Interview commissioned by the Massachusetts League of Community Health Centers and conducted by James Hooley.

See also:

• The New England College of Optometry Clinical System
• Affiliation Between Hahnemann University and the Pennsylvania College of Optometry
• Illinois College of Optometry and the University of Chicago Affiliation Agreement
• Charles F. Mullen’s Speech at the Kennedy Library
• Distinct and Separate Legal Structures for Optometric Clinical Programs

Thus, October 16, 1997 was my best day in optometric education and reinforced my conviction that cooperation between the two disciplines presents numerous opportunities for enhancing patient care and clinical training for students and residents, and for fostering a better understanding and respect between the two professions, while reinforcing their natural synergism. The affiliation continues to this day, as a vibrant patient care and clinical education collaboration.

Although I remain convinced that affiliation with academic medicine will significantly enhance both clinical education and patient care for both optometry and ophthalmology, there are other challenges that also need to be addressed before optometric clinical education can reach its full potential. Some schools and colleges of optometry have addressed several of these challenges, but much still needs to be done. With continued support from the American Optometric Association (AOA) and the Association of Schools and Colleges of Optometry (ASCO), many of these objectives can be achieved within the next five years.

• Include optometry in the federal programs of Graduate Medical Education (GME) and the National Health Service Corps (NHSC).
• Increase collaboration with community health care programs and increase commitment to public health responsibilities.
• Downsize large single purpose and costly campus-based clinics and replace with smaller referral centers and community-based training sites.
• Achieve Joint Commission for the Accreditation of Health Care Organizations (JCAHO) accreditation for campus-based and college-operated clinical facilities.
• Reorganize the colleges’ clinical programs into separate legal entities with their own administrations and governing boards.
• Implement incentive-based compensation (IBC) plans for faculty that integrate student and resident training.
• Develop and operate ophthalmic surgi-centers in partnership with medical school affiliates.
• Establish a national clearinghouse and placement service for optometric externships.
• Fund the Regional Centers of Eye Care Excellence (RCEE) within the Department of Veterans Affairs (VA) and expand the Vision Impairment Centers to Optimize Remaining Sight (VICTORS).

Dr. Mullen was president of the Illinois College of Optometry from 1996 to 2002. He is currently on the Board of Trustees at the Pennsylvania College of Optometry and on the Board of Directors of the New England Eye Institute.

Journal of Optometric Education, 2006

The agreement, only the second of its kind in the United States, brings together faculty from separate, often competing, professions.

This affiliation emphasizes the complementary roles of each profession. It is intended to increase mutual awareness, improve and expand the training of both types of providers, and coordinate and enhance patient care.

“This far-reaching and quite unusual cooperative agreement brings together the disciplines of optometry and ophthalmology in a productive and rational way,” said Charles F. Mullen, OD, president of ICO. “Optometry students and residents, medical students, and ophthalmology residents will train side by side, learning a new respect and appreciation for each other’s disciplines.”

“The best eye care requires cooperation between doctors providing that care at multiple levels,” said Terry Ernest, MD, PhD, chairman of Ophthalmology and Visual Science at the University of Chicago. “As technology advances and financial pressures multiply, the optimal system for providing the broad range of eye care has grown beyond the scope of any single provider.”

Under this cooperative agreement, which has been in practice since September 1, 1997, University of Chicago faculty will teach and faculty physicians and residents will see patients who may require specialty care at the Illinois Eye Institute, the College of Optometry’s clinical facility.

The affiliation will expand training and clinical experience for students in each program. Students from ICO will come to the University for scientific and clinical training.

The two institutions will also create a joint OD/ PhD program, which will prepare optometrists to combine their clinical practice with eye care research.

Optometrists spend four years in optometry school, after college, studying the diagnosis and treatment of common eye diseases. Ophthalmologists spend four years in medical school, followed by another four to six years of specialized training as residents. Students in the OD/PhD program will combine four years of optometry training with three or more years of study of the basic science of vision and complete a substantial research project in their specialty area.

The only similar agreement was arranged between the Pennsylvania College of Optometry (PCO) and Hahnemann University in Philadelphia in 1988. At that time Dr. Mullen was executive director of PCO’s Eye Institute.

