New England College of Optometry Clinical System (PPT)

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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

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Honored guests.

This morning, I would like to share with you the beginnings of optometry’s first program to collaborate with community health centers to improve access to eye and vision care services and enrich optometric clinical training.

I will attempt in my brief remarks to relate the common elements of the initial program to the new corporate structure and community governance model of the New England Eye Institute. I plan to outline the challenges which, I believe, still lie ahead for the new organization and finally, with your permission, offer a few observations or suggestions from my years of experience in interprofessional cooperation.

In the late 60’s and the early 70’s, the New England College of Optometry decided to expand and enrich the clinical training environments to which its students had access.

We knew that optometry students would benefit from health care environments in which the optometrist was one of many health care professionals contributing to the care of the patient.

Inner-city demographic data suggested that students would have the opportunity to participate in the care of patients with serious eye and vision problems unlike the university students they typically examined at the College’s Kenmore Square Clinic.

We wanted students to learn in a quality health care environment and not a teaching clinic as was customary at that time. Quality clinical training could only be achieved in a quality health care setting.

Coincident with our educational mission and not at all incompatible with it was a commitment to providing eye and vision care services to inner-city residents who were unable to meet this health care need in their own communities.

We concluded that the most promising scheme for fulfilling both our educational and community service objectives was to form an innovative network of affiliations with existing health care centers. Innovation was an important element in the development of the clinical network as it is today for the New England Eye Institute.

As we began to develop the program, any illusions we may have had about the ease of executing our new strategy were quickly dispelled. We learned a lot about skills we thought had nothing to do with eye care or optometric education: about convincing skeptics, compromising, introducing safeguards, planning, and negotiating.

In the first place, there was a reluctance on the part of health center administrators to permit students to participate in their programs.

Historically, the health center community was disenchanted with receiving its health care in the emergency rooms of large teaching hospitals and our proposed program, they thought, was precisely what they were seeking to escape.

Our second problem revolved around the reluctance of medical staffs at some health centers to work directly with optometrists, since the physicians had little experience working with us.

It was necessary to convince the medical staff at a very fundamental level of the ability of optometrists to function in and contribute to an interdisciplinary environment.

We also encountered considerable political pressure from the ophthalmological society which opposed cooperation between optometry and ophthalmology in the new eye and vision care model to be developed in the community health centers.

I am always reluctant to single out individuals for fear of omissions, but I would be remiss without citing the bold leadership of a few who were responsible for the success of the 70’s community eye care initiatives: Health Center administrators, Jim Hooley, Dorchester House, Mel Scovell and Tris Blake of the South End Community Health Center and Bob Morgan of the Dimock Community Health Center in Roxbury. Bill Baldwin, President of the New England College of Optometry for granting me the opportunity to participate in the development of the clinical network.

The optometrists who were willing to pioneer a new approach to interprofessional collaboration: faculty from the New England College of Optometry–Ralph Levoy, Jerry Selvin, Matt Garston, Jeff and Neal Nyman and the young Barry Barresi.

And, three courageous ophthalmologists, David Miller from Beth Israel Hospital and Harvard and Marc Richman and Andre Quamina from Boston University, who believed in the new model and were committed to providing comprehensive eye and vision care to the community health center clients. They withstood the persistent political pressure and the new optometric-ophthalmological interactional model was implemented at the South End and Dimock Community Health Centers and the Dorchester House for the first time in the United States. Bold leadership was as important then as it is now.

This eye care protocol has now evolved throughout the country, more recently into a comprehensive affiliation among the Illinois College of Optometry, the University of Chicago Medical School and its University Hospital System for the provision of ophthalmic care, medical and optometric education and research.

And, the fourth problem had to do with the antagonism our new eye care model aroused among private optometric practitioners, many of whom were our own alumni and friends. They felt that we were intruding into an area that is rightfully theirs.

I was pleased to learn that this issue has been largely resolved through the leadership of the Massachusetts Society of Optometrists.

The common element that emerged throughout the development process was the importance of effective collaboration among all of the constituencies. Community health center boards and community advocacy groups at first were skeptical, then later became strong supporters of the effort. Their support was critical to the success of the program.

The College and health center collaboration soon began to develop into a successful story of mutual respect and aligned missions. These were the key ingredients in improving community access to eye and vision care services in the 70’s, as they are today.

After successfully negotiating a mutually acceptable agreement with the Dorchester House Multi-Service Center and after strengthening our affiliation with the U.S. Public Health Services Hospital in Brighton, we went on to develop additional relationships in Boston. The South End Community Health Center, Dimock Community Health Center, Eye Research Unit of the Joslin Diabetic Foundation, the Kennedy Hospital in Brighton, Cotting School for Handicapped Children, Department of Veterans Affairs Outpatient Clinic, and the Gundersen Eye Clinic at Boston University.

Other institutions, upon hearing of the success of our collaboration and new eye care model, asked for assistance in establishing eye and vision services. These included: the Massachusetts Institute of Technology, Harvard Community Health Plan and the University of Massachusetts at Amherst.

All of these organizations were willing then to take the risks of new programs and innovative approaches to community eye and vision care as the New England Eye Institute member organizations are willing to take the risks of new programs and innovative approaches in this exciting new venture.

In 1976, upon leaving for Philadelphia, I wrote in an article later published in the Journal of the American Optometric Association on my assessment of the initial phase of the program.

We have reason to believe that we have achieved most of our clinical development goals to a greater degree than we ever could have anticipated.

Over 45,000 eye visits were provided to community residents in 1976. Many community residents had never before received eye or vision care.

Our students are seeing more challenging patients than their predecessors saw.

They have learned from and worked effectively with ophthalmologists and with professionals in pediatrics, internal medicine, nursing, psychology, and low vision.

Faculty and students were successful in convincing many that optometrists can make an important contribution in an interdisciplinary health care setting.

A very workable eye care protocol involving technicians, optometrists and ophthalmologists was developed and implemented.

Our graduates have very different professional aspirations as a result of their community health center experience. Some went on to work in community health centers and some have become deeply involved with the whole issue of public health and some are seeking to broaden their education and assume roles in health care policy. We have a living example here today in Barry Barresi.

A new level of innovation and collaboration has been introduced in the 21st century to build on a program created in the 70’s.

A major step was taken by the New England College of Optometry by reallocating its clinical assets into a community governed organization. Even with a history of over 30 years of collaboration, much work is still needed to be done to truly transform the New England Eye Institute into a leading community services organization for Greater Boston and a model for other cities around the country. Several challenges can be identified.

Educational programs need to be expanded to include trainees not only in optometry, but also ophthalmology, medicine, nursing, and other health care professionals, such as occupational therapists, social workers, low vision and blind rehabilitation specialists.

It will not be sufficient to provide only eye and vision services, for the New England Eye Institute needs to embrace a community oriented approach to health promotion and prevention.

The new organization must be flexible and integrated to truly meet the public need. It must position the Institute to meet the needs of special populations – the homeless, the frail elderly, the home bound, the developmentally disabled, the severely visually impaired, and others.

The quality of care must be monitored and maintained with appropriate mechanisms and oversight.

And, development efforts need to be aggressive in seeking the necessary operating and capital funds to support the Institute.

Finally, I would like to conclude with a few observations based on my many experiences in interprofessional collaboration that could be applied to the New England Institute.

The key ingredients in any successful collaboration are mutual respect and aligned missions.

Innovation must be proceeded by careful planning and boldness tempered by fiscal reality.

There are few cities better positioned than Boston to achieve excellence in collaboration to meet the public need in eye and vision care services, in health professions education, and health promotion and prevention.

I urge the many collaborators in this new initiative to reflect on the approaches and successes of a few bold individuals who in the 70’s were willing to take risks of new programs and innovative approaches and apply the same persistence, commitment and risk taking to the New England Eye Institute.

Thank you for remembering me.

Dr. Charles F. Mullen
Kennedy Library, Boston, MA
May 14, 2003

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A CONTINUED HISTORY OF THE ILLINOIS COLLEGE OF OPTOMETRY
1997 – 2000

PREFACE

The conclusion of the book Optometry in America (1872-1995) offered a glimpse at the Illinois College of Optometry’s bright future. In February 1995, the College received a positive accreditation review by the American Optometric Association Council on Optometric Education (COE). Also that same year, the first stage of an ambitious campus expansion was completed in the building of a new residential complex on Indiana Avenue at 33rd Street.

By March 1996, however, the school’s bright future was overshadowed by controversy. A politically motivated article appeared in a Springfield, Illinois newspaper. This news item was picked up and published by the Associated Press. These two events triggered a series of allegations and investigations that resulted in the resignation of ICO President, Dr. Boyd B. Banwell.

Upon Banwell’s departure, a management team was formed by the Board of Trustees that included: Board Chairman Dr. John E. Brandt, Chairman-Elect Dr. Albert H. Rodriguez, Jr., and Trustee Dr. Joseph Henry. The team worked to maintain the daily operations of the college and assuage the concerns of faculty, students and staff. They also worked with legal counsel to satisfy the Office of the Illinois Attorney General, the Internal Revenue Service and the College’s financiers.

A search committee, chaired by Dr. Henry, initiated the recruitment of a new college president. This team included representatives from the Board of Trustees, faculty, staff, and students. After an exhaustive search, Dr. Charles F. Mullen – who was serving as the Director of Optometry Service at the Department of Veterans Affairs in Washington, D.C. at that time – was appointed the Illinois College of Optometry’s fourth president. Taking office on November 1, 1996, the college that Dr. Mullen encountered was not quite the utopian institution which many – both inside and outside the college – believed existed.

