question is to determine the extent to which one can accept the newer pattern of nonphysician data acquisition with physicians retaining the decisionmaking role. The exact place of this kind of effort is yet to be determined, but that there is an important place seems very highly probable indeed.

1a. Are there any particular problems that may be anticipated in the acceptance of multiphasic screening programs by the public or by the medical profession?

Answer. Acceptance by the public will undoubtedly be something less than complete. Already the chief criticism laid against physicians by the general public is the relatively impersonal and somewhat hurried contact that increasingly characterizes the patient-physician relationship. The intrinsic impersonality of screening batteries will accelerate this problem.

The acceptance of the medical profession will also be mixed since they will recognize that data acquisition is not, in fact, readily separable from judgment as to health status. The intellectual content of a skilled physician taking a medical history is different than the intellectual content of a nonprofessional person asking the same questions. There will also be concern about the effectiveness of the relationship between the data acquisition of the screening program and the system of professional responsibility for judgments based on that data. Finally, there will be the question of whether the capacities of this new data collection system should be added as resources to our present delivery system for health services or whether it will stand apart from it.

All of these matters have been handsomely described in the reports of the Commission on Chronic Illness which operated between June of 1949 and June of 1956. The results of this Commission's efforts were published in four volumes between 1956 and 1959. They include careful accounts of multiphasic screening programs in both an urban and a rural setting.

2. Have any members of the faculty or staff of your college participated in the organization or operation of a multiphasic health screening program?

Answer. Yes.

2a. May we have names, addresses and a brief description of the program?

Answer. Dr. William M. Mikkelsen, associate professor of internal medicine at the University of Michigan Medical School, is responsible for the periodic faculty health appraisal program which is a multiphasic screening program conducted under the auspices of the University of Michigan and serving faculty members at the university. The results of this multiphasic screening program now extend over almost 10 years.

Dr. Thomas Francis, Jr., professor of pediatrics and communicable diseases and professor and chairman of the department of epidemiology at the medical school and the school of public health at the University of Michigan, is senior investigator for the so-called "Tecumseh project" which is a total community health surveillance study which is, to my knowledge, unique within the United States.

Supported primarily by grants from the National Institutes of Health, this is a combined project of the medical school and the school of public health of the University of Michigan. It is an extended, longterm study in the epidemiology and natural history of disease, looking forward to the preventive and early detection criteria that can be utilized. The program focuses primarily on cardiovascular disease but inevitably involves total health surveys.

Dr. Frederick H. Epstein, professor of epidemiology in the school of public health, is associated with Dr. Francis in the Tecumseh project and has a special and direct interest in the multiphasic data collection on this population.

Dr. Harold J. Magnuson, professor and chairman of the department of industrial health of the school of public health and professor of internal medicine of the medical school of the University of Michigan. Dr. Magnuson has had very broad experience, both within the U.S. Public Health Service and more recently at this university, in the problems of periodic health appraisals in industry and the standardization of data collection and reporting. Although his special concern is with health hazards related to industry, in order to evaluate these a total health appraisal is, of course, necessary. A great deal has been done in industry to utilize nonphysician personnel and Dr. Magnuson's experience in this field has been important.

Dr. A. James French, professor and chairman of the department of pathology and director of laboratories at the University of Michigan Medical School. The whole question of how the laboratory is to be organized has been an important concern of Dr. French. In its simplest terms, it may be less expensive to do an automated batch of laboratory examinations on a single blood specimen than to be selective about which ones are to be done. The entire problem of automation of laboratory examinations is central to the concept of maximal application of laboratory techniques to health appraisal.

3. Do you have any suggestions for effective screening or other health maintenance programs for persons below age 60? Above age 60?

Answer. I would suggest that we are not yet prepared for nationwide programs and should look forward to investing in a series of carefully controlled experimental efforts of large enough dimensions so that they can be extended fairly rapidly to the general population. My relationship to the rural study in the chronic illness survey of the Commission on Chronic Illness and more recently to the Tecumseh study in Michigan has been from the viewpoint of an administrator rather than a fieldworker. From this viewpoint I have been impressed with the very great difficulty of obtaining funds for support of these efforts. For instance, in the chronic illness study in the Hunterdon County area no provision was made for followup studies after the initial survey. The crucial question of the actual effect of this kind of information gathering on the health of the population therefore remains unanswered and we are left only with a onetime effort. To my knowledge, the same problem exists in the urban study conducted in Baltimore. The size of the samples were restricted and the range of screening efforts was also constricted in large part as a result of shortage of funds for these pilot efforts.

In the Tecumseh study, the continuing health surveillance of the total community has been a point of extensive discussion and very difficult administrative problems, in large part because it does not fit precisely the mission of any one of the established budgetary units in the Federal Government. It is not so much that the surveillance has been left undone but that it has been done less extensively than we would have wished and at the cost of an enormous investment of manhours that could possibly have been better expended. I cite these examples not as complaints but rather to indicate that the sort of careful study of effectiveness that is necessary has not yet been done. Before we go too far in establishing a new program no matter how plausible it may appear to be, I would hope that we have more secure data than are now available on the actual effectiveness of such a program in improving the health of the people. The peril is that we would establish an enormous data collection and analysis apparatus that in the last analysis would have a very limited effect on health. To avoid this, we need to understand more clearly how improved data collection can reinforce the professional decisionmaking and the education of the individuals concerned.

4. May we have names and addresses of any individuals who may have special knowledge of, or interest in, our subject?

Answer. I refer you to the publication cited previously from the Commission on Chronic Illness which lists a large number of people who have deep concern and experience in this effort. In particular I would recommend to you Dr. Edmund D. Pellegrino, who was director of medicine at the time of the rural chronic illness survey and subsequently helped to develop the medical center in Kentucky. Most recently, Dr. Pellegrino has been appointed professor and chairman of the Department of Medicine at the State University of New York at Stony Brook and he will direct the medical center during its planning phase.

