Charles F. Mullen

Challenges and Opportunities in Optometry and Optometric Education

An Affiliated Educational System for Optometry with the Department of Veterans Affairs

An unprecedented opportunity exists for the Department of Veterans Affairs (VA), the Association of Schools and Colleges of Optometry (ASCO), and the American Optometric Association (AOA) to develop jointly a large scale affiliated optometric educational system. Coordinated strategic action would establish and direct the dynamics of interaction among VA, ASCO member institutions and AOA, and could result in enhanced optometric patient care, education, and clinical research opportunities with the Department of Veterans Affairs.

Veterans Health Administration

The Department of Veterans Affairs includes three distinct organizations: Veterans Benefits Administration, National Cemetery System, and Veterans Health Administration (VHA).

The VHA administers the world’s largest comprehensive health care system for the nation’s 26.9 million veterans. It includes 172 medical centers, plus more than 700 outpatient clinics, nursing home care units, domiciliaries and vet centers throughout the United States and the Philippines. Operating with an annual budget of over $13.5 billion, VHA treats 1.1 million inpatients and records over 23 million outpatient visits annually.

In addition to its primary mission of providing health care to veterans of the U.S. armed forces, VHA has three other roles. First, in times of war or national emergency, VHA serves as the backup health care system to the Department of Defense. Second, VHA trains a broad range of health care providers, including optometrists. Third, VHA works to enhance patient outcomes through clinical research. Each year VHA appropriates over $200 million for medical and prosthetics research. Currently, nearly 6000 investigators are engaged in more than 10,500 research projects located at VA medical facilities.

Optometry Service

In 1974 VHA recognized optometry’s contribution to veterans’ health care and named its first Director of Optometry to address the eye and vision care needs of veterans. Initially, the Director could not attract optometrists to service because of the outdated personnel system and salary schedule. There were just 8 full-time optometrists in the system and no residents.

In 1976 VHA designated optometry a Service and placed staff optometrists under title 38, in the same personnel pay system as physicians, dentists, and nurses. This provided more competitive salaries, created teaching programs, and increased optometric care for veterans. By 1980 there were over 70 full-time optometrists in the VA.

In the early 1970s, the VA also began establishing successful and innovative affiliations with schools and colleges of optometry. For instance, the nation’s first clinical education program for optometry students began at the Birmingham VA medical Center, in affiliation with the University of Alabama School of Optometry. Also, the nation’s first VA optometry residency program began at the Kansas City VA Medical Center. By 1980, 12 residency programs had been established.

Providing primary eye care by staff optometrists proved to be cost-effective and efficient, and veterans and veterans’ service organizations enthusiastically endorsed optometric care. This allowed VA Optometry Service to expand steadily and to begin to address the unmet need for primary eye care in the VA.

At present, 220 full- and part-time optometrists (150 FTEE) provide eye care services to veterans at 138 VA medical facilities. Optometrists manage over 300,000 patient visits annually and provide clinical training for 500 optometric students and 53 optometric residents at 79 academically affiliated VA facilities. Since many VA facilities have multiple affiliations, currently 121 affiliation agreements exist among schools and colleges of optometry and VA medical centers.

Included in Optometry Service’s responsibility is the provision of vision rehabilitation services at three Vision Impairment Centers to Optimize Remaining Sight (VICTORS), three Low Vision Clinics, and five Blind Rehabilitation Centers (BRCs).

The Field Advisory Group is an integral part of Optometry Service. Fifteen chairpersons, all optometrists practicing within the VA medical system, head special committees on areas critical to the development of the Service and the delivery of quality eye care, education, and research. They remain in constant contact with the Director and address issues ranging from total quality to improvement of public relations. The chairpersons, representing the dedicated work of their committees, provide invaluable assistance at biannual strategic planning meetings of the entire Field Advisory Group.

With regards to external relations, the Director of Optometry Service maintains liaisons with the AOA, ASCO, National Association of VA Optometrists (NAVAO), and the Special Medical Advisory Group (SMAG) Subcommittee on Eye Care. The Field Advisory Group and representatives from these organizations combine to form a significant network of advisors.

