Charles F. Mullen

Opportunities and Challenges in Optometry and Optometric Education

NAVAO Founding Member Spotlight: An Interview with Dr. Charles Mullen

The following interview was published in Optimum VA, The Official Newsletter of the National Association of Veterans Affairs Optometrists (NAVAO), Summer 2015.

Seal of the US Department of Veterans Affairs

Upon being asked to be featured in the NAVAO Optimum VA Newsletter, Dr. Mullen expressed the following:

“Thank you for your kind invitation to share my experiences in VHA and also to offer recommendations for the future of VA Optometry. It is an unexpected privilege to recall my tenure as Director,
VA Optometry Service (1990-96). In reviewing my files in preparation for this interview, I remembered the many outstanding VA optometrists whose dedication and support were essential in developing and implementing the objectives of the Optometry Service Strategic Plan. It was an honor to have such outstanding clinicians and educators as colleagues.”

How did you first become actively involved with VA Optometry?

In the 1970s, while serving as the Director of NECO’s clinical program, Dr. Ken Myers, Founding Director of the VA Optometry Service, called and asked if NECO was interested in sponsoring a VA funded residency program at the Boston VA OPC. After establishing the OPC residency program and agreeing to further development of residency programs at other Boston VA facilities, I then served on Dr. Myers’ Advisory Group for a number of years. Ken and I shared a similar view on the importance of optometrists practicing in collaboration with physicians. I became increasingly interested in the potential that VA Optometry could offer in advancing the Profession of Optometry in patient care, clinical education and research. When Dr. Myers resigned as Director in 1990, I enthusiastically agreed to succeed him.

What contributions to VA Optometry have you participated in that you feel proud of?

After arriving at VACO, I soon learned that Dr. Myers had built a solid foundation for the VA Optometry Service. His meticulous attention to detail in working with the AOA Washington Office positioned VA optometrists in Title 38 along with physicians and dentists. Dr. Myers wrote the Qualification Standards which established very high standards for the appointment and promotion of optometrists. He also developed the first optometry residency program and academic affiliation with a college of optometry, and later established numerous clinical training programs for optometry students and residents. He wrote the Optometry Service’s first Plan and encouraged the development of NAVAO. Although my contributions pale in comparison to the significant accomplishments of Dr. Myers, I am proud of the following:

  • Appointed the first Optometry Field Advisory Group.
  • In collaboration with NAVAO, ASCO and the AOA, I updated and enhanced the Optometry Service Strategic Plan. ASCO forwarded the Plan to VACO and the Undersecretary for Health instructed me to implement the key elements of the Plan including the addition of 53 centrally-funded optometry positions, 21 residents and the necessary eye care equipment.
  • At the invitation of the Undersecretary for Health, briefed the senior administration of VHA on all aspects of the Optometry Service and gained standing in VACO for the Optometry Service.
  • Standardized the optometry clinical education program in cooperation with ASCO.
  • Disseminated numerous clinical guidelines including preferred practice patterns, credentialing and privileging, eye care space criteria, staffing models and productivity standards.
  • With assistance from several NAVAO members, conducted a system-wide inventory of all VHA eye care (optometrists and ophthalmologists) manpower, facilities and training programs. The results were presented to SMAG by the Optometry Representative along with recommendations to further increase eye care manpower, facilities and equipment.
  • At the request of the VHA senior administration, interviewed and recommended for appointment the first ophthalmological consultant to VHA, and effectively advanced an agenda of cooperation between the two eye care disciplines.
  • Appointed by the Undersecretary for Health to a high level Eye Care Advisory Group consisting of nationally recognized optometrists and ophthalmologists. In consultation with the Group, advised the Undersecretary on policy to improve collaboration between the two eye care disciplines in patient care, education and research.
  • Stimulated research in low vision rehabilitation with $6 million in funded research projects.
  • Reduced the average waiting time for primary eye care services by 30%.
  • Initiated a nation-wide recruitment effort to reach under-represented groups for placement in VA optometry staff and residency positions resulting in a significant increase in female staff and residency appointments.

