necessity for providing for adequate followup for whatever abnormalities may be uncovered. Should you desire it, Dr. Spencer would be happy to help out with this problem in any way he can. Sincerely yours, KINLOCH NELSON, M.D., Dean. MICHIGAN STATE UNIVERSITY, COLLEGE OF HUMAN MEDICINE, OFFICE OF THE DEAN, East Lansing, Mich., September 13, 1966. Hon. MAURINE B. NEUBERGER, Chairman, Subcommittee on Health of the Elderly, DEAR SENATOR NEUBERGER: I was much pleased to receive your letter of August 24 and appropriate enclosures concerning the issue of multiphasic health screening in delivering health care to our citizens. I am certainly not expert in this particular field of public health, and I am certain that far more valid information concerning the significance of this approach to early diagnosis is available to you. I would, however, like to develop a suggestion which emanates from a recent experience in the Upper Peninsula of Michigan. This section of the State, as you know, is exceedingly rural, underprivileged, and economically deprived. The population is characterized by an exceedingly high percentage of elderly persons and the number of physicians is very small. It was told to me that there are many communities where people live and die never having had the benefits of a physician's care. While visiting with the director of the laboratory of one of the hospitals in an Upper Peninsula community, I was informed of the frequency with which diagnoses are made in the laboratory; diagnoses which, with a higher ratio of physicians to population, would be made by the physician through appropriate specialist consultation. For example, it was pointed out to me that it is not uncommon in this hospital for the diagnosis of diabetic coma to be made by the discovery of a high sugar value in the child's spinal fluid. An alert pediatrician would not need to resort to the spinal fluid examination of a child in diabetic coma. A physician less experienced in the diseases of childhood, however, would do the normal thing for a child in coma; namely, do a spinal tap. The laboratory would then give him the correct diagnosis. In other words, in this setting the laboratory is assuming a more front-line role in diagnosis than is usually the case in American communities today. It is apparent, therefore, that the laboratory can assume a more "firstline" role in medical care than has traditionally been the case. Furthermore, it would seem that, properly applied, a more routine use of the multiphasic screening techniques could be an important factor in more effective application of medical care in rural areas where physician manpower is scarce. In other words, for the child just described, a routine urine or blood sugar test several months prior to her sinking into coma would have diagnosed the diabetes before her life was threatened. This university, with its land-grant tradition, is particularly sensitive to the problems of rural medical care, and I am certain that multiphasic screening imaginatively applied could be a most important feature of medical care of the future in thinly populated areas. I once participated in a multiphasic screening program in a rural community at Hunterdon Medical Center, Flemington, N.J. This program was set up in 1953 under the directorship of Dr. Ray E. Trussell, currently in the department of hospital administration at the Columbia University School of Public Health. This program was well received by the community, and physicians accepted it well, since each patient gave the name of his physician and the reports were sent directly to him. This was, indeed, a case-finding mechanism which could do nothing but help the physician. If you do not have his name already, Dr. Robert Henderson, medical director of the Hunterdon Medical Center, could give you a followup on this program, and its history from the standpoint of acceptance. Our medical school is new, currently limited to the preclinical, first 2 years of medical education, and taking its first class this month. Therefore, we do not have any faculty at the present who have been involved in the initiating of such a program. I feel this to be the limit to which it would be fair for me to go in answering the questions contained in your letter. Like every other modality in health maintenance, multiphasic screening is no panacea, and cannot completely replace those ministrations of the physician or other helping person which have to do with personal observation and examination of, and interaction with the individual. I do feel that new laboratory technology applied according to the principles of multiphasic screening can be much more utilized than is presently the case, to the great benefit of many of our citizens. If there is anything more that I can do to help, do not hesitate to let me know. Sincerely, ANDREW D. HUNT, Jr., M.D., Dean. NEW YORK MEDICAL COLLEGE, DEPARTMENT OF PREVENTIVE MEDICINE, New York, N.Y., September 9, 1966. Senator MAURINE B. NEUBERGER, Special Committee on Aging, DEAR SENATOR NEUBERGER: This is in reply to your letter of August 29, 1966, asking for additional comments on several points raised in the paper I presented at the University of Michigan School of Public Health. Therapeutic measures in heart disease are clearly limited in value because they cannot alter the pathological changes which have already occurred and which continue to occur in a diseased heart. The most important approach, therefore, is to prevent the occurrence of the disease processes which result in damage to the hear. 69-803 066 -22 Fortunately, research in the epidemiology of coronary heart disease indicates that we may be on the threshold of a major breakthrough in the prevention of this most important cause of heart disease. It has been firmly established by observational studies that the incidence of coronary heart disease is directly associated with the serum cholesterol level. It has also been demonstrated that the serum cholesterol level can be lowered significantly by dietary changes, that is, by switching to a diet such as the "prudent diet" used by the Anticoronary Club of the New York City Department of Health. What has not yet been accomplished is the experimental demonstration that lowering the serum cholesterol level by dietary means will in fact reduce the incidence of coronary heart disease. The data obtained to date by the New York City Department of Health suggests that this may well be the case; however, their series is still too small to warrant firm conclusions. The national diet-heart study which is now being developed under the auspices of the Public Health Service may provide the answer to this question. If the answer is positive namely, that an altered diet will cause a significant reduction in the incidence of coronary heart disease, then screening methods can play an important role in heart disease prevention. It will be possible to screen the population to discover individuals with high serum cholesterol levels for referral to physicians and clinics for dietary counseling and supervision. As I indicated in my paper, we have rather good evidence on the value of early diagnosis in cancer. We know, for example, that currently available screening methods are effective