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(d) The mechanism created for the registration, referral, and followup of people in the community should bring many of the

“hard to reach” into the mainstream of health care. 3. I am not alone in my conviction that medicare and medicaid are milestones in the development of health care systems which, hopefully, will furnish what we all earnestly desire—the highest quality health care for all people.

Unfortunately, medical care for the elderly is still largely episodic, fragmented, discontinuous, and far from comprehensive.

Legislation has eased the financial burden of the elderly. But major changes are needed to create systems of delivery of health services which are responsive to individual needs and furnish high quality care. This, in turn, has two requirements:

(1) A radical shift of emphasis from consideration of the patient as an inert container in which reside one or more disease processes, to looking

at him as a social being. (2) Since the hospital is the primary provider of health care to the poor older person, it must reorganize its ambulatory care program. A basic requirement of good outpatient care is having a single physician assume the role of guardian of the patient's health. This arrangement will avoid the situation where several highly trained specialists concurrently treat specific diseases, but no one treats the patient as a person.

I would conclude with a plea for a reappraisal of our approach to the entire problem of health services for the elderly. This in no way underestimates or derogates the need for meeting the existing problems.

Every effort should be made to reduce the economic burden of the elderly, develop more efficient systems for delivery of health services, increase health manpower, reevalate the role of the physician, nurse, social worker, and other health professionals, and improve the quality of health care. But all we can hope for is a holding action until we can make a significant impact on the incidence and morbidity of chronic disease.

The health needs of the elderly, far outstripping our current health resources, are increasing at such a rapid rate that we, very likely, will never catch up.

The enormous unmet health needs of the elderly derive not primarily from the fact that he is aging, but is an expression of the disabilities produced by chronic illness. Logically we should, therefore, address ourselves to the problem of chronic disease prevention.

The early detection of disease, before the individual presents symptoms, offers the most promising preventive aproach. It is for this reason that we at the Brookdale Hospital Center are developing a multiphasic health screening program. We strongly urge increased support of demonstration programs of this type.

We are fortunate in that two agencies in the U.S. Public Health Service have concerned themselves with multiphasic screening. The National Center for Chronic Disease Control is funding development of instrumentation and systems, and the Adult Health Protection and Aging Branch is supporting demonstration programs. A significant expansion of their currently modest programs would provide an adequate base for a logical, basic approach to the problem of highquality health care services for the elderly—the prevention of chronic illness.

We can ill afford the luxury of indecision and delay. It is imperative that we intensify the study of preventive health systems now. Thank you. (Dr. Gitman's complete statement follows:)

PREPARED STATEMENT OF LEO GITMAN, M.D., DIRECTOR, DEPARTMENT OF COMMU

NITY HEALTH MULTIPHASIC HEALTH SCREENING PROGRAM, THE BROOKDALE HOSPITAL CENTER, BROOKLYN, NEW YORK

The subject of inquiry is, “Costs and Delivery of Health Services to Older Americans”. Having no special competence in the economics of medical care, I will confine my remarks to the delivery of health services.

May I begin with a caution. Too many discussions of health care services are characterized by John Galbraith's "wordfact" which he defines as follows:

“The wordfact makes words a precise substitution for reality. This is an enormous convenience. It means that to say something exists is a substitute for its existence, and to say that something will happen is as good as having it happen. The saving in energy is nearly total."

A closely related species is the “wordglow". In this case, the use of words as slogans with little attempt at precision, provides the user with a glow of satisfaction. After sufficient repetition, this replaces the need for accomplishment.

A good example, perhaps, is the use of the phrase "high quality health care". No reasonable member of society would deny the desirability of high quality health care. But what is it exactly, that is found so desirable? A valid definition is crucial, because without it we cannot define our goals. I would propose a simple definition. High quality health care results from the application of current knowledge and developing research findings to safeguarding the health of the population with minimal lag time.

