We must not let anyone else write our future.

– Dr. Ronald Hopping, President AOA

Restructuring the Profession of Optometry (PDF)

Restructuring the Profession of Optometry (PPT)

Charles F. Mullen
Roger Wilson
Janice E. Scharre
David S. Danielson

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Thank you for this high honor. It is a distinct privilege to join my fellow honorees, Dr. Joan Exford and Dr. David Reynolds on the dais this morning.

Trustees, President Scott, colleagues, honored guests and above all doctoral degree candidates.

I know you are eager to receive your degrees and celebrate your hard earned achievement. However, as tradition dictates—there will be no degrees until the old alumnus speaks.

Today, I join with families and friends in sharing the pride of an outstanding accomplishment—your Doctorate in Optometry.

You have been fortunate for the past four years to have received your professional education at an institution that is a leader in community-based clinical training and collaborative medical care.

Your future is bright with unparalleled opportunities in a rapidly evolving health care environment.

An excellent faculty and clinical attending staff have thoroughly prepared you for success in the areas of public health, patient care and clinical education.

In the area of public health—There are opportunities for you to meet the needs of special populations in medically underserved areas.

Those who live in poverty, the homeless, the frail elderly, the homebound, the developmentally disabled and the visually impaired.

The College’s subsidiary, New England Eye’s network of affiliations serves as the National model for outreach to special populations.

In patient care, practice opportunities are available in interdisciplinary care as optometrists manage more complex clinical conditions and diseases.

Telemedicine technologies and electronic health records provide the means for more effective patient management.

The model of inter-professional collaboration between optometry and ophthalmology pioneered at the New England College of Optometry formed the basis for affiliations between optometry colleges and medical schools in Philadelphia and Chicago.

The College’s nationally recognized research programs provide valuable insights to clinicians in the diagnosis, treatment and prevention of eye and vision conditions.

In clinical education, there are opportunities for you, as preceptors, to share your experiences in:

• patient-centered clinical education
• and clinical training in interdisciplinary facilities.

The College’s externship program is the most extensive and diverse in optometric education.

My education, like yours, prepared me not only to be a clinician, but also to contribute to the profession’s future.

Your professional status will provide entree to numerous civic and political activities.

In the past, the foresight and persistence of dedicated optometrists expanded the profession’s responsibilities by including pharmaceuticals, advanced clinical procedures, creation of the VA Optometry Service and participation in Medicare.

You are now called upon to make such a contribution.

Important matters face the profession of optometry.

Board Certification and Continued Competency initiatives require your attention and understanding of their place in your profession.

I encourage your active participation at the local, state or national level in planning for your profession’s future.

With major changes expected in health care policy at the Federal level, there are unprecedented opportunities for optometry to seek inclusion in three major Federal programs.

First and already in progress, is the expansion of optometry’s impact in the community health care system.

The New England College of Optometry was the first optometric institution to recognize its responsibility to the medically underserved community by developing affiliations with Boston Area community health centers.

Today, community health centers provide accessible and cost effective primary medical care to 20 million Americans in rural areas and poor urban neighborhoods.

However, only 20% of federally qualified health centers offer eye care services, despite the growing need in rural and inner-city America.

It is estimated that 5,000 optometrists would be needed in the Nation’s underserved areas over the next decade.

Federal funding is required to establish optometric services in all of the Nation’s community health centers.

Second, efforts must be made to attract more optometrists to medically underserved areas through financial incentives, such as tax free student loan repayment, by including optometrists in the National Health Service Corps.

Third is optometry’s inclusion in the Graduate Medical Education program, GME, the clinical educational component of Medicare. Participation in this $10 billion program would address:

• the increasing costs of clinical training as the scope of optometric practice continues to expand.
• and growth in the demand for eye care services by the Medicare population.

Optometrists have been participating physicians in the Medicare program since 1987 and currently provide $1 billion in services annually.

Now is the time to join medicine, dentistry and podiatry as a recipient of GME funding for clinical training.

