The Continuing Evolution of Optometry

Summary

For some time now, articles have been encouraging general practice optometrists to more fully utilize the expanded scopes of medical treatments authorized to them as all state optometry licensing laws have been increasingly updated since 1972. On the one hand however, there has been a shift towards retail store practices and commoditization of optometry while, on the other hand, the initiation and rapid growth of residencies in medical optometry that first began within Veterans Administration hospitals in 1975 and then spread to private clinics and schools has continued.

This combination of changes since 1972 suggests the further splitting of optometrists into three types of practice settings.

Retail optical store.
Private office practice.
Practice within health care facility.

Also consider the other changes arising since 1972.

The increasing percentage of general practice optometrists in retail store practices.
The impact of surplus optometrists produced by new schools of optometry as well as high student debts.
Post graduate residency training, testing and board certification in the specialty of medical optometry.
A lack of standardized model practice acts for general practice optometrists or those board certified in medical optometry.
The limited extent to which the growing percentage of optometrists at optical stores can, or should “get medical”.

Until about 1970 most optometrists practiced at independent sites they owned but are becoming increasingly “associated” with retail stores they do not own.

This has happened not just to optometry. Once most pharmacies were owned and operated by pharmacists but today 80% of pharmacists are employees of five major chain pharmacies and “big box” merchandisers and medical physicians are rapidly becoming employees of corporate health care institutions rather than private office practice owners.

How physicians feel about this can be judged by visiting www.kevinMD.com which documents how they are losing their autonomy and professionalism from becoming employed “health care providers”.

The problems facing optometrists can be judged by reading Dr. Epstein’s weekly “Off the Cuff” editorials at “Optometric Physician”. For example, see the last paragraph of this recent “Off the Cuff” where Dr. Epstein addresses the topic of Medical Optometry and changes within the profession.

I have been saying this for a long time, and I fear that for a growing number of us, it may now be too late. If you have not embraced medical eye care, you are on a rapidly sinking ship to nowhere. Optometry has moved on and refractive eye care is rapidly becoming more consumer than profession driven. Economics will hasten its demise, but automation and technology will surely seal the coffin…

These changes were triggered when the Federal Trade Commission decided permitting advertising by doctors and health professionals as well as drug companies would reduce health care costs by making it a “commodity” sold in the market place. At that time health care costs were 9% of our country’s GNP but are now 18% and, while American health care is now the most expensive, its quality ranks 7th among developed nations per the World Health Care Organization. The fact that only two developed nations in the world permit direct advertising to the public of prescription pharmaceuticals… New Zealand and the United State… should also tell us why making health care a commodity sold in the market place was a bad idea for the public weal.

Why? Because commodities are generic common goods like cans of peas, gallons of milk or pork bellies and advertised and marketed by stores to the public by stressing two things.

Competitive pricing.
Convenient location of store site.

For optometry, commoditization led to store ads of “Two pairs of eyeglasses and examination for $69” or “free eye examinations”.

While recent articles encouraging all general practice optometrists to “get medical” would be advantageous for their practices this will be difficult for those practicing at optical stores since the general public does not associate them with medical eye care and most stores lack incentives to provide medical eye care.

1: Two Roots of “Getting Medical”

By 1968 optometry schools had made such significant advances in medical education, length of training, and entrance requirements that all original state optometry practice acts enacted from 1901-1927 had become obsolete since they barred optometrists from providing “medical eye care”. That changed following the 1968 LaGuardia meeting which redefined optometry as a primary eye care profession and then led to state-by-state expansions of optometry practice acts to include medical eye care that continues today.

Dr. Haffner & the LaGuardia Meeting that Changed Everything (Article and Audio). OD Wire, 2013 discussion of 1968 Meeting.

Next, in 1973, the Veterans Administration’s Department of Medicine and Surgery opened the first hospital externships for optometry students and, in 1973, after recommendations by the U.S. Government Accounting Office, the Association of Schools and Colleges of Optometry and the Congressional Veterans Affairs Committees, opened the first hospital residency training in medical optometry in 1975. Since then, the VA employs some 976 optometry medical staff members; half of all optometry students serve one or more VA hospital externships and 220 optometrists enter VA postgraduate residency training programs each year.

