have any knowledge that anything is going wrong. Prevention is much better than treatment and early diagnosis is the answer to a great many cures. As far as the elderly are concerned and these are the individuals, as you know, over the age 65, need a procedure set up for them so that conditions that arise in them can be treated and alleviated long before they become manifest by symptoms. This, gentlemen, will allow these people to end their years in comparative health and happiness. Senator NEUBERGER. Dr. Martens. Dr. MARTENS. After Dr. Buff's remarks, I am not so sure we are not all going to be replaced by the computers. Very simply, what I have to say can be summed up very readily by the fact that automation in the laboratory is here to stay. I think it is an excellent idea. My only concern is that when it is used, it is used properly and well controlled. My experience has been primarily in laboratory medicine, and I am located in an 800-bed general hospital, and we do approximately 800,000 to 900,000 laboratory tests a year. It, of course, is quite obvious that we have had to automate many of our procedures to do this. To do it accurately requires a constant surveillance of the techniques that are being used. Automation does not apply only to chemistry. Automation can be used in hematology and other disciplines in the laboratory. At present, I think we are just scratching the surface. We have used, as Dr. Buff has indicated, at the AMA exhibit laboratory, a variety of tests, actually, approximately 23 different tests, and some of these, many physicians would dispute as being of value in the socalled screening procedure. Actually, I think that we don't know what these things mean at the present time, and it is only by experience of this type of examining a large number of people we may be able to come up with some accurate data which will be of some use. We use a variety of automatic procedures in our exhibit laboratory. Overall, we did something like 50,000 tests. Of this group, approximately 1,500 had to be discarded because the results were in error. We had a very accurate quality control problem. We had Dr. Michael Lubran from the University of Chicago, who ran a continuous quality control on all our procedures. By this means, we were very quickly able to pick up errors that had occurred. If we had enough serum left, we could repeat the analysis. In some cases, we didn't, and they had to be completely discarded. This is the plea I make. So often, these machines sound like such marvels that they don't have to have the controls that people think they need and in this way, a lot of erroneous data can be accumulated, which would be of more harm than good. I will be glad to answer any questions or go off into anything that you would desire. (Dr. Martens' statement follows:) STATEMENT BY VERNON E. MARTENS, M.D., WASHINGTON HOSPITAL CENTER, WASHINGTON, D.C. I speak for the American Society of Clinical Pathologists and as a practicing pathologist in the District of Columbia, Director of Laboratories and Chairman of the Pathology Department of the Washington Hospital Center. I am certified by the American Board of Pathology in both Clinical Pathology and Anatomical Pathology. Before this I was Director of Laboratories at the Naval Medical School, Bethesda, Maryland, for 7 years. My particular interest for many years has been in Clinical Pathology and particularly in clinical chemistry. We have highly automated many of our procedures in the Laboratories to provide more rapid recording to the physician on the condition of his patient. The American Society of Clinical Pathology is represented by 5000 members all specialists in laboratory medicine. This Society is particularly interested in automation as it applies to the clinical laboratory. At present they are developing an institute in pathology which will be located in Chicago, Illinois. At present plans are underway to study and further develop automated techniques in all phases of laboratory procedures. In addition they have developed programs of workshops and symposia for both physicians and technologists to further their training in this particular area. I have also had considerable experience in the past several years in running an automated Exhibit Laboratory at the Annual AMA Convention. Here a screening type of procedure was done in which a battery of 21 laboratory tests were done on each physician who came to the Laboratory; this included a variety of tests on serum and urine. This type of health examination for physicians has been done for the past six years and each year a number of abnormalities are picked up that have been totally unsuspected by the practicing physician. You can well understand that I am an enthusiast as far as this type of examination is concerned. I would prefer limiting my remarks to Laboratory medicine because this is my particular field of endeavor. The physical examination is also extremely important and a very necessary part of health evaluation but my experience in this field is limited. Each year newer and better instrumentation becomes available to the physician interested in laboratory medicine. I am sure you have heard of the marvelous results that can