UNIVERSITY OF CALIFORNIA, LOS ANGELES, Los Angeles, Calif., September 14, 1966. Senator MAURINE B. NEUBERGER, Chairman, Subcommittee on Health of the Elderly, DEAR SENATOR NEUBERGER: In answer to your letter of August 23, inviting our viewpoints in connection with a study of modern health screening methods by the Subcommittee on Health of the Elderly, we welcome the opportunity to comment on these vital and timely public health questions. There can be no question about the inevitability of computerized diagnostic screening centers of the type proposed by Mr. Williams, and currently conducted by the Permanente Medical Group in Oakland and San Francisco. However, transition to an era based on such screening techniques involves a number of considerations which I believe have been confused by inadequate and perhaps erroneous information. Appropriate attention must be paid to these factors or the period of transition, probably quite rapid, could produce a period of chaos rather than improved medical care. Unlike the acute diseases, chronic diseases are rarely cured. They must be observed and treated for prolonged periods, usually the lifetime of the patient. For this reason it is exceedingly improbable that the early detection of chronic disease will result in reduced rather than increased pressure on professional personnel. For example, prior to insulin, the average life expectancy of the diabetic was about 4 years. With insulin, his lifespan approaches that of a normal individual, obviously the result we desire, but one that increases medical service requirements. Screening procedures have added another dimension. Asymptomatic individuals with mildly abnormal glucose tolerance curves will now be referred to their physicians. Since, in the absence of curative techniques, early detection does not alter progression of abnormal glucose tolerance curves into clinical diabetes, these individuals will require an even longer period of professional observation. Similarly in glomerulonephritis; chronic hemodialysis and kidney transplantation as a means of treating kidney failure increase rather than reduce the professional burden. The problems of following all patients with proteinuria further add to this load, and, as in diabetes, the establishment of the diagnosis is not yet associated with any technique for slowing the inexorable course of glomerulonephritis. The situation with arteriosclerosis poses a similar problem. There is no conclusive evidence of a regimen which will decelerate the progress of arteriosclerosis, and in the foreseeable future the later clinical problems will probably be treated just as they are today. The patient must be examined frequently to abort complications as they occur. It has been widely advocated that each individual be examined at least once a year for effective preventive medicine. While there is approximately 1 physician for every 750 individuals in the United States, those physicians available for triage include only general practitioners, pediatricians, and internists. Since they represent about 50 percent of all practicing physicians, the ratio of physicians to patients is reduced to 1 to 1,500. At this ratio, a physician practicing 5 days a week, 50 weeks a year, would have to see six patients a day in order to screen the total population. This would, of course, be in addition to the time required for care of patients with overt disease. If the physician spent a minimum of 1 hour with each patient, this alone would require 6 hours a day. Thus I question the proposition that the multiphasic health checkup would reduce the stress on the physician's time. Examination of diagnostic procedures performed by the Permanente survey indicates that very few of them are performed by the physician at the present time, but by the laboratory or the radiologist. Further, Mr. Williams quotes data from the Public Health Service indicating that in persons over 45 years, 29.2 percent have hypertension and hypertensive heart disease, 18 percent have arthritis and rheumatism, and 10 percent have bronchitis. Thus, in this age group, a minimum of 29.2 percent and a maximum of 57.2 percent, depending upon the duplication of diagnoses, would be referred for further examination on the basis of these three diagnoses alone. It is probable that for good preventive medicine almost all of these patients would have to be seen regularly. It is obvious, therefore, that whatever the approach, more patients will be seeing physicians than ever before. An important point is that the screening features amplify and supplement, but in no way replace, the usual history and physical examination. In fact, because early causes may be less obvious, early abnormalities usually require a more prolonged and careful examination. Certainly the diagnosis of obscure conditions, many of which are treatable, would not be picked up by the computer. Patients cleared by the computer might be reassured and not seek further examination. As the computers become increasingly sophisticated diagnostically, the diagnostician will become increasingly responsible for the more sophisticated