Point/Counterpoint
Are There Too Many O.D.s?
Two opposing views on whether we're meeting unmet vision needs.

"No. We'll need more optometrists if we're to address this country's growing eyecare needs."

Are we facing an oversupply of optometrists? We are, if you take the Workforce Study of Optometrists commissioned by the American Optometric Association literally. The study, released in February 2000, concluded that all things being equal, we'll see a substantial oversupply of optometrists in the next 2 or 3 decades.

But I believe that all things aren't equal and that this projected overabundance could easily turn into an undersupply. To avoid having too few optometrists, the following would have to remain true:

• No substantial increase in the demand for eyecare services during the next 2 or 3 decades
• No significant decline in enrollment in optometry schools and colleges and in ophthalmology residencies
• No addition of routine eye exams or eyewear as covered Medicare benefits by the Federal government and no legislation of mandatory "socialized" healthcare for all citizens.

But none of these assumptions is guaranteed. Let's look at each one in more detail.

Demand for service. The demand for eyecare services is likely to increase. Aging baby boomers, the growing focus on eye exams for infants and children, the expected increase in eye diseases needing treatment and the increase in computer use and its associated vision problems are some of the factors increasing eyecare demands.

Enrollment statistics. Enrollments in optometry schools and residency programs for ophthalmologists are slightly declining. However, this decline will have little effect in the short term because many students are currently in the pipeline.

Government recommendations. No one knows what the federal government will do with eye care, but state governments signal a trend. Last year, for instance, Kentucky passed legislation requiring all students to have full eye examinations before entering school. Similar legislation is currently under consideration in half a dozen other states.

We need to convince consumers that routine eye exams are necessary to discover ocular and systemic problems. We also need to persuade them that comfortable vision results in more efficiency at the workplace and more enjoyment in life overall. We need to induce those who periodically get eye exams that just seeing well for distance or near objects isn't enough -- that good vision goes far beyond that.

What's more, we need to visually evaluate young children (not just screen them) and make sure that motor vehicle operators see properly to drive. We need to give people whose vision we can't correct by customary means the opportunity for correction using less common means. And we need to arrange to examine our population on a more regular basis so that we can discover systemic conditions, such as diabetes, that manifest through eye problems.

Doing the numbers

Statistics on current vision-related problems and conditions suggest the scope of the particular needs that go unmet.

• At least 14 million Americans have diagnosed low-vision problems.
• Prolonged use of computers leads to computer vision syndrome (CVS). This condition definitely affects performance by disturbing the comfort and efficiency of computer operators. In 1995, the National Institute of Occupational Safety and Health reported that 66 million people in the United States worked with computers more than 3 hours per day and a whopping 88% of them suffered from eye strain. Using the same criteria, the number of prolonged computer users in 2000 was more than 75 million people.
• Only 14% of American children under age 5 have received a comprehensive eye exam, and some 18 million won't have had an eye exam by an eye doctor by the time they enter school.
• Some 10.3 million people are diagnosed with diabetes. Conservative estimates are that another 5.4 million have diabetes but haven't received a diagnosis.

Calls to action

Addressing these many problems will take both individual effort from ECPs and collective efforts from eyecare groups and associations.

Here's what we can do about some of the major issues that confront us:

LOW VISION
Individual efforts

• Attend continuing education (CE) courses on the subject.
• Outfit and decorate your office to reflect your interest in caring for partially sighted patients.
• Buy a generous supply of modern low-vision aids. Make sure at least one of the devices includes a television or similar monitor so that your low-vision patients can see the magnification that's possible.
• Teach staff members about low-vision problems and ask them to talk with patients about this "new" service. Inform patients who were told years ago that nothing could help them see better about how technology has created new devices that can often restore useful vision.

Collective efforts

Eyecare associations should issue periodic media releases with low-vision data and information on the correction of partially sighted persons. They should also join with groups such as Lions Clubs International to develop publicity programs on low vision.

These groups should also work on getting Medicare and Medicaid payment for low-vision devices.

