In the following article Dr. Kenneth Myers delineates the rationale for a new educational model for optometry. He recommends changes to the existing model to improve efficiency and cost effectiveness. He also describes the negative impact of high educational costs and student debt. The article concludes by discussing a new optometry training model to place optometry in parallel with medical education to qualify for the Graduate Medical Education Program (GME).
by Kenneth J. Myers, Ph.D.,O.D.
Introduction
Teaching methods at optometry schools, like undergraduate counterparts, have changed little. While a revolution in communications began over a century ago, didactic educational teaching remains essentially unchanged in spite of increasing tuition costs. While professors no longer wear gowns, students still sit in lecture halls taking notes and essentially teaching themselves by reading those notes, textbooks and talking with other students. Those lecturing them are often part-time faculty or graduate assistants since about one-half of undergraduate credit hours are not taught by senior faculty who are, instead, occupied with research and consulting.
But clinical training demands real-time, on-site teaching, personal supervision by licensed practitioners and personal interaction with patients; a form of the guild-system adapted to medical training. In this model, those doing the training are practitioners earning their living caring for patients.
Recently, some universities have offered MOOC [Massive Open Online Courses] programs or accelerated training programs. Since 1972 the New England College of Optometry has offered, and state licensing boards have accepted, a two year OD program open to selected candidates holding Ph.D. degrees in allied fields. Recently 47,000 students at Ohio State University signed up for a calculus MOOC and there is no reason knowledge sets in optometry can not be made prerequisites, “tested out”, eliminated if seldom part of modern practice or taught online by “master teachers” to students at cooperating, sponsoring schools.
My point is that most non-clinical training can be better, more cost-effectively taught and additional funding sources found for clinical teaching, thereby reducing tuition costs.
Already, many optometry schools devote the 4th academic year to off-campus, clinical training rotations at medical facilities such as the VA with didactic and initial clinical training limited to the first 3 years at the school and its campus clinic.
Tuition costs-per-credit hour meanwhile have skyrocketed, outstripping inflation rates, and minimum wages have lagged to the point it takes three-times the number of minimum wage hours for one tuition hour compared to 25 years ago thereby reducing the value of student part-time employment. University optometry schools have not been exempt from large tuition increases as most states have reduced their funding by as much as 60%, leading one state university president to remark his university is no longer “state-supported” but “state-associated”.
Many optometry graduates carry such large student debt it excludes their starting a private practice; practicing in underserved or rural areas or practicing within an existing optometry office as a potential partner or practice buyer since most “entry-level” salaries may not service student debt.
Federal and private student loans laid the ground work for this “education bubble” and total student debt now exceeds total US personal credit card debt. Unlike the home mortgage “bubble”, federal student loans can not be discharged by bankruptcy and can haunt graduates like Caesar’s ghost and influence career decisions.
Purpose of Article
This article outlines a more efficient optometry educational model which will reduce the costs of non-clinical training and develop new revenues sources for clinical training via federal Graduate Medical Educational (GME) support for clinical teaching facilities training residents and billing Medicare.
Proposed by Dr. Mullen, this model reflects his experiences introducing optometry teaching clinics into neighborhood health clinics, serving as Director of an Eye Institute, Director of the VA Optometry Service and president of an optometry college.
Current Optometry Model
An undergraduate degree in a related physical or biological science degree is generally required for admission with the O.D. degree awarded after 4 years of which not all are 12 months long.
Unlike medicine and osteopathy, which limit classroom training mainly to two years, most optometry schools continue classroom instruction well into the 3rd year and some require attendance at campus courses in the final, 4th year thus restricting student travel to distant clinics.
Until the 1970’s, clinical training was conducted solely at school campus optometry clinics and students had little (or no) opportunity to train with medical students, interns and residents. This changed when the U S Department of Veteran Affairs, in 1976, by an Act of Congress, formed an Optometry Service, and began the first optometry residency programs for graduates and student clerkships.
As a result, the VA now trains optometry students and residents in the same manner it trains medical, osteopathic, and dental students and residents. Without this VA support, some optometry schools might have been unable to provide the type and breath of clinical training required by the expanding scopes of practice granted ODs by licensing statues since the 1970s.
