This means, then, that we are not giving the best information that we can for the detection and followup of lung diseases.

The solution to the problem in reference to spirograms is obviously not for the physicians to go back to school to try to learn some very difficult techniques, or to impose upon them the need to do computations that they are not set up to do in their clinics, but to have nonphysicians run the tests and a machine system to do the computations (H 100).

THE KAISER PROGRAM

Not all of the instruments described above are in actual everyday use in field screening programs. But they have been thoroughly tested and found to be practical and efficient. The most extensive use of instrumentation is now underway at the Permanente Foundation Multiphasic Health Screening Clinic in Oakland, Calif. Dr. Morris Collen, clinic director, told the subcommittee that he believes "what we have done is to put together the largest organized program that functions on line with a computer."

The Permanente Clinic is associated with the Kaiser Foundation health plan, a prepaid comprehensive medical care and health program which provides hospital and medical services to members on the west coast and in Hawaii. Automated multitest laboratories are operating in the Kaiser-Permanente Medical Centers in Oakland and San Francisco, where each is processing 2,000 cases per month within a 40-hour week schedule.

Dr. Collen described a series of 20 stations at which patients stop during 2 to 3 hours in the clinic:

At the first station, a patient registers at the reception desk approximately every 3 minutes from 1 to 8 p.m. daily. Here he receives a clipboard which contains a medical questionnaire form and a deck of cards which are prepunched with his medical record number for computer input.

This is an actual deck of cards as they are prepared by the computer for the patient before his appointment.

The patient at station 2 removes the outer body garments in a dressing booth and puts on a disposable paper gown. The patient then proceeds to station 3, where the six-lead electrocardiogram is recorded. These are subsequently read by the cardiologist, who records his interpretation on a card, using pencil marks which can be sensed directly by a card-reading machine for input into the computer. Automatic analysis of the electrocardiograms by the computer is being tested.

The patient drinks a solution of 75 grams of glucose in carbonated water, and the time of glucose ingestion is recorded by a time stamp on the back of the card, and the patient at that time is assigned a sequencing number from 1 to 24 for control purposes.

The patient then proceeds to receive a chest X-ray, which is subsequently read by the radiologist, who records his interpretation on the mark-sense card. X-rays of the breast are performed on all women over 45, and these are also read by the radiologists.

Weight and skin thickness are measured, and then by means of an automated anthropometer, a dozen height and transverse body measurements are recorded directly onto the patient's punchcard in 3 minutes. At the next station, pulse rate and blood pressure are measured and recorded.

The patient then returns to his dressing booth and redresses. Visual acuity is then tested by reading a wall chart, and ocular tension is measured by a nurse with a tonometer, and the reading is recorded on a card. A drop is then placed in one eye to dilate the pupil for later retinal photography. The vital capacity is measured with a spirometer. The hearing is tested with an automated audiometer, and the readings are recorded on a mark-sense card.

At station 14, a self-administered medical questionnaire form, which the patient received at the first station, and which was completed while waiting between stations-this questionnaire is now audited by the nurse. The patient is

then assigned to 1 of 24 questionnaire booths in accordance with the sequencing number which was assigned to the patient at station 4.

Here the patient receives a box which contains a deck of 207 punched cards, each having a separate question printed on the card. The questions have been selected which are adjudged medically to be of value in discriminating patients with specific diseases from nondiseased persons. The patient responds to each question by taking the card from the top section of the divided letterbox and dropping the card into the middle section if his answer is "Yes" or into the bottom section if the answer is "No." This procedure automatically sorts "Yes" responses for direct input into the computer by means of a card-reading machine.

As a part of the preventive medical program, the patient receives a booster dose of tetanus toxoid, and when an hour has elapsed since the ingestion dose, the patient is called from the questionnaire booth and sent to the laboratory, where blood samples are drawn for hemoglobin, blood count, test for syphilis, and rheumatoid factor; these test factors are recorded on the mark-sense cards.

Also, eight blood chemistry determinations-glucose, albumin, total protein, cholesterol, creatinine, uric acid, calcium, and transaminase-are simultaneously done within 12 minutes by the multichannel automated chemical analyzer, with the test results directly punched in the cards. A urine specimen is collected, and tests are done for bacteria, for the urine pH, glucose, blood, and protein and the results are marked into the patient's test cards.

The patient then returns to his questionnaire booth, and when he has completed all of his questions, he then goes to the next station, where a photograph is taken of the right retina, with a camera. These retinal photographs are subsequently read by an ophthalmologist, who records his interpretation on a marksense card.

The patient now returns to station 20, the last station, where he turns in his clipboard containing the marked and punched cards, and the questionnaire form, and there exchanges the box which contains assorted medical questionnaire cards for a second box of cards by which a psychological test is evaluated. By the time the patient turns in this last questionnaire, the on-line computer processing has been completed and supplemental tests and appointments are advised by the programed rules of the computer, and these are arranged for the patient.

