In 1970, the New England College of Optometry initiated major revisions in its curriculum with a primary purpose that of enriching and expanding optometric students’ clinical experience.

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.