STATEMENT OF DR. FREDERICK C. SWARTZ, CHAIRMAN, AMERICAN MEDICAL ASSOCIATION COMMITTEE ON AGING, LANSING, MICH.

Dr. SWARTZ. Thank you.

I am Dr. Frederick C. Swartz, of Lansing, Mich., in the active practice of internal medicine, and chairman of the Committee on Aging of the Council on Medical Service of the American Medical Association. With me is Mr. Bernard Harrison, director of the AMA's Department of Legislation.

I am here today, and at the subcommittee's invitation, to present my own personal views, as well as those of the Committee on Aging, on certain phases of the prevention of chronic illness.

For the sake of completeness, this paper includes some definitions and explanations, and with the subcommittee's permission, I will merely present the mainstream of thought embodied in this paper as it pertains to the subject matter under immediate consideration.

Senator NEUBERGER. We will appreciate that.

Dr. SWARTZ. I submit that a definition of terms is mandatory before we can discuss intelligently the prevention and detection of chronic illness. The Association's Committee on Aging has developed some tentative definitions which may help in this and future considerations of this subject. Chronic condition includes the other terms which we hear so often, chronic disease, chronic illness, long-term illness. The proposed definition of "chronic condition" is as follows:

Any condition that (a) is outside the pale of normal variance and that is abnormal in a recognizable, functional or structural way, either before or after a complete history, physical and laboratory examination, and (b) has been present for or can reasonably be expected to persist for some period of time."

If we accept this type of definition, then we can divide individuals who have one or more chronic conditions into three categories, from the standpoint of the health and other professional services that they may need:

(a) The asymptomatic and nondisabled group: These individuals have neither symptoms nor disability resulting from their chronic condition(s), and require no more medical attention than their group as a whole, but may benefit from suggestions in the area of public health maintenance, such as good nutrition, physical and mental activity, and the shedding of unphysiologic habits.

(b) The intermediate group: These individuals present some degree of disability and/or symptoms resulting from a chronic condition(s), but are able, either with or without medical attention and guidance, to administer to their own needs, and to carry on their own vocation or avocation in essentially the fashion to which they are accustomed. They, too, could benefit from some suggestions in the area of positive health maintenance.

(c) The long-term care patient group: These individuals are disabled and/or symptomatic as a result of a chronic condition, and need-in addition to a physician's attention and care the services of one or more additional types of personnel and/or facilities: for example, the visiting nurse, the social service worker, physical or occupational therapist, homemaker-home health aid, nursing home, foster

home, rehabilitation centers, and at times the general hospital. In a limited fashion, this group as well could benefit from suggestions from the area of positive health.

In medicine, we frequently have been accused of being disease oriented. This vantage point is admittedly a good one when you are dealing solely with the sick. When there is an absence of organic or psychosomatic or psychiatric disease, however, the practitioner may be at a loss to make contributions to the health of the people from a positive, nondisease point of view. It is important, therefore, within this discussion of chronic disease, that we do not limit our approach to this subject to one of disease detection alone. Much can be learned, and much more can be accomplished, if we include in this discussion not only those who have a chronic condition, but also those who do not have. In this way, we can apply to the latter group what we have learned from studying the former.

The Committee on Aging has, during the years since its creation, developed a six-point health program for older citizens, which is spelled out in a booklet entitled "Medicine's Blueprint for the New Era of Aging." This "positive health approach" has important implications for the subject under discussion today.

The basic premise of this program was based on an early recognition by the committee that there are no diseases specifically attributable to the aging process, and that those of the older group who are sick present the same many sided problems as the sick of any age group. The chronic disease and long-term illness which constitute the major problems of medicine today are the end product of the recurring and irritating effects of environment on protoplasm over long periods of time. They result from these irritants, and not from the passage of time.

For this reason, medicine has the responsibility and the opportunity to ameliorate or dilute these environmental insults by emphasizing a positive health maintenance program with those individuals who are apparently well.

The responsibility of the physician in this program is to institute a program of periodic health appraisals and to coordinate the contributions of other disciplines for the benefit of the patient.

