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Dr. HoFF. Not any more in Virginia. They have passed a new optometry law in Virginia which does not permit the advertisement of professional ability or professional services.

Mr. HARSHA. If we should enact this legislation that you are supporting today, then you would still have the problem in Maryland. Dr. HOFF. I believe that problem will be attacked in time, sir.

Dr. MCCRARY. Mr. Chairman, with your permission I would like to present our next witness, Dr. Meridith W. Morgan, Jr., dean of the School of Optometry of the University of California. Mr. WHITENER (presiding). All right, Doctor.

STATEMENT OF MEREDITH W. MORGAN, JR., O.D., PH. D., DEAN, SCHOOL OF OPTOMETRY, UNIVERSITY OF CALIFORNIA

Dr. MORGAN. Mr. Chairman and members of the subcommittee, my name is Meredith Morgan and I reside at 11 Silver Leaf Court, Lafayette, Calif. I obtained my degree in optometry in 1934 from the University of California, Berkeley. In 1936 I returned to the university as a graduate student in physiology and received an M.A. in 1939 and a Ph. D. in 1941. Since 1942 I have been a member of the faculty of the School of Optometry at Berkeley and for the past 5 years I have served as dean of the School of Optometry of the University of California.

It should be clearly understood that the opinions I express are my own and do not necessarily represent the opinion of the university, the American Optometric Association, or any other group or individual. My claim on your attention and my reason for being here is that I hope I know something about optometry after serving as an optometric educator for nearly 25 years.

The field of optometry, as presently constituted, has been determined by its historical heritage; by the laws regulating and defining it; by court decisions interpreting these laws; by custom, practice, and public opinion; and by what has been and what is being taught in its schools and colleges. Since these are all changing factors, not everyone looking at the evidence presented will come to the same conclusion as to the real field of optometry. The interpretation which I will present represents, I believe, the opinion of the vast majority, and the Council on Optometric Education, the officially recognized accrediting body in optometry.

Technically, optometry is the clinical application of the physiological optics, the science of vision. It deals with all phases of the optics, physiology, and psychology of vision. It is particularly, but not exclusively, concerned with the detection, measurement and correction of optical defects, physiological malfunctions, and psychological perceptions which detract from efficient visual performance. Optometry is dedicated primarily to the enhancement of vision. Therefore it is also concerned with the preservation of vision and thus accepts the responsibility for the intelligent referral of individuals with ocular or systemic diseases, and patients in need of corrective surgery. Today optometry considers itself to be one of the health care professions based on the biophysical sciences.

At the present time optometric education is in a transition stage from a 5- to a 6-year program of collegiate education. All but 2 of the 10 schools of optometry are operating on a 6-year program and, soon,

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all schools will be on such a program. The programs of the various schools vary in details but the general academic plans are similar. Since I am best acquainted with the program at my own school, which will hopefully prepare some of the future optometrists for the District of Columbia, I will use our program as a model. I would like to submit our page proof of our bulletin.

Mr. WHITENER. Without objection, it will be included in the record.

(The material referred to appears in the appendix on pp. 329–348.) Dr. MORGAN. The educational objectives of the school of optometry

are:

First. To provide the student with the necessary professional training and education so that he may successfully engage in the practice of optometry and that he be sufficiently competent to deserve the trust of his patients and the esteem of his professional colleagues.

Second. To provide him with the basis for an understanding of the place of optometry in, and its relation to, society.

Third. To prepare the student for intellectual, political, and cultural citizenship and leadership.

Fourth. To instill in the student a respect and desire for knowledge and truth which will continue through his lifetime. In order to achieve these objectives our curriculum has been divided into two categories: preprofessional education and professional education.

The preprofessional curriculum may be completed at any accredited collegiate institution and consists of a minimum of 90 quarter hours in the same kinds of courses usually taken by premed and predental students. The following subject areas must be included: general chemistry, organic chemistry, analytical geometry and calculus, English, bacteriology, general physics, psychology, and physiology or biology. Theoretically a college student should be able to complete such program in 2 years but the usual student takes 3 years.

The professional program requires 4 years of intensive work and is designed to meet all of the stated educational objectives. The first year consists largely of advanced work in the basic sciences and includes courses in general human anatomy, ocular anatomy, geometrical and physical optics as advanced physics courses, general and mammalian physiology, the optics of the eye, and mechanical optics. In addition, a course in biometric statistics is required.