Dr. Mullen quickly realized that although a plan had been developed for the physical expansion of the campus, a more comprehensive plan was required that encompassed improvements in ICO’s academic culture, administrative operations, financial health, institutional image, revenue streams, as well as the physical plant. Working with the President’s Advisory Council, an administrative team assembled from existing faculty and senior staff, Dr. Mullen began the Herculean task of putting the college back on course and preparing it to meet the challenges dictated by the rapid changes in the health profession’s educational requirements.

Recording the events that took place since Dr. Mullen took office, The Road to Excellence serves as a supplement to Optometry in America, chronicling – in his own words – Dr. Mullen’s first four years at Illinois College of Optometry.

INTRODUCTION

Given the Illinois College of Optometry’s historically prominent position within the field of optometric education, I was concerned when I learned of the difficulties the college was experiencing in 1996. I believed these matters had the potential to harm not only ICO, but possibly even the profession of optometry itself. When I was offered the position of president, I felt it was my responsibility to my profession to accept this role. I was confident that, in a relatively short period of time, I could redirect the college’s resources and energies, creating a culture in which all members of the ICO community were actively engaged in strengthening the institution.

We immediately made a philosophical shift from emphasis on facility development to emphasis on programmatic improvements and on the personal service provided to our students, patients and alumni.

We set out to realize a culture at ICO that was based on innovation and creativity: where personal initiative coupled with individual and collective accountability are the norm. Our goal was to develop an institution managed by fact and outcome measures, resulting in heighten productivity; a model of ethical behavior and integrity; and a culture committed to growth and improvement.

The pages that follow document our progress in realizing this new culture at ICO.

CHAPTER ONE
DEFINING EXCELLENCE

Documented in the 1996 book Optometry in America, the Illinois College of Optometry (ICO) can trace its origin to 1872. ICO, however, has only existed under its present name only since 1955: the result of the merger of the Northern Illinois College of Optometry and the Monroe College of Optometry.

Between 1955 and the present, ICO has had only four presidents: Eugene W. Strawn, O.D. (1955-71), Alfred A. Rosenbloom, O.D. (1972-82), Boyd B. Banwell, O.D. (1982-96) and now, Charles F. Mullen, O.D. (1996 – present).

The ICO Board of Trustees appointed Dr. Mullen as President on November 1, 1996. He assumed his duties on a full-time basis one month later. Mullen brought with him twenty-six years of administrative experience. He had served as Special Assistant to the President for Clinical Development (1970-76) at New England College of Optometry; as Executive Director, The Eye Institute (1976-1990) at Pennsylvania College of Optometry; and as Director of Optometry Service of Veterans Health Administration (1990-96) at the Department of Veterans Affairs, Washington, D.C.

Three years after he took office, Dr. Mullen discussed his initial impressions and objectives in a guest editorial that appeared in the Journal of the American Optometric Association (September 1999):

“Although I found there was an understandable sense of uncertainty regarding the immediate future of the College, morale was surprisingly good. It was my perception that faculty and staff were not only willing, but eager, to ‘right the ship’ and to positively engage in strengthening and improving the institution. I felt confident I could immediately assemble a capable administrative team from the existing faculty and staff.

My initial objectives included:

• Initiation of a strategic and tactical planning process.
• Enhancement of the academic culture by increasing support for faculty development, research and scholarly activity.
• Expansion of the clinical educational program by initially adding 50 community-based training sites.
• Initiation of a search for a new Dean/Vice President for Academic Affairs.
• Review and modification, as appropriate, of the administrative organization.
• Enhancement of the institutional culture, by improvement of services to students, patients, alumni and employees.
• Ensurance of the financial stability of the institution, including the enhancement of revenue streams.
• Review and modification of the master buildings and facilities program.
• Improvement of management information systems.
• Enhancement of personnel management.
• Development and implementation of public relations and fund-raising programs.
• Redirection of resources formerly allocated to an ambitious building program into programmatic improvements.

I believed that it was vital that our planning process promote open avenues of dialog with internal and external constituencies.”[1]

To achieve his objectives, Dr. Mullen formed the President’s Advisory Council (PAC) that included senior administrative management for the College and the Illinois Eye Institute (IEI),which is the school’s clinic facility. The PAC began to develop a strategic plan that defined the term “excellence” as it relates to ICO. The plan, titled Prescription for Excellence, contained five major goals, accompanying appropriate action, identification of departmental responsibility for each goal and designated completion dates.

CHAPTER TWO
PRESCRIPTION FOR EXCELLENCE
YEAR ONE

Dr. Charles Mullen understood the importance of open communication between internal and external constituencies in both the planning process and the implementation of each designated strategy in the Prescription for Excellence. As part of this process, President’s Advisory Council (PAC) members were given the opportunity to voice their opinions and concerns on a variety of subjects and to experience full responsibility for the achievement of each department’s goals. To begin their work, PAC commissioned surveys that addressed alumni and alumnae needs and concerns and student satisfaction. The compiled results had immediate impact on Dr. Mullen’s Prescription for Excellence.

In order to establish improved dialog with the community and to include them in the planning process, Dr. Mullen established a Community Advisory Board (CAB). Leaders of neighborhood organizations, school principals, clergymen, representative of community-targeted government agencies and senior ICO administrators were invited to join this team. The CAB continues to consider such issues as employment opportunities, real estate transactions, and minority student recruitment that have a direct impact on both ICO and its surrounding community.

In the Journal of the American Optometric Association (September 1999), Dr. Mullen discussed his strategic plan in great detail:

“It was now our task to channel these processes into a tangible plan of action. With input generated through countless meetings, reviews, evaluations, and re-evaluations, we created a 70-page document, the Prescription for Excellence. It contains five major goals, each with detailed, quantifiable action steps and completion dates. These action steps also identified the department responsible for their implementation. Regular monthly meetings were scheduled to evaluate our progress. These meetings – which continue today – are open to all members of the ICO community.

The Prescription for Excellence was immediately effective. The goals and directions we established continue to be important, but even more important is the process we created whereby each member of every ICO constituency has the opportunity to be meaningfully involved in the planning process…

Several important themes emerged during the planning process that have helped create a new culture at ICO. Through the planning process, five major goals were crystallized:

1. Provision of excellence in education and scholarly activity.
2. Creation and maintenance of reputation as an institution that is characterized by exceptional accountability.
3. Provision of excellence in service, as defined by our students, patients, alumni, and employees.
4. Provision of excellence in health care.
5. Achievement of recognition as a center of influence within the profession and the community.

These goals are now the basis for the performance agreements that exist between every member of senior administration and the President, as well as an agreement between the Board of Trustees and the President. These agreements are what each of us is measured by: they are the basis for budgeting and for departmental planning.”[2]

The results of that first year of implementation were noteworthy. Dr. Mullen reported those achievements to the ICO community at his first “State of the College Address” in October, 1997:

“What I have to share with you today is important to all members of the Illinois College of Optometry community. Today’s address deals with where we are at this point in time …and what our future course needs to be.

ACADEMIC CULTURE

“We have made steady progress in evaluating and improving the quality and cost effectiveness of our external clinical affiliations and our satellite facilities with a goal of achieving budget neutrality. Contracts have been renegotiated (and) as a result…we have reduced the net cost of our satellite programs by approximately $172,000. At the same time, we were achieving these reductions in costs, we have expanded our community based clinical affiliations from a handful to 75 (collaborations), providing more than 210 student rotations annually.

We have made several significant changes in ICO’s curriculum. The focus was changed to give students an overview of an optometric examination with a greater emphasis on technical skills. The optometry sequence has been modified…to complete the teaching of technical skills by the end of the winter quarter of the second professional year. This will make room…for closely supervised clinical experiences prior to the more independent work done during the third professional year…An interpersonal skills course has been added to the spring quarter of the second year including topics (such as) inter -and intra-professional communication.

A summer curriculum will be added to the third professional year beginning in May, 1998. The benefits (of which)…will include a smoother transition from pre-clinical training to actual patient care experience and more patient care experiences for third year students.

An agreement has been reached with the Department of Ophthalmology and Visual Science at the University of Chicago to coordinate clinical, medical, educational and research programs with ICO. This is only the second such agreement between a college of optometry and a university ophthalmology program in the country…Among its benefits will be the creation of an O.D./Ph.D. program; increased opportunities for collaborative research; shared lecturers; and an expanded clinical base.

(The) faculty now has a voice in the deliberations of ICO’s Board of Trustees through elected representatives. A Faculty Council has been created with a written constitution and leadership provided through an elected Executive Committee.

In our efforts to develop external funding for research, we have made significant progress in improving our opportunities with various Federal Agencies by making certain we are in compliance – or making substantial progress toward compliance – in several areas from institutional protocols to record keeping.

ADMINISTRATIVE ISSUES

“We have thoroughly reviewed our organizational structures. We will shortly be submitting to the Board a revised organizational chart that reflects functions rather than individuals and is organized in a way to maximize our efficiency and service to our students and our patients.

Simultaneously with this review, we have taken steps to review all personnel and initiate changes to improve their efficiency. These include the creation of the ‘President’s Advisory Council’ to assist me in managing ICO. We are committed to diversity in our staff, faculty and student body and have taken steps to ensure a diverse ICO community.

