Article Date: 12/1/2003

Giving Tomorrow's O.D.s a Helping Hand
Externships can benefit both students and your practice. Here's how to make them work.
BY KIMBERLY REED, O.D., F.A.A.O., Fort Lauderdale, Fla.

As a member of the optometric education community for more than 13 years and as the externship director at Nova Southeastern University for nearly three years, I've seen a number of changes in the way we educate future optometrists. One of the more significant changes is the use of non-school-based clinical sites to round out students' clinical experiences.


Getting a better perspective

The main benefit of the college of optometry is that, through externships, students can participate in a variety of clinical settings and educational experiences not otherwise available at the school itself. While our clinics allow us a great deal of autonomy in the delivery of patient care, we're often limited in exposing our students to the more basic aspects of running a business. Decisions regarding billing procedures, practice management, marketing, whether or not to join a third-party plan and service hours are handled at a different level in most college-based clinics than they are in virtually every other type of optometric setting.

Also, many colleges of optometry don't offer all types of eye and vision care services onsite; externships help to fill this potential void, exposing the students to a more diverse variety of patient care, often in sub-specialty areas such as sports vision and vision therapy. These settings, along with the multidisciplinary and surgical care sites, allow students to explore various avenues of practice before applying for a residency program or initiating practice in a chosen area.

Maintain the quality

Having this expanded scope of educational experience isn't without a sacrifice, however. During school-based clinical rotations, student performance is generally monitored much more closely, allowing experienced optometric educators to accommodate individual student needs. This attribute is lost when students are at sites away from the college, in some instances thousands of miles away. So the burden falls on the college administration to ensure that the quality of education is comparable among the various externship sites. It accomplishes this in various ways, most commonly by evaluating the numbers and types of patients that the externs see, and through site evaluation during and after the extern's rotation.

Essential Information for Externs

If you're working with an extern, make sure she gets the following information.

  • Contact information for all pertinent personnel at the clinic
  • Hours of operation
  • Description of your patient base
  • A narrative of a typical day at the office
  • A copy of a blank chart and any other patient-related forms
  • Expectations of the student regarding dress code, behavior, clinical skills, etc.
  • Suggested reading and outside research
  • A list of any required equipment.

Look before you leap

So how would having a student as an extern affect your optometric practice? At first glance, it may seem like a dream come true -- here's a person who's compelled to come to your office every day, who's already been trained in refraction, binocular vision evaluation, entrance testing, ocular health evaluation, and diagnosis and management of visual and ocular disorders. You don't even have to pay her!

In most cases, an externship is a mutually beneficial experience. But occasionally an extern may appear at your doorstep who, for some reason, isn't the answer to your staffing needs after all. In this case, the following suggestions may help smooth the way:

Be fully informed as to your responsibilities as a site director. Will you have to attend meetings at the college? How much paperwork is involved? Is there a minimum number of hours each week, or patients each rotation, for which you must schedule the student? Does the college require that you have certain equipment onsite, such as teaching tubes (specialized equipment so that the student can directly observe the doctor's examination techniques) or a computer? Are you expected to provide didactic education to the student, such as journal reviews or slide quizzes? What will the college or the extern expect of any other physicians or paraprofessionals who deliver patient care at your site (copies of CVs, credentials, etc.)?

What are the college's expectations for the student's performance? How will the student be graded? How "good" is he supposed to be at various points during the year? What do you do if an extern calls in sick excessively or is chronically late? Most importantly, what do you do if an extern is ill prepared for patient care at your site?

Most colleges have behavioral objectives and goals to guide you as to the level of performance you should expect from the extern. Make sure you get a copy of those before agreeing to take on the responsibility of student education.


Look to Educate, Forget the Office Help


Richard A. Goodson, O.D., M.A., director of Externship Program at the Southern College of Optometry, cautions O.D.s that taking on an extern is work. SCO considers the onsite directors, or preceptors, as adjunct faculty members. If they do their jobs properly, there's a definite impact on their practices.

"If you're looking for additional help in your office, that's really not what our program is for," Dr. Goodson says. Preceptors are an important part of educating SCO students and their job "entails recognizing deficiencies in students and helping them improve. This will affect patient flow."

And while some optometrists view educating an extern as an opportunity to find a future partner, Dr. Goodson warns that this, too, is the wrong approach. The externship program, "is not a placement service. If that's why you're in the program, you're in it for the wrong reason."

He says that students shouldn't have a family or business relationship, or a potential business relationship, with their preceptors because it would inhibit the "cross fertilization of ideas." Students should bring fresh ideas and information to the practice, Dr. Goodson says, not simply be trained by a practice owner in how he wants to run his practice.

Dr. Goodson is an associate professor at SCO. Call him at (901) 722-3366 or e-mail

At what level is the student expected to "practice optometry"? While this may seem an insignificant question, it's perhaps the most frequent cause of discord between students and sites. Are students expected to see the patients "front to back," meaning performing the entire examination, including the drafting of an assessment and plan, and presenting the case to you when they have finished? The most frequent complaint I hear as externship director is, "They treat us like techs at that site." It's imperative that the students understand, before embarking on their various externships, that there is some give-and-take.

In other words, yes -- students will be putting in some time serving as staff support to the site, and in return, they're exposed to that site's unique attributes, whether they're surgical observations, rare specialty binocular vision cases, excellent practice management strategies, etc. It's the college's responsibility to make sure the students understand this concept.

You, as a potential site director, need to know the college's expectation of where it all balances out. Four and a half days of "work ups" and one half day of "following the doctor" isn't likely to make yours a popular site; on the other hand, schools don't expect you to reduce your patient load so you can show every student every interesting presentation of a particular condition.

Create a win-win situation

If after careful consideration you decide to take on an extern, then these tips will help you uphold your end of the relationship with the college:

► Stay in touch with the externship director. If the student assigned to your site isn't performing well, let the college know as soon as possible so that you can work together in developing a solution.

► Adhere to the established deadlines for submitting paperwork, especially grades (practices might not run on the academic calendar, but colleges live and breathe by it).

► Develop an externship manual, or similar orientation materials, to provide to potential externs before they arrive at your practice. See "Essential Information for Externs" on page 56 for a list of items to include.

► Talk to your externs frequently about their expectations and needs. One might welcome the opportunity to perform gonioscopy whenever possible while another might taken an interest in contact lens fitting.

► When a student arrives at your practice, she isn't "finished" yet. You'll likely notice some gaps in her skill set and knowledge base and it's your job to help fill in those gaps during your time with her. Similarly, externs assigned to your site at the beginning of their fourth year of optometry school probably aren't as efficient or as skilled as an extern who's assigned at the end of their last year. Plan accordingly and keep your schedule flexible to accommodate individual student abilities.

Think about it

With a little planning and a good understanding of your role, an extern might fit perfectly into your practice. Talk to colleagues who mentor externs and decide if it's a situation that's right for you. You may find that you have a lot more to offer than you ever thought.

Dr. Reed is an associate professor of optometry at the Nova Southeastern University College of Optometry. She has served as Director of Externships since 2001. Contact her at




Optometric Management, Issue: December 2003