Now the largest clinical trainer of 4th year optometry students and optometry residents, the VA operates 73 optometry residency programs totaling 170 residents while over 1,200 4th year students serve a VA clerkship rotation. Over 700 full-time VA ODs see a million-plus unique patients. Funding for staff, equipment and resident stipends to support VA clinical optometry training is separate and distinct from the GME system and can not be used to support training within other medical systems or at the schools.
All schools, however, operate campus teaching clinics which generally do not recover operating costs from patient fees nor provide the degree of medical-related eye conditions found at VA teaching clinics. This means student tuition must underwrite campus clinics despite the massive VA in-kind support since 1976 as a result of PL 94-581 and students serving VA clerkships continue to pay tuition to the schools which incur practically no expense to operate these clerkships.
GME can not support optometry residency training at this time because optometry state licensing boards do not require residency training for licensing (all medical licensing boards require a residency for licensure).
GME supports medical-osteopathic residents via supplemental Medicare payments to facilities training medical residents. This means residency programs at optometry schools that bill Medicare are not now eligible for GME support.
New Educational Model
Dr. Mullen presents a cost-effective educational model in which the OD degree is awarded in 3-years with a one-year, postgraduate residency in general practice optometry required for licensure and general practice. With this model, a student still receives the OD degree and is eligible for state licensure after 4 years but has also completed a residency, become eligible for board certification in general practice and the school’s residency programs could apply for GME funding and thereby reduce the cost of its clinical operations.
A 3-year MD system is now being implemented at several medical schools.
Some existing optometry schools could readily adopt this new model as they already devote most of the 4th year to clinical training. Meanwhile, optometry specialty residencies have existed since 1976, originating in the VA medical system. [About 18% of graduates serve specialty residencies, most in medical optometry]
This new model would be especially effective at schools co-located with medical or osteopathic schools chiefly because:
- Low marginal costs of sharing infrastructure and teaching of basic science and clinical courses.
- Enhanced clinical teaching and GME support of optometry residents.
As a result, this model can be viewed as an attractive alternative to the traditional 4 year curriculum and exist in parallel with the current 4-year career path leading to licensure as a general practice optometrist. In this new model, the residency following the 3-year degree would equate to the PG-1 level and those serving 1 year specialty residencies after licensure would equate to the PG-2 level as used in the medical-osteopathy model.
Implementation
State licensing boards require a candidate for licensure to have completed an accredited OD program and passed specified written and clinical examinations administered by the National Board of Examiners in Optometry. The 18% who now proceed to serve specialty residencies after graduation can continue to so in this new model as a PG-2 trainee.
To conform to the medical educational model and be eligible to apply for GME residency support via Medicare billings, the following changes are necessary:
- All didactic course work and basic clinic training completed in 3 calendar years with award of O.D. degree. By agreement with state licensing boards, holders of the 3-year OD degree would not be eligible for licensure at this juncture. (Most licensing boards do not stipulate the length of required training for the OD degree.)
- The 3-year OD must then successfully complete an accredited one-year residency in general practice to become eligible for licensure and board certification in general practice optometry. This process could be accomplished via the National Board of Examiners in Optometry.
- Those wishing to specialize can, as now, then proceeds to an existing specialty residency as a PG-2 resident and then seek board certification in that specialty by a specialty board. Specialty residencies have existed since 1976 and the specialty of medical optometry has a specialty board that issues board certifications recognized by credentialing committee at Joint Commission accredited health care organizations. [abcmo.org]
- It is likely that, in time, additional specialty boards will be created as the Association of Schools and Colleges of Optometry list 10 areas suitable for residency specialty training.
Results
In the 3-year OD model, licensed ODs will have completed a PG-1 residency in general practice optometry and, based on today’s numbers, about 18% will proceed into a PG-2 specialty residency. Schools using this new model will become more closely aligned with the traditional medical educational model.
The 3-year plus 1-year residency in general practice will reduce the costs of education to both students and their clinical training facilities via opening the door to apply for GME funding while requiring no major changes to the current system of granting degrees and licensures.
As in medicine and osteopathy, many schools may continue with the current 4-year model and students will be able to choose between the two models, which will allow for a gradual increase in general practice residencies needed for this model.
A school must not, however, be permitted to convert to, or originate, a 3-year plus residency program without having secured sufficient PG-1 residency programs to allow its graduates to serve a one-year residency in general practice since such a residency will be required for licensure of their graduates.
Dr. Myers was founding Director of the VA Optometry Service, dean of an optometry school and currently president of the American Board of Certification in Medical Optometry.