UNIVERSITY OF UTAH, COLLEGE OF MEDICINE, OFFICE OF THE DEAN, Salt Lake City, September 13, 1966. Hon. MAURINE B. NEUBERGER, Chairman, Subcommittee on Health of the Elderly, DEAR SENATOR NEUBERGER: I have received your letter regarding the activities of the Subcommittee on Health of the Elderly of the U.S. Senate Special Committee on Aging. In general, I find it difficult to give very definitive opinions about these matters, but I will answer them as best I can. 1. The value of multiphasic health screening in health care is somewhat controversial. On the face of it, it appears that is should be of great value, but I am not aware of good documentation as to its actual value. Some tests that are simple and inexpensive would no doubt be of great value. Others that are more expensive and more time-consuming may not be. Obviously, there will be a point of diminishing re turns. In answer to the second part of the first question, I would say that the main problems would be in getting the medical profession in private practice to accept this, but I believe the public would like it. 2. So far as I know, none of our faculty have participated in the organization or operation of a multiphasic health screening program. We have discussed inaugurating such a plan for the faculty of the University of Utah, but have not actually done so. 3. I do not have any specific suggestions at this time. 4. I would suggest that you contact Dr. George R. Edison, clinical instructor and director of the student health service at the University of Utah. In summary, I believe that multiphasic screening programs do have a field of usefulness, but it is hard for me to define exactly what it should be at this time. I believe we need more comprehensive studies on those that have been carried out in order to evaluate them. We very much enjoyed your visit to the University of Utah a year or two ago and hope that you will be able to return soon. Sincerely yours, K. B. CASTLETON, M.D., Dean. THE UNIVERSITY OF VERMONT, COLLEGE OF MEDICINE, OFFICE OF THE DEAN, Burlington, Vt., September 14, 1966. Senator MAURINE B. NEUBERGER, Chairman, Subcommittee on Health of the Elderly, Special Committee on Aging, U.S. Senate, Washington, D.C. DEAR MRS. NEUBERGER: Thank you for your letter of August 24, 1966, inquiring about screening programs at Vermont. With the development of inexpensive, rapid screening procedures, it is obvious these techniques will receive wider application in the coming years. Individual physicians and medical college teaching hospitals do, of course, utilize certain screening tests on a routine basis. These include serologic tests for syphilis, Pap smears for cervical cancer, urine and often blood sugar examinations for diabetes, and tonometry to detect glaucoma on all hospital admissions over age 40. Instruction in the techniques of multiphasic screening and interpretation of results is part of the medical college curriculum. Also research studies of unrecognized illness in certain populations are in progress. Skin testing of veterinarians for Q fever is one example. The medical college per se has not yet embarked in multiphasic screening programs, but judging from experience of the Vermont Health Department, no major problems regarding public acceptance are anticipated. The University of Vermont Home Extension Service has done much to generate interest in the health department diabetes screening program which has tested some 16,000 people in the past 2 years. (These activities are described in a letter to you from Dr. Graveline dated August 26, 1966.) For many years, the Division of Industrial Hygiene, Vermont Department of Health, has been taking annual chest X-rays of workers in the granite and talc industries. At first this program met resistance from local physicians. However, it soon became apparent that numerous people were calling on their family doctors for definitive diagnosis and treatment following annual X-rays; consequently, resistance by the medical profession was short lived. It should be recognized that screening is no substitute for a complete medical evaluation by one's family doctor or a specialist. It is merely a rapid, inexpensive way to identify certain people most likely to have a certain illness in its early stages. You inquired about appropriate cutoff ages of people screened. That of course depends on a number of factors, including the disease or condition in question and what one regards as an acceptable return in terms of positive finding. For example, there is more deafness in the elderly, but because this handicap has important implications for education, screen testing of hearing is limited at present to a standard part of school health examinations. Again, the incidence of diabetes increases with age, and it is important that the person with incipient diabetes know it as early as possible. With the development of accurate, inexpensive tests, these techniques can now be used on a larger proportion of people in their young adult or middle years. Dr. Duane E. Graveline, an instructor in the department of medicine, and director of the division of Chronic Illness Control in the Vermont Health Department, is the faculty member most actively involved in screening programs. Thank you for the opportunity to pull together some of our ideas on this interesting and important topic. Sincerely yours, ROBERT J. SLATER, M.D., Dean. THE UNIVERSITY OF VERMONT, Hon. MAURINE B. NEUBERGER, COLLEGE OF MEDICINE, Burlington, Vt., September 3, 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 letter of August 31 concerning multiphasic preventive health screening and the Senate hearings to be devoted to this subject on September 20 to 22. I feel honored by being consulted in this matter. In reply to your inquiry, I must point out in the first place that I have no personal experience in health screening (except for the development of a new test concerning predisposing anomalies of the autonomic nervous regulation of cardiac function and metabolism, the predictive value of which still remains to be established). However, a screening program of the type which you have in mind, is at present being initiated by the Vermont State Department of Health, Division of Chronic Illness Control, under the direction of Dr. Duane E. Graveline. A memorandum, issued by Dr. Graveline, is herewith attached, and I would suggest your contacting him directly. Having been actively interested for many years in the problem complex of early prevention of degenerative heart disease both in theory and practice, I feel that the above-mentioned local program has great merit, and that it will be in line with Senator Harrison A. Williams? pioneering proposal for long overdue prevention-oriented legislation. To complete my answer, I would like to add a specific comment with regard to the anticipated value of screening for degenerative (so-called coronary or ischemic) heart disease: In sharp contrast to the foreseeable