When I landed in a doctorate program in developmental optometry, after some years working in public education and tech, I was surprised at what I had found – pleasantly so. Having studied neural science, neuropsychology, and education, my mind and thinking had evolved around constructs of wiring on the one hand (as though the brain was simply a massive network of fixed contacts and connections), and how to design effective learning models, on the other. While I could explain vision in some detail at a cellular level, it was really only important to me in that it was simply one part of a larger neurological infrastructure to learning, and while ‘seeing’ was obviously important, it amounted to just another means of acquiring information.
My mentors at Pacific University College of Optometry, and many more from beyond, have been instrumental in reshaping my thinking on vision. I now understand that there was a large piece of the puzzle missing in my conception of what is arguably our primary sensory system. Vision is pervasive and touches most of our brain systems, but it is also multi-faceted and dynamic: More than ‘seeing’, vision is the active process of ‘looking’ to confirm our own expectations. The fundamentals of visual function and how this ‘active looking’ occurs allows developmental optometrists to address vision-related behaviour concerns in a manner that answers needs no other profession can even begin to touch. Based on my initial and pre-study exposure to optometry, a world of pink eyes and basic refractions, I would never have thought that the profession would have anything to say about brain injury and learning disability, for example, let alone offer anything to help.
For those who study vision science, there is little doubt that the field is deep and broad. One colleague, an MD/PhD in ophthalmology, has spent his professional life of nearly 50 years studying the intricacies of the evolution of myopia. Another colleague holds a PhD in human physiology and is particularly interested in degenerative retinal disease. Each of these researchers is well-versed in the details of neurology and retinal physiology, but their individual work is far removed from the other. This is one example where specialized interests advance the entire field.
Indeed, when we think of different professions, we are accustomed to the notion of ‘specialised interests’. Medicine is well-known for its many areas of specialty practice, and people are familiar with ‘going to a specialist’ for varied concerns: We would not want a proctologist to work on our eyes for example, and even within ophthalmology, there are numerous areas of specialisation. We see this in law, in accounting, even in auto mechanics: People generally recognize that there are some practitioners who are better than others at dealing with certain circumstances and situations, and that this is by virtue of what they study, where their interests lie, and what they do clinically.
When I was an educator, we had numerous specialties to manage the many varied student needs – my own area of expertise was in science instruction, and integration of learning technologies, which were only just emerging at the time. When I work in tech, as in software development, I am glad to pull from the countless specialties and ‘experts’ in their fields. This sort of expertise is a natural outgrowth of a profession where the extent of knowledge and skills are too broad for any one individual to master. These professions recognize that you can be a generalist, that is, a jack of all trades, or a true specialist where interest, research, and practice leads to a more profound understanding and skill set which then provide critical benefits to clients who need that sort of expert help.
This natural growth into sub-specialties also adds credibility to profession in that that group of professionals recognises the need for specialisation, and supports this through referrals. Outside of the profession, the public perception is that there is a difference between doctors, in the case of medicine for example, and that these differences matter.
Why, then, is it that Canadian optometry is so reluctant to encourage, let alone recognise, internal specialties? There is need to specialise in optometry in order to answer patient needs: From pediatrics, strabismus, amblyopia, and learning and development, to contact lens practice, ocular surface disease, performance enhancement, and low vision. Still, as I’ve been told by a regional appointee to national discussions taking place this weekend, while Alberta is in favour of recognition of specialties, the general feeling is that the division of optometric practice in this way is undesirable and will be resisted strongly at a national level. This is an interesting situation in that there is no national licensing body, but that the Provinces are reluctant to proceed independently even though Provincial Colleges have the freedom and mandate to recognise such specialties. This is an unfortunate situation that damages the profession, lowering its credibility, but it also harms patients who would otherwise benefit from a robust program of internal referrals.
What does the reluctance to recognise specialisation in optometry say about the profession? For one, given the lack of internal optometric referrals for those issues listed above in the last paragraph, those clients are more likely to receive no care, or inadequate care in the hands of other fields such as occupational therapy, general practitioner optometrists, or through medicine. So, by our own doing, we defer to another profession in an admission that ‘our profession cannot help that’, and that we need ‘real’ doctors to handle more complex situations. It also speaks to the great lack of communication from our professional associations to members regarding even the mere fact that optometric specialties exist. Next, not recognising specialisation belies a narrow understanding of the potential of our own profession, and implies that ‘everything that can be known is known’ by all general optometric practitioners; this is in part due to the limited scope of instruction in Canadian colleges of optometry, which are more heavily influenced by medicine than by classical or behaviour optometric principles. We can also surmise that the politics of a loosely defined national ‘family’ of optometrists trumps professional advancement and evolution. It is more important, in other words, to keep then peace and maintain lower standards rather than to edge forward. Not that there is a low standard assumed in general practice, but that disallowing specialisation suggests there is no need to do so. Finally, optometrists are discouraged from conducting clinical research or writing – not actively by decree, but implicitly by the sheer futility of it: Why pursue specialised work in a vacuum?
Many optometrists will have heard the comment ‘optometrists aren’t real doctors’ – and while I have many respected colleagues whom I count as some of the best doctors I know, period, part of being a ‘real’ doctor is in strong advocacy for public health and advancement of the profession. The lack of support for professional specialisation means that there will be no growth in the profession, or only marginal growth, for the foreseeable future. The growth we will see will be in incremental expansion of medical scope, and this under the watchful eye of another profession, that of medicine.
Optometric associations, both provincial and national, are mandated to promote the profession and to help it grow, but it appears there is more affinity to become junior ophthalmologists by incremental expansion of medical scope, rather than to grow as a unique, diverse, and meaningful community of doctors of optometry through internal specialisation. In the end, it is the patient that suffers the most, with the profession coming in a close second for overall damage. If we cannot support specialisation within the profession, there is no chance that others will follow. Even as patients now benefit from the specialised care provided by developmental OD’s, for example, there is virtually no public funding for this care, and many go without as a consequence. This is not what a real doctor would advocate for.