This article is best viewed in a PDF Format.
|
|
After decades of stagnation and apparent impasse, more Italian legislation to control the practice of optometry and to re-define the roles of the eye care professions is at last imminent. The new rulings have been anticipated by the profession since earlier legislation from 1928.
It is often said that 'politics is power' and perhaps this is nowhere more apparent than in the Mediterranean European member countries. In a recent meeting in Rome, Professor Luigi Lupelli drew this analogy in relation to optometry. For decades efforts to enhance the profession with new legislation have been slow. There is now a need to re-define the roles of the traditional ottici (equivalent originally to the British dispensing optician), including clear understanding of the optometrist's role, now that university courses for both activities are a reality. The public needs clarification to avoid confusion. However, the situation is very different from that in the UK, both in the training and practice of opticians and optometrists.
Typically from the age of 15 to 19 optician students are trained to carry out the typical British dispensing roles to become ottici opticians. They also learn to refract, although their scope by law is limited in this area since they cannot correct astigmatism or hyperopia. They can then undergo an optional course in optometry, which, depending on the training establishment can be of two, three or four years' duration. Thus optometry has traditionally developed within optical schools in Italy.
Stalling in this process over past decades has largely been the result of effective opposition by the ophthalmological lobby. This is why many leading Italian optometric educators have welcomed alliances with university physics departments. Throughout Europe, pure science courses have suffered from a fall in popularity accordingly, physics departments are well disposed towards embracing optometry. Of course, this route was known when optometry developed within some British universities in the 1960s. Such sub-departments enjoyed considerable academic freedom as student numbers increased and teaching improved. Higher degrees and original research led to the development of departments in their own right. In recent years there has been a trend to move departments to within schools of health sciences or medical sciences in the UK and this may well be a pattern that emerges in Italy. Allied health professions in physiotherapy, osteopathy and radiography, with courses for medical and dental technicians in Italy are currently moving to degree courses within universities.
European integration
One aim of European integration has been the ratification of standards of professional training, regulation and practice as far as possible, thus permitting greater movement between states. This has taken time. Efforts by the IOOL and World Council of Optometry highlighted the need for a common standard throughout European optometry, but in practice this would take several generations. Development of degrees in optometry in many European countries has followed the earlier British model, which itself followed North American trends.
The GOC currently requires Italian trained optometrists to complete some courses in British universities and to show evidence of success in selected examinations. For those with suitable experience, the pre-registration year is waived. It is not surprising that such requirements have meant that only a few have been prepared to move from Italy to the UK. In the light of upgraded courses throughout Italy, Britain may very soon need to reassess requirements.
The Italian model
Regulation of the supply and fitting of visual aids in Italy dates back to the 1928 Act. Opticians can freely fit and prescribe contact lenses as well as carry out subjective and objective refraction, although the law states that there should be an agreement with an ophthalmologist in practice, this requirement is overlooked. Of the 12,000 opticians in Italy today, almost all operate within family practices outside the state medical health service. They set their own charges for eye examinations and the supply of appliances to correct vision. Approximately 2,000 additional ottici would describe themselves as optometrists. Many of these largely concentrate on refraction and eye examination, leaving a colleague to act as the ottico within the same practice. Nevertheless, the boundaries are blurred, the roles of the two professions being poorly defined.
In 1952, courses for ottici began in Rome at the 'Istituto Superiore di Stato E De Amicis', a state technical college. Courses in optometry for the successful ottica started in 1975 at the existing optical schools in Milan, Vinci (near Florence) and in Rome in 1980 but each with a very different structure and duration. For example, in Vinci a two-year course operated for 30 years, while in Milan there was a three-year course. In Rome a course began as three years and developed into four years of additional training in optometry. The establishment of these courses was quite an enlightened development at that time because only the work of an optician is regulated by law.
Upgrading training
In the 1970s, educators in Italy saw the need for further training in subjects to embrace optometry since some enlightened ottici had, in effect, become optometrists through self-improvement, having recognised that the UK model was worthy of imitation. Private tertiary education has traditionally flourished in Italy in technical colleges or institutes. Thus at that time state and private provision for training ottici and ottici-optometristi co-existed harmoniously. Nevertheless, medical profession opposition sought to limit the scope for further development of optometry as a profession in its own right. While this had also been the case in the UK in the early 20th century in Italy the pressure was more intense.
Traditionally, the Italian system allowed much freer access to university courses than in the UK. When British optometry degrees were established in the 1960s only 2 per cent of 18-year-old students gained admittance to university, and academic competition determined entry. This rose to 5 per cent in the 1970s and now the figure is closer to 30 per cent. Italy has made few limits on entry and hardly governed the amount of attendance for many non-practical classes it has trained more medical doctors than nurses over the last few decades. This tradition has inevitably provided an unusual degree of power to the ophthalmological lobby in Italy, which attempted to thwart progress for optometry as an emerging profession. The politics of power has had a considerable influence through the years.
British involvement
Subjective and objective refractive procedures continued to be taught to ottici in state and private institutions. Many of these specialised in contact lenses and there is no doubt that in many cases the level of professional practice was good. Students and practitioners motivated to read English language optometry textbooks and/or to attend international conferences in optometry naturally gained new knowledge to enhance their professional activities. Many European educators in optometry realised that British and North American modes of training might eventually be copied in their own countries. Spain, France, Scandinavia and Italy then worked towards this goal. Perhaps progress was slower in Italy.
