Mr. ALGER. How much more medical education does a physician have beyond the optometrist, would you say?

Dr. EXFORD. I now have a daughter in Indiana University, a thirdyear student at the school of optometry. I am following her course very closely. She is taught by the same people who teach the physician. She takes identical courses in physiology, pathology, anatomy, as the rest of them. They have a tremendous background in the pathology, the physiological and anatomical background of the human body before they are allowed to practice.

Mr. ALGER. Maybe you didn't get my question. How much more training does a physician have to have in bodily disease and so forth than an optometrist?

Dr. EXFORD. You have to have a B.S. or B.A. degree from a recognized college plus 4 years of M.D. An optometrist has to have a minimum of 5 years and usually 1 more year to get his O.D. degree.

Mr. ALGER. Do you see any danger in an optometrist not being able to properly diagnose or treat diseases of the eye?

Dr. EXFORD. Definitely not. In my little practice I have in my file 20,000 individuals. I would hate to think with respect to any one of those 20,000 people that I was guilty of not being able to detect an eye disease.

Mr. ALGER. Were you here when Dr. Jaeckle testified?

Dr. EXFORD. Yes.

Mr. ALGER. You heard the examples he gave. He gave one example as I recall of a patient who for 2 years had been under the care of an optometrist. This is just one case, of course. And the optometrist told this patient to go to the doctor or told the doctor it would be necessary for the cataract operation to take place and the physician then found that the cataracts did not need to be removed, now that the vision had been lost, but rather it was the result of high blood pressure, that had the proper diagnosis been made at the outset the trouble might have been cured. Now this leads me to the question to ask you your view, is there the danger that any optometrist, no matter how highly principled or highly motivated, could unintentionally by their lack of knowledge that the physician or opthalmologist has, not properly diagnosed and, therefore, not give the proper aid to prevent the blindness which in this bill we are attempting to do, to be preventive and rehabilitative. Is there that danger that the optometrist might?

Dr. EXFORD. There is always room for error. May I use the old adage, physicians bury their mistakes but optometrists can't.

Mr. ALGER. You may but it does not tell me a thing. Either I am too ignorant or you said it too fast.

Dr. EXFORD. In my own mind, in my own thinking, I am thoroughly versed in the field of optometry. I think every optometrist coming out of school in the last decade is thoroughly trained in the ocular pathology. I would abhor the thought I was guilty of overlooking one single case of pathology and being responsible for that patient's being blind or sending him to the grave.

Mr. ALGER. We have had some cases. You say the physicians bury their patients while the optometrist might let them go blind-if you want to be facetious. Dr. Jaeckle gave us three examples. I suggested that in point of time if he had others he might give them to us. I would suggest to you that you may want to see those examples in the hearings and make rebuttal to them for the purpose of our record.

Dr. EXFORD. May I make a statement. We all make mistakes. The doctor may bring up a few isolated cases where optometrists have not recognized pathology but I have thousands of cases where opthalmologists may have completely given wrong prescriptions for glasses. They have misfits in their professions the same as we do in our profession.

Mr. ALGER. The optometrist and ophthalmologists are coequal in the knowledge of the eyes?

Dr. EXFORD. As far as the knowledge of the eyes, I think they are;

yes.

Mr. ALGER. The diseases that cause the eye difficulty?

Dr. EXFORD. I think the optometrist is just as qualified to detect the accurate pathology as the ophthalmologist.

Mr. ALGER. That would be the point of difference between the two. If I asked that question of the ophthalmologist he would say “No.” Dr. EXFORD. It would be an endless argument.

Mr. ALGER. It is always important to understand where we disagree. Dr. EXFORD. Definitely.

Mr. ALGER. I am completely bewildered by the fight between ophthalmologists and optometrists as to exactly what the case is. You did make an interesting point that there are only 4,000 ophthalmologists and, therefore, there is a limitation, but that there are 18,000 optometrists.

Dr. EXFORD. 18,000 to 20,000 at the present time licensed to practice. Mr. ALGER. You are saying there are not enough ophthalmologists to do the job?

Dr. EXFORD. There are not enough optometrists. We are going through a shortage of both. In my local community the optometrists and ophthalmologists are one group allied. We have the best of relations. We all agree there is a job to be done. There are many optometrists and ophthalmologists that are needed in this field.

Mr. ALGER. Aren't you worried that if I can't get you two together I may not go to either of you and I may not be able to see anything? Mr. THOMPSON (presiding). Mr. MacCracken, do you wish to testify?