By combining the strengths of each profession, the Illinois affiliation pulls together a range of providers that is ideally suited for the emerging competitive environment of managed care. Primary eye care will be provided by the ICO’s network of optometrists. More complex cases, such as corneal or retinal surgery, will be treated by sub-specialists at the University.

“This arrangement provides the patients of the Illinois Eye Institute and the University of Chicago Hospitals with a closed loop for all eye care needs,” added Dr. Mullen, “from routine exams to the most complicated surgical problems.”

The combined programs now handle nearly 70,000 patient visits per year, more than 45,000 at ICO and another 20,000, including the most complex cases, at the University.

Both institutions are not-for profit. Each will retain autonomy over its operations and finances.

The University of Chicago Medical Center
Office of Medical Center Communications
850 E. 58th Street, Room 106, MC6063
Chicago, IL 60637
Phone (773) 702-6241 Fax (773) 702-3171

The decision to enter into an arrangement with the Department of Ophthalmology and Visual Science at the University of Chicago – a decision in which, I might add, Dr. Ernest played a major and always productive role – was finalized in July. In essence, therefore, today we are taking time to acknowledge that which has already occurred.

It is altogether fitting that we should do so, for this is truly a significant moment in our history as a college and in our careers as ophthalmic practitioners. The ceremonial documents to which we will soon be affixing our signatures are reflective of a legal agreement that delineates perimeters for coordinating clinical, medical, educational and research programs between our two institutions. Among the benefits of our collaboration will be the creation of an O.D./Ph.D. Program, increased opportunities for collaborative research, shared lecturers and an expanded clinical base.

However, today’s celebration does not blur the distinctions between our institutions or our disciplines. We each have our respective roles and importance. Today’s celebration reaffirms the natural synergism between optometry and ophthalmology.

The true significance of the affiliation we celebrate today will be found in its impact upon those we serve. Through this agreement we will create an educational system that fosters a better understanding of the disciplines of optometry and ophthalmology by those who will treat tomorrow’s patients. It will help further narrow the gap between our knowledge and the needs of our patients. Our affiliation will produce better optometrists and better ophthalmologists, and it is the patients who will benefit.

That is the true significance of what we celebrate today.

Dr. Charles F. Mullen
Affiliation Ceremony Speech
October 11, 1997

Health care financing and provision are issues that affect virtually every individual in the United States today. As health care costs continue to rise, providers, third-party payers, and patients alike actively seek more effective and efficient provision systems. If providers fail to provide quality and cost-effective health care, they will be left behind in the increasingly competitive market. Similarly, if patients and third-party payers do not use more effective and efficient systems, they will assume an even greater share of the rising health care expense.

Affiliation between professional institutions presents numerous opportunities for enhancing the educational and clinical training of students, residents, and practitioners. Institutions that are developing their respective professions can collaborate in many ways of mutual interest.

Two Philadelphia health care institutions, located within 9 miles of each other, HU and PCO, cognizant of the changing health care environment and the possible benefits of collaborative education, have begun to explore new approaches to patient care provision and ophthalmic education. On March 2, 1988, the two institutions signed an agreement for an affiliation. The agreement, effective July 1, 1988, proposes that the professions of medicine and optometry combine resources to develop unique approaches to ophthalmic education, eye care provision, and ophthalmic research.

The Context and the Decision to Affiliate
Ophthalmology and optometry have existed as separate, often antagonistic, professions since their inceptions, so why affiliate now? The impetus comes from outside parties – particularly third-party payers, health care policymakers, and legislators – who will attempt to define the roles each profession will play in the future of eye care provision if the two professions do not actively define these roles themselves. The ophthalmology community maintains that the diagnosis and treatment of eye disease should be restricted to physicians. The optometry community, on the other hand, proposes that optometrists should be the primary eye care providers and should offer an even greater range of eye care services than they do now. Interprofessional disputes involving the treatment of eye disease by optometrists, preoperative and postoperative management, and the use of laser technology in refractive treatment remain unresolved in many areas of the country. Debates in journals and in legislative chambers, however, may or may not produce satisfactory outcomes for either profession. In our opinion, the time has come for ophthalmologists and optometrists alike to acknowledge that through collaborative efforts the two professions can define a future for eye care provision that will satisfy their needs as well as those of patients and policymakers.

