What Has Changed?

Optometry is a profession of the twentieth century. It was first legally organized in the State of Minnesota in 1901 when a state licensing and regulatory board was established. Other states followed during the next decades, culminating in 1924 with the District of Columbia. Not only were legal recognition and licensure regulation established in these initial state statutes, but the scope of professional responsibility was defined as well. It is interesting to note that the scope of professional responsibility, as defined at the beginning of the century in Minnesota, was not significantly altered for the first seven decades after its establishment. Indeed, no alteration in the scope of professional responsibility occurred until 1973 in Rhode Island and, thereafter, throughout the rest of the country. The major progenitor of change was undoubtedly the establishment and enhancement of the structured system of formal professional and scientific education of the optometrist. At the time of initial enactment in Minnesota, the length of formal education was 2 years after high school. Today, all schools and colleges of optometry are professional programs of 4 years’ duration, constructed upon prior baccalaureate undergraduate experience with appropriate concentration in advanced sciences and mathematics. Table 1 lists the current schools and colleges of optometry in the United States together with the dates of founding. In the second half of the twentieth century, all newly established institutions have been university based. Only three private universities engage in such professional education. Five independent colleges remain; they are the older institutions. The oldest was founded 125 years ago. Another aspect of change that is a byproduct of the alteration of its formal system of professional education is the uniformity of its terminal academic degree. It was not until the late 1960s that the public universities, although established decades earlier, finally agreed to offer the O.D. degree, the Doctor of Optometry, thus confirming a single and uniform degree conferred at the conclusion of the professional education program. All schools and colleges established since that significant development have conferred the O.D. degree and all such institutions have been part of universities, mostly public. The introduction and confirmation of the O.D. as the terminal professional degree, last recognized by the state universities in the 1960s (University of California at Berkeley, Indiana University and The Ohio State University), required a process of educational upgrading for those optometrists already in practice who legally did not have the O.D. degree. The introduction and authorization of the O.D. degree provided for no “grandfather” process—that is, no legal right to its use for those optometrists who did not legitimately have it. A series of special educational programs were undertaken, generally 18 months in duration, to provide an intensive professional and academic education “upgrade,” upon successful completion of which the O.D. degree was conferred. That process of academic and professional upgrade was repeated in the 3 decades that followed in two specific areas involving scope of practice and professional responsibility. They involved the introduction of diagnostic pharmaceutical agents (DPA's) and therapeutic pharmaceutical agents (TPA's). Again, with their respective introduction into practice for existing optometric practitioners, and with the deliberate absence of legal grandfather authority, DPA's and then TPA's were two events that provoked separate and specific educational upgrades. All three processes were in the public interest. No state or other legal jurisdiction incrementally increased authorized entitlement without rigorous educational enhancement. Conversely, no enhancement in standing (in the use of the O.D. degree or in the progressive expansion of the scope of professional responsibility) was enacted without commensurate structured educational programs. Moreover, the optometric community never sought statutory grandfather authority to avoid educational upgrades. The last two decades has seen an upsurge of optometry publications, both texts and journals, on a variety of subject areas. A cursory review of titles tends to confirm that the preponderance of attention, however, has focused on the diagnosis and treatment of ocular disease. It reflects the dramatic changes in the scope of professional responsibility that were enacted in state after state. This burst of scholarship has been noted and is exceptional for its depth. Likewise, the last 2 decades has demonstrated a remarkable increase in vision science research both in the laboratories and in the clinics. Much of the research activity has been underwritten by federal grants. It is a time-honored maxim that the responsibility of a profession is to advance and enhance the knowledge bases of the disciplines that support it. Indeed, vision science research, in its broadest aspects, becomes an obligatory function and is imperative to secure the progressive development of optometry. In this regard, the institutional setting is the primary base for research and scientific investigation activities. Clearly, the schools and college of optometry and the VA medical centers are the principal environments for the development of the research function. The introduction of the use of pharmaceutical agents into the regimen of optometry, a profession that was previously “drugless,” was a rather dramatic change. Called for in the late 1960s as a logical progressive change, it was based upon two premises. The first was that there was an adequate educational base to support its use in the profession. The second is that such a move was clearly and definitively in the public interest. Without these two essential prerequisites, such a major expansion in the scope of professional responsibility could not have occurred. The change from a drugless profession