Since 1968:

All state legislatures have expanded their scopes of medical practice for general practice optometrists and continue to expand their scopes of medical practice state-by-state.
Since the states differ in their expansions of medical practices authorized for licensed optometrists, a patch-work of different practice acts exists.
The number of ophthalmologists in residency training has remained essentially constant over 20 years and the recent 2014 Lewin Reports predicted future shortages of them.
The numbers of optometrists in training has nearly doubled since 2000 due to new schools and while the Lewin Reports predicted increasing surpluses of optometrists their national survey of optometrists found that average optometrists had about 30% open chair time in 2014.
There is no national standardized model curriculum for training general practice optometrists or specialty residents.
Political optometry continues to believe all general practice optometrists should “get medical” in spite of increasing numbers of retail store optometrists.
The development of VA hospital optometry residencies occurred independently within them in order to meet increasing eye care demands.
The percentage of licensed optometrists who are AOA members is declining because store optometrists are growing in numbers but join the AOA at half the rate of office optometrists.
Store optometrists join the American Association of Corporate Optometrists which has over 13,000 members while the AOA has about 21,000 members, the American Academy of Optometry about 4,000 Fellows and approximately 6,000 practicing optometrists have joined no organization.
Current estimates are that about 42,000 licensed, active optometrists are in practice.

2: Surpluses and Student Debt “pushes” Graduates to Stores

Some still do not acknowledge the extent to which retail optometry care (and health care) has been made a commodity with the shifting of so many public practices from offices to corporate store sites where medical optometry is less likely to take root. And, the growing surplus of optometrists and their high student debt levels (graduates have the highest ratio of debt to projected earnings of all “health care providers”) which made it difficult to establish, or be employed at office practices.

Some even claimed the growing surplus of optometrists is good because the predicted shortages of ophthalmologists will be filled by surplus optometrists because, the Lewin Reports falsely assumed, optometrists “essentially” have the same scopes of practice as ophthalmologists.

But no state has ever granted optometrists the same privileges of ophthalmologists.

It is more likely only optometrists completing residencies in medical optometry or those having office practices in suburban-rural settings will have significant opportunities “to get medical”.

For example, the visits to optometry sites the author made in a metropolitan area 21 years ago (Appendix K) found that even then over 50% of optometrists practiced at retail stores and only 33% of those were AOA members whereas 72% of office optometrists were AOA members; which explains why the percentage of AOA membership has declined.

But, there are few accurate databases holding the numbers and types of practice settings at which optometrists practice. The Lewin National Survey of optometrists did ask which one of 17 different types of practice sites listed best described where they practiced which would have provided important information. But, unfortunately, Lewin would only publish two of those 17 types of practice locations; giving the percentage of optometrists who were, or were not, employed at their practice site.

3: A Lens is Not a Pill!

Minnesota first recognized optometry as an independent licensed profession in 1901 and optometrists at that time insisted they did not practice medicine because “lenses were not pills” and must not to be licensed by the state medical board. Physicians only insisted they could continue to prescribe eye glasses without having to hold optometry licenses. As a result, over the next 26 years all states adopted non-medical optometry licensing and there was essentially uniformity on how optometrists wished to practice until 1968 when the “LaGuardia Meeting” called for optometrists to become primary eye care providers and state practice laws then started to expand to more accurately reflect optometry medical training.

Dr. Haffner & the LaGuardia Meeting that Changed Everything (Article and Audio). OD Wire, 2013 discussion of 1968 Meeting.

The Meeting that Changed the Profession – La Guardia Meeting. Optometry Cares, AOA Foundation. Historical review of 1968 Meeting.

4: Where Do Optometrists Practice?

Essentially three settings:

Optical stores that emphasize Rx writing.
General practice offices offering primary medical eye care.
Optometry and/or ophthalmology office practices, state or local hospitals, optometry or medical schools and Federal, State or local health care facilities (VA, Department of Defense hospitals, U.S. Public Health hospitals, and local health clinics.)

The updating of state optometry licenses has enabled many general practitioners to offer medical eye care but some older optometrists did not upgrade their licenses. And, since state licensing laws vary, general practice optometrists provide different levels of medical eye care depending on the state where they practice. A model state practice act does not exist for general practitioners.

5: The first Specialty Offering Board Certification

Medical optometry residencies were begun by the VA to provide a cadre from which to recruit future staff optometrists with advanced medical training and hospital practice experience.

While specialists in medical optometry have much in common with general practitioners they differ in having more extensive medical training and experience working as part of a medical team and from having seen a broad number and types of ocular diseases.

6: Can Optometry Fragmentation Be Reduced?

Probably not. But we can, and should, minimize the variations between state licensing laws by developing a model curriculum and a licensing law that prepares all general practitioners to provide one standard level of medical eye care.

A model practice act for those board certified in medical optometry is also needed to avoid another patchwork of practice privileges for them.

Accomplishing this will not be easy but history tells us failure to develop a more uniform system of state licensing will exacerbate additional fragmentation of our profession.

For far too long Optometry believed its licensing prepared general practitioners to competently practice all aspects of optometry; a belief once held by medicine, dentistry, podiatry and nursing but long abandoned as they developed specialty residency training.

