Optometry within the Indian Health Service (IHS) can provide an exciting and rewarding career for new grad ODs and seasoned optometrists alike. As of 2017, there are 567 federally recognized American Indian and Alaska native tribes, a population of close to 3 million people. Many of these people currently live on Indian reservations, with the largest being the 16 million-acre Navajo Nation spanning through Arizona, New Mexico, and Utah.
Reservations are federally recognized lands also known as missions, rancherias, villages, and pueblos, depending on location. Some reservations are remnants of original tribal homelands, while others are the result of tribal relocation.
Many reservations have nearby IHS affiliated clinics, health centers, and/or hospitals. As an optometry student on the east coast, we rarely heard anything about what practice was like in IHS settings. It wasn’t until I was applying for my 4th year rotations that I became aware of this avenue.
When it comes to learning about ocular disease management from a student’s perspective, VA hospitals are typically seen as the Holy Grail of clinical settings. Without question, the VA healthcare system is an amazing place to see and learn a lot about ocular and systemic pathology. The Indian Health Service, however, is an often overlooked avenue for students, residents, and optometrists also seeking to practice within the medical model of our profession.
Co-management in the IHS
Unfortunately, the prevalence of most ocular and systemic disease is significantly greater among American Indian and Alaska native populations. The prevalence of type 2 diabetes is twice as high when compared to the non-Hispanic white population, with an increasing impact on children and adolescents. In some native communities, up to one-third of the population is diabetic.1-3 Due to the growing epidemic of metabolic disease, it is not unusual to see walk-in patients for neovascular glaucoma, proliferative retinopathy, vasculopathic cranial nerve palsy and tractional retinal detachment. As ODs on the frontline, we’re constantly in contact with primary care doctors in regards to ocular findings of systemic disease, advising on additional testing, neuroimaging, or lab work. This is especially true in hospital-based settings like IHS.
Autoimmune and rheumatic diseases are also significantly more prevalent and severe among these patients, with onset of disease occurring at younger ages.4-5 A 2017 systematic review of rheumatic disease among natives showed prevalence of RA exceeding 5% among some populations (over 10 times higher than U.S. average).6 Rates of systemic lupus erythematosus (SLE) are also significantly higher, and in some areas double that of the non-Hispanic white population.6,7 Many of these patients are treated with plaquenil and other immunosuppressive medications, and will be followed by optometry to rule out ocular toxicity. Due to higher prevalence of patients with HLA-B27 positive serotype, IHS optometrists frequently see walk-in cases of severe inflammatory eye disease, including anterior and posterior uveitis.
The IHS setting: a day in the life
Given that IHS optometrists see patients of all ages, male and female, clinic days can be quite exciting and diverse. One moment you’re seeing an amblyope with 7.50 diopters of cylinder, and the next you’re doing scleral depression, dilation/irrigation, removing a metallic foreign body, or even fitting a custom RGP lens for a keratoconic patient.
Many IHS optometry clinics share an after-hours call schedule between the resident and other ODs, which helps triage ocular urgencies and emergencies presenting to the ER. In these rural settings, it’s also not unusual to see walk-ins for corneal foreign bodies and abrasions, or ocular blunt trauma. Depending on the IHS location, there could potentially be only 1 or 2 ophthalmologists within a 150 mile radius.
Given the scarcity of OMDs and logistical burden for patient transportation, optometrists see and manage many conditions that would otherwise be referred in many urban settings. I remember feeling immense satisfaction as a resident when I reflected on the multitude of different cases I’d see in just one day. Optometry students and residents in IHS settings are also involved in community outreach activities, such as school vision screenings or mobile diabetic retinal exams within surrounding communities. The experience gained while working with the IHS is a great way for optometrists to build clinical confidence while opening doors to a multitude of professional opportunities.
Compensation and finances for your IHS optometry residency
When it comes to pursuing optometric residency, some final-year OD students are unable to make that additional training-year work financially. The reduced salary compensation for most residency programs is a significant barrier for the new grad OD. Fortunately, most IHS residency programs are competitive with compensation, offering upwards of twice the typical salary of other programs. The increased compensation empowers IHS residents to get a jumpstart on paying down student loans while also maintaining an excellent standard-of-living.
Residents are able to network with other IHS residents/doctors at quarterly journal club meetings, which usually turn into weekend outdoor adventures. Many national parks are within driving distance of most IHS hospitals. Many IHS residents will also have various public speaking opportunities, including their residency case report at the biennial IHS eye care meeting in Fullerton, CA or Durango, CO.
Depending on your personal and professional goals as an OD, working with the Indian Health Service can provide a challenging and rewarding career. Clinical learning curves happen quicker simply from the greater frequency in ocular and systemic pathology seen. Since most of these positions are in rural settings, competition is low and the demand for medical professionals is quite high. For students, residents, and experienced ODs looking to practice full scope optometry and expand their clinical toolbox, working with the Indian Health Service is a great way to go. From student to optometrist, no matter how long or short your time with IHS is, the experience is sure to be exciting and unforgettable.
Most IHS optometry residency programs throughout the southwest are affiliated with Marshall B. Ketchum University, Southern California College of Optometry (SCCO) and Midwestern University in Arizona.
Many rural IHS sites also offer government subsidized housing and a tax credit for being a rural healthcare provider. Post-residency, optometrists within the IHS have the opportunity to apply for the IHS Loan Repayment Program. This award requires a minimum 2-year commitment within your respective IHS clinic/hospital, and can help pay a significant portion of your student loans
Optometrists who seek a longer-term position/career within the IHS can become part of the commissioned corps, a branch of the U.S. Public Health Service, and receive many federal benefits.
Similar to the VA healthcare system and most other hospital-based settings, optometry positions available within the IHS require prior residency training (preferably ocular disease but not necessarily). The IHS.gov website lists the current IHS optometry positions available.
- “Statistics About Diabetes.” American Diabetes Association.
- Schumacher C, Ferucci ED, Lanier AP, et al. Metabolic Syndrome: Prevalence among American Indian and Alaska Native People Living in the Southwestern United States and in Alaska. Metabolic Syndrome and Related Disorders. 2008;6(4):267-273. doi:10.1089/met.2008.0021
- Lombard, K. A., Beresford, S. A. A., Ornelas, I., Topaha, C., Becenti, T., Thomas, D., & Vela, J. G. (2014). Healthy Gardens/Healthy Lives: Navajo perceptions of growing food locally to prevent diabetes and cancer. Health Promotion Practice, 15(2), 223–231.
- Peschken, Christine A., and John M. Esdaile. “Rheumatic Diseases in North America’s Indigenous Peoples.” Seminars in Arthritis and Rheumatism, W.B. Saunders, 15 Dec. 2004,
- Hurd, K., & Barnabe, C. (2017). Systematic review of rheumatic disease phenotypes and outcomes in the Indigenous populations of Canada, the USA, Australia and New Zealand. Rheumatology International, 37(4), 503–521.
- McDougall , Cairistin, et al. “Systematic Review of Rheumatic Disease Epidemiology in the Indigenous Populations of Canada, the United States, Australia, and New Zealand.” Seminars in Arthritis and Rheumatism, W.B. Saunders, 1 Nov. 2016.
- Peschken, C A, and J M Esdaile. “Systemic Lupus Erythematosus in North American Indians: a Population Based Study.” The Journal of Rheumatology., U.S. National Library of Medicine, Aug. 2000.