to the state of optometry today took place in three phases. The first, beginning in 1973 in Rhode Island, initiated the use of DPAs. The second phase, begun in North Carolina and West Virginia in 1975, authorized the use of TPAs for the treatment of diseases of the eye, including glaucoma. I stated that the change in the scope of professional responsibility occurred in three phases. Indeed, it has. I join with my colleagues in sociology to assert that the third phase, currently well underway, is the institutionalization of the culture, habits, practice models, and professional environment of optometry resulting from both DPA authority and TPA authority. This third change probably will proceed for yet another generation, although it can be already be measured in social and behavioral terms. Indeed, its fundamental importance should not be diminished. Moreover, a body of understanding, reflected in the optometric literature, remains to be constructed. Another development of enormous significance, already established in Oklahoma, is on the horizon in other state jurisdictions. It relates to the limited use of surgical procedures with the use of laser technology. With appropriate education at the College of Optometry at Northeastern State University in Tahlequah, Oklahoma, and with intensive clinical training at the Indian Health Service Hospital in Tahlequah, optometrists, with appropriate background and education, are being certified to perform such procedures. Optometric students who will graduate after 1999 will have that authority under the optometry license and as part of the education and clinical background during their 4 years of professional schooling. At the time of this writing, plans are being made to introduce statutory changes in at least seven states, with others clearly to follow. As in prior expansions in the scope of professional responsibility, there will be no grandfather clause to cover the existing licensed practitioners in optometry. Rather, they will have to obtain an appropriate educational background to qualify for this important expansion in the scope of professional responsibility. The advancement of new technology, in exciting forms of instrumentation, provides yet another horizon for change. New technology, based upon sound scientific principles, is being introduced at a pace quite unlike anything the eye care field has seen in the recent generation—a generation that saw extraordinary technological progress. Much of the new technology is computer driven and semiautomated. However, no changes will be introduced to alter the scope of optometric responsibility without sound scientific and education based experience that is more than adequate to meet the professional and technical demands that the technology seeks to address. Again, the introduction of new technology that impinges upon an existing scope of professional responsibility will not be sought without the education and clinical training necessary to support the intent of the technology. The public health initiative in optometry began in the mid-1950s, with the establishment in the American Optometric Association of its Committee on Social and Health Care Trends. It was a catchall effort to direct attention to the structural and functional changes that were taking place on the American health care scene. The period of the 1950s and 1960s saw the evolution of the public health movement into a significant force in optometry. The study of public health in the curricula of the schools and colleges of optometry had its beginnings in the 1960s. Moreover, OD's were encouraged to enter serious graduate studies in public health and in public administration of health services and health policy. Today, more than 200 OD's hold MPH, MPA, and related degrees, and several hold advanced degrees at the doctoral level. Several other developments are worthy of note. OD's who were interested in public and community health became active participants in the public health associations locally, at the state level, and in the American Public Health Association. The twenty-fifth anniversary of the establishment of the Vision Care Section signals the enduring commitment of optometry as a public health profession. Worthy of note is that the American Academy of Optometry (AAO) established a Section on Public Health and Environmental Vision simultaneously with the founding of the Vision Care Section; moreover, the AAO developed a Diplomate Program, now 15 years old. The public health effort in optometry has been bolstered by the proliferation of scholarly and research reports primarily, though not exclusively, related to community health activities in optometry. No discussion about changes in optometry of major significance can be documented without recognition of the progressive development of institutional optometry, primarily in the Department of Veterans Affairs. The development of the optometrist as an integral part of hospital (or institutional) professional services has been most sophisticated in the VA medical centers. This likewise exists in the Indian Health Service and in the health services of the three branches of the military. Departments of optometry in hospital and group practice clinical environments have had remarkable growth and development since the 1990s. This growth coincides with the critically important expansion of the scope of professional responsibility. What has changed? In summary, optometry has changed in a dramatic metamorphosis. It is a profession rendering primary eye care. This metamorphosis, in which the profession is still engaged, along with major institutional and community associations, shows little sign of slowing. That optometry is now more centrally placed in the mainstream of health care services is evident in a host of daily circumstances and, indeed, by its work and by its institutional focus as a public health profession in the public service. Presented at the Section on Public Health, Seattle, Washington, December 10, 1999.