FINANCE

“We have reorganized the Business Office to improve our financial management. We have completed a structured budgeting process with time lines and approval processes built in to insure that all ICO needs will be addressed in the budget process and properly prioritized within our educational and patient service commitments ….(and) to improve accountability.

We have also constructed a long-term debt management plan. ICO currently has an outstanding tax-exempt variable rate of indebtedness of $37 million dollars. We have been successful in negotiating productively to refinance this debt in a way that minimizes its burden on ICO and maintains our position of excellence in optometric education.

INSTITUTIONAL IMAGE

“How we see ourselves to a very large extent projects how others view us. For that reason, I have made improving internal communications (among faculty and staff) a high priority during the past year and will continue to do so.

We have attempted to address the information needs of our external constituencies, especially our alumni…This was the impetus for the creation of a quarterly newsletter. We are also in the process of creating an Internet mailing list of our alumni and developing a web site for ICO’s alumni and friends. We have initiated a mentoring program with the Illinois Optometric Association to link optometry students with practicing optometrists in Illinois, the majority of whom are graduates of ICO, furthering the ties between the College, our students and our alumni.

We have also created a public relations program with specific goals and objectives in the areas of media relations, community relations and greater visibility in professional journals and optometric associations. The public relations program contains a strong marketing component, chiefly (involving) the Illinois Eye Institute.

OPERATIONS

“The future of both health care and education will be greatly influenced by developments in communications. Without a significant increase in capital spending, ICO has moved forward aggressively in this arena through the efforts of our Information Systems Department.

Personnel management has been enhanced through greater accountability. Formal performance agreements have been created for each member of the administration, creating an objective measurement against which (each employee can be evaluated for his or her) performance.

PHYSICAL PLANT

“We are continuing to make necessary improvements to our (physical) plant. We recently installed exterior signage, increasing our visibility in the community and improving the marketability of our (Illinois) Eye Institute. We will shortly be changing our internal signage as well, making it more informative, user friendly, consistent and within Federal regulations.

Renovation of the Illinois Eye Institute is nearly complete. When finished, we will have a facility whose exterior and interior appearance matches the outstanding qualities of those who serve there.

At the same time, we have carefully evaluated the existing construction master plan, not only in terms of our needs but also within the framework of sound financial considerations and the need to maintain a competitive economic stance. As a result of this review, we have reduced the previous master plan by more than $23 million dollars over the next five to seven years.

REVENUE STREAMS

“We have made significant progress in increasing (the number of) alternative sources of revenue for ICO…(because) we cannot afford to neither compromise excellence nor over-burden our students with significant tuition increases.

We have begun with the creation of a marketing plan for the Illinois Eye Institute that recognizes that in addition to its educational mission the IEI must be competitive in its efforts to attract patients.

We have reinvigorated our commitment to fundraising, or ‘development,’ – so named in recognition of the fact that the creation of a significant philanthropic base is a developmental process (that occurs) over time.

In order to better fulfill our educational role to practicing optometrists – and to improve our revenue stream through education – we have adopted a more user-friendly stance toward continuing education or CE. We are in the process of creating a CE program (that will be) systematically planned and timed to coincide with the two-year cycle of CE requirements for licensure renewal in Illinois and one that stresses advanced competency.

We are also strongly committed to enhancing our efforts at student recruitment and retention, but please let me emphasize that this must not ever come at the expense of quality.

Our focus this year was to move admissions from a paper oriented (process) to more of a people-oriented process. In August, we held an open house for prospective students. An aggressive schedule of visits to undergraduate campuses for recruiting purposes has begun. Before the year is out, members of our faculty and staff will have visited more than 50 colleges and universities.

STRATEGIC PLANNING

“A Strategic Plan for an institution such as ICO…must do more than chart a course for the future. It must reflect the collective wisdom of the College. We have created such a plan and named it the Prescription for Excellence. It is now in the process of some final revision before being presented to our Board. It is available to all who wish to review it in its entirety. It is a living document in that it is intended to be amended as conditions and opportunities warrant. It addresses all aspects of our continued growth as an institution of health care education. And, as its name implies, it requires excellence as the standard of all our efforts. This is not a mere title, but a recognition of our potential and also of what will be required of those who will thrive in today’s health care environment…..I am confident that ICO and its students, faculty and staff will be among those who excel.”[3]

During this same month, Dr. Mullen was installed as Illinois College of Optometry’s fourth president at a ceremony that was held on October 18, 1997 in the Rockefeller Chapel on the University of Chicago campus.

CHAPTER THREE
PRESCRIPTION FOR EXCELLENCE
YEAR TWO

During Dr. Mullen’s second year at ICO, the benefits of his mandate for openness and communication among the student body, faculty, staff, alumni and administration became more apparent. Working closely with Janice E. Scharre, O.D., M.A., who had been appointed Dean/Vice President for Academic Affair in November 1997, a faculty opinion survey was developed and distributed to determine the College’s perceived strengths and weaknesses. The information was gleaned and processed into a series of positive actions that were designed to enhance ICO’s academic culture.

A similar survey was sent to students, requesting input on virtually every aspect of student life. Improved communication among the student body, faculty and administration produced a more user-friendly Student Guide; increased flexibility in student leave policies; and an expanded and simplified work study program.

The responses to an alumni-directed questionnaire would result in an initiative to freeze tuition, increased funding for scholarships and incremental reduction of entering class size.

In his second “State of the College Address,” which he presented on October 2, 1998, Dr. Mullen detailed some of the accomplishments achieved during the year.

FINANCE

“Let me start with our successful bond issue of $45 million dollars (in variable-rate, tax-exempt bonds by which ICO was able to successfully restructure the College’s debt. This freed $22 million in assets, which were previously held as collateral. Those assets were freed up to be applied to more flexible investments). This guarantees the sound financial footing we need to successfully continue ICO’s tradition of excellence into the next century…But the real significance of the bond issue is not in dollars, but in the confidence the financial community demonstrated in ICO’s future.

STUDENTS

“I am pleased to be able to report that the state of our student body – whose progress in advancing the profession is the yardstick by which we are all ultimately measured -remains extremely strong…We have implemented several new avenues for their input. Town hall meetings were instituted. The Dean’s Advisory Group has been reinvigorated and a student satisfaction inventory was administered last month, seeking input form every ICO student about virtually every aspect of student life.

(To enhance the students’ educational experience,) ICO continues an aggressive expansion of the externship program…(which has) grown from 13 sites in 1996 to 79 (sites which are) currently located throughout the United States and abroad…We have implemented an evaluation and monitoring process for our sites…(and) taken care to remain fiscally prudent during this period of expansion. We will continue to analyze our community-based sites, seeking to renegotiate financial arrangements when possible; increase patient volumes; and modify our time commitment to individual sites when desirable. External sites, such as (the ones) we have developed, allow students a greater breadth of experience. They allow students to choose diverse locations and types of clinical settings, better preparing them for the realities they will face as practicing optometrists.

FACULTY

“The state of the faculty is also strong. A revised Faculty Handbook, which consolidated the old handbook and academic policy manual – was developed cooperatively by the faculty and the Dean. During the past year, significant emphasis was placed on faculty scholarly activity….Faculty attendance at professional meetings increased by 71 percent during the past year…Twenty-seven faculty presented (papers) at last year’s American Academy of Optometry meeting. Publications by junior faculty have increased significantly.

The faculty has also made a concerted effort to increase research, specifically in securing external research funding. ICO received over $100,000 in external research grants in fiscal year 1997-98, including significant grants from the Pearle Vision Foundation and the Illinois Society for the Prevention of Blindness. To insure that progress continues in this area, we have been sending faculty members to AOA grant writing workshops as well as the Academy Research Symposium.

Continued improvement of faculty teaching effectiveness is a high priority. We have created a Faculty Teaching Circle, in which informal monthly meetings focus on various teaching topics. One outcome of these meetings has been the creation of student-faculty colleague groups. A faculty retreat featured guest speakers from the University of South Carolina and the University of Chicago who spoke on the importance of developing effective feedback mechanisms from students so educational techniques might be refined and improved at ICO.

CONTINUING EDUCATION

“Through our Institute for Advanced Competency, 197 practicing optometrists received 358 hours of continuing education. In this fiscal year, we have already provided 323 hours of continuing education for 270 optometrists. We have also entered into agreements with various members of the ophthalmic community to provide CE. Included are: Cole Vision, EyeQuest, Consolidated Vision Group, Vistakon and TLC.

ILLINOIS EYE INSTITUTE

“The Illinois Eye Institute continued to make great progress in successfully marketing its services to the community. Through a fiscally conservative strategy…including print and radio advertising, direct mail and an increased presence at health fairs and neighborhood events, IEI (patient visits) increased by 4 percent in 1997-98, while producing a 10 percent increase in revenue. Through the first two months of this fiscal year, figures indicate that patient encounters are up by 16 percent as compared to the same period one year ago.

Various venues for patient feedback gave been created, such as surveys and a telephone comment line. Responses are being analyzed and changes in IEI resource allocation will be influenced by patient response.

In the realm of managed health care, the College is committed to enhancing the role of the optometrist as the primary eye-care provider. Along with our affiliate, the University of Chicago, we are in the process of developing a university-based, comprehensive eye-care product.