Pennsylvania College of Optometry, which graduates approximately 140 optometrists each year, and HU, comprising a medical school, graduate school of health sciences and humanities, and a teaching hospital, considered the potential benefits of a cooperative arrangement between the professions of medicine and optometry. In 1987, they began to explore the possibility of an affiliation. Such an affiliation was unprecedented and, given the political environment, highly controversial. Therefore, before agreeing to proceed with the affiliation discussions, representatives from both institutions considered the following issues:

1. How will the professional communities respond to the affiliation?
2. How will alumni and other constituencies respond?
3. Should the services rendered under the affiliation be marketed? How will the professional communities react to joint marketing efforts? Will the managed health care systems accept a joint provision model?
4. What are the roles of ophthalmology and optometry in primary care?
5. How will patients be managed under the terms of the affiliation agreement?
6. Will the model of patient care provision defined by the affiliation be in compliance with state and federal laws and regulations?
7. Will the affiliation create competition between ophthalmology residents and optometry students for primary care encounters?
8. How will the introduction of new technology, such as lasers, be administered under the terms of the affiliation?
9. What is the proper and ethical role for each institution in the areas of patient management and financial agreements?
10. What are the positive and negative consequences of such an affiliation?

Of these issues, those involving the reactions of health care communities were perhaps the most sensitive. Some ophthalmologists feared that the affiliation would undermine ophthalmology’s role in primary eye care. Locally, some ophthalmologists threatened to refer patients elsewhere if HU proceeded with the affiliation; in fact, a number of ophthalmologists did stop referring patients after the affiliation took effect. Nationally, some ophthalmologists voiced their disdain for a cooperative agreement between medicine and optometry (Argus. November 1988:8, June 1989:4, and December 1989:22). Optometrists nationwide questioned whether or not the affiliation would place their profession in a subordinate role to ophthalmology.

Alumni of HU voiced their disagreement with the affiliation through letters, telephone calls, and refusals to continue to support the school financially; PCO alumni, on the other hand, tended to view the affiliation positively.

Given the emotional nature of the affiliation, the marketing issue was all the more troublesome, and the planning stages proceeded with deliberation. The first efforts at marketing involved educational radio announcements, simply informing the public that the two institutions now offered joint services. These proved successful in piquing the interest of potential patients and third-party payers, such as health maintenance organizations. Marketing in the future will use both radio and newspaper media.

Issues regarding the provision of services and the roles of ophthalmologists, optometrists, students, and residents are addressed in a series of protocols, which will be discussed in greater detail below. Currently, these protocols are in draft form and are revised as necessary. However, they still constitute the backbone of the affiliation, and set the rules by which we operate. If care is not provided according to the terms of the protocols, the affiliation will fail, perhaps causing irreparable damage to the future of relationship between ophthalmology and optometry.

Recognizing a mutual desire to influence the future direction of the eye care professions, the two institutions decided to move ahead with the affiliation despite the risks and expected negative reactions. A primary goal of the affiliation is to define the role each profession will play in the changing environment before third-party payers and regulatory agencies mandate new policies. By engaging in curriculum discussions and in joint research efforts, the institutions hoped to enhance their own educational and research programs and, at the same time, design a health care provision system that would become a national model acceptable to all parties: ophthalmologists, optometrists, patients, and policymakers.

The Agreement
Philosophically committed to the affiliation, representatives of the two institutions began to define the elements of the agreement. It was decided that the firm foundation and base of the agreement would be education, on which other aspects of the agreement would be built. Many months of negotiations culminated in the written agreement to affiliate. Salient aspects of the agreement are summarized below:

1. Each institution will retain autonomy over its operations and finances.
2. An Affiliation Executive Committee will provide guidance, advice, and oversight on matters relating to the affiliation, including education, research, clinical, and administrative issues.
3. The Chairman of the Department of Ophthalmology at HU and the Dean of Academic Advancement at PCO will be responsible for administering the affiliation.
4. Appointments to the faculty or staff of either institution will be made in accordance with the policies and procedures of each institution.
5. On request, the clinical faculty and house staff at HU will provide consultative subspecialty medical/surgical services to the patients of PCO in a location dedicated to subspecialty care. Consultative subspecialty services will be provided for a full spectrum of medical ophthalmic conditions, including, among others, cataracts, cornea and external disease, diseases of the ocular adnexae, diseases of the retina and vitreous, glaucoma, neuro-ophthalmic disease, ocular trauma, pediatric ophthalmic disease, and strabismus. In addition, HU will provide continuous emergency medical/surgical backup services to patients of PCO.
6. Clinical faculty, residents, and other staff at PCO will provide consultative optometric, vision rehabilitative, and other services to patients of HU on request. Consultative optometric services will include contact lens evaluation and fitting, low-vision rehabilitation, eyeglass dispensing, orthoptics, and learning and disability evaluation and treatment.
7. Patients will be referred to HU or to PCO, as appropriate, when such referrals are in the best interest of the patient, are agreed to by the patient, and are consistent with applicable laws and regulations, such as those mandated by the Medicare and Medicaid programs and by professional ethics.
8. Students at HU, with approval from the dean of the School of Medicine, may take courses taught by PCO faculty. Likewise, PCO students, with the approval of their dean of Academic Advancement, may take courses taught by HU faculty.
9. The faculties of both institutions will engage in joint educational programs, such as didactic and continuing education lectures, clinical preceptorships, seminars, electives, and grand rounds.
10. The faculties of both institutions may participate in joint research efforts. Joint research programs will be approved and administered in accordance with the polices and procedures of each institution.
11. The faculty and administration of both institutions will seek to develop new and innovative health care provision systems.
12. All publicity, marketing, and fund-raising materials regarding the affiliation must be approved by the Affiliation Executive Committee.
13. Neither institution will use the affiliation for its own or its profession’s political gain.
14. All health care providers operating under the affiliation must have appropriate and adequate professional liability insurance as required by law.
15. Each institution will make available to the other institution, on request, all pertinent information regarding legal, financial, contractual, managerial, and other issues relevant to the affiliation. All such information will be held strictly confidential.

An interim financial agreement was added as an addendum to the original agreement. A global financial agreement addressing the provision of clinical as well as educational services is still under negotiation. It will supersede the interim agreement as soon as it is finalized.

The faculty, medical staffs, and administrations of both institutions were informed of the affiliation discussions and most supported the initiative.

The Model and the Implementation Process
The model of eye care provision eventually agreed on assumes that ophthalmology and optometry are complementary, and it seeks to emphasize the strengths of each profession. It stipulates that primary eye care provided at PCO is delivered by optometric staff. Patients with conditions requiring subspecialty medical or surgical intervention are referred for consultation, management, or both to the HU ophthalmology staff. After the consultation and any necessary medical or surgical treatment are completed, the patient is referred back to the referring optometrist for ongoing care. Likewise, patients who receive their primary eye care by ophthalmologists at HU and who require contact lenses, low-vision rehabilitation, orthoptics, or learning disability services are referred to PCO optometric staff for treatment. Ongoing medical/surgical care is provided by ophthalmologists. In our opinion, therefore, ophthalmologists and optometrists work in tandem to provide appropriate, cost-effective, and high-quality care.

Educational Programs
A fundamental goal of the affiliation is to develop joint education and research programs. Therefore, much effort has been spent in restructuring existing programs and creating new ones. Basic science and clinical faculty at HU currently offer courses in ocular microbiology/immunology, pharmacology, clinical medicine, and microanatomy at PCO. In the future, HU faculty will be offering courses designed for students of optometry in general and medical pathology and physical diagnosis.

Programs in clinical education also are being redefined. Ophthalmology residents accompany HU faculty on rotation in subspecialty care at PCO’s clinical facility, The Eye Institute. In addition, PCO’s faculty offers ophthalmology residents rotations in contact lens and low-vision rehabilitation services. Similarly, optometry residents and a few students are afforded the opportunity to rotate through ophthalmology subspecialties under the tutelage of the ophthalmology staff. Further, ophthalmology faculty participates in clinical conferences at PCO. Students and residents of both institutions are thus exposed to a broadened clinical base and an array of ophthalmic disorders. The hope is that such exposure will result in a more well-rounded clinical education.