The first objective of the health appraisal would be to detect and treat organic disease. This is the chief concern of the patient, and most frequently the real reason for his seeking medical aid. Careful, routine medical history and physical examination will discover most overt ailments or provide clues for further investigation. If organic disease is found, the proper treatment is begun. If no disease is found, the patient is so informed, but the responsibility of the examiner does not end here. What for the future?

At this point we usually discuss with the patient the possibility of potential disease in the future, the effects of unnecessary emotional strain at home or at work, the real benefit to be obtained from good posture, physical exercise, mental activity, and good nutrition.

Finally, we have learned from our efforts at rehabilitation the importance of motivation on the part of the patient. We have learned from civil defense programs the importance of adequate, thoughtful, planning for catastrophe.

Putting these two ideas together, we concluded that it would be good medicine to try to premotivate persons to be prepared to fight back at catastrophes that might befall them in later life.

The American Medical Association has for some years been concerned with the area of multiphasic screening. The AMA Council on Medical Services published a study on multiphasic screening, giving a description of data on 33 screening programs. We are currently working in a consultant capacity to the United Health Foundation in their project to develop basic criteria for evaluating multiphasic screening programs in the community.

Along with many other groups, we are continuing to study developments in this field, and to identify more precisely both potentials and problems inherent in multiphasic screening.

Some of these problems are:

"Periodic examinations-and I am referring to multiscreening tests at the moment-when accompanied by positive action on the part of the patient, may be very helpful. However, when not accompanied by intelligent action, it may have the following disadvantages: (1) If the report is negative, the person acquires a false sense of security; while disease may not be evident at the time of the survey, it can develop a few weeks or months later, but the person is inclined to pay little heed to symptoms and delays going to his physician, because 'he was well at the time of the survey'; (2) it may and does cause undue apprehension in persons with false positive' diagnoses; (3) it can result in considerable expense to those who are reported as having findings suggestive of disease, but in whom disease is not confirmed in subsequent examinations; (4) those who have no opportunity for appraisal of the 'negative' group by a physician, yet in this group will be found persons who need medical attention."

The great difficulty in multiphasic screening is that the interpretation of diagnostic tests is of little value without a history of the patient, and understanding of his personality and familiarity with his whole family background ***. Some 960 of the 1,000 persons who passed through the multiple-screening tests came up with negative results. This group do not know that the negative test has little value. The tests are not intended, of course, to give the individual a rapid, clean-cut, and precise series of competent diagnoses. But that is exactly what the average man thinks they do; otherwise, he would not go through the procedure.

And now, with the permission of the committee, I will leave the work of the American Medical Association for the moment and speak entirely from the viewpoint of one who is in the private practice of medicine.

I have, since returning from the Armed Forces in 1946, retained the practice of internal medicine along the lines suggested above.

My files have people that have come in for periodic examinations ever since we have been in practice. Obviously, there have been some changes in the group for various reasons from time to time, but others who have become acquainted with the advantages of periodic health appraisals have kept this an ever-growing group.

We do a complete history and physical examination on every patient. At the same time, we are subjected to a screening type of program that is dictated by the history and physical examination, which includes using an X-ray of the chest and certain laboratory procedures, including the use of blood count, certainly procedures which are found to have value when repeated on a yearly appraisal basis.

We are therefore utilizing what one may call a screening type proof our own.

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In our office we recognize and subscribe to the definition of the National Commission on Chronic Illness of screening as "the presumptive identification of unrecognized disease or defect by the application of tests, examinations, or other procedures that can be applied rapidly."

It is generally agreed that the tests used in the multiple-screening program should be simple of administration, should be easy to interpret, should be relatively inexpensive, should require little time to perform, and should meet the five criteria suggested by the Commission on Chronic Illness. These are: reliability, validity, yield, cost, and acceptance.

In my opinion, there is little doubt that multiphasic screening programs, when wisely selected, can contribute some help to the detection of disease. However, transmission and interpretation of results to the patient must be entirely through the hands, eyes, experience, and judgment of the physician. After all, these tests are done by manmade machines, under man's direction, and human error is still a factor.

