Mr. BABB. I would also like to put into the record as the last example, a "confidential memorandum" from one of these commercial operators to his doctors. I won't read it all, but this is instructions to his doctor on how to examine the eyes of children, and all through it you will find where he encourages his doctors to use the ophthalmometer, or the ophthalmoscope because he says this is a very impressive instrument, and the whole tone of the memorandum is how to impress the parents, more than how to care for the vision of the children.

He also submits in here, and I will hand it up, he instructs the optometrist to fit children with prescriptions which are such that they will wear glasses all the time so that their patients will not think they do not need glasses.

(The "confidential memorandum" referred to follows:)

Confidential memorandum to: All optometrists.

AUGUST 2, 1960.

Subject: Review of procedure to be used on examining school and preschool children.

GENTLEMEN: Dr. N. Jay Rogers has requested that all optometrists be sent a copy of the memo of last summer with reference to examination of school and preschool children. Please review it carefully as you will be examining many children prior to the beginning of the school year.

Sincerely,

FELLOW DOCTORS OF recommendations I offer.

possible.

W. ED ALLEN.

(Copy of memo of July 1959)

OPTOMETRY: The following are the suggestions and
Please study them carefully and use them wherever

1. Have parent in examination room.

Retain some

2. Put child at ease by speaking in a friendly, soothing manner. illumination in room during examination, as child will be more at ease.

3. Get thorough case history. Attempt to get as much of case history from parent as possible.

4. Make thorough external examination including photopupillary and accomodative pupillary reflex; also "cover test" for any apparent muscular deviation. Do not invert eyelids. Just draw them back slightly and examine.

5. Make ophthalmoscopic examination. Explain to parent the condition and findings of the interior of the eye when you complete the internal examination. This is important.

6. Make examination with ophthalmometer if refracting room is equipped with one. This is an impressive instrument.

7. Do not check unaided vision without phoropter in front of patient unless a vision deficiency is definitely indicated from case history or old Rx if worn (or old Rx record). You may have a child who definitely needs glasses but whose vision may not be impaired. The parent may get an erroneous impression if the child's vision is 20/20 unaided. You can always get unaided vision through the phoropter through plano. If you wish to demonstrate child's deficient vision to parent, it can always be done at end of examination.

8. Make static retinoscopic examination. Attempt to get as accurate findings as possible, especially the cylindrical power and axis. Be sure and record findings. If necessary, ask parent to assist in maintaining fixation.

9. Make dynamic retinoscopic examination. If a definite error of refraction is indicated by your retinoscopic findings, explain to parent what appears to be the eye condition of child. This will convince parent you are able to diagnose and ascertain the condition even before you have made any subjective vision tests. This is important. If parent is properly impressed with your knowledge and skill at this point, you will have achieved about 90 percent success already.

10. Make subjective examination. Limit subjective tests to the very minimum required to ascertain the desired Rx. Ask your question of the child in as clear and understandable a manner as possible, so that parent will never think the child is giving you the wrong answer. Use red-green test and flip-flop cross cylinders wherever possible; but keep subjective to a minimum, for the sake of proper impression of parent. Clock dial is not a good subjective test with children. 11. Make phoria tests wherever possible; far and near.

12. Test for amplitude of accommodation.

13. If there is a vision deficiency that can be demonstrated to parent, do so. If not, but if glasses are needed, simply forgo vision demonstration, and explain fully to parent why child needs glasses and how the lenses will correct the child's symptoms and trouble. Explain, also, how the child is to wear the glasses; whether to be worn constantly or just at certain times. It is generally best to prescribe a correction which the patient can wear as much as possible so that the parent will not feel that the child could probably get along without them since the child wears them so little of the time. Whenever possible it is generally best that the child be made to wear the new Rx constantly for the first 3 or 4 weeks in order to become accustomed to wearing glasses as well as adjusting to the new Rx. Of course, if glasses are for constant wear, the above would not be applicable.

14. A progress examination in 3 or 4 weeks should be recommended. Child should be brought back during the middle of the week to see if child is progressing properly with the new lenses. Parent should be told there is no charge for this progress examination, but that you just want to be sure child is getting along well and is adjusted to new lenses.

