Trees Don’t Grow to the Sky

The first major threat to our profession has to be the near doubling of graduates from un-needed new schools of optometry opening at small rural universities since the turn of the last century which created what is now a rapidly growing surplus of graduates. The reasoning used by those universities that probably led them to add marginal optometry programs was a combination of their believing the U.S. Bureau of Labor Statistics (BLS) projections of a need for more optometrists in the future (based on overly rosy data fed BLS); a belief additional schools would lead graduates to practice in underserved rural areas (this has never worked for medicine) and the need of these small universities to develop additional tuition revenue streams as non-elite university enrollments declined as high school graduation rates declined and states reduced support of public higher education. Optometry was also appealing because starting schools of optometry was relatively easy due to our accreditation standards that, while recently updated, remain far less rigorous than those of medical and dental schools.

The increase in available optometry school seats the new schools produced, and the decline in college graduates, has combined to reduce the ratio of qualified optometry school applicants to available seats to almost one-to-one which then forced some schools to admit lesser-qualified applicants or, due to applications canceling at the last moment (termed shrinkage), have some empty seats.

Now, the pandemic is creating yet another threat to some schools of optometry such that they may not survive or be forced to reduce enrollments.

This 10 year, ill-founded boom in creating new schools of optometry based upon questionable projections offered the BLS by our profession is similar to booms in the stock market and, like those, will eventually burst. This is why experienced brokers remind investors that “trees don’t grow to the sky.”

-Editor

Comments are welcome and can be sent to editor@abcmo.org for publication under the author’s name.

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The article below was originally published February 15, 2018 in Review of Optometry. Additional commentary and resources added July 2020.

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How the Diploma Deluge is Reshaping Optometry

The student population is booming, but applicants haven’t kept pace. Here are three ways to protect academic standards and avoid a glut.

By Bill Kekevian

You’ve heard the knock on optometric education: there are too many optometry colleges, pumping out too many new grads and coaxing them through the curriculum instead of holding them to appropriately rigorous standards. Though it may be a caricature, some elements ring true, say experts within and outside academia. “If you want to get into optometry school, you can,” laments one educator.

Six new optometry colleges opened in the last decade, and more are on the way. Wingate University, a private institution in North Carolina, recently announced plans to break ground on a new school of optometry, and at least two more are exploring the option (Note 1). Established schools like SUNY College of Optometry have also expanded, adding 24 seats since 2008.

Growth itself isn’t inherently bad. A bigger footprint for optometry gives the profession more clout with legislators and insurers. But while the number of seats has gone up, applicant volume hasn’t, explains David Damari, OD, dean of Michigan College of Optometry at Ferris State University and president of the Association of Schools and Colleges of Optometry (ASCO). In fact, recent years have even seen declines. “That’s going to make for some difficult choices,” he says. Some schools “may have to fill classes with applicants who are seriously at risk of not completing the program or passing national boards.”

Nathan Lighthizer, OD, assistant dean of clinical care services at Northeastern State University in Oklahoma, puts it this way: his institution offers seats to 28 students each year, the smallest class size in the country. With new options opening, some of the top students selected by Northeastern are likely to end up elsewhere. If, for instance, five students make that call, Northeastern has to offer spots to choices 29 through 33. It’s a sort of domino theory of admissions standards, and educators are starting to worry that it’s diluting the pool of qualified candidates.

Another concern: will new grads find productive roles in regions most in need of eye doctors, or merely bloat the ranks of well-served cities and towns? While more opportunities exist today — necessitating more optometrists — putting these new ODs where they can best serve the public remains a challenge.

Here, Review of Optometry considers recent data on the state of optometric education, what problems it presents and the safeguards being put into place to protect the discipline.

Click to enlarge table. Source: ASCO. Note 2 and Note 3.

More Seats, Fewer Applicants

After a 20-year lull, optometry’s current boom started in 2009 with the dual openings of schools at the University of the Incarnate Word and Western University of Health Sciences. Another four soon followed. Those six additions, plus incremental growth at established schools, expanded available seats by 31% from 2008 to 2017 (Table 1). Note 2 and Note 3.

Educators stress that while the increased number of seats may worry some, it’s the number of applicants that worries them. The applicant-to-seat ratio is trending down and stands at roughly 1.4 applicants per seat. (Note 4). ASCO reports a 4.4% year-over-year decline in applications from 2016 to 2017 but an increase of seats by 2.5% over the same period. Thus far in the 2018 cycle, applications are down 11.5% over the year prior, according to ASCO.

That doesn’t leave a lot of room for schools to be selective, explains Joseph Bonanno, OD, professor and dean at Indiana University School of Optometry. Some students are being accepted who otherwise wouldn’t, especially at the newer institutions. ASCO data shows that the six newest schools accept objectively lower-scoring applicants (Table 2) (Note 5). In 2017, they accepted GPA averages ranging from 3.20 to 3.41 with a group average of 3.32; for the six oldest schools, it was 3.39 to 3.66 and an average of 3.49. Of the six lowest GPAs accepted in the United States last year, five come from the newest institutions (Table 2).

Click table to enlarge. Note 5.

