, Heritage writer
The Automated Multiphasic Examination
Second part, follows “Screening for Better Health: Medical Care as a Right”
Last summer a major medical news story splashed across the world: “Historic Kaiser Permanente Data to Aid in Long-Term Study to Determine Extent of Ethnic Disparities in Brain Health and Dementia; new $13 million study funded by National Institute on Aging will revisit patients who were first screened as long as 50 years ago.”
Where did this remarkable trove of data come from?
In 1961 the U.S. Public Health Service awarded the Kaiser Foundation Research Institute a grant to study the automation of the multiphasic health testing it had been conducting manually for 10 years. Members would now go through the screening stations with computer cards that got marked along the way. At the end of the session, which took a couple of hours, there would now be a computerized medical record of their current health status. The Automated Multiphasic Health Test was born.
The first AMHT center was at a new building on the Oakland Hospital campus at 3779 Piedmont Ave. By the end of 1966, Kaiser Permanente had enlarged and updated its testing facility and laboratories nearby at a state-of-the-art center at 3772 Howe Street, and expanded the computer center and offices in the Piedmont building. A second center in San Francisco was linked to the mainframe computer in Oakland.
Dr. Collen, in the Journal of the American Medical Association (1966), accurately predicted that “The advent of automation and computers may introduce a new era of preventive medicine … [The computer] will probably have the greatest technological impact on medical science since the invention of the microscope.”
The AMHT continued to be seen as a vital tool in the diagnosis and treatment of occupational and industrial illnesses. A 1967 article in the Archives of Environmental Health discussed the employment data gathered, which included a list of 170 occupational titles and a battery of work-related health questions. “The computer storage of data on more than 40,000 adults annually permits extensive epidemiological research, especially directed toward the preventive aspects of chronic disease.”
It wasn’t just union members who benefitted. The Modern Hospital, May 1966 called the periodic health examinations to more than 4,000 patients monthly “… an impressive investment in the concept of ‘health medicine.’”
The test expanded to about 20 stations, measuring everything from hearing to heart function. It even went beyond mere testing – if recommended, a patient could get a tetanus booster via the new high-pressure injector system.
A 1970 article by Dr. Garfield in the prestigious New England Journal of Medicine with the provocative title “Multiphasic Health Testing and Medical Care as a Right” began with this abstract:
Although no long-term evidence exists that the course of disease is influenced by multiphasic health testing, this is largely irrelevant. Such programs are essential for other very important reasons. The existing and spreading concept of medical care as a right, with its elimination of personally paid fees, is creating a demand for periodic health checkups and health appraisals. This demand cannot be met by traditional methods totally involving the physician without great waste of doctor time.
Multiphasic health testing can help separate the entry mix of patients into the well, the asymptomatic sick and the sick. This separation makes possible optimum use of physicians’ services, which can be devoted to the area where they are most needed: the care of the sick.
The efficiencies of the AMHT were sufficient that these programs were sometimes adopted by private practice, large companies, and public health agencies. Dr. Collen remarked:
It is still of great interest to me and much personal satisfaction that the AMHT is still flourishing in Japan, Taiwan, and in China; and in the past when I visited them I found the AMHT centers in Japan to be primarily employer-sponsored for employees. I found the newest AMHT centers in Taiwan and China to be for-profit, marvels of efficiency and associated with health education centers open to the public, and with a high level of provider and patient satisfaction.
But despite the AMHT’s popularity, it was discontinued by Kaiser Permanente by the late 1970s when a federal grant supporting the work dried up and Kaiser Permanente declined to commit further resources.
Dr. Collen himself noted some of the challenges to quantifying the benefits of screening:
…Epidemiologists required us to report on gross mortality, and since the potentially postponable conditions comprised only about 15 percent of all the causes of death, most people died from other conditions … some of the criticism of urging checkups is based upon the fact that one does not decrease total gross mortality. That is, everyone eventually dies from something.
Gary Friedman, MD, former director of Kaiser Permanente’s Division of Research, recently explained additional medical limitations to the AMHT:
Initial enthusiasm for multiphasic health screening was tempered by experience in using it and by scientific studies that did not confirm benefits vs. costs of specific screening tests. For example, it was initially hoped that routine chest x-rays, included in AMHT, would lead to early detection and increased curability of lung cancer. Studies did not confirm this benefit. A yes/no question about chest pain provoked by exercise and relieved by rest was included in the AMHT symptom questionnaire. Although a yes answer seemed almost diagnostic of angina pectoris, this often did not prove to be the case in the follow-up examination by the physician, who could question the patient in greater detail, consuming valuable time.
Clearly however, the value of some screening tests has been amply confirmed. Finding and treating high blood pressure in asymptomatic individuals prevents strokes. And screening for colorectal cancer by the various tests available can lead to early detection and cure, or the removal of polyps that could later progress to cancer.