be achieved with new automated equipment that can report 12 different serum components on a very small sample of blood. There is no question about it, the instruments that are becoming available today are engineering triumphs, but I would like to voice a word of caution. While this type of instrumentation has tremendous advantages, it can be worse than useless if not properly controlled. In our own program at the AMA we had extreme difficulty in keeping the instruments in proper quality control. Unfortunately some users of this type of instrumentation feel that controls are not really necessary; but if this is not done and if each batch is not very carefully controlled, all the values can be in error without it becoming readily apparent. This type of problem is not contributed to any one instrument or manufacturer but we have found that any of the various types of equipment available can very easily go out of control. Our own practice is to standardize the instrument very carefully with known standard solutions and then in a blind control phase insert serum controls which are unknown to the operator of the instrument. In summary I would like to say that I am quite an enthusiast about automation in the laboratory and I think it will be a big boom in health screening and health evaluation. However, my biggest concern is that this type of program be very carefully planned and directed under well-trained medical personnel. Senator NEUBERGER. I ask you as a pathologist in a private hospital, Is a patient billed separately for any pathology that is done, or is it part of Dr. MARTENS. Yes. In the institution I am in, the patient is billed separately, except for certain categories. We have categories of city patients, indigent patients, and so on. Senator NEUBERGER. Yes, but the normal hospital patient who goes there for an operation, then the tests, are some of them automatic, or are they ordered by the doctor? Dr. MARTENS. There are certain tests that are required by the medical staff, when the patient is admitted to the hospital. Blood counts, urinalysis, in our particular institution, we don't require serology. Some institutions do. However, it has become a practice of practically all the physicians that ordered serology as routine anyway, so these are the things we do as routine. Then, in addition to this, all other tests are ordered by the physician. We do the tests that he requests. Now, what happens in the labora tory, of course, as we are doing certain procedures, for instance, in surgery, it is routine to have electrolytes, blood typing, coagulation studies. These are not required by the institution, but the surgical staff themselves have more or less put this on as necessary for patient care. In doing these tests, a lot of times, we will pick up abnormalities in serum, call it to the physician's attention, and actually can go ahead and do further tests which were indicated. Senator NEUBERGER. Well, I suppose, actually, this would be an ideal place; if you had a good screening system, every hospital patient should be screened. You have got them there, and just for this sort of thing. Dr. MARTENS. Well, in a hospital population, I think screening is excellent, where you are doing examination for a routine physical. I am not so sure that for a hospitalized patient, this would be a good idea. What I am trying to get at, I think you should establish a baseline metabolic pattern for people. A person comes in who is sick. This person's baseline is not going to be of too much value to you, except to following that patient's illness. In this particular illness, you possibly would not want all the things you might do in a screening procedure. Senator NEUBERGER. The patient could be in the hospital for one thing, and then go home, and the next day, find that he did have diabetes, or something that had never been discovered, couldn't he? Dr. MARTENS. Well, a person has overt diabetes, this should be picked up in the urinalysis. Senator NEUBERGER. Well, what I was really getting at is how much does this pathology that you would say would be pretty much average add to the cost of the hospital bill? Dr. MARTENS. You mean, adding all the automatic Senator NEUBERGER. Well, what would be considered average that would be generally, let us say, a surgical patient coming in, for surgery that does not say, an appendectomy. How much is the pathology connected with that case? Dr. MARTENS. Approximately, surgical specimens would run about $15. The laboratory work would run another $15. It would be about $30. Now, if you were going to add all the other screening tests, I think that your suggestions, such as blood glucose, uric acid, b.m., and so forth, that would add approximately another $30 to the patient's bill. Senator NEUBERGER. But if the patient had been through something like the Permanente center, and had a screening test, and went to the doctor, and was going to have his appendix out, would this history that he had with him save him some of that pathology, or would they do it all over again? Dr. MARTENS. It would be done all over again. For the very reason that a patient's condition can change rather rapidly. It would depend upon-if it was done this