I wish you would remain on the witness stand, because I understand the next witness is familiar with your department.

Mr. Leonard Stevens, will you come forward please?

Mr. Stevens is a science writer, and he has had some experience with this center we have just heard about. We would like to hear from you, Mr. Stevens.

STATEMENT OF LEONARD A. STEVENS, SCIENCE WRITER, NEW MILFORD, CONN.

Mr. STEVENS. Madam Chairman, I have a statement that I wrote, but perhaps it would be better if I just reviewed it for you briefly. Senator NEUBERGER. Fine.

Mr. STEVENS. I pointed out that I became interested in this problem 2 years ago, when I wrote a book for the President's Council on Aging, which was published by the Government Printing Office. It is called, "On Growing Older."

And in going over the subject with a great many authorities, some of whom have already appeared before these hearings, Dr. White being one, I became impressed with the need for preventive medicine, especially in the field of aging.

Last winter I had the opportunity to do an article, under assignment, on the Kaiser Foundation Center, and I was allowed to go through the automated physical that Dr. Collen has been telling you about. I have been invited to come here, as you know, to comment on my feelings about it-whether it was an impersonal experience, whether it had qualities of the assembly line, or what.

I have to admit that when I first heard about the center, I didn't know much about it, and some of the terms that go with it—"automated," "computerized," "multitest," and so forth-stirred some rather interesting images.

But actually, in the experience itself, I don't think it is emphasized enough that you are really dealing with people. And these people give you the tests. You are not connected into machines any more than you ever would be in a physical examination. They use equipment, and it is equipment that almost anyone may have experienced if he has had a number of physical examinations.

The computer is something that the typical patient going through the center never sees, and I don't think he is even aware that the data is being processed as it is taken from him.

The people giving the exaininations do a commendable job. They are obviously selected for their personality, for being able to deal nicely with people. I remember in particular a lady giving the tonometer tests for glaucoma. She was very willing to discuss what she was doing. She would not discuss anything in a diagnostic sense; I don't mean that. But people are interested in this center and in the equipment, and it makes a difference if those administering the tests are willing to talk to you.

I might mention that the person right behind me of the some 150 going through that afternoon, a young man, was found to have glaucoma, and he knew nothing about it.

I think Dr. Collen and his colleagues really should be commended for the organizational job they have done at the center. And this is

very, very important. I think any such center that is established has to be very carefully organized, and the personnel very carefully selected.

One important fact about this, and especially for older people, is that you are not rushed as you go through. You are not put in a line, No. 1, No. 2, No. 3, and made to follow that order. It is relaxed. If you cannot keep up, the person behind you is allowed to move on. And there are plenty of seats throughout the center, so that you can sit down and rest and you can take your time to answer the some 600 questions given at that time.

I think this was revealed, in that, after my going through the center, the following day I interviewed a number of the patients to talk about some of the things that you have been asking about. And I found nobody who considered this an impersonal experience. In fact, I don't think they had even thought about it. They were more concerned that this was a very reassuring experience.

Let me just tell you about what happened with my family doctor at home in the small town of New Milford, Conn., where I live. When I went out to Oakland, I asked him if he would confer with me on the results of this examination which would be mailed directly to him. He was extremely negative about it. He immediately misunderstood what the center was about, and I was not in any way able to help him out of that misunderstanding at that point. He felt that anything automated and computerized would certainly lack the personal, intuitive, human qualities that are so important to a doctor in such examinations.

However, when the results were sent to him on a computer read-out sheet, a large sheet of paper, I went back to him, and he reviewed them with me and completely changed his mind. He decided that he was wrong. He had really misunderstood it. He saw this more, as I think it really is, as a laboratory, that could relieve him of time that he would be spending asking questions and doing such tests. And he needs it, I know, because the previous physical to the one I took in Oakland, was given by him.

Let me just tell you very briefly about it, but first let me say that this doctor is a wonderful doctor. He is our family doctor, and we depend upon him, and we have a great deal of faith in him, and I will continue to go to him as long as I can. However, to get an appointment for a physical examination is a trying experience and he knows it.

My physical that I had there was scheduled one evening for 8:30. When I went into his waiting room it was packed with people, and he told me I would have to be the last patient there to be attended to. He came out at 10:30, and the man was so tired that I felt that I needed to treat him instead of his treating me.