CVS
Individual efforts

• Make sure your staff asks patients if they use a computer and, if so, how long they use it per day on average.
• Be familiar with vision problems related to prolonged computer use and probe to see if those problems exist with your patients.
• Be aware of other problems that cause discomfort with sustained computer use -- lighting, background and seating.
• Perform your eye examinations with computer use in mind.
• Know how to design lenses for prolonged computer use -- or buy lenses that are specially designed for computer operators.

Collective efforts

• Associations should develop and distribute brochures about CVS and work on getting Medicare and Medicaid payment for this condition.
• Associations should place articles on CVS and its treatment in the media, particularly in publications designed for computer owners.

INFANTS AND SMALL CHILDREN
Individual efforts

• Make it known that you welcome infants and young children in your practice. Put up posters in your reception area, mention it in your newsletters, appear on radio talk shows and give speeches on children's vision problems.
• Participate in one of the many groups active in optometry that's trying to make the public aware of the need for eye exams for infants and children. The College of Optometrists in Vision Development, Optometric Extension Program Foundation, Operation Bright Start, See to Learn and Kids Welcome Here are some of the efforts that need your support.
• Take courses in examining infants and children. Learn not only the newer exam procedures, but also understand the do's and don'ts of managing young children.
• Stock a substantial number of frames for small children in your dispensary and set up displays that call attention to your interest in children. Put a school desk and similar items in your reception area.
• Write to pediatricians in your target area and offer them data on children's vision problems that often go undetected. Ask them to refer infants to your practice.
• Speak to Parent Teacher Association groups and explain the difference between eye screenings and eye exams.
• If you have friends or patients active in politics, talk with them about the new Kentucky law that requires all children to have a full eye exam before entering school. Encourage them to work on similar legislation.

Collective efforts

• Associations should encourage more seminars nationwide on examination techniques and procedures to use with children.
• These associations should put the adoption of laws similar to the one in Kentucky high on their legislative activity list.

DIABETES
Individual efforts

• Perform dilated eye exams.
• Display fundus pictures of both normal and diabetic patients in your exam rooms.
• Insert items in your office newsletter to encourage diabetic patients and people who have diabetes in their families to get frequent eye examinations.
• Join the list of optometrists who participate in American Diabetes Month.
• Keep primary care physicians informed of your examinations of their diabetic patients and advise those physicians of any fundus abnormalities.
• Place diabetic patients on your short-hop appointment schedule.

Collective efforts

• Continue to work with the American Diabetes Association and other groups on initiatives to encourage patients who have diabetes or those who have the potential to develop diabetes to get their eyes examined.
• Provide support materials for eyecare association members to cooperate with national and local programs to identify patients who have diabetes.

GLARE, REFLECTIONS AND ULTRAVIOLET (UV) LIGHT
Individual efforts

• Make sure you and your staff ask all patients if they're troubled by glare and reflections.
• Post displays in exam rooms and the dispensary that demonstrate glare and reflections and how polarized lenses and lenses with anti-reflection (AR) coating can help reduce these problems.
• Wear AR-coated lenses if you need glasses and polarized sunglasses whether you need a prescription or not. Have your staff do the same.
• Suggest UV-coated and AR-treated lenses to all patients or include one or both as integral features when prescribing all ophthalmic lenses.

Collective efforts

• Urge associations to send periodic releases to the media about glare and reflection control and problems with UV light.

Continuing to meet needs

Other unmet needs, including protecting the eyes of people who have home workshops and those employed in hazardous occupations, remain. A growing number of children and adults participate in contact sports or work with animals and need impact-resistant ophthalmic lenses and frames.

Meeting the unmet vision needs of America requires both individual and united efforts. In no instance is this self-serving. We'll need more optometrists to guarantee the public's visual welfare, which is, after all, our paramount concern.

I've looked at the subject of unmet needs and the number of optometrists needed to fill them now and in the future, much as the optimist and the pessimist look at a half-full or half-empty glass of water. I see our situation as a half-full glass. OM

Dr. Bennett practiced optometry for more than 40 years in Beaver Falls, Pa. He has authored numerous articles and lectured on practice management subjects. At one time, he was editor and publisher of OM. He was also a member of the AOA Project Team that commissioned the Workforce Study mentioned in this article.

