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NEED FOR PUBLIC EDUCATION

People will be better able to recognize their need for medical care when they have a better understanding of glaucoma and other eye disease. Educational literature, such as the National Medical Foundation for Eye Care leaflets on glaucoma, will help. The glaucoma identification card of the foundation serves both to educate the patient, his family, and his neighbors, and to increase the probability of uninterrupted medical care (fig. 1). The physician's office is a center for community health education as well as for health care services.

All patients must realize that glaucoma, and sometimes other diseases, produce symptoms which to the patient might suggest a need for eyeglasses. Certainly every individual should realize that when symptoms persist despite proper eyeglasses the services of an eye physician are always required.

All physicians have the opportunity to help find the early glaucoma patients. The family physician and the internist especially will keep in mind that watering, burning, and aching of the eyes, and blurring of print, frequently do not indicate merely a presbyopic need for glasses, but a need for medical treatment. Early diagnosis of glaucoma may be made possible when an optometrist, whether or not he suspects glaucoma, recommends medical examination and advice when vision is not normal with glasses, or when a patient has any sign of abnormality other than refractive error. If at that time he refrains from prescribing glasses, the patient will be likely to follow the recommendation. If he prescribes glasses, the patient may delay seeking medical care indefinitely.

SOCIOMEDICAL IMPORT OF EARLY DIAGNOSIS OF GLAUCOMA

In one of every eight blind persons in the United States the organic disease which caused the blindness is glaucoma.

Blindness is a sensory disability which deprives a person of the natural guide for all motor activity and establishes a barrier to communication. Loss of sight is equivalent to 100 percent impairment of the whole man. Glaucoma produces irreversible blindness. Although it may occur at any age, it is primarily a disease of middle and later life, with increasing incidence and prevalence with each decade. It has been estimated that 1 of every 50 people over the age of 40 bas glaucoma. The number of people in the age brackets most affected is increasing more rapidly than the population as a whole.

Diagnosed glaucoma can be treated. If treated early it can in most instances be controlled, with preservation of good vision throughout life. The importance of early diagnosis, then, is evident-the importance to the individual who has the disease, the importance to a society which ultimately pays for the disability of its members.

Dr. JAECKLE. Delayed medical care has occurred not only in glaucoma, but in many other diseases, including brain tumor, ocular malignancy, and vascular disease. It has meant blindness which need not have been.

Many who, despite the proper glasses, have impaired vision due to disease, are not blind, but present themselves for the determination of blindness, as applicants for aid to the blind. Clearly they need medical care, and clearly their rehabilitation will be speeded if they approach at the outset those qualified to give the care needed. It is not just a question of determining loss of vision but, more important, the purpose of this bill is to emphasize prevention and rehabilitation. With respect to blindness, this purpose can be achieved only by diagnosis and treatment of diseases affecting vision. Diagnosis and treatment of these conditions can be given only by a physician.

We are concerned not only that the responsibility for determination of blindness has been assigned to the optometrist, but that this clause leads to the inference by the optometrist and by others that he is

Copies of "Glaucoma-Thief in the Night" and "Living With Glaucoma," and a supply of identification cards may be obtained without charge from National Medical Foundation for Eye Care, 250 West 57th Street, New York 19, N.Y.

qualified to advise people about diseases of the eye and as to the need for medical care. In our opinion this clause is not in the public interest. We respectfully request that the committee amend the bill so that in the proposed addition of the new title XVI to the Social Security Act, it shall read:

SEC. 1602(a). A State plan for aid to the aged, blind or disabled, or for medical assistance for the aged, or for aid to the aged, blind or disabled and medical assistance for the aged must

(12) provide that, in determining whether an individual is blind, there shall be an examination by a physician qualified in the diseases of the eye. We further respectfully request that section 1002 (a) (10) of existing law be similarly amended.

We will appreciate the privilege of filing a supplemental statement to be incorporated in the printed record.

The CHAIRMAN. Doctor, how long would your supplemental statement be?

Dr. JAECKLE. It would be about as long as this statement.

The CHAIRMAN. Could you get it to us in a reasonable time?
Dr. JAECKLE. Yes, sir.

The CHAIRMAN. Without objection, it may be included in the record. (The supplemental statement referred to follows:)

SUPPLEMENT TO THE STATEMENT OF CHARLES E. JAECKLE, M.D., DEFIANCE, OHIO, ON BEHALF OF THE NATIONAL MEDICAL FOUNDATION FOR EYE CARE, NEW YORK, N.Y.

