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 diseases and long-term illnesses which constitute the major problems in 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 itself.

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.

Accordingly, a program of positive health maintenance and improvement became a major objective of the AMA Committee on Aging and a basic part of its six-point program.

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

The term "periodic" is used to indicate the need for repeated examinations. The interval at which these will be performed will be dictated by the needs of the patient.

The term "health appraisal" is really the old term "physical examination" with broader implications. Added are such items as mental and emotional evaluation, nutritional history, history of physical exercise and recreation, history of radiation exposure, sensitivities and allergies, expanded laboratory and x-ray investigations, and a socio-psychomatic section as a parallel to the present illness. This gives the physician a chance to match recurring symptomatology with psychologic trauma.

The Committee strongly supports the concept that a periodic health appraisal is a basis for positive health programs. It believes further that the earlier in life such a program is instituted, the greater will be its accomplishments.

As a guide for the individual physician in furtherance of the perodic health appraisal as a part of his practice, the Committee has prepared a personal history form (Exhibit B) including what might be referred to as the glossary explaining various items.

The form itself is not a rigid recommendation. It attempts, rather, to suggest a logical thinking pattern that a physician might use in making a record of the health appraisal. It is not a blank paper which allows extreme latitude for the wordy, nor a checklist which leaves no place for space for elaboration. Its headings are designed to remind the examiner of all things that might be important in the appraisal, and in general to provide adequate space for necessary recording.

As envisioned by the Committee, this form is bounded by the history-taking ability of the examiner on one hand and the use of the special senses, the otoscope, the sphygmomanometer, tongue blade, the percussion hammer, the stethoscope, the pin and the finger cot on the other. The physician with a minimum amount of equipment is all that is necessary to accomplish the appraisal. The procedures that require special training equipment other than the above and those where "payoff" in findings are small have been omitted. Any special type examination may be added at the physician's discretion.

What can the practitioner hope to achieve with this type of evaluation?

The first objective of the health appraisal should be to detect and treat organic disease. This is the chief concern of the patient and most frequently the real reason for 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 of the future?

At this point we usually discuss with the patient that while we were looking for outright disease, we were not unmindful of the possibility of potential ailments. The diastolic pressure that persistently stays in the high normal or low hypertensive level particularly in a patient whose family presents a history of vascular vulnerability—cannot and should not be dismissed without mapping out a course for future living that will best postpone the expected difficulties. The periodic health appraisal frequently exposes a patient who is hard pressed with harmful and unnecessary emotional strains and traumas. The emotionally disturbed may be as handicapped as the organically diseased. Recognition of 69-803 0-66—11

these forces as the etiologic factors in the production of symptoms is necessary to the solution of a great number of patients' problems. Tact, sympathy, understanding and direction is good preventive psychiatry in the physician's office. Even the patient who has no evidence of real or potential organic disease is rarely so perfect that he can't be improved by a discussion of posture and physical exercise as it pertains to him and his future health. Daily exercise that improves muscle tone and circulation should be recommended. This activity is almost always over and above the activity involved in making a living. The doctor is also in the unique position of being able to advise about mental activity without hurting the ego of the patient. It is important to advise a patient to venture into stimulating intellectual levels that prevent limitation of horizons and too much attention to self.

Nutrition is an important part of the periodic health appraisal. Those who are unmistakably and unquestionably overweight become a major problem in weight reduction. Those who are not actually overweight must be surveyed carefully for the possibility of being undermuscled and overfatted. A gross review of usual food intake frequently indicates areas that need correction.

The periodic health appraisal would certainly be incomplete without its preventive phase. Shots and inoculations that have merit should be discussed and used. Safety measures for young and old at home, in traffic, in school and office need to be mentioned with the authority of the medical profession. A mention of the importance of mood as a backgrund for accidents is important. 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 have concluded that it is good medicine to try to premotivate patients in advance to fight back at some of the catastrophes that might befall them in later life.

The American Medical Association has for some time been concerned with the area of multiphasic screening. In 1955, the AMA Council on Medical Service published a study of multiple screening giving descriptive data on 33 screening programs. We are currently working in a consultant capacity to the United Health Foundations 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 the potentials and problems inherent in multiphasic screening.