What advice would you give to new ODs entering the profession?

Complete a Specialty Residency Program and achieve Specialty Board Certification preferably in Medical Optometry. The most challenging and rewarding positions in optometry will be within hospitals and other medical facilities and specialty credentials will be required for appointment.

What would you like to see happen in the future of VA Optometry?

Dr. Townsend has done an outstanding job in increasing the number of VA optometrists, residents and students on clinical rotation. He has instituted innovative programs such as research fellowships while significantly expanding low vision programs. He has developed the VA Optometry Service into one of the most productive in VHA. The Eye Care Handbook he authored has positioned optometry as a major patient care and clinical training component in the VA as an equal partner with ophthalmology. The Handbook is considered the model for all optometry programs located within medical facilities.

Despite the impressive progress, more needs to be done. I would like to see the following completed in the next two years.

  • Optometry Qualification Standards updated to include requirements for Specialty Residency Training and Specialty Board Certification in appropriate sections.
  • Optometry Service Strategic Plan Updated in collaboration with NAVAO, ASCO and AOA and submitted to the Undersecretary for Health with specific recommendations.
  • Restrictions or caps on optometrists pay removed to encourage retention of the most experienced clinicians.
  • Optometry Service Field Advisory Group to brief the new Optometry SMAG Representative on the challenges and opportunities in VA Optometry.
  • Encourage more active involvement of academic affiliates with VA facilities including participation on Deans Committees and other advisory groups.
  • Appointment of a VA representative to the ACOE.
  • Continue VA Optometry’s leadership in Specialty Training and Board Certification by ABCMO. Encourage the development of the American Board of Optometry Specialties (ABOS) similar to the American Board of Medical Specialties (ABMS). This oversight board would establish and ensure high standards for all Specialty Certification Boards.

Thank you for the opportunity to share my VA experiences with NAVAO.

by Charles F. Mullen

Is Optometry on the Same Path as the Legal Profession? – Executive Summary

Law schools waited too long before taking action to address the oversupply of lawyers and now face the crisis of a serious decline in student applicants and underemployment and unemployment of recent graduates.

Paper/Presentation

Is Optometry on the Same Path as the Legal Profession? – Executive Summary (PDF)
Is Optometry on the Same Path as the Legal Profession? – Executive Summary (PPT)

To read the full article, including complete references, click here.

by Charles F. Mullen

Is Optometry on the Same Path as the Legal Profession? – Full Article

Law schools waited too long before taking action to address the oversupply of lawyers and now face the crisis of a serious decline in student applicants and underemployment and unemployment of recent graduates. Many law schools face serious financial issues, staff and faculty layoffs. Lower-tier law schools are merging and at least one school plans to close. Increases in law school enrollments (53 new law schools opened since 1973) without corresponding increases in demand have resulted in 45% of recent law graduates unable to find full time employment. The top 14 law schools now find it necessary to employ from 4-17% of their graduating classes. As a result, applications to law school continue to decline – down 37% from 2010.

Optometry schools and colleges now face the similar effects of oversupply (12,672 FTE excess) of optometrists including declining student applicants and declining full time employment opportunities. There were seven new optometry schools added and increased enrollments at existing schools in the last six years without a demonstrated increase in demand. Full time positions with sufficient income to service educational debt are difficult to find, and now 40% of recent graduates practice at two or more part time locations. Even for those employed or self employed optometrists function at only 68% of their practice capacity. Like the legal profession, there are no signs of abatement in the poor full-time employment market or decline in optometry school applicants. The decline in applicants is exuberated by continuing expansion of new optometry schools.

