4. Within our institution the most knowledgeable individual in this area would be Dr. Harold Hinman, Department of Preventive Medicine, Jefferson Medical College. With kindest regards, I am, WILLIAM A. SODEMAN, M.D., Dean and Vice President for Medical Affairs. THE JOHNS HOPKINS UNIVERSITY, SCHOOL OF MEDICINE, Baltimore, Md., September 16, 1966. Hon. MAURINE B. NEUBERGER, Chairman, Subcommittee on Health of the Elderly, U.S. Senate, Washington, D.C. DEAR SENATOR NEUBERGER: Your letter concerning modern health screening methods arrived while I was in England and I regret the delay in replying. First, let me say that your exploration of the value of these methods is timely and a genuine contribution to the problem of better health care for the American people. We are fortunate in having on our faculty Dr. Joseph Sadusk, professor of medicine and associate dean for community medicine, who is experienced in this field and has a deep interest in it, and I have asked him to write you directly on the questions raised in your letter to me. You may recall that Dr. Sadusk served for a while as medical director of the U.S. Food and Drug Administration, but he came to that post after a long experience in California where he had firsthand knowledge of the Kaiser-Permanente multiphasic screening program. He is now engaged in directing for Johns Hopkins a feasibility study of the problem of complete prevention and medical care for a new city, Columbia, to be developed between Baltimore and Washington, a project incidentally which might lend itself as an important trial area for any new methods developed in respect of screening techniques. I suggest, therefore, that you and your committee may wish to consult further with Dr. Sadusk in these matters. To answer somewhat more specifically the questions posed in your letter: 1. On the basis of present knowledge I would say that there is a place for multiphasic health screening in American medicine. Acceptance by the public.and the medical profession will depend more upon administrative arrangements than upon any defect in basic philosophy. 2. I have already referred to Dr. Sadusk's activities in this connection. 3. I have no specific suggestions at this time, but I believe multiphasic screening has just as much applicability to those under 60 as to those over that age. 4. Again, I refer you to Dr. Sadusk. Thank you for your courtesy in advising me of your most interesting plans. Sincerely, THOMAS B. TURNER, M.D., Hon. MAURINE B. NEUBERGER, DEAR SENATOR NEUBERGER: I have returned to my office to find Dr. Turner's response to your letter of August 23. This letter deals with the subject of screening methods for disease and the scheduled hearings of the Subcommittee on Health of the Elderly of the U.S. Senate Special Committee on Aging for September 20-22. Dr. Turner has asked me to comment on your letter in my positions as professor of medicine and associate dean for community medicine. I concur in his statements on multiphasic screening procedures. The continuing development of screening methods for the detection of disease if of great importance in increasing life expectancy since our modern programs of preventive medicine are based on the early discovery of disease. But to simply increase life expectancy by prolonging miserable years of life is not enough. It is imperative that such programs be developed with the concept and philosophy of increasing useful life expectancy. Consequently, these programs must be planned not only for the elderly but must include studies encompassing those of middle and young age before the ravage of disease has taken its toll. We must detect disease in its potential and incipient stages rather than wait for overt manifestations of disease. Prominent among such screening efforts is the Kaiser-Permanente multiphasic screening program which, in my opinion, has advanced to a considerable degree of sophistication and application in health maintenance. It makes excellent use of paramedical personnel, leaving the physician that part of health care for which he has been specifically trained the physical examination and final judgmental decisions in diagnosis, therapy, and prevention of disease. But it must also be stressed that since such programs are relatively new, further investigations into the scope and methodology of these projects is needed before final decisions on applicability can be made. Here the Government can play a substantial role in encouraging and supporting such investigations on methods of health screening since there is not yet universal acceptance of the types of tests which should be included. There yet have to be specifically defined those procedures which will give our public the best investment for its medical dollar. With regard to the concept of increasing useful life expectancy, I would suggest that you contact Dr. Lewis C. Robbins. He is a special consultant to the Health Hazard Appraisal Study, Division of Health Services, Bureau of States Services, U.S. Public Health Service, 4040 North Fairfax Drive, Arlington, Va. His telephone is 521-5600, Ex. 7314. In 1963 and 1964, while professor and chairman of the department of preventive medicine and community health at the George Washington University, I was associated with Dr. Robbins under a U.S. Public Health Service contract in the development of methodology for a programed health examination, utilizing health hazard ratios with which every person is faced by virtue of age, sex, and race and which change as the years go along. These ratios were necessarily based on mortality statistics since accurate data did and still does not exist for the morbidity of disease, with the possible exception of the reportable diseases. Dr. Robbins is carrying this work forward in his present connection with the U.S. Public Health Service and I believe much will come of it since the goal is to use the patient's health care dollar in a manner where it will yield the greatest return in promoting useful life expectancy for that patient. I should like also to suggest that you contact Dr. Kerr L. White of our Johns Hopkins faculty, an individual who is highly qualified in the field of application of medical and hospital care to large groups. Dr. White is a professor in the Johns Hopkins School of Hygiene and Public Health and is chairman of the division of medical care and hospitals of that school. I believe he can make valuable contributions to your knowledge on the subject in which you and your subcommittee are interested. And, finally, I should like to tell you of the potential interest of Johns Hopkins in promoting studies on methods of application of health care in a new community. The Rouse Co. of Baltimore, Md., is acting as the developer of Columbia City, which is to be carved out of the rolling farmlands in the Baltimore-Washington corridor, straddling route 29. This city will reach a population of 110,000 by 1980. It is not an ordinary real estate development-rather, it will be a unique city in many aspects and selfsufficient in cultural, educational, industrial, and family-society aspects. The Johns Hopkins Medical Institutions have been invited to provide comprehensive medical care to this community and my task at present is to perform a feasibility study to this end. The potential for studying methods of application of medical care and health maintenance for the young and old, utilizing all