Patients Seldom Pick Their Treatment, Professor Finds : Medicine: He says doctors decide care by habit and other methods, not from a person’s choice based on evidence of how to get the best results.

HANOVER, N.H. — To those Americans who fear that health care reform will deny them the opportunity to choose the best medical treatment, Dartmouth University professor John Wennberg’s research yields some startling news.

In most cases, Wennberg finds, patients now play little or no role in deciding their own treatment. Instead, doctors prescribe treatment according to instinct, habit or community norms--but not according to scientific evidence of what produces the best results.

Based on three decades of studies of medical practices, Wennberg’s views turn the usual arguments against health care reform on their heads. In his opinion, those who fret that President Clinton’s reform proposal will necessarily bring a Draconian system of medical rationing do not understand the shortcomings of the current system.

Contrary to what most members of Congress are saying, Wennberg argues that the guiding principle for reform should not be to preserve the current pattern of doctor-patient relationships but to improve it. Unlike many opponents of reform, he looks at it as a way to provide patients with a better opportunity to make informed choices between treatment options.

Not surprisingly, officials of the American Medical Assn. view Wennberg’s theories skeptically. But his theories are widely shared by other prominent medical researchers.

Nor does Wennberg simply talk about reform. He and his team of researchers at Dartmouth’s Center for Evaluative Clinical Sciences have devoted themselves to supplying physicians with research on treatment outcomes to guide their decision-making and to producing interactive videos that inform patients in vivid detail of the treatment options available to them.

In one such videotape, men who have undergone prostate surgery talk candidly about the potential risks, such as incontinence and impotence. In another tape, women with breast cancer discuss the pros and cons of different types of surgery--even baring their chests to demonstrate the results.

Using these videos, Wennberg and like-minded physicians hope to revolutionize the practice of medicine in the United States in a way that would preclude the need for harsh rationing of care or federal limits on total health expenditures.

After viewing the tapes, Wennberg found, patients are more likely to choose a less invasive and less costly approach than are their physicians. In one trial, for example, after 284 prostate patients viewed the tape, only 30 of them opted for surgery.

Such findings suggest that this process could help the government slash health care expenditures without having to resort to rationing or spending strictures.

For Wennberg, 59, who studied at Stanford University, McGill Medical School and Johns Hopkins University, producing these videos is just the latest step in a long intellectual journey that began a quarter of a century ago when he discovered an unexplained variation in the way children’s tonsils were treated in two neighboring Vermont towns.

In one community, 65% of the children had tonsillectomies; in a nearby town, the rate was 7%. Wennberg said he quickly realized that physicians in the second town “were not neglecting tonsils--they were just treating them differently.”

Although his findings caused grumbling in some quarters, many Vermont doctors quickly took them to heart and changed their practices. But Wennberg also recognized that the changes did not necessarily represent an improvement because doctors “adopted new treatment patterns that were equally arbitrary.”

Ever since the days of Florence Nightingale, medical practitioners had discussed the need to determine which procedures produced the best results, but--with the exception of federal regulation of drugs--the profession had never insisted on having such data.

It was this realization that caused Wennberg to become a recognized leader in the science of evaluating the results of medical procedures, now known as “outcomes research.”

“More than any other person, Jack Wennberg gets the lion’s share of the credit for starting the outcomes-research ball rolling in this country,” said Robert Keller, executive director of the Maine Medical Assessment Foundation, which was established with Wennberg’s help.

Working with other prominent medical researchers throughout the Northeast, Wennberg--who moved to Dartmouth from Harvard University in 1978--has focused on variations in treatment of enlarged prostate glands. Although the prostatectomy is the second most common surgical operation for men under Medicare, no one had studied whether surgery or non-surgical treatments offered better results.

What Wennberg’s researchers found surprised many physicians. Although prostatectomies were often undertaken on the theory that they would lengthen life, it turned out that surgical patients actually had shorter life expectancies. Furthermore, although the patients experienced less difficulty urinating after surgery, they often suffered other serious complications that reduced their quality of life.

These findings caused Wennberg and his colleagues to conclude that patients should be informed of all the options before surgery. If the treatment options for most illnesses posed trade-offs as significant as those for prostate surgery, they reasoned, why shouldn’t the patients themselves have an opportunity to make the choice?

Using focus groups, researchers found that patients with similar symptoms often made different choices. “The point was that you had to ask the patient,” Wennberg said. “There was no way you could predict how the patient would react.”

The interactive videos, produced at Dartmouth as part of a collaboration with physicians from other New England medical institutions, were the logical result of these findings, he said. In addition to the tapes on enlarged prostates and breast cancer, videos have been produced on hypertension, heart bypasses and back pain.

Outcomes research will not necessarily lead to lower spending for every illness, as it has with prostate surgery. In Maine, Keller said, a recent study has shown that women with uterine problems may be more likely to choose surgery after learning the facts from a videotape.

“But overall,” he said, “our general belief is that shared decision-making will bring utilization rates down. We’ve known for a long time that patients are more risk-averse than doctors. When you give patients the right to assess the risks, there will be a net decrease.”

Wennberg argues that proposals to ration care or limit total expenditures are based on the assumption that consumer demand drives the rate at which high-technology procedures are used. But until patients are permitted routinely to choose their own treatment based on the results of outcomes research, he says, no one will ever know the natural level of demand.