To mitigate the effects of an oversupply of optometrists, optometry schools and colleges’ leadership must immediately acknowledge and directly address the serious challenges impacting on the stability of optometry schools and colleges including:

  • Current and future oversupply of optometrist: 12,672 FTE excess now and oversupply remains at 9,000 FTE in the future.
  • Increase in number of optometry schools and increased enrollments at existing schools: Seven new schools added in last 6 years while graduates increased from 1127 in 1997, when supply equaled demand, to 1600 now. At full enrollment of all schools, graduates will increase to over 1800.
  • Decline in the student applicant pool – less than 1.5 applicants per entering seat, while number of entering seats has increased from 1160 to 1763 in six years.
  • High graduate debt – over $200,000 for many graduates vs. income potential to service debt.
  • Decline in college age students – .5 million less than in 2012.
  • Decline in full-time employment opportunities for recent graduates. 40% of graduates practice at multiple part time locations.
  • Lack of Federal support for clinical training, scholarships and loan repayment – Optometry excluded from $11.5 billion Graduate Medical Education Program, National Health Service Corps and Title 7 programs.

In view of the data in the Rand, Abt. and Lewin Optometric Manpower Studies indicating a substantial excess of optometrists, it would be prudent to mitigate the effects of a decline in full time employment of graduates and decline in applicants for admission by the following actions:

Action 1: Proactively Address the Oversupply of Optometrists

  • Reduce enrollments at all schools and colleges of optometry and adjust corresponding revenue and expense projections.
  • Demand clarification and correction of Bureau of Labor Statistics (BLS) projections. It appears these projections are significantly contributing to the oversupply of optometrists by encouraging the development of new schools of optometry. Conflicting data on optometric manpower: Rand Study-1995, Abt.Study-2000 and Lewin Study-2014 all indicated significant surpluses. Meanwhile the Bureau of Labor Statistics (BLS) projects high demand for optometrists. In view of all the evidence and studies to the contrary, it is logical to assume the BLS based their projections on inaccurate or obsolete data.
  • Insist the Accreditation Council on Optometric Education (ACOE) develop quantitative standards similar to medicine and dentistry for evaluating accreditation for new and existing school and colleges of optometry. Only accredit new schools when the quality and quantity of student clinical training opportunities can be demonstrated.
  • Increase demand for optometric services by addressing the underlying public health need for eye care in inner-city and rural areas. Only 20% of federally qualified community health centers provide optometric services. However, Boston community health centers have made a successful and sustained 40 year effort to address unmet need for optometric services in inner-city Boston. See: New England College of Optometry Clinical System. Inclusion of optometry in Federal incentive programs (loan forgiveness, scholarships, National Health Service Corps, etc) is essential to providing optometric services in rural and inner-city America.
  • Conduct cost analysis of all clinical training venues and adjust clinical training placements to reduce overall operating costs. Review Relative Costs per Clinical Teaching Encounter: Campus-based clinics are by far the most costly. ($100-350). Affiliated facilities less ($10-30). Externships least costly ($.50-1.00).
  • Visit/Revisit the advantages of a Faculty Practice, integrated with clinical training, in terms of increased IEI revenue, supplemental faculty income, faculty recruitment/retention and compliance with Medicare/Medicaid Guidelines for Teaching Physicians. Faculty Practice also addresses the Center for Medicare/Medicaid Services (CMS) compliance vulnerabilities by changing from a Student-Centered Clinical Training Model to a Physician-Centered Program. Students cannot provide billable services to Medicare and other insurance plans. Two Optometry Schools fined for violations with current Student-Centered Training Model. Combined fines are nearly $1.0 million.
  • To provide full-time employment for graduates, optometry schools and colleges should fund government related fellowships. These positions would be used to provide experience to graduates in Federal and State health care policy.

Action 2: Address High Graduate Debt vs. Income Potential

  • Reduce student debt by shortening the length of overall education for the OD degree. Eight medical schools (DO & MD) have or are developing three year programs. Salus University/PCO is piloting a three year program. NECO has in the past offered a 3-year program.
  • Encourage accelerated admissions from undergraduate institutions.
  • Remove course redundancies and move selected course work to undergraduate prerequisites.
  • Reduce student debt by qualifying for Federal scholarships and loan repayment programs, such as the National Health Service Corps and Title 7, Section 747 through a comprehensive Federal advocacy strategy.