The Mayo brothers, instrumental in developing medical specialties through residency training, believed a field of endeavor that did not develop specialties was an occupation rather than a profession.

The need for model curriculum for general practice optometrists was recently shown when the State of Vermont’s Office of Professional Regulation rejected adding more medical procedures for optometrists because it could not find sufficient information about the training optometry schools provide students.

Vermont Office of Professional Regulation – Optometric Advanced Procedures. 2019.

7: Appendix

More detailed information and the findings of the 1999 survey of optometry practice sites within the Akron Metropolitan Area (K).

A: Optometry has been successful in both expanding the medical practice of general practitioners since 1968 and matured to the point it should differentiate between general optometry practitioners and specialists as they were earlier differentiated by medicine, dentistry, podiatry, and osteopathy which usually took them about 40 years for each specialty to be established.

It is no coincidence therefore that medical optometry residencies began 45 years ago, the specialty examination in medical optometry (ACMO) was first administered 15 years ago, the specialty board (ABCMO) in medical optometry formed 10 years ago and credentialing committees at Joint Commission medical facilities first began to recognize medical optometry as a board certified specialty 6 years ago. All told a span of 39 years.

And, since that 1968 LaGuardia meeting, the commoditization of health care and optometry accounted for these changes.

Wide differences now exist between the scopes of medical optometry permitted general optometry practitioners.
Standard scopes of practice and training curriculum for general practitioners and medical optometry specialists do not exist.
The growing surplus of optometrists continues to “push” younger graduates into the arms of optical store practices.
Nearly 29% of graduates serve a residency, most frequently related to the practice of medical optometry.
Private equity firms (Hedge Funds) are buying up office practices with the goal of later selling them as chains.
Ophthalmic goods/services are increasing purchased on the internet and advertised directly to consumers.
Medical physicians have shifted from ownership of office practices to employment within corporate medical systems.
Ophthalmology residencies have not increased and their general practices have evolved into incorporated group practices that own their practice sites and advertise to the public or in surgical specialties that may, in the case of Lasik surgery, become part of a chain offering the specialty.
Physicians have increasingly lost autonomy; AMA membership has fallen to under 10% and AOA membership to about 50% from once being 75%.
Optometry graduates have the highest student debt to projected earnings ratio of all health professions.
The majority of optometry students are now female.

B: Specialization First Considered

In 1965 Henry Peters, then at the Berkeley College of Optometry and later founding dean of the UAB optometry school, read a paper at the American Academy of Optometry before its Section on Public Health and Occupational Optometry that recommended establishing optometry specialties and a system for certifications in them. He later established the first VA student hospital externship in 1973 as founding dean of the UAB School of Optometry and served as advisor to the VA Optometry Service for many years. Dr. Haffner was later appointed to the VA Special Medical Advisory Group to the head of the VA where he served for many years. Another early supporter of VA teaching affiliations was Richard Hopping, past President of the former Southern California College of Optometry.

As interest in specialties increased the American Optometric Association formed a Committee on Optometric Specialties to undertake a two-year study to determine if specialties should be developed. In 1986 the Committee recommended to the AOA House of Delegates that residencies in specialties be developed and independent specialty boards be established to certify those completing specialty residencies. However the House of Delegates voted to not adopt that Committee’s recommendation and no actions were taken.

AOA Commission on Optometric Specialties. AOA, 1986.

AOA Rejects Specialty Certification. AOA News, 1986.

Also, in 1986, the Executive Council of the Academy noted the growing number of VA residency programs and issued this statement to clarify the difference between certification of clinical competence in a specialty and knowledge/research in a specialty.

“To clarify an issue of concern because of the growing attention to credentialing and certification, the Executive Council expressed the position that neither Academy fellowship nor section Diplomate status constitute certification of specialization, and that diplomates are knowledge based, not competency based.”

As a result, the development of residencies in medical and rehabilitative optometry evolved independently through clinical residency training as had specialties in medicine, osteopathy and dentistry… as autonomous independent entities.

C: Changes to State Optometry Licensing Laws

(Adapted from Review of Optometry)

1968 LaGuardia meeting, optometry should provide medical care.

1971 Rhode Island, eye drops to visualize fundus of eye.

1976 West Virginia, eye drops to treat glaucoma.

1977 Montana, Kansas, diagnostic eye drops.

1977 North Carolina, therapeutic eye drops, treat glaucoma.

1980 Georgia, diagnostic eye drops.

1984 Oklahoma, therapeutic eye drops.

1987 Eight states add diagnostic eye drops.

North Carolina, injectable medical agents.

1989 Maryland, 50^th state to add diagnostic eye drops.

Wisconsin, legend tablets, injections.