Some evidence suggests that the ripple effect of lowering admissions standards may have spread to other optometry programs, just as Dr. Lighthizer described. Students are being accepted with lower optometric admission test (OAT) scores nearly across the board compared with a decade earlier (Table 3). (Note 2 and Note 3). Averaging all changes in OAT scores (i.e., increases as well as decreases) gives an overall decline of 1.75%, but individual schools saw declines as high as 5%. Of the 17 US optometry schools that existed in 2008, 14 lowered their accepted academic average OAT score by 2017—11 by five points or greater. See Note 2 and Note 6.

What’s the picture like at the end of a student’s college experience? Also troubling. Optometry board pass rates published in late 2017 found a national rate of 91%, with some schools falling well below the average (Table 4) and (Note 6). Above-average student populations don’t always correlate with below-average pass rates. Of the bottom five, Salus University’s Pennsylvania College of Optometry (PCO), whose ultimate pass rate is 84.2%, has the largest class (152 candidates) and Southern California College of Optometry (SCCO) at Marshall B. Ketchum University is second (85.6% pass rate) with 97 candidates. But the other three are mid-range on class size, with Western University of Health Sciences hosting 76 candidates (only 68.4% pass), Rosenberg hosting 64 (84.4% pass) and Massachusetts College of Pharmacy and Health Sciences (MCPHS) hosting only 59 (74.6% pass). See Note 6.

Altogether, eight schools fell below the National Board of Examiners’ (NBOE) average pass rate. Among those were the five that accepted the lowest OAT scores in 2013 (the year the class of 2017 would have entered the program). Note 7. However, while the connection exists on the low end of the chart, the trend doesn’t necessarily indicate that low OAT scores correlate directly with low ultimate pass rates. Take for instance, New England College of Optometry, which, at 90.4%, fell below the NBOE’s average pass rate, but in 2013 accepted an average academic OAT score of 320 and an average total science score of 318. That’s on par with the average OAT scores for the entering class of 2013 (whose academic average was 320 and average total science score was 317). Conversely, Midwestern University’s Arizona College of Optometry accepted students in 2013 with average scores of 319 (academic) and 315 (total science) (tied for fifth lowest) and a 3.37 GPA (seventh lowest) and, yet, 95.4% of its students pass boards. UAB is another example where, although its OAT scores fall below the average (academic, 315; total science, 311), 94.6% of students pass boards. See Note 6 and Note 7. This suggests that while being selective with the students who enter the program can impact the outcome, ultimately a school has the opportunity to right its students’ ship.

Click table to enlarge. Source: Note 2 and Note 3.

Numbers Don’t Tell All

To wit, educators say students’ personal stories can counter the notion that lower scores make for less suitable candidates (See “I’m More Than My GPA“).

While GPA and OAT scores can be predictors of success in optometry school, there’s a third factor that’s harder to quantify. “You can’t just look at GPA on face value, says Joseph Pizzimenti, OD, an educator on the admissions board at UIW’s Rosenberg School of Optometry. “A physics major from University of Chicago may have only graduated with 2.95,” but someone with that degree from that school “will likely perform well in optometry school,” as long as their OAT scores measure up. “If that kid can communicate during an interview, I’m going to take her every day of the week and twice on Sunday,” he says. “You do this long enough and you know where the quality [undergraduate] programs are.”

Across the country in Pennsylvania, James Caldwell, OD, dean of student affairs at PCO, agrees about the value of communication skills. “I don’t know where the study is that says you have to have a 3.7 GPA to be a better optometrist than someone with a 3.3 GPA.” PCO looks for “appropriate coursework in the appropriate combination,” he says. That is, a mix of multiple science courses, “pre-med quality work,” participation in school organizations and community service. “You want to have a nice, solid portfolio. You don’t want to be all academic and no personal skills.”

In fact, in a 2008 ASCO survey, eight schools rated students’ OAT scores “significant” in influencing their admission process, another eight rated it only “moderate” and one even said it had no influence at all. But they all required an in-person interview (Note 3).

Bright and motivated students can succeed just as well as undergraduate superstars, say educators in the trenches. But an objectively weaker pool (on purely academic measures) of candidates and rapidly evolving clinical responsibilities are causing institutions to revamp some elements of their programs, or at least contemplate doing so. Broadly speaking, three actions can keep these trends from inflicting damage to institutions, practitioners and the profession as a whole.

Click table to enlarge. See Note 6 and Note 7.

1. Adapt

With downward pressure on admissions standards, the education community may need to enact some short-term reforms to ensure a stronger long-term outlook.

“The fact that there are more seats available while we have the same number of candidates presents a challenge,” says Dr. Damari. “And it’s difficult for some programs to decrease their class sizes.”

But if they did, it wouldn’t be without precedent. For example, in the 1980s Southern College of Optometry (SCO) did reduce its class size. “When I came in in 1980, my class had 152 students,” says Lisa Wade, OD, director at SCO’s Hayes Center for Practice Excellence. “They soon reduced it to 90 over concerns about the quality of applicants” and cut tuition by 27%. “At that time, SCO was the most expensive optometry college in the country, and they realized they were on a path that could not be sustained or continue to attract quality applicants,” Dr. Wade says. Today, SCO has 132 seats, up by only eight from 2008, when the current boom began. See Note 3.

