gorical disease basis. The National TB Association, State and local health departments, together with the U.S. Public Health Service, have for years carried out an important program of early detection of TB. The American Cancer Society has fostered programs of early detection of cancer and similarly other societies concerned with one or another disease have developed and financed programs for the early detection of specific diseases. These programs have contributed much, but they are limited in approach, since each is concerned with a single disease or organ and is less interested in the broad problem of preserving health.

In the more recent past-that is, since 1949-there has been considerable interest in multiphasic screening as the method of case finding. As one examines some of the reports written in the early 1950's, certain advantages are emphasized repeatedly.

First of all, multiphasic screening is a more efficient and economical method of case finding than the categorical disease approach.

Second, it tends to be more favorably received by the public for there is less concern about a single disease. Very often the screening for TB or cancer, the actual fear of the disease, will sometimes prevent the person from being screened; when it is a multiphasic screening, I think that these kinds of fears of a specific disease is less.

Senator WILLIAMS. This is psychological.

Dr. EBERT. The other thing which has been interesting to note, one survey that has been made for glaucoma is that most of the patients who came in to find out if they had glaucoma were people already under treatment for glaucoma, and what they were really doing was checking the findings of their own physicians.

Sometimes the categorical search is not as effective.

Senator WILLIAMS. I think I understand what you are talking about. If you have a general area of examination, there is more likelihood that you will be amenable to taking the general examination that includes all of the components, rather than coming in for a specific test. Dr. EBERT. Yes. The third thing is that the discovery of many cases of unsuspected chronic illness, particularly of disease in early stages, when treatment is most effective, has been obviously one of the stated advantages.

In addition, I think it conserves to a degree the patient's time. I hope you found it conserves your time rather than going through all of these separately, and it also conserves medical manpower, because quite clearly a wide range of tests can be done, lots of them by automation, and many of them by the use of technicians, and it saves the more highly skilled manpower which doesn't need to devote itself to this particular kind of screening, except in the interpretation.

Now, in addition to these advantages, a number of qualifications are made by those who have commented on this method.

One is and I think you referred to this, Senator Neubergerthat it does not substitute for a periodic health examination. This is a screening; it is not really diagnosis. What it attempts to do is to either indicate that there may be disease present or there probably is no disease present, at least of the diseases that have been screened for, but it does not as a rule make a specific diagnosis.

Let me give an example of this. A screening film, X-ray of the chest, may show a spot in the lung. That by itself does not tell you

what that spot is, because it could be TB, it could be cancer, it could be histoplasmosis, it could be a variety of other things. It could be a patch of subsiding pneumonia. But it does pick it up at a stage when it would not otherwise be found. I stress the point that this needs to be followed with further study if it is to be meaningful.

Senator WILLIAMS. That is why we emphasize the screening that we suggest in the legislation which, of course, this committee cannot report. But screening is a preliminary to referral to the physician who can follow the finding.

Dr. EEERT. Right. But I think it should be stressed that very often disease is picked up which otherwise would go unsuspected. I think this is the point.

Senator WILLIAMS. What this preventicare idea does is really put the warning light up and when the warning light is up, then the physician would be brought in to analyze finally just what the warning signal means. Is that not right?

Senator NEUBERGER. Yes.

Dr. EBERT. Another qualification or at least a warning that has to be made is that there has to be constant attention to the accuracy of the methods which are used so that the number of false positives or false negatives, that is to say, positives where there is no disease, negatives where there is, should be as low as possible, because obviously a false negative that is to say, an interpretation of no disease being present when it is, is clearly giving the patient a false sense of security; and equally a false positive can be psychologically quite disturbing to the patient and to the physician.

But the point is, this is simply a technical matter of how one works out the screening methods and this is within the limits of the technology. It can be done but, the point really is, there has to be careful appraisal of the accuracy.

I think today the technology of multiphasic screening should really present no great difficulties if done properly, because the development of things like the AutoAnalyzer permits rapid and accurate diagnosis. Senator NEUBERGER. Auto-what?