A crude systems analysis indicates the existence of a transmission mechanism originating in the store of existing knowledge and research activity, and ending in the man in the street. Closer scrutiny reveals two subsystems; delivery of medical knowledge to the physician and other health professionals, and delivery of health services to the population.

I submit that these subsystems must be considered jointly for it would be senseless to develop an effective mechanism for dispensing second-rate health ca re.

Let us first consider the lag between existing and developing knowledge and the physician. This essentially relates to continuing education. The American Medical Association, county medical societies, medical schools, chapters of the American Academy for General Practice, have, for many years, provided post-graduate courses, many of excellent quality. There is, however, serious doubt that the “one-shot” course of instruction is an effective means of improving the physician's management of patients. I firmly believe that there must be an on-going daily involvement in learning in a fostering environment. First-rate hospitals, community or university, are most likely to offer this setting.

In many instances, the general practitioner may be considered the "disadvantaged" physician. He is busy, harassed, and with little time to keep abreast with the medical literature. He must cover a wide spectrum of medical subjects, in contrast to the narrow specialization of other physicians. To make matters worse, the generation of new medical knowledge proceeds at a bewildering rate. In addition, in too many instances, he is not a member of the staff of a firstrate hospital. It is here that the new knowledge becomes part of the daily experience, where he can absorb it efficiently and effectively. He strives against tremendous odds, and finally, like other disadvantaged members of society, he throws his hands up in frustration.

SPECIAL PROBLEM IN GERIATRICS In the case of geriatrics—the medical care of the elderly—special problems exist. The medical profession, with some exceptions, often disregards the special body of medical knowledge relating to aging. This holds true for the medical education programs of hospitals, where the post-graduate training of medical

students and the continuing education of practicing physicians takes place. There is also a lack of appreciation of the physician's role in the social system created by the doctor-patient relationship, especially when the patient is aged.

Several years ago, I studied the effectiveness of a Geriatric Coordinator in a hospital setting in remedying this situation.

A well trained physician with experience in health care for the aged, in its broadest aspects, was designated Geriatric Coordinator. His function was to stimulate consideration of age-related factors in staff conferences, bedside and informal discussions which constitute the learning experience of hospital work. The findings of this study were as follows:

1. The level of knowledge of the physicians studied about the unique problems of and resources for dealing with the health of the aged, was low.

2. Specialized conferences and seminars on aging, per se, were not an effective means for fostering interest and increasing knowledge in this field. If aging is considered a stage in the continuum of human development, it is logical to strive for an awareness of its impact being incorporated into the warp and woof of the daily professional activity of the hospital.

3. Analysis of the clinical presentations and discussions at the departmental conferences revealed the importance of the role of the Geriatric Coordinator. Initially, many case discussions failed to take into account agerelated aspects where these considerations were pertinent. When this was discussed with the Directors of Service, the performance improved considerably. Performance tended to deteriorate until jogged by further pressures by the Coordinator. It was apparent that an on-going effort was

required to prevent retrogression. At the conclusion of this study, we found a significant increase in the awareness of health resources for the aged by the physicians; an increased acceptance of the legitimacy of special concern with the health problems of the aged and of directing services to them; a milieu in which this greater concern and awareness was more acceptable.

With these considerations in mind, the following recommendations for upgrading the delivery of health knowledge to the physician are offered :

1. All general practitioners in a hospital's community become members of the staff of a hospital. It is the hospital's obligation to aid in accomplishing this. This applies to community, university, and government hospitals. This appointment should not be a superficial one. The general practitioner must be intimately involved in the daily activity of the hospital and his responsibilities should be commensurate with his training and skill as in the case of other hospital staff members.

2. A coordinator for Geriatrics be appointed to hospital staffs to work with the Director of Medical Education to stimulate and incorporate the teaching of age-related biomedical changes in patients. 'An important part of the program should focus on the psycho-social role of the physician in his relationship to patient.