The mix of didactic vs. hands-on training might be in need of a rethink, too. “We’re ready to make the most efficient modifications to make sure our students are best prepared,” said PCO Dean Melissa Trego, OD, in a videotaped response to the NBOE board pass rate data, including ending a program that allows third-year students to work in an off-campus clinic in January (Note 8). Now, they’ll remain on campus so they can be prepared for part one of the boards, which begins in March. She also stresses that the NBOE figures are only first-time scores. “Ultimately, when students graduate, they are able to pass part one,” Dr. Trego adds. “We’ve already started the process of developing a new curriculum which provides multiple opportunities to be tested.”

Some schools may have figured out a way to both bring in a high number of students, including those whose GPAs may drag down their average, and still see nearly every single student pass boards.

Look at Nova Southeastern University in Ft. Lauderdale, Fla., which has hosted more than 100 students per class since 2011 and its average incoming GPA in 2014 was 3.36, tied for fourth lowest. How, then, have administrators managed to keep its ultimate pass rate at 97.9%? Perhaps it has something to do with how the school evaluates students on their way in.

Both Nova and Indiana University have safety nets to catch students before they fall. “We’ve created a new program wherein we identify applicants we think would struggle and we put them on a five-year path that spreads out the academic burden,” Dr. Bonnano says of Indiana University. “OD programs demand a lot of course hours, and they’re all science courses.” Undergrads aren’t used to taking five science courses at once, he notes. “We’re interested in students’ success. We want to lower our attrition rate. I think you’re going to see this popping up at other schools,” he says. “The curriculum’s gotten tougher, too.”

It may sound a bit like coddling, but ASCO President Dr. Damari doesn’t see it like that. He says it’s a way to correct an imbalance. “Students from diverse economic backgrounds may not have had the best educational preparation because of the circumstances under which they grew up,” he says. “This gives us the opportunity to bring more people from different backgrounds into the profession, which is extremely valuable for any health care profession if you’re going to serve a diverse population.”

While the students entering at the bottom of the class have a chance to catch up, those nearing graduation have an option for a different kind of fifth-year: taking on a residency. To be clear, a residency is not a fifth academic year but rather a chance for hands-on experience. Optometry colleges today “must teach at the broadest scope of practice,” says Dr. Pizzimenti. “Students need to be able to sit for any state board in the country.” That includes states such as Oklahoma, where optometrists can perform laser procedures and a nationwide trend toward optometric surgical comanagement.

Formal residency programs represent a new level of training more suited for the needs of a modern OD, with students learning a style of medical practice that would have been unrecognizable a generation ago. In 1976, the Veteran’s Affairs Medical Center in Kansas City, Mo., founded the first formally accredited one-year residency for optometrists (Note 9). Today, approximately 235 Accreditation Council on Optometric Education (ACOE) accredited residencies place hundreds of new ODs every year into programs as broad as family practice optometry and as narrow as vision therapy and rehabilitation. See Note 9.

“There’s only so much you can fit into a four-year curriculum,” explains Caroline Beesley Pate, OD, associate professor and director of residency programs at the University of Alabama’s School of Optometry in Birmingham, Ala. “Although the scope of practice has changed drastically in the last 30 years, optometric education has largely remained a four-year program,” she says. Educators have to cover the same fundamental skills as in previous eras while incorporating everything that reflects a modern scope of practice, one that extends as far as injections, lasers and minor surgical procedures. “Doing a residency enables you to further expand if you’re interested in those areas.”

2. Incentivize

Education reform can address the changing nature of both the applicant pool and optometric responsibilities, but those new doctors still need to find a spot for themselves in the profession. The greatest need lies in rural areas, where health care demand and resources are often at their most unbalanced.

“Central Appalachia has the highest incidences of severe vision loss from other factors such as diabetes and hypertension,” said a 2015 University of Pikeville press release announcing its intentions to launch an optometry program. “Our objective is to provide access and education to the people of the mountains and to address a critical health care need.” See Note 10.

“Optometrists have sort of congregated in urban areas,” says Wingate University Vice Provost Robert Supernaw in a statement about its upcoming expansion into optometric education. “We thought that we could correct that.” The national average is 1.3 ODs per 10,000 population, says Wingate. In North Carolina, it’s just 1.1, “and many counties in eastern North Carolina have well below the national average—or no optometrists at all.” The school will include a community clinic to serve indigent local residents. See Note 1.

While those university clinics provide much-needed care, they can’t meet the ballooning demand on their own. “There’s plenty of people emailing me from rural areas with job opportunities, not only within Alabama, but throughout the Southeast,” says Dr. Pate. “The question is, are these graduates willing to go where the opportunities are?” She theorizes that optometry can withstand the influx of new students if they are willing to disperse from urban centers. As a state-funded program, a portion of UAB’s support relies on accepting a higher percentage of students from within the state. But, Dr. Pate says, she knows of no real school-sponsored incentive program to keep them in that state.

Some states have experimented with incentive programs. Those help to balance the pro/con lists a new doctor draws up, but can fall short. After her own graduation from PCO, Dr. Pate’s home state of Maryland agreed to reimburse her for a percentage of her tuition if she agreed to practice there for four years. But when an opportunity at UAB presented itself, she opted to forgo the deal.

