Excerpt from ICO Matters, Summer 2023 – ICO and the OD/MD Alliance

All kidding and nostalgia aside, in 1997, Charles Mullen, OD, ICO’s fourth president, forged an alliance with the neighboring University of Chicago Hospital and Department of Ophthalmology that has flourished in the decades since. For over twenty-five years, the two institutions have worked to improve care and access to services for Chicago’s South Side that Dr. Mullen recently described as the ‘gold standard’ of vision care.

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Paradoxically, during the same period, there has been extensive expansion of the scope of practice. This has strengthened optometry’s position as a medical eye care provider, and as a valued healthcare profession.

The implications to optometric education of the paradoxical evolution of the profession of optometry are profound:

1. Is the current 8 years of education unnecessarily long for Retail Practice? See: Optometric Education in Crisis, Slide 15, Enhance Appeal for Careers in Commercial, Office Practice and Medical Eye Care.
2. Does the current curriculum adequately prepare graduates for expanded scope practice? See: Three Critical Elements for Expanded Scope of Optometric Practice.
3. There has not been an increase in the optometry student applicant pool in a decade. See: An Analysis of the Optometric Applicant Pool Relative to Matriculants.

The above fundamental issues present a significant challenge to the optometric educational enterprise.

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• While the University of Chicago’s NORC surveys indicate optometry is considered a high prestige profession, the increased visibility of Retail Optometry is projecting an image different from potential applicants’ expectations of what it means to be a “doctor.”
• Association with the selling of eyeglasses: Is an optometrist a health care provider or a merchant?
• While the applicant pool has not increased in 10 years, less qualified matriculants have increased thereby diluting the quality of the optometric workforce.
• New schools of optometry exacerbate the situation of less qualified matriculants.

See: An Analysis of the Optometric Applicant Pool Relative to Matriculants

Income to Debt Ratio

• A high percentage of income is required to pay educational debt: 15% of income is the highest of all health care professions.
• Starting income is relativity low when loan payments are considered.
• Income growth accrues primarily to private practice owners. Retail optometrists’ and employed optometrists’ income remains effectively level throughout their careers.
• The magnitude of debt takes years to repay.

Oversupply of Optometrists

• Lewin Survey Finds Large Optometry Surpluses

Education

• Concern education is too long and too costly for return on investment?
• No Federal support for costly optometric clinical training.

Optometric Practice

• Paradoxical Evolution of Optometry.
• When scope of practice does increase additional education/clinical training is required.
• No profession-wide recognized Specialty Certification Boards. The public considers Board Certification as the “Gold Standard” for quality practitioners. See: Optometry Specialty Certification Boards Provide a Uniform Indicator of Advanced Knowledge and Skills.

Recommendation

The first step in solving any problem is to honestly identify the cause or causes. Once the causes are identified then the task of implementing corrective measures should commence.

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There is a need for increased postgraduate clinical training and Optometry Specialty Certification Boards to manage the rapid expansion of the Scope of Optometric Practice. See: Three Critical Components for Expanded Scope of Optometric Practice.

Board Certification is understood by the health care community and general public to mean that a physician has acquired advanced knowledge and skills in a specialty area such as Internal Medicine, Family Medicine, Pediatrics, etc.

Although there are many types of Optometry Residency Programs, only ABCMO offers residents the opportunity to be Board Certified in an Optometry Specialty. This leaves many other residents without the opportunity for Board Certification in their respective Specialties. This deficiency can be addressed by the development of additional Optometry Specialty Certification Boards.

To facilitate the development of Optometry Specialty Certification Boards, and to ensure high standards for all specialties, the American Board of Optometry Specialties (ABOS) was created. Similar to the American Board of Medical Specialties (ABMS), which provides oversight and guidance to independent Medical Specialty Certification Boards, ABOS provides oversight and guidance to independent Optometry Specialty Certification Boards.

American Board of Optometry Specialties (ABOS)

ABOS currently has one member optometry specialty certification board and recommends the formation of an additional three.

American Board of Optometry Specialties (ABOS)

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• Nomenclature
  • The name of the Residency Program must be the same as the Clinical Specialty, e.g. Family Optometry, Pediatric Optometry, Low Vision Optometry, and Medical Optometry.
  • The name of the Post-Residency Fellowship must be the same as the Clinical Subspecialty, e.g. Glaucoma, Retina, Cornea/External Disease, Neuro-Ophthamic, Sports Vision, Geriatric Vision, Adolescent Vision, etc.
• Each Specialty must have its own Certification Board.
• The Certification Board determines the requirements for Specialty and associated Subspecialty certifications.
• Only the Specialty Certification Board can grant Specialty and Subspecialty Certifications.
• Residency Trained clinicians must first be certified in the Specialty by the parent Specialty Board before qualifying for Subspecialty Certification.
• Only clinicians who are Board Certified in a Specialty may use the title, Specialist, and only those certified in a Subspecialty may use the designation of Subspecialist.
• Each Specialty Certifications Board submits to oversight by an independent third party*.

