automated techniques to health care make it mandatory for us to seek new and more efficient methods for doing the job. Whereas most of us who are now in middle life or older remember the days when the doctor-patient relationship tended to be a very personal thing, with distinct advantages, at least in the psychological sphere, I personally do not believe that it is realistic to assume that this kind of arrangement can be maintained in these times. Further, even though, as I have indicated, the doctor-patient relationship had very positive values often, utilization of the advances that have come to medical science will in many instances outweigh the disadvantages of employing, at least in part, a less personal form of health care. I am not suggesting that there should be no contact between physicians and patients. Obviously there must, and in the very significant number of instances where psychological and emotional problems represent the major issue, involvement by the physician and other members of the health care team is mandatory. Nonetheless, we are going to have to use newer technology if we are to give patients the kinds of benefits that are potentially available, particularly in terms of screening them for certain diseases, early diagnosis of which will promise longer life and better health. In terms of your second question, I regret to say that none of us has been actively involved in the organization or operation of a multiphasic health screening program. I would add, however, that as we look at the long term development of our patient care programs at Stanford, both in terms of patient care per se and in terms of the education of tomorrow's physicians, we hope very much to get into this kind of activity. We are now beginning to program a new ambulatory care center, and we visualize one of the features of the center will be the creation of some kind of screening program that will enable us to serve a good many people in the most efficient manner possible. In terms of developing the most effective screening programs for patients both below age 60 and above age 60, I think that the kind of thing that Dr. Collen is doing is very valuable. Over a period of time, it will be possible to determine what screening procedures produce results that can in fact lead to the prevention or at least the amelioration of disease. We have a number of examples from times past where screening procedures have not been shown to be valuable. For example, I think it is quite clear that to do routine gastrointestinal X-ray examinations in asymptomatic individuals does not turn up enough unsuspected lesions of significance to justify the expense and effort. involved. It may be that some day we will have better techniques, and the situation will be altered but certainly I believe the foregoing statement is a valid one at this point. On the other hand, chest X-rays, in all adult groups, on an annual basis have been shown to be valuable preventive and diagnostic tools. What I am suggesting is that we will have to carry out careful experimental studies, on large numbers of patients, evaluating the importance of any one of many diagnostic aids, and on the basis of the results, we can then determine whether the procedures are justifiable. very I can't suggest anyone who has special knowledge of this field, above and beyond those whose names you already know. I would like to make one suggestion, however, that might be helpful. Dr. Leland Blanchard of San Jose, a distinguished family physician who is an active participant in our teaching program, and who has thought long and hard about the problems of medical care, would be an excellent individual for you to contact. Dr. Blanchard is in my experience a rare person: he is aware of what is happening in medicine, and understands the needs for change; on the other hand, he has had a long and distinguished record as a fine physician, and he also, therefore, can bring to consideration of new approaches the perspective of a long experience and a sound understanding of patient attitudes. Dr. Blanchard can be addressed at 678 East Santa Clara, San Jose, Calif., and I hope that you give him the opportunity to comment on this subject. Thank you again for writing me. Please let me know if I can be of further help. Very sincerely yours, ROBERT J. GLASER, M.D. STATE UNIVERSITY OF NEW YORK AT BUFFALO, MAURINE B. NEUBERGER, SCHOOL OF MEDICINE, OFFICE OF THE DEAN, Buffalo, N.Y., September 14, 1966. Chairman, Subcommittee on Health of the Elderly, DEAR SENATOR NEUBERGER: This is in response to your letter of August 23, 1966, concerning the work of the Subcommittee on Health of the Elderly of the U.S. Senate Special Committee on Aging, I am happy to provide you with the following viewpoints which are based on discussions with members of the medical school faculty. (1a) "Is there a place for multiphasic health screening in health care in our country?" There is a place for multiphasic health screening in health care. Early detection of certain pathological processes might well result in complete prevention, or at least, in an effective control of the conditions. For instance, if detected early, uterine cancer can be cured, and phenylketonuria discovered soon after birth will not cause mental retardation if an appropriate dietary regimen is instituted. Current knowledge in various fields of medicine will permit the initiation of a scientifically sound effective screening program based on an appro priately designed battery of laboratory tests. The suspicious and definitely abnormal cases then be followed up by full medical examination. Existing screening programs however have suffered from at least two shortcomings. The extent to which the programs are followed up by the individual screened is not clearly known, neither is the integration of the screening procedure with a definitive medical work-up by a physician. (1b) "Are there any particular problems that may be anticipated in the acceptance of multiphasic programs by the public or by the medical profession?" Yes, there are several problems to be solved before a full-scale nationwide program can be launched. Among the problems are the following: Past experience with "health check-up" was not altogether satisfactory. Too many false negatives (i.e., rather advanced disease missed by the check-up routine) aroused distrust among physicians and gave a false sense of security of "proven health" to the patients. Recent progress in laboratory medicine will increase considerably the reliability of health screening programs. The evidence produced by pilot screening programs should convince the medical authorities about its value, and education of the public should place such a screening in proper perspective. Mass screening is undoubtedly expensive. The advent of medicare, however, makes us all aware of our collective liability as to the health of our aged. A hospital bed is $40 to $50 a day. The cost of preventive screening should be weighed against the expenses of a long hospitalization. We are strongly convinced that investment in disease prevention is economically sound. Critical shortage of skilled personnel may be another problem. Fortunately, rapid progress in automation is a powerful answer to this difficulty. An automated regional screening center could