Maryland may have lost Dr. Pate, but the gambit makes sense. In their mid- to late-twenties, many recent grads aren’t only settling into a career but also into family life. Encouraging young doctors to stay in a particular area at a time when many are getting married, buying a home or perhaps having children, doesn’t necessarily ensure they won’t move after four years, or break their contract at some point before then, but it helps establish roots young doctors may be reluctant to break.

Unfortunately, Dr. Pate is not exactly an outlier. “Those kinds of programs are decreasing,” says Dr. Damari. States have found that more students are willing to pay the penalty to get out of the contract, he notes.

Urban centers offer personal and professional advantages that many new optometrists deem too good to pass up, be it quality of life improvements that come with population density or professional access to the broader health care infrastructure, which, not coincidentally, also clusters in major cities. The expanding palette of optometric practice creates in many students career aspirations ill-suited to rural areas. See “Wanting More” below.

Of the many threads that weave together to form the complex state of optometric education in 2018, this inability to match health care needs with resources in the form of human capital is perhaps the most intractable.

3. Promote

If there’s any consensus among optometric educators, it’s that optometrists must do more to raise its profile and attract more qualified candidates. “As a profession, we need to brag about who we are,” Dr. Caldwell says. “We need to embrace the diversity of practice opportunities and the diversity of educational programs.”

“If we did a better job of letting the public know why they need vision care, not just eye disease care,” says Dr. Damari, “there would be more demand out there than we could know,” for both optometric care and optometric careers. “Look at what dentistry did in the 1960s and what nursing did in the 1980s and 1990s” to raise their profiles. “Our field has really lagged behind on that and we really need to step up.”

Toward that end, Dr. Damari explains, ASCO has gone as far as to hire a public relations firm to get help growing the profession’s visibility in the eyes of the public. But, he and others suggest, there are several actions individual optometrists can take today to help in the effort, including keeping their eyes open for young patients who may have what it takes to go into optometry school and making in-roads into their communities.

Inventing the Future

More new schools are coming. Although ASCO and others can advise stakeholders on the burden new educational facilities may create, optometry cannot halt private development. Those closest to the issue suggest the field grow parallel to new institutions by broadening the definition of optometry, pushing for scope of practice expansions — and trusting the next generation. “I think a lot of people are just afraid of change,” says Ms. Scrimger. “But, for our generation, maybe not so much.”

Optometry has always been a self-made discipline. Fifty years ago, a group of ambitious young ODs were dismayed to find many of the diagnostic and therapeutic skills they learned in optometry school could not legally be put into practice (Note 11). They lobbied legislators for change and transformed optometry from a refraction-based job to a primary eye care profession. “The best way to predict the future is to invent it,” said computer pioneer Alan Kay. That’s always been optometry’s way forward.

Related

The Future of Optometric Education – Opportunities and Challenges by Charles Mullen.

New Optometry Schools and Programs Status and Discussion

Footnotes

1. Yost K. Wingate pursuing optometry school. Article on Wingate Facebook Page

2. ASCO. Profile of the 2017 Optometry Entering Class (PDF).

3. ASCO. Annual student data report academic year 2008-2009.

4. Mullen CF. The Future of Optometric Education.

5. ASCO. Profile of Applicants to OD Degree Programs for Fall 2017 Entering Class (PDF).

6. ASCO. NBOE 10/2016 – 9/2017 Institutional Yearly Performance Report (PDF).

7. ASCO. Profile of the 2013 Optometry Entering Class (PDF).

8. National Board of Examiners in Optometry Pass Rates.

9. ASCO. FAQs about Residencies.

10. Kentucky College of Optometry Set to Recruit Inaugural Class.

11. Haffner A. The La Guardia Conference — The Meeting that Changed the Profession. Hindsight: The Journal of Optometry History. 2010;41(1):17-20.

Below is a link to an interesting book, The Education Apocalypse: How It Happened and How to Survive It

The book explores the causes of the “Apocalypse” – rising student debt and the now crashing bull market in higher education stimulated by low interest rate loans and a government campaign to promote the idea that one must have a college education to be successful.

The Education Apocalypse: How It Happened and How to Survive It

Editor

Recently, on consecutive days, National Public Radio ran segments about declining enrollment at universities.

And today, the president of a state university 60 miles from me (without an optometry school) noted, for the first time, a decline in his entering freshman class sizes while the president of the state university nearest me (with an optometry school) had maintained entering freshman enrollment by changing entrance requirements.

This website has, for ten years, been a critic of the many new optometry schools that have opened and the almost doubling of optometry school graduates that has produced a decline in numbers of “qualified” applicants per optometry school seats. The ratio of “qualified”, non-duplicate applications now flirts with one per seat. The universities creating those new optometry schools justified them by citing “inflated” federal reports (based upon optometry provided estimates) claiming more optometrists were needed, and that new optometry school would provide “jobs” or provide eye care to underserved areas. However, the number of optometrists per capita had already been climbing for some time and there is ample evidence increasing optometry graduates does not proportionally increase the numbers practicing in underserved areas unless given monetary incentives such as student load abatements for practicing there. In the absence of incentives graduates will continue to open practices in urban areas rather than poverty stricken rural areas.