Routinely advised are a sigmoidoscopy for all patients aged 40 or more and for all women a gynecological examination with cervical smear for cancer detection. A majority of the data is recorded on prepunched or mark-sense cards, so as to permit its immediate introduction into the data processing system. Thus, as an on-line procedure, while the patient waits at station 20, the computer processes the information from the punched cards, from the prepunched sorted cards, and from the reproduced mark-sense cards; in the central facility these punched cards are entered directly into the computer.

In the San Francisco facility, the punched cards are read into a data communicating system, and transmitted via telephone line to the central computer in Oakland, 15 miles away. The processor now goes through a program routine containing various test limits and decision rules and prints out a report constituting "advice" as to any additional procedures which should be done prior to the patient's next visit.

These advice rules have been previously established by the internists, and the receptionist is instructed to arrange certain additional tests and appointments for the patient before his physical examination yisit with the physician.

For example, if the 1-hour serum glucose is greater than a predetermined normal limit for the patient's age and sex and hours since last food intake, the computer prints out instructions to the receptionist to return the patient to station 16 for a 2-hour serum glucose. If a serious abnormality is detected, an earlier appointment with the physician is advised. As an off-line procedure, the computer collates and stores on the random access disk pack the physician interpretations that arrive 2 days later. These are the mark-sense reports from the X-rays, electrocardiograms, and the remaining laboratory tests.

When all the information has been received and stored, the computer then produces a printed summary of all the test reports and the questions answered "Yes" by the patient.

When he sees the patient, the internist reviews the summary report at the time of the patient's first office visit. The physician directs his attention toward elaborating on the questions to which the patient has answered "Yes" and to the test abnormalities reported from the automated multitest laboratory. He completes his physical examination and then proceeds to arrange whatever medical care is necessary for his patient in a customary manner (H 215–217).

Dr. Collen also gave extensive testimony on the effectiveness and findings of the multiphasic program:

During the year 1965, the Permanente Clinic processed 39,524 patients, 40 percent of whom were age 50 or over, hypertension and hypertensive heart disease was diagnosed in 9 percent of all patients, the electrocardiogram detected abnormality in 20 percent, significant amounts of sugar were detected in the urine specimen of 11.5 percent of all patients. Additional findings were reported in Dr. Collen's testimony in the transcript of hearings on page 217.

AMERICAN MEDICAL ASSOCIATION CONVENTION SCREENING

Thirteen years ago, a screening examination for physicians was initiated at the annual AMA convention. I.E. Buff, MD., a cardiologist from West Virginia and one of the founders of the screening program, told the subcommittee:

*** We felt there were a great many physicians dying, because they didn't have an examination previously, and these deaths might have been prevented.

The program now includes history taking, height and weight measurements, blood pressure, glaucoma tests, X-ray of lungs, electrocardiograph, a timed vital capacity for the function of the lungs, and approximately 23 pathology tests.

Of the physicians tested in 1966, 7.7 percent had abnormally timed vital capacities, 15 percent had abnormal cardiograms, and 5 percent had borderline readings.

Of these physicians who had abnormal cardiograms and borderline readings— Said Dr. Buff

I might add that 80 percent were not aware that they had any heart disease whatsoever. Of the lung disease, approximately 80 to 90 percent were not aware of this. And of the glaucoma, which we had 1.2 percent of positives, practically none were aware of this (H 275).

POTENTIAL NEW ADVANCES IN TECHNOLOGY

Though much work has already been done with instrumentation of advanced design, many witnesses called for more widespread programs in order to advance screening technology more rapidly. Dr. Caceres said, for example:

We can

We are now only in the infancy of automation in the field of health. foresee that widespread use of automation and modern communications media can reduce the total costs of medical tests from dollars to cents. We see that the diverse battery of medical and laboratory tests now available only on a selective basis can become fully accessible to the entire community (H 103). [Emphasis added.]

Dr. DeBakey said:

*** As far as the multiphasic screening and detection techniques are concerned, there has been a considerable amount of experience with various types and I hope there will be greater research in this area. I think if we are going to make these types of detection more effective with greater yield, it will be necessary to apply more sophisticated techniques than at the present (H 36).

Dr. Lester Goodman, Chief of Biomedical Engineering and Instrumentation Branch, National Institutes of Health:

It has also been mentioned, and I will reiterate, that there is a need to enhance the speed, accuracy, precision, and economy of treating these measures, and extend their application to a communitywide basis.

I would point out that technical feasibility is established. [Emphasis added.] The major question remaining is concerned with the allocation of resources to accelerate development (H 128).

Much the same conclusion was given in a letter from Dr. Lester Breslow, director of the State department of public health in California, where many public screening projects have been sponsored:

What has been achieved in the case of tuberculosis, diabetes, cancer of the uterus, and other forms of cancer, hypertensive heart disease, and many other chronic diseases, is due to a relatively simple form of attack on the problem. That attack consists of early detection of the disease process and prompt treatment with modern methods. The technical basis for a successful attack on many important chronic diseases is well established. All that is needed is an organization in the full-scale application of available tools (H 173). [Emphasis added.]