1994 Mississippi, 25th state to add topical glaucoma treatment.

1997 Massachusetts, final state to add legend tablets.

1998 Oklahoma, types of laser treatment.

1999 Arizona, oral antibiotics, antihistamines and NSAIDs.

Nevada, glaucoma treatment and lab testing.

2001 South Carolina, topical steroids.

2002 New Hampshire, topical glaucoma treatment, topical steroids, antivirals and oral antihistamines.

Michigan, certain narcotics and orals.

Pennsylvania, steroids and topicals, oral glaucoma treatment.

2003 Washington, injectables and Schedule III,IV,V narcotics.

Minnesota, 26^th state to permit injectable agents.

2004 Ohio, oral antiviral and antihistamine drugs.

Vermont, 49^th state to permit oral glaucoma treatment.

2006 New Hampshire, oral antivirals.

2011 Kentucky is 2^nd state to add types of laser.

2013 Florida, oral drugs, narcotics and injectables.

2014 Louisiana, certain laser procedures.

2018 Virginia, steroid injection, corneal crosslinking, intense pulsed light

2019 Virginia certain surgical procedures.

D: More Uniform Standards Required

General practice optometrists should now strive to reduce the patchwork of differing scopes of state practice licenses towards more uniformity. And to consider the degree to which store based optometrists can, or should, “get medical” as there are already many medical eye procedures not suitable to be performed at store practices. The numbers of optometrists practicing at each of 17 different types of practice sites should be obtained from the Lewin data (funded and supervised by the AOA) and a listing of medical procedures appropriate for store and office sites developed.

Bill Kekevian, author of that Review of Optometry article last year urging optometrists to “get medical” concluded his article with this conjecture.

“As ophthalmology eschews medical management in favor of surgery, optometry will catch all those patients. As refraction either becomes automated or the primary domain of big box retailers and their optical departments, maybe the time for optometry to split is here again – just as it was in 1968.” (Emphasis added).

Since general practice optometrists have already practically split into two groups, offices vs. stores, it makes no sense to continue to expand practice acts for all general practice optometrists regardless of where they practice which is why years ago medicine and dentistry developed training and board certification in their specialties.

The American Board of Optometry Specialties (ABOS).

The State of Optometry Specialties and Subspecialties. Charles Mullen O.D., 2018.

E: Growing Surpluses of Optometrists

Over 20 years ago grass roots concern arose that too many optometrists were being trained because two prior studies predicted future surpluses of optometrists but those studies were paid little attention by optometry leaders.

But the opening of so many new optometry schools this century reawakened that concern and led the AOA to commission what it described would be a “definitive” study to determine if there was a growing surplus and funded the Lewin Corporation, a Washington D.C. “beltway” research firm, to do a manpower supply-and-demand study of ophthalmologists and optometrists and a national mail survey of optometrists about where and how they practiced and their degree of satisfaction. Most importantly, that survey asked optometrists to select, from a list of 17 types of practice settings, the one best describing where they practiced.

But Lewin only reported findings for two of the 17 practice sites. Those findings were that about a third of optometrists were employees where they practiced and about two thirds were not employees where they practiced. This told us nothing about the suitability of their site to practice medical optometry since both the Mayo Clinic and some stores pay salaries to their optometrists and private offices and some stores pay their optometrists as a function of net proceeds.

In 2014 the two Lewin studies were released but non-AOA members had to request and pay for them which few did. And most just read the Executive summary which painted an unrealistic picture by claiming a surplus of optometrists was actually a good thing and a golden opportunity for optometry.

The Lewin National Survey of Optometrists. Kenneth Myers O.D., PhD., 2018.

Lewin Study Finds Large Supply of Optometrists – An Editorial Analysis. Kenneth Myers O.D. PhD., 2014.

As a result some optometry leaders claimed a “Golden Opportunity” to “get medical” if states grant optometrists the same privileges as ophthalmologists so surplus optometrists could fill the shortage of ophthalmologists.

F: How Should Optometry “Get Medical”?

While our profession should support efforts to assist general practice optometrists to “get medical”, one should question the extent to which a practice site, should or could “get medical” due to both the rise in store practices and the rise of residency training in medical optometry.

We should fully understand the underlying assumptions behind the push to “get medical” are based upon the Lewin reports that hid the increasing surpluses of optometrists and that its mail survey reported an average optometrist in 2012 had 36% free “chair time” and could see additional patients without more staff or equipment.

Lewin had to assume future optometrists and ophthalmologists will provide identical services with surplus optometrists filling the shortage of ophthalmologist (1.36 optometrists replace one ophthalmologist vacancy) and both are called “eye care providers”.

The Executive Summary then did not even mention optometry and ophthalmology but called both “eye care providers” and that there would be an adequate supply of eye care providers in the future without mentioning some of them would be optometrists practicing as ophthalmologists.