It is also well known that the numbers entering universities tend to rise in economic recessions and to decline in good times and that optometry school applicants rise and fall proportionally with university enrollments. Our Nation, since the end of the Korean War, has gone from about 20% of high school graduates attending a university to over 60%.

It is therefore concerning that while the numbers of optometry graduates has almost doubled (and another new school is proposed) the ratio of qualified applicants to seats has seriously declined and the country is overdue for a recession from being in the longest “bull market” to exist on Wall Street.

Nor is it reassuring that a recent independent study found that optometry school graduates have the highest ratio of student debt to projected earnings of any health profession (medical school graduates have one-half the debt to earnings ratio facing optometry graduates).

And, at last count the total national student debt held by current and former university students was over 1.4 trillion dollars, larger than all the credit card debt held by the entire US population.

Meanwhile, for the last 15 years, the numbers of medical and dental students have remained almost constant while the number of podiatric students has declined.

Nor is it realistic to think this Nation could afford to repay all outstanding student loan debt or to “wave a wand” and forgive all student debt.

For all these reasons I believe some optometry schools should plan how to survive in the future by reducing their class size.

For an unacceptable response would be to reduce entrance requirements and put less qualified students in those seats.

And it is possible that some optometry schools may have to either close or water down their entrance standards which will damage our profession and patients.

This may be why one of the newer schools posting faculty recruitment ads specify they are non-tenure track.

Editor

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After posting the above, a colleague sent this link to me.

The Higher Education Apocalypse

Editor

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In his article “Medical education needs to stop burning out students — now,” Augustine Choi suggests the culture of medical education is responsible for increasing rates of depression and burnout among medical students, and suggests that more programs are needed to address self-care and wellness in order to build resilience…

Read the full article here: To extinguish burnout, bring back physician autonomy

Editor

The most divisive issue in optometry continues to be whether general practice optometrists should take additional CE hours “above” those required for license renewals and then pass additional periodic examinations “beyond” the multiple NBEO examinations they had to pass for graduation and initial licensing in order to become “board certified” by the American Board of Optometry (ABO).

The ABO believes optometrists should go “above and beyond” what it calls the “minimum” standards and training required for graduation, licensing and then license renewals and seek to become “board certified” by ABO. See Note 1.

The ABO credential is not required by any state licensing board or health/vision plan. Since ABO does not require residency training in a specialty or passage of a specialist examination it is also not a specialty board.

ABO refuses to recognize that medicine, osteopathy, dentistry, and podiatry only award “board certification” to those who complete specialty residency training and pass specialty examinations after licensing.

And to support ABO the AOA will close, next year, its annual Optometric Recognition Award, established in 1975 and given by the AOA President each year to AOA members completing more CE hours than required for license renewal.

The ABO remains criticized by many because:

• All other Medicare physician groups offer board certifications only to residency-trained specialists within their professions. Optometry is a profession and not a specialty of a profession.
• ABO continues to imply its certification will become required by health plans which has not, and will not happen due to restraint of trade statues.
• ABO suggests those it certifies will be seen by the public as being “above” other optometrists which pits optometrists against each other.
• No optometry, medical, dental, osteopathic or podiatry state licensing boards require board certification though all those professions have board certified specialties.
• By established (settled) law, the requirements to practice optometry remain a professional degree and a state license and the power to regulate optometry is reserved by the states and not the federal government.

Still, ABO continues to try to blur the line between its “substitute board certification” and real specialty board certification by now offering a reduced fee of $500 rather than $950, to residents and new graduates if they take the ABO examinations within 10 years of graduation.

Residents training in medical optometry should understand:

1. ABCMO is a specialty board that requires passage of the Advanced Competence in Medical Optometry examination offered by NBEO after completing an accredited medical optometry residency.
2. Only ABCMO board certification is accepted and required for appointment as a specialist in medical optometry at health facilities accredited by the Joint Commission. See Note 2.

Although optometry residencies only began in 1975, today 30% of graduates enter into residency training in a specialty.

Those serving residencies in specialties without a certifying body will eventually set up specialty boards to certify them.

In addition there are learned societies they can join now (Optometric Glaucoma Society, Optometric Retinal Society) and low vision, blind rehabilitation and visual training groups and the Diplomate program at the American Academy of Optometry and special interest groups

Notes

1. No data was ever presented by those creating ABO to show there was a need for additional training and testing of licensed optometrists in general practice and optometry malpractice insurance rates remain remarkably low. In addition to the costs and time required to become ABO certification, costs and time are required to attend courses and take exams to “maintain” ABO certification. These programs are called Maintenance of Certification (MOC).

2. The Joint Commission is the Gold Standard for accreditation. It inspects and accredits over 21,000 US health care programs. The credentialing committees required at Joint Commission accredited facilities recognize and accept ABCMO board certification.

The Joint Commission is also known by its previous names, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Joint Commission on Accreditation of Hospitals (JCAH).

This question recently came to mind while noticing my dentist’s board certification in oral surgery hanging next to his D.D.S diploma and State License.