TECHNOLOGY

“While focusing on human elements, we have not neglected the bricks and mortar side of ICO during the past year, as well as computer software and hardware. Compulink, a new clinical software system, is about to enter the testing and training phase. Our target date to have this system “live” is late January of 1999. The CARS system, our financial and administrative system, is approximately 75 percent complete. We have upgraded all of our desktop computers with the addition of Windows 95 and Office 97. (And) Internet access was provided to most desktop computers. Currently, a new library system us under evaluation and selection. The long anticipated One Card System, which will allow ICO students (to use) a single card for security access, identification and purchasing, is on schedule and will be implemented in 1999.

BOARD OF TRUSTEES

“With the support of our Board, we remained fully committed to increasing diversity at ICO last year. One outcome of this commitment was the appointment of ICO alumna, Dr. Millicent Knight, to the Board the first female African American to so honor her alma mater.

COMMUNITY

“(ICO has) successfully reached out to the community. The recently created Community Advisory Board is comprised of eleven individuals, representing area churches, schools, community groups, government agencies, and members of ICO Administration. (Its purpose) is to discuss areas of mutual concern and to formulate plans for improving the quality of life for all the residents of our community.

Our students have played a significant role in strengthening our ties to the community. Through patient care in the IEI and also through such neighborhood projects as unity day, the literacy program and donating toys for Christmas, students have helped show our care and concern for our neighbors on a very real, one to one basis.

ALUMNI

“As the largest college of optometry in the country, ICO benefits from having the largest number of alumni of any of the schools or colleges of optometry. Through newsletters, direct mail, individual and group meetings and receptions at various professional meetings, we continue to forge strong bonds with our alumni.

A benefit to our students, we hope, will be an increased commitment on the part of the alumni to the ICO Endowment Fund. We are aggressively pursuing deferred and major gifts from our alumni and our friends in the ophthalmic industry to add to our endowment.

OPHTHALMIC INDUSTRY

“We are continuing to reach out to our partners in the ophthalmic industry. The Practice

Opportunities Symposium (which took place) this past spring was enthusiastically endorsed by representatives from a wide range of practice options. (This symposium provides the students with the opportunity to learn about all modes of optometric practice.) Through both… our alumni and our partners in the ophthalmic community, we have realized over $300,000 in pledges and gifts this year.

ACCREDITATION SITE VISITS

“During this past fiscal year, we benefited from two highly successful accreditation site visits: the Council on Optometric Education Interim Site Visit and the Primary Care Residency Reaccreditation. The COE visit confirmed that recommendations and suggestions made in its earlier report had been accomplished. The Primary Care Residency Reaccreditation was also highly successful as the accrediting team reported that all nine of its standards had been fully complied with. Preparations are now underway for the North Central Association accreditation visit in March of 1999…I am fully confident we will benefit from this examination and once again exceed expectations.

One year ago, I stood before you and announced that we had completed a strategic plan, our Prescription for Excellence (which would be) a living document to guide us through the coming year and into the next century….To date, of the 798 action items contained in the plan, 438 (items) or 55 percent have been completed. (Although) the Prescription for Excellence will continue to be our guide for the coming year…we have already begun the next phase of planning – identifying outcome measures, adding baseline data, and revising the plan to include new initiatives and linking a five-year operational budget to the plan.

As you know, this year we officially began our observation of our 125th anniversary as America’s oldest college of optometry. Over the years, the manner in which our profession is practiced and the way in which it is taught, has changed, but through it all our commitment to excellence has remained firm. With that continued commitment, I am confident that our progress over the next 125 years will be just as exciting.”[4]

It was during this academic year that Dr. Mullen led the school on a two-year journey toward excellence.

CHAPTER FOUR
JOURNEY TO EXCELLENCE
YEAR ONE

ICO’s 125th anniversary year (1998-99) marked not only a celebration of the College’s long history and its stature in the optometric profession. It also commemorated the beginning of momentous changes which would positively position the school as it entered the twenty-first century.

At the spring Interim Board Meeting, the Board of Trustees acted upon an alumni-inspired initiative and approved freezing tuition at the 1998-99 level ($22,668), while simultaneously increasing allocated funds for scholarship aid to $400,000 and gradually reducing entering class size for five years beginning in 2000. These directives had a crucial impact on ICO’s budget planning process, requiring mandatory expense reduction in order to maintain a balanced budget.

An ambitious $8.5 million campus capital improvement program – funded with revenues from the restructure of ICO’s debt – was completed during that year. The program included renovations to the physical plant; the purchase of new ophthalmic equipment; and the installation of extensive informational systems technology. With improvements to the campus’ external appearance along with other college-owned property, ICO participated in the continuing resurgence of community development.

Affiliation with the University of Chicago continued to flourish. A course in basic eye-care procedures for second-year University of Chicago medical students was developed and implemented.

In his “State of the College Address,” which he delivered on October 22, 1999, Dr. Mullen reflected on his years at ICO and the challenges that the College would face to maintain its leadership position:

“In preparing this year’s address, I found it useful to reflect back upon my arrival at ICO in 1996. At that time, I said three elements would characterize my presidency. (These were:)

1. The need to recognize the challenges that confront us and to clearly define them.
2. The importance of pervasive and detailed planning so we might marshal our resources and measure our progress in meeting these challenges, making adjustments as necessary.
3. Open and productive dialog among all members of the ICO family … the Board of Trustees, alumni, our many friends and partners in the ophthalmic community and businesses, and the residents of the community in which we are located.

I believe that our commitment to these three concepts provided the basis for significant progress at ICO during the past year. We have now successfully completed over 70 percent of the action items in our original strategic plan, Prescription for Excellence.”

Dr. Mullen further described in this same address some of the noteworthy accomplishments from that year as well as some of the challenges that lay ahead:

“We are in the process of (establishing) a faculty practice plan making ICO more attractive to (present) and prospective faculty.

Thanks to the hard work of our community based education staff, we have continued to expand our externship program…at over 100 sites throughout the United States and abroad. From these sites, combined with the Illinois Eye Institute, our students will benefit from more than 150,000 clinical teaching opportunities, significantly enhancing their educational experience. Student–patient encounters are up 68 percent compared to three years ago.

Our residency program has grown to include residencies in cornea/contact lenses and anterior segment/refractive surgery.

With the support of the Board of Trustees, we have embarked on a bold course to insure our position of leadership…(by freezing) tuition while simultaneously increasing scholarship aid. At the same time we committed to gradually reducing the size of future entering classes, beginning with a reduction by five for the class admitted in the year 2000.

To do this will be a tremendous challenge, but I am confident we can do it. However, these are not the only challenges facing ICO as we prepare for the next millennium. To maintain our position of leadership we must do the following:

• Continue to emphasize strategy and tactical planning with outcome-based assessment as the measure of progress.
• Amplify the voices of students in College affairs, including representation on the Board of Trustees.
• Continue to expand our recruitment of gifted foreign students beyond the confines of North America, while remaining a strong institution of choice for outstanding students from our neighbors to the north.
• Increase the size of the Board of Trustees, furthering its diversification. And recruiting members with needed expertise and philanthropic capabilities.
• Further enhance personnel relations within the ICO family, particularly as it pertains to fostering a positive attitude and respect for one another.
• Restructure the clinical education program to be more cost-efficient while we maintain academic quality.
• Accelerate the upgrade of instructional technology.
• Ensure that our curriculum is consistent with defined entry-level attributes.
• Develop and implement an advanced competency curriculum.
• Significantly increase the revenues of the Illinois Eye Institute.
• Implement a faculty practice plan.
• Continue to improve faculty scholarly activity with more externally funded research, clinical trials and publications.
• In cooperation with the University of Chicago, develop our role as a provider of comprehensive eye care services within the Chicagoland managed health-care market.
• Achieve continuing accreditation from the Council on Optometric Education.
• Achieve accreditation for the Illinois Eye Institute from the Joint Commission on Accreditation of Health Care Organizations, a first for an eye-care facility (that is) affiliated with a college of optometry.
• Launch major capital and deferred-giving campaigns to sustain an ongoing and significant development effort in keeping with our status as America’s largest college of optometry.
• Complete the cultural shift of the institution to one devoted to the continuous improvement of our programs, services and products.

Tomorrow night we will officially conclude our… celebration of our 125th anniversary. The highlight of the evening’s festivities will be the recognition of 125 individuals, organizations and institutions for their outstanding lifetime contributions to optometry. Some have contributed through research, others through practice, some through teaching, and some in the business world. Their contributions are as varied as their numbers…They have witnessed tremendous change in the way optometry is taught and the way it is practiced. They have learned to thrive in an environment of rapid change.

In the last year we have accomplished much…I look forward to reporting further progress in the years ahead.”[5]

Dr. Mullen then devoted the next year to the implementation of additional initiatives that had emerged during the previous identification and developmental period.

CHAPTER FIVE
JOURNEY TO EXCELLENCE
YEAR TWO

The mandate to successfully freeze tuition and increase the scholarship budget while maintaining a balanced budget and preserving the quality of education had a visible impact on ICO. Working on a 5-year budgeting plan, necessary expense reductions were made and continue to be implemented each year to achieve ICO’s goals.

A Voluntary Early Retirement Incentive Program was approved by the Board of Trustees, which took effect on January 1, 2000. Full-time employees with at least ten years of service and who are age 55 or older were eligible. Seven employees accepted the early retirement package. Responsibilities were reassigned so that, in most cases, those employees were not replaced.

The College worked diligently to increase income from non-tuition sources. Assets that could be invested grew by $6.5 million to more than $27 million since 1996. A Vision for the Future Campaign has been launched with the goal of growing the total endowment to $60 million by the year 2010. The Office of Institutional Advancement helped the President raise more than $1 million during the previous year.