I trust these responses are of value to you.

My own personal opinion is that this kind of multiphasic data collection related to health should be supportive of, rather than competitive with, other techniques of obtaining such health related information. Ultimately it should look forward to becoming a part of a national health information network. Although it is perfectly obvious that much data needed by the physician is already collected by technical personnel and that we must, to the fullest possible extent, utilize the physician as a decisionmaker rather than simply an information gatherer, it is not so clear that our present level of understanding of so-called multiphasic health screening will suitably accomplish this end. We badly need research efforts that are objective and critical. Much of multiphasic health screening has heretofore been undertaken by enthusiasts who have a prior commitment to its benefits. If full utilization of multiple screening is to be obtained, then these enthusiasts must submit their judgments to the same kind of analysis of actual effectiveness and acceptability that is characteristic of all other modes of diagnosis and therapy.

Sincerely yours,

W.N. HUBBARD, Jr., D.D., Dean.

MAURINE B. NEUBERGER,

UNIVERSITY OF MINNESOTA,

COLLEGE OF MEDICAL SCIENCES,

Minneapolis, Minn., September 7, 1966.

Chairman, Subcommittee on Health of the Elderly,

U.S. Senate,

Washington, D.C.

DEAR SENATOR NEUBERGER: Miss Rausch has asked me to answer your letter of inquiry concerning the current status of multiphasic health screening.

The faculty of the University of Minnesota Medical School has been particularly interested in this problem during the past year, and it is our hope to develop an experimental clinic during 196768 in which we can explore some of the questions which you have raised. As a member of the outpatient clinic directors group of the university hospital, I have recently prepared a report for the directors of our outpatient clinics which explores some of the information currently available on this subject. On the assumption that you may be interested in this report, I will forward a copy to you. This report does not presume to cover all of the important work which is being done in this area; however, it may serve as a jumpoff point for you in your investigation of this complicated problem.

You have referred to the work of Dr. Collen in California. I have visited his laboratory and studied his clinical screening program and agree that it is very impressive. As you are well aware, a field which is moving rapidly will almost invariably demonstrate a variety of approaches to the solution of a common problem. The field of laboratory medicine is no exception. Two of the outstanding contributors to this field whose approaches have been somewhat different from that of Dr. Collen are Dr. David Seligson at Yale University and Dr. Ralph Thiers at Duke University. My opinions are included in the report which I am forwarding. I believe that the observations of Dr. Seligson and Dr. Thiers would be of particular assistance to you as their work in particular illustrates the breadth of this problem.

Yours sincerely,

PAUL E. STRANDJORD, M.D., Director, Clinical Chemistry Laboratory.

STUDIES OF THE UTILIZATION OF THE CLINICAL LABORATORY AS A ROUTINE ADJUNCT TO THE HISTORY AND PHYSICAL EXAMINATION

"Classically there are three major avenues of gathering information with reference to patient management: the history, the physical examination, and the laboratory examination. The roles of the history and the physical examination have become relatively well established. The role of the laboratory examination is rapidly changing,

1P. E. Strandjord, Lab. Med.-A Prospectus, Minnesota Med., May 1966, 773.

69-808 0-66 -24

however, and may be expected to change even more dramatically in coming years. It is now accepted practice to gather historical information and physical findings concerning all of the major systems of the body at the time of a detailed clinical examination. It will soon be feasible to provide a similar laboratory examination which will reflect information regarding many of the major systems of the body. Such a battery of tests will be directly analagous to the current screening type of physical examination which provides information regarding heart, lungs, liver, etc. Laboratory examinations of this type will be performed at the time of hospital admission, as well as during periodic health examinations. Information gathered from such examinations will be recorded in a form facilitating retrieval and will be helpful in detecting asymptomatic pathology, in facilitating earlier diagnoses, and in shortening periods of hospitalization. Data will be considered not only on the basis of what is normal in the general population, but what may be considered normal for an individual of a specific age and sex. In addition, compilation of such information will facilitate establishing normal values for given individuals. Values which could be considered normal in reference to norms based on the general population may appear abnormal when considered in reference to a patient's own established 'normal values.""

SUMMARY OF FINDINGS OF SEVERAL RECENT SCREENING STUDIES 2

I. Glucose and diabetes mellitus.

A. Determinations of both blood and urine glucose concentration should be performed 1 hour after a "carbohydrate load." B. A number of studies have shown that the average incidence of unsuspected diabetes is approximately 1.14 percent or 1 case of diabetes for every 100 people tested. (The number of undiagnosed cases of diabetes mellitus is probably equal to the number of known cases of this disease.)

C. False positive blood and urine glucose tests occur especially in young children and pregnant women.

D. Unsuspected abnormalities in blood sugar tests-2 percent, in urine sugar tests-6 percent.

II. Serum calcium and parathyroid function.

A. The incidence of unsuspected hyperparathyroidism is about 0.15 percent; hypoparathyroidism about 0.03 percent; and pseudohyperparathyroidism about 0.04 percent.

B. The incidence of unsuspected serum calcium abnormalities has been reported as being 0.96 percent or approximately 1 in 100 subjects tested.

III. Šerum uric acid and gout.

A. Unsuspected gout-0.6 percent.

B. Unsuspected abnormalities in uric acid-4 percent.

IV. Kidney function tests and renal disease.

A. Unsuspected renal disease-0.5 percent.

B. Unsuspected abnormalitites: BUN-1 percent, Cr-0.5 percent, Urine albumin-3.8 percent.

The data include only findings picked up as a direct result of the screening procedures under investigation.