The Opportunities

In the Armed Forces, Health Maintenance Organizations (HMOs), and the private practice sector, the ratio of optometrists to ophthalmologists is a little over two to one. This balance has evolved naturally in response to the need for a cost-effective, logical approach to primary eye care services, subspecialty eye care services, and surgery. In VA, the ratio is reversed; there are at least two ophthalmologists for every one optometrist. An opportunity exists to develop and implement a highly efficient and cost-effective national model for the provision of eye care, a model that minimizes duplication and overlapping of services among the eye care providers.

By the year 2000 the number of Veterans at visual risk will increase from 4.0 to 5.7 million impacting greatly on the total number of eye care visits to VA facilities. Optometry Service presents a cost-effective means of providing primary eye care.

The veteran population of 26.9 million is aging. It is a population with a high incidence of ocular and vision disorders. VA presents opportunities for eye care research in early diagnosis and management of eye disorders in the elderly. Significant clinical studies of age-related macular degeneration, diabetic retinopathy, cataract, and glaucoma could be mounted.

Leaders within VA, ASCO, and AOA have a chance to dramatically shape the future of eye care delivery and optometric education. Opportunities within VA for enhancing patient care, clinical education, and research abound. The climate is right to jointly initiate constructive, strategic action.

Climate

VA has a history of support for sharing agreements and affiliations. VHA medical centers share extensively with academic health care centers demonstrating a history of commitment to clinical education and research. Thousands of sharing agreements exist between the VHA, the Department of Defense, and the Indian Health Service.

VA has an ongoing and active policy of cultivating new affiliations. Within the past two years 18 new academic affiliations have been developed among VA medical facilities and schools and colleges of optometry. Also, three existing programs have been expanded. More affiliations are possible and have been encouraged by various government organizations and VA advisory groups.

Related to this is VA’s high technology sharing program. This allows VA medical centers and its academic partners to purchase expensive equipment jointly and to share in the cost of operation. Technology sharing agreements with schools of optometry should be explored.

The quality and cost-effectiveness of health care delivery is of prime importance to VA. Optometry Service provides quality, cost-effective, and accessible care and is often used as an example of a model program in which high quality patient care is inextricably combined with the training of students and residents.

Funds were recently made available for 35 new optometric staff positions. In an effort to improve accessibility to primary eye care, additional funds for staff expansion are anticipated.

With its Field Advisory Group, Optometry Service already presents a highly qualified team ready for constructive interaction with ASCO, NAVAO, and AOA leaders. This extensive network of advisors covers every aspect of Optometry Service’s operation. Together we will be ready to address the issues. Together we will be ready to face the challenges ahead.

The Challenges

VHA is concerned with health services research and the structure of eye care services delivery in particular. Optometry Service, ASCO, and AOA, along with VA Offices of Quality Management, Health Services Research and Development, and Clinical Programs could respond to the challenge by creating Regional Centers for Eye Care Excellence. These Centers would involve the disciplines of optometry and ophthalmology and their respective academic affiliates in the collaborative provision of eye care, ophthalmic education, and research. They would serve as demonstration and evaluation sites for evolving eye care models.

Within the VA, as in the private sector, sensitive issues surround the respective roles of optometrists and ophthalmologists. A unique, coordinated health services research project which addresses the interaction between optometry and ophthalmology in the VA could be developed.

Such a demonstration project would examine reporting relationships for optometrists and ophthalmologists in VA medical centers. It would also study the extent of clinical privileges granted to ophthalmic clinicians. The project would address the issue of new and developing technologies and Clinical Practice Indicators for VA eye care.

Conclusions defining the practice of optometrists in relation to ophthalmologists and other health care providers could serve as guidance for the entire system.

VA, ASCO, and AOA should move forward in designing and implementing a comprehensive affiliation system. This would, however, present challenges in maintaining quality patient care and integration of educational programs. It is imperative that any system under consideration include guidelines for optometric faculty, resident, and student participation. Appointing all affiliated optometry school deans to VA Deans’ Committees and appointing selected optometry school faculty as consultants and attending optometrists at VA medical centers would assist in maintaining proper integration of patient care and clinical education.

Participants in the September 1991 ASCO Workshop on VA Optometric Academic Affiliations stated that in the development of large scale education initiatives there is a need for consultation by the AOA’s Council on Optometric Education (COE), which has been successful in accrediting and counseling optometric programs within the VA.