Despite these issues, Dr. Collen defended the value of the AMHT in a 1986 UC Berkeley oral history by Sally Smith Hughes:
…The study [on AMHT] did clearly demonstrate that for those conditions that are potentially postponable, there is a significant decrease in mortality.
He went on to note larger policy and commercial impediments to the AMHT:
Blue Cross/Blue Shield and other indemnity insurers to this day still do not pay for checkups. They take the position that periodic health checkups are schedulable and elective, so are not insurable events. Medicare to this day does not pay for checkups. The contrast, in other countries, like in Japan and in France, their social security and governmental supportive systems pay for periodic health checkups for well people, but do not pay for sick care. Just the opposite from the U.S. So if our Public Health Service is so interested in
preventive medicine, why do they fail to support the financing of checkups? A very key reason that multiphasic testing has not proliferated in the United States is because it is not reimbursed by any of the insuring agents. That has been reported by vendors who try to sell the systems.
I should point out that the Public Health Service had asked us to patent the system because it was an invention. Whether I was right or wrong, I refused to do so. I felt that it should be in the public domain, and it is. It’s never been patented.
Dr. Collen concluded with deep pride in the accomplishments:
We actually developed the most comprehensive inpatient and outpatient medical information system in the world. And this book, Hospital Computer Systems, describes that. There were only a half-a dozen others in the world that were doing that.
As the 2016 medical news story about the persistent value of the AMHT data shows, this was a significant accomplishment in medical practice. Thank you, Dr. Collen.
Short link to this article: http://k-p.li/2n00mcW
By Lincoln Cushing
Second in a series
Efforts to combat obesity, childhood obesity in particular, are making news. Examples include First Lady Michelle Obama’s signature public health campaign “Let’s Move!” the Home Box Office (HBO) documentary series “The Weight of the Nation,” and the popular charge to incite health providers, schools and communities to join the fight to stop the spread of obesity.
But the current attention devoted to this issue in a culture obsessed with fad diets and alarmist health news raises the question: Is this really a significant problem?
To begin with, medical experts do not universally acknowledge “obesity” as a disease, like AIDS or lung cancer. There have always been overweight people, and for many the driving concern for weight loss has been more about the aesthetics of body image than physical health.
But two significant and disturbing facts have changed over the past two decades. First, for reasons not fully understood, there has been a measurable increase in the numbers and demographic distribution of obese people. And second, there has been an accumulation of research linking excess body weight to bad health.
The obesity epidemic
Data reveal our population’s progressive ponderosity over time. Medical concern over weight and obesity show up in the mid-1960s. A 1965 UC Berkeley student paper by a physician noted “Estimates run as high as 25 million overweight Americans (based on desirable weights taken from actuarial tables). Some epidemiologists might consider that we have an epidemic of obesity in America. . . A tremendous amount of time, effort, and money is being devoted to the understanding of the problem of obesity and its significance and solution. Diet foods are a multimillion dollar industry. The military attempts to legislate weight and physical fitness with compulsory standards.”1
A 1984 article in Kaiser Permanente’s KP Reporter noted that the Metropolitan Life Insurance Tables showed that a “surprising” 40% of American men and 55% of American women were overweight, currently defined as those having a Body Mass Index (BMI) between 25 and 29.9. The more serious condition is obesity, with a BMI over 30. (BMI is computed by dividing a person’s weight by the square of his or her height.)
A 1987 Planning for Health Kaiser Permanente (KP) member newsletter article stated that “Obesity is our nation’s number one nutritional problem.” Last year the Centers for Disease Control and Prevention reported that between 1980 and 2008, obesity rates had doubled for adults and tripled for children. During the past several decades, obesity rates for all population groups — regardless of age, sex, race, ethnicity, socioeconomic status, education level, or geographic region — increased markedly. More than one-third of U.S. adults (over 72 million people) and 17% of U.S. children are considered obese.
The main reasons proposed for this alarming phenomenon include a more sedentary lifestyle, unhealthy diet, a proliferation in the use of sweeteners (first the “white death” sugar, eclipsed now by high-fructose corn syrup) in food products, and lack of exercise.
Even greater use of worksite microwave ovens during the 1980s was described as adversely affecting healthy eating habits. But other, more complex, causes have been proposed as well, and Kaiser Permanente has embraced a range of treatment modalities and education techniques to help keep members healthy.
Nutrition and health
Doctors advise patients to eat right and in moderation, with increasing medical evidence supporting the case that excess weight contributes to life-shortening conditions such as diabetes, heart trouble, and high blood pressure. Kaiser Permanente early on recognized that the changing dietary behaviors of its members were having a negative effect on waistlines.