Dr. EBERT. This is a machine called the AutoAnalyzer. What it does, it can very rapidly do a variety of blood chemistry studies, that is, blood sugar, nonprotein nitrogen, blood proteins. It can do a gambit of them and it can do them all on one sample of blood and can do them automatically, so they obviously save a great deal of time in terms of technicians, and this obviously can be applied on a large scale.

Senator NEUBERGER. I have just been told by staff counsel that the AutoAnalyzer is going to be demonstrated for us tomorrow. That is good.

Dr. EBERT. Right. In addition, it is possible to do certain kinds of psychological testing more rapidly and effectively than it was possible in the past. Obviously more advances are going to be made in this kind of automation of testing that will, and studies at the present time are going on in this area.

But the two most important problems, I think, in any program which applies itself to early detection of disease is, first of all, the technique for sampling the population or providing it to the population; and, secondly, the followup.

In order to do adequate screening of any sort, it is important to know what population is being screened and in a sense who is coming. If you do this, for example, out on the street corner, which is one of the ways in which screening has always been done, there is a kind of a preselection by the person themselves and very often it may very well be the person who least needs the screening. That is not always true, but there is a kind of self-selection, and to be most effective, screening should be done with populations which can be defined.

In other words, screening in factories, all people over 40, or screening-perhaps the most important area, and this sounds like a contradiction, but nevertheless it is true, that probably the most fruitful screening that can be done is in hospitals-patients in hospitals and out-patients.

The reason I say this is because in the first place, it is already a selected population of people who at least think they are ill, and secondly, unless screening is done, many diseases go undetected. Senator WILLIAMS. Now, could I interject here?

Dr. EBERT. Please.

Senator WILLIAMS. We have this mobile unit right now within 300 feet of where we sit. It is on the street. This is rather comprehensive screening for potential illness or disease. How long is this unit. going to be here 3 days? Three days.

You know, they are clamoring the staff people, the secretaries, the men on the staff-to get an appointment and frankly they are trying to use influence. The schedule is filled, and they are trying to use influence to get a chance to be tested.

Dr. EBERT. I think this is absolutely right, Senator Williams, but I think this is precisely the point I wanted to make, that the people most knowledgeable about health and those who really have the best access to medical care today are the likely ones that are going to be screened. In other words, the difficulty is getting the screening done in areas and with populations who have very little in the way of health services and don't know how to use them, because a part of this is obviously health education, and I think the population that one sees here is a group better motivated to preserving their health than many others. Senator WILLIAMS. Now, this is a District of Columbia Public Health unit and this unit, evidentally, moves around town. It has reached 30,000 people. I just don't understand waiting until they get to the hospital.

Dr. EBERT. Well, let me give you the example of this. I am not suggesting this is the only place where screening should be.

Senator WILLIAMS. I should not interrupt you. I have to go to make a quorum in the Labor Committee.

Dr. EBERT. I am used to being interrupted and I don't mind it at all.

Senator WILLIAMS. I understand.

Dr. EBERT. But the point really is, let me give you the example of screening chest X-rays.

Now, many patients who come into hospitals because of a particular illness would not in the normal course of events have a chest X-ray, because it would not be indicated. But it has been found that the most productive place to take chest X-rays on a screening basis is in the hospital.

Senator WILLIAMS. Now I am beginning to understand you. I hate to be personal about matters dealing with health. My father has been ill for 4 years, 5 years, with prostrate condition. Even though he has been in the hospital-in and out-several times, it was only recently they found that he had diabetes. This is exactly the point

Ďr. EBERT. This is exactly the point I am making, and this is a very easy place to do this kind of screening for all of these other things which really you are not there for, but it can be simply done and this is why I say this is one place where one can do the screening and actually the other thing really that one can do is, one can also follow it up, because no screening program will really be of any substantial value in terms of health maintenance unless there is an adequate followup of abnormal findings. There have to be adequate medical resources in the community which are available to the patient.

