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Challenges and Opportunities in Optometric Education: Keynote Address by Charles Mullen on Installation of NECO President

ICO President Shares Vision of the Future at Installation of Incoming New England College of Optometry President.

On June 10th ICO President Dr. Charles Mullen represented the Deans and Presidents of America’s Schools and Colleges of Optometry and spoke at the installation of Alan Laird Lewis, O.D., Ph.D., as incoming President of the New England College of Optometry (NECO). Inasmuch as the challenges and opportunities envisioned apply to ICO as well as NECO, Alumni Matters is pleased to reproduce Dr. Mullen’s brief remarks in their entirety.

Dr. Lewis, Chairman Spector, members of the Board of Trustees, distinguished members of the New England College of Optometry faculty and administration, colleagues and honored guests.

It is indeed a pleasure and a privilege for me to be here today as the representative of the Deans and Presidents of America’s Schools and Colleges of Optometry, as a friend and colleague of Dr. Lewis, and to return to my Alma Mater.

Over the years Dr. Lewis and I, to some extent, followed similar paths. We are both graduates of the New England College of Optometry. We both served as officers in the United States Navy and we both pursued careers in optometric education.

As Director of the Optometry Service at the Veterans Health Administration, I had the opportunity to work with Dr. Lewis while he was Dean at the Michigan College of Optometry. We worked closely during those years to expand clinical training for optometric students at various Department of Veterans Affairs medical facilities.

I have the greatest respect for Dr. Lewis’ abilities as an administrator and as an educator. He possesses those rare and most desirable talents of a keen intellect with the ability to comprehend and act on the larger issues, challenges and opportunities along with an appreciation for the importance of detail.

The challenges and opportunities all of us in optometric education will face during Dr. Lewis’ tenure as president are numerous.

We will see a lessening of our dependency upon campus-based facilities for the clinical education of students. Perhaps initially driven by economic considerations, the greater diversity of educational experiences provided by externships will increase pressure for more community-based training sites. The New England College of Optometry maintains a leadership role in the development and management of community-based sites and is already meeting this challenge.

College based clinics will play a significant role, however, as faculty practice becomes more important as a means for enhancing faculty income and improving our ability to recruit and retain highly qualified clinicians.

We will see a movement away from traditional classroom teaching toward more technology assisted self-learning through the rapid advances being made in communications and computer-based technology.

There will be an increased recognition that the function of a school or college of optometry is to prepare graduates for a lifetime of learning. We will redefine the entry-level attributes of our students and modify our curriculum to emphasize a lifelong commitment to learning. Students will learn to commit to a philosophy that emphasizes the acquisition of knowledge over mere information absorption and memorization.

We will recognize our responsibility to expose our students to a wide variety of practice opportunities.

We must also be prepared to offer meaningful advanced competency education to practicing optometrists as a core value of institutions of optometric education.

And, we must be ready to assist our faculty in adapting their teaching strategies to reflect this new paradigm.

And, finally we must find ways to reduce the level of indebtedness students face upon graduation, perhaps by controlling tuition increases and by providing increased scholarship support.

I also believe that the future direction of optometry will be fueled more than ever by the economics of the managed care marketplace. Quality assurance programs, appropriate advanced competency certifications and accreditation of clinical facilities will become increasingly important.

Consultation among professionals and the national academic eye centers of excellence will take advantage of advanced technology to become a standard practice. Precise retinal images and other data will be instantly transmitted from one point to another in real time.

We will see the development and utilization of a national faculty in several disciplines linked through developing technology. Schools and colleges of optometry will be able to access a faculty of our finest educators.

In such an environment, made possible by advances in technology and made necessary by economic imperative to be as efficient as possible, there will be unprecedented pressures to work together in a cooperative spirit. In this environment Dr. Alan Lewis, who has earned the respect and admiration of his peers will be indispensable as a leader.

I am confident that his contributions to the College, optometric education and the profession will be numerous and his leadership exceptional.

I pledge to Dr. Lewis my personal support and that of his fellow Deans and Presidents of Schools and Colleges of Optometry, and I wish him continued success as the President of The New England College of Optometry.

Thank you.

Alumni Matters – Summer 2000
Illinois College of Optometry
Charles F. Mullen O.D.