diagnoses beyond the reach of the computer. Therefore, the level of ability and training of physicians in many areas may actually require upgrading rather than downgrading because of computer assistance. As one involved in medical education at various levels for over 20 years, I doubt that the personnel performing diagnostic, and especially therapeutic procedures, can be safely downgraded. At our present level of achievement, further gains can be made only by improving the present quality of personnel and training. There is one area in which multiphasic screening would undoubtedly conserve physician time. At present the physician must choose the procedures to complement his history and physical examination which have a high probability of yield in relationship to cost. Thus, he must examine the patient first, then order the tests, and at a subsequent time review the initial examination and correlate the test results. The availability of these results in advance, perhaps even supplemented by computer-determined additional tests, might increase his efficiency. Institutions which handle large numbers of outpatients, and especially those institutions where patients present themselves directly for hospitalization, would benefit. In conclusion, there is no question that the proposed computerized techniques will improve the scope and accuracy of medical diagnosis. Yet, I question whether their full utilization will result in increased economy of health services. I believe that widespread use of screening procedures as proposed would increase the professional load at a rate faster than could be compensated by proposed expansion of training facilities. We are now at the level of medical achievement where a simple linear increase in results requires a logarithmic increase in effort and economic and social expenditure. The goal of improved health must be sought, but it must be recognized that this is costly. In particular, the increased need for personnel at all levels is an overriding concern. In answer to question (2) Dr. John Chapman (professor of epidemiology) has been involved in a multiphasic screening program evaluating the development of heart disease in county employees for the past 10 to 15 years. Ultimately, screening should be performed at all ages (question 3) and it would seem advisable to set up pilot programs on the basis, rather than for some arbitrary age group. Finally, question (4), Prof. Ralph Goldman, chief of chronic diseases and geriatrics and director of the Rehabilitation Institute would certainly be interested in this program. Sincerely, SHERMAN M. MELLINKOFF, M.D. UNIVERSITY OF CALIFORNIA, SAN FRANCISCO MEDICAL CENTER, OFFICE OF THE DEAN, San Francisco, Calif., September 6, 1966. Senator MAURINE B. NEUBERGER, Chairman, Subcommittee on Health of the Elderly, Washington, D.C. DEAR SENATOR NEUBERGER: Your letter addressed to former Dean Reinhardt was referred to me for reply. Our current Dean, Stuart C. Cullen, is away from the medical center at the present time but I have discussed these matters with him and the comments that I will make reflect his opinions as well as those of numerous faculty members concerned. We are very familiar with the multiphasic screening program adopted by the Kaiser Foundation in California and have had many discussions regarding multiphasic screening with Dr. M. F. Collen, who directs this program for the Kaiser foundation. Several members of the faculty have visited the multiphasic screening centers in San Francisco and Oakland, Calif. There is no doubt in our mind that some type of multiphasic screening will prove to be of significant value in the earlier detection and prevention of disease. Data is not yet available, based on long-term followup of patients participating in multiphasic screening to determine completely what type of screening and in what age group screening would be of most value in the earlier detection and prevention of disease. Therefore, it seems that university medical centers whose main commitments are to teaching, research and patient care would have a vital interest in developing new knowledge in this area of medicine. The greatest block preventing the successful development of experimental multiphasic screening units in association with a university medical center is the demand for space and faculty time. It is our opinion that any bill which seeks to implement research and teaching in the area of multiphasic screening should provide funds for construction of multiphasic screening units as well as funds for adequate staffing. The funds for construction will probably have to be on the 69-803 0-6623 basis of a 100-percent funding of new space, if necessary, as well as 100-percent funding of remodeling of existing space if such is available. We believe that a special category for participation by university medical centers should be developed in pending legislation in addition to the proposed regional and community oriented health protection centers. This category should include demonstration and experimental centers housed in medical schools where the emphasis would be on teaching