However, he insisted on going through a physical examination in his office, which was completed at 10 of 12 that evening. Then, after that, I had to go to the local hospital and complete the tests, some of the same ones I later was to receive in around 2 hours in Oakland. In fact, in Oakland I received many more tests than I would have at the hospital, in New Milford. But now I have to confess I never got to the New Milford hospital, because of procrastination, and the fact that nobody was pushing me.

Anyway, I would like to conclude by saying that I am very much in favor of such automated laboratories, and I would like to see them widely available to the citizens of the country. I know the examinations could be especially valuable to the good health and long life of our millions of older people, but I also would like to see some centers available to people of all ages.

I believe that preventive measures so important to the later years should be started as early in life as possible.

I brought along the article that I wrote. It was condensed in the Reader's Digest and Dr. Collen has told me it has created almost too much interest; he has had so many people there to see his center. And the USIA has, I will now tell him, picked up the article and is going to publish it in their Russian and Polish editions of America.

Senator NEUBERGER. It is very interesting to have your personal experience.

I realize that your situation, in being in the screening center, was unique in that you had not been referred there.

Mr. STEVENS. Yes; but I made a point to see that I was not treated specially. I asked that I not be identified as a writer. And I don't think any of the technicians or nurses knew who I was. Senator NEUBERGER. I see that in your statement. thinking of, though, was the end result.

Mr. STEVENS. Right.

What I was

Senator NEUBERGER. You were given personally the results of the screening tests?

Mr. STEVENS. No. They were returned to my doctor in New Milford, Conn.

Senator NEUBERGER. That is what I wanted to know, because this is where the great criticism seems to come from, from the ignorant and uninformed. The patient will get the screening tests and it will be discovered that he has some chronic disease or some latent malignancy that he didn't know about, and thus bring on trauma and psychiatric troubles and worries and scares.

Mr. STEVENS. I think there was concern out at Oakland that this might happen to me, and I might be treated specially, because I had come there to do a story. But they were very careful not to do that. They informed me that all the information would have to be sent back to my personal physician.

Senator NEUBERGER. If, over the years, with the kind of work going on at Permanente, it is discovered that there is value to a large area of the population through this kind of screening, what are we going to do to allay the fears and you are not the only witness who said this about doctors of those distrustful of this kind of thing? What can we do to allay the fears?

Now, you had a doctor who was converted or saw the value, by study and seeing the evidence.

Mr. STEVENS. He became involved in it.

I am giving only my opinion on this, but I think you would have to inform the doctors. But how you do that, I don't know.

Senator NEUBERGER. What-about going back to the medical schools? And shouldn't our graduates in 1966 and so on be made aware that they can make use of automated equipment and computers, so that they

wouldn't even question it? Do you know if that is being done, Dr. Collen?

Dr. COLLEN. Yes, many medical schools are doing just that, and more are adding them every year. The present graduates of many of the medical schools are very sophisticated in computer programing and utilize the equipment right in their physiology laboratories.

Senator NEUBERGER. You are close to a bilingual school. The one I am closest to is Stanford. Will the doctors coming out of there know they can be relieved of history taking? Will they want this?

Dr. COLLEN. Answering the first question, most of the students know about it. I have described our program to graduate students on the Berkeley campus, and to medical students at Cal and at Stanford.

To come back to the previous problem, it is our experience that the physician goes through three stages, like all people when something new is introduced. The first one is skepticism and distrust. Later when the physician has an opportunity to participate, to receive patients who have received these reports, they become openminded. Then after it becomes evident that it provides more and better service to their patients, they demand it. I think it is only a matter of time before patients and physicians will both demand it.

Senator NEUBERGER. It seems to me they would be ready to accept it. For years they have been accepting the reports of laboratories. The dentist doesn't make inlays any more. I suppose when you go to dental school now, you still learn how to do it, but you don't really plan to do it and it is given to a technician.

Mr. STEVENS. Might I add something that I don't think was brought out? I remember that Dr. Collen told me when I was at Oakland these centers he can correct me if I don't remember correctly-might have commercial possibilities if they could be located in areas-I think you said of 200,000 population. I think that, in this vein of educating doctors, if the centers could be proven and started on a commercial basis, you might make considerable headway with them.