One is faced with the dilemma that the population with the easiest access to medical care is the one which is perhaps the least important to screen. There is more undetected disease in the central and in certain rural areas than in the suburbs, but there are also fewer health services. So the point I want to make is it really doesn't do a great deal of good to screen if one does not make sure that there is the opportunity to follow up the findings.

Let me give you an example of this. This is a story told by one of my colleagues who is now with me and was in the Public Health Service for a good many years. As a young man he worked in a rural area on a venereal disease control project, and being an eager young man, he also thought he would do a little screening. So, among other things, he tested for diabetes and he found, one of the first days he spent in the clinic in a small town, a patient who had diabetes. It is easily diagnosed and easily proven, and he went to his superior and said, "Look, here is a woman with diabetes and we have to do something about it."

The supervisor said, "Why don't you go home with her?" So he did. He took a bus and they went back to the home and he found that she lived in a house which had no plumbing, no facilities, and there was only one doctor within an area of about 40 miles. He came back and he said, "Well, it was perfectly clear she could not be treated. There was no possibility of treating her with diet, there was no possibility of treating her with insulin."

This is an extreme example, but the point I want to make is unless one looks at both parts of this problem, that is to say, the part of early detection so that one can find disease early enough to treat, but also how you provide the care once it is detected, then I think it will not be the most productive effort that one could make.

Senator WILLIAMS. We need not more medical schools, but more opportunity for young people want to go to medical school to get into medical school?

Dr. EBERT. This is true, Senator Williams, and I think we need, as you have indicated, we need more physicians, we need more schools and we need actually to utilize more effectively the talent that we have.

Senator WILLIAMS. You know what happens to me. Maybe it happens to Senator Neuberger, too. Parents or young people come to me to try to help them get into medical school. Now, what can we do about getting anybody into medical school? So, these are limited, indeed. Dr. EBERT. Right.

Senator WILLIAMS. We are undermanned. What would you say we are undermanned in terms of physicians for population in this country?

Dr. EBERT. Well, this is a very difficult question to answer, Senator Williams, because it depends upon how

Senator WILLIAMS. Is there not a rule of thumb, one doctor for every-what-1,000 population?

Dr. EBERT. Roughly. The point really is, though, and I think this is pertinent in a sense to this whole hearing, these formulas are based on, in a sense, the utilization of physicians as it has been over the last 50 years.

I think we have learned how to use people more efficiently or potentially we could. The very fact you can do this kind of multiphasic screening, and do it well without even having a doctor in attendance most of the time, proves you can provide efficient service most of the time if it is organized.

I think what it boils down to, we need more physicians, I would agree; we need more schools and the schools in existence are going to have to expand their schools.

Second, we need more people in the supporting health professions; and third, we need, and we need it badly, some effective and efficient ways of providing the care, particularly in areas which are undermanned and understaffed in terms of health and manpower. And I think in this latter part, in determining how you can best organize care, is the creation of models from various areas. This is one of the most productive places where this sort of screening could be done, because I think this is a terribly important part of health maintenance. All I am saying is there is another step to it which is equally important, and that the two must really go together.

Senator WILLIAMS. I apologize for interrupting, but I just got a call. I have to go up there. Let me ask you this: How many applications for the Harvard Medical School do you have and how many can you take annually?

Dr. EBERT. We take about 120

Senator WILLIAMS. And your applications run what?

Dr. EBERT. Around 1,200. In all fairness, however, I want to say that most of these people get into other medical schools that we do not take.

Senator WILLIAMS. Well, I will never bother you. I do not think it is our job. I apologize that I have to leave. This was very helpful testimony.

Senator NEUBERGER. Fine, you come back.

The more each witness talks, I know the more I am going to see how much I don't know and the questions we need answered. I do not want to detain you much longer, except to ask if Harvard Medical School, per se, is doing anything in this area or are you just interested in it? Dr. EBERT. No; I think that as far as a specific motivating reason is concerned, there have been various activities that have gone on in the school in the past. Dr. David Rutstein has written about this and has been involved in the evaluation of multiphasic screening and determining it.

We are in the process, which is something which is somewhat closely related, to try to determine something about the health needs of the