Anticipating challenges such as the contracting student applicant pool and the changes in the healthcare industry, the administration tackled each situation head-on. Dr. Mullen reported these changes in his fourth annual “State of the College” address:

“We have had an outstanding year, thanks to every member of the ICO community. I am especially grateful to those who have played important roles in our ongoing strategic planning process. Much of our current and future success stems from those efforts.

It has allowed us to open new avenues of dialogue – within the college and within the profession, the healthcare industry and our constituents at large. It has allowed us to implement performance-based monitoring and measurement of our progress. And it has allowed us to positively engage faculty, administration and students in continuously improving our institution and our performance.”

Dr. Mullen then recounted some of the year’s achievements and strengths.

“Academically, we are stronger than ever. We have expanded externship sites to 118 (current sites) today…The (Illinois) Eye Institute and (these sites) now provide over 180,000 clinical encounters for our students each year. Our students’…pass rate on the National Board exams, at time of graduation, now stands at 94 percent. ICO has historically performed very well on the clinical sections of the National Boards and this year’s performance in Basic Science…significantly exceeded the national average.

Our student attrition rate is at an all time low of only 2.7 percent. We have expanded residency programs in cornea and contact lenses, refractive surgery and primary eye care…(We) have built research laboratory facilities and made significant technological improvements in our lecture centers.

Our graduates enter into practice better prepared to succeed thanks to significant improvements in our practice management course and programs such as the Practice Opportunities Symposium, Private Practice Club and ICO Placement Services.

Our affiliation with the University of Chicago’s Department of Ophthalmology and Visual Science stands unique among colleges of optometry. Our collaborative course for medical students speaks directly to our rigorous commitment to the arts and science of both medicine and optometry. We have also formalized our cooperative O.D./M.S. and O.D./Ph.D. programs with the University of Chicago.

Our faculty has enhanced its pursuit of scholarship. During the past year, a total of seven research grant proposals were submitted and six were funded. In addition, 21 articles were published in professional journals. Faculty representation in the American Academy of Optometry at the fellowship and diplomate levels stands at 87 percent up from 48 percent just four years ago.

Clinically, we are stronger as well. (There are) marked improvements in patient satisfaction and a 23 percent increase in Illinois Eye Institute revenues since 1997. Professionally, we have strengthened our outreach and built better relationships with other health care professionals and organizations through our Professional Advisory Board.

Financially, we are stronger than ever. Our (investment-worthy) assets have grown to more than $27 million, up more than $6.5 million in just four years. We have launched our Vision for the Future Campaign, with its goal of growing our total endowment to $60 million by the year 2010. Through a grant from the State of Illinois for $250,000, we have reestablished our indigent patient care program. We expect to reach thousands of high-risk patients in the coming year with this support.

We have also been able to freeze tuition at its level of two years ago (while increasing) the scholarship budget by nearly 50 percent…I want to recognize both the faculty and the students for independently and successfully launching and funding new scholarship programs to benefit students. Governance has grown even stronger through the Board’s concerted efforts to increase and diversify its members. We now have a voting faculty member on the Board of Trustees and student representation as well. But we cannot rest on our achievements and expect to maintain excellence. Challenges lie ahead. We must face them squarely. We can and we will.

Over the next few years, we have pledged ourselves to meet these challenges through continuous refinement of our strategic planning capabilities. Soon we will enhance patient care and clinical education by developing and implementing a Faculty Group Practice Plan.

In the face of a decreasing student applicant pool, we continue our commitment to recruit and admit only the most qualified students and assist them in managing the high cost of a quality education by continuing to freeze tuition and by increasing scholarship support.

Financially, we have committed ourselves to refining our financial planning in line with the goals of our strategic plan, Journey to Excellence. And we will continue to sustain and strengthen our capital and planned giving efforts. We will continue to enhance our academic culture through support of our faculty in their roles as teachers and through expanded opportunities for faculty research and scholarship. We will evaluate and modify our curriculum, striving to maintain an effective entry-to-practice model. We can prove our commitment to excellence in patient care by going forward with seeking accreditation from the Joint Commission on Accreditation of Healthcare Organizations.

The state of the College is strong because of the hard work and dedication of a great many people. Today, I would like to thank all of you…We’ve had an extraordinary year. We have an extraordinary future ahead of us as we continue to provide an outstanding education for future eye care professionals. I look forward to continuing on our Journey to Excellence with each and every one of you.”[6]

By meeting each of the Prescription for Excellence’s goals and applying the strategies in the Journey to Excellence, ICO is now prepared to face the future with confidence and a commitment to excellence.

CHAPTER SIX
COMMITMENT TO EXCELLENCE
WHAT LIES AHEAD

During these early years of the twenty-first century, both optometric education and the profession of optometry are facing new challenges: challenges that are both necessary and inevitable. Dr. Mullen predicted what the profession and Illinois College of Optometry might face in a guest editorial that appeared in the Journal of the American Optometric Association, (September 1999).

“The challenges facing ICO – to a greater or lesser extent – are the same issues that face many of the schools and colleges of optometry. In general I see the following trends in optometric education:

• We will see a lessening of our dependency on campus-based clinics for the clinical education of third- and fourth-year optometry students. Driven initially by economics – but, I believe, providing for greater diversity of educational experiences – we will see more community-based training sites or externships for fourth-professional-year students and some third-year rotations.
• Campus-based clinics will remain valuable for first- and second-year students.
• College-based clinics will serve a significant role as (the) faculty practice becomes more important as a means to enhance faculty income and improve (both) schools’ and colleges’ ability to recruit and retain highly qualified clinicians.
• We will see a movement away from traditional classroom teaching toward more technology-assisted self-learning through the rapid advances being made in communication and computer-based technology. The college, however, must be prepared to assist the faculty in changing their teaching strategies.
• Acquisition of critical analysis skills will become as important as a solid foundation in the basic and health sciences.
• There will be recognition that the function of a school or college is to prepare doctors of optometry for a life-time of learning in their field.
• We will have to redefine the entry-level attributes of our students and modify our curriculum to emphasize a lifelong commitment to learning.
• While graduates must learn to be well-grounded in the fundamentals of their profession, the purpose of this grounding must be to position them to continue the learning process.
• Students must learn to focus on the opportunity for interaction with faculty and with one another while on campus. They must commit to a philosophy that emphasizes the acquisition and appropriate application of knowledge over information absorption and memorization.
• We will see the development and utilization of a national faculty in several disciplines, linked through developing technology. All schools and colleges of optometry will be able to access a faculty made up of our very finest educators.
• Cooperation between optometry and ophthalmology that began at the New England College of Optometry’s Boston clinics and carried forward at PCO (Pennsylvania College of Optometry) with Hahnemann University and at ICO with the University of Chicago – will continue and intensify.
• We must then be prepared to offer meaningful advanced competency education to practicing optometrists as a core value of optometric education.
• Residency programs will continue to increase, but at a more modest rate. I believe the future direction of the profession of optometry will be fueled by the economics of the managed care marketplace.
• The cooperative environment among opticians, optometrists, and ophthalmologists that exists at the academic level and – in several instances – in other practice modes will intensify.
• Distinctions in practice modes will continue to blur among the three groups. Economic realities will override emotional opposition and force closer cooperation. Individual claims of priority and historical territorial imperatives will be forced to give way.
• Quality assurance programs and advanced competency certification and accreditation will become increasingly important.
• The expansion of the scope of practice of optometry will consist mainly of amendment and clarification to existing practice laws.
• Ultimately, all states will grant appropriate and extensive prescription authority to optometrists.
• The expanded use of laser technology by optometrists will evolve slowly over the next two decades.
• Consultation among practicing professionals will take advantage of advances in technology. Consultants with national eye centers of excellence will become the norm, as precise retinal images and other data are instantly transmitted from one point to another in real time.
• We will see fewer independent, private practitioners of optometry in the future and more multi-practice settings, more optometrists in HMOs, hospitals and other institutional settings. What is often termed ‘corporate optometry’ will continue to expand for the foreseeable future.
• Schools and colleges of optometry will recognize their responsibility to expose their students to a wide variety of practice modes and to discuss each opportunity openly and honestly.
• Health care third-party payers will continue to exert enormous influence on the practice of health care-eye care included. In this vein, it is imperative that optometry solidify its position as the primary eye care provider within the managed care market.

We live, learn, teach and practice in tremendously exciting times. I believe the future of optometry is as great as our ability to translate our vision for the profession into strategic and tactical plans of action – as promising as our courage and tenacity to implement those plans.”[7]

[1] Excerpted from “Interview with Charles F. Mullen, O.D.” Journal of the American Optometric Association 1999; 70:556-60. (Copyright © 1999 by the Journal of the American Optometric Association. Reprinted with permission.)

[2] Excerpted from Interview with Charles F. Mullen, O.D. Journal of the American Optometric Association 1999; 70:556-60. (Copyright © 1999 by the Journal of the American Optometric Association. Reprinted with permission.

[3] Excerpts from “State of the College Address – October 01, 1997” which was delivered by Dr. Charles F. Mullen.

[4] Excerpts from “State of the College Address – October 02, 1998” which was delivered by Dr. Charles F. Mullen.

[5] Excerpts from “State of the College Address – October 22, 1998” which was delivered by Dr. Charles F. Mullen.