morning, or yesterday, this would not be necessary, of course, to do another urinalysis, or a complete blood study, but if it was done a week ago, it certainly should be done. Senator NEUBERGER. I see. I must not delay too long, because we have to get on. I was interested while you were talking, Dr. Buff, that I wished some representative of the American Tobacco Institute had been in this room with us during this last 3 days, because I sat through hearings with them, and they brought witnesses from the American Thoracic Society, cardiologists, who said there was no evidence that there was a connection between cigarette smoking and emphysema and heart conditions. Dr. BUFF. Well, there are lots of doctors. There are lots of opinions. There is a lot of p.b.p., which is pocketbook persuasion. There are many physicians, many interests, who are connected with a tobacco group, but that is like saying that the fireman, and that the instance of emphysema in a fireman, in a man who fights fires, is very, very high, and that is like saying that the smoke has nothing to do with it. And I live in an area, Senator, that has one of the highest rates of emphysema in the United States. We have not only the effects of tobacco, but we have air pollution. We are the second most polluted area in the country, and this makes another problem. Now, whether you want to say do cigarettes cause the emphysema or does air pollution cause the emphysema, I think you are in a little difficult situation, but living in an area with air pollution, you really should not smoke, because you will certainly get it. Senator NEUBERGER. Yes. We have some controlled studies on this that were done in the Los Angeles area, which show that it is true that, occasionally, emphysema is found among people who do not smoke, but when you took the incidence of the nonsmoker out in the Imperial Valley, with the nonsmoker in Los Angeles, and the smoker in the Imperial Valley with the smoker in Los Angeles, there seemed to be a pretty close connection, of course, as you say. Well, anyhow, there is a saying that seems to be valid, that Sloan Kettering Institutes, that they have discovered very little lung cancer among nonsmokers. And from this in the cancer area, they have drawn some conclusions. Dr. Burr. Well, I don't know if you know of the other axiom, and that is, when a physician has a patient in back of the fluoroscope, and there is a spot on the lung, and he asks that patient, "Do you smoke?" and the patient says, "I never smoke," the chances of cancer of the lung are very, very small. Senator NEUBERGER. Very interesting. Dr. BUFF. There are less doctors smoking today than have at any time previously, and they are learning quite rapidly that they should not smoke. Senator NEUBERGER. This is where an educational process has really been going on. They know how to read the evidence. Thank you both, very much. The next witnesses are Dr. Thomas Weber and Dr. Cheraskin. 69-803 0-66- -19 STATEMENT OF THOMAS B. WEBER, PH. D., MANAGEMENT CON- Senator NEUBERGER. Dr. Weber is a Ph. D., is that right? Senator NEUBERGER. Management consultant, predictive medicine program of the Retail Clerks Union, Local 770, food, drug, and general sales employers benefit funds, and he is also manager of the advanced research for medical development of Beckman Instruments. in Fullerton, Calif. Are you a dentist, Dr. Cheraskin? Dr. CHERASKIN. I am both a physician and a dentist. Senator NEUBERGER. We will introduce you now, as consultant and medical director of the predictive medicine program, and of the same group, and chief of the department of oral medicine at the University of Alabama, in Birmingham, Ala. How are you going to handle who is speaking first, Dr. Weber? Dr. WEBER. I shall start with a brief review of the predictive medicine concept from the measurement standpoint and Dr. Cheraskin will elaborate on the concept and discuss the program he is directing. You can question either or both of us as you prefer. Senator NEUBERGER. Thank you. Dr. WEBER. I am here as a member of a team concerned with the development of predictive medicine programs. The team consists of medical scientists versed in the application of the life sciences to the healing arts, and measurement scientists versed in the application of the physical sciences to precision measuring instruments and techniques. Since predictive medicine depends in great part on precise measurements and their interpretation, its progress requires the combined efforts and experience of both medical and measurement scientists. Senator NEUBERGER. I notice you use the term "predictive medicine." Dr. WEBER. That is correct, and we want to define that term. Predictive medicine means maintenance of health through very early detection and measurement of tendencies toward disease and initiation of appropriate countermeasures to forestall or minimize clinical illness. You could say that predictive medicine means, in a sense, the detection and arresting of disease tendencies before they become serious. By aiming at the detection of changes very early in the development of a disease process, predictive medicine is acutally an extension of and a supplement to preventive medicine. |