Some of these problems have been identified in the 1955 AMA study I referred to earlier. They are:

"Periodic examinations (referring to multiple screening), 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 disad vantages: 1. If the report is negative, the person acquires a false sense of security; while disease may not be evident at the time of 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 survey.' 2. It may and does cause undue apprehension in persons with 'false positive' diagnosis. . . 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 on regular examination. 4. Most multiphasic screening techniques leave no opportunity for appraisal of the 'negative' group by a physician; yet in this group will be persons who need medical attention." (Editorial appearing in California Medicine, September, 1954)

"The great difficulty in multiphasic screening is that the interpretation of diagnostic tests is of little value without a knowledge of the history of the patient, an understanding of his personality and a familiarity with his whole family background . . . Some 960 of the 1000 persons who pass through the multiple screening tests emerge with negative results. This group is treated most unfairly. They have a false sense of security. They do not know that negative tests have little value. . . The tests are not intended, of course, to give the individual a rapid, clean-cut and concise series of comprehensive diagnoses. But that is exactly what the average man thinks they do; otherwise he would not go through with the procedure." (Simillie, Journal of the American Medical Association, April 21, 1951)

The most recent AMA statement on this subject was made by the Association's House of Delegates in 1959. Speaking to the use of multiphasic screening in industry, the House of Delegates adopted these conclusions:

"In industry, multiphasic screening, in selected instances, appears worthy of further trial if carefully conducted and confined to relatively few, simple and significant tests according to the needs of a particular situation. If multiphasic screening is to be considered as a part of an occupational health program, it should be directed to occupational groups, be related to the job and its environment, and should come within the scope, objectives and functions of occupational health programs Multiphasic screening should include provisions for a 'follow-up' program and referral of the reports of the tests to the personal physicians of persons examined."

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

I have since returning from the Armed Services in 1946 maintained a practice of internal medicine essentially along the lines discussed above.

My associate and I have a card index file of about 1,000 people who have come in for a periodic health appraisal every year or two and have done so 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 appraisal have kept this an ever growing number.

We do a complete history and physicial examination on every patient, and at the same time they are subjected to a screening type of program which includes an x-ray of the chest and certain routine laboratory procedures which include the usual blood count and certain blood chemistries that have been found to have significant predictive value when repeated on the yearly appraisal basis. We are, therefore, utilizing what one may call a "screening type program" of

our own.

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 to administer, 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:

The test must be reliable in that information be available concerning the reproductibility of results as limited by the technical procedure.

The validity of a test is measured by the frequency with which the result of the test is confirmed by acceptable diagnostic procedure.

The yield of a screening program can be measured by the number of the previously unknown verified cases of disease among the total population surveyed, the number of persons with previously unknown verified disease benefited by referral to medical care, the number of previously known cases not under medical care benefited by return to it, the number of individuals who believe they have a disease, have a positive screening test, but are not found to have the disease at subsequent diagnostic examination, and the number of cases of communicable diseases who are prevented from spreading their disease to the family or the community.

The size of the yield of the screening program must be balanced against the cost-measured in monetary terms and in the relative amounts of time of professional and non-professional personnel.

Reliability, validity, yield and cost are essential criteria for evaluation of screening tests and programs. The measurement of acceptance of the program by physicians, individual laymen and the community is a useful additional criteria of the effectiveness of the screening program. The goal of multiple screening is to find those conditions which require early attention from the physician and to obtain the correction of the conditions in the physician's office. It is this latter part, the referral of the patient to the physician's office for early care, that is the prime objective of multiple screening.

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 a physician. After all, these tests are done by man-made machines under man's direction, and human error is still a factor to be recognized. Within the last month on our office screening program, we have had three fasting blood sugar tests returned that definitely placed the patients test in the classification of diabetes mellitus. After three days of high

carbohydrate diet, a glucose tolerance test was run on each one of these patients and every one of them turned out to be perfectly normal.

As mentioned previously, the patient and even the physician can be lulled into a sense of false security by a battery of negative tests. The doctor knows that the only test that says what it means is the positive test, that is, if it is not a false positive test. The negative test today may become the positive test of tomorrow. In my internship, I remember very well a patient suspected of having tuberculosis who had negative sputum tests on every morning for 29 days, but on the 30th day she had a generous supply of tubercle bacillus. This type of experience makes one wonder about the value of negative tests.