[6] Excerpts from “State of the College Address – October 20, 2001” which was delivered by Dr. Charles F. Mullen.

[7] Excerpts from “Interview with Charles F. Mullen, O.D.” Journal of the American Optometric Association 1999; 70:556-60. (Copyright © 1999 by the Journal of the American Optometric Association. Reprinted with permission.)

First published in 2001 by
Illinois College of Optometry
3241 South Michigan Avenue, Chicago, IL 60616 USA

Cover design:
Anistatia R. Miller
Jared M. Brown

Book design:
Alan Pouch

Photographs:
Ray Reiss, Sparkfactor
Andrew Fils, The Paul Studio
Alan Pouch, Illinois College of Optometry

Preface & commentary:
Barbara B. Renard
Copyright © 2001 by Charles F. Mullen, O.D. and Barbara B. Renard

All rights reserved.
No part of this book may be reproduced, stored in or introduced into a retrieval system, or transmitted in any form or by any means (including electronic, mechanical, photocopy) whatsoever without written permission from the above publisher of this book, except by reviewers who may quote brief passages to be printed be a magazine or newspaper.

ISBN #: 0-9652759-Printed in the United States by Paperback Mfrs.

The post The Road to Excellence: Illinois College of Optometry appeared first on Charles F. Mullen.

Before presenting my thoughts on the future of externships, it might be useful to review where we are, and how we got here.

The Past

Community based clinical education – commonly referred to as externships – has its roots in the late 1960’s. Several factors coalesced at that point in time to create the impetus for what was then a new direction for optometric education.

First, faculty and administrators had become increasingly aware of the need to enhance student-patient encounters, both in terms of quantity and in diversity of experience. This impetus was bolstered by increases in class size at several institutions. Space and patient volumes at many college-operated clinics simply were not adequate to meet student needs.

Second, and closely connected, there was a growing recognition that student-patient encounters would be more beneficial to the students’ education if they took place in an environment outside the traditional academic environment. Supporting this view was the awareness of the need to train optometry students to interact with other health care disciplines.

Third, pressure was coming from practicing optometrist to expand the scope of our profession. Those of you who were in the service as optometrists in those days many recall that military protocols allowed optometrists greater latitude in treatment options, particularly in regard to pharmaceutical agents, than did state regulations. Having expanded their practice while in the Military, these optometrists were reluctant to step back into the more restrictive guidelines of civilian practice. They realized that optometry students, as well as the faculty, needed training in the use of pharmaceutical agents.

Fourth, several colleges of optometry had urban campuses, often in areas with significantly undeserved populations in terms of health care. These institutions had a strong commitment to provide eye care to those residing in proximal neighborhoods.

As a result of these concurrent pressures, several institutions, acting independently of one another, came to the conclusion that the most promising avenue for meeting these needs was to form networks of clinic affiliations with existing health care institutions. However, any illusions regarding the ease with which this strategy would be executed were quickly dispelled.

Those attempting to create externships encountered reluctance on the part of health center administrators to permit students to participate in their programs. Medical staffs were unfamiliar with Optometry, and the benefits optometry students could provide. Ophthalmologists did not have a history of interacting with Optometrists, and were often reluctant to do so. The new model of community based clinical education also aroused antagonism among community optometric practitioners who perceived it as an unwanted competitive threat.

Nonetheless, the need for externships was too great to be denied, and the creation of externships proceeded. These first externships shared several characteristics. Criteria for site selection and evaluation were ill defined. The terms of the affiliations themselves were not always well drafted. Student selection/assignment processes lacked consistency. The length of student rotations varied widely, from a half a day in some to a year in others. In too many instances there was little staff support from the parent institutions.

The first externships were located in a variety of settings, but primarily they were in community health centers, nursing homes, prisons, military facilities, public health facilities, the VA, university student health services, and even in some private practice settings.

Fortunately, many of these facilities encouraged, or even required, the use of pharmaceutical agents by optometrists. This experience would prove invaluable as optometry faculty were called upon a few years later to provide instruction in diagnostic and therapeutic agents as state practice laws changed.

Despite a rather awkward beginning, and with all the missteps and mistakes notwithstanding, the movement towards community based clinical education in the late 1960’s had a profound impact on our profession, and must be considered one of the most important innovations in the development of optometric education. It was through the creation of these external affiliations, and the availability of large patient volumes, that the base was established for the subsequent growth of optometry into a true primary care profession.

The Present

Today community based clinical education has expanded dramatically in terms of the quantity and quality of externships. A recent ASCO survey found that all the schools and colleges of Optometry responding reported that they had externship programs. The number of sites per institution ranged from 25 to 200.

While great progress has been made, it has been uneven. In some areas the problems experienced by those early externships continue. However, most externships enjoy strong support from their parent institutions. Today’s students typically serve two rotations of twelve weeks each. Student preference is an important consideration in the assignment process; housing, meals, and a stipend are provided on a limited basis.

Today site selection and evaluation procedures are in place. Formal affiliation agreements provide guidance and define and expand responsibilities – but with varying degrees of thoroughness. In general those affiliations that include a government entity tend to be better defined than those that do not.

Externship preceptors are recognized with some form of faculty rank, often an adjunct appointment. Externships are predominantly located in government health care facilities, such as those operated by the VA, the Indian Health Service or the Military. They are also found in public and private hospitals, rehab centers, and referral centers. They continue to be found in private practice arrangements, nursing homes, prisons, special needs schools, and university student health clinics. They are also located in community health centers and facilities operated by HMO’s.

In general, the overall state of the national externship program is strong, significant in its impact, well managed and improving. It is firmly established as an essential component in the education and training of today’s optometry student.

The Future

What is the future of externships? As important as the externship has become, I would suggest today that its role is about to increase significantly. Once again forces are coalescing to create a climate conducive to, and even more demanding than the 1960’s.

Today’s health care environment is being driven by the demands of managed care and government that costs be reduced while quality and efficiency are increased.

In this environment I believe externships will become the primary source of clinical experience for optometry students. And while there will always be a need for some sort of sheltered workshop for clinical training of first and second year students, such as college operated campus clinics, the role of these clinics will be correspondingly diminished as the role of the externship grows in importance. Campus based clinical education will be limited to special emphasis areas such as pediatrics, vision rehabilitation and advanced ophthalmic care, while primary care education will be delegated to multiple affiliated health care facilities.

Just as several unrelated and related forces combined in the ‘60s to created externship, a combination of forces at work in the ‘90s will once again drive their expansion.

The large numbers of close-at-hand underserved patients, once the backbone of institutionally based clinics, have become attractive to managed care providers as government units have turned to managed care to administer health care. Once spurned by third party payers as a burden, they are now sought by those who, unencumbered by an educational mission, are able to respond rapidly, efficiently and cost effectively. The ability of large single purpose eye clinics, such as those operated by most schools and colleges of optometry, is now seriously compromised.

Forced to allocated scarce resources to market to what was formally a virtually reserved patient base, such clinics are finding it even more difficulty to be cost effective, if indeed they ever were. As patient numbers decline, educational inefficiencies increase, and operating deficits increase.

Externships, by contrast, are highly cost effective, offer a challenging clinical environment, and are often staffed by seasoned preceptors. This nicely compliments the basic clinical training provided by college faculty. The clinical experience gained at externships is both progressive and stimulating for students.

I believe, therefore, that the demand for more externships, geographically distributed, will increase in the years ahead. Longer rotations, and more rotations, will be the standard. Advances in communication, such as telemedicine and the internet, will make it easier for institutions to effectively manage a widely distributed network.

There exists today a vast, and largely untapped, potential within the federal sector for externships in optometry, where the growth will take place.

However, I must raise a cautionary note. We learned a great deal from the mistakes that were made in the ‘60s in the creation of externships, and we have benefited from that knowledge. However, that does not mean we must continue to rely on trial and error as the path to wisdom. To the extent that we are able, we must anticipate the problems that will inevitably arise from the creation of a national network of externships.

The Challenge to Optometry

A significant challenge to us all will be the efficient and equitable use of this national network of externship sites by the schools and colleges of optometry. If we follow the competitive model of the past, some schools will find they have a surplus of externships, zealously guarded as a resource, while other schools will find they have an unmet need for student placements.

We must begin to work together to establish a national clearing house and placement service for externships in optometry. Through such a clearinghouse all institutions of optometric education will fully share in this enormous national resource, and each site will be appropriately and fully utilized. The clearinghouse could facilitate the development and implementation of national standards for externships, possibly leading to some form of accreditation for participating sites.

Our purpose, after all, is not to compete with one another, but to cooperate in the advancement of optometric education and the profession. By so doing we not only assure an efficient and effective use of the opportunity that is being presented to us, but we also best serve the needs of our students, the affiliated facilities, and the patients they treat.

I realize this will not happen over night. It will require much discussion and a decision to accept challenges and make compromises. It will require a recognition of the fact that the traditional environments in which we have lived will not be the models for tomorrow. It will require change. It will not be easy. It will be necessary.

Acknowledgements

The author thanks Drs. Daniel Roberts and Stephanie Messner of the Illinois College of Optometry who assisted in the preparation of these remarks.

These remarks were originally delivered to the Optometric Education Section at the December 1997 American Academy of Optometry meeting.

The Journal of the Association of Schools and Colleges of Optometry.
Optometric Education. Volume 24, Number 1. Fall 1998.
Charles F. Mullen, O.D., Guest Editorial

The post The Past, Present and Future of Externships in Clinical Education appeared first on Charles F. Mullen.