Faculty of PCO have commented that the educational programs have enabled them to enhance their own clinical skills and knowledge base. However, educational programs are not limited to the faculty and students of the affiliated institutions; programs have been designed to benefit community providers as well. Faculty of HU have lectured at PCO grand rounds and have participated in the college’s continuing education seminars. Programs such as these encourage interaction between the professions and therefore, are consistent with the goals of the affiliation.

Clinical Services
Before clinical services were actually provided under the terms of the affiliation, clinical faculty of both institutions worked together to draft patient care management and referral protocols, to outline the management process, and to establish quality assurance standards. To date, protocols have been approved for referral from PCO to HU regarding the following aspects of care: (1) cataracts, including preoperative and postoperative care; (2) cornea and external disease; (3) disease of the ocular adnexae; (4) disease of the retina and vitreous; (5) glaucoma; (6) neuro-ophthalmic disease; (7) ocular trauma; (8) strabismus; and (9) pediatric ophthalmic disease.

When a patient is referred to HU for management, the ophthalmologist assumes ultimate responsibility for treating the disorder. The referring optometrist may observe the operation and may assist in the preoperative and postoperative care. However, medical/surgical care is always rendered personally by the physician. Referrals from HU to PCO may include the following: (1) contact lens care; (2) eyeglass dispensing; (3) orthoptics; (4) low-vision and vision rehabilitation; and (5) learning disabilities.

The protocols define a “closed loop provision system” that enables providers to monitor more effectively the quality of care rendered. Under PCO’s previous program, patients were referred to independent consultant ophthalmologists for medical/surgical treatment. This system was open-ended, and methods of record keeping were informal. In the closed system model, providers are in regular communication, and referral information is compiled and reported on a monthly basis. Furthermore, independent computer systems currently being implemented at both HU and PCO will allow providers to monitor care more effectively and determine when patients miss appointments or leave the system so that appropriate follow-up communication can be initiated.

While the protocols were being finalized, administrative staff began to define the operation of the provision system. Issues such as scheduling, personnel, space requirements, equipment requirements, medical records management, and billing policies and procedures were addressed. Given the high volume of clinical activity at The Eye Institute, HU employs a full-time office manager at that facility to oversee the Department of Ophthalmology’s clinical and financial operations. This person is responsible for patient scheduling, registration, charge entry, and medical record preparation. Pennsylvania College of Optometry operates contact lens and low-vision services at HU one-half day each week. The Eyewear Center, located at HU, and also operated by PCO, is open 5 days each week and is staffed by PCO employees.

Joint clinical chiefs’ meetings are held regularly to monitor the progress of the affiliation in general and, in particular, to evaluate the protocols, discuss quality assurance issues, and to review clinical programs. These meetings help maintain open communication among the providers and facilitate patient care provision. To date, revisions have been made in the glaucoma and cataract protocols.

Research
The affiliation agreement encourages joint research ventures and, indeed, opportunities for collaborative research are considerable. Approximately 75,000 outpatient visits are recorded each year at The Eye Institute. Likewise, 282,000 outpatient visits for medical problems, including eye disease, are scheduled at HU. As a result of the affiliation, investigators have a large base from which to draw patients for studies. Faculty at both institutions are currently working together on research projects, which include learning disabilities and macular degeneration. Protocols for excimer laser investigations also have been discussed. Should these be pursued, optometrists will engage in basic research while ophthalmologists and other physicians will conduct clinical trials.

Of special note is the fact that research areas have not been limited to eye disorders and disease. Faculty at HU’s Department of Neurology and Psychiatry have joined faculty at the PCO’s Learning (Disabilities) Center in research investigating learning disabilities.