15. In any case where glasses are not indicated, it is as important to be sure of this as it is to be sure that glasses are indicated. Remember this: if you tell the parent glasses are not needed, but if in fact they are needed, should that child continue in school without glasses, you have done a grave injustice to the child and parents. If it is a borderline case, and you are uncertain, advise the parent that glasses are not indicated at this time, but your findings indicate the possibility of need of them in the future. Have the parent bring the child back in no more than 6 months for another examination. Be sure and tell the parent the importance of another examination.

CONCLUSION

It is just as important that the parents have trust and confidence in you, as it is that your Rx be accurate.

This can be accomplished by the manner in which you make your examination and what you tell the parent.

When parents will refer their families and friends to you as a result of your satisfactorily examining and fitting their child, you can then claim and justly so, genuine optometric success for yourself and optometry. I hope I have been helpful, even if only in small measure.

Sincerely,

NATE ROGERS, O.D..

Mr. BABB. Mr. Chairman, I apologize for taking so much of the committee's time. I know you have been patient in hearing me, and that you have a lot of witnesses, but we feel that these are good examples, once you open the door, of the things that this act is trying to stop. This is the type of consideration that the public in the District will get from those who try to commercialize this profession. I thank you and with that I will be glad to answer any questions. by any member of the committee.

Mr. DowDY. Thank you, Mr. Babb. We appreciate your coming and presenting this testimony in this case. I am sure it will be quite helpful to the committee in its deliberations when it gets to the bill. Mr. BABB. Thank you, Mr. Chairman.

Mr. DOWDY. Do you have any questions, Mr. Sisk?

Mr. SISK. Mr. Chairman, I think we ought to commend Mr. Babb for a very excellent and very thorough statement here which I think brings out very ably some of the very things that we have had some experience with here in the District, particularly with this type of advertising which the witness mentioned, and I certainly want to commend him on making a very clear statement as to the problems involved and the basic objectives sought to be achieved here. Mr. DowDY. Thank you, Mr. Babb.

Mr. BABB. Thank you, Mr. Chairman.

Mr. Dowdy. Dr. Dryden, Dr. Albert, and Mr. Magee, you were here yesterday, and we are sorry to interrupt, but these people were from out of the District and from afar, and we did want to relieve them and allow them to testify so that they may leave.

Mr. MAGEE. We will be willing to step down any time, Mr. Chairman, if any other witness is in the same position-any time.

Mr. DOWDY. I am informed that Dr. Dryden had completed his statement, and Dr. Albert had not, and I didn't know whether he had one or not.

Mr. MAGEE. Dr. Albert has a statement, and I have a statement also, Mr. Chairman, which I would like to give, just a brief one.

STATEMENT OF DAN G. ALBERT, M.D., PRESIDENT, SECTION ON OPHTHALMOLOGY OF THE MEDICAL SOCIETY OF THE DISTRICT OF COLUMBIA

Dr. ALBERT. Mr. Chairman, members of the committee, ladies and gentlemen, I am Dan G. Albert. I have practiced ophthalmology in the Greater Washington area for the past 12 years. In 1938 I was graduated from the Ohio State University School of Optometry, receiving a B.S. degree. I practiced optometry in the State of New York for the next 4 years. During this time it became increasingly obvious to me that I was not satisfied with the limited training I had had to render eye care that I felt the public should receive. Following a 4-year tour of duty in the armed services, I entered Syracuse University College of Medicine and received an M.D. degree from that university in 1950. Following a year of internship, I took a 3-year residency program at the old Episcopal Eye, Ear, Nose, and Throat Hospital here in Washington, D.C., and started the private practice of pediatric ophthalmology with Frank D. Costenbader, here in Washington. In 1955 and 1956 I took the special examination in ophthalmology and am now board certified. It appears to me that

I have, by extending my education, done through education what the bill under consideration is apparently trying to accomplish by legislation.

I am president of the Section on Ophthalmology of the District Medical Society. This is an organization of over 120 members. To be a member of this organization one must be a member of the medical society and must be certified by the American Board of Ophthalmology or be board eligible. Board eligible means that one have the educational requirements sufficient to take these examinations which at the present time requires graduation from medical school, a year of internship, 3 years of residency in ophthalmology, and a year of private practice. One is then entitled to take the written examination. If successful in the written examination he is invited to take the oral examination which is a very extensive 3-day oral examination covering all phases of ophthalmology.