practical effectiveness of screening; e.g., unrecognized diabetes, glaucoma, tuberculosis, etc., the situation in the area of degenerative heart disease, this country's No. 1 health hazard, is quite different for several reasons: Positive screening results for clearly recognizable morbid entities, such as those mentioned above, will, in all likelihood, be followed immediately by appropriate therapeutic action and will involve only a relatively small fraction of the population. On the other hand, more than one-half of the American people are potential candidates for disability and death from degenerative cardiovascular disease. About 250,000 persons per year die from it prematurely; i.e., under 65 years. Screening techniques for so-called coronary proneness are probably less conclusive than those for the other, above-named diseases. AÏthough this should not, by any means, constitute a deterrent from their maximal possible utilization, the inescapable question arises as to what the results of sophisticated screening will be in terms of positive preventive action beyond mere individually diagnosing the need for such action. This dilemma is intimately connected with the national pattern of living habits as it has evolved from industrialization, prosperity, grow ing spiritual aimlessness, boredom, and a decline of self-control and willpower, symbolized by what the late President Kennedy called the soft American. From this point of view, attempts at building up a universal national mass motivation for cardiac as well as general health maintenance, i.e., for adherence to a proper diet, daily vigorous exercising, nonsmoking, and development of a serene, positive outlook on life, appear as the most urgently needed preventive approach. For the time being, it remains a moot question as to whether positive cardiac screening results per se, and subsequent individual counseling will provide a sufficiently effective stimulus for the many millions of endangered adults to change their living habits. One might expect that a Government-directed strong and incessant psychological reinforcement of collective motivation will be necessary to make diagnostic screening optimally fruitful for action, even if only in a limited but worthwhile minority of prospective heart victims. Unfortunately, the medical profession (including cardiologists) is notoriously underinformed and lethargic in matters of scientifically rational heart disease preventability, and medical school curricula are totally inadequate in this respect. To be sure, the recent reduction of smoking among physicians and only among physicians-appears encouraging but it is probably motivated by fear of lung cancer rather than by concern about heart disease. Preliminary attempts have been initiated by the undersigned to organize a nationwide "Doctor's Self-Survival League", by appealing to American physicians to practice themselves what they (ought to) preach on the grounds of their professional and moral responsibility for both their own and the Nation's health preservation. Premature deaths from heart disease among cardiologists are common, as again illustrated by the recent sudden death of the Chief of the National Heart Institute, Dr. Robert P. Grant. Vast heart disease prevention programs have existed abroad for many years, consisting of perennial public educational campaigns, intensively prevention-focused medical school curriculums, large-scale organized physical fitness programs for adults, and the operation of thousands of rural preventive heart reconditioning centers. In this country, the number of community exercise programs is increasing (usually conducted by YMCA's), and of more complex "Heart Attack Prevention Programs," e.g., those in Glens Falls, N.Y. (Dr. I. R. Juster) and here in Burlington at the University of Vermont and the local YMCA (see enclosure). Even though these are only small beginnings, they may be regarded as an indispensable corollary to the highly desirable but merely preparatory diagnostic phase of preaction screening procedures. Hoping that these comments will be found useful in a matter of grave and pressing national concern, I am, Respectfully yours, W. RAAB, M.D., Emeritus Professor Experimental Medicine. P.S.-Some pertinent publications are enclosed. If I can be of any further service, please let me know. STATE OF VERMONT, Burlington, Vt. Memorandum to: Vermont physicians. From: Chronic illness control division. Cardiovascular disease is presently the leading cause of death in Vermont and the Nation. Coronary heart disease accounts for twothirds of all heart disease deaths. Thirteen hundred persons per year die from coronary heart disease in Vermont, of which 250 occur in men under 65 years of age. Deaths in this latter group can be considered premature and potentially preventable. This group is the logical primary target of any organized prevention program. Any effective program for the primary prevention of coronary heart disease must originate in the office of the practicing physician. The Chronic Illness Control Division of the Vermont State Department of Health in conjunction with the Vermont State Medical Society, the Vermont Heart Association, and the University of Vermont Department of Medicine, and others, is developing a service program for physicians, in an effort to reduce the morbidity and mortality of coronary heart disease in Vermont. For the practicing physician, the program would operate to assist in the identification and management of high coronary risk individuals. It would provide a referral service to aid in the identification of high coronary risk individuals, and a counseling service to assist in the management of individuals demonstrated to be in a high coronary risk group. Function testing to aid in the assessment of a patient's coronary disease proneness will be conducted on an OPD basis by the cardiopulmonary lab of the University of Vermont Department of Medicine. This evaluation will be combined with a comprehensive questionnaire of daily living habits, a general physical exam, a 12 lead ECG, coronary cineradiography and chest X-ray, serum cholesterol, GTT, and other necessary tests. The counseling service, directed entirely at the patient's wife to increase her familiarity with the rationale for obesity control, diet regulation, smoking discouragement and encouragement of physical activity, will promote the concept "What the wife can do to help her husband." Public health nurses will play a key role in this wife orientation. Your suggestions and guidance for the continued development of this service would be appreciated. THE UNIVERSITY OF VERMONT, COLLEGE OF MEDICINE, Burlington, Vt., September 12, 1966. Hon. MAURINE B. NEUBERGER, Special Committee on Aging, U.S. Senate, Washington, D.C. DEAR SENATOR NEUBERGER: Your letter of August 31 was followed by another similar one, dated September 7, but I trust that, in the meantime, you received my reply of September 3. |