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.
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.
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.
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.
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