Interview with the Journal of the American Optometric Association

Three years have passed since Charles F. Mullen, O.D. assumed the presidency of the Illinois College of Optometry (ICO), the oldest and largest educational facility dedicated solely to the teaching of optometrists. This fall, ICO concludes its year-long celebration of its 125^th anniversary. In response to the Editor’s questions, Dr. Mullen shares his responsibilities at ICO, his objectives for the college, and to what degree they have been achieved. He also discusses the future direction of ICO, optometric education, and the profession of optometry.

Why did you accept the position of President of the Illinois College of Optometry?

Given ICO’s historical position of prominence within optometric education, I was concerned when I learned of the difficulties the college was experiencing in 1996. I believed these difficulties had the potential to harm not only ICO, but possibly even the profession of optometry itself. When approached by the Search Committee, I felt a responsibility to my profession of thirty years to interview for the position. Since I had extensive experience in health care management and clinical education, I felt confident that with the support of the Board of Trustees, faculty, and staff, we could redirect the resources and energies of the college toward programmatic improvements and that in a fairly short time we could create an institutional culture in which faculty, staff, and students were positively engaged in strengthening the institution.

The interview process for the presidency began in the summer of 1996. I met with the faculty. The faculty provided anonymous evaluations of my potential as ICO’s new president. The returns were favorable. By November, I was commuting between Washington, D.C. and Chicago. In December 1996, I assumed the presidency of the Illinois College of Optometry.

What were your expectations and initial objectives when you arrived at ICO?

Although I found there was an understandable sense of uncertainty regarding the immediate future of the College, morale was surprisingly good. It was my perspective that faculty and staff were not only willing, but eager, to “right the ship” and to positively engage in strengthening and improving the institution. I felt confident I could immediately assemble a capable administrative team from the existing faculty and staff.

My initial objectives included:

Initiation of a strategic and tactical planning process.
Enhancement of the academic culture by increasing support for faculty development, research, and scholarly activity.
Expansion of the clinical educational program by initially adding 50 community-based training sites.
Initiation of a search for a new Dean/Vice President for Academic Affairs.
Review and modification, as appropriate, of the administrative organization.
Enhancement of the institutional culture, by improvement of services to students, patients, alumni, and employees.
Ensurance of the financial stability of the institution, including the enhancement of revenue streams.
Review and modification of the master buildings and facilities program.
Improvement of management information systems.
Enhancement of personnel management.
Development and implementation of public relations and fund-raising programs.
Redirection of resources formerly allocated to an ambitious building program into programmatic improvements.

I believed that it was vital that our planning process promote open avenues of dialog with internal and external constituencies. I knew from my PCO experiences that each graduate of ICO is important to the college. I needed their perspective, but – even more importantly – I had to make them part of the decision-making process. I commissioned a survey of alumni/alumnae needs and concerns that not only had an immediate impact on our strategic planning, but led to the creation of ongoing communication channels that continue to affect our strategic planning. One very dramatic outcome of alumni input was ICO’s recent decision to freeze tuition, increase scholarship funding, and reduce the entering class size.

We also brought the broader community into the planning process. The Illinois Eye Institute had a long and well-recognized record of serving the community and we wanted to be even better neighbors. We appointed a Community Advisory Board (CAB). This Board includes leaders of neighborhood organizations, school principals, representatives of government agencies serving the community, clergymen, and members of ICO’s senior administration. We deal with various issues of mutual interest to ICO and the community, such as employment opportunities, construction projects, real estate transactions, and minority student recruitment.

It was now our task to channel these processes into a tangible plan of action. With input generated through countless meetings, reviews, evaluations, and reevaluations, we created a 70-page document, the Prescription for Excellence. It contains five major goals, each with detailed, quantifiable action steps and completion dates. Thee action steps also identified the department responsible for their implementation. Regular monthly meetings were scheduled to evaluate our progress. These meetings – which continue today – are open to all members of the ICO community.

The Prescription for Excellence was immediately effective. The goals and directions we established continue to be important, but even more important is the process we created whereby each member of every ICO constituency has the opportunity to be meaningfully involved in the planning process. The Prescription for Excellence is now in its second generation, as the Journey to Excellence.

Several important themes emerged during the planning process that have helped created a new culture at ICO. Through the planning process, five major goals were crystallized:

Provision of excellence in education and scholarly activity.
Creation and maintenance of reputation as an institution that is characterized by exceptional accountability.
Provision of excellence in service, as defined by our students, patients, alumni, and employees.
Provision of excellence in health care.
Achievement of recognition as a center of influence within the profession and the community.