3. Training courses for Geriatric Coordinators should be organized.

4. Since the Director of Medical Education in hospitals is a key figure in planning and orientation, an educational effort to convince him of the

need for instructional activity in the field of aging is necessary. These recommendations can be implemented in the near future. They do not require expenditure of large sums of money. They do not require radical innovations in the current practice of medicine. What is required is the hospital's acceptance of its responsibility and the practitioner's willingness to expend the necessary effort to meet his obligations to continuing education and hospital activity.

In our consideration of the doctor-patient relationship, let us consider some of the psycho-social factors which act upon the physician. One of these is his own self-image, and as part of this, his self-esteem. The physician generally accepts the role of savior or helper which the patient assigns to him. He, therefore, bases his self-evaluation on his effectiveness in helping the patient. When the symptoms are numerous and vague, the history difficult to elicit, the number of diagnostic possibilities bewildering, and therapy ineffective, the physician's selfesteem is threatened. He becomes frustrated and disengages himself.

This disengagement or withdrawal may take many forms. One of these is loss of interest, resulting in haphazard, ineffective management. Another form of withdrawal is symptomatic treatment. The physician no longer looks at his patient searchingly. A prescription is given for each symptom, resulting in a list of multiple, often confusing, medications.

Another form of disengagement is excessive referral to specialists. The old man presents such difficult and frustrating problems, that it is very easy to believe that he needs the services of a trained psychiatrist or other specialist.

Another possible consequence is—uncritical diagnostic evaluation—which becomes a form of withdrawal. The physician presented with an obvious diagnosis in an aged patient closes his mind, and additional important and perhaps curable disorders remain undetected.

Another danger is attributing abnormal test results or lack of therapeutic response, in some vague way, to the advanced age of the patient. If his liver function tests are abnormal, or if the medication prescribed doesn't help the patient, the physician doesn't re-examine his approaches and techniques.

GAPS IN SERVICE DELIVERY

Now, let us turn our attention to the gap in the transmission line between physician and patients, i.e. delivery of health services.

Here, the significant variables are the amount and nature of health care resources available in a community, and the characteristics of the population to be serviced.

For the past several years, I have been Director of the Department of Community Health of The Brookdale Hospital Center. I will use my experience in that setting as a basis for discussion.

With regard to health care resources of our community, I present some pertinent data in Table I.

We have compared the four least deprived health areas in our hospital community with the four most deprived. The population per physician in the former is 1,142, and in the latter 6,325. This is almost a six-fold difference! The age distribution of the physician is also significant. Eighty-four percent of the physicians practicing in the most deprived areas are over age 50, whereas 58% are over age 50 in the least deprived areas.

In two of the four most deprived health areas with a population of 43,000, there is a total of two physicians, one in the 66 to 70 and one in the 71 to 75 years age bracket.

The dearth of practicing physicians in the ghetto area is painfully apparent. One may question the significance of these findings with the statement that these areas are not isolated, so that people could reach health resources by public transportation. This belief disregards the fact that the elderly in this kind of community are often doubly afflicted—they are poor and they are chronically ill.

In view of the lack of physicians in the area, it is the responsibility of the Hospital to cooperate with the City and other agencies in efforts to provide adequate medical services.

The total population of the Hospital community is approximately 500.000. It is obviously impossible to service this number directly by The Brookdale Hospital Center. Several years ago, we proposed a regionalization of health care services in our Hospital area. According to this plan, The Brookdale Hospital Center would be the back-up resource for the Department of Health District Health Clinics and neighborhood health centers which would be strategically sited in the community to provide complete coverage for the area in cooperation with existing resources. This concept coincides with the current master plan of the Health Services Administration and Department of Health of New York City, with whom we are working closely in establishing this network in our

core area.

This regionalization should ease the problem of travel distance to health service resources and since the satelite units will be situated in the community, the sociological separation between provider and user of health services will also be narrowed. Although this applies to all age groups, it is of special importance to the aged.