Your participation in advancing initiatives in Community-Based Eye Care, the National Health Service Corps and the Graduate Medical Education Program is essential to their success.

Although the work ahead will be challenging, optometry’s inclusion in these three major Federal programs would provide eye care to tens of thousands of underserved Americans, new practice opportunities, and forever change the clinical training and financial landscapes of optometric education.

I am confident that the profession’s future leaders are in the auditorium today.

And as those before you, you must move forward with a balance of discretion and audacity.

Be willing to take risks with innovative approaches.

In whatever you do, follow the example of your Alma Mater and strive for pinnacles of excellence.

For excellence is a mandate not an option.

Values will always be a source of strength. Character and contribution will define your success.

For in the final analysis, it is neither about financial rewards nor power, but pride in your professional and personal achievements.

Thank you and congratulations.

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

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

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

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

Benefits of a Medical School Affiliation

Education

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

Patient Care

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

Constituent and Public Relations

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

Economic Impact

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

Research

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

Concerns of a Medical School Affiliation

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

The Affiliation Agreement

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

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

The following should also be considered:

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

Conclusion

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

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

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The need for improved clinical education facilities became urgent during the 1972-1974 period. Following the installation of a new administrative team headed by the College president, Norman E. Wallis, the curriculum had undergone extensive revision. Emphasis was placed on preparing future optometrists for an expanded scope of practice which addresses the problems of the whole patient. An academic program was devised to provide a thoroughly integrated background in the biological, behavioral, visual and clinical sciences that can be applied to patient care. Throughout this process the conviction developed that the mission of all optometric education is excellence in patient care.

Yet, while the prime objective was to bring clinical education and patient care experiences forward as the critical element in the education of the practicing clinician, the College was handicapped by seriously inadequate clinical facilities.

In 1974, a thoroughly investigated and carefully planned proposal for a new clinical education and patient care facility was submitted to the U.S. Department of Health, Education and Welfare. In 1975, the Pennsylvania College of Optometry was granted the entire amount requested, $3.8 million. The total cost of the new building was $5.1 million.

The New Building

The architectural firm of Hardy, Holzman, Pfeiffer Associates of New York was selected, principally because they promised to challenge the College on every preconceived idea regarding the development of a clinical facility for the profession. Planning involved all segments of the College community, as well as leaders in the optometric and other health care professions on the local, national, and even international level. The architects came to understand that the College wanted not only to develop a facility for patient care and education, but also to impact on the public and add to the recognition of the profession. They agreed that recognition of the worth of a profession by the public grows out of respect for the educational institutions in which the professionals are trained.

The basic function of The Eye Institute was to be a regional resource – for the College’s educational process, for the community, for all health care professionals – and a national resource for the profession of optometry. The architects were outstandingly successful in creating a physical environment which facilitates and demonstrates this function.

Of modern design, the building is on two levels totaling approximately 52,000 square feet. The upper level houses all primary care facilities, while the lower level incorporates secondary specialized care suites, administrative offices, a 147-seat amphitheater, a conference room, and optical and ophthalmic drug dispensing areas.

The Primary Care Service Module is the patient’s entry point into the Institute’s eye care delivery system. Each of five such units operates with a degree of independence from the whole and is physically somewhat separate. The purpose of dividing primary care into the service modules is to provide an environment in which the patient receives personalized continuity of care as he or she would within a small private group practice; yet, the advantages of scale – multidisciplinary skills, complex instrumentation and quality assurance mechanisms – are available.

Each module is comprised of a preliminary testing area, eight fully-equipped examining rooms, staff offices, and a consultation area. A reception station and a comfortably furnished waiting area are shared by paired modules. A sixth modular areas has been reserved for the future creation of a group family practice in which all primary prescribing professions will be represented. This experiment in interdisciplinary cooperation will provide students assigned to this module experiences in a multidisciplinary setting.

