

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