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I would submit to you three names in our institution who might have special knowledge. I have mentioned two of them above. They are Dr. John Cobb, professor and chairman of the department of preventive medicine, and Dr. Jerry Aikawa, chief of our central laboratories. I would also suggest the name of Dr. C. Henry Kempe, professor and chairman of the department of pediatrics. Each of these men may be reached by directing a communication to the University of Colorado Medical Center, 4200 East Ninth Avenue, Denver, Colorado, 80220. Should you desire further information about the possibility of screening for pulmonary diseases, I would suggest that you contact Dr. Roger S. Mitchell, professor of medicine and director of the WebbWaring Institute for Medical Research and Dr. Thomas L. Petty of our division of pulmonary diseases. The latter two men may be reached at the above mentioned address also.

If you are interested in further information concerning objective tests for hearing and vision, I should be glad to supply it. I have been working with Dr. Geary McCandless of our department of audiology insofar as evoked visual responses are concerned.

I hope I have submitted to you some helpful information. Please do not hesitate to write if I can be of further help to you.

Sincerely yours,

GEORGE S. TYNER, M.D.,

Associate Dean and Assistant to the Vice President
for Medical Affairs.

SCHOOL OF MEDICINE,

UNIVERSITY OF LOUISVILLE,

OFFICE OF THE DEAN,

Louisville, Ky., September 1, 1966.

MAURINE B. NEUBERGER,

Chairman, Subcommittee on Health of the Elderly,

U.S. Senate, Washington, D.C.

DEAR SENATOR NEUBERGER: This letter is in response to your recent inquiry concerning multiphasic health screening.

Along with most physicians I believe such screening to be a valuable and necesary adjunct to comprehensive care.

The essential problems arise in connection with

1. Who will do the work?

2. How may effective and continuing followup be arranged so that full potential advantages may be exploited?

3. What percentage of any age, ethnic or economic category of the public will cooperate beyond the first screen?

I do not profess to have any competence in estimating the answers, but I am certain that a program based on the level of medical indigency or age alone would not be terribly effective.

We, of course, in effect accomplish multiphasic screening as a byproduct of our out patient clinics and ER activities, but it is not a formally organized program in the sense of your query.

My only suggestion would be to begin with demonstration programs on multiphasic screening so that some organized and reportable data may be collected for continuing planning.

Sincerely yours,

DONN L. SMITH, M.D., Dean.

UNIVERSITY OF ILLINOIS AT THE

Hon. MAURINE B. NEUBERGER,
U.S. Senate, Washington, D.C.

MEDICAL CENTER, CHICAGO,
Chicago, Ill., August 29, 1966.

DEAR SENATOR: I am writing in response to your inquiry of August 24 to Dean Bennett who is abroad and may not return to our campus in time to be helpful with your inquiry about health screening methods and chronic illness.

I am not aware of a single method or methods in use at our medical center that would necessarily be useful on a more widespread basis; however, we do have medical faculty who are seriously interested in several phases of this problem and I am furnishing the names of two of these:

Dr. Adrian Ostfeld, professor and head of the department of preventive medicine and community health, is in the midst of a largescale research project that deals with examination and certain screening procedures of an older age population in order to discover information that may be useful in preventing stroke and vascular diseases. His mailing address is University of Illinois at the Medical Center, 1853 West Polk Street, Chicago.

Dr. Joyce C. Lashof, associate professor of preventive medicine and community health, and formerly director of the outpatient clinics in medicine at Presbyterian-St. Luke's Hospital, has conducted new multiphasic screening procedures on a large scale but with a restricted clinic population at the Presbyterian-St. Luke's Hospital. Her mailing address is Presbyterian-St. Luke's Hospital, 1753 West Congress, Chicago, Ill. 60612.

Sincerely yours,

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Hon. MAURINE B. NEUBERGER,

Chairman, Subcommittee on Health of the Elderly,
U.S. Senate, Washington, D.C.

DEAR SENATOR NEUBERGER: In reply to your letter of August 23, 1966, we do favor multiphasic health screening if done in conjunction with programs of comprehensive medical care. We do not believe there will be any major problem in acceptance by the patient and the doctor if the screening is done in conjunction with comprehensive medical care in which both the doctor and the patient are involved on a continuing basis.

We do conduct such screening and comprehensive medical care in this medical school on a limited basis. We hope to expand these programs when more resources are available. These programs have been under the direction of Dr. George Entwisle and Dr. Harle V. Barrett as far as adults are concerned and Dr. Ray Hepner for the children's programs.

I am enclosing a copy of a letter I have just received from Dr. Entwisle which may be of interest to your committee.

Sincerely,

WILLIAM S. STONE, M.D., Dean.

UNIVERSITY OF MARYLAND,

SCHOOL OF MEDICINE,

DEPARTMENT OF PREVENTIVE MEDICINE AND REHABILITATION,

WILLIAM S. STONE, M.D.,

Baltimore, Md., September 1, 1966.

Dean, University of Maryland School of Medicine.

DEAR DR. STONE: Thank you for letting me review Senator Maurine Neuberger's letter to you of August 23 concerning the activities of the Subcommittee on Health of the Elderly. I would like to make a few comments about the content of his letter as well as the additional material that appeared in the Congressional Record.

First, some information for a few of the specific questions in Senator Neuberger's letter. We are planning for the development of a multiphasic screening program in our outpatient department. The medical care clinic of our outpatient department has been renamed the evaluation clinic and in this space is now located the medical screening room (transferred from the first floor), as well as the screening activities of the former medical care clinic. We have had a screening program in the medical care clinic for some years and it is our plan to enlarge this program for more of the ambulatory patients. Our screening program in the medical care clinic has consisted of the following for all adults: height, weight, blood pressure, STS, hemoglobin, urine (albumin and sugar), visual acuity, tonometry (over age 40), and cervical Papanicolaou smears (for all women over age 15). A modified program is available for the children. We were particularly interested in developing screening for cervical cancer and glaucoma in a public assistance population since both these conditions are much more common in the low social classes. You will note also that now we do routine PAP smears beginning in the older teenagers and not above age 40 as we did a few years ago. The most recently diagnosed patient with cervical carcinoma-in-situ in this screening program was a 29-year-old woman.