These goals are now the basis for the performance agreements that exist between every member of senior administration and the President, as well as an agreement between the Board of Trustees and the President. These agreements are what each of us is measured by; they are the basis for budgeting and for departmental planning.

What progress have you made in addressing your objectives and have your expectations been met?

Strategic planning has been very successful at ICO and not just by our own measurement. Nearly 70% of the initial action items contained in the original plan have been completed. The following are all the direct outgrowth of ICO’s planning process:

Appointment of Janice E. Scharre, O.D., MS, as Dean/Vice President for Academic Affairs.
Achievement of continuing accreditation by the North Central Association of Colleges and Schools, without stipulation or monitoring.
Creation of open dialog with key constituency groups.
Achievement of strong financial position for the institution.
Diversification of the Board of Trustees, including the appointment of faculty representatives and minority representation.
Achievement of increase in patient encounters at the Illinois Eye Institute.
Successful restructure of ICO’s debt through the issuance of $45 million in variable-rate tax-exempt bonds, which allowed more flexible investment of $22 million in assets.
Institution of numerous financial controls and safeguards.
Reorganization of the administrative team, including the formation of a President’s Advisory Council
Improvement of student services and culture by response to a comprehensive student satisfaction survey.
Affiliation with the Department of Ophthalmology and Visual Sciences at the University of Chicago.
Expansion of externships from 9 sites to 97 sites in the United States and abroad.
Completion of $8.5 million in campus capital improvements, including renovations to the physical plant, purchase of new ophthalmic equipment, and installation of extensive informational systems technology.
Achievement of an all-time high student retention rate of 97.1%.
Participation in the continued resurgence of the neighborhood development around the College by improvement of the external appearance of the college campus and other college-owned property.
Reinstatement of a faculty practice plan.
Enhancement of employee and trustee communications by issuance of a comprehensive Employee Manual, a revised Faculty Handbook, and a Board of Trustees compendium of Resolutions and Action Items.
Receipt of a report from the Council on Optometric Education, during an interim site visit in 1998, that ICO had addressed all previous recommendations and suggestions.
Revision and improvement of the Practice Management course, including the initiation of an annual practice opportunities symposium, in which students have the opportunity to learn about all modes of optometric practice.
Enhancement of faculty governance with creation of the faculty executive committee and expansion of the committee structure.
Achievement of increased student-patient care encounters by 68%.
Development and implementation of a course for University of Chicago second-year medical students in basic eye care procedures.
Expansion of ICO’s residency program to include residencies in cornea/contact lenses and anterior segment/refractive surgery.
Achievement of increased quality of entering students, as measured by average GPA and OAT scores over the past three years.
Settlement of all outstanding legal matters.
Freeze of the tuition at FY98-99 level.
Achievement of increased scholarship funding.
Improvement of relations with the corporate community.

I can honestly say that my expectations have been greatly exceeded. I attribute this to the dedication, hard work, and perseverance of ICO’s Board of Trustees, faculty, staff, and student leadership for their support and willingness to adjust to my management style.

I am very proud of our affiliation with the Department of Ophthalmology and Visual Sciences at the University of Chicago. It came about, in part, as a result of the account of my earlier experiences with cooperative efforts between optometry and ophthalmology that had appeared in Archives of Ophthalmology. Terrance Ernest, M.D., Ph.D., chairman of the Department of Ophthalmology and Visual Sciences at the University of Chicago, had read the article I co-authored with Myron Yanoff, M.D. in 1990 on the affiliation between Hahnemann University and PCO. Dr. Ernest believes – as I do – that there is tremendous potential for further cooperation between optometry and ophthalmology. Now that I was at ICO, Dr. Ernest approached me with the possibility of a similar agreement with the University of Chicago. The proposed affiliation quickly became part of our planning process. In October 1997, Dr. Ernest and I signed the affiliation agreement as one event of my inaugural-week activities. The affiliation continues to be highly successful as the relationship expands and new elements are added to the basic agreement.

What is the future direction of ICO, optometric education, and the profession of optometry?