Only with the improbable assumptions that surplus optometrists will become and fill in for “missing ophthalmologists” could the future “golden opportunity” for optometrists to “get medical” exist.

G: How Many Will “Get Medical”?

It seems improbable the growing surpluses of general practice optometrists practicing at stores will ever replace ophthalmologists but very likely that growing surplus of optometrists will make it easier to recruit young debt-laden optometrists into store practices.

Nor is it likely general practice optometrists will be granted privileges identical to ophthalmologists.

But it is likely office practices will continue for some time being bought by venture capitalists (for resale to, or as chains) while VSP continues to openly compete with general practice optometrists and direct-to-the-consumer sales of ophthalmic goods by phone, internet and mobile “apps” grow.

This means that ophthalmic goods will continue to be viewed by the public as commodities sold at stores and the “race to the bottom” that always takes place with commodities will continue.

Prior to his death, Dr. Haffner (of the 1968 LaGuardia meeting) had begun to have increasing concern that some optometry schools were beginning to look more like trade schools than professional schools and that optometry was devolving into a trade rather than a profession.

In his address to the graduates of The Ohio State University College of Optometry a few years ago he also stated the American Board of Optometry offering “board certification” to general practice optometrists was a mistake as it did not require the residency training of all other doctoral health professions. (To date ABO has certified only about 4% of general practice optometrists. And the other two groups that once offered board certification of general practice optometrists have closed.)

With such forces pulling optometry in three directions (store practice, office practice, and medical settings) the author of the Review of Optometry Editorial is probably correct. Optometry is about to split again but into three types of practice settings.

H: A Profession Without Specialties Is a Trade

While optometry has understood, since 1968, the need for expanded scopes of practice, it pursued this goal by striving to expand the scope of all those in general practice rather then developing specialties requiring residency training and testing leading to certification; the approach taken by medicine, osteopathy, dentistry and podiatry.

This was understandable because in 1968 optometrists still saw themselves as general practitioners, training sites at hospitals did not exist nor were sought by schools, and the commercialization of health care had yet to take off.

Optometry also did not consider that in some states the “final” license to practice medical specialties requires internship and then residency training and medical sub-specialists then also serve fellowships. A dental oral surgeon for example, serves a 3 to 4 year residency after dental school and some states require podiatrists to have competed residencies for final licensure or offer “stages” of medical licensure that require internships and residencies.

Dr. Haffner had learned any field so narrow it does not develop specialties is a vocational trade while serving as Vice Chancellor of Professional Studies for the entire New York SUNY system (between stints as President of the SUNY College of Optometry) when he was responsible for graduate level medical, dental, optometry and other health training programs.

The LaGuardia group had not considered in 1969 that expanding optometry care might best be done through medical residency training (that then did not exist) rather than ad hoc training programs of general practitioners that would vary greatly from state-to-state.

Dr. Haffner & the LaGuardia Meeting that Changed Everything (Article and Audio)

I. Where Do General Practitioners See Patients?

The degree to which general practice optometrists can “get medical” will depend upon the site where they practice, the state in which they practice and whether they are residency trained.

The lack of standardized training and licensure was recently noted by the Vermont Office of Professional Regulation (OPR) during its determination of whether Vermont should grant “advanced procedures” to optometrists. It recommend to not to so and stated:

“Most significant for OPR is the lack of evidence showing that optometric education prepares optometrists to perform these proposed advanced procedures. Despite multiple efforts through various sources, OPR was unable to gather specific or detailed information about the curricula and courses offered by the U.S. schools of optometry in these advanced procedures. Other states attempting to gather such information have met with similar refusal to disclose detailed curricula.”

Vermont Office of Professional Regulation – Optometric Advanced Procedures. 2019.

J. Lack of Practice Site Data

There has never been agreement within our profession on how to characterize the sites at which optometrists practice and a seeming reluctance to so because many leaders believe store sites are “beyond the pale”.

As mentioned previously the only really detailed, national site survey was the 2012 Lewin survey that asked optometrists to pick, from 17 the one best describing their practice. But, while collecting this rare information, Lewin reported on only 2 of those 17 practice site types; whether the optometrist was self-employed or an employee at their site of practice.

The large variety of how optometrists may practice is shown by the various “descriptors” optometrists have used over the years

Past Descriptors of Practice Sites

Private practice Self Employed

Solo practice owner Employed by others

Commercial practice Practice Owner

Independent practice Franchisee

Office practice Independent contractor

Group practice Separate-door practice

One-door practice Employed by optometrist

Two-door practice Employed by ophthalmologist

. .

But the site at which an optometrist practices is important because the public image of optometry is influenced by the impression formed when they visit a practice site.