and research. In these special centers, service responsibilities would be defined in terms of teaching and research needs. Such units would fit in better with current teaching programs and would be more acceptable to medical school faculties. It would allow university medical centers to develop multiphasic screening units and treatment centers in conjunction with existing outpatient departments which would emphasize teaching and research without a mandatory increase in service load. Such a teaching and research unit would be valuable to the Nation's health because much research needs to be done in the area of integrating information received from multiphasic screening into the management of patients by individual physicians. This area of relating automated procedures to ongoing patient care, particularly as regards the rational use of data collected by automated methods, needs careful study. In our opinion we would favor the inclusion of women, age 40 and older, in those covered by any multiphasic screening program because of the importance of screening for mammary and cervical cancer in this age group. If we can be of any further assistance to you in this matter, please do not hesitate to write. Sincerely, ROBERT H. CREDE, M.D., Professor of Medicine, Chairman, Division of Ambulatory and UNIVERSITY OF CALIFORNIA, Hon. MAURINE B. NEUBERGER, Chairman, Subcommittee on Health of the Elderly, DEAR SENATOR NEUBERGER: This is in answer to your letter of August 23d concerning multiphasic screening methods, particularly in trying to prevent chronic illnesses. You ask me to respond to several questions; the first being, is there a place for multiphasic health screening in health care in this country, and are there any particular problems anticipated? Answer: Not only is there a place for multiphasic health screening in the health care in the country, but there are scores and scores of places that are beginning to do it, some very extensively and some rapidly developing. The excellent and explosive growth of the automated equipment permits this, and any examination of the companies, such as Audiotechnicon or Beckman instruments, thoroughly demonstrates this expanding area. It is already expanding so rapidly that the problem is to do it in a coordinated manner and to be sure that the material is available for physician study and analysis. As you may know, this is a standard procedure now at many medical meetings, such as the American Medical Association, where physicians themselves while looking at the exhibits have these multiphasic screening tests so as to familiarize the physicians themselves with the techniques available and, thus, stimulate the efforts. In view of the rapid acceleration in this area, I would question whether or not there is any need whatsoever to further stimulate it since its value is well known and it is such a logical method so broadly accepted by anyone with any knowledge in the medical field. You ask whether any members of our faculty or staff have participated in multiphasic health screening programs. The answer is "yes", to variable degrees. Many of our faculty are in hospitals that already do this. Some county health departments do this, as well as, of course, numerous large industries. Again, this whole idea is by no means new. In question 3 you ask for suggestions for people over 60 or below 60. I have always felt this age is entirely arbitrary and without medical substance. Screening methods that work well above that age work just as well below. Certain tests are obviously emphasized in older age groups and different from those in younger age groups. These differences are widely recognized by people in this area and need hardly occupy the attention of your committee. May I repeat and emphasize again that although Kaiser Foundation does this, this is generally known in Government, particularly since that is a very fine hospital and has many and close contacts with the Government and an excellent publicity staff. Although it was an early starter of these screening programs, many other fine centers were in there doing the same and, as you know, the National Institutes of Health, under Dr. George Williams, already has very elaborate screening methods with great batteries of tests already generously supported by Federal research funds and others. I do hope your committee will not make the mistake of feeling that in this sense it is moving into a new, unexplored, or untried area. It is being well done and as quickly as can be done with current personnel resources. Medicare, obviously, will stimulate it further. I would suspect the main problem will be to not have it overextend itself and end up by sacrificing quality and accuracy while these methods try to respond to great demands. Respectfully, WARREN L. BOSTICK, M.D. UNIVERSITY OF CALIFORNIA, SAN DIEGO, Senator MAURINE B. NEUBERGER, La Jolla, Calif., September 14, 1966. U.S. Senate, Special Committee on Aging, Washington, D.C. DEAR SENATOR NEUBERGER: I am very pleased to respond to your letter of August 24 which was on my desk when I returned from vacation earlier this week. |