Although in retrospect I believe I may have underestimated the complexity of the issues facing optometric education when I assumed the presidency of ICO, I remain as optimistic of the future as I did on my arrival. But I do see changes ahead for ICO and optometric education. Indeed, my optimism is grounded in the belief these changes are not only necessary, but inevitable. I believe for ICO to continue to excel, we must:

Successfully mange the decreasing optometric and health care student pool.
Reduce student indebtedness.
Address issues of eye care manpower.
Restructure the clinical education program to be more cost-efficient while we maintain academic quality.
Launch major capital and deferred giving campaigns and sustain an intense development effort.
Significantly increase the Illinois Eye Institute revenues and expand our faculty practice plan.
Further diversify the Board of Trustees and increase its size by recruiting Board members with needed expertise and philanthropic capabilities.
Continue to provide students with a voice in College affairs, including representation on the Board of Trustees.
Improve faculty scholarly activity – specifically, externally funded research, clinical trials, and publications.
Greatly expand instructional technology.
Ensure that curriculum is consistent with defined entry-level attributes.
Continue the emphasis on strategic and tactical planning with outcome-based assessment as the measure of progress.
Develop and implement an advanced competency curriculum.
Enhance our position – in cooperation with the University of Chicago – as a provider of comprehensive eye care services within the Chicago-land health care market.
Develop and implement and O.D./Ph.D. program in cooperation with the University of Chicago.
Achieve continuing accreditation by the Council on Optometric Education.
Improve personnel relations with ICO – particularly as it pertains to positive attitude and respect for one another, with a special effort to acknowledge individual and group achievements.
Expand our foreign student recruitment program to extend beyond North America.

The challenges facing ICO – to a greater or lesser extent – are the same issues that face many of the schools and colleges of optometry. In general, I see the following trends in optometric education:

We will see a lessening of our dependency on camps-based clinics for the clinical education of third and fourth-year optometry students. Driven initially by economics – but, I believe providing for greater diversity of educational experiences – we will see more community-based training sites or externships for fourth-professional-year students and some third-year students.
Campus-based clinics will remain valuable for first- and second-year students.
College-based clinics will serve a significant role as faculty practice becomes more important as a means to enhance faculty income and improve the schools’ and colleges’ ability to recruit and retain highly qualified clinicians.
We will see a movement away from traditional classroom teaching toward more technology-assisted self-learning through the rapid advances being made in communication and computer-based technology. The college, however, must be prepared to assist the faculty in changing their teaching strategies.
Acquisition of critical analysis skills will become as important as a solid foundation in the basic and health sciences.
There will be recognition that the function of a school or college is to prepare doctors of optometry for a lifetime of learning in their field.
We will have to redefine the entry-level attributes of our students and modify our curriculum to emphasize a lifelong commitment to learning.
While graduates must learn to be well-grounded in the fundamentals of their profession, the purpose of this grounding must be to position them to continue the learning process.
Students must learn to focus on the opportunity for interaction with faculty and with one another while on campus – they must commit to a philosophy that emphasizes the acquisition and appropriate application of knowledge over information absorption and memorization.
We will see the development and utilization of a national faculty in several disciplines, linked through developing technology. All schools and colleges of optometry will be able to access a faculty made up of our very finest educators.
Cooperation between optometry and ophthalmology – that began at the New England College of Optometry’s Boston clinics and carried forward at PCO with Hahnemann University and at ICO with the University of Chicago – will continue and intensify.
We must then be prepared to offer meaningful advanced competency education to practicing optometrists as a core value of optometric education.
Residency programs will continue to increase, but at a more modest rate.
I believe the future direction of the profession of optometry will be fueled by the economics of the managed care marketplace.
The cooperative environment among opticians, optometrist, and ophthalmologists that exists at the academic level and – in several instances – in other practice modes will intensify.
Distinctions in practice modes will continue to blur among the three groups. Economic realities will override emotional opposition and force closer cooperation. Individual claims of priority and historical territorial imperatives will be forced to give way.
Quality assurance programs and advanced competency certification and accreditation will become increasingly important.
The expansion of the scope of practice of optometry will consist mainly of amendment and clarification to existing practice laws.
Ultimately, all states will grant appropriate and extensive prescriptive authority to optometrists.
The expanded use of laser technology by optometrist will evolve slowly over the next two decades.
Consultation among practicing professionals will take advantage of advances in technology. Consultations with national eye centers of excellence will become the norm, as precise retinal images and other data are instantly transmitted from one point to another in real time.
We will see fewer independent, private practitioners of optometry in the future and more multi-practice settings, more optometrists in HMOs, hospitals, and other institutional settings. What is often termed “corporate optometry” will continue to expand for the foreseeable future.
Schools and colleges of optometry will recognize their responsibility to expose their students to a wide variety of practice modes, and to discuss each opportunity openly and honestly.
Health care third-party payers will continue to exert enormous influence on the practice of health care – eye care included. In this vein, it is imperative that optometry solidify its position as the primary eye care provider with the managed care market.