"Yes. The market is already supersaturated, and we need to take other measures to address unmet vision needs."

Nobody likes to try to refute one of the legends and heroes of our profession. Nor do they like to tell their beloved colleagues that our profession is in serious trouble.

But I feel that it's unacceptable to sit by and watch the profession that I love and for which I have shed blood for over 30 years, be pandered to, patronized and fed "whitewashed" information. Rather, someone must share some hard realities with those optometric practitioners who wonder, "Am I the only one hurting?"

No, my friend. In spite of the "conspiracy of deceit" our profession is enduring from Pollyannas in our professional journals and from professional associations trying to provide "feel good" rhetoric, your pain is all too real. And unless you understand the hard, painful realities, their causes and potential effects, our profession may not survive the next decade or two.

Point-by-point rebuttal

The arguments about the need for more optometrists to meet an array of "unmet vision needs" don't address the real critical issues optometry is facing. We must address these real issues (securing quality optometry school applicants and addressing the changing environment, to name a couple) if our profession is to survive and grow in the coming decades.

Demand for service. Yes, the demand for eyecare services will increase over the next 2 or 3 decades. However, sources will meet that demand in different ways than we currently address eyecare needs. Eye care practitioners (ECPs), especially the growing number providing third-party and federally reimbursed care, will continue to experience financial squeezing and will need to provide services more efficiently for more patients.

Technology will help with that efficiency (if optometry adapts to and adopts new technologies quickly enough -- that is, before our medical and optical competitors do). However, we'll still feel negative financial implications, which will affect our future modes of practice. When have increased third-party care and federal reimbursement ever helped providers financially?

Enrollment statistics. The decline in optometry school enrollments may not ultimately be as much a question of quantity as one of quality.

Government recommendations. The government will administer entitlement programs in Kentucky and those ". . . under consideration in half a dozen other states" for young and old in the most cost-effective manner.

Access to care improves with entitlement programs, but neither financial benefits to professionals nor better eye care to patients has ever been a byproduct of such programs.

Refuting the numbers

The following are my thoughts on the statistics that suggest that particular needs are going unmet:

• The benefits that we know good pediatric optometric care can provide are more than offset by a painful reality. In large part, pediatricians and family practitioners control children's vision through their professional advice and referrals. All of the marketing approaches that the optometric profession might use to capture these newly entitled pediatric patients and referrals are woefully inadequate when matched against the medical establishment that directs the care and generally rejects optometric services, especially regarding pediatric care.
• The care described for low vision patients sounds engaging, but in reality these measures will never support the growth and survival of optometry.
• Regarding the diabetes diagnosis argument: Once again, the realities far outweigh "what should be" in this care. Physicians' control of these patients and the medical influence over the associations and advocacy organizations in these areas of care seriously limit optometrists' potential for success in this growing arena of eye care.
• Furthermore, as ophthalmologists seek more medical management of eye care to supplement ever-decreasing surgical procedural fees, the effect among medical colleagues and their influence with third parties, especially relative to oculosystemic disease care, will dramatically weaken optometrists' ability to participate effectively.

The real issues

I see optometry's future in serious jeopardy. In fact, the optometric profession faces a crisis based on a number of current and evolving issues that I'll attempt to summarize.

Optometric education and thus the future of our profession are in harm's way. The cost of an optometric education (especially in the private schools) continues to escalate, while the financial value of the end product of such an investment continues to diminish.

Obviously, this situation will ultimately produce a reduction in overall enrollment in optometry schools. But the more insidious problem is one of securing quality applicants.

Consider that the highly qualified undergraduate student can choose a career in optometry (or any health profession), business, computer science, engineering, etc. All of the latter options may or may not require an extra year or two of training at moderate undergraduate or master's level tuition rates, plus living expenses and a resultant lost income for the extra educational time. Most of these careers have entry level earning potentials of $40,000 to $80,000 with virtual open-ended, long-term (ceiling) earning potential.

