DISTRIBUTION OF REFERRALS

Responses to the questionnaire were well distributed geographically with a fair division between urban and rural areas as shown by table 1. There was no essential difference between the data from rural and urban areas. In four States the urban optometrists referred Hore patients and in four others the rural referrals were greater.

As near as can be determined, there are 18,500 optometrists in active practice in this country at the present time. If these data are projected on the basis of the total number of optometrists in active practice, it can be estimated that in the United States optometrists received 37,368,000 patient-visits annually. Of these, 818,360 patients are formally referred to others for some type of health service.

Of all formal referrals, 86.55 percent were made to some branch of medicine. As would be expected, the larger share of referrals was made to ophthalmologists; 53.7 percent being made to them and 32.8 percent to general practitioners. Referrals to the general practitioner would be greater if full data on the desirablebut-elective type of referral were available. According to the study, 3.3 percent of the formal referrals were made to dentists. Of the balance, 5.1 percent were made to other optometrists and 5 percent to other miscellaneous health care personnel.

If this same distribution holds for the entire optometric profession, it would be projected to the following annual total of referrals:

In order to determine if there were any significant difference in referrals among older and younger optometrists, or in the number of years in practice, the data in tables 2 and 3 were compiled. These tables show a higher rate of referrals by older optometrists, though the returns from those over age 65 were too few to be fully significant. The higher percentage of referrals by the older optometrist reflects the higher average age of his patients which keeps pace with his own increased years. (4) The incidence of health problems increases with the age of the patient. This pattern holds true when referrals are grouped in accordance with the number of years the optometrist has been in practice. The rate of referrals increases with the number of years, with a significant jump when the optometrist arrives at the 51-65 age level or has been in practice from 16 to 30 years. Referrals to his colleagues also increase from less than 1 percent on the under-50 group to 5.5 percent in the over-50 group.

REFERRALS BY SEX

There were 2,543 females and 2,076 males referred by optometrists in this study. This represents 81.6 males to 100 females, and follows closely the study made of optometric practices in California, in 1956.(5) It demonstrates that the optometrist sees 80.8 males to 100 females in his regular practice.

TABLE 3.-Referrals related to number of years in practice

The best interests of the public are served when there is full and free communication between the optometrist and the professional to whom the patient is referred. The findings of the optometrist contribute to the understanding and remedial care of patients whom he refers. The knowledge communicated (3) to the optometrist adds to the latter's learning and skills. It also helps him to plan the subsequent visual care of the patient who was referred.

Of the 2,772 referrals that were directed to ophthalmologists in this study, 71.3 percent were acknowledged, either in conversation or by written communication. Of the 1,683 referrals to physicians in general practice, 45.5 percent were acknowledged. The difference is significant and may be explained by several factors. The greater area of mutual interest increases the frequency of communications between optometrists and ophthalmologists. The fact that the number of ophthalmologists is smaller than that of general practitioners means more referrals to individual eye physicians by optometrists. This, in turn, builds a greater rapport between the two. Also, by the very nature of their practice, most specialists are more adept at maintaining communications with those who refer to them (6).

FUTURE STUDY

This study of formal referrals, from optometrists to other health professions, points to other avenues for inquiry and study. It would be desirable to make a broader study, covering a more representative group of optometrists, and giving more attention to desirable-but-elective type of referral. It should include a search for information on better screening methods and procedures for determination by optometrists of any deviation from normal function. A study could be made of communications between optometrists and other professional people. This could point out the relationship of frequency of referrals to their acknowledgment. It might be directed to searching for better technics for communication between professional people. It would be desirable to know what constitutes a "patient visit" at an optometrist's office, and what relationship exists as to frequency among various kinds of visits.

CONCLUSIONS

1. Optometrists see a large volume of patients, many of whom exhibit signs and register symptoms of disease and malfunction that fall outside the scope of their service. If the present sampling is projected to the 18,500 optometrists in active service, it represents 37,368,000 patient visits per year.

2. Projecting the 2.19 percent referrals to patient visits in this study shows that optometrists refer 818,360 people to others for health services.

3. The greater share (53.7 percent) of optometric referrals is made to ophthalmologists according to this study. This represents 439,460 patients.

