Charles F. Mullen

The following editorial, written by Dr. Kenneth Myers, President of ABCMO, can be found in its entirety at https://abcmo.org/continuing-evolution-of-optometry/. The abridged version below has had the Appendix and several highly detailed supporting studies removed.

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The Continuing Evolution of Optometry

For some time now, articles have been encouraging general practice optometrists to more fully utilize the expanded scopes of medical treatments authorized to them as all state optometry licensing laws have been increasingly updated since 1972. On the one hand however, there has been a shift towards retail store practices and commoditization of optometry while, on the other hand, the initiation and rapid growth of residencies in medical optometry that first began within Veterans Administration hospitals in 1975 and then spread to private clinics and schools has continued.

This combination of changes since 1972 suggests the further splitting of optometrists into three types of practice settings.

• Retail optical store.
• Private office practice.
• Practice within health care facility.

Also consider the other changes arising since 1972.

• The increasing percentage of general practice optometrists in retail store practices.
• The impact of surplus optometrists produced by new schools of optometry as well as high student debts.
• Post graduate residency training, testing and board certification in the specialty of medical optometry.
• A lack of standardized model practice acts for general practice optometrists or those board certified in medical optometry.
• The limited extent to which the growing percentage of optometrists at optical stores can, or should provide medical eye care.

Until about 1970 most optometrists practiced at independent sites they owned but are becoming increasingly “associated” with retail stores they do not own.

This has happened not just to optometry. Once most pharmacies were owned and operated by pharmacists but today 80% of pharmacists are employees of five major chain pharmacies and “big box” merchandisers and medical physicians are rapidly becoming employees of corporate health care institutions rather than private office practice owners.

How physicians feel about this can be judged by visiting www.kevinMD.com which documents how they are losing their autonomy and professionalism from becoming employed “health care providers”.

The problems facing optometrists can be judged by reading Dr. Epstein’s weekly “Off the Cuff” editorials at “Optometric Physician”. For example, see the last paragraph of this recent “Off the Cuff” where Dr. Epstein addresses the topic of Medical Optometry and changes within the profession.

I have been saying this for a long time, and I fear that for a growing number of us, it may now be too late. If you have not embraced medical eye care, you are on a rapidly sinking ship to nowhere. Optometry has moved on and refractive eye care is rapidly becoming more consumer than profession driven. Economics will hasten its demise, but automation and technology will surely seal the coffin…

These changes were triggered when the Federal Trade Commission decided permitting advertising by doctors and health professionals as well as drug companies would reduce health care costs by making it a “commodity” sold in the market place. At that time health care costs were 9% of our country’s GNP but are now 18% and, while American health care is now the most expensive, its quality ranks 7th among developed nations per the World Health Care Organization. The fact that only two developed nations in the world permit direct advertising to the public of prescription pharmaceuticals… New Zealand and the United State… should also tell us why making health care a commodity sold in the market place was a bad idea for the public weal.

Why? Because commodities are generic common goods like cans of peas, gallons of milk or pork bellies and advertised and marketed by stores to the public by stressing two things.

• Competitive pricing.
• Convenient location of store site.

For optometry, commoditization led to store ads of “Two pairs of eyeglasses and examination for $69” or “free eye examinations”.

While recent articles encouraging all general practice optometrists to provide medical eye care would be advantageous for their practices this will be difficult for those practicing at optical stores since the general public does not associate them with medical eye care and most stores lack incentives to provide medical eye care.

1: Two Roots of Optometry to Include Medical Eye Care

By 1968 optometry schools had made such significant advances in medical education, length of training, and entrance requirements that all original state optometry practice acts enacted from 1901-1927 had become obsolete since they barred optometrists from providing “medical eye care”. That changed following the 1968 LaGuardia meeting which redefined optometry as a primary eye care profession and then led to state-by-state expansions of optometry practice acts to include medical eye care that continues today.

Dr. Haffner & the LaGuardia Meeting that Changed Everything (Article and Audio). OD Wire, 2013 discussion of 1968 Meeting.

Next, in 1973, the Veterans Administration’s Department of Medicine and Surgery opened the first hospital externships for optometry students and, in 1973, after recommendations by the U.S. Government Accounting Office, the Association of Schools and Colleges of Optometry and the Congressional Veterans Affairs Committees, opened the first hospital residency training in medical optometry in 1975. Since then, the VA employs some 976 optometry medical staff members; half of all optometry students serve one or more VA hospital externships and 220 optometrists enter VA postgraduate residency training programs each year.

Since 1968:

• All state legislatures have expanded their scopes of medical practice for general practice optometrists and continue to expand their scopes of medical practice state-by-state.
• Since the states differ in their expansions of medical practices authorized for licensed optometrists, a patch-work of different practice acts exists.
• The number of ophthalmologists in residency training has remained essentially constant over 20 years and the recent 2014 Lewin Reports predicted future shortages of them.
• The numbers of optometrists in training has nearly doubled since 2000 due to new schools and while the Lewin Reports predicted increasing surpluses of optometrists their national survey of optometrists found that average optometrists had about 30% open chair time in 2014.
• There is no national standardized model curriculum for training general practice optometrists or specialty residents.
• Political optometry continues to believe all general practice optometrists should provide medical eye care in spite of increasing numbers of retail store optometrists.
• The development of VA hospital optometry residencies occurred independently within them in order to meet increasing eye care demands.
• The percentage of licensed optometrists who are AOA members is declining because store optometrists are growing in numbers but join the AOA at half the rate of office optometrists.
• Store optometrists join the American Association of Corporate Optometrists which has over 13,000 members while the AOA has about 21,000 members, the American Academy of Optometry about 4,000 Fellows and approximately 6,000 practicing optometrists have joined no organization.
• Current estimates are that about 42,000 licensed, active optometrists are in practice.

