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PRACTICE STRATEGIESPRACTICE STRATEGIES

Selecting a mode of practice: Veterans Health Administration Gay Tokumaru, O.D., Brian Kawasaki, O.D., and Scott Slagle, O.D.

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art IV of seriesThe Practice Strategies “Selecting a mode of practice”eries is intended to help new practitioners become familiarith the various modes of practice from which today’sptometrists can choose. Past articles have looked at pri-ate practice, the Public Health Service Commissionedorps, and Community Health Centers. Future articles will

over multidisciplinary clinics and other practice options.)The Veterans Health Administration (VHA), a part of the.S. Department of Veterans Affairs (VA), offers optome-

rists the opportunity to provide eye and vision care for theation’s veterans as part of a comprehensive health careystem that has consistently been the leader in the develop-ent of the multidisciplinary approach to care. The largest

ntegrated health care provider in the United States, theHA, employs more than 200,000 people with an annual

are budget exceeding $20 billion. The VHA treats nearly50,000 patients on an in-patient basis and provides morehan 40 million outpatient visits at more than 600 healthare facilities throughout the country. The VHA Optometryervice, established in 1976, provides eye and vision care inirtually all of them. Over the last 30 years, the VHAptometry Service has become the provider of the majorityf primary eye care and low vision rehabilitation servicesor the nation’s veterans. VHA eye and vision care clinics

ay Tokumaru, O.D., is the President of the National Association of VAptometrists (NAVAO). Brian Kawasaki, O.D., is the Vice President ofAVAO. Scott Slagle, O.D., is a member of NAVAO. Opinions expressed

ong a leader in comanaged eye carend low vision rehabilitation services,he Veterans Health Administration of-ers practitioners the opportunity toractice the full scope of today’s optom-try in a technologically advanced, mul-idisciplinary environment, with oppor-unities for professional advancement,ducation, and clinical research.

ore those of the authors and not necessarily those of the Americanptometric Association.

529-1839/07/$ -see front matter © 2007 American Optometric Association. Alloi:10.1016/j.optm.2006.11.007

enerally have the latest in state-of-the-art ophthalmicquipment.A fair number of optometrists enter their careers already

aving had at least some experience in the VHA healthystem. The VA’s high-quality optometry education pro-rams are affiliated with the Accreditation Council onptometric Education’s (ACOE) accredited schools and

olleges of optometry (see Figure 1). Every year, more than00 future optometrists, primarily those in their senior yearsf the 4-year, post-baccalaureate optometry professionalducation program, rotate to VHA medical facilities forlinical education and training. About two thirds of the,200 to 1,300 who graduate from the 17 ACOE-accreditedchools and colleges of optometry in the United States eachear have performed public health care services at VHAedical facilities.In addition, more than 110 optometry residency positions

re available each year for the development of advancedlinical competence. Three optometric research fellowshiprograms are available to train the next generation of eyend vision care researchers. All of these VA postgraduateear (PGY1) optometry residency programs are ACOEccredited and affiliated with schools and colleges of op-ometry.

Because a notable percentage of the VA’s older adultatient base is significantly visually impaired or legallylind, the VA has become one of the largest providers ofow vision rehabilitation services in the nation. Lowision rehabilitation services are provided through theA’s in-patient Blind Rehabilitation Centers, outpatient

ow vision rehabilitation clinics and innovative Visualmpairment Center to Optimize Remaining Sight (VIC-ORS) program.The VHA has long been a leader in comanaged eye care.hrough the Medical/Surgical Strategic Healthcare Group

SHG) in Patient Care Services at the VA Central Office, theisciplines of optometry and ophthalmology work togethers equal partners to provide the full spectrum of primary,econdary, and tertiary eye care services. The VHA believeshat by utilizing the complementary strengths of both eyeare professions, the nation’s veterans have greatly bene-ted. Breakthrough VHA clinical practice guidelines, suchs the VHA Clinical Guideline on Management of Diabetesellitus and the VHA Clinical Practice Guideline on

creening for Glaucoma in the Primary Care Setting, have

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utlined effective programs for the utilization of the com-