You probably also have your ABCMO board certification on the wall with your State License and O.D. diploma. But, if you are on the medical staff of an accredited health facility you must do more.

Your Credentialing Committee needs to know you served a medical optometry residency, passed a written examination, and met additional requirements for ABCMO certification because it recommends all medical staff appointments, clinical privileges, and is part of the advancement and promotion process.

Credentialing Committees are required to contact ABCMO every two years to verify your board certification (VOC).

Some optometrists at medical facilities may have not yet notified their Credentialing Committee of their certification or updated their official personnel file (OPF) to include board certification.

Failing to do this is unwise as Credentialing Committees evaluate and determine their privileges, evaluations and promotions.

For example, at VA health facilities, Form SF 171 must contain your specialty, name of specialty, residency program and specialty board address because their Credentialing Committees forward this information to the Central Office committee that processes all optometrist appointments, promotions and advancements.

Be sure your personnel folder at your facility is up-to-date because Credentialing Committees are required to verify board certification by checking directly with ABCMO every two years and not by inspecting the documents on your office wall.

Off the Cuff: Students, Debt and the Future of Optometry was written by Arthur B. Epstein, OD, FAAO and Chief Medical Editor of Optometric Physician.

Part 1 – Off the Cuff: Students, Debt and the Future of Optometry

Student debt is a steadily escalating problem for health care professionals. It has gotten so bad that this past week, the NYU School of Medicine announced that it is waving tuition for all new and existing medical school students. Their action is in response to growing debt among young doctors and the trend away from lower-paying, but much-needed, primary care practice. The school reportedly views this as a public health issue. The hope is that other medical schools will follow suit.

Unfortunately, optometry doesn’t appear that fortunate or farsighted. To my knowledge, no optometric program is planning to wave tuition or even reduce it to more affordable levels. In sad fact, optometry school graduates have a higher debt-to-income ratio than any other health care professionals with an earning capability far lower than most. With even more new schools on the already crowded horizon, it’s difficult to not view additional optometry programs as predatory, preying on increasingly less-qualified students who have dreams of becoming a doctor.

For many of these young ODs, I fear that their dreams may quickly turn into a nightmare. The glut of new graduates will eventually exceed demand, if it hasn’t already. With continuing advances in technology and too many practices still mired in traditional refractive care, OD salaries are likely to tank while competition for a shrinking number of positions grows exponentially. More and more of these young ODs will be working just to pay off their student loans, and some may not be able to pay them off at all. If reimbursements drop to fuel Medicare for all, it won’t be pretty for any of us, but especially painful for young and in-debt grads.

Unfortunately, there is no simple answer. By the time the law of supply and demand kicks in, it will be too late. Some have suggested that we actively discourage prospective new ODs from pursuing optometry as a career. The only thing that will accomplish is to deprive the profession of a greater number of quality candidates rather than dissuade the poor ones.

Eventually, some existing schools will have to close and new ones not open, but that will never happen as long as there are students willing to pay, and schools are making money from minting new ODs. The one solution that would work and might actually save the profession is the hardest. Raise entry and training standards to almost painful levels. That would ensure qualified candidates and well-prepared ODs, and force the worst schools to close. Ultimately, the future of optometry lies in the hands of the AOA and its Accreditation Council on Optometric Education.

Subscribe to the Optometric Physician e-Newsletter (scroll down to “Reviews Group”)

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Off the Cuff: The Big Bang was written by Arthur B. Epstein, OD, FAAO and Chief Medical Editor of Optometric Physician.

Part 2 – Off the Cuff: The Big Bang

Over the past few months I’ve written extensively about my concerns for the future of our profession. This is an emotional issue and, as you might expect, has generated a good deal of comment. In fact, no topic has ever generated more email with the exception of the very divisive topic of board certification—or what we call board certification.

From colleagues across the country, the general consensus—with virtually no dissent—has been that we have too many schools, too many graduates and a profession that, if it doesn’t right itself will soon, be in serious trouble. Rarely have I seen so many on the same page on a single issue. Unsurprisingly, some in academia don’t see these concerns in the same way and have taken my comments as personal attacks on their institutions or have convinced themselves that I have declared a holy war on optometric education. Nothing could be further from the truth.

Here is the truth as I see it. Every academic institution has an inviolable duty to serve the public good by producing qualified, knowledgeable and skilled graduates. This starts with the admission process where entering students must be selected that can be molded into capable clinicians and successful practitioners. Our institutions have an obligation to the profession at large to responsibly plan for the needs of the public and ensure that its graduates can achieve professional success and financial independence. Ideally, this process should be self-regulating, as it has historically been in other professions. Organizations such as ASCO, the AOA and the ACOE should approach with balance and transparency and discourage new and existing programs that fail to meet the needs of the public and the profession. The most recent ASCO/AOA optometric manpower study and its subsequent spin was neither balanced nor transparent.

Let me make it clear that I don’t think the problem is our new schools. The problem is too many schools. I recently visited Midwestern University Arizona College of Optometry, and I was honestly blown away by how the program has evolved and grown since its inception. Likewise, I have visited older programs that are excellent. Truth be told, some newer and some older programs have not kept up, and their continued existence should be in question. Common sense planning suggests that we clearly don’t need more than one program serving a single city or state unless there are truly extenuating circumstances.