This screening program in the medical care clinic has been under the direction of Dr. Harle V. Barrett and he is trying to develop a larger multiphasic screening program for our outpatient department. We would hope to incorporate routine X-ray mammography on middle aged and older women, but the details of this have not yet been worked

out.

Two or three years ago, we looked at our screening program in the medical care clinic and found that we were getting cervical Papanicolaou smears on slightly over half of the women over age 40. There are several reasons for this poor performance but we decided the best method for correcting this deficiency would be to have one of our nurses trained to do these Pap smears and have them done at the time the patient registers in the medical care clinic. This was discussed with Dr. Arthur Haskins and he approved this in principle, and for the last year and a half, one of our nurses has done routine

way, our program

has been

Pap smears on all eligible women. In this vastly improved. In addition, our nurse has also been trained by Dr. Richard Richards' staff in the performance of routine tonometry and this is also done at the time of registration on adults aged 40 and over. We feel that the use of paramedical personnel in performing these screening tests is necessary and should be encouraged further. Senator Neuberger arranged for printing in the Congressional Record a number of letters from distinguished health officials in support of comprehensive screening and expressing interest in the establishment of health protection centers. It should be recognized that many individuals are not convinced of the value of multiphasic screening in terms of reducing morbidity and mortality. It is clear that for some screening tests (cervical smears, the best example) there is good evidence of reduced mortality or morbidity (glaucoma screening). There are, however, published papers indicating that individuals provided with periodic health examinations do not live longer than others not afforded these examinations, and a number of people have questioned the value of specific tests included in a multiphasic screening program. As you know, and as Senator Neuberger has pointed out, the Kaiser Foundation project should give us important information on the impact of a multiphasic screening program on morbidity and mortality. I think their data will be more useful since their multiphasic screening program is part of a larger comprehensive care program of their medical centers and presumably the physicians in this group practice will be acting directly upon the results of multiphasic screening. I think this is important and pertinent to question 1 of Senator Neuberger's letter since such multiphasic screening clearly will identify individuals at greater risk of dying from certain dis

orders.

Multiphasic screening programs frequently obtain, from partici pants, information other than laboratory tests. This information is in the form of personal or behavioral characterists which is useful in identifying groups at greater risk of developing chronic diseases. For example, one can identify, using the data from the Framingham study, those individuals in an adult population who are at greater risk of developing clinical coronary heart disease than other groups in the same population. Identification of such individuals is important if (1) a method of management of the high risk group is available and (2) this method of care will reduce the risk of this identified group. The answer to the second point is not completely clear at the moment, and the best we can do now is to take an educated guess.

Our identification of individuals at greater risk of developing certain chronic diseases is based on the determination of the presence or absence of certain characteristics and these characteristics can be divided into two groups. One group represents those the physician cannot change, such as age, sex, race, and genetic background. The other set of characteristics include ones that might be changed but these characteristics relate directly to patient behavior and therapy requires changes in such behavior. Changes in obesity, fat intake. exercise, smoking habits, and long-term treatment of asymptomatic hypertension have been strongly recommended for a number of these chronic diseases, but we recognize that there are problems associated

T

with long-term behavioral changes in patients who feel quite well. More data in support of such behavioral changes are needed and the establishment of health protection centers should assist in providing these data. However, I feel that changes in behavior of the public will be best accomplished by the use of community campaigns complementing a medical program where the patients are provided continuity and coordination of care. In my judgment, individual behavior changes of the type mentioned above have the greatest opportunity for success in a situation where a patient is identified with a personal physician in a setting of comprehensive care. I feel, therefore, that the best data on multiphasic screening will be obtained in a setting where comprehensive care is also provided the population under study. As you know, we are hoping to develop this kind of program in our medical center for at least part of the ambulatory population and our plans along these lines include the development and appraisal of a multiphasic screening program. When successful, our comprehensive care program will provide services to a medically indigent population and the data from this program should complement the Permanente project since the latter is focused on a middle-class population.

I would hope that Maryland would be elected for the establishment of one of the proposed health protection centers.

Sincerely yours,

GEORGE ENTWISLE, M.D.

THE UNIVERSITY OF MICHIGAN,

MEDICAL SCHOOL,

Ann Arbor, September 1, 1966.

Hon. MAURINE B. NEUBERGER,

OFFICE OF THE DEAN,

Chairman, Subcommittee on Health of the Elderly,

Senate Office Building,

Washington, D.C.

DEAR SENATOR NEUBERGER: Thank you for your letter of August 23 referring to the study of modern health screening methods being undertaken by the Subcommittee on Health of the Elderly of the U.S. Senate Special Committee on Aging.

I will turn first to answers to your specific questions.

1. Is there a place for multiphasic health screening in health care in our country?

Answer. The term "multiphasic health screening" when examined closely is a confusing set of words. As I understand it, it refers to a data collection technique wherein a standard battery of inquiries, both verbal and laboratory, are developed and administered by nonphysicians with the results being organized and finally submitted to a physician who makes a judgment about their relevance to the health status of the individual. Since there is no way to examine for health as such, the actual screening procedure is for deviations from a range of normal and is an illness survey, in truth, rather than a health survey.

Such an approach to a patient is a direct extension of the traditional complete examination provided for patients by physicians. The real

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