methods of discovery of disease in its potential and incipient stages, and the application of preventive measures is great. Needless to say, multiphasic screening will play a prominent role in this report. It is my intent to submit this feasibility study to the Johns Hopkins Medical Institutions by January 1, 1967. Shortly thereafter, the institutions should be in a position to arrive at a decision as to whether or not to engage in this project. It is my hope that your Subcommittee on Health of the Elderly will see fit to recommend the support of intensive studies into the methodology of multiphasic screening programs. I should be most pleased to come to Washington at your convenience and tell you about Columbia City and our current thoughts in the application of comprehensive medical care. For telephone contact, my number is 955-6553 (area code 301). Cordially yours, JOSEPH F. SADUSK, Jr., M.D., Associate Dean for Community Medicine. THE JOHNS HOPKINS UNIVERSITY, Senator MAURINE B. NEUBERGER, Chairman, Subcommittee on Health of the Elderly, DEAR SENATOR NEUBERGER: I apologize for not replying sooner to your letter of August 31, 1966, but I was away both when it arrived and at the time of your hearings and was unable to write you. I don't know whether these comments will be helpful at this juncture but you may wish to have them for the record. I have previously commented on Senator Harrison A. Williams' bill and will not repeat myself. With respect to the specific questions you ask, I have the following comments: 1. I believe there is a place for multiphasic health screening in our country. I base this judgment less on the potential contribution of such screening programs to early diagnosis and prevention than I do on their contribution to changing the attitudes of the public and the profession. As yet, we do not have conclusive evidence with respect to the sensitivity, specificity, and yields of a variety of screening procedures. This is because the screening procedures have yet to be carried out on large general populations. The Kaiser Foundation Clinic is a step in this direction but it still has not screened a general population. By a general population I mean one that is not selected by any form of enrollment or payment and which is broadly representative of all groups in the community. Any introduction of multiphasic health screening should be accompanied by a strong program of research and evaluation. I believe that the programs would receive wide acceptance on the part of the public. The health examination survey conducted by the National Center for Health Statistics has had an unusually high response rate; the same is true of the Kaiser program also, I believe. There undoubtedly will be social class differentials in the acceptance of such programs; there have been in the past and there will continue to be in the future. I believe there will be major problems with the medical profession. As you know, the orientation of medical education in this country is toward acute, episodic illness treated in hospital beds. Unlike some other countries, we do not orient our physicians toward community medicine, preventive medicine, early diagnosis, and medical care. Unlike the other social service systems in our country, medicine is unequipped and largely unacquainted to deal with the modern methods of handling information and the variety of processes and procedures. Medicine has been described as a "cottage industry." The introduction of automated screening procedures, a rapid delivery of printouts, and the possibilities for automatic followup from a multiphasic screening program would be a powerful force for encouraging physicians to improve their own operations. The computer encourages where it does not require forms of cooperation with which most mortals are unfamiliar. There may be some resistance on the part of the medical profession because of the possible provision of a "free service." Clearly the service will not be free but must be paid for by taxes, fees, or charges of some kind. A multiphasic screening program should make the work of the physician much more efficient and effective. At least this has been the experience of the Kaiser program. I believe that in formulating the health screening program, it should be done on a modest basis initially. I would suggest that screening programs be associated with medical centers and health departments initially, possibly in connection with the regional medical programs. The program should serve a well-defined community so that the findings of the program can be related to a definite population base. The program should not be organized along categorical lines but should be available to general patients with or without symptoms. In suggesting that the multiphasic health screening program be related to the regional medical programs, my interest would be in developing information about the distribution of a variety of diseases and conditions in the community. In time, I believe, the folly of attempting to organize health services along categorical lines as proposed in the regional medical programs currently might be demonstrated. I would also urge in the formulation of these screening programs that careful attention be given to the information system designed to report the findings back to the physicians in the community and for following up the outcome of the screening program. Again I emphasize the need for research and evaluation with these centers. 2. There are a number of possible screening procedures for children particularly with respect to vision, hearing, posture, behavioral problems, congenital malformations, and dental care which are believed to be effective. Similarly there are a number of screening determinations, particularly those represented by the Kaiser battery, which are believed to be effective for those over 50. Again, it is difficult to generalize on the effectiveness of individual tests because few have been subjected to application and scrutiny in a general population. I believe this needs to be done. There is a substantial body of literature on screening procedures not only in the United States but also in Great Britain and in Scandinavia. I would assume that your staff is familiar with this literature. 3. I have visited the Kaiser multiphasic screening program. I have commented previously on its benefits in my letter to Senator Williams. Again my apologies for not replying sooner. Please let me know if I can be of any further help to you. Yours sincerely, KERR L. WHITE, M.D., Professor and Director, Division of Medical Care and Hospitals. Hon. MAURINE B. NEUBERGER, Washington, D.C. LOMA LINDA UNIVERSITY, SCHOOL OF MEDICINE, Loma Linda, Calif., September 6, 1966. DEAR SENATOR NEUBERGER: I am writing in reply to your inquiry regarding the possible value of modern health screening methods directed toward chronic illness. In reply to your questions I would say that there is a place for multiphasic health screening in this country though obvious screening techniques would have a much higher yield of disease in many other parts of the world. It is my impression that appropriate screening programs could be well accepted if they were tied to some regional medical center or the patient's personal physician for followup. There is no one on this school's faculty or staff who is operating a multiphasic screening program at this time although there is interest |