The subcommittee has received information on various other techniques for disease detection in the experimental or developmental stage. Included among these are techniques employing thermography, ultrasonics, breath and saliva analysis, and arteriography. In the opinion of the subcommittee, emphasis on an early detection program would lead to rapid development of many new detection devices suitable for inclusion in a screening program.

Finding 7

Multiphasic screening could result in considerable time savings for physicians an important consideration in the face of severe and growing medical manpower shortages

Witnesses agreed that the best way to insure early discovery and control of chronic diseases would be for all Americans to have thorough physical examinations regularly while under continuous medical management. But they also agreed that this is impractical because of heavy demands upon physicians and other professional medical personnel.

To Dr. Peeples, multiple screening offered an opportunity to reduce demands on doctors:

Since there is a great shortage of medical manpower existing in this country and since multiphasic screening does not require highly trained technicians to perform most of the tests done, this offers a resource to the medical and public . health profession which would possibly strengthen a diminishing manpower situation in the field of health, especially if such screening tests were performed prior to regular visits of patients to the physician's office. Much time could be saved by having these tests prior to that examination. In addition, those chronic illnesses which are remediable could be detected at any early stage thereby reducing the length and severity of disability and the cost of medical care (H 44).

To other witnesses, it was quite apparent that the physician already is overburdened with routine tasks that do not make full use of his training. Dr. Wagner estimated that the physician spends about 40 percent of his time with repetitive, logistically oriented work that could be taken off his hands. Dr. Thiers drew a distinction between "quantitative data" or information that can be gathered by machines or other routine procedures-and "qualitative data"-which are clinical judgments made by physicians on the basis of quantitative data, their own examinations, and their professional training and experience. Dr. Thiers saw no reason for physicians to take quantitative data or to operate laboratory-type screening instruments:

If the physician insists on operating this equipment, he is wasting his training (H 125).

Dr. Chinn saw a clear need for new techniques if widespread screening is to be advanced:

How do we identify the presence of early and preclinical disease? Traditionally, this is done by a physician. With the aid of a carefully taken history (usually built around a physical or mental complaint), a physical examination, and suitably indicated laboratory determinations, the physician establishes the presence or absence of disease. From the point of view of physician time, this is a costly procedure. It is prohibitively costly when applied to the individual who has no given set of symptoms, for there is less likelihood of finding disease in such an individual than there is for one who has specific complaints.

Even eliminating the economic aspects, it is unthinkable to suppose that such disease detection measures could be carried out on any substantial portion of the population by the traditional physician-patient, one-to-one relationship. There is far too little physician time available for any major activity of this sort.

As an example, consider the average practicing physician who, at any point in time, is responsible for the health of a thousand people. If we take the minimum figure of 1 hour of physician time per preventive examination and provide such an examination once every 2 years for each person, we have to conclude that this doctor would need to devote the equivalent of 10 weeks of full time each year in order to accomplish the objective. [Emphasis added.] There are few who believe that this amount of physician time can or should be withdrawn from an overloaded schedule devoted to the diagnosis and treatment of sickness which is already evident or strongly suspected.

If we are to accept the thesis, therefore, that early chronic disease detection is a rational approach to reducing or holding in check the increasing magnitude of sickness in this country, it is clearly apparent that something needs to be added to the physician's armamentarium to assist him in undertaking this task (H 302).

Dr. Collen, describing the program already in operation in Oakland and in San Francisco, said that preprocessing of routine data actually increases the time a physician can spend with the patient:

When all of the data are collected and are preprocessed, we even provide on the summary report an asterisk if a test is outside the normal limits. The physician can then conserve his time for decisionmaking, diagnosismaking, deciding on treatment, and advising and counseling the patient, so that in fact there is more individualized and personalized service as a result (H 220).

WOULD SCREENING INCREASE TOTAL DEMAND?

If multiphasic screening programs were to be adopted on a widespread basis, obviously it would increase the number of persons who might see physicians. At least one witness believed that doctors would be busier than ever. The basis for his belief was this: screening programs almost always require that findings be referred to a physician, with abnormalities clearly indicated. The person screened then visits his physician for closer examination and diagnosis. Thus, many persons who may not have even considered a visit to a physician may do so even though they may look well and feel well. The subcommittee recognizes that such considerations are not to be dismissed lightly, but it also believes that:

1. This Nation cannot wait until it solves all medical manpower problems before it undertakes programs for prevention of disease. We must consider our long-range goal, which is to reduce the need for costly and time taking treatment of illness by detection and prevention of disease.

2. The subcommittee has received many examples clearly indicating that physicians have given support and cooperation to State or local screening programs. In many cases, physicians were initially skeptical of the efficacy of the programs, but after involvement, became enthusiastic about its possibility as a tool for medical practice.