The second and third years add the clinical and optometric sciences to the advanced basic sciences. For example: In the first year the student studies anatomy and physiology including a course on cellular mechanisms underlying bioelectric, secretory and contractile phenomena in living organisms. In the second year he studies the vegetative functions of the eye including such topics as the physiology of the cornea and lids; formation and function of the lacrimal fluid, metabolism and circulation in the eye; physiology and biochemistry of the lens; iris, and pupil; accommodation; and the characteristics of drugs producing miosis, mydriasis, cycloplegia, accommodative spasm, and anesthesia of ocular surfaces. Then after the study of normal function, it is natural to study abnormal function in an introduction to pathology. This includes a study of basic pathological processes in human development, senescence and disease and correlated survey

of disturbed function in disorders of visceral systems, including disturbances of electrolyte and fluid balance and of metabolism. Other similar examples in optics, refraction, and the analysis of clinical data could be given but I do not wish to make this presentation too long. The fourth and final year is almost entirely clinical. It is during this year that the student applies all he has learned by helping patients obtain the most efficient vision possible.

In addition to the basic sciences, the advanced sciences, and the clinical sciences, we are this year adding work designed to give the student an appreciation of social and community structures, the community agencies, health care problems, and modern society. We believe that the various health-care professions such as optometry must be better prepared to serve in a modern, complex, coordinated society in which most forms of health care will include the practitioner, the patient, and third parties such as agencies of government.

The present-day optometric education is designed to prepare an optometrist to differentiate the normal from the abnormal; to measure all of the functions of the eye; to use lenses; prisms; visual training, orthoptics, and pleoptics; and to intelligently refer patients with nonoptometric problems.

I wish to emphasize that the optometrist is qualified to recognize the presence of disease by virtue of his training, and that he considers himself obligated to do so. He is deeply concerned with the detection of any condition which may require referral of the patient. He gives a careful, detailed examination to detect the presence of eye disease, of the symptoms of any general disease as evidence in the eyes.

First he inspects the exterior of the eyes and lids and may measure the pressure within the eyeball. Where the examination or the history indicates the need, he investigates the field of vision. Then by means of the ophthalmoscope, an instrument which shines a bright light into the interior of the eye, he is enabled to examine the optic nerve head and determine whether it presents a normal appearance. Do the blood vessels appear normal, or are they constricted, tortuous, or otherwise abnormal? Have there been hemorrhages? Is there any evidence of pathology?

It is the legal and moral responsibility that the examining optometrist be qualified to recognize pathology of the eye. Optometrists, of course, do not treat diseases of the eye, but the optometrists graduating from our schools of optometry throughout the Nation have been well trained to recognize these diseases so they can refer the patients so afflicted to medical specialists. Many persons do not know they have an eye disease until the condition is discovered during a routine eye examination. Since 75 percent of the optical devices are prescribed by optometrists, much eye disease would go undetected if the optometrist were not trained to recognize it.

Not only do individual optometrists make referrals to other professions, but records of the Optometric Society for the District of Columbia show that from July 1, 1964, to January 1, 1966, some 214 persons were referred to ophthalmologists or hospitals for emergencies or other medical eye problems. These persons telephoned the society office and were referred directly by the society to other practitioners for attention to their problems.

Throughout the United States a study made several years ago indicates that something in excess of 2 percent of optometric patients are referred to other practitioners for additional services. I wish

now to present reference to this that was a reprint from the American Journal of Public Health.

Mr. WHITENER. Without objection, it will be made a part of the record.

(The material referred to follows:)

[Reprinted from American Journal of Public Health, vol. 51, No. 11, November 1961; copyright by the American Public Health Association, Inc., 1790 Broadway, New York, N.Y.]

Optometrists see large numbers of people, some of whom require referral to other health personnel. This study reports on the referrals made by optometrists to ophthalmologists, general physicians and others, and suggests means for making more effective use of optometrists referrals in health care.

OPTOMETRY'S ROLE IN HEALTH MAINTENANCE-A STUDY OF REFERRALS (By Galen F. Kintner, O.D.)