Twelve third or fourth year optometric students, assisted by second year students, are assigned to each Primary Care Service Module. Student interns are supervised by two professional staff members holding academic rank at the Pennsylvania College of Optometry, and one optometric post-doctoral Fellow. In addition, ophthalmological personnel are assigned to the module to provide diagnostic consultation and supervision of general therapeutic services for patients discovered to be suffering from ocular disease. In support of professional staff, there are optometric technicians, optometric assistants and clerical personnel.

Operating Procedures

All patients are seen by appointment except in emergencies. When the patient registers at the service module’s reception desk, a unitized case record is created which contains all reports relating to that patient from all sources, including specialists to whom the patient may be referred. A licensed optometrist is always assigned the responsibility for case management, as the patient’s attending doctor.

The patient next undergoes a series of preliminary screening tests to evaluate the state of his/her ocular and general health. Hypertension and glaucoma screening, visual acuity, and visual skills are included in this protocol. The results are used to generate a problem-oriented patient record, and to determine the level of care required to solve the problem(s) uncovered. If the screening tests indicate no evidence of an urgency, the patient proceeds to a comprehensive eye examination, aimed at disease detection and the determination of a prescription for achieving optimum visual efficiency. The patient is then assigned to the student most appropriate to conduct the examination.

The Optical Service of The Eye Institute, located on the lower level of the building, offers the patient the option of having his/her ophthalmic prescription filled on the premises. No prescriptions are filled for persons who are not patients of The Eye Institute.

When the patient is referred outside the Primary Care Module for consultation or therapy, the professional within the module is not relieved of his/her responsibility to the patient. He/she continues to monitor and coordinate the management of the case, whether the problem was ocular or systemic. In this way, three objectives are met: (1) the patient receives the most cost beneficial care by professionals best equipped to solve his or her problem; (2) the patient remains under the case management of the primary care provider who assures that care is not fragmented by split responsibility; and (3) each professional is challenged to perform at the highest level of his/her training and capabilities because the process assigns the patients in a rational manner.

The specialty service units are located on the lower level of The Eye Institute. Access by patients to specialized services is by referral only, either by a professional staff member of a Primary Service Module or by a private health care practitioner. Patients referred by other than eye care professionals generally visit a Primary Care Module for case work-up prior to receiving secondary services.

Specialized Services

Specialized services within The Eye Institute include the following:

• Ophthalmological Service: The ophthalmological suite is comprised of four examination/treatment rooms, and private offices. Provisions have been made for expansion of this facility so that, in the future, ambulatory surgery may be accomplished. — While general ophthalmological services are provided in the Primary Care Services Modules, this Service offers consultation in the sub-specialties of corneal-, retinal-, and neuro-ophthalmology. A second opinion service is also available to patients, primary care physicians, and third-party health insurers.
• Ophthalmic Photography: Instrumentation and skills exist for performing all types of ocular photography – external, slit lamp, and fundus (including sterioscopic).
• Electrodiagnostic Service: The Eye Institute has one of the finest and most complete installations for electrodiagnosis in the country. Dark adaptometry and comprehensive color vision testing is also offered with this Service. Referring doctors receive copies of biopotentials tracings and an interpretation of them, with the conclusions reached by the consultant.
• Pediatric Unit: This Unit addresses the problems of binocular dysfunction in adults as well as children. Fully equipped for both diagnosis and vision therapy, the Unit is staffed by specialists in binocular vision, oculomotor anomalies, and visual perception. A pediatric ophthalmologist is also on the staff to provide medical balance to the optometric view of functional anomalies. A post-doctoral residency program in binocular vision is conducted by this Unit. — The Pediatric Unit specializes in the visual problems of the retarded, the learning disabled, the perceptually immature, and the visually handicapped child. It is also equipped to perform infant and early childhood vision analysis – a neglected area in eye work.
• Vision Rehabilitation: Since the merger into this Service of the practice of William Feinbloom, D.O.S., Ph.D., internationally recognized expert in the field of low vision, this facility is named “The William Feinbloom Vision Rehabilitation Center.” This Service receives referrals from the professional community, government, and social service agencies for the management of patients with impaired visual acuity and/or significant field restriction. The work of the Vision Rehabilitation Service is carried out through the integration of a multidisciplinary team including social service, ophthalmological, electrodiagnostic, and mobility-training personnel (the latter through an affiliation with the Philadelphia Center for the Blind.) — Special contact lenses are included in the armamentarium of this Service for such conditions as keratoconus, corneal leucoma, iris coloboma and aniridia. The Service also has a rarely available space eikonometer and other instrumentation for providing measurement and consultation in the area of aniseikonia.
• Sports Vision: Staff members have developed special skills in testing, evaluation, adapting and enhancing an athlete’s visual performance to the particular demands of his sport. They offer consultation to athletic coaches, team managers, and school health authorities, as well as to referring eye care practitioners and other physicians.
• Consultation Services: The Eye Institute has initiated a unique service in recognition of the obligation of an optometric educational institution to support optometrists in private practice. Eye Institute professional staff members, each of whom have developed some special skill or area of expertise, will consult by telephone or in writing with any practitioner who requests it.
• Pharmaceutical Service: When the pending licensing arrangements are concluded, a pharmacy for the dispensing of ophthalmic drugs will be in operation. This Service will be available to Eye Institute patients and to optometrists, ophthalmologists, and other appropriately licensed health professionals. A full line of ophthalmic prescription drugs for both diagnostic and therapeutic purposes, as will as over-the-counter preparations for contact lenses, ocular irrigation and decongestion, will be stocked.