*In Medicine, Specialty Boards are overseen by the American Board of Medical Specialties (ABMS). In Optometry, Specialty Boards are overseen by the American Board of Optometry Specialties (ABOS).

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Medical Education leads the Medical Profession by developing the educational structure and clinical training programs in advance of new patient care initiatives. In contrast, State Optometric societies lead the Optometric Profession with Optometric Education reacting to the States’ expanded scope of practice initiatives with specific educational programs. Consequently, there is not a comprehensive educational structure nor a uniform indicator of an optometrist’s knowledge and clinical skills to support all of the States’ expanded scope of practice initiatives.

Requiring postgraduate clinical training in medical eye care for optometrists is not only essential preparation for Expanded Scope of Practice, but also positions optometry for inclusion in the $18 billion Graduate Medical Education Program (GME).

These are the three missing components that need to be developed:

1) Necessary Capacity for Advanced Clinical Training in Medical Eye Care

• In 1931 Medicine acknowledged that clerkships contained within the four year medical school curriculum were inadequate preparation for rapidly changing medical practice, and instituted mandatory postgraduate clinical training.
• Even though optometric practice has dramatically and rapidly expanded encompassing medical eye care, clerkships within the four year optometry curriculum remain the only required clinical training component.
• The current four year curriculum does not provide optometry graduates with the types and quantity of clinical teaching encounters necessary to practice expanded scope of practice in all States.
• Postgraduate clinical training in medical eye care is now essential preparation for advanced optometric practice.

2) Federal Funding to Support Advanced Clinical Training

• Optometry is not included in the $18 Billion Graduate Medical Education Program (GME) because clinical education takes place primarily within the four year curriculum, and not in postgraduate residencies.
• Inclusion in GME, the educational component of Medicare, would not only encourage the development of new residency positions in Medical Eye Care by providing funding to host facilities, but also by providing funding to directly support advanced clinical training.
• Optometric Education needs to change from providing clinical education within the current four year curriculum to a Postgraduate Clinical Training Model to qualify for GME.
• Like medicine, clinical clerkships or rotations would take place within the final years of the curriculum.

3) Nationally Recognized Certification Board to Provide a Uniform Indicator of an Optometrist’s Advanced Knowledge and Skills to Practice Expanded Scope of Practice Optometry

• The American Board for Certification in Medical Optometry (ABCMO) is a well-established Board that meets GME expectations. However, ABCMO serves mostly Department of Veterans Affairs (VA) optometrists, and needs to be recognized by the entire Optometric Profession.

More Information

• The State of Optometry Specialties and Subspecialties
• Optometry Scope of Practice in the United States
• Changes Necessary to Include Optometry in the Graduate Medical Education Program (GME)
• The American Board of Certification in Medical Optometry (ABCMO)
• Principles to Follow in Developing Specialties and Subspecialties
• Required Postgraduate Clinical Training for Optometric License
• American Board of Optometry Specialties (ABOS)

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• Briefing Points for Advocates for Inclusion in GME
• Changes Necessary to be Included in GME

2. Mandatory Postgraduate Residencies Facilitate Specialty Training Followed by Board Certification

• Required Postgraduate Clinical Training for Licensure

3. Accreditation

• Accreditation of Residency Programs in Medical Optometry by ACOE Required

4. Definition of the Specialty of Medical Optometry and Associated Subspecialties

• State of Optometry Specialties and Subspecialties

5. Medical Optometry Specialty Certification Board

• American Board of Certification in Medical Optometry (ABCMO)

6. Oversight Board for All Specialties

• American Board of Optometry Specialties (ABOS)

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• Optometry is a significant provider of medical eye care services to Medicare beneficiaries ($1.33 billion annually) for conditions such as glaucoma, cataracts and retinal diseases, but is not included in the Graduate Medical Education Program (GME), the educational component of Medicare.
• Medicine, Podiatry and Specialty Dentistry receive $18 billion in GME support annually for postgraduate clinical education. Podiatry was included in GME in 1972 by amendment, and changed its clinical training model in 1990. Podiatry now receives regular GME payments to support resident training.
• It will be necessary to include Optometry in GME by amendment to appropriate laws/regulations or by inclusion in proposed legislation in advance of the introduction of a new optometry postgraduate clinical education model.