People get enough education from odd sources these days that if certain findings are borderline or slightly abnormal, they can become extremely disturbed. If interpretations are not handled by physicians, the possibility of iatrogenic disease may well overbalance the good intended by the screening programs.

The character of multiphasic screening programs has changed somewhat over the years. In this day of computerized processing of medical data, it would seem to me that the positive aspects of multiphasic screening, properly conducted, and under favorable circumstances, may outweigh the negative ones. This will be true only if the agencies responsible for the screening see to it that all findings go directly to the physician, and that it be only through him that the patient receives interpretations of results.

Up to this point, I have limited our discussion largely to the people who have a chronic condition, and special emphasis has been placed on those who have some symptoms or disability resulting. This group includes only a few million people in this country. What of the many others who do not have a chronic condition? This may be the biggest field in the medical practice in the future. It is from this reservoir that the chronically diseased come. What do we know about them? How near are the members of this group to becoming members of the group with a chronic condition? If they do not have a chronic condition, are they really well? Are they all in the same degree of "wellness"? Are those who have chronic conditions without major disability resulting any less capable of doing and enjoying living than those who do not have a chronic condition? Is there any way to measure degrees of wellness?

Suppose, as you tell a patient who has just passed a complete history and physical examination, that so far as you know he does not have any medical disease; that he is within the pale of normal variance, and considered well. The patient, quite happy, but in a thoughtful mood, asks, "OK, Doctor, but how well am I? Could I run a block? Could I run a mile? Could I ride with the astronauts?" These sound like timely and intriguing questions, to me. We must find an answer

to them. The patient of the future will be asking questions regarding the future. He not only wants to know whether he is well now, but whether he has the possibility of being well for 5 more years, or 10 more years, of whether he can expect a coronary in the next 3, or whether he can take a job with added responsibilties, and many other things.

I firmly believe that this is going to be a major field in the future. It is a major challenge to medicine today. Medicine needs to develop for patients who do not have a chronic condition, and for those who have chronic conditions without major disability, ways to test the functional capacity of the cardiovascular system, the pulmonary system, the musculature and nervous system, and the liver. Collections of data of this sort, under resting and stressful conditions, would form a body of knowledge so that the physician could tell the patient with a fair degree of reliability just how well he was. With this kind of information, the patient could better plan his future, and if we could do a better selling job, we might well improve the health of the race and ultimately reduce the size of the group who have chronic conditions. For the information of the committee, I have taken the liberty of attaching to my statement, in addition to the previously named exhibit, some other pertinent pamphlets prepared by the AMA Committee on Aging. These include: "Health Promotion for Adults," "Needs of the Long-Term Patient," and "Retirement, a Medical Philosophy." 1

Madam Chairman, I thank you for the opportunity of presenting the views of the American Medical Association Committee on Aging and my own personal thoughts. I will be glad to answer questions if I could.

Senator NEUBERGER. Yes. Thank you, Dr. Swartz. We are very interested in having your views as they represent you and the AMA, both.

I was wondering, when you were talking about the screening process, if you were at all familiar with Dr. Collen's work at the Kaiser Foundation?

Dr. SWARTZ. Yes; in a limited fashion. I have attended meetings where these programs have been presented. I don't know much about it in detail, but in general.

Senator NEUBERGER. Well, the reason I ask was that you seem to question, or you seem to have some questions, about how the result of the test would be used, and I think, as I know it, there, they certainly give all the tests to the physician.

I don't know that any screening that any of us could anticipate, where that would be the final step. I think it just automatically would have to be putting the results in the hands of the patient's physician. Is that one of the fears you have?

Dr. SWARTZ. Oh, I don't really have any fears, particularly. I think that men of good intention can work out a solution to the problem.

But in the practice of medicine, as I do it out at the front, where I am treating patients every day, it is surprising the number of questions that arise from little details that come from laboratory tests that are done here and there, and they are not related. People get quite excited over these things, and raise their blood pressure up. It is a problem.

1 Exhibits referred to will be found in committee files.