4. The next larger group of referrals (32.8 percent) is sent to general medical practitioners. This represents about 271,622 of this type of referral.

Its role in the

5. A smaller group of referrals (3.3 percent) was made to dentists. 6. Optometry represents a considerable health resource. maintenance of health could be developed more effectively.

REFERENCES

1. Howe, Henry F. Procedures in Consultation and Referrals. Gen. Practice 20:218-227 (November), 1959.

2. Means, J. H.

Profession or Business.

New England J. Med. 261:791-797

(Oct. 15), 1959. 3. Bornmeier, W. C. Referral and Consultation. J.A.M.A. 154:440 (Jan. 30), 1954.

4. Ravine, Stanley I., and Hofstetter, H. W. Age Relationships Between Optometrists and Their Patients. J. Am. Opt. A. 30:124-127 (September), 1958. 5. Joint Council on Visual Care, Los Angeles, Calif. Survey of Optometric Prescriptions. (Unpublished.)

6. Fitts, Wm. T., Jr. Bull. Am. Coll. Surgeons 41;23-31 (Jan.-Feb.), 1956. (Dr. Kintner is an optometrist, and a member of the District Board of Health, Lynden, Wash.)

(This paper was presented before the Medical Care Section of the American Public Health Association at the 88th annual meeting in San Francisco, Calif., Nov. 2, 1960.)

Dr. MORGAN. I make this point solely to indicate that optometrists are cognizant of the fact that there are optometric eye problems and there are medical eye problems. It is and always has been our policy to deal objectively and fairly with the patient's problem and to handle it in the patient's best interest. It is imperative, therefore, that optometrists have a knowledge of anatomy and physiology, vision, refraction, visual anomalies and their correction. They must have the ability to conduct an adequate visual examination and analysis of visual needs. They must understand the fundamental laws of light, lenses, and prisms and their application to vision. They must study the relationship of psychology to the visual process and to the care of their patients. In addition, they must have the mechanical ability to fit and adjust the optical device to the eye for maximum comfort and best vision. To qualify for his license, the optometrist should be required to pass a rigid comprehensive clinical and written examination or in other manner specified in the law to prove his proficiency in these areas.

Contact lenses comprise a specialty requiring special training.

I have here, if you gentlemen would like it presented in evidence, the Encyclopedia of Contact Lens Practice which covers some of the information that must be taught in teaching optometrists to fit contact lenses.

Mr. HARSHA. Dr. Morgan, before you get on to contact lenses, can I ask you, Does the present District of Columbia law require the type of study and preparation that you indicate is given through schools taken by an optometrist?

Dr. MORGAN. I understand that it does not.

Mr. HARSHA. Does this bill have language in it that would provide such a prerequisite?

Dr. MORGAN. Yes, sir.

Mr. HORTON. Would you at this stage, Doctor, distinguish or give us the difference between the ophthalmologist and the optician? Dr. MORGAN. You mean their educational difference?

Mr. HORTON. Yes, and also what an ophthalmologist deals with, the treatment of the diseases of the eye, and also in preparing for surgery, to perform surgery.

Dr. MORGAN. I think, as I mentioned in the beginning of my statement, optometrists are primarily interested in the enhancement of visual performance by any physical means, usually by means of lenses or visual training.

Of course, where one is interested in enhancement of individual performance he must be certain, and most optometrists feel morally

obligated and are legally required to refer patients needing medical or surgical attention.

The ophthalmologists, on the other hand, give their primary attention to the treatment of diseases of the eye and surgery, although they also may legally prescribe lenses and frames, and is interested in the enhancement of visual performance as well.

The optician, on the other hand, is primarily a mechanic, and the amount of training varies tremendously among the 50 States. I am not familiar with the way it is here. They are not licensed in the District of Columbia, so that anyone may call himself an optician who wishes to. So that we have two licensed groups and an unlicensed group in general, although the opticians are licensed to some extent.

For instance, in my own State of California, opticians are licensed, but they may receive a license by the simple process of having three physicians sign their petition to the medical board of examiners, and they take no examination and need not present any evidence that they are certified in any way.

Mr. HORTON. How can department stores provide this advertising and provide this service under the existing law in the District of Columbia?