K: A 1998 Akron Site Survey

I had once visited 72 Akron, Ohio optometry practice sites in 1998 while on vacation and categorized each as an “office” or “store” from having wondered for years why there was so little data about where optometrists practiced and having earlier served as advisor to the Federal Trade Commission study of the effect of advertising on quality of optometry care.

While my site descriptors -“office” or “store”- below, are subjective, I found it was not difficult to decide whether a practice site was a “store” or “office”.

See Photos of “Offices” and “Stores” Circa 1997

Akron Site Descriptors

Office

Name(s) of the optometrist(s) practicing at the site were clearly displayed, minimal references made to, or display of, ophthalmic goods and their costs. Appointments generally required except for emergencies, and the site located in the suburbs as separate structures owned by one or more optometrists or in small office parks in suburbs.

Store

The Name(s) of the optometrist(s) practicing at the site were not shown (or not visible) and the location marketed under a “brand” and located within the population center. Displays of ophthalmic goods featured and visible from the street, walk-in patients accepted and costs for eyeglasses/exams advertised. Most “stores” were well within Akron city limits and inside a mall or “big box” merchandiser.

Differentiation of office vs. store sites also agreed closely with where and how they were listed within Akron phone book listings.

Background

The data I gathered (which I was later advised not to publish) came from visiting 72 optometry practice sites I located from the Akron Ameritech Yellow Pages; the current membership list of the Ohio Optometric Association; the current membership list of the American Academy of Optometry, or from happenstance.

At those 72 sites a total of 91 licensed optometrists practiced full, or part-time. Some of the 91 were not listed in any optometry membership list, the Akron residency phone book or in ads of optical stores and also resided outside the Akron metropolitan area. They represented to me sort of an “underground of optometrists”.

External photographs of each site were taken and sometimes inside.

At each site I asked what type of an examination would be made and observed how, or if an appointment were arranged.

Sample size:

72 practice sites with 91 different optometrists distributed among them with 28 optometrists practicing at more than one site.
69% of optometrists at offices were AOA members compared to 33% of those at stores. AOA membership for all 91 optometrists combined averaged to 55%.
Two of 91 optometrists were Fellows of the American Academy of Optometry and office-based.

Ownership vs. Employee by Practice Site Type:

27 optometrist-owned offices
7 optometrist-owned small optical stores
35 optometrist “employees” at large optical stores
3 optometrists employed at ophthalmology offices

Primary Practice Site:

34 optometrists practiced only, or mainly, at offices.
52 practiced only, or mainly, at stores.
3 practiced only at ophthalmology offices.

Examination Fees:

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

Were asymptomatic new patients dilated?

Always: At 31% of offices.
Sometimes: At 31% of office-store practices.
Never: At 39% of stores.

Of the 91 optometrists, 26 (29%) were not in the Akron Ameritech Yellow Pages under any listing and did not have home addresses or have residence phone numbers in the Akron metropolitan area. Of these 26 “underground optometrists” 16 practiced within large mall optical stores.

L: Summary of Survey

In the Akron metropolitan area about one-half of practice sites were optometrist(s) owned.

The majority of optometrists practiced at a store or stores.

Well over one-half of all optometrists (at office or store) did not dilate eyes while performing eye examinations of new patients.

Optometrists practicing in offices were more likely to:

Dilate new patients (only 31% always).
Be AOA members.
Charge higher examination fees.
Schedule appointments and not see walk-ins.
Be located in the suburbs.

One finding stood out. The practice model once held to the author’s generation by the American Academy of Optometry… be located in a building containing professionals on a floor above street level without advertising at street level… was rare.

Only two practice sites, among the 72 in metropolitan Akron, met that former AAO standard. (The Academy later removed those standards upon the advice of council and fear of FTC.) One of the two had patients waiting in its waiting room with two optometrists on staff, and a plaque stating they were AOA members, while the other site was closed with an aged sign showing the phone number to call for an appointment on the door.

M: Discussion

It has long been the belief among optometry leadership that whether a site markets itself as an office or a store signals the professionalism of the optometrist(s) at that site and quality of care. My survey in Akron supports this belief as did the 1989 FTC national survey of which I served as principal advisor. In addition, past mail-in opinion surveys by Consumer Reports found similar findings.

But while the debate over this has continued it is a significant factor that must be considered as to whether store optometry practices will be interested in, or should “get medical”.

The other question, which type of practice seems dominant, is, judging by this small Akron study, store practices at least around population centers and where most of us live. Perhaps most disheartening is that in 1999 only a minority of even office practices dilated first time patients.