Our organizations must take strong charge of controlling our profession’s future. That control starts with the number and quality of our educational programs. However, we all must have a voice in this. I am asking you to complete this simple open questionnaire about your perceptions regarding optometric education, the number of programs we have and need and of the quality of current optometric education. Let your voice be heard.

Link to Questionnaire

Subscribe to the Optometric Physician e-Newsletter (scroll down to “Reviews Group”)

This is an abridged version of the author’s paper distributed after an invited talk to the study body of the Illinois College of Optometry in Chicago, Illinois in 1998. Notes were added August 2018.

Introduction and Purpose

There are few accurate studies of how optometrists practice. And no studies cited in the literature have been made by physically visiting practice sites to gather practice data first-hand.

The only comprehensive study, the 2012 Lewin National Eye Care Workforce Survey of Optometrists, did collect detailed data on types of practices using a mail survey in which optometrists were asked, among many other questions, which of 17 specific practice types listed on the survey response sheets best described how they practiced.

For undisclosed reasons, Lewin collected this data but did not publish it. Instead of reporting the percentages of optometrists in each of the 17 practice types, Lewin reported only whether responding optometrists were self-employed [70%] or employed-by-others [30%].

By reducing the survey’s 17 possible practice types to only two types, whether the optometrist was, or was not, employed by others, severely limited information about how the surveyed optometrists actually practiced as it left out the other 15 different types of practice.

In 1998 the Author spent two weeks visiting all the optometry practices he could locate in the Akron, Ohio metropolitan area via the Akron Ameritech Yellow Pages, the membership list of the Ohio Optometric Association and membership list of the American Academy of Optometry. He visited these 72 optometry practices on site and identified 91 licensed optometrists who practiced at one or more of 72 practices. These 91 optometrists included several not listed in any membership list or the phone book who resided outside the Akron metropolitan area.

While at the practice site the author took pictures showing the location and surroundings of the practice for later determination as to whether the practice appeared to market itself as an office–based or store-based practice. While such determination is somewhat subjective, those who assisted the author in picking which marketing method was used by each of the 72 practices were seldom in disagreement but, when reasonable doubt existed the practice was classed as office-based rather than store-based.

Summary of Results

Sample Size

• 72 practice sites and 91 optometrists distributed among them with 28 practicing at more than one site.
• On average, 72% of optometrists based at offices were AOA members compared to 33% at stores with AOA membership for all 91 optometrists averaging at 55%.
• Two of the 91 optometrists were Fellows of the American Academy of Optometry (2%) and they were both office-based.

Ownership of Practice Sites

• 35 commercial-owned optical stores
• 27 optometrist-owned offices
•  7 optometrist-owned stores
•  3 ophthalmology offices

Optometrist’s Primary Practice Site

• 52 practiced only, or mainly, at optometrist-owned stores
• 34 practiced only, or mainly, at optometrist-owned offices
•  5 practiced only at ophthalmology offices

Examination Fees

• $25-$43 at store sites
• $50-$72 at office sites

Optometrist dilated asymptomatic new patients?

• Routinely; 31% usually O.D.s at offices
• Sometimes; 31% a mix of offices and stores
• Never; 39% usually O.D.s at stores

Of the 91 optometrists, 26 (29%) were not listed in the Akron Ameritech Yellow Pages and did not have home addresses in the metropolitan area. Of these 26, 16 practiced at commercial stores.

In summary, in 1998, about half of practices were optometrist owned; the majority of optometrists practiced at stores, and about one-half of optometrists did not dilate eyes performing general eye examinations.

Optometrists practicing in office-type settings were more likely to dilate their patients, be AOA or AAO members, charge higher fees, schedule by appointments vs. walk-ins, and be located in the suburbs of Akron.

One striking fact however stood out to the author (licensed in 1974) when the practice model held out to our generation was the “professional practice” located within an office building containing other professionals and located above street level.

Only two practices among the 72 visited met those 1974 requirements. And while one of these two was vibrant with patients in its waiting room, the other practice had a hand written sign at its door indicating the phone number to call for an appointment and was located in an old two-story building up a creaky, musty staircase.

Survey Methods

The survey was designed to visit all 72 locations in the Akron metropolitan area found to have practicing optometrists and to determine ownership of each location, names of optometrists working full or part time at that location, costs of eye examinations, whether dilated exams of new patients were made and the overall style of the practice as to its orientation towards a private office or a store atmosphere. AOA and AAO membership or fellowship was determined by waiting room observation, asking questions and/or consulting membership lists of the Ohio Optometric Association and the AAO listings of Fellows. Desk personnel were asked about available appointments and whether a new patient would be dilated. Photographs were taken for later use to determine whether the site appeared as an office or store. Sample photos are in the appendix.

Examinations were not obtained so quality of examinations and materials were not determined. The chief purpose of the survey therefore was to determine types of practices in which optometrists practiced and the ownership of those practices to differentiate between what are commonly called “private practices” and “store practices”; terms that do not have precise meanings and can be misleading so a classification system was used that spanned 18 distinctively different types of practices.