Mr. MACCRACKEN. Mr. Thompson, I merely thought it might be of interest to the committee and save them looking up in their records concerning the 1950 amendments to the social security law. It was Chairman Doughton of the Ways and Means Committee in H.R. 6000 that put in, I think it is clause 10, of section 1002 (a) of title X of the law which made the services of optometrists available to the beneficiaries who desired to utilize them. That is all. It did not compel anybody to go to an optometrist. That was done after extensive hearings and considerable of a battle. On the Senate side they amended the language of the House bill and it went to conference but it came out of conference with the House language intact. Now the statement that was submitted this afternoon asked this committee to repeal what was done by the former committee back in 1950 and which has been on the statute books for 12 years. As far as I know it had not been challenged. It may not have worked perfectly but this is the first time in the 12-year history that it has been questioned in Congress. I followed it fairly closely because I have been representing the American Optometric Association on the Washington scene

for about 20 years. I know something of the battles that they have had in order to make their services available. They don't try to force themselves on anybody.

Congressman Alger, if he wants to go to an ophthalmologist, he is perfectly free to do so. So is everybody else. But we do believe that the American people ought to have a free choice of practitioners, not only among the individuals but among the disciplines. Optometry is an independent discipline in the eye field.

Mr. ÅLGER. I notice on page 53 of this bill the optometrist is mentioned.

Mr. MACCRACKEN. That is right.

Mr. ALGER. Why is it necessary to further amend the bill by inserting the optometrist in several other instances, would you say?

Mr. MACCRACKEN. I think Dr. Exford mentioned that, Congressman Alger, in his statement, that there are other places in the bill where, because it deals with different titles, we thought it ought to be in because if Congress does not put it in expressly, then they will have to come back and get an amendment.

Mr. ALGER. It is expressly in here, though.

Mr. MACCRACKEN. That is only in title XVI.

Mr. ALGER. You want it repeated in each one of the sections?

Mr. MACCRACKEN. In certain places. It is not in each one but there are a half dozen places where we felt that the wording should be clarified. No place does it make it complusory. It is merely clarification.

Mr. ALGER. You want it in several times and the ophthalmologist wants it deleted.

Mr. MACCRACKEN. They want it deleted from the bill and deleted from title X of the law as it has been in the past 12 years.

Mr. ALGER. No hope of getting you two together?

Mr. MACCRACKEN. I think the effort has been on our part and none on theirs.

Dr. EXFORD. We would like very much to have 100 percent cooperation for the benefit of the American people.

Mr. ALGER. Provided they agree with you.

Dr. EXFORD. The people of America are the ones that are suffering because of this.

Mr. MACCRACKEN. I don't know whether Congressman Alger knows this or not but the American Medical Association has a resolution which makes it unethical for an ophthalmologist to cooperate with an optometrist on a professional basis. Of course, that is something like our old prohibition law. It is violated more than it is observed but there are those who do observe it in the medical profession. They have in many instances kept medical professors off the faculties of optometry schools although they have not been completely successful. They have tried to do it.

Mr. ALGER. I think the physicians are very sincere in thinking that the optometrists do not have the level of training. I think there is a very definite clash between the two of you. I was kidding when I thought you would get together. From what I have seen this afternoon this is not so.

Mr. MACCRACKEN. What I was trying to point out is this. I think if they were sincere they would cooperate to the extent of at least let

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ting their men teach our students, the optometry students. Yet they won't do it without violating their canons of ethics. There are some of them that defy it. Of course, as you know probably, a good many of the faculty members in our optometry schools are imported from foreign countries. They are not as amenable to the dictates of the American Medical Association.

Mr. ALGER. I suspect that the medical association probably thinks you should have a number of other courses, too, rather than just teachers of the courses you have. I don't know unless we get them up here and have a little debate between the two of you.

Dr. EXFORD. The AMA recognizes the need for optometry. It is a human impossibility to care for all the human beings. They would like to exterminate optometry, to reduce it to a field of technicians under medicine. We don't want to do that.

Mr. ALGER. You can't cooperate and exterminate at the same time. (Additional report referred to above is as follows:)

SUPPLEMENTARY STATEMENT SUBMITTED BY HAROLD W. OYSTER, O.D., DIRECTOR, DEPARTMENT OF NATIONAL AFFAIRS OF THE AMERICAN OPTOMETRIC ASSOCIATION (Pertaining to H.R. 10032, and the statements of Charles E. Jaeckle, M.D. of the National Medical Foundation for Eye Care and letter of F. J. L. Blasingame, M.D., executive vice president of the American Medical Association) One of the causes of confusion in dealing with the subject of blindness is that there are varying degrees of this affliction. Any person whose vision cannot be corrected to better than 20/200 is usually regarded as legally blind and yet these individuals, with the aid of telescopic lenses and other prosthetic devices, coupled with training, can actually see and even read.