serially test 2 to 3 million people with a remarkably small number of highly trained personnel, if supported by electronic data processing and computer techniques. Automation drastically reduces the cost per test, and at the same time, improves the quality of the test. The remarkable accuracy of automated equipment will enhance the confidence of the physician in the test reports. Only 2 to 3 years ago, a nationwide screening program would have been branded by the medical profession as an unrealistic utopia. Automation combined with computer handling of the results brings such a program within the realm of reality. If properly organized and conducted, such a program could well alter the pattern of the entire Nation's health needs by leading to better utilization of physicians and health facilities. Obviously, a screening program will not replace a physician's judgment or reduce the importance of medical interpretation of the results. It will only sort out the potentially abnormal cases. This alone, should justify the cost and effort of operation. A national network of computers would offer an unprecedented possibility of storing all pertinent health data of individuals from birth to death, along with all screening data and illness records. Such a monumental "health memory bank" will give the necessary scientifically firm ground upon which can be built the national health of tomorrow. (2) "Have any members of the faculty participated in the organization or operation of a multiphasic health screening program?" At the E. J. Meyer Memorial Hospital, one of our teaching hospitals, a pilot project was started in 1963. Supported by a research grant from the National Institutes of Health, under the direction of E. R. Gabrielli, M.D., 40 apparently healthy volunteers were studied with a large battery of laboratory tests repeated annually. The aim was to observe the "preclinical phase" of certain diseases, i.e., the pattern of mild changes preceding the clinically observable signs and symptoms of the actual disease. These studies were recently expanded to include the investigation of the "community's normal values". Com puter techniques have been employed to store, analyze and interpret results. Edward Marra, M.D., our professor of preventive medicine, has been associated with the Erie County Health Department in a small, multiphasic health screening program, the Well Aging Clinic. (3) "Any suggestions for persons below the age 60? Above the age 60?" A comprehensive screening program should include the entire population, since many diseases could conceivably be traced back to the pediatric age. The initial pilot project(s) might be limited to a geographic area. A medical advisory task-force could compile the initial battery of tests. Careful, computer-assisted evaluation of the results of such pilot study (s) would serve as a guide for a subsequently launched nationwide screening program. The success of the broad program will depend on effective organization of the pilot project (s). Effective screening is best integrated into programs of general health and social welfare activities. Isolation of a health screening program deprives it of full educational value to the recipient and of lasting interest for the physician. (4) Individuals interested in the subject: Edward F. Marra, M.D., professor of preventative medicine, school of medicine, State University of New York at Buffalo, Buffalo, N.Y. Elmer R. Gabrielli, M.D., assistant clinical professor of pathology, 462 Grider Street, Buffalo, N.Y. I trust that the above information will be of assistance to you and I will follow developments in the area with interest. Sincerely yours, DOUGLAS M. SURGENOR, Dean. STATE UNIVERSITY OF NEW YORK, Hon. MAURINE B. NEUBERGER. Chairman, Subcommittee on Health of the Elderly, DEAR SENATOR NEUBERGER: In my mind, there is a place for multiphasic screening programs, but I am not at all sure that we have yet found how to do them well. What continues to disturb me is that too many people, shortly after a complete health checkup, die of a heart attack or of some other disease with sudden onset. This tells us that we have not learned how to examine with results and predict the future with a high degree of accuracy. On the other hand, I would not put off initiating the multiphasic health screening because of this. There are certainly many areas in which the prediction is accurate, such as radiographs of the chest, vaginal smears for uterine and cervical cancer, and many other types of activities. We do not have anyone in this medical school who has special interest in this subject. Sincerely yours, ROBERT A. MOORE. TEMPLE UNIVERSITY SCHOOL OF MEDICINE AND HOSPITAL, Hon. MAURINE B. NEUBERGER, OFFICE OF THE DEAN, Philadelphia, Pa., August 30, 1966. Chairman, Subcommittee on Health of the Elderly, DEAR SENATOR NEUBERGER: I am writing in response to your letter of August 23 and am very happy to give some information to you which may be helpful as you conduct your hearings referable to the advisability of multiphasic screening programs. There is growing evidence that multiphasic health screening will probably prove to be a sound and economic way of detecting many chronic diseases at an early enough stage to reduce morbidity and the economic loss associated with advanced chronic disease. I am sure that you have a great deal of information from many sources around the country and I shall restrict my own comments to a specific study done in this institution. Dr. Eugene Magnier, a member of our faculty, has been working on the development of a computerized multiphasic screening program which would include a wide series of blood chemistry tests, electrocardiogram, phonocardiogram, blood pressure, pneumotachogram, venous pressure, vital capacity, maximum breathing capacity and possibly several other determinations. A simulated model has indicated that the patient time would be less than 15 minutes and that the computer and personnel time would be quite limited. He has checked the validity of this system by examining a random sample of hospital charts and has been able to demonstrate that such computerized equipment would have saved time and money for 79 percent of the surgical patients and 85 percent of the medical patients admitted to the hospital. Obviously, one cannot translate this study to an outpatient and presumably well population but my own opinion would be that the incidence of chronic disease is high enough in those above the age of 60 to warrant a multiphasic screening at least once for each individual and perhaps annually or biannually thereafter. I know that Dr. Magnier would be very happy to give any assistance to you or your committee and if you would care to communicate with him you may do so through this institution. I presume that your concerns relate almost entirely to this specific program in the chronic disease problem but if I can be of further help in your excellent efforts to meet this large problem I shall be happy to do so. Sincerely yours, ROBERT M. BUCHER, M.D., Dean. TULANE UNIVERSITY, SCHOOL OF MEDICINE, New Orleans, La., September 14, 1966. Hon. MAURINE B. NEUBERGER, US. Senate, Washington, D.C. DEAR SENATOR NEUBERGER: Screening programs are urgently needed if the health of the elderly is to be maintained and improved. To be |