After the FTC study I had served on it seemed to me the shift towards store practice sites, whether owned by optometrists or not, accelerated despite the FTC findings store optometrists gave less thorough examinations and spent less time with their patients (the FTC did not mention those findings in its report; only that eyeglasses were less expensive at advertising sites).

Also discouraging is that AOA membership appears to be declining and it had to cut or reduce programs in recent years, including its print journal. Even the American Medical Association has continued to lose members since physicians are increasingly employees rather than practice owners.

One must also consider the first paragraph in the editorial “Let’s Get Medical” published in the Review of Optometry last year.

“Despite the growing need for medical eye care services, more than 70% of the average optometrist’s income still comes from goods and services related to glasses and contact lenses.” (Source, AOA Excel and Jobson Medical Information, “The State of the Optometric Profession (PDF)“, 2013.)

And consider in the 2019 Fall issue of the American Academy of Optometry e-newsletter Dr. Agustin Gonzalez’s editorial in the “Clinical Corner” entitled “Medical Optometry: No Longer An Option.”

Both articles argued general practice optometrists should provide more medical services because “prescriptions by optometrists still represent a very low percentage of medical glaucoma care.”

How will general practice optometrists “Get Medical” if the majority of sites at which they practice are “stores” and those stores continue to increase? And, in Akron, even “office” based optometrists dilated new patients only 31% of the time?

When the author presented this survey to the student body at ICO some years ago, it was entitled the “Mitosis of Optometry” to stress our profession seems to continue to be splitting into store vs. office with ever greater numbers practicing in store settings.

That shift has accelerated as new schools began opening, causing the number of graduates to almost double in the last 20 years.

This mitosis of optometry will continue with general practice office optometrists under ever greater stress, especially in large metropolitan areas that continue to grow while rural areas do not, and that trying to encourage store optometrists “to get medical” will not have much impact.

We can only hope the growing number of optometrists in medical optometry residencies will mitigate the shift to store practices. Former residents are more likely to seek office settings within medical organizations or in large optometry or ophthalmology group practices. (In Akron, a group ophthalmology practice had ophthalmologists and optometrists on staff who had once worked together as residents at the Cleveland VA hospital.)

To a real degree, it may be “beating a dead horse” to expect significant numbers of general practice optometrists to expand their medical eye care capabilities unless they are younger for it is unlikely older general practitioners will do so.

The fact VA hospital medical residency training has increased rapidly since 1975 is suggestive this group of optometrists do look “to get medical”.

We must also hope that, in the future, “getting medical” will be done the way other health professions have done it, by residency training, rather than by adding more piecemeal license endorsements that do not require residency training nor lead to specialty board certification.

It was to further the careers of those who seek to practice in medical settings that the Advanced Competence in Medical Optometry examination was created by the National Board of Examiners in Optometry which now offers this examination to those completing medical optometry residencies. Passage of the exam makes them eligible for board certification by ABCMO which is now recognized by credentialing committees at over 100 Joint Commission accredited medical facilities across the nation and used by Department of Defense Medical programs to authorize specialty pay to optometry officers who are ABCMO certified. (Ironically, the VA has yet to follow suit.)

Clearly, those completing residency training in medical optometry have the best motivation and opportunity to “Get Medical”.

It was unfortunate, but typical, that Dr. Karpecki’s editorial in Review of Optometry and Dr. Gonzalez’s editorial did not mention the growth of optometry residencies or that 29% of graduates now serve a residency and increasing numbers of optometrists are on the medical staffs at hospitals with the VA Optometry Service the largest trainer of optometry students, residents training in medical optometry and employer of optometrists.

Sadly, this shows that mainstream optometry continues to think of optometry as a uniform profession able to care for all types of patients rather than one recognizing it is splitting into three types of practice.

The significance of the VA leading the way for optometry “to get medical” should be recognized and capitalized on by our profession. Medical schools have long recognized (since 1946) that without the VA hospital system they would be unable to provide today’s levels of training of students and residents and the reason so many medical schools are close to VA hospitals.

N. Detailed Akron Findings

Not have enough convincing?

The Akron survey was designed to visit all 72 locations in the Akron metropolitan having practicing optometrists and determine ownership of each location, names of optometrists full, or part time, costs of eye examinations, whether dilated exams of new patients were made and the overall style of practice as to orientation towards office or store, AOA membership and AAO fellowship and 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 to document whether the site marketed as an office or store. Sample photos are in the appendix.

If the reader will view the attached practice site photographs it will become clear it was easy to determine whether a practice site was an office or a store.