Up to this point, I have discussed the delivery of medical knowledge to the physician and the facilities program for the delivery of health services.

What kind of health services are needed? Two years ago, we critically reviewed our Out-patient Service practices, with special emphasis on the elderly patient.

Some of the pertinent findings with regard to patients, age 65 and older, are presented in Table II. It was found that one out of seven patients had attended the Out-patient Service for five or more years; more than half were admitted as patients, and an equal proportion utilized the Emergency Room. One out of three utilized all three facilities-Out-patient Service, Emergency Room, and In-patient Services of the Hospital. These data appear to indicate that the aged poor utilized the Hospital as their primary and chief source of medical

care.

Another significant finding was that one out of four attended four or more separate specialty clinics in the Out-patient Service. This might, at first glance, appear to indicate good medical care since the patient is being seen by specialists. Unfortunately, this is not true. Concurrent attendance of numerous clinics usually indicated fragmented uncoordinated care. The patient's failing heart, arthritic joints, diabetes, and high blood pressure were being treated—but no one was concerned with the patient as a person.

On the basis of this study, we formulated an ambulatory care program, designed to provide a doctor-patient relationship. Hitherto, as in most Outpatient Services in this country, the patient reported to a room. The physician assigned to that room for that session was the patient's doctor for that visit. The next visit would be to the same room, but, very likely, the patient would be seen by another physician, unfamiliar with his condition, who would spend precious time trying to reconstruct the medical situation from a chart difficult to decipher.

At this point, I must note that the considerations and recommendations made above leave the basic problem untouched. Just as the building of more roads doesn't appear to catch up with the increasing number of motor vehicles in circulation, so will the construction of health care facilities and services be unable to adequately meet the problem of inadequate health care for the elderly. The needs of the elderly, far outstripping our current health resources, are increasing at such a rapid rate that we, very likely, will never catch up. These needs derive not primarily from aging, but are an expression of the disabilities produced by chronic illness.

Our concern should be with the "well" person with no significant health complaints. We should attempt to detect disease in its earliest stages, so that the subsequent course of the disease could be halted or altered to minimize chronic illness and disability. Only then, would it be possible to get ahead of the game.

BROOKDALE MULTIPHASIC SCREENING PROJECT At The Brookdale Hospital Center we are developing a Multiphasic Health Screening Program designed to evaluate its effectiveness as a chronic illness preventive. This program is partially supported by the Adult Health Protection and Aging Branch, Bureau of Health Services, U.S. Public Health Service.

I would add, parenthetically, that the activity of this Branch and National Center for Chronic Disease Control, is making a significant contribution. NCCD's support of development of automatic disease detection equipment and systems, coupled with the Adult Health Protection and Aging Branch's support of programs which would utilize these techniques, serve as a potent stimulus to further development.

The Brookdale Multiphasic Health Screening Program is based on the use of automated testing equipment and the Hospital's fully automated laboratory and computer facility. It is designed to provide, with careful quality control, screening tests results in large numbers of apparently "healthy” adults, age 40 and over, in an efficient, effective manner.

The program is part of a health program aimed at detecting and treating disease in its earliest stages. In the present state of medical science, this concept offers the most promising approach to the prevention of chronic illness.

During the screening process, the participant passes through a number of test stations, including the following: medical history questionnaire; standard scalar electrocardiogram and vectorcardiogram (Frank), blood pressure, Papanicolaou smear for cervical cancer, height, weight, chest x-ray, visual acuity, tonometry, dental examination including exfoliative cytology and survey dental x-ray, audiometry, spirometry, retinal photography, and laboratory tests consisting of: RBC, WBC, hematocrit, mean corpuscular volume, hemoglobin and hemiglobin concentration, WBC differential count, urinalysis; blood chemistries: (1 hour postglucose challenge), glucose, urea nitrogen, total protein, albumin/globulin, alkaline phosphatase, bilirubin, SGOT, LDH, calcium, phosphorus, uric acid,

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