Clinical Training of Optometrists

• Optometry has traditionally provided clinical education within the four year optometry school curriculum with postgraduate clinical training being optional, thus, optometry’s current clinical education model does not meet GME requirements.
• Costly, optometric clinical education receives no Federal Support, and is largely financed by student tuition contributing to high graduate debt of approximately $200,000.
• Optometry graduates have the highest loan payments as a percentage (14.9%) of income of all professions.
• High debt is a contributing factor in that applicants to optometry schools and colleges have not effectively increased in 10 years.

Reasons Optometry Should be Included in GME

1. Nationwide expansion of the scope of optometric practice by numerous changes to State Practice laws.
2. A steadily increasing demand in providing Medicare beneficiaries with medical eye care services – Optometrists currently provide $1.33 billion in services annually managing serious eye conditions of Medicare recipients.
3. A major increase in optometric management of serious eye conditions will accompany the proposed addition of refractive care (refraction, eyeglasses and contact lenses) in Medicare.

• The above will require the schools and colleges of optometry to restructure their traditional clinical education approach into a Postgraduate Medical Clinical Educational Model in order to provide the quantity and diversity of clinical teaching encounters necessary to properly prepare optometry graduates for clinical practice.
• In 1930 Medicine adopted required postgraduate clinical training because the 4 year medical school curriculum did not provide the quantity and diversity of clinical encounters to properly train physicians.
• Postgraduate optometric clinical education can be provided in cost effective outpatient facilities. GME’s hospital-based training requirement needs to be waived.

Optometry’s Inclusion in GME is Necessary

• GME is needed to support optometry’s postgraduate clinical education to meet current and future demand for well-trained optometrists in advanced medical eye care practice.
• GME support will ensure a sufficient number of well-trained optometrists to meet current and projected demand for eye care services of Medicare beneficiaries.

See Also

• Changes Necessary to Include Optometry in the Graduate Medical Education Program (GME)
• Rationale for Optometry’s Inclusion in GME (PowerPoint)
• Opportunities Lost – Opportunities Regained
• Democrats Hope To Beef Up Medicare With Dental, Vision And Hearing Benefits

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In 1965 Medicare was enacted by the US Congress providing health insurance to American seniors that covered most medical/health conditions, however, vision care, eyeglasses and contact lenses were omitted from the law. Now 78% of older voters demand Vision Care be included in Medicare. There is considerable interest by the Democratic congressional leadership to include Vision Care. The implications of inclusion of vision care, and prescribed eyeglasses and contact lenses in Medicare follow:

1) The demand for optometric services will increase significantly. Optometrists will not only provide more refractive services, but also more medical eye care services for an elderly population with a high incidence of eye conditions requiring medical management.

2) The Social Security Law will be opened for amendment to include Vision Services providing optometry the opportunity to include optometry in the Graduate Medical Education Program (GME) language. Once optometry’s clinical training model meets GME expectations, then optometric residency programs would be eligible to receive GME payments. ASCO and AOA should have a joint plan if the opportunity arises to include optometry in GME language.

3) Corporate optical retailers, anticipating a dramatic increase in demand for eyeglasses, and with difficulty in placing optometrists in certain retail locations, will likely lobby State/Federal Governments to authorize technicians, utilizing automated devices, to measure refractive error suitable for prescribing eyeglasses.

See Also

• Changes Necessary to Include Optometry in the Graduate Medical Education Program (GME)
• Rationale for Optometry’s Inclusion in GME (PowerPoint)
• Recommended Briefing Points for Advocates of Optometry’s Inclusion in GME

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Optometry is on the same path followed by medicine for specialty training and Board Certification; however, there is an important difference between optometry and medicine regarding postgraduate clinical training and licensure. Medicine requires postgraduate clinical training for licensure while optometry does not, although most States require additional education and/or clinical experience to meet requirements of expanded optometric scope of practice laws. These additional requirements are simply not adequate preparation for the expanded responsibilities of modern, expanded scope optometric practice.

Expansion of practice capabilities for optometrists requires formal postgraduate clinical training in Medical Optometry. Mandating postgraduate training in Medical Optometry for licensure would:

1. Facilitate adequate and uniform preparation of optometrists for expanded scope of practice
2. Initiate the process for Specialty Board Certification
3. Position optometry for inclusion in the multi-billion dollar Graduate Medical Education Program (GME) and
4. Enhance the prestige of the profession of optometry.

By converting the current 4th year in the optometry school curriculum to the first year of postgraduate clinical training with emphasis in Medical Optometry, the immediate need for a significant increase in Medical Residencies could be met while simultaneously expanding the current network of optometric medical residencies.

See also: Changes Necessary to Include Optometry in GME

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