OPTOMETRIC REFERRALS

Most patients seeking the services of an optometrist have, or presume to have, symptoms of disorders connected with the eyes or their use. The optometrist, in taking a careful case history, observing the patient, making various tests and in evaluating his findings, must decide if solution of the patient's problem lies within his circumscribed field. This is a differentiating activity requiring skill and understanding since many symptoms of visual disorder are similar to those manifest by a patient with general disease, dental or eye health problems. If other than optometric services are required, the optometrist refers his patient to other health professions or agencies for further attention. Thus the optometrist in his routine practice regularly originates referrals to other professions as part of his responsibility to his patients. This report is concerned with various aspects of these referrals.

The visual system is a generous window to a number of the patient's health problems. While the optometrist's area of service includes refraction and coordination problems (with lenses, orthoptics, subnormal visual aids, and the like), his field of investigation includes much more in determining the state of health of the patient and his visual system. Case histories are revealing; the reflexes of the eyes and adnexa are rich sources of neurological information; the appearance of blood vessels, tissue structure, and pigmentation are prime indicators of both general disease and localized diseases of the eye. The normal physiology and anatomy of the eyes is so well understood that any deviation from it is readily recognized by the observant optometrist.

As the optometrist originates many referrals his activities often partake of the nature of the general practitioner, (1) rather than that of a specialist. Even though the public is becoming more sophisticated in its self-diagnosis (2) and hence its choice of health specialists, the fact is that a great number of people with vague symptoms come first to the optometrist. In serving these patients the optometrist frequently consults with the general practitioner to insure correct referral. Conditions requiring medical or surgical treatment of the eyes are generally referred directly to an ophthalmologist. Close cooperation between the optometrist and the consultant contributes to more efficient use of community health resources.

FORM OF REFERRALS

Referrals (3) of patients by optometrists take many forms depending upon the factors that the patient's problem and degree of urgency may present. On the one hand it may be such an acute situation that he actually accompanies the patient to the physician conferring with him on the signs and symptoms that actuated the referral. At the other end of the scale, the optometrist may decide that the patient need only be given the recommendation that he see his physician or dentist at his earliest convenience. Between these two extremes are all gradations, with all types of communication between the optometrist and the other members of the health care professions to whom he sends his patient.

In general, referrals can be divided into two groups: the desirable but elective, and the more formal or specific referral. The former presents the larger portion of the direction of optometrists to their patients to seek the service of others. These referrals are for conditions of less than an acute nature. Dental caries, periodic health examinations, obesity, general hygiene, and such subjects of health manage

ment are examples of the matters that an optometrist typically calls to the patient's attention. Rare indeed is the older patient that does not need some encouragement for better health management.

The present study is concerned with the more formal or specific type of referral, characterized by the fact that the optometrist not only undertakes to motivate the patient to seek the services of others but also initiates the communications with the essential third party to whom the patient is referred. In this type of referral the optometrist not only determines that the patient needs the services of others but that these services are required at an early date and with more certainty than the product of casual conversation or direction. These referrals are generally made to a specific practitioner or office always consulting the patient on his choice. Communication is between principals and typically generates more return discussion between them in the patient's interest.

To date, no information with_an_authoritative background was available on this subject of optometric referrals. In the development of their activities, several committees of the American Optometric Association felt that such a study would be desirable for several reasons: to provide information essential to proper development of the profession in a changing world; to provide information for the optimum development of interprofessional relations; and to develop information which could be used to improve the educational preparation of optometrists.

THE QUESTIONNAIRE

In order to provide a source of material for the current study on optometric referrals, a questionnaire was designed. It was mailed to a random sampling of 1,350 optometrists who were asked to return 1 copy each month for 6 consecutive months. Of the 306 who responded by returning the first month's questionnaire, 133 completed the entire series. A total of 1,360 monthly questionnaires were returned.

The questionnaire asked for information on the optometrist's age and length of practice, the population of his city, and the number of patient visits for that month. It asked about the number of eye physicians in the locality and the number of miles to the nearest eye physician. The age and sex of each patient referred that month and the number of years the patient had been served were included. Referrals were categorized to ophthalmologists, general practitioners of medicine, dentists, other optometrists, and other health personnel, and their record of formal acknowledgement of the patient's appearance was listed.

TABLE 1.-Geographical distribution of replies to questionnaire

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1 The term "patient visit" means visits to the optometrist for any reason. It is estimated that the refracted patient uses 24 visits in connection with one refraction.

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