2: Surpluses and Student Debt “pushes” Graduates to Stores

Some still do not acknowledge the extent to which retail optometry care (and health care) has been made a commodity with the shifting of so many public practices from offices to corporate store sites where medical optometry is less likely to take root. And, the growing surplus of optometrists and their high student debt levels (graduates have the highest ratio of debt to projected earnings of all “health care providers”) which made it difficult to establish, or be employed at office practices.

Some even claimed the growing surplus of optometrists is good because the predicted shortages of ophthalmologists will be filled by surplus optometrists because, the Lewin Reports falsely assumed, optometrists “essentially” have the same scopes of practice as ophthalmologists.

But no state has ever granted optometrists the same privileges of ophthalmologists.

It is more likely only optometrists completing residencies in medical optometry or those having office practices in suburban-rural settings will have significant opportunities to provide medical eye care.

For example, the visits to optometry sites the author made in a metropolitan area 21 years ago (Appendix K) found that even then over 50% of optometrists practiced at retail stores and only 33% of those were AOA members whereas 72% of office optometrists were AOA members; which explains why the percentage of AOA membership has declined.

But, there are few accurate databases holding the numbers and types of practice settings at which optometrists practice. The Lewin National Survey of optometrists did ask which one of 17 different types of practice sites listed best described where they practiced which would have provided important information. But, unfortunately, Lewin would only publish two of those 17 types of practice locations; giving the percentage of optometrists who were, or were not, employed at their practice site.

3: A Lens is Not a Pill!

Minnesota first recognized optometry as an independent licensed profession in 1901 and optometrists at that time insisted they did not practice medicine because “lenses were not pills” and must not to be licensed by the state medical board. Physicians only insisted they could continue to prescribe eye glasses without having to hold optometry licenses. As a result, over the next 26 years all states adopted non-medical optometry licensing and there was essentially uniformity on how optometrists wished to practice until 1968 when the “LaGuardia Meeting” called for optometrists to become primary eye care providers and state practice laws then started to expand to more accurately reflect optometry medical training.

Dr. Haffner & the LaGuardia Meeting that Changed Everything (Article and Audio). OD Wire, 2013 discussion of 1968 Meeting.

The Meeting that Changed the Profession – La Guardia Meeting. Optometry Cares, AOA Foundation. Historical review of 1968 Meeting.

4: Where Do Optometrists Practice?

Essentially three settings:

• Optical stores that emphasize Rx writing.
• General practice offices offering primary medical eye care.
• Optometry and/or ophthalmology office practices, state or local hospitals, optometry or medical schools and Federal, State or local health care facilities (VA, Department of Defense hospitals, U.S. Public Health hospitals, and local health clinics.)

The updating of state optometry licenses has enabled many general practitioners to offer medical eye care but some older optometrists did not upgrade their licenses. And, since state licensing laws vary, general practice optometrists provide different levels of medical eye care depending on the state where they practice. A model state practice act does not exist for general practitioners.

5: The first Specialty Offering Board Certification

Medical optometry residencies were begun by the VA to provide a cadre from which to recruit future staff optometrists with advanced medical training and hospital practice experience.

While specialists in medical optometry have much in common with general practitioners they differ in having more extensive medical training and experience working as part of a medical team and from having seen a broad number and types of ocular diseases.

6: Can Optometry Fragmentation Be Reduced?

Probably not. But we can, and should, minimize the variations between state licensing laws by developing a model curriculum and a licensing law that prepares all general practitioners to provide one standard level of medical eye care.

A model practice act for those board certified in medical optometry is also needed to avoid another patchwork of practice privileges for them.

Accomplishing this will not be easy but history tells us failure to develop a more uniform system of state licensing will exacerbate additional fragmentation of our profession.

For far too long Optometry believed its licensing prepared general practitioners to competently practice all aspects of optometry; a belief once held by medicine, dentistry, podiatry and nursing but long abandoned as they developed specialty residency training.

The Mayo brothers, instrumental in developing medical specialties through residency training, believed a field of endeavor that did not develop specialties was an occupation rather than a profession.

The need for model curriculum for general practice optometrists was recently shown when the State of Vermont’s Office of Professional Regulation rejected adding more medical procedures for optometrists because it could not find sufficient information about the training optometry schools provide students.

Vermont Office of Professional Regulation – Optometric Advanced Procedures. 2019.

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To continue reading this editorial, including an appendix of detailed studies and a great photo gallery of Akron, OH practice sites in 1997, please visit https://abcmo.org/continuing-evolution-of-optometry/.