In cooperation with the schools and colleges of optometry the VA Optometry Service and Quality Management Office could review and update Optometry Service’s Quality Improvement Program. Further, quality could be insured by encouraging continued review of the VA Optometry Service patient care programs by the Joint Commission on Accreditation of Health Care Organizations (JCAHO). However, optometric representation in JCAHO is essential to the success of the accreditation programs.

The greatest challenge faced by the VA, ASCO, and AOA will be interacting on a comprehensive scale; planning will require foresight and coordination. However the outcome – a newly acquired ability to mount large scale educational initiatives, to evaluate new technology, to test quality assurance mechanisms, and to develop innovative eye care programs – will be worth the effort.

VA, ASCO, and AOA could work to develop or enhance affiliation agreements between ASCO member institutions and key VA facilities. VA medical centers in New York, Philadelphia, Houston, Memphis, Indianapolis, and Boston present significant training opportunities not currently realized by ASCO members.

Summary

The time is right for VA, ASCO and AOA to take action. Cooperative strategic action by the health care system (VA), educational institutions (ASCO), and the professional association (AOA), could lead to the placement of hundreds of new optometric residents and externs in educationally cost-effective and clinically challenging environments.

If the initiative is consistent with the VA’s mission and addresses the challenges previously described, it will succeed. If the initiative creates improved models for optometric academic affiliations and includes discipline specific protocols for resident and extern placements, it will succeed. If the initiative includes innovative models for more accessible, cost-effective and efficient eye care delivery, it will succeed. And above all, if the initiative systematically addresses the eye care needs of our nation’s veterans, it will succeed.

Journal of the Association of Schools and Colleges of Optometry.
Optometric Education. Volume 18, Number 2. Winter 1993.
Charles F. Mullen, O.D.

by Charles F. Mullen

Optometry and Medical School Affiliations

Affiliation with a medical school presents numerous opportunities for enhancing the education and clinical training of optometric students, residents and practitioners. The advantages of medical school affiliation seem to be easily outlined while the disadvantages are somewhat less apparent.

The decision-making process concerning affiliation must include a careful cost benefit analysis. Evaluation should include a best and worst case scenario, and a timetable for implementation, perhaps in a step-like fashion to permit both parties to assess the effectiveness and impact of the relationship.

Analysis should be of sufficient depth so as to insure that all facets of the affiliation have been thoroughly explored in both quantitative and qualitative fashion, as it relates not only to educational and patient care factors, but also to finance, research and public relations.

Obviously, the most desirable affiliation for an educational and public image perspective would be with the most prestigious medical school. Geographical accessibility is another factor. Financial strength and quality of medical and ophthalmological staff and resultant patient care are also important factors.

The integrity and qualifications of the administration and faculty who are involved in negotiating the agreement and who will be directly involved in the joint programs are of paramount concern in order to protect the college of optometry from an adverse outcome in either the short or long-run.

Benefits of a Medical School Affiliation

Education

  1. Increased access by optometric students and resident to patients with eye disease, systemic disease and pre- and post-ophthalmic surgical cases.
  2. Increased interaction by students, residents and faculty with ophthalmic and other health care professionals via grand rounds, workshops, seminars, conferences and observation.
  3. Lectures by medical school faculty in areas not currently taught by optometric faculty, and in areas currently taught where qualitative and/or quantitative improvement is possible – eye disease management, patient interviewing, gerontology.
  4. Increased educational opportunities and research capabilities through the creation of joint centers or institutes in such areas as glaucoma, neuro-ophthalmic disease, cataract/aphakia, corneal physiology/contact lenses; immunology/allergy; pediatric and geriatric eye care.
  5. Opportunities for advanced specialty training for optometric students, residents and faculty.
  6. Expanded continuing education program in eye disease management through increased ophthalmological participation.
  7. Medical school faculty appointments for optometric faculty.

Patient Care

  1. More effective management of surgical patients, whether the surgery is performed at the medical school/hospital or at the optometric facility.
  2. More effective back-up for true ocular and general medical emergencies.
  3. Increased and more readily available access to sub-specialty care.
  4. Enhanced control and direction for optometry school’s medical staff in areas such as patient care protocols, quality assessment/assurance mechanisms, credentialing.
  5. Hospital privileges for optometrists.