Other Activities

A Social Services Department is under the direction of a person experienced in health care counseling. It assists all patients who need and request guidance through the health care delivery system, or offers assistance with eye-related personal problems. Referral to other agencies for help in nutrition, shelter, and other life problems is accomplished. A volunteer aide program operates under the supervision of this department.

Student, faculty and volunteers are available to present programs in eye health care to various groups. Most such educational programs are given in The Eye Institute amphitheater through arrangement with schools, civic organizations, and senior citizen groups.

Aside from the critical peer review normally operative in an academic environment, The Eye Institute has established a structured Quality Assurance program. Through records review and other studies, the program monitors and evaluates health services rendered.

Impact on Clinical Education

The impact of The Eye Institute on the student body has been dramatic. Rather than acceptance of clinical assignments as another “course,” students are enthusiastic about participation in a patient care practice which avoids the depersonalization inherent in the institutional “clinic.”

Organization into Primary Care Service Modules closes the feedback loop in the student’s clinical education, allowing them the opportunity to provide a continuum of services to individuals and families. Such patients can then relate to “their doctor” rather than The Institute as a whole. The students are thereby enabled to monitor the outcome of their management plans.

Reinforcing and supporting the student clinician’s ability to provide continuity of care is the fact that a total range of ambulatory eye services is available under one roof. By retaining supervisory management of the patient within a single “system,” the clinician is assured of receiving consultants’ reports as input to his/her decision-making process. The presence of the wide variety of primary and secondary service activities also serves to broaden the students’ clinical interests. Their rotations through the various services and participation in many ancillary activities provide exposure to all aspects of eye care practice.

The Eye Institute’s success in enhancing the clinical education of student optometrists grows out of two premises upon which all planning is based:

1. While the Pennsylvania College of Optometry operates The Eye Institute as a teaching facility, patient care is co-equal with education as its mission. The guiding principle here is the conviction that only in the context of an excellent patient care delivery system can future optometrists receive clinical experiences of high quality. The Eye Institute may be regarded as being analogous to a teaching hospital affiliated with a medical school.
2. A team of health care professionals – optometrists, ophthalmologists, opticians, technicians, and consultants in other specialties – must work cooperatively at the highest level of their training and competence, with the visual welfare of their patients as their highest priority.

The improvement in the clinical education process will become evident as PCO’s graduates enter private practice and public health optometry, striving to emulate the scope and quality of work they experienced in The Eye Institute.

Charles F. Mullen, O.D.
Journal of Optometric Education
Volume 4, Number 1, Summer 1978

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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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