July 15, 2009
Regina Benjamin, M.D., M.B.A.
United States Surgeon General (designate)

Dear Dr. Benjamin:

Please allow me to extend my most sincere congratulation on your nomination as Surgeon General. Given your credentials, unique experience and dedication, you are ideally suited for this challenging position at a critical time for health care in our nation.

I am sure you are aware of the numerous health care issues facing inner-city and rural America. One issue that I find particularly troubling is the unmet need for programs to address preventable threats to visual health. The Department of Health and Human Services Healthy People Program identified the most significant threats to visual health and established goals to reduce those threats. The program addresses visual impairment due to eye disease/conditions including glaucoma, diabetic eye disease, cataract, amblyopia and refractive error and recommends: regular eye examinations for children and adults, vision screening for preschool children, eye injury prevention, and low vision examination.

These visual health goals can only be achieved when all Americans and, particularly those in rural and inner-city areas, have access to eye care services. Only about 20 to 30 percent of all federally qualified health centers provide eye care services, despite the growing disparities that exist for rural and inner-city Americans.

Efforts must be made to attract more optometrists to rural and inner-city areas through financial incentives such as student loan forgiveness and equipment purchasing grants and loans. Inclusion of optometry in the National Health Service Corps (NHSC) is essential to the placement of optometrists in these areas. I was most interested when you proudly spoke of your experience in the NHSC during your nomination speech and how it shaped your career path.

Federal and state governments should also encourage visual health education, describing the benefits of regular eye examinations for adults and children, including vision screening for preschool children and eye injury prevention. These efforts should be provided through culturally sensitive and appropriate materials and venues.

Optometry’s first program to collaborate with community health centers to improve access to inner-city Americans was developed in Boston by the New England College of Optometry in the late 1960’s, in cooperation with three community health centers. Today, the program has grown to include 14 health centers and 30 other affiliations and inner-city programs. It was also the first collaborative model of care between optometry and ophthalmology in the Nation. This community based program is now managed by the College’s subsidiary, the New England Eye Institute, and has evolved into a national model demonstrating the compatibility of a commitment to community eye care and clinical education. While few inner-city and rural health centers have eye care services, nearly all Boston health centers provide these services. Once you are sworn in as the next United States Surgeon General, you may want to review this highly effective model for possible application to other parts of our country.

Thank you for willingness to take on the challenge of Surgeon General and again congratulations.

Sincerely,

Charles F. Mullen, O.D.
Member, Board of Trustees
New England College of Optometry

Click here to see the fullscreen presentation.

To download this presentation (as .ppt or .pdf) maximize the slideshow (small box next to slide numbers) and choose “Actions”

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

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

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 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.