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Practice Strategies 35

lementary strengths of the 2 eye care professions in anffort to reduce preventable vision loss. The VHA plans toontinue to develop similar innovative strategies to improvehe delivery of high-quality eye care services and clinicalutcomes in the future.By virtue of the diverse veteran population, VHA optom-

trists have the opportunity to manage patients who presentith a wide variety of ocular pathologies and visual condi-

ions. Optometrists truly function as primary eye care pro-iders in the VHA health care system. In the course of aay, optometrists may perform routine eye examinations foratients requiring spectacles, evaluate patients with diabetesor diabetic retinopathy, and diagnose and manage a wholeost of ocular pathologies, including glaucoma, macularegeneration, vascular occlusive diseases, inflammatoryiseases such as uveitis, and corneal pathologies. In addi-ion, they are consulted by other health care providers tovaluate patients for emergencies such as red eyes, trauma,orneal foreign bodies, and sudden loss of vision, as well asor ocular manifestations of systemic diseases such as hu-an immunodeficiency virus, multiple sclerosis, and sar-

oidosis.VHA optometrists can provide full-scope care (seeigure 2). They consult with other health care providers.hey can order radiologic studies such as computed

omography imaging or magnetic resonance imaging,aboratory tests, and carotid Doppler studies. They have

igure 1 Optometry students, taking part in the VHA internshiprogram, review clinical cases. Education is emphasized in the VHA system.

igure 2 Providing a full scope of optometric care, VHA optometrist

urgical procedures, and record retinal images for use in long-term eye disease m

he authority to perform injections, remove foreign bod-es, and prescribe a wide range of topical and therapeuticgents. In addition, VHA optometrists may also providepecialty contact lens fittings (e.g., keratoconus, apha-ia), as well as perform fluorescein angiograms andcular photography. In some VHA settings, the primarymphasis is on providing rehabilitative services for theisually impaired or for those who have suffered araumatic or vascular brain injury.

Most VHA optometrists are also highly involved in clin-cal education and devote a significant amount of time in thelinic to the clinical supervision of both optometry residentsnd students. In addition, they may be involved in theidactic or clinical education of other health care providersuch as medical students, medical residents, nurses, andhysicians. Of the more than 400 clinically privileged op-ometrists in the VHA, about 60% have optometric facultyppointments and are involved in the clinical training andducation of optometric residents and students. Approxi-ately 10% of VHA optometrists have a faculty appoint-ent at a school or college of medicine. VHA optometrists

lso have the opportunity to network and collaborate withn array of health care professionals as well as with some ofhe most prominent and experienced optometrists in theountry. The VHA has perhaps the highest percentage ofesidency-trained optometrists in the nation. This allowsHA optometrists to continually expand their clinicalnowledge and grow professionally.Many VHA optometrists actively participate in basic

esearch, multicenter clinical trials, and low vision rehabil-tation research. Research grants for VHA optometrists areommonly funded by the VHA Research Service, the Na-ional Eye Institute of the National Institutes of Health, andrivate sources. The VHA research program has consis-ently been a source of major studies on a wide array of eyend vision conditions and has made major contributions toelds such as ocular disease prevention and low visionehabilitation.

dvantages of VHA practiceractice in a VHA health facility can offer a number ofdvantages for an optometrist (see Box 1). VHA optome-rists have the opportunity to independently diagnose, man-ge, and treat a wide variety of ocular and visual patholo-

left, check the anterior segment and posterior segment, perform minor

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36 Practice Strategies

ies. They practice in a multidisciplinary setting with accesso imaging/radiologic and laboratory services and interactith other health care and medical subspecialties. Theyave the opportunity to provide highly specialized, sophis-icated, and multidisciplinary low vision care in theICTORS programs. They practice in one of the most

ntegrated, technologically advanced health care systems inhe world, with an innovative electronic medical recordsystem that provides immediate access to such informations laboratory and imaging results. They have the opportu-ity to network and collaborate with some of the world’sest optometrists.VHA optometrists practice in an environment that is

