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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 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

State

Number of
monthly
replies

Number of

patient
visits!

Number of
referrals

Percentage
of referrals
to patient

visits

41 151

6,826 26, 164

166 722

2. 43 2. 76

54 97

8, 155
21, 346

304
347

3. 73
1. 62

1. 99

95
55

17, 901
9,758

357
291

2. 98

38
76

6,137
10, 404

102 222

1. 66 2. 13

California:

Rural

Urban. Florida:

Rural

Urban. Illinois:

Rural.

Urban Massachusetts:

Rural

Urban. Michigan:

Rural

Urban Pennsylvania:

Rural

Urban Teras:

Rural

Urban Other States:

Rural.

Urban.
Total of all States:

Rural.
Urban..

64
88

9, 394 20, 156

179 320

1. 90 1. 59

93
93

11, 688
16,800

322
236

2.76
1. 40

25 94

3, 972 14, 292

57 194

1. 44
1. 35

103
193

16, 184
36, 135

403 924

2. 49 2. 56

513 847

80, 257
155, 055

1, 890
3, 256

2. 35
2. 10

Grand total.

1, 360

235, 312

5, 146

2. 19

"The term “patient visit" means visits to the optometrist for any reason. It is estimated that the refracted patient uses 244 visits in connection with one refraction.

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:

Patients Ophthalmology

439, 460 General practice.

271, 622 Dentistry

26, 990 Optometrists.

41, 736 Miscellaneous

40, 918

REFERRALS BY AGE OF OPTOMETRIST 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 2.-Referrals related to age of optometrist

Percentage of total patient visits referred to

Age of optometrist

Dentist

Others

Ophthal- General
mologist practitioner

Other
optometrist

All referred

Under 30 30 to 40 41 to 50 51 to 65. Over 65.

1. 36
1. 18
1. 06
2. 40
2. 84

1. 74
.86
.68
. 51

0.04

09
08
04

0.14
.01
. 20

08
.06

0.11

. 13 .12 .09

3. 40 2. 31 2. 14 3. 16 6. 42

. 25

. 03

. 03

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

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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.

5. A smaller group of referrals (3.3 percent) was made to dentists.

6. Optometry represents a considerable health resource. Its role in the maintenance of health could be developed more effectively.

REFERENCES

1. Howe, Henry F. Procedures in Consultation and Referrals.

20:218–227 (November), 1959.

Gen. Practice

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 Opto

metrists 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 bis 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. Morgun. 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

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