As experience continues to accumulate, it becomes evident that perhaps the greatest promise lies in the field of primary and secondary prevention. Primary prevention implies the development of a body of knowledge that will indicate what agents might, on coming in contact with the patient, produce chronic conditions and communication of this information to the patient. It must be recognized, however, that even when evidence is overwhelming, it is hard to make the human individual change his habits. The success of any health effort, whether it be primary or secondary prevention or the treatment of existing disease and disability, depends largely upon the motivation of the patient. The physician and all his helpers can only point the way-the patient alone makes the journey. In my opinion, we will probably make very little progress against cancer of the lung so long as the nation continues to consume cigarettes in prodigious numbers. We will make very little progress against obesity and all its consequences so long as feasting is such an important part of the American way of living. Not much can be expected from treatment when patients lose contact with their physicians or, logic based on faulty premises, stop taking indicated medication.

Up to this point, we have limited our discussion largely to people who have a chronic condition, and special emphasis has been placed on those who have some symptoms or disability resulting. This group numbers 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 of 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 of 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 chronic conditions? Is there any way to measure degrees of wellness?

Suppose 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 diseases; that he is within the "pale of normal variation" and considered well. The patient, quite happy but in a thoughtful mood, asks, “O.K. doctor, but how well am I? Could I run a block? Could I run a mile? Could I ride with the astronauts?" These all sound like timely, 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 five more years, or ten more years, or whether he can expect a coronary in three years, or whether he can take a job with added responsibility, and many other things.

I firmly believe that this is going to be a major field in medicine of 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. Collection of data of this sort under resting and stressful conditions would formulate a body of knowledge with predictive value 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 exhibits, some other pertinent pamphlets prepared by the AMA Committee on Aging. These include:

Health Promotion for Adults (Exhibit C).

Needs of the Long Term Patient (Exhibit D).

Retirement, A Medical Philosophy & Approach (Exhibit E).

Madam Chairman, thank you for the opportunity of presenting the views of the American Medical Association and my own personal thoughts. I will be glad to attempt to answer any questions the Subcommittee may have.

Senator NEUBERGER. Next we will hear from Drs. Cowan, Borhani, and Petrie.

Dr. Cowan is president of the Association of State and Territorial Chronic Disease Program Directors, and director of the Division of Adult Health of Lansing, Mich.

How do you want to handle your presentation, here? Each one individually?

Dr. CowAN. Yes. If you don't mind, Madam Chairman, I will start out with the statement from the association, and then that will be followed up by Dr. Borhani, who is secretary-treasurer of that organization, and then by Dr. Petrie.

Senator NEUBERGER. All right. Suppose you begin, Dr. Cowan.

STATEMENT OF DR. JOHN A. COWAN, PRESIDENT, ASSOCIATION OF STATE AND TERRITORIAL CHRONIC DISEASE PROGRAM DIRECTORS; DIRECTOR, DIVISION OF ADULT HEALTH, MICHIGAN DEPARTMENT OF HEALTH, LANSING, MICH.

Dr. COWAN. Needless to say, I am delighted to be able to make the statement today.

I am representing, as you stated, the Association of State and Territorial Chronic Disease Program Directors.

That is a group of physicians who are extremely motivated to the conservation of health, and in this association there is one representative from each of the States who have as their whole career planned to conserve the health of the individual and the group. Their business is primarily in diagnosing and treating the community, rather than the individual.

I asked Dr. Borhani, the secretary-treasurer, to poll our organization, to get their information and their opinions about screening, and the benefit of their experiences in the States that they represent. Dr. Borhani has informed me that not only has this been done, but it is on file in the records and proceedings for this committee.

So on that basis, we will not go into the details of that.

I would like to point out, though, that the consensus resulted in three recommendations to this committee:

1. That multiple screening should be comprehensive, rather than single-disease oriented.

2. That there should be no age limit.

3. That State and local health departments be responsible for planning and administration.

State and local health departments have been doing this for years, as you will note from the formal statement put in the record. They have had a great deal of experience in all community planning, community organization, and they can feel the pulse of the people in their communities and design a screening program that will particularly fit their area. This not only may vary from State to State, but may vary considerably within a State, depending on the type of population, rural, urban, distribution, and so on.