Action 3: Federal Funding for Clinical Training

Create eligibility for the $11.5 billion Graduate Medical Education (GME) program by restructuring the curriculum, changing state licensing requirements and aggressive advocacy to amend the Social Security Act to include optometry. Restructure the curriculum to potentially qualify for GME, the educational component of Medicare: New model would consist of 3 years for OD degree + final year of postgraduate training to qualify for licensure and board eligibility. Social Security Act amended to include optometry and training in outpatient facilities. GME pays an average of $100,000 per medical resident annually to hospitals. Requiring postgraduate training for state licensure along with Board Certification would place optometry in parallel with medicine and enhance qualification for the GME program. “Best Practices” model would parallel medicine and consist of degree + postgraduate training = licensure + specialty board certification. See: Changes Necessary to Include Optometry in the GME Program.

  • Apply for a Center for Medicare/Medicaid Services (CMS) Innovation Grant to fund a pilot project of the new curriculum/clinical training model (3 years for OD + 1 year of postgraduate training).

Action 4: Investigate Alternative Strategies to Prevent Financial Crises at Schools and Colleges

Primary References

The Legal Profession

The Optometry Profession

by Charles F. Mullen

Guest Editorial: Lewin Survey Finds Large Optometry Surpluses

In the following comprehensive analysis, Dr. Kenneth Myers critiques the Eye Care Workforce Study prepared by Lewin Associates and released by the American Optometric Association (AOA) and the Association of Schools and College of Optometry (ASCO) in 2014. The Lewin Study (when “excess capacity” of 32% is taken into account) is consistent with previous eye care workforce studies, including Rand (1995), Abt. (2000) and Myers (2014), in finding an excess of optometrists. The most revealing finding of the Study is that optometrists function only at 68% of their practice capacity.

Lewin states “In fact, our estimates indicate that there is a significant excess supply (12,672 FTE in 2012) and though it declines modestly over the forecast period it remains substantial at about 9,000 FTE by 2025. Accounting for two of the factors that could increase demand, increases in insurance coverage under the ACA and increased prevalence of diabetes excess supply is reduced substantially to 4,000 FTE by 2025.” Dr. Myers questions the plausibility of these Lewin predictions “that could increase demand”, as well as Lewin’s assumption all ophthalmology shortages will be filled with surplus optometrists at the rate of 1.36 FTE optometrists filling 1.0 FTE ophthalmology shortage. He also believes the effective optometry surplus will approximate 11,000 FTE in 2025.

The author discusses the Bureau of Labor Statistics (BLS) prediction of a 24% growth in employment or 8,100 additional optometrists by 2022. This prediction is obviously not consistent with the Rand, Abt. Myers and Lewin studies. This optimistic prediction has been cited as the rationale for the development of new schools of optometry. The reliability of the data and methodology used by BLS in making this prediction need to be evaluated and reconciled with the findings of the previously cited eye care workforce studies.

The author attributes the optometry surplus to a significant increase in the number of graduates from optometry schools and colleges. Since 2006, six new schools in CA, AZ, TX, MA, KY and VA have been founded and three more are under consideration in IL, NC and WI. Already, the number of graduates has increased from 1029 in 1985 to 1600 in 2014. When all new schools reach full enrollment, the number of annual optometry graduates will further increase to 1900. Also, the addition of new optometry schools dilutes the already flat student applicant pool.

All academic leaders in optometry are encouraged to read the entire Lewin Study and draw their own conclusions about the optometry workforce. The terminology used in the publicity associated with the Lewin Study’s release was ambiguous with no reference to an excess or surplus of optometrists. “Adequate” is not the same as surplus. It is also suggested that the leadership review the current oversupply situations in veterinarian medicine and the legal profession and the impact on employment opportunities for graduates and number of applicants for admission in these two professions.

The unmet need for optometric services in rural and inner-city America was not addressed in the Lewin Study. Presumably, this omission occurred since inclusion of optometry in key Federal incentive programs such as the National Health Service Corps and Title VII would be necessary to be a realistic practice option. Only 20% of Federally Qualified Community Health Centers provide eye care services.

Lewin Survey Finds Large Optometry Surpluses (PDF)

Lewin Survey Finds Large Optometry Surpluses (DOC)

by Charles F. Mullen