The Section on Ophthalmology of the District Medical Society is opposed to H.R. 12937 because we feel that it is not in the public interest. We realize that the present Optometry Act leaves some things to be desired. However, we have been informed by legal counsel that these changes could be made by the existing authority vested in the District Commissioners. It is our understanding that the Commissioners, acting through the board of optometry set up under existing law, can change the educational requirements of optometrists and as the optometrists indicate they desire to raise these standards. We are of course in favor of this and of all efforts of optometrists to raise their standards in this particular field. But I wish to point out that the Commissioners, at the request of optometrists, have twice enacted regulations. The first of these was to increase the educational requirements of optometrists and this is covered by an order of the Board of Commissioners, dated September 26, 1930, which appears in the District of Columbia Code. The Commissioners also included the fitting of contact lenses as being covered by the provisions of the Optometry Act of 1951. However, if the Congress feels that a new optometric law should be written for the District of Columbia the Medical Society of the District of Columbia recommends that the following changes be made in H.R. 12937.

I will now discuss the changes which the medical society recommends and with which the section on ophthalmology fully agrees. Before going over the bill with our suggestions I want to state that I have listened to the statement given here yesterday by Dr. Dryden and I fully support his statement.

Section 2, referring to the present bill, on pages 1 and 2 of the bill should be amended to definite optometry correctly. Optometry should be defined "a skilled mechanical art involving human vision,' which it is. It is not a learned profession. The last sentence in section 1 should be amended by deleting therefrom the words "admitted to the practice of optometry in the District of Columbia under the provisions of this Act." This should be done because as the act is now drawn up the practices covered by this bill can only be done by optometrists licensed under the provisions of this act. If not changed, this will eliminate the nurses and technicians working under a physician's supervision and other areas of concern which Dr. Dryden covered in his statement yesterday.

We further recommend that section 3 be amended and that optometry be defined as it is now defined in the District of Columbia Code. As presently defined by law, "the practice of optometry is defined to be the application of optical principles through technical methods and devices in the examinations of the human eye for the purpose of determining visual defects and the adaption of lenses or prisms for the aid and relief thereof." We have left in the definition the provisions that deal with the prescribing of contact lenses or eyeglasses which are as presently worded.

As Dr. Dryden pointed out yesterday for this committee, the bill would authorize optometrists to engage in "the identification of any departure from the normal condition or function of the human eye including its associated structures." Such broad terminology would carry the optometrists into the field of practicing medicine. "Associated structures" in medical terms includes the brain, the lacrimal apparatus, the eyelids, the paranasal sinuses, the endocrine glands, and many other things which the optometrist should not be involved with at all.

We further recommend that the present provisions of the District of Columbia Code section 2-511 be inserted in lieu of section 4section 7

Mr. DOWDY. You said in your statement, section 4.

Dr. ALBERT. That is correct, section 4 of the bill.

Rather than have the Congress of the United States attempt to fix the qualifications of optometrists, we feel this matter should be left to the discretion of the District of Columbia Commissioners. Educational qualifications can be changed from time to time as the Commissioners determine to be in the public interest.

We further suggest that section 5(a) of the bill be deleted and there be inserted in its place section 2-518 of the District of Columbia Code which is a very simple, clear statement to the application of the reciprocity principle of optometry.

It has been brought out in the hearings that an optometrist under the existing law cannot use drops, dyes, drugs, or any other chemical which comes in contact with the human eye; therefore, we suggest that Congress make this clear by adding on page 7 of the bill a new subsection titled (1A) reading as follows: "The use of drops, dyes, drugs, or any other chemical which comes in contact with the eye."

We suggest that the word "profession" be deleted from section 7(a), line 15, on page 9 of the bill and the word "optometric" be substituted. We also suggest that a new section (2) be inserted on page 9 of the bill and that this be clarified in order to provide that the adapting and fitting of lenses, prisms, and contact lenses be the only phase of the bill which requires a written prescription from a physician or an optometrist licensed to practice medicine or optometry. Accordingly, we suggest that section 8(4) on page 11 of the bill be rewritten to read as follows:

"Adapt and fit lenses, prisms, or contact lenses without a written prescription from a physician or optometrist licensed to practice medicine or optometry. We feel that the requirement that the physician or optometrist be licensed to practice in the District of Columbia only, should be eliminated from the bill in order to afford the millions of visitors who come to the District of Columbia the right to have lenses, prisms, or contact lenses made when they have