Recent Developments and Future Directions
Over the past year, many of the goals of the affiliation have been realized, and the future looks very bright to us. As participants of the PCO externship program, a few selected optometry students soon will have the opportunity to share in patient care in the Department of Ophthalmology at HU. New projects under discussion include a joint prison eye care program and the establishment of satellite clinics and faculty private offices, which will be structured according to the provision model previously described. Satellite clinics would be geographically located in the Philadelphia area to serve areas populated by the “underinsured” – the working poor who do not have adequate health care coverage. The faculty private offices would be strategically located to enhance the marketing potential of the affiliation.

Marketing initiatives already are underway; efforts will be directed to optometrists in private practice, primary-care physicians, managed-care systems, commercial insurers, and the general population. The opportunities for marketing are perhaps greatest in the managed-care sector. The model of eye care provision developed under the eye care affiliation is consistent with that used by many managed-care systems, i.e., optometrists provide primary eye care, while ophthalmologists provide medical and subspecialty care. The vehicle for marketing services to managed-care systems will be EyePA Ltd, Philadelphia, a for-profit subsidiary of PCO. On a contractual basis, EyePA Ltd provides eye care services to managed-care systems, self-insured corporations, and other insuring entities. EyePA Ltd is a multifunctional specialty organization that (1) manages utilization of eye care services; (2) provides, on a capitated or fee-for-service basis, a full range of professional eye care services through a network of contracted professionals; and (3) credentials specialty eye care providers and institutions.

Comment
Many individuals maintained that doctors of medicine and doctors of optometry could not work together as colleagues sharing the same goals and aspirations.

Looking back over the past 17 months, we believe that the skeptics were wrong. The affiliation has exceeded our expectations and has progressed much more quickly than any of the planners had imagined. Events to date suggest that joint educational, clinical, and research programs have been advantageous to both medicine and optometry, and that teams of medical doctors and optometrists can work together as colleagues in one eye care provision system.

Archives of Ophthalmology
Controversies in Ophthalmology
Volume 109, Number 2. February 1991.
Charles F. Mullen, O.D.
Myron Yanoff, MD
Laura A. Wilson, MS

The decision-making process concerning affiliation must include a careful cost benefit analysis. Evaluation should include a best and worst case scenario, and a timetable for implementation, perhaps in a step-like fashion to permit both parties to assess the effectiveness and impact of the relationship.

Analysis should be of sufficient depth so as to insure that all facets of the affiliation have been thoroughly explored in both quantitative and qualitative fashion, as it relates not only to educational and patient care factors, but also to finance, research and public relations.

Obviously, the most desirable affiliation for an educational and public image perspective would be with the most prestigious medical school. Geographical accessibility is another factor. Financial strength and quality of medical and ophthalmological staff and resultant patient care are also important factors.

The integrity and qualifications of the administration and faculty who are involved in negotiating the agreement and who will be directly involved in the joint programs are of paramount concern in order to protect the college of optometry from an adverse outcome in either the short or long-run.

Benefits of a Medical School Affiliation

Education

1. Increased access by optometric students and resident to patients with eye disease, systemic disease and pre- and post-ophthalmic surgical cases.
2. Increased interaction by students, residents and faculty with ophthalmic and other health care professionals via grand rounds, workshops, seminars, conferences and observation.
3. Lectures by medical school faculty in areas not currently taught by optometric faculty, and in areas currently taught where qualitative and/or quantitative improvement is possible – eye disease management, patient interviewing, gerontology.
4. Increased educational opportunities and research capabilities through the creation of joint centers or institutes in such areas as glaucoma, neuro-ophthalmic disease, cataract/aphakia, corneal physiology/contact lenses; immunology/allergy; pediatric and geriatric eye care.
5. Opportunities for advanced specialty training for optometric students, residents and faculty.
6. Expanded continuing education program in eye disease management through increased ophthalmological participation.
7. Medical school faculty appointments for optometric faculty.

Patient Care

1. More effective management of surgical patients, whether the surgery is performed at the medical school/hospital or at the optometric facility.
2. More effective back-up for true ocular and general medical emergencies.
3. Increased and more readily available access to sub-specialty care.
4. Enhanced control and direction for optometry school’s medical staff in areas such as patient care protocols, quality assessment/assurance mechanisms, credentialing.
5. Hospital privileges for optometrists.