Meanwhile, optometry requires an additional 4 years postgraduate training at expensive, doctoral-level tuition rates plus living expenses. Potential state university totals could reach $70,000 to $100,000, while private school totals and living expenses could go as high as $180,000 -- plus 4 years of lost income.

This investment in an optometric education results in an entry-level income potential of $30,000 to $60,000 and probable potential earning ceilings that are substantially less than many other professions (especially with health care's increasing third-party and federal reimbursement controls).

Granted, while many qualified undergraduate students may have an emotional calling to "be a doctor," the painful financial realities of choosing optometry as a career are yielding continually decreasing numbers of qualified applicants to optometry schools (the pool of "legitimate" applicants is already less than the available seats in optometry schools) and there isn't anything on the horizon to suggest this crisis will improve.

The philosophy of "more is better" regarding the number of practicing optometrists is beginning to show its deleterious effects. Optometric academic institutions are primarily tuition-based operations (especially the private schools) that need to have a minimum number of students to meet their budgets. Thus, we can't realistically expect them to address this problem for our profession.

Again, notwithstanding the rationale for "increasing vision needs" and thus a need for more optometrists, this constant influx of new optometrists (without an equilibrating attrition rate) has resulted in an already supersaturated marketplace of ECPs (both O.D.s and M.D.s), getting worse.

Meanwhile, market influences, demographics and technological advancements continue to reduce the need for so many ECPs. Market-wise, commercial practices are providing an increasing volume of eye care, for better or for worse, with a system of fewer optometrists seeing more patients.

Demographically, increasing numbers of ophthalmologists (now being termed "comprehensive ophthalmologists") continue to see more routine eyecare visits (with technicians doing their refractions) at greater rates and volumes than comprehensive, routine optometric providers.

And last, but definitely not least, new technologies and appropriate delegation of data-gathering functions continue to increase the efficiency of providing routine eye care. These three influences are dramatically changing the landscape of the way eye care is currently being delivered and how it will be delivered in the future.

We must analyze any discussions about the "need for more optometrists" in the light of these changes and realities in the eyecare delivery system.

Because we have such limited control over them, the previous issues I've identified are frustrating to those of us who so dearly want to see our profession survive and grow.

One last issue, however, I feel is the most relevant because it's one that we do have control over, which ultimately leads to our control over our own professional destiny. It's our need to honestly and realistically address the changing environment that our profession faces and to deal with the critical issues we face as a profession.

Tackling some tough realities

Our only hope as a "minority profession" (as Dr. Alden Haffner has described us) is to recognize the realities we face, look to the future and structure a plan to address the critical needs for success. I suggest that we must:

• realistically appraise the manpower needs in optometry by creating a multi-profession-wide blueprint in conjunction with ophthalmology and opticianry (and public health analysts) to assess future eyecare needs and how to meet them relative to evolving demographics, new technologies and the changing nature of eyecare delivery.
• realistically address how we can best, most efficiently and most effectively contribute to evolving eyecare needs and the changing eyecare delivery system.
• recognize and embrace new eyecare technology in our training programs, continuing practitioner education and competencies and in optometric practice.
• be realistic about how to deal with and ultimately to work with our ophthalmologic colleagues and the medical system in general.
• rapidly adapt to the changes occurring in the evolving eyecare delivery system rather than try to structure our future on past ideals, philosophies and strategies that we once used to grow the optometric profession.

Building a better future

I've always said that we see further by standing on the shoulders of such giants as Dr. Irving Bennett. But now, with the greatest humility and respect for Dr. Bennett and his predecessors, and in appreciation for all they've done for our profession, I believe it's time to look ahead and realistically address the challenges of optometry's future. To do this, though, we must address the aforementioned points quickly and efficiently.

Dr. Catania is an internationally acclaimed clinical educator and author. He is a recognized expert in anterior segment care, refractive surgery and new eyecare technologies. He's currently performing clinical research on the cornea and is developing eyecare technologies as well as serving as a consultant and advisor to multiple ophthalmic companies and professional journals. He holds academic ranks at numerous educational institutions and continues to write and lecture extensively worldwide.