The Clinical System was charged with the educational responsibility of developing optometric students into competent patient care professionals who could apply scientific knowledge, tempered by clinical insight and overall concern for the patient, to the solution of problems of human vision. Coincident with this educational mission, was a commitment to providing eye care to indigent and inner-city residents who either could not afford to meet this health need or were unable to do so in their own communities.

It was concluded that the most promising scheme for fulfilling both objectives was to form a network of clinic affiliations with existing health care institutions so that students could receive clinical training in efficient multidisciplinary health care delivery centers. These affiliations have broadened the environments in which the college’s students serve their clinical rotations; expanded their experience in specialty areas such as pediatrics and vision rehabilitation; increased their number of primary clinical teaching encounters (up from an average of fifty to a current average of approximately 400 by the time the student graduates); increased the ophthalmological input into their education and their consequent ability to identify ocular disease; enhanced their ability to work effectively with ophthalmologists and professionals from other disciplines such as medical pediatrics, psychiatry, internal medicine and psychology; and in short, better equipped them to function in a changing health care delivery environment.

Objectives

In 1970 The New England College of Optometry (then the Massachusetts College of Optometry) initiated major revisions in its curriculum. One of the goals of these revisions was to enrich and expand optometric students’ clinical experience. The Clinical System was charged with the educational responsibility of developing optometric students into competent patient care professional who could apply scientific knowledge, tempered by clinical insight and overall concern for the patient, to the solution of problems of human vision.

Specifically, the Clinical System was assigned seven educational objectives:

1. To develop the student’s ability to apply knowledge in visual science to prevent and solve problems of human vision.
2. To develop the student’s ability to utilize appropriate knowledge in the behavioral, social, and other health sciences to alleviate human suffering.
3. To encourage the development of the student’s sense of clinical insight and judgment.
4. To develop a high level of technical competence in the use of modern optometric techniques.
5. To engender high standards of professional competence and responsibility.
6. To engender an appreciation for continued study, not only in visual science, but also in the behavioral, social, and health sciences.
7. To develop the student’s ability to work effectively with other health professionals and ancillary personnel in alleviating human problems.

With a view toward achieving these objectives, precise clinical education guidelines were established for each of the three years in which students receive clinical training.

First Clinical Year (Second Professional Year)

Although exposed to most routine optometric clinical procedures in his or her pre-clinical year, the student can be expected to have achieved proficiency in only a few. The objectives for the first clinical year were:

1. To engender an appreciation for the model of patient care set forth in a Patient Bill of Rights.
2. To achieve technical competence in basic optometric examination techniques.
3. To begin development of the technique of taking a case history as a means of eliciting, defining, and delineating patient problems.
4. To establish professional patterns of patient interaction.
5. To develop the student’s ability to distinguish between pathological and non-pathological problems.
6. To encourage self-confidence in patient-examiner relationships.
7. To begin to develop the student’s ability to understand patient complaints as manifested in examination results.
8. To introduce the student to more advanced clinical testing.

Second Clinical Year (Third Professional Year)

In this year there was to be an intensification and advancement from the previous year in preparation for greater patient care responsibilities in the final clinical year. Objectives of the second clinical year follow:

1. To develop a high level of technical competence in all basic examination procedures and adequate competence in special procedures.
2. The refinement of case-history taking as a diagnostic tool.
3. To develop the ability to understand most patient complaints as manifested in examination results.
4. To begin development of the student’s ability to manage patients with ocular disease manifested in the eye.
5. To develop the student’s ability to select appropriate referral sources.
6. To develop the student’s professional inquisitiveness to seek new and/or additional sources of information to solve patient problems.

The Objectives of the Third Clinical Year (Fourth Professional Year)

1. To encourage the student to accept broad responsibility in the diagnosis and management of general optometric problems.
2. To develop the student’s role as a member of a health care team through interdisciplinary participation.
3. To expose students to the specialties of pediatric and rehabilitative optometry.
4. To expose the student to various modes of practice and to various socioeconomic groups of patients.
5. To develop the student’s ability to recognize ocular pathology and systemic pathology manifested in the eye.
6. To develop the student’s ability to utilize pharmaceutical agents in the diagnosis and management of patients.
7. To acquaint students with diagnosis through the use of advanced clinical techniques such as visual evoked response, electroretinography, and fluorescein angiography.

The student was to be evaluated by his or her preceptor in terms of achievement of the objectives for a given clinical year. The preceptor would use a variety of methods to appraise student abilities, including direct observation, discussions with the preceptee, clinical proficiency tests, papers and quizzes, review of the student’s patient records, and observations of other faculty members.

Development

In 1969, only fourth professional year students participated in the clinical program conducted at The New England College of Optometry’s General Clinic located in Kenmore Square in Boston. Training in the optometric specialties of pediatric, vision rehabilitation, and environmental vision was very limited. The students acquired some reasonably valuable experience in managing patients in this setting, but it was evident that only the most basic clinical skills would be acquired. In the first place, the typical General Clinic patient was young, healthy, white, and middle-class. Optometric student clinicians learned to mange only the narrowest range of vision and ocular anomalies in the course of treating this population. Secondly, because our students were unable to interact with professionals from other disciplines, they were conditioned to perceive patients primarily as optometric problems and not as total human beings. In short, they were not receiving realistic health care delivery experience.

The College wanted to expand and enrich the clinical teaching environment to which its students had access. We knew our students would see a higher incidence of ocular and vision anomalies in patient populations from low socioeconomic strata and also we knew that they would benefit from health care environments in which the optometrist was one of many health care professionals contributing to the care of the patient as a whole person.

Coincident with our educational mission, and not at all incompatible with it, was a commitment to providing eye care to indigent and inner-city residents who either could not afford to meet this health need or were unable to do so in their own communities. The New England College of Optometry was further committed to developing a one-class delivery system serving in the same manner the needs of all patients regardless of race, color, religion, national origin, or ability to pay.

We concluded that the most promising scheme for fulfilling both our educational and patient care objectives was to form a network of clinic affiliations with existing health care institutions so that our students could receive clinical training in efficient multidisciplinary health care delivery centers.

As we began to develop the program, any illusions we may have had about the ease of executing our new strategy were quickly dispelled. In the days to come we were to learn a lot about skills that had (we thought) nothing to do with optometry or optometric education: about convincing skeptics, compromising, introducing safeguards, planning, and negotiating. In the first place, there was reluctance on the part of health center administrators to permit students to participate in their programs. Historically, the health center community was disenchanted with receiving its health care in the emergency rooms of large inner-city teaching hospitals, and our program, they thought, was precisely what they were seeking to escape.

Our second problem revolved around the reluctance of medical staffs at certain health centers to work directly with optometrists. We found it necessary to convince them, at a very fundamental level, of the legitimacy of the ability of optometrists to function in and contribute to an interdisciplinary environment.

A third problem had to do with the antagonism our new educational model aroused among private practitioners, many of whom were our own alumni and friends. We cannot say with any honesty that we have completely solved this problem. Many private practitioners continue to feel that we are intruding into an area that is rightfully theirs, although patient records indicate that many of the patients we are seeing at neighborhood health centers have never before received eye care.

After successfully negotiating a mutually acceptable agreement with the Dorchester House Multi-Service Center and after strengthening our affiliation with the United States Public Health Services Hospital in Brighton, Massachusetts, we went on to develop additional relationships: The South End Community Health Center (Boston), Dimock Community Health Center (Roxbury, MA), Gundersen Eye Clinic, University Medical Center (Boston), Central State Hospital (Milledgeville, GA), Massachusetts Laborers’ Clinic (Boston), Massachusetts Institute of Technology, Medical Department, Eye Clinic (Cambridge, MA), Teamsters’ Eye Clinic (Charlestown, MA), Carpenters’ Union Eye Clinic (Cambridge, MA), Eye Research Unit, Joslin Diabetic Foundation (Boston), University Health Services, University of Massachusetts (Amherst, MA), Cotting School for Handicapped Children (Boston), Huntington General Hospital (Boston), Walter Reed Army Medical Center (Washington, DC), Hadassah University Hospital (Jerusalem, Israel), Veterans Administration Out-Patient Clinic (Boston), Connecticut Visual Health Center (Bridgeport, CT), Harvard Community Health Plan, (Boston), and externships with selected practicing optometrists and ophthalmologists and certain specialty clinics in the United States and abroad. The college currently maintains nineteen clinical relationships in addition to operating three of its own facilities – a General and two Specialty clinics. Teaching outpatient activity, at all clinics last year exceeded 40,000 patient visits.

These relationships broadened the environments in which students and faculty gained clinical experience and expanded training in specialty areas such as pediatric and vision rehabilitation. For example, Boston University’s Gundersen Eye Clinic allows optometric students to evaluate visually impaired patients referred to Boston University Medical Center from all over the world. In rendering optometric care students learn to work closely with psychologists, social workers, and other health professionals in the rehabilitation of the visually impaired. And at Central State Hospital in Milledgeville, Georgia, students learn techniques for performing optometric examinations with patients who are severely retarded.

Sixty-eight professionals currently participate in the NECO clinical program on a full-time, part-time, or consulting basis. Forty-eight O.D.’s, six O.D.-Ph.D.’s and fourteen M.D.’s interact in various clinical capacities.

In 1969, our graduating students averaged only fifty primary encounters each. Today, the typical student has rendered primary care to over 400 patients by the time he or she graduates.