Senator NEUBERGER. This committee has no legislation before it, but we are exploring all these ideas, and you have had experience and it is a part of the record, and maybe some of these things will come to pass. I have kept you a long time, but yesterday we had a demonstration by Dr. Slack. Are you familiar with his computer method of taking history, and is that different from yours?

Dr. COLLEN. Yes, I have visited Dr. Slack. We have had several meetings together, and I have a very high regard for his work. His work on the matter of history taking is more advanced than ours, and we have been following his work with great interest.

In our self-administered questionnaires, the patient either checks a form, or sorts the prepunched cards. The latter adds one step, in that the response of the patient can be read directly into the computer.

Dr. Slack has gone one step further, in that not only can the patient. communicate with the computer, but he can go on through branching questions. In our program if a patient answers "yes," we present that "yes" to the doctor and the doctor goes through the branching process of: If yes, so what? and so forth.

Dr. Slack's program permits the computer to ask: "If yes, so what?" And it can pursue the history taking all the way to the ultimate, the same as the doctor.

Now, the reason we have not yet installed a program like his, is the matter, again, of economics.

The boxes we have made with the cards are very cheap. They only cost us $1.17 to make, and cards are only $1 per 1,000. In order for us to install cathode-ray tubes for our 24 stations open at San Francisco and do what he is doing would, of course, involve $100,000 or

more.

Senator NEUBERGER. Thank you both very much. It has been a very enjoyable hour we have spent with you.

(Prepared statement of Dr. Stevens follows:)

STATEMENT BY LEONARD A. STEVENS, SCIENCE WRITER, NEW MILFORD, CONN.

Two years ago, while retained by the President's Council on Aging to research and write the Council's book, "On Growing Older," I interviewed many authorities concerned with the medical problems of aging. They impressed me with the increasing need for preventive health measures as a person grows older. A chapter in the book is devoted to the subject.

At the same time I learned that preventive medicine has not developed with the same remarkable progress found in symptomatic medicine. While we talk a good case for taking preventive measures the practice of it leaves a lot to be desired. This point interested me as a writer; therefore it was a welcomed assignment when last winter a national magazine asked me to fly to Oakland, California, to do an article on the Kaiser Foundation's automated health examination.

I suggested to the Kaiser people that my initial reporting consist of taking an automated physical. They kindly agreed and one afternoon I joined about 150 people who went through the center. To those working there I was just another patient, for I had asked that my identity as a writer not be revealed. I wanted no special treatment.

I have been invited to comment before this subcommittee on what the examination was like. In particular, was it impersonal? Was it reassuring?

Before going to Oakland I had some images come to mind about the forthcoming experience thoughts that must arise when most anyone first hears of the center. An automated physical? Given in a multitest or multiphasic laboratory? A medical examination by computer? It was easy to come up with some unusual mental pictures of being inspected by machine-perhaps being personally wired into a computer.

After my trip to the Coast I kept a 4:30 p.m. appointment at the Kaiser Center where I was immediately guided through the center's 20 stations. In each I received one or more tests from a lady technician. Between the stations I was kept busy answering some 600 questions about my medical history. By 6:45 I was through with the tests and assured that nothing had been found of an emergency nature.

While the words "automated" and "computerized" had initially produced images of a mechanically oriented examination, the experience was anything but that. It was an examination by people. They used technical equipmentbut so has every doctor or technician in every examination I have ever experienced. The test data was processed by computer, but I wasn't at all involved. My confrontation was with human beings, all of whom were pleasant, relaxed and willing to discuss what they were doing.

I particularly remember the technician who gave me a tonometer test for glaucoma. She said she had applied the test thousands of times, but hadn't become bored because the work's importance held her interest. She felt that glaucoma was unfortunately being discovered more and more in young people. Incidentally, I learned later that a young man who followed me through the tests was found to be a glaucoma victim, though he had no idea of the problem. While Dr. Morris Collen and his colleagues are to be commended for a magnificent technological job in creating this exciting center, it may not be well enough recognized that they have also done an equally outstanding job at organizing and operating the center in terms of personnel. All the technicians and nurses were obviously chosen for personal qualities as well as technical competence. This kind of attention, in my opinion, is an essential foundation stone for any such center.