Constituent and Public Relations

1. An enhanced image which can have a positive effect on student and faculty recruitment, fund raising, grantsmanship, community relations, and professional relations.

Economic Impact

1. Increased census in primary care and optometric specialties.
2. Sharing of revenue from surgical services provided at the medical school/hospital or out-patient surgical facility of the optometry school.
3. Increased practitioner referrals both from the optometric and medical communities.
4. Opportunities for sharing of plant, capital equipment, people, and resources.

Research

1. Increased potential for joint research projects utilizing respective strengths of optometry and medical schools. Access to special populations.

Concerns of a Medical School Affiliation

1. Erosion of optometry school’s mission to train primary eye care clinicians.
2. Competition among optometric students/residents and ophthalmological residents for primary care patient encounters.
3. Danger of optometry being placed in a subordinate position related to ophthalmology.
4. Some loss of control over optometry school’s ophthalmological group/faculty.
5. Restriction on referral patterns due to implied exclusivity of agreement.
6. Loss of opportunities for affiliation with other institutions.
7. Possible negative reaction by alumni or other constituencies.
8. Negative public relations if affiliation does not succeed.

The Affiliation Agreement
The elements of an affiliation agreement or, if a step-by-step process is desired, a memorandum of understanding with intent to affiliate may be broadly stated with detailed attachments added as the various aspects of affiliation are realized. The following elements should be present in the initial document.

1. Statement of support for each other’s educational mission, particularly as it related to the expanding scope of optometric practice.
2. Mutual desire to meet the health care needs of the community in a cooperative manner, desire to provide mutually beneficial and cost effective means for educating health care practitioners, and a recognition of the public benefits of collaborative research in visual and related sciences.
3. Actively encourage and cultivate inter-institutional endeavors in education, research and patient care.
4. Recognize each other’s autonomy as it relates to overall institutional mission, structure and governing authority.
5. Those terms contained in the agreement which specify financial arrangements should not become effective until such arrangements have been mutually agreed to in writing.
6. Facilitate inter-institutional cooperation in education by such means as faculty exchange, discussions on curricula development, teaching and evaluation techniques, seminars, workshops or symposia.
7. The faculties of both schools agree to participate in education programs such as didactic lectures, clinical preceptorship, seminars, electives, grand rounds, and continuing and post-graduate education as deemed appropriate.
8. Encourage cooperative research efforts and the application for external funding in the basic and clinical sciences by means of faculty exchange, sharing of laboratory resources and sharing of technical expertise.
9. Develop a cooperative arrangement in clinical education by reciprocally granting credentialed individuals faculty rank and/or clinical privileges, and by integrating medical and optometric staff, fellows, residents and students into appropriate clinical activities at each other’s institution.
10. Optometry school agrees to recognize the hospital and clinical faculty of the medial schools as the preferred providers of general medical and surgical care, ophthalmic surgical care and associated ancillary services for optometric patients.
11. Medical school agrees to recognize school of optometry and its clinical faculty and residents as the preferred providers of optometric care.
12. Optometry school agrees to make available members of its faculty to provide optometric services at medical school/hospital in accordance with mutually approved policy, protocol and procedures. This would include endorsement and signing of standing orders by appropriate medical director to allow optometric staff to treat eye disease if not permitted by state statue.
13. Medical school agrees to make members of its faculty available to provide onsite services at college of optometry’s clinical facilities.
14. Medical school agrees to make members of its faculty available to provide 24-hour emergency consultation and support services for optometric staff and residents.

The following should also be considered:

• Use of an external consultant experienced in hospital/institution mergers to review the affiliation structure.
• Creation of a third entity for administration of the various joint programs and for resources development purposes, e.g., The Foundation for Optometric/Medical Eye Care.
• Jointly sponsored grant application should be considered to offset start-up costs.

Conclusion
I have attempted in this brief presentation to outline the benefits and potential costs of medical school affiliation. Although there many be alternative means of enhancing optometric education and training with less political risk, affiliation appears to offer an immediate opportunity for quantitative and qualitative improvement in our ability to prepare optometrists to treat eye disease.

Journal of Optometric Education.
Volume 12, Number 2. 1986.
Charles F. Mullen, O.D.