The February 2018 cover story, “How the Diploma Deluge is Reshaping Optometry,” presented comments from educators and data from the Association of Schools and  Colleges in Optometry (ASCO) to look at the impact of optometry’s expanded educational footprint. The feature generated criticism, praise and suggestions, some of which is addressed in the following letters and our reply.

Behind the Drive

Kudos for your well researched and appreciated article. I believe one cannot have a “deluge” of graduates without producing a surplus of optometrists, and that this surplus was self-induced and is counterproductive to patient care. This surplus was first predicted in a 1995 Rand study and again by an Abt. Associates study in 2000.1,2 But both underestimated future surpluses because graduates have since increased about 40%.  

In 2011, the Lewin Group—with AOA-appointed advisors—was commissioned to survey how optometrists practiced and to estimate the future supply of, and demand for, eye care. Its 2012 survey found a 32% optometry surplus and its supply/demand model in 2014 predicted greater future optometry surpluses but increasing ophthalmology shortages.3 However, Lewin’s findings stated, “There would be an adequate supply of eye care providers in the future,” which was egregiously misleading. Lewin buried the optometry surplus within the surplus of “eye care providers” and characterized it as “an adequate supply of eye care providers.”

In 2014, Lewin next developed optometry and ophthalmology supply/demand projections and found future surpluses of optometrists and shortages of ophthalmologists. These initial projections assumed no surplus of optometrists existed in 2012 despite the findings of its own national survey of a 32% “excess capacity.”

The group then constructed a complex model that did include the 2012 optometry “excess capacity,” but increased future eye care demands due to the Affordable Care Act, the growing diabetes rate and child health insurance plans. In this “unified eye care market,” optometrists and ophthalmologists were assumed interchangeable. The final model’s assumptions claimed:   

  1. No increase in future ophthalmologists or their productivity.
  2. Optometry “excess capacities” will “fill” shortages of ophthalmologists.
  3. Optometrists and ophthalmologists have identical scopes of care and considered interchangeable generic “eye care providers.”
  4. A rate of 1.36 optometrists provide the care equivalent of one ophthalmologist.

These were, of course, implausible assumptions.

The chief impetus for the “diploma deluge” were Bureau of Labor Statistics reports claiming high demand for optometrists that led the media to report optometry was “hot.” But the primary source for those forecasts were rosy projections supplied by the AOA leadership and bitterly resisted, over the years, by some staff officers.

Today’s annual graduation rate of 1,900 will eventually produce a workforce of 76,000 practicing optometrists, a density of optometrists per 1,000 nearly twice today’s.

It has been too easy, for too long, for schools to meet Accreditation Council on Optometric Education (ACOE) accreditation standards, which are far less robust than medical and dental schools due to a lack of quantitative standards for required student contacts by types/numbers during training. 

—Kenneth J. Myers, PhD, OD

President, American Board of Certification in Medical

1. Lee P, Jackson C, Rolles D. RAND, Estimating eye care provider supply and workforce requirements. 1995.
2. White A, White C, Doksum T. Workforce study of optometrists. St. Louis, MO: Abt Associates Inc. American Optometric Association. 2000.
3. American Optometric Association/Lewin Group. Eye Care Workforce Study: Supply and Demand Projections. Executive Summary. April 25, 2014.


The Whole Truth

Your recent article identifies a subject worthy of discussion by the profession in looking to plan for the future. Unfortunately, the article appears to be something written more for a deadline than for a serious consideration of all the aspects. The effect of mandatory board passage for graduation and its effect on graduation rate was not even mentioned, nor was the recalibration of the Optometric Admission Test (OAT) during the years across which the author compares scores. While footnotes are used to imply some vigorous research, all the data is not given. For classes that matriculated in 2017, the University of the Incarnate Word Rosenberg School of Optometry had an entering class GPA that was higher than four of the six oldest institutions listed. 

The entire article must be viewed with suspicion as it shows the Arizona College of Optometry to have been established in 2017 and yet provides its pass rates on licensing examinations. Once you realize the magnitude of that error you begin to question everything else the article asserts.

—Timothy A. Wingert, OD

Dean, University of the
Incarnate Word
Rosenberg School of Optometry

Keeping Us Honest

We thank the above readers and others who reached out to comment on the article. Several readers pointed out that Midwestern University’s Arizona College of Optometry’s first class was in 2009, not 2017. We regret the error. The online version has been corrected.

Second, Table 3 of our article compared the OAT scores of matriculating students from 2008 with those from 2017. Some readers pointed out, correctly, that the scoring was modified in 2009. The test is graded on a scale of 200 to 400. In 2009, adjustments were made to reduce the average score—which had crept up to 320—to 300. According to Association of Schools and Colleges of Optometry President David Damari, OD, the changes included “changing the way raw scores (number of items answered correctly) were converted to the standard scores reported.” He went on to explain that, “As the test ages—so to speak—the average score goes up a little bit at a time, for various reasons, especially in reading comprehension.” 

Every year, administrators review the test to determine whether it’s still a predictive indicator for schools. Before the 2009 test, they decided it was not. However, the adjustment was “not really a change in the test, it’s a change in how many items the student needs to get correct in order to get to 300,” Dr. Damari explains. “It’s an adjustment, not a major rescaling.” There’s an ebb and flow to all testing, he suggests. Once a test starts to mature, average scores go up and that’s how administrators know it’s time to recalibrate the test. In fact, educators are looking again to adjust the scoring. Dr. Damari notes that “2008 was just before one calibration and 2017 is probably going to end up being right before another recalibration. If anything, that’s an incredibly fair comparison.” 

The article also makes use of recently released statistics from the National Board of Examiners in Optometry revealing the percentage of graduates who pass the boards. However, we did not discuss a caveat to those numbers; that some schools require students to pass part one or parts one and two of the boards (nobody requires passing part three) before it allows them to graduate. Although it does impact what that ultimate board pass rate is, this really raises a philosophical question. If optometry schools exist to educate future optometrists, should they do all they can to ensure their students success—and does “doing all they can” include guaranteeing they can pass the boards? 

Look at Southern College of Optometry (SCO), which started requiring the national boards in 1990, according to Lisa Wade, OD, director at SCO’s Hayes Center for Practice Excellence. It suffered from low pass rates before that and its reputation was negatively impacted. When the school started requiring board passage, that changed drastically; in fact, it influenced other schools in the South to embrace requiring board passage. A rising tide lifts all boats.

Others wonder whether requiring students to pass a test that the institution itself does not compose itself amounts to a violation of the institution’s autonomy. After all, the school issues a degree, not a license.

As our story noted, the numbers don’t tell all. Optometry schools’ standards clearly exist on a spectrum and, although they can be measured in a variety of ways, they can never really be ranked. There will always be some incongruity or unique circumstance. Although we can quantify performance and use data to predict success, we cannot quantify human beings and, ultimately, that’s what optometric education must focus on: training actual human beings from a variety of backgrounds, to become skilled, dedicated, passionate doctors. 

If it’s to thrive, optometric education must serve two masters, one from the idealistic world of academia and one from the sober, hard-nosed world of capitalism. And while doing that may require schools to compromise from time to time, the educational system’s influence over the future of optometry is not absolute. The real future is in the hands of the students themselves, who—we hope our article demonstrated—strive to grow the profession while preserving the legacy of their predecessors. 

—Bill Kekevian

Senior Editor,
Review of Optometry