Finances

Initially, the plan to expand and diversify our clinical program promised (or threatened) to be a very expensive one. If we are to look at the clinical system in terms of revenues and expenses, it is not yet financially self-sufficient. However, the deficit of clinical operations has decreased significantly from fiscal year 1972-73, when we experienced a direct cost operating deficit in our clinical system of $187,644 to a projected deficit of $41,967 for fiscal year 1975-1976. And it should be noted that no student tuition funds were allocated to support clinical activities. We believe that revenues from patient fees and affiliation contracts will continue to increase at a modest rate throughout fiscal years 1975-76 and 1976-77 and that grant revenues for clinical activities will continue to increase at a significant rate in 1976-77, placing the clinical system in a financially stable posture by the end of fiscal 1976-77.

Analysis of patient fee revenues, affiliation contracts, and grant revenues suggest growth both in income and expense. However, when the value of all clinical resources is calculated, using a rationale of calculating the value of contributed resources, the sum for the current year, 1975-76, of the total value of all clinical resources is $882,145. This is a dramatic increase and does more accurately reflect increases in clinical activity. We do, in fact have appropriate access to facilities and services for which a fair outlay this year would be approximately $900,000. Grant revenues for clinical activities also have continued to increase significantly from $34,136 in 1972-73 to $491,325 for fiscal year 1976-77. These funds serve as excellent investments in the expansion of our clinical teaching program. It is our eventual objective to make all advanced level clinical teaching units self-sustaining.

We define a clinical teaching module as a teaching unit operating approximately forty hours per week, year-round, in which one full-time optometric clinical faculty member, one consulting ophthalmological faculty member, and other preceptors as available teach three or four students and serve patients along with support personnel in a physical facility adequate to the task. Two to four fully equipped examination rooms, plus special testing space and equipment and supporting facilities, are required. We have determined that an average cost of supporting one teaching module in fiscal year 1974-75 was $51,500.

Partial units can be calculated on the basis of less than full-time operation or less than a full complement. When patient fees, affiliation contracts, and contributed clinical teaching operating resources are summed, the total value of resources used in clinical training during the 1975-76 year is almost $900,000.

Evaluation

We have reason to believe that we have achieved most of our clinical development goals to a greater degree than we ever could have anticipated.

Today’s students are seeing more challenging patients than their predecessors saw – from the retarded or orthopedically handicapped child to the aged man or woman who, having never been seen by an eye care professional before, often has multiple uncorrected vision and ocular problems. Our students have had much greater ophthalmological input in their education and are receiving excellent training in identifying ocular disease.

They have learned to work effectively with ophthalmologists and with professionals from disciplines such as pediatrics, psychiatry, internal medicine, and psychology. They have come to appreciate the enormous amount of knowledge these disciplines have to contribute to optometry and have played an active role in acquainting representatives of these disciplines with the fact that the optometric profession, in turn, has a great deal to contribute. Faculty and students have been responsible for convincing many that optometrists, given the opportunity to do so, can make important contributions in an interdisciplinary health care setting.

A very workable eye care protocol – involving the optometric technician, the optometrist, and the ophthalmologist – has evolved from our experience with various institutions with which we are affiliated. Currently, NECO, Tufts University Medical School (Department of Ophthalmology), and the Veterans Administration Hospital in Boston, are working on the development of grant proposals to refine and evaluate the protocol still further.

Our students have learned to communicate more effectively with patients, other health care professionals, and administrators. And in a changing environment these skills are unquestionably valuable.

Many of our graduating students have very different professional aspirations as a result of their clinical experience. Some of them want to and will create eye care services in neighborhood health centers, others are seeking HMO appointments, joining the military service, or seeking appointments in other institutional settings. Many of those going into private practice are looking for group practice where they can continue to enjoy the professional interaction which they have found to be a source of growth during their preceptorships at NECO. Some of them have become deeply involved with the whole issue of public health and are seeking to broaden their education and assume roles in which they would have a larger voice in health care policy-making. Certainly, the health care delivery environment is changing, and we believe The New England College of Optometry had taken steps to meet our obligation to the profession and to the patient we serve to develop an optometrist capable of operating effectively in that environment.

Plans and Goals

Our future plans and goals for the New England College of Optometry Clinical System include both the improvement of existing programs and the establishment of new ones. Additionally, we are focusing on ways of enhancing the value of the Clinical System to the faculty and students who participate in it as well as to the patient population the system serves and the entire optometric community.

We plan to expand the capabilities of all clinics in the system so that they are better able to serve both educational and patient-care needs. Those plans include the establishment of ocular photographic capabilities throughout the system (currently, capabilities vary widely); the development and implementation of general health screening programs, hypertensive and diabetic screening; and the implementation of perceptual skills screening programs throughout the system (only NECO’s own Specialty Clinic currently performs such screening on a regular basis). On a smaller scale – but still with the goal of improving performance and value – we plan to add additional clinical teaching aids such as closed circuit television systems and other related educational materials to the clinical program, and to refine and enhance the clinical reference library system. And, because we understand our obligation to advance optometric knowledge and technology, rather than simply to provide patient care in accordance with current procedures, we plan to enhance our clinical research programs.

We are very concerned with improving the professional value of the clinical experience for our clinical faculty and with improving their ability to contribute creatively to the system. We are seeking funds though grant support and increased revenues from other mechanisms to upgrade the salary levels of clinical faulty to increase the research, library, and conference time allotted for clinical teaching faculty, with the expectation that such time would permit them to make important contributions to the body of optometric literature.

In order to increase the educational value of the clinical experience, we plan to continue to improve the integration and interdigitation of the didactic and clinical programs, and to formalize a student/clinical instructor interaction protocol.

We intend to increase our effort to monitor student progress and to facilitate this effort by developing and implementing a system-wide peer review/patient care quality assurance program.

Additionally, we plan to increase still further our student’s patient contact. Currently, our fourth professional year students spend two quarters in their final year in clinical training, or 24 weeks. Nearly all of their clinical training is conducted in external environments. We plan, effective July 1, 1976 to expand our external clinical training program to include students from the third professional year. Third professional year students will spend time in an external environment as well as continue to participate in our General Clinic. We plan to continue to have our second professional year students gain clinical experience in our own General Clinic. This scheme, we hope, will increase the number of primary encounters per graduating student to well over 400, with an intermediate goal of 1000 primary encounters per graduating student.

Some of our plans which will enable us to further expand and vary our student’s clinical experience include our attempts to find funds to build new internal clinic facilities; to bring our Electrophysiology Clinic into full clinical operation; to expand our Community Vision Screening Program; to develop over the next year eleven additional clinical teaching affiliations, particularly with pediatric and rehabilitation patient populations; and to develop and seek funding for a mobile home care/nursing eye care program.

Some of the new affiliations additionally will serve as training rotations for newly developed residencies in vision rehabilitation, optometric pediatrics, and general optometry.

We will work vigorously to reinforce and refine the optometric-ophthalmological interaction protocol we have developed and to see that it is operating optimally in all existing and planned clinical settings. Plans along these lines include evaluation of the protocol by external consultants and the development of a joint optometric-ophthalmological teaching program with Tufts New England Medical Center, the Boston Veterans Administration Hospital and the New England College of Optometry.

Our most ambitious goal involves thorough integration of the NECO Clinical System into the optometric community. We would like to improve the sense of participation of clinical faculty in over-all institutional programs and increase the sense of participation in and identity with the Clinical System on the part of private practitioners. Our first step toward achievement of our integrational goal will be to appoint to our Clinical Advisory Board, consumers, private optometric practitioners, and other health care professionals.

Conclusion

Development of the New England College of Optometry’s Clinical System over the past seven years has been extensive and fundamental. Generally, we think we have been successful in creating a system that more effectively serves the educational needs of our students and the vision care needs of our patient population. Certainly, our plans for the future will not involve changes as fundamental as those made since 1969. On the other hand, we have no illusions that our work is done. Our goals for the future are ambitious and, we feel, accessible. As we achieve them, we will establish new ones in a continuous attempt to make the New England College of Optometry Clinical System responsive to the needs of its constituents and to a changing environment.

About our Author

Dr. Charles Mullen is director of the Division of Patient Care and associate professor at the Pennsylvania College of Optometry in Philadelphia, a position he assumed June 1, 1976. He previously served as special assistant to the president for clinical development at The New England College of Optometry (formerly the Massachusetts College of Optometry). This article is based on his experiences in the latter capacity.

Dr. Mullen, a graduate of the University of Virginia, earned his O.D. at The New England College of Optometry (NECO). In addition to his administrative responsibilities while he was at NECO, Dr. Mullen served as a clinical preceptor at various affiliated institutions including the Kennedy Memorial Hospital in Brighton and the Dimock Community Health Center in Roxbury, Massachusetts. He has served as a consultant to numerous organizations, including the University of Massachusetts’ University Health Services; the Veterans Administration’s Department of Medicine and Surgery; Massachusetts Department of Public Welfare; and the Optometric Center of Maryland. He is a Fellow of the American Academy of Optometry and a member of the American Optometric Association and American Public Health Association.

His professional interests include clinical pharmacology and ocular anterior segment disease. He has lectured in the United States, Europe, and Australia on these and other subjects and he was a member of the instructional group responsible for certifying the first American optometrists in the use of diagnostic pharmaceutical agents.

Journal of the American Optometric Association
Volume 48, Number 7, July 1977
Charles F. Mullen, O.D.

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