What Is an Optometrist?

Just what is an optometrist? According to the American Heritage Dictionary, he or she is “a person who is professionally trained and licensed to examine the eyes for visual defects, diagnose problems or impairments, and prescribe corrective lenses or provide other types of treatment.” 1 Surely, this does not describe a 2004 American optometrist? A more appropriate definition would be more substantial and dynamic. The World Council of Optometry’s Concept of Optometry (WCO) 2 is as follows: Optometry is a health care profession that is autonomous, educated, and regulated (licensed/registered), and optometrists are primary health care practitioners of the eye and visual system who provide comprehensive eye and vision care, which includes refraction and dispensing, detection/diagnosis and management of disease in the eye, and the rehabilitation of conditions of the visual system. This is probably closer to a useful working statement, but it, too, includes some contentious issues. Can there be optometry without licensing and registration and what if a jurisdiction legislates that optometry is something quite different? An alternative way to view an optometrist is to look at a two dimensional array of an optometrist’s actual performance. The first dimension would be that which is the legal scope of practice in a particular jurisdiction, whereas the second would outline capability or competency in a task. Each individual competency has three parameters: its definition, its measurement, and its standard. This approach is now the basis of the model favored by regulating authorities to the extent that at a meeting of international regulatory bodies in conjunction with the U.S. Association of Regulatory Boards of Optometry (ARBO) and WCO (Dallas, December 2003) it was tentatively agreed to develop an internationally accepted set of optometric competencies based on the Australian Competency Document, 3 which has evolved since its original version in 1991. This document confines itself to the definitions of competency. Europe and Canada 4, 5 have also begun the process of definition and measurement of individual competencies. A possibly more important issue is the process by which standards are set, or to put it more colloquially: “Who examines the examiners?” It seems to us that a reasonable system already exists. On the one hand, registration boards are charged by their governments to protect the public by maintaining appropriate standards. On the other hand, many boards either alone (e.g., the General Optical Council in the United Kingdom) or in concert (e.g., the states of Australia and New Zealand, the states of the U.S.A., and the provinces of Canada) have already well established accreditation methods. Mutual recognition by these accrediting bodies or, better still, an international accrediting body would be a significant step toward standardization. By using the competency approach, regulating authorities will be able to determine the skills and knowledge of any internally or externally trained optometrist applying for registration in a justifiable and objective way. A further benefit is that educational institutions can be accredited against an accepted set of standards that is comparable around the globe. It should therefore be possible to define optometry in any jurisdiction as a subset of the full matrix of competencies. This should amount to a potentially greater ease of mobility for optometrists to move around the world, not only to practice but also to receive continuing education and to help developing nations in the pursuit of better eye care for their people. Ironically, an American optometrist would then be able to register and practice optometry in another country, such as Australia, which has just signed a free trade agreement with the U.S.A., far more easily than in another state of the U.S.A. Mutual recognition of registration as a concept already exists among the Canadian provinces, the states of Australia and New Zealand, and slowly but conditionally in Europe. One perception often used to counter this process is the protectionist argument. That is, a horde of optometrists will flood into a country, thereby reducing the standard of eye care and threatening the quality of life of the existing optometrists. Optometry legislation is rarely concerned with human power or quality of life issues. However, to a certain extent, the quality of care issue is politically legitimate because many laws enabling changes in scope of practice have been gained as the result of bitter legislative battles. Once additional privileges are gained in a jurisdiction, boards are required to ensure that entering optometrists have equivalent or similar credentials as those of the local optometric practitioners. The WCO has facilitated the development of competencies as an objective measure as a potential precursor to any governmental action within the General Agreement on Trade and Services initiative. The World Trade Organization is actively encouraging professions to establish international standards to facilitate the free flow of professionals throughout the world. Optometry now has the tools to participate in this movement if required. Optometry’s scope of practice differs dramatically between jurisdictions; indeed, there are many who would term the work of some practitioners more accurately as opticianry than optometry. Recently, Gavzey and Masnick, 6 through the Legislation and Regulation Committee of the WCO, set out to compile an international database of current optometric practice with the aid of an elementary questionnaire. 4 The survey results show a snapshot of optometry in 30 countries and are available on the WCO Web site. 7 A review of the country profiles shows that optometry has a wide footprint. There is recognizable practice on the five continents with most practitioners being at least 4-year, tertiary-educated professionals with access to diagnostic drugs, although only a minority have therapeutic prescribing rights. These include most parts of the U.S.A., Canada, Colombia, Nigeria, Tanzania, and three states of Australia. In contrast, Japan, a country highly regarded for its technological excellence, does not have optometry as a registered profession and diagnosis is not part of standard practice. Those who work within that area may only suggest a prescription for spectacles. It is solely the ophthalmologists who have what we would normally expect to be optometric prescribing rights. Russia appears to have a similar situation. In most areas outside North America, there is still a distinct emphasis on the dispensing of spectacles as an integral part of optometry. In various regions of Africa, for instance, where there may be only a single practitioner for many tens of thousands of people, the ability to construct or repair an appliance is a crucial service. Thus far, only two countries, Australia and Canada, have an optometric education system and profession that is substantially based on competencies. The trend in Europe, although slow, is to acknowledge the merits of these and begin to approach the profession from this perspective. Interestingly, optometry is appearing in many developing countries as a result of graduates returning from overseas studies and governments acknowledging the value of optometry as part of the WHO Vision 2020 initiative. Holden has eloquently stated optometry’s case in this historic and immense project: “Throughout the world optometry has been the major provider of vision correction, but usually from a private practice setting. Public health optometry has not reached the communities that are in most need in any organized way. Despite this, on their own initiative, thousands of private optometrists worldwide have regularly visited communities in need to provide vision care and dispense spectacles. The opportunity now is for optometry to develop a concerted effort to create local capacity in these communities, in collaboration with its partners in Vision 2020, through service delivery, by creating human resources and by helping to develop the infrastructure needed, the three cornerstones of the Vision 2020 programme.” 8 Optometry has emerged as a coherent and definable part of the total eye care system, and with the advent of the universally accepted competencies, the role in the community is clearly established. In countries where optometry seeks to be established, optometry itself can now start with an internationally accepted turnkey operation in exactly the same way as any other profession. So what is an optometrist? An optometrist is the logical primary care gatekeeper of world eye care, contributing a known but flexible set of defined professional skills and ethics in a most effective and cost-efficient way. These skills can be assessed objectively and fairly so that politics can be removed from registration boards’ aegis to those whose remit it is to debate and decide such issues. The freer and fairer movement of optometrists throughout the world will benefit most people who are without affordable or available eye care. As the principal provider of primary eye care, the optometrist is key to the well-being and visual development of the world’s children. Even the best educational programs in the world will falter without this most essential of senses.

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