onducive to strengthening and expanding clinical skills andnowledge. They have the opportunity to perform clinicalesearch, especially in more specialized areas such as lowision or teleretinal imaging. Educational opportunities arevailable through specialized programs for qualified staffnd students, including tuition support for job-related andontinuing education courses, VHA national and regionalducational programs, and paid time off for approved con-inuing education programs. VHA optometrists often haveccess to educational programs that provide more involve-ent with the education of optometry, medicine, and nurs-

ng students as well as optometry, medicine, and ophthal-ology residents.VHA practice comes with a government benefits package

hat includes 26 vacation days per year with rollover ability,eparate allotment of sick days, government holidays, lifend health insurance, and retirement benefits. Professionaliability protection is provided. VHA practitioners haveewer distractions from clinical care because of the relativendependence from eye and vision insurance plans.

Mobility is commonly cited as an advantage of VHAractice as well. VHA health care facilities are located in all0 states, the District of Columbia, Puerto Rico, and thehilippines. An employee may seek employment at any

ocation where there is a vacancy and, if hired, transferithout loss of benefits and usually no loss in pay. Perhaps

he greatest benefit of VHA practice is the pride practitio-

Box 1

Advantages of VHA practice● Independent diagnosis, management, and treatment

multidisciplinary setting● Opportunity for specialized, sophisticated low vision● Educational programs● Opportunity to network and collaborate with some of

trists● Government benefits package● Opportunity to perform clinical research● Minimal claim filing functions● Practice in highly integrated and technologically adva

ers take in their mission: caring for the nation’s veterans.

isadvantages of VHA practiceypically, VHA facilities offer little to no opportunity forediatric practice or cosmetic contact lens fittings be-ause these services are typically not provided at VHAye Clinics (see Box 2). VHA optometrists have lessutonomy in scheduling and selecting support staff thanrivate practitioners and may have less flexible scheduleshan private practitioners. In addition, the availability ofupport staff and equipment is dependent on budgetllotments at the local and federal levels, and the clinicorkload can be substantial. Base salary levels may oray not be comparable with those in other modes of

ractice depending on the location of the facility and theualifications of the practitioner. However, the federalovernment offers a very competitive benefits package,nd VHA optometrists may also have the opportunity toeceive both monetary and honorary recognition forverall superior performance and special or uniquechievements. In addition, monetary awards may bearned through participation in VHA’s Employee Sug-estion Program when employees offer creative solutionso problems or ideas for improving procedures and ser-ices.

wide variety of ocular and visual pathologies in a

orld’s most accomplished and well-recognized optome-

health care system

Box 2

Disadvantages of VHApractice● Little pediatric practice● Limited cosmetic contact lens fitting● Less flexibility in practitioner schedule● Less autonomy in staff scheduling and selection of

staff● Budget-dependent availability of support staff and

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Practice Strategies 37

hen considering VHA practicehe ranks of the VHA include some of the world’s mostccomplished and well-recognized optometrists. Standards forhose who wish to join the VA Optometry Service are high.pplicants must pass a board review, and preference is given

o residency-trained optometrists for VHA staff positions. TheHA optometrist must feel comfortable managing a wideariety of ocular and visual pathologic conditions. Moreover,HA optometry takes its commitment to the advancement of

linical care seriously. Although the VHA offers many oppor-unities for professional advancement, that advancement isependent on a variety of professional activities in addition tolinical duties, such as participation in professional organiza-ions, research, presentations, publications, and education.

However, for the new optometrist who truly wishes to

ractice the full scope of today’s optometry in a technolog- r

cally advanced, multidisciplinary environment, the VHAan offer opportunities that are hard to beat. And the prideA practitioners take in caring for the nation’s veterans

annot be overstated.To gain a firsthand view of VHA health care, interested

ndividuals are encouraged to arrange to visit VA facil-ties in their area by calling or writing for an appoint-ent. Telephone numbers are listed in local directories

nder “U.S. Government.” Correspondence may also beirected to the Human Resources Management Service.ecause starting salaries for primary care providers andssociated health professionals are based on educationnd experience and can vary by location, applicantshould directly contact the facility at which they wouldike to work for specific information about salaries cur-

ently being offered.