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 production 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 ques

tionnaires were returned.

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 1 refraction.

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 prac tice 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 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. 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

4 Ravine, Stanley L., and Hofstetter, H. W., "Age Relationships Between Optometrists and their Patients," J. Am. Opt. A. 30: 124-127 (September), 1958.

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.

ACKNOWLEDGMENT OF REFERRALS

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 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.

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

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.

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 techniques 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.

Joint Council on Visual Care, Los Angeles, Calif., "Survey of Optometric Prescriptions." (Unpublished.)

Fitts, Wm. T., Jr., Bull. Am. Coll. Surgeons 41: 23-31 (January-February), 1956.

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.

Dr. EXFORD. Our association has not had an opportunity to take a position with reference to the Fogarty bill, H.R. 10014, but it is my personal opinion that this bill is the one which should be enacted.

I have only one amendment to suggest. That appears on page 2 of the bill, line 15. I would strongly recommend that the word "medical" be stricken from the bill. This would not eliminate medical science from the program, but would make optometric science a part of it.

We have found that any legislation which contains the word "medical" but does not expressly provide for optometric services is administered so as to exclude optometrists. Clearly in this instance in a bill dealing with the development of programs which will benefit older persons, the basic legislation should be broad enough to provide for optometric services and the report of this committee, I trust, will so

state.

Respectfully submitted, Donald C. Exford, O.D.

Mr. BAILEY. Doctor, we appreciate having your viewpoints on one of the problems in the field of aging, and we are all aware of the fact that it is absolutely necessary, if we are to properly care for the people in this age group, that they have special attention given to their eyesight.

We are glad to know that you are organized within your own profession to present these matters, and to care for them insofar as possible.

We are glad to know that you are interested in the broad field that affects the elderly people not only in the field of leisure, but in other things that will provide for their well-being in their declining years. Thank you very much.

Dr. EXFORD. Thank you, Mr. Chairman, for the opportunity of being heard here.

And I would like to leave a copy of the text, "Vision of the Aging Patient,” which covers considerably more than what I have been able to present.

Mr. BAILEY. It will be accepted for the benefit of the committee. Now, if we are going to meet our obligations to the gentleman from New Jersey, we will have to recess until 1:30 o'clock.

(Whereupon, at 12:15 p.m., the subcommittee was recessed, to reconvene at 1:30 p.m., the same day.)

AFTER RECESS

(The subcommittee reconvened at 1:30 p.m., Hon. Cleveland M. Bailey (chairman of the subcommittee) presiding.)

Mr. BAILEY. The subcommittee will be in order.

We will resume our hearings started at the morning session. Our first witness will be Richard S. Robbins, of the Richard S. Robbins, Ltd.

Mr. Robbins, I see you have a voluminous presentation, here.

STATEMENT OF RICHARD S. ROBBINS, RICHARD S. ROBBINS, LTD.,. NEW YORK CITY, N.Y.

Mr. ROBBINS. I am not going to read it, sir.

Mr. BAILEY. Will you summarize it? We will submit your whole statement for the record.

Mr. ROBBINS. My name is Richard S. Robbins, New York City. I am a marketing consultant in senior housing, senior citizen employment, and community management and recreational programs for senior citizens.

Mr. Chairman and members of the committee, in our work, the first thing I want to talk about is the necessity for research in community housing.

The instrument really is not into the necessity of financing the housing, because the Government has the necessary mortgage money and insurance financing for this, but it is the kind of housing and the necessary facilities within the housing to make it easy for senior citizens to live comfortably, and the necessary recreational facilities and employment facilities within their communities.

Also in connection with housing there seems to be some need to have some counseling effort on the part of the Government to give the necessary information to organizations who are interested in obtaining the necessary Government help and financing for their housing program.

The next thing I want to talk about is a program whereby we would use the senior citizens who are now living in various senior citizens' communities throughout the country, which are being established in various States, like California, Arizona, Florida, and there is even a very successful one in New York State.

These senior citizens are mostly of the executive classes, who have moved away from their home communities and are now living in new surroundings, but their talents as executives could be used by the industries which they represented, and were retired from, in helping and guiding the young people, who are solicited by the industries from which they were retired, and guiding them through the corporate structure and social life of their new environment. These are young people who, from the universities, have been taken by industry.

The way I recommend this be done is that the Government organize the original idea and start the ball rolling, so that industry can pick it up from there and use this personnel, because they are already paying them pensions and retirement salaries. They are losing a great many of their young people after they have got them trained in industry, and the feeling is that if these young people could get further guidance, they would probably stay with the industries of their original choice, and be more valuable both to the industry and to the Nation.

The next program that we have found in need is: When these villages are established, particularly those that are being financed for housing of the people of the working classes, or social security retirement, preparation of plans be made for facilities for industry to move in with small-type activity which they could work 1 or 2 days a week.

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