Fast food chains, offering cheap high-fat, high-sugar, and high-salt meals, grew enormously during the 1960s and 1970s. Soon KP challenged this trend as an unhealthy one. A 1987 Planning for Health newsletter posed the question, “Burger King, McDonald’s, Wendy’s, Jack-In-The-Box. Everyone is familiar with the names of these fast food restaurants. But how many of us are aware of the ingredients found in their food? Take a few moments to complete our Fast Food Facts quiz.”2
Influencing young people to eat a healthy diet and control their weight is crucial. In 1975, developmental psychologist Mary Wheeler, PhD, and pediatrician Karl Hess, MD, in KP’s Ohio Region started the Optimal Growth Center to help overweight children learn new eating habits. They addressed the social stigma of being overweight, with the long-term view that if they didn’t change their condition they would face significant risks of hypertension, heart disease, and diabetes as adults. 3
Education and outreach
As early as 1956, the Oakland Kaiser Permanente staff realized that peer groups could help people lose weight, and they instituted a group treatment program for overweight patients. In small, informal, round-table support groups of eight to 10 participants, physicians offered information and the group discussed mutual problems.
In the late 1980s, Kaiser Permanente Nutrition Services Departments hosted workshops for members on subjects such as “The Right Way to Good Nutrition.” One Health Plan member who benefitted from the program commented, “When I had a physical last fall, my physician said I was showing signs of arteriosclerosis (hardening of the arteries). After taking three nutrition workshops, I recently had another physical. My cholesterol count was down 20 points and I’ve lost 11 pounds.”4
One successful medium for reaching youth is KP’s Educational Theatre Project. For 25 years the troupe has used live performances at public schools to engage youth audiences on a range of health subjects, including childhood obesity in “1½” and “Give Peas a Chance.” In 2007 KP partnered with educational publisher Scholastic, Inc., to launch an online game based on another play, “The Amazing Food Detective,” teaching children about healthy eating and maintaining an active lifestyle. The game automatically shut off after 20 minutes and encouraged players to get up and exercise or perform some activity away from the computer screen.
Kaiser Permanente was also quick to acknowledge the role that gender and social (rather than medical) standards played in defining “desirable” weight. Second-wave feminism of the 1970s challenged the standard guidelines, noting that women were particularly susceptible to exaggerated concerns about weight that could have negative health consequences of their own.
A 1984 KP Reporter article “Fear of Fat” asked: “Why have we saddled ourselves with an ideal of beauty which torments most women over the age of 20, not to mention many teenagers? One reason is purely commercial. Fifth Avenue has chosen human clothes-hangers who can model any style of clothing.” It goes on to say: “Kaiser-Permanente offers weight-loss programs that do not make a fetish about fat but rather stress good nutrition, exercise, and behavior modification.”
Obesity as a shield against attention
Another connection between self image and weight came out of research conducted by the Southern California Permanente Medical Group. In 1982 Vincent J. Felitti, MD, then a San Diego Kaiser Permanente internist, developed a program to help obese people lose weight, which matured into the Positive Choice Weight Loss Program in 1985. He was confounded by the observation that many of those who experienced success began to drop out. After studying hundreds of patients he learned that many were unconsciously using their obesity as a shield against unwanted sexual attention, a behavior based on experiencing physical or sexual abuse as children.
Subsequent research resulted in a comprehensive assessment protocol, Adverse Childhood Experiences (ACE), that examines the hidden legacy of childhood trauma and helps identify patients for whom conventional weight reduction programs don’t work. More than 17,000 San Diego KP members have been diagnosed using ACE and the study has produced 72 scientific publications thus far.
As Dr. Felitti describes it, “The program involves the essential linkage of two disparate elements: prolonged absolute fasting using the supplement “Optifast” to preserve health in the absence of food intake, and a psychodynamic approach whose function is to help each person discover the unconscious forces underlying their use of eating for its psychoactive benefits and the possible advantages of obesity in their life. Using this approach it is possible to reduce a person’s weight about 300 pounds in a year and help them tolerate that emotionally.”5
Kaiser Permanente is one of the sponsors of the Home Box Office (HBO) upcoming documentary series “Weight of the Nation,” which covers the issue of obesity in America. For more information about KP’s involvement in the fight against obesity: http://bit.ly/kptwotn
1 “Obesity and its Measurements as it Relates to a Multiphasic Screening Program,” by Clarence F. Watson, MD; student paper from UC Berkeley public health class PH274A, Fall, 1965. Dr. Watson’s essay makes the case that “skinfold measurement” using calipers rather than BMI is a more accurate indicator of obesity.
2 “Fast Food Facts,” Planning for Health newsletter (Richmond edition), Winter 1987-1988
3 “Helping Overweight Children,” KP Annual Report 1979
4 “The Path to Good Nutrition,” Planning for Health newsletter (Vallejo/Napa/Fairfield edition), Summer 1988
5 Email correspondence from Dr. Felitti 3/22/2012. For more about Dr. Felitti’s California Institutes for Preventive Medicine: http://www.caipm.org/about/index.html