Mr. Chairman and members of the committee, we thank you for the courtesy extended to us at the hearing on H.R. 10032 on February 13, and for the privilege of filing a supplemental statement. We respectfully request that this statement be incorporated in the official record for consideration by the committee. In our initial statement and testimony before the House Ways and Means Committee we dealt solely with the matter of the necessity of determination of blindness by a physician. In the testimony of the representatives of the American Optometric Association, Mr. William MacCracken and Donald C. Exford, O.D., amendments to the bill were requested specifically to increase the participation of optometrists in the various public welfare programs. In the discussion which followed it was brought out that there is lack of agreement between optometrists and the members of the medical profession as to the functions which the optometrist is qualified to perform. This supplemental statement will supply additional factual material requested by members of your committee, will explain the basis for the disagreement between medicine and optometry, and will supply information to correct erroneous impressions that would otherwise be gained from the optometric testimony as to the availability of medical care for eye patients and the role actually performed by optometrists.

The American Medical Association has been concerned for many years with the failure of many Americans to get adequate medical care for their eye problems despite the fact that the medical care is available and the public is seeking that care. The association established a special committee of physicians, in other branches as well as ophthalmology, which was specifically directed "to study the relation of medicine to optometry." This committee devoted 2 years to its study and reviewed the actions of the American Medical Association in this area from 1934 up to the present time. Its report, "Medical Care for Eye Patients," was adopted by the AMA House of Delegates in New York City, June 29, 1961. A copy of this report is attached to this statement as appendix A. It states, in part:

"*** The attempt to equate the optometrist with the eye physician presents a serious public health problem.

"The potential dangers existing in the present situation are known best to those physicians who are primarily concerned with eye care. The full significance has not been generally recognized by the medical profession as a whole or by the public."

It should be emphasized that the issue is between optometry and medicine and not between optometrists and ophthalmologists. But since, as the American Medical Association has pointed out, "The potential dangers * ** are known best to those physicians who are primarily concerned with eye care,” those physicians-i.e. ophthalmologists have a special responsibility to make their knowledge of the present situation available to the public and to the Congress. The National Medical Foundation for Eye Care is the recognized spokesman for the American ophthalmology in public affairs. Its founders and its leadership include the most distinguished names in the eye field, both in medical education and in medical practice.

In the testimony of Donald C. Exford, O.D., it was stated "optometrists provide over two-thirds of the vision care of the entire population and even a larger percentage of the care of those citizens over 65 years of age;” and of optometrie training, “* **the minimum requirement for graduation is 5 years at the college level." Concerning the medical profession, it was stated, “The medical profession has a specialty known as ophthalmology but there are only about 4.000 board certified ophthalmologists in the entire United States. Most of these practitioners are located in the larger cities and specialize in surgery and the medical care of the eyes. There are approximately 18,000 to 20,000 optometrists licensed ***. Many of them are to be found in the small communities, which means that they are more accessible to our aging population." We submit that these statements do not represent the true facts of the present situation.

The term "vision care" is not defined. Presumably it is intended to mean something different than eye care and different from medical care for eye påtients. Medical care for eye patients includes examination, investigation, diagnosis, prognosis, managment, and treatment. Diagnosis is not a single observation and is not simply inspecting, observing an abnormality and attaching a name to it. Diagnosis is a continuing process which demands of the practitioner such a knowledge of all the factors which may contribute to the patient's complaints as to enable the doctor to inquire into everything about the patient's medical history and life as may pertain to the complaint. As stated in the AMA report, "Medical Care for Eye Patients," "Ocular diagnosis can only be made by the meticulous integration of the patient's medical history with the functional, optical, and physical findings, pharmacological responses, corneal tonometric readings, and laboratory findings, all interpreted in relation to the individual and his environment." We believe it is self-evident that this function cannot be performed equally well by two individuals one of whom has had a medical training, and one of whom has had less than this; indeed some of these procedures are authorized by law only to the physician. Treatment includes. în addition to lenses (and in a very small percentage of patients training exercises for functional disorders), the use of medications, surgery, physical agents, occupational and all other forms of therapy as may be needed, and that degree of psychiatric treatment which must be practiced in every branch of medicine by all physicians. Any care less than this does not justify the designation “eye care."

It would seem that "vision care" means essentially the use of lenses to correct the focus of the eye. This prescribing of glasses is performed both by optometrists and by physicians in ophthalmology. There will be some difference in their activities even in this area, because of the eye physician's competence to use all of the methods which provide information useful in the prescribing of glasses (medications are required in a certain percentage of cases), and because physicians, before prescribing glasses, determine not only the lens which will properly focus light in the eye, but also the significance this refractive condition has for the patient, and its relation to other factors which bear on the patient's complaints.