Constituent and Public Relations

  1. An enhanced image which can have a positive effect on student and faculty recruitment, fund raising, grantsmanship, community relations, and professional relations.

Economic Impact

  1. Increased census in primary care and optometric specialties.
  2. Sharing of revenue from surgical services provided at the medical school/hospital or out-patient surgical facility of the optometry school.
  3. Increased practitioner referrals both from the optometric and medical communities.
  4. Opportunities for sharing of plant, capital equipment, people, and resources.

Research

  1. Increased potential for joint research projects utilizing respective strengths of optometry and medical schools. Access to special populations.

Concerns of a Medical School Affiliation

  1. Erosion of optometry school’s mission to train primary eye care clinicians.
  2. Competition among optometric students/residents and ophthalmological residents for primary care patient encounters.
  3. Danger of optometry being placed in a subordinate position related to ophthalmology.
  4. Some loss of control over optometry school’s ophthalmological group/faculty.
  5. Restriction on referral patterns due to implied exclusivity of agreement.
  6. Loss of opportunities for affiliation with other institutions.
  7. Possible negative reaction by alumni or other constituencies.
  8. Negative public relations if affiliation does not succeed.

The Affiliation Agreement

The elements of an affiliation agreement or, if a step-by-step process is desired, a memorandum of understanding with intent to affiliate may be broadly stated with detailed attachments added as the various aspects of affiliation are realized. The following elements should be present in the initial document.

  1. Statement of support for each other’s educational mission, particularly as it related to the expanding scope of optometric practice.
  2. Mutual desire to meet the health care needs of the community in a cooperative manner, desire to provide mutually beneficial and cost effective means for educating health care practitioners, and a recognition of the public benefits of collaborative research in visual and related sciences.
  3. Actively encourage and cultivate inter-institutional endeavors in education, research and patient care.
  4. Recognize each other’s autonomy as it relates to overall institutional mission, structure and governing authority.
  5. Those terms contained in the agreement which specify financial arrangements should not become effective until such arrangements have been mutually agreed to in writing.
  6. Facilitate inter-institutional cooperation in education by such means as faculty exchange, discussions on curricula development, teaching and evaluation techniques, seminars, workshops or symposia.
  7. The faculties of both schools agree to participate in education programs such as didactic lectures, clinical preceptorship, seminars, electives, grand rounds, and continuing and post-graduate education as deemed appropriate.
  8. Encourage cooperative research efforts and the application for external funding in the basic and clinical sciences by means of faculty exchange, sharing of laboratory resources and sharing of technical expertise.
  9. Develop a cooperative arrangement in clinical education by reciprocally granting credentialed individuals faculty rank and/or clinical privileges, and by integrating medical and optometric staff, fellows, residents and students into appropriate clinical activities at each other’s institution.
  10. Optometry school agrees to recognize the hospital and clinical faculty of the medial schools as the preferred providers of general medical and surgical care, ophthalmic surgical care and associated ancillary services for optometric patients.
  11. Medical school agrees to recognize school of optometry and its clinical faculty and residents as the preferred providers of optometric care.
  12. Optometry school agrees to make available members of its faculty to provide optometric services at medical school/hospital in accordance with mutually approved policy, protocol and procedures. This would include endorsement and signing of standing orders by appropriate medical director to allow optometric staff to treat eye disease if not permitted by state statue.
  13. Medical school agrees to make members of its faculty available to provide onsite services at college of optometry’s clinical facilities.
  14. Medical school agrees to make members of its faculty available to provide 24-hour emergency consultation and support services for optometric staff and residents.

The following should also be considered:

  • Use of an external consultant experienced in hospital/institution mergers to review the affiliation structure.
  • Creation of a third entity for administration of the various joint programs and for resources development purposes, e.g., The Foundation for Optometric/Medical Eye Care.
  • Jointly sponsored grant application should be considered to offset start-up costs.

Conclusion

I have attempted in this brief presentation to outline the benefits and potential costs of medical school affiliation. Although there many be alternative means of enhancing optometric education and training with less political risk, affiliation appears to offer an immediate opportunity for quantitative and qualitative improvement in our ability to prepare optometrists to treat eye disease.

Journal of Optometric Education.
Volume 12, Number 2. 1986.
Charles F. Mullen, O.D.

by Charles F. Mullen