Initial locations of practice sites were determined by using the 1998 Akron Ameritech Yellow Pages but, during the survey, 26 additional, unlisted optometrists and 3 additional locations were identified.

Types of Practice and % of Each Practice Type

Locations Owned by Optometrist(s)

Office-Based Practice

1. Solo office in professional office building    5.6%
2. Office, 2 or more optometrists in professional building    2.8%
3. Solo office in professional mall or plaza    6.9%
4. Office, 2 or more optometrists in professional mall    5.6%
5. Solo office in dedicated free-standing building    5.6%
6. Office, 2 or more optometrists in free-standing building    1.4%
7. Solo office in commercial mall or commercial setting    6.9%
8. Office, 2 or more optometrists, commercial mall    2.8%

Store-Based Practice

9. Solo store in dedicated free-standing building    1.4%
10. Solo store in commercial mall or zone    2.8%
11. 2 or more optometrists in free-standing store building    1.4%
12. 2 or more optometrists in mall or commercial setting    4.2%

Locations Not Owned by Optometrist(s)

Store-Based Practice

13. Co-op optical stores, a local cooperative    5.4%
14. Union Eye Care stores, local optical cooperative    4.3%
15. Mall Optical stores (Lenscrafters, EyeMasters, Pearle, etc.)    16.7%
16. Department Store optical stores (Sears, Penny, Ward, etc.)    8.3%
17. Local optical/optician stores    13.9%

Office-Based Practice

18. Free-standing ophthalmology group practice    4.2%

With these 18 types of practice settings it was possible to enumerate all practice types at the 72 locations in the Akron metropolitan area at which optometrists practiced.

While perhaps appearing overly detailed, this complexity came from the widely diverse types of settings at which the 91 optometrists practiced. Only this level of detail can avoid ambiguity as to optometrists’ practice types and show the wide variety and compartmentalized ways in which optometrists practice.

Which is why studies using less precise typing of sites can offer little substantive data. For example, studies using only two or three vague terms such as “self-employed”, “employed”, “private practice”, to represent the 18 types of practices are misleading and imprecise.

The 91 optometrists distributed across these 18 types of practices resulted in:

• 47.2% of optometrists practiced in an optometry owned location of which 37.5% were offices and 9.7% stores.
• 48.6% of optometrists practiced in a commercial optical store.
• 4.2% of optometrists practiced in an ophthalmology office.

The most frequently encounter location types were:

• Mall chain optical store    12
• Local optician/optical store    10
• Office in office mall    9
• Office in commercial area    7
• Co-op/Union optical store    7
• Dept. store optical    6
• Office in office building    6
• Office in dedicated building    5
• Store in commercial area    5
• Ophthalmology office building    3
• Dedicated store building    2

Office or Store Optometrist?

While it was relatively simple to determine whether a location was an optometry office or optometry store, it was more difficult to decide if an optometrist was office or store based since a good number of optometrists practiced at 2 or more locations.

For while most optometrists located at offices did not practice at stores, a few spent 1 day/week at a commercial store location and it was common for store optometrists to practice at several stores and even different corporate stores. As one example, the optometrist who practiced at a Wards Optical Department, a Wal*Mart Vision Center, an optician’s store and an optometrist’s office.

• Including ophthalmology offices, 42.9% of optometrists practiced primarily at offices.
• The majority of optometrists, 57% practiced in a store location owned by an optometrist or non-optometrist.
• Locations at which optometrists practiced were almost equally divided between offices and stores owned by optometrists (47%) and stores owned by non-optometrists (48.6%) with the remaining 4.2% at ophthalmology offices.
• Of the 91 optometrists 26 (29%) were not listed within the Yellow Page listings and 16 of these were based at commercial mall optical stores.

Yellow Pages Marketing

Optometrists marketed in Yellow Pages under:

• “Optometrists-Doctor of Optometry (OD)”    62%
• Within ad in “Optical Goods”    26%
• Under “Optical Goods”    8%
• Somewhere within Yellow Pages    71%
• No listing*    29%

*16% of these were at stores rather than offices.

Author’s Notes

In 1998 the author stated there were about 31,000 U.S. licensed optometrists and about 22,717 dues paying AOA members for a national 73% AOA membership rate.

In 2018 there are about 43,000 licensed optometrists and about 20,600 dues paying AOA members for a national 48% AOA membership rate.

To the degree these numbers are accurate, it seems quite possible that since this survey (and others) found a lower (37%) AOA membership among commercial optical store O.D.s compared to a 69% rate among optometry-owned offices-stores, that the decline in national AOA membership from about 73% to 48% may be due to the relative increase in commercial-store-based optometrists, the rapid increase in optometry schools and graduation rates and the shift of optometrists from privately owned practices and stores to essentially “piece rate” or “hourly” corporate employees.

Such a major shift has now taken place among pharmacists who, historically, owned their own pharmacies but today 80% are employed by the five largest national pharmacy store chains.

Sensing this change in how optometrists practice led the author to title this survey, in 1998. “The Mitosis of Optometry” for, as the data from 1998 show, by that time, the way optometrists practiced had already become highly fragmented.