We live, learn, teach, and practice in tremendously exciting times. I believe the future of optometry is as great as our ability to translate our vision for the profession into strategic and tactical plans of action – and as promising as our courage and tenacity to implement those plans.

Charles F. Mullen, O.D.
Journal of the American Optometric Association.
September 1999. Volume 70. Number 9.

The Past, Present and Future of Externships in Clinical Education

I believe that the future of Optometric externships in clinical education is of the greatest importance to us as educators, and to the future direction of the profession of optometry. I would even venture the opinion that where, and under what circumstances, clinical experience is gained by optometry students will determine the direction of clinical optometry.

Before presenting my thoughts on the future of externships, it might be useful to review where we are, and how we got here.

The Past

Community based clinical education – commonly referred to as externships – has its roots in the late 1960’s. Several factors coalesced at that point in time to create the impetus for what was then a new direction for optometric education.

First, faculty and administrators had become increasingly aware of the need to enhance student-patient encounters, both in terms of quantity and in diversity of experience. This impetus was bolstered by increases in class size at several institutions. Space and patient volumes at many college-operated clinics simply were not adequate to meet student needs.

Second, and closely connected, there was a growing recognition that student-patient encounters would be more beneficial to the students’ education if they took place in an environment outside the traditional academic environment. Supporting this view was the awareness of the need to train optometry students to interact with other health care disciplines.

Third, pressure was coming from practicing optometrist to expand the scope of our profession. Those of you who were in the service as optometrists in those days many recall that military protocols allowed optometrists greater latitude in treatment options, particularly in regard to pharmaceutical agents, than did state regulations. Having expanded their practice while in the Military, these optometrists were reluctant to step back into the more restrictive guidelines of civilian practice. They realized that optometry students, as well as the faculty, needed training in the use of pharmaceutical agents.

Fourth, several colleges of optometry had urban campuses, often in areas with significantly undeserved populations in terms of health care. These institutions had a strong commitment to provide eye care to those residing in proximal neighborhoods.

As a result of these concurrent pressures, several institutions, acting independently of one another, came to the conclusion that the most promising avenue for meeting these needs was to form networks of clinic affiliations with existing health care institutions. However, any illusions regarding the ease with which this strategy would be executed were quickly dispelled.

Those attempting to create externships encountered reluctance on the part of health center administrators to permit students to participate in their programs. Medical staffs were unfamiliar with Optometry, and the benefits optometry students could provide. Ophthalmologists did not have a history of interacting with Optometrists, and were often reluctant to do so. The new model of community based clinical education also aroused antagonism among community optometric practitioners who perceived it as an unwanted competitive threat.

Nonetheless, the need for externships was too great to be denied, and the creation of externships proceeded. These first externships shared several characteristics. Criteria for site selection and evaluation were ill defined. The terms of the affiliations themselves were not always well drafted. Student selection/assignment processes lacked consistency. The length of student rotations varied widely, from a half a day in some to a year in others. In too many instances there was little staff support from the parent institutions.

The first externships were located in a variety of settings, but primarily they were in community health centers, nursing homes, prisons, military facilities, public health facilities, the VA, university student health services, and even in some private practice settings.

Fortunately, many of these facilities encouraged, or even required, the use of pharmaceutical agents by optometrists. This experience would prove invaluable as optometry faculty were called upon a few years later to provide instruction in diagnostic and therapeutic agents as state practice laws changed.

Despite a rather awkward beginning, and with all the missteps and mistakes notwithstanding, the movement towards community based clinical education in the late 1960’s had a profound impact on our profession, and must be considered one of the most important innovations in the development of optometric education. It was through the creation of these external affiliations, and the availability of large patient volumes, that the base was established for the subsequent growth of optometry into a true primary care profession.

The Present

Today community based clinical education has expanded dramatically in terms of the quantity and quality of externships. A recent ASCO survey found that all the schools and colleges of Optometry responding reported that they had externship programs. The number of sites per institution ranged from 25 to 200.

While great progress has been made, it has been uneven. In some areas the problems experienced by those early externships continue. However, most externships enjoy strong support from their parent institutions. Today’s students typically serve two rotations of twelve weeks each. Student preference is an important consideration in the assignment process; housing, meals, and a stipend are provided on a limited basis.