In the late 1970s a private technical institute based in Perugia in Umbria, with a large branch in Rome, believed that it would benefit from co-operation with a British university concerning training Italian optometrists.
With considerable foresight the director, Professor Francesco Fornari, approached Professor Robert Fletcher, the first Professor of Optometry in the UK, at City University, London. With the co-operation of colleagues, such as Gerald Dunn and Arthur Bennett, plans were developed for a block release mode of instruction this would appeal to ottici in practice wishing to upgrade their clinical skills, enhancing their knowledge of ocular anatomy and visual optics. The programme was designed and directed by Professor Fletcher who supervised examinations at the end of each year.
Professor Fornari hoped that a British university might grant a certificate of qualification for the Rome-based course. This proved difficult at the time although now attitudes have altered, allowing more flexible accreditation for courses based abroad.
At the time, there was little realisation of the extent of the impact these courses could have on developments in Italy. Some 45 students undertook the Rome course, enthusiastically making great efforts to attend regularly many travelled considerable distances from Sardinia, Sicily and the far south of Italy, leaving their practices for the intensive periods of study in the capital. Some were mature students who recognised the opportunity and had the vision to enhance their profession, being highly motivated. Some went further to qualify as ophthalmologists others became highly competent optometrists and contact lens specialists, as well as being prominent educators particularly in the continuing education field, which as in the UK is compulsory. Professor Lupelli was one such, showing during the original units of the course his exceptional clinical understanding and vision for the future of the profession. He later joined the teaching group, in addition to his work in the state course for ottica education. He later played a major role in founding the Italian Optometric Association and Contact Lens Association. His original research in varied aspects of contact lenses and partial sight aids has been used in many journals and lectures to professional groups in Italy and abroad. He has also co-authored major textbooks with British optometric collaborators and has developed considerable co-operation with Italian ophthalmologists. In particular, he has worked with a leading ophthalmologist on keratoprosthesis implants with an optical component.
Italian degree courses
Leading optometric educators working through the Italian Optometric Association for some years have aimed towards establishing university degree courses in optometry. The considerable historical friction between ophthalmology and optometry in Italy has been caused partly because most ophthalmologists there work virtually as full-time optometrists only about a third work in hospitals in a surgical capacity.
To the British mind this may seem to be wasteful, but it must be seen in the context of an over-production of medical doctors in Italy, compared to the needs of the population and the fact that any person with an inclination can enrol on a medical course in Italy with no prior selection.
Accordingly, it has been natural to incorporate the new optometry degree courses within university departments of physics. In 2002, the first programme began in Milan. Two years later the University of Padua, also in the north of the country, started a course with the assistance of a Canadian-trained Italian optometrist. Courses followed at the University of Lecce in the south and at Molise University in Isernia, in 2005. It was in 2006 that the final three courses were established at the major universities of Rome, Florence and Turin. In each case around 30 students are enrolled each year, apart from 10 being enrolled at Isernia and 70 at Rome, which is still the largest. The need for regional training follows the tradition for Italian students to study in or near their home town and to reside with their families. Thus there is no rivalry between courses and while the bulk of the syllabus has been modelled on the original Milan course, there are small individual variations. At Isernia, for example, the courses in contact lenses are taught by an ophthalmologist but elsewhere by optometrists. Each course, of three years' duration, confers the title Dottore in ottica e optometria in a similar way to the North American OD degrees. Nevertheless, the degrees awarded by the universities do not in themselves confer the right to practise as an optometrist.
About a third of students are women. Over 70 per cent have a family background in the profession and up to a quarter are mature students already in practice who are keen to upgrade their qualifications. With no pressure to complete the course in any rigid time frame (the norm in all Italian higher education) and with the right to retake failed examinations almost indefinitely, this arrangement works well for the mature students combining study with their normal professional work.
There are no interviews before admission as Italian law permits any student to register for any higher education course. There is an admission exam. Last year there were 150 applicants for 70 places. Such features are, of course, very different from the British system where entry to degree courses is by academic competition and opportunity to re-take failed examinations is strictly limited. In the UK, optometry students in training cannot work in any professional capacity until registered with the GOC, although dispensing opticians undertaking optometry degrees typically work in vacations and at weekends as dispensers.
The university departments are able to provide biologists, chemists and psychologists from their own staff to teach general and ocular anatomy, mathematics and optics, staffing has yet to be resolved. So is the integration, closure and identity of the original courses for ottici in 20 state institutes throughout Italy. Until agreement has been reached on the expected new professional profile for eye care practitioners in Italy, following discussion at the Ministry of Health, the separate courses in dispensing for ottici and optometristi at universities will co-exist. If the outcome of discussions to regulate the professions leans towards one professional mode (the ottico-optometrista) it is likely that non-degree courses at the institutes will cease and universities alone will train the professionals. There are evident similarities with the manner in which the professional education of optometrists has changed in Norway but also a marked difference with the British model. In the UK dispensing opticians are mostly educated independently of optometrists.
Professor Giovanni Stefani, Professor of Physics at Rome Tre University, in whose department optometry courses are now established, makes it clear that eventually higher degree programmes in optometry are to run alongside current PhD degree programmes in physics.
It is clear that optometric practice can only be taught by optometrists in the university. Ophthalmologists are to be involved for teaching abnormal conditions, as they now do in the institutes. Access to patients for practical experience remains a grey area in professional training as far as responsibility is concerned. Current students are permitted to practise on each other, their relatives and staff. Greater links with medical departments in universities might extend the scope for more access to a larger and more diverse pool of patients.
? Dr Janet Voke is