Information from manufacturers concerning the channels of distribution of glasses to the American public provides data as to the relative number of people for whom glasses are prescribed by physicians and by optometrists. Twenty percent of all glasses procured by the American public are provided directly by the eye physicians who prescribe them. Most of these eye physicians (ophthalmologists) are located in relatively small communities. Opticians, chiefly in urban areas, supply another 25 percent of glasses, and these glasses are also prescribed by physicians. This combined 45 percent of all glasses distributed through medical and ancillary medical channels does not represent the total proportion of glasses prescribed by physicians. Of all glasses, 55 percent are distributed through optometric channels, and of these an additional unknown quantity are prescribed by physicians, but supplied by optometrists functioning as

The

opticians; this has been estimated at from 5 to 10 percent of all glasses. remaining major fraction of this 55 percent are prescribed by optometrists. Therefore optometrists prescribe approximately half the glasses in the country. The contribution of optometry then has been to prescribe and to supply approximately half the eyeglasses in the United States. This is quite different from "over two-thirds of the vision care," no matter what that term may mean. The fitting and adjusting of eyeglasses, incident to their prescription is performed by an estimated 18,000 optometrists, 10,000 opticians, and 5,000 technical assistants in the physicians' offices.

The prescribing of glasses which represents only a fraction of the work of the eye physician, is done as an integral part of his diagnosis and treatment of patients. The physician specializing in the eye (ophthalmologist or oculist, both of which terms have the same meaning) provides the surgical care of eye patients and most of the treatment of eye patients involving the use of medications and other modalities. Ophthalmologists also provide eye care in the form of consultations in response to requests from physicians in other branches of medicine. Thus an ophthalmologist may advise a surgeon in the care of a patient with head injury, a neurosurgeon considering the diagnosis of brain tumor, a cardiologist desiring evaluation of the vascular condition as it may be seen in the retina of the eye, an internist treating a patient for diabetes or any one of many other diseases, an obstetrician confronted with a pregnant woman with toxemia, seeking information from the ophthalmologist as to the patient's general condition as manifested in the eye in order that it may be determined whether the patient may safely continue in pregnancy to normal delivery or will require cesarean delivery. But the prescribing of glasses, the performance of eye surgery, the medical management of eye patients, and ophthalmological consultation, which constitute the work of the ophthalmologist, do not comprise all of the medical service to eye patients. Eye care is also provided by many thousands of physicians who are not ophthalmologists, principally in general family practice, in pediatrics, and in general surgery. These physicians who are not engaged in ophthalmology prescribe one-third of all the eye medications in the United States and competently treat innumerable injuries involving the exterior of the eye. Considered in relation to all the eye care received by the American public, the optical care furnished by optometrists is seen to be a very small fraction.

The number and distribution of ophthalmologists in the United States is pertinent to the provision of eye care. There are 10,000 physicians, doctors of medicine, in the United States who specialize in the eye. Certification by the American Board of Ophthalmology indicates the highest formal recognition of training for a physician desiring to practice in the field of the eye. Twenty years ago it required 3 years of training after internship; for some years the requirement has been 4 years. Four thousand five hundred practicing eye physicians hold the certification of the American Board; others have met, for example, the qualifying standards of the American College of Surgeons. Such certification of specialists in the various branches of medicine was pioneered by ophthalmology in 1916; it was adopted in general surgery 21 years later. It has become the standard in medicine.

It is virtually impossible to gain acceptance as an eye specialist in this country without 2 or 3 years of training after internship. An eye physician must hold the confidence of his fellow physicans, who assume certain legal responsibilites when they refer their patients to a physician-specialist in any branch of medicine. It must be remembered that all are fully qualified physicians and with rare exceptions today provide in their own communities the bulk of all the eye care needed by the people, referring to other ophthalmologists in the same community or in adjacent communities those patients who require a surgical service which some eye physicians do not undertake. These 10,000 eye physicians are widely distributed in communities of every size. A recent survey conducted by a medical journal showed that eye physicans are practicing in communities as small as 5,000 population. It may be said that eye physicians are well distributed to meet the medical need of the people. Although many are in small communities, it is correct that the majority are located in areas where the majority of the people of America live-the urban areas. Not every community large enough to require a physician requires also an eye physician. People have occasion to visit the eye physician much less frequently than the generalist. It is also important to note that eye patients are transportable, and are transportable by the family car, in contrast to patients who because of fracture, serious abdominal disease,