Today site selection and evaluation procedures are in place. Formal affiliation agreements provide guidance and define and expand responsibilities – but with varying degrees of thoroughness. In general those affiliations that include a government entity tend to be better defined than those that do not.

Externship preceptors are recognized with some form of faculty rank, often an adjunct appointment. Externships are predominantly located in government health care facilities, such as those operated by the VA, the Indian Health Service or the Military. They are also found in public and private hospitals, rehab centers, and referral centers. They continue to be found in private practice arrangements, nursing homes, prisons, special needs schools, and university student health clinics. They are also located in community health centers and facilities operated by HMO’s.

In general, the overall state of the national externship program is strong, significant in its impact, well managed and improving. It is firmly established as an essential component in the education and training of today’s optometry student.

The Future

What is the future of externships? As important as the externship has become, I would suggest today that its role is about to increase significantly. Once again forces are coalescing to create a climate conducive to, and even more demanding than the 1960’s.

Today’s health care environment is being driven by the demands of managed care and government that costs be reduced while quality and efficiency are increased.

In this environment I believe externships will become the primary source of clinical experience for optometry students. And while there will always be a need for some sort of sheltered workshop for clinical training of first and second year students, such as college operated campus clinics, the role of these clinics will be correspondingly diminished as the role of the externship grows in importance. Campus based clinical education will be limited to special emphasis areas such as pediatrics, vision rehabilitation and advanced ophthalmic care, while primary care education will be delegated to multiple affiliated health care facilities.

Just as several unrelated and related forces combined in the ‘60s to created externship, a combination of forces at work in the ‘90s will once again drive their expansion.

The large numbers of close-at-hand underserved patients, once the backbone of institutionally based clinics, have become attractive to managed care providers as government units have turned to managed care to administer health care. Once spurned by third party payers as a burden, they are now sought by those who, unencumbered by an educational mission, are able to respond rapidly, efficiently and cost effectively. The ability of large single purpose eye clinics, such as those operated by most schools and colleges of optometry, is now seriously compromised.

Forced to allocated scarce resources to market to what was formally a virtually reserved patient base, such clinics are finding it even more difficulty to be cost effective, if indeed they ever were. As patient numbers decline, educational inefficiencies increase, and operating deficits increase.

Externships, by contrast, are highly cost effective, offer a challenging clinical environment, and are often staffed by seasoned preceptors. This nicely compliments the basic clinical training provided by college faculty. The clinical experience gained at externships is both progressive and stimulating for students.

I believe, therefore, that the demand for more externships, geographically distributed, will increase in the years ahead. Longer rotations, and more rotations, will be the standard. Advances in communication, such as telemedicine and the internet, will make it easier for institutions to effectively manage a widely distributed network.

There exists today a vast, and largely untapped, potential within the federal sector for externships in optometry, where the growth will take place.

However, I must raise a cautionary note. We learned a great deal from the mistakes that were made in the ‘60s in the creation of externships, and we have benefited from that knowledge. However, that does not mean we must continue to rely on trial and error as the path to wisdom. To the extent that we are able, we must anticipate the problems that will inevitably arise from the creation of a national network of externships.

The Challenge to Optometry

A significant challenge to us all will be the efficient and equitable use of this national network of externship sites by the schools and colleges of optometry. If we follow the competitive model of the past, some schools will find they have a surplus of externships, zealously guarded as a resource, while other schools will find they have an unmet need for student placements.

We must begin to work together to establish a national clearing house and placement service for externships in optometry. Through such a clearinghouse all institutions of optometric education will fully share in this enormous national resource, and each site will be appropriately and fully utilized. The clearinghouse could facilitate the development and implementation of national standards for externships, possibly leading to some form of accreditation for participating sites.

Our purpose, after all, is not to compete with one another, but to cooperate in the advancement of optometric education and the profession. By so doing we not only assure an efficient and effective use of the opportunity that is being presented to us, but we also best serve the needs of our students, the affiliated facilities, and the patients they treat.

I realize this will not happen over night. It will require much discussion and a decision to accept challenges and make compromises. It will require a recognition of the fact that the traditional environments in which we have lived will not be the models for tomorrow. It will require change. It will not be easy. It will be necessary.

Acknowledgements

The author thanks Drs. Daniel Roberts and Stephanie Messner of the Illinois College of Optometry who assisted in the preparation of these remarks.

These remarks were originally delivered to the Optometric Education Section at the December 1997 American Academy of Optometry meeting.

