With the opening of The Eye Institute, the Pennsylvania College of Optometry has the opportunity to attain one of the highest goals set by its founder nearly sixty years ago. Dr. Albert Fitch had stated, “A proper college of optometry must compare with any of the colleges of the other health professions, such as medicine and dentistry, and be on a par with the best of them.” The Eye Institute provides the means to close the final gap in achieving a favorable comparison of the College with other educational institutions in the health professions. In fact, fresh approaches to the integration of patient care and clinical education may result in The Eye Institute serving as a model for all.
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.
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 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.
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:
- 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.
- 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