The report submitted to the White House Conference on the Aging states: "Only 25 percent of the 'total blind' people have no perception to light, while the remaining 75 percent have varying degrees of useful vision, from the bare minimum capable only of giving guidance, to sufficient amounts to allow reading. Many of the senior individuals heretofore classified as 'blind' have found that what vision they do have can often be mobilized and made more efficient through the use of various optical aids developed by research in optometry." Blindness is not a disease, but it may be caused by disease. There is no question but that where disease is a contributing factor to loss of vision which may ultimately result in blindness, the interest of the patient and of the taxpayer, who bears much of the financial burden, requires that the optometrist and the ophthalmologist should work together as a team. Optometry recognizes this fact and is ready, willing, and able to cooperate. However, there is a recalcitrant group of ophthamologists, represented by the American Medical Association and the National Medical Foundation for Eye Care, which refuses to cooperate with optometrists unless compelled to do so by law. It should be pointed out that in many places at the grassroot levels there is good teamwork. as evidenced in studies of referrals, between the two professions.

An innuendo pertained to the failure of optometrists to make proper referrals. The 1961 public health reports of the U.S. Department of Health, Education, and Welfare referred to a study of referrals by optometrists to members of other health specialties. It was based on a random sampling of 1,350 of the estimated 18,500 optometrists in active practice in the United States and indicated that more than 800,000 patients are referred by optometrists annually. Substantially over half of this number are referred to ophthalmologists, approximately one-third to general practitioners, and of the remainder only 5 percent were referred to other optometrists.

The 1950 amendments to title X of the social security law made the services of optometrists available to the beneficiaries of that act. The results have been satisfactory in all of the States of the Union. A few years ago, a questionnaire was sent to the welfare departments of the various States. Not a single one reported unsatisfactory results from the operation of the aid to the blind pro

gram as a result of the 1950 amendments to title X. One of the outstanding responses came from California from which the following excerpt is taken:

"It has now been almost 6 years since the law became effective authorizing county welfare departments in California to use the services of optometrists in determining degree of blindness in connection with eligibility of aid to the blind. At present there are more than 215 optometric examiners rendering this service. During the past year more than 1,200 optometric eye examinations were completed to determine eligibility for aid to the blind.

"The services of optometrists have proved over the years to be a valuable addition to the social welfare programs for the blind in determining eligibility as to degree of blindness. This is particularly true for the less populated communities where there is scarcity of examiners. The availability of optometric examiners has meant that the State could take action with respect to eligibility to aid to the blind without the cost to county of transporting the applicants to a neighboring community to secure the required eye examination; and, of course, without resultant inconvenience to the client."

This clearly indicates what it means to the partially sighted who live in small towns, villages, or rural communities, not to mention the saving to the taxpayers who bear the travel expenses of the indigent. Even in the larger metropolitan areas, the patient load of the ophthalmologist is so great that the elimination of the services of optometrists from the aid to the blind program would work considerable hardship on the beneficiaries.

In such well-known clinics as the Illinois Lighthouse for the Blind and the Industrial Home for the Blind in Brooklyn, N.Y., the cooperation of the optometrist and the ophthalmologist has brought almost unbelievable benefits to their patients. In the commentary to a survey published by the Industrial Home for the Blind, "Optical Aids Survey," covering the first 500 cases, Richard E. Hoover, M.D., ophthalmological consultant, stated:

"This program could not have attained the popularity which it enjoys and the success indicated in this report without the support, sincere interest, and capabilities of the director, the ophthalmologist, the optometrist, and the service and administrative personnel who gave encouragement, instruction, and help in the use of the aids. A much-needed service has been rendered."

Dr. G. Ottenheimer Hellinger, O.D.S., in his commentary said:

"The success of the first program established anywhere for the rehabilitation of the near blind by means of optical aids is due mainly to the courage and foresight of IHB's executive director, Peter J. Scanlon. It is largely owing to his efforts that the virtual elimination of the differences between optometrists and ophthalmologists concerning the use of telescopes and microscopes has been accomplished. * The gratifying results achieved here with the complete cooperation of the other professions involved, indicate the tremendously valuable aid that is possible to the near blind."

Of particular interest is the commentary of Leo Esbin, M.D., staff ophthalmologist, as follows:

"As an ophthalmologist I have watched with keenest interest the development of the optical aids service at the Industrial Home for the Blind, the more so that the 500 clients served were persons who, on the basis of an ophthalmological examination were found to come within the legal definition of blindness. All of them had had ophthalmological service-some of them very extensive service over a period of years-and most of them had been told that nothing more could be done to improve their vision. Against this background, it was surprising to find that 68 percent of the group had obtained a useful increase in visual acuity through the use of optical aids." [Italic supplied.]

The quotations are from the publication of the home in September 1957, and the first 500 cases were handled during the period March 1953 to December 1955, all of which was subsequent to the passage of the Doughton amendment to title X in 1950 which medicine opposed and now seeks to have repealed.

The Optometric Center of New York City is another example of outstanding service by members of the optometric profession to the needy with impaired vision. This statement is borne out by two letters of recent date, one written by Maj. E. C. Hinkle, manager of the Social Service Center for Men of the Salvation Army in New York City. In writing to Dr. Alden N. Haffner, the optometrist who is executive director of the Optometric Center, Major Hinkle said:

"The many times we have contacted you on behalf of unfortunate and handicapped men for eye treatment and glasses is truly appreciated."