in finding cancer of the cervix in the early, curable stages. We also know that this is not true for cancer of the lung; by the time lung cancer has progressed to the point where it can be detected by X-ray, it is usually too late. We need to know more about the effectiveness of screening programs for other chronic diseases. Diagnosis of asymptomatic disease by screening methods is clearly useful in some diseases where treatment applied in the early stages can halt or retard the disease process. In other diseases, however, treatment in the early stages may have little or no effect, either because the disease cannot be detected early enough, as in lung cacer, or because the available therapy is inadequate. There is a need for well designed followup studies to determine the value of specific screening procedures from this point of view. Such studies could be done effectively by the Permanente program in California because of the availability of medical care to the screened population. They could also be done by medical schools which establish multiphasic screening centers. Investigation also needs to be carried out to discover new and better screening methods. One other point needs to be emphasized. Screening can be effective in the Permanente program because all those screened have complete medical care available to them. The objectives of a screening program will not be achieved unless there is adequate provision for the followup and treatment of all individuals with positive tests. The great need at the present time is, I believe, the establishment of regional multiphasic screening centers by medical schools and health departments. These centers would have an important educational function in relation both to the medical profession and to medical stu dents. The centers would carry on research to determine the value of various types of screening procedures, to develop new screening tests, and to ascertain the most effective methods of guaranteeing adequate followup and treatment of persons with positive tests. Such centers would, finally, provide the base for further development of screening programs in their respective regions. Sincerely yours, MILTON TERRIS, MD., Professor of Preventive Medicine. THE PENNSYLVANIA STATE UNIVERSITY, Hon. MAURINE B. NEUBERGER, OFFICE OF THE DEAN, Hershey, Pa., August 29, 1966. Chairman, Subcommittee on Health of the Elderly, Special Committee on Aging, U.S. Senate, Washington, D.C. DEAR SENATOR NEUBERGER: Thank you for your inquiry of August 24. The Milton S. Hershey Medical Center of the Pennsylvania State University is just in the process of organization. We do not anticipate opening our teaching hospital before the summer of 1969, so that we are several years away from actively implementing any clinical care programs. We have not, up to this moment, made any decision on whether we will implement multiphasic screening programs or not. We have decided to organize a department of family and community medicine, and it would be possible for us to implement such a program through that department. Up to the present, none of our faculty or staff have actually participated in the organization or operation of a multiphasic health screening program. I feel that such a program, to be effective, must begin below the age of 60. The chronic diseases that might be detected are often lifelong. If the effects of the disease are to be reduced in extent or prevented, measures must be started as far back in the life of the individual as possible. I believe there is a place for multiphasic health screening in health care. In many of the clinical problems, the actual history of the illness, as obtained by talking with the patient, is one of the most important diagnostic tools. The self-administered history, which can be evaluated by computer, may have some value; but they cannot, in my opinion, substitute for a personal history taken by a physician. Whether or not a history is taken and a physical examination done, the interpretation of the laboratory findings usually done in the screening techniques must be done by a physician in the light of the other aspects of the patient's health. I have reviewed the tear sheets you sent me from the Congressional Record of February 25, 1966. You have the names of some of the most knowledgeable people in this field. I recall very pleasantly the invitation of Senator Harrison Williams last year to comment, which I did. I hope these remarks have been helpful. If there are other points on which you wish specific comment, please feel free to write me. Sincerely, GEORGE T. HARRELL, M.D., Dean. STANFORD UNIVERSITY SCHOOL OF MEDICINE, Hon. MAURINE B. NEUBERGER, Washington, D.C. STANFORD MEDICAL CENTER, Palo Alto, Calif., September 19, 1966. DEAR SENATOR NEUBERGER: Thank you for your letter of September 14. I certainly have no objection to your including my letter in your hearing record. I'd like to suggest in the fourth paragraph of my letter, if you use this portion, that there be inserted in line 4, before the word "involvement" the phrase "continued, close." In other words, the second sentence of that paragraph would then read, "Obviously there must be, and in the very significant number of instances where psychological and emotional problems represent the major issue, continued, close involvement by the physician and other members of the health-care team is mandatory." At the risk of belaboring a point, let me again suggest the possibility of your contacting Dr. Leland Blanchard of San Jose, to whom I referred in my letter. When last I talked to Dr. Blanchard a week or so ago, he had not heard from you. I simply want to reiterate my views that he has a unique record in terms of thinking about these problems, and I am sure his comments would be of interest. I much appreciate your willingness to send me a copy of the transcript of hearings when the transcript is printed. I will look forward to seeing it. With kindest regards, I remain, ROBERT J. GLASER, M.D. STANFORD UNIVERSITY SCHOOL OF MEDICINE, STANFORD MEDICAL CENTER, Palo Alto, Calif., August 30, 1966. Hon. MAURINE B. NEUBERGER, U.S. Senate, Washington, D.C. DEAR SENATOR NEUBERGER: I read with interest your letter of August 23, dealing with the study that your subcommittee is about to undertake. I was particularly interested to learn of your emphasis on health screening methods. I have also reviewed the material from the Congressional Record that you included with your letter. I am not sure how helpful I can be but I am delighted to have an opportunity to respond to the four questions that you have raised. I might say that I am reasonably familiar with the Kaiser programs; some of my associates and I have been to Oakland to see first hand Dr. Collen's operation, and I must say we were all tremendously impressed by it. Recognizing that it is still in the study phase, I will nonetheless be surprised if the ultimate results do not indicate the value of this sort of approach. This brings me into your first question, relative to the place for multiphasic health screening programs. As I have implied above, I certainly believe there is a place for this kind of approach. The incredible advances in medical science, and the opportunities to apply |