[From the American Journal of Public Health, vol. 51, No. 11, November 1961] OPTOMETRY'S ROLE IN HEALTH MAINTENANCE-A STUDY OF REFERRALS

(Galen F. Kintner, O.D.1)

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.

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 deviations 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 early 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.

1 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.

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 management 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 one 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.

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

It is estimated that the

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 acknowledgment of the patient's appearance was listed.

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 more 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 37,363,000 patient visits annually. Of these $18.360 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 desirable but 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-to-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, 1956 (5). It demonstrates that the optometrist sees 80.8 males to 100 females in his regular practice.

Under 5.

6 to 15. 16 to 30. Over 30.

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 conversion 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 most 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 enquiry 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 acknowledgement. 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 ontometrists 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 (Nov.), 1959.

Gen. Practice

New England J. Med. 261:791-797

(Oct. 15), 1959.

2. Means, J. H. Profession or Business.

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

4. Ravine, Stanley L., and Hofstetter, H. W. Age Relationships Between Optometrists and Their Patients. J. Am. Opt. A. 30:124–127 (Sept.), 1958. 5. Joint Council on Visual Care, Los Angeles, Calif.

Prescriptions. (Unpublished.)

Survey of Optometric 6. Fitts, Wm. T., Jr. Bull. Am. Coll. Surgeons 41:23-31 (Jan.-Feb.), 1956.

The American Red Cross exists for the purpose of preventing or lightening mankind's sufferings from war, natural disaster, and disease. To achieve its objectives requires the best of a great many attributes, one of the most important of which is vision.

Good vision is necessary in the countless tasks which are performed by volunteers such as Gray Ladies, Motor Service, and Nurses' Aides, all of which have become synonymous with Red Cross, as well as the highly skilled and technical services performed by the staff in the blood program, nursing services, disaster services, and numerous others.

Good vision is necessary, also, to help Red Cross see its ever-increasing responsibilities to a needy world; to help us see outward, not inward; to give us an enlarged vision which sees beyond barriers and difficulties. Indeed, this kind of vision is necessary to help our Nation behold its place in the family of nations that we, as a people, may help others live more abundantly.

We read in the Book of Proverbs: "Where there is no vision, the people perish." Surely this was never more true than it is today.

GEN. ALFRED M. GRUENTHER, PRESIDENT, THE AMERICAN RED CROSS After 38 years as an officer in the U.S. Army, Gen. Alfred M. Gruenther retired from active duty in 1957 to become president of the American Red Cross, taking over command of some 3,700 chapters of volunteer workers and services. A 4-star general, he last served as Supreme Allied Commander of Europe, a post he held since 1953. He previously served as Chief of Staff of the 3d Army under General Krueger in London. He later was named Chief of Staff of Gen. Mark Clark's 5th Army in North Africa and Italy.

General Gruenther was appointed Director of the Supreme Headquarters of the Allied Powers in Europe in 1951, and later he was named Supreme Allied Commander in Europe. He is the holder of many special citations and medals for valor and service, including a vast number of decorations by a numbers of foreign countries.

A GREAT WEALTH OF PROFESSIONAL EYE CARE

(By Arthur S. Flemming, Secretary of Health, Education, and Welfare) As with many of our greatest blessings, we are inclined to take vision for granted. We tend to forget that our sight must be protected, that much blindness is preventable, that many visual problems can be reduced if action is taken in time.