The Journal of the Association of Schools and Colleges of Optometry.
Optometric Education. Volume 24, Number 1. Fall 1998.
Charles F. Mullen, O.D., Guest Editorial

Changes in the Department of Veterans Affairs and Their Implications for Optometric Education

In the coming years the veterans’ health care system will be affected by powerful societal and health care industry dynamics. These factors will influence the manner in which the VA accomplishes its mission and they provide the context in which it must operate.

My discussion of the future of the veterans’ health care system is based on the following assumptions:

The role of the federal government in American society will continue to be reevaluated, and competition for federal government funding will become even more intense.
Most health care in the United States will continue to be provided by the private sector.
There will continue to be marked turmoil among and consolidation of medical groups, hospitals, health maintenance organizations, and other elements of the private sector.
Managed care within integrated delivery systems will become the most common mode of health care delivery in the United States.
Medical and scientific information will continue to grow at an astonishing rate.
Technological innovations will continue to revolutionize clinical practice. In addition, the trend of providing care in nonhospital settings will continue, and even accelerate, as concern about health care costs continues.
Advances in information and communication technology, and imaging systems in particular, will open up many new opportunities for improving the delivery of health care.
Integrated information systems will be the key to success for future health care systems.
Nonphysician providers will be increasingly used in health care systems of the future.
Health care organizations will be increasingly expected to prevent disease and promote community wellness, in addition to treating individual cases of illness.
There will be increased demand for accountability in health care and increased emphasis on health care outcomes and measurements.
While the rate of increase of health care costs has diminished in recent years, health care costs will continue to be a major driving force in the industry. Nonetheless, quality of care and customer service will become more important issues.
The veteran population eligible for care at VA facilities will continue to age and decrease. However, the need for both acute and long-term care services for this aging population will rise disproportionately to the decrease in users due to greater health care needs associated with aging.
In addition to the “macro” issues, there will be local and regional dynamics impacting individual VA facilities and networks.

In envisioning the veterans’ health care system of the 21st century, it is assumed that the future is unpredictable and that the VA must be flexible enough to rapidly respond to unforeseen circumstances.

The mission of the veterans’ health care system is to serve the needs of America’s veterans by providing specialized care for service-connected veterans, primary care, and related medical and social support services.

To accomplish its mission, the Veterans Health Administration (VHA) should be a comprehensive, integrated health care system that provides excellence in health care value, excellence in service as defined by its customers, and excellence in education and research. It also should be an organization characterized by exceptional accountability.

There are numerous changes underway in the VA which specifically affect optometric education and they present both challenges and opportunities – opportunities for significant gains if optometric institutions are proactive and significant losses if they are passive. The VA is currently:

Reengineering the operational and management structure of the veterans health care system.
Implementing the Veterans Integrated Service Network (VISN) management structure. This new structure has resulted in a shift of operational control and some policy development to the local level.
Management Assistance Councils consisting of external advisors are either operational or being established in all Networks.
Restructuring VHA headquarters.
Implementing multidisciplinary “service line” rather than discipline-specific clinical care in recognition of the Transdimensional nature of health care today. Optometry and ophthalmology have been placed in the HQ Primary and Ambulatory Care Strategic Health Group forming the eye care program. This is likely to be emulated in VA field facilities.
Standardizing clinical processes (e.g., with nationally developed clinical guidelines) and delegating clinical care responsibility to nonphysician providers.
Exploring ways of improving the accessibility, quality, and cost-effectiveness of VA’s special emphasis programs, e.g., VICTORS.
Increasing the proportion of the VA’s work force providing primary care.
Developing tailored training/retraining programs in primary care.
Reducing the variation in professional staffing that exists among facilities and services having similar missions and work loads.

Although we may experience reductions at certain facilities, overall continued growth in optometry is projected. Since 1990, VA Optometry Service has added 86 FTEE staff and residents. This growth has facilitated our involvement in the following activities:

Increased sharing of activities with academic affiliates and the Department of Defense.
Promoting a VHA culture of ongoing quality improvement that is predicated on providing health care value.
Establishing a VA clinical “Centers of Excellence” program to celebrate and disseminate best practices and to foster studies that identify organizational characteristics that lead to performance excellence.
Promulgating customer service standards and ensuring that they are known by both staff and patients, e.g., 30 days maximum wait for eye care.
Decreasing waiting times for appointments. Although reduced from over 100 days in 1990 to the current level of 47, it still is far from acceptable.
Ensuring the VHA’s educational offerings emphasize areas of greatest societal need and are responsive to the needs of veterans today and in the future.
Convening Residency Realignment Advisory Committees for physicians and other health professionals to provide guidance in ensuring the VA’s postgraduate training programs are responsive to the needs of the VA and the nation. Possible overall reduction in optometry positions could result from general downsizing. Also, the lack of formal requirements for optometric residency training increases the vulnerability of the program. Most likely there will be a reduction in multiple resident placements.
Increasing the proportion of trainees in primary care disciplines.
VA facilities are reevaluating their affiliation(s) in light of VHA’s restructuring and vision of the “new VA,” and the present educational role of VA. Affiliation agreements should defend the prerogatives of VA, control the use of VA resources, and protect the interest of VA patients.
Initiating review and renegotiation of all academic affiliation agreements.
Reassessing the role and function of Deans Committees in light of today’s changed health educational environment and effect changes where needed.
Academic affiliations and residents are likely to be negotiated on a Network basis.
Clinical credentialing and privileging will probably be conducted on a Network basis.

The VA’s Current Contributions to Optometric Education

There are currently 155 academic affiliation agreements at 103 facilities. Five hundred thirty optometry students annually rotate through VA facilities. Seventy-five residents and 9 WOC are currently funded at 44 program sites. A significant increase in requests for “without compensation placements” (WOC) has been noted. There is a potential of 400,000 annual clinical teaching encounters. Research opportunities abound with currently over 7.0 million in funded optometric research.

There is a corps of well-qualified clinical preceptors with some VA optometrists released to teach at affiliates. VA clinicians are also active contributors to the literature and national continuing education programs.

What Can Individual Schools and Colleges Do to Preserve VA Affiliations?

Above all, be an active partner.
Assist VA facilities with Quality Improvement activities.
Assist VA facilities in improving staff productivity and reducing waiting times for appointments. Low productivity will likely result in loss of residency funding and possibly staff FTEE. Chronic long waiting times could result in local frustration and contracting out to commercial providers. This is already a reality in one Network.
Seek appointment of school-based optometric faculty as consultants at VA facilities.
Enter into contractual “sharing’ arrangements, e.g., VICTORS, Eye Care Centers of Excellence.
Seek appointments to Network Management Assistance Councils. Already, Drs. Haffner, Hopping, and Walls have been appointed and I have received positive feedback on their contributions.
Increase awareness of VA affiliations by publicizing your institution’s activities.
Seek new academic affiliations within your Network.
Prepare thoroughly for COE accreditation visits and address problems before COE visits. Less than full accreditation will likely result in loss of VA funding.
Seek cooperative research projects with VA affiliates.
Consider WOC residency programs as a means to initiate new programs.
Understand the new JCAHO accreditation standards and survey process and their implications to optometry.

What Can ASCO Do Collectively?

ASCO should implement the recommendations agreed to in the 1992 AOA/ASCO/NAVAO Strategic Plan. For example:

In cooperation with the VA, assist in the development of and implementation of a system wide Total Quality Improvement Program.
Improve management of affiliations programs by: participation on Network Management Assistance Councils. (Originally the Deans’ Committees.)
Stimulate research proposals in cooperation with VA medical centers.
Review faculty appointment procedures and benefits for VA preceptors and enhance them wherever permitted by institutional governance.
Residency expansion in VA should be carefully managed to assure well-balanced clinical educational programs nationwide.
ASCO should endeavor to publicly promote its relationship with the VA, increasing positive support of VA activities and accomplishments and increasing the public and the government’s knowledge of optometry.
Monitor affiliations through the ASCO Committee on Residencies and Externships and through COE reports.

This is a time of great change in the VA. It presents many challenges, but also many opportunities. The shift of control to the Networks (local) level makes it more important than ever that every affiliated optometric institution be an active partner with its VA affiliated facilities and Network leadership. There is the possibility for significant gains if there is local initiative and likewise the possibility for significant losses if the schools and colleges of optometry are inactive.

At the time this article was written, Dr. Mullen was Director of the Optometry Service, Veterans Health Administration. This article is based on the VA’s new strategic plan entitled Prescription for Change. Dr. Mullen is currently the president of the Illinois College of Optometry.

The Journal of the Association of Schools and Colleges of Optometry.
Optometric Education, Volume 22, Number 3. Spring 1997.
Charles F. Mullen, O.D.