Dr. MORGAN. I would have to defer that to one of the people who is more familiar with the present District law than I am. read the new act, but I am not familiar with the old act.

I have Mr. HORTON. In your judgment, will the new act prohibit that? Dr. MORGAN. Yes, sir. I should say my experience would be temporarily.

Mr. HORTON. Would you explain that?

Dr. MORGAN. Well, we have in California, for instance, a restriction against price advertising. It is in the California Optics Act. This worked very well for a while, until some clever attorney found out that one way around this was to insert an ad "Call us up and find out what our low one price is." I mean no price was mentioned. And so it was necessary to amend the Optometry Act to make this also illegal, and this was done recently.

Mr. HORTON. In other words, that is not in the bill that is proposed here?

Dr. MORGAN. I am not an attorney, so I would not be in a position to know.

Mr. HORTON. From your practical experience in California, would the provisions of this act be sufficient to cover that type of advertising by department stores and the like.

Dr. MORGAN. Well, this act, I think, is more extensive than our present Optometry Act in California, in that it prohibits any advertising, not only price advertising. The California act merely prevents advertising.

Mr. HORTON. Thank you.

Dr. MORGAN. Preprofessional courses that are concerned with developing optometrists' competence to make professional judgments with respect to contact lenses, orthoptics, presence of ocular pathology, et cetera, are: biology, chemistry, physics, math, and psychology.

To understand how corneal tissue is affected by contact lenses, one must understand the metabolism of the cornea. Such understanding begins with biology and chemistry.

To understand how miniscule changes in curvature of the ocular surface of the contact lens affect the relationship between lens and cornea, one must begin with physics and mathematics.

To assist patients in proper adaptation to contact lenses, one must understand human behavior, the formal study of which begins with psychology in preoptometry.

It is my opinion that optometry has not only earned its place in contact lens placing, but that place is preeminent because the profession has met the needs for education and for research and has developed the most significant literature in the contact lens field.

I might add parenthetically that one of my own faculty members. Robert Mandel, has recently published a book I think that most authorities would consider the authoritative textbook on contact lens practice.

Some of the previous witnesses have emphasized the evils of optometric practices in commercial establishments. I think the members of the subcommittee will be interested in some of the classified ads which have appeared during the past few months in the Optometric Weekly trying to lure our graduates into these mercantile companies. I have here several of the ads, and they are marked. (The material referred to follows:)

EXHIBIT No. 2

[From the Optometric Weekly, 5 North Wabash Avenue, Chicago, Ill.]

Indiana optometrist wanted for Indianapolis area. $25,000 for man with qualifications. Address B-333 Optometric Weekly.

Optometrist Wanted: Ohio licensed or M.D. for qualified refractionist. Excellent opportunity, refracting only. $12,000 to $15,000 per year. Replies confidential. Address B-373 Optometric Weekly.

INDIANA O.D.-Exceptional opportunity to make $19,500 per year refracting only Indianapolis area. Replies confidential. Address Box B-89 Optometric Weekly.

Dr. MORGAN. From the salaries offered, one can well imagine the fantastic profits that must be made from selling eyeglasses and contact lenses. I would like to quote from some of these advertise

ments.

Wanted: Indiana licensed optometrist for association in growing optometric practice. Diversified functions. Beginning salary $15,000 plus profitsharing. Other fringe benefits. * * *

Wanted: Indiana optometrist.

Earn $20,000 in optometric practice. Refracting, general duties, and management. * * * Wanted: Arizona optometrist. Earn $35,000-plus first year. Refract only. * * *

Michigan optometrist wanted for Muskegon, Mich. Salary $15,000 per year plus vacation and other benefits. Refracting only. Contact lens experience important. ***

Indiana optometrist wanted for Indianapolis area; $25,000 for man with qualifications. * * *

Optometrist wanted: Ohio licensed or M.D. for qualified refractionist. Excellent opportunity, refracting only. Salary $12,000 to $15,000 per year. * * * Wanted: Alabama licensed optometrist. Start $15,000 with paid vacation. * * *

Indiana, O.D. Exceptional opportunity to make $19,500 per year refracting only. * * '*