See Photos of “Offices” and “Stores” Circa 1997

Examinations were not obtained so quality of examinations and materials were not determined. The chief purpose of the survey was to determine types of practices in which optometrists practiced, the ownership of those practices and to differentiate between what are called “private office practices” and “retail store practices”; terms that do not have precise meanings and can be so nuanced that a classification system was used that 18 distinctively different types of practices were encountered (much like the suppressed Lewin Survey findings)

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

Type of Practice Site

% of each

Site Owned by Optometrist(s)

Office-Based Site

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 Site

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%

Site Not Owned by Optometrist(s)

Store-Based Site

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 opticals (Sears, Penny, Ward, etc.) 8.3%

17. Local optical/optician stores 13.9%

Office-Based Sites

18. Free-standing ophthalmology group practices 4.2%

With these 18 types of practice sites it was possible to enumerate all practice sites 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 sites at which the 91 optometrists practiced. Only this level of detail can avoid ambiguity as to optometrists’ site types and show the wide and compartmented sites at which optometrist practice.

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

The 91 optometrists distributed across the 18 types of practice sites resulted in:

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

The most frequently encountered site types were:

Mall chain-optical store 12
Local optician/optical store 10
Office in an office mall 9
Office in a commercial site 7
Co-op/Union optical 7 (A cooperative union employer owned)
Department store optical store 6
Office within an office building 6
Office in separate building owned by optometrist(s) 5
Store in commercial area 5
Ophthalmology group office building 3
Dedicated optical store building 2

Office or Store Optometrist?

While it was relatively simple to determine whether a site 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.

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

O. Summary of Akron Survey

Including ophthalmology offices, only 42.9% of optometrists practiced primarily at offices.
The majority of optometrists, 57%, practiced full-time in a store owned by an optometrist or non-optometrist.
Sites 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.

Phone Book Marketing

Optometrists marketed under:

“Optometrists-Doctor of Optometry (OD)” 62%

Within ad under “Optical Goods” 26%

Under “Optical Goods” 8%

Somewhere within Yellow Pages 71%

No listing 29% ; 16 of these were at stores rather than offices.

Additional Notes

In 1998 the best data suggested 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 were about 43,000 licensed optometrists and about 20,600 dues paying AOA members for a national AOA membership rate of 48%. A significant decline from 73% to 48%.

To the degree these numbers were accurate, it seems that since this survey found, in 1998, a low AOA membership rate of only 37% among commercial store-site O.D.s, compared to a 69% rate among optometry-owned office-store sites, the decline in national AOA membership is due to a relative increase in store-based optometrists; the rapid increase in optometry schools and graduation rates; and the shift of optometrists from privately owned offices and stores to becoming what are essentially, defacto employees.

Such a major shift took place among pharmacists years ago. While in the past pharmacy stores were usually owned by pharmacists, today 80% of pharmacists are employees at the five largest national pharmacy chains.

Sensing this sea change in how optometrists practice led the author to title the 1998 survey “The Mitosis of Optometry” for, by that time, the sites at which optometrists practiced had already become highly fragmented

Personal Footnote about Influence of FTC

In 1978 the author was asked to be principal advisor to the Federal Trade Commission’s national survey that would conduct on-site visits to sites where optometrists practiced to determine whether eyeglasses from optometrists who advertised differed in their quality and accuracy from those that did not advertise. I stated there would be little difference in the quality/accuracy of eye glasses but that optometrists at advertising sites likely performed significantly less thorough eye examinations compared to non-advertising optometry sites and the thoroughness of the examination be determined if I was to take part. After much arguing the FTC agreed to evaluate the quality of eye examinations by pre-training the FTC “patients” for a week at an optometry schools about the instruments and procedures used in an examination and I would design a detailed evaluation check list for the “patients” to fill out of the time and types of instruments used during their examinations and whether they would recommend their examining optometrist to friends. The results showed the most thorough examinations were given by Fellows of the American Academy of Optometry and the least thorough by optometrists at advertising store sites.

But, in its final report, the FTC only reported that advertising optometrists issued equally accurate prescriptions while charging less without mentioning that they performed significantly less thorough eye examinations. (In one case the advertising optometrist examined but one eye and wrote equal Rxs for both eyes.) I refused to sign off on the final report and wrote to the members of the FTC commission about this and that I did not endorse the findings for their being incomplete and misleading. None-the-less the FTC then went on to tout the value of allowing optometrists to advertise as their eyeglasses were less expensive and “the race to the bottom was endorsed” by our government…

Over the years Consumers Reports also conducted surveys among its readers about their satisfaction with the services they received at various optometry locations. Based upon those survey results, CR concluded that “private” optometrists in their offices, while charging higher fees, were rated as giving more thorough examinations than those at “stores”. It was also suggested by CR that those having more complex eye problems seek out a private optometry office.
A similar “store” vs. “office” competition also exists in the case of hearing aids.
Typical photographs of Akron optometry practice sites follow this page. Note how easy it is to decide which are “store settings” or “office settings”.