Charles F. Mullen

The Paradoxical Evolution of Optometry

For the past several decades there has been a significant increase in Commercial/Retail Optometry. Some lament Optometry’s returning to its mercantile roots.

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:

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.
Does the current curriculum adequately prepare graduates for expanded scope practice? See: Three Critical Elements for Expanded Scope of Optometric Practice.
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.

Potential Factors Contributing to a Decade of No Growth in the Optometry Student Applicant Pool

Image of the Profession

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.

Optometry Specialty Certification Boards Provide a Uniform Indicator of Advanced Knowledge and Skills

Background

There is a need for increased postgraduate clinical training capacity, 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 that a physician has acquired advanced knowledge and skills in a specialty area such as Internal Medicine, Family Medicine, Pediatrics, etc.

Although there are more than ten different types of Optometry Residency Programs, only ABCMO offers enrolled 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 further development of Specialty Certification Boards as outlined in this paper.

This paper details an approach for Optometry to develop Board Certification capabilities similar to medicine in the specialties of Family Optometry, Low Vision and Pediatric Optometry in addition to the currently successfully operating American Board of Certification in Medical Optometry (ABCMO).

In order to facilitate the development of Optometry Specialty Boards, and to ensure high standards for all specialties, the American Board of Optometry Specialties (ABOS) was implemented. ABOS is the optometric analog of the American Board of Medical Specialties (ABMS).

The State of Optometry Specialty Certification Boards and Associated Specialties and Subspecialties

The following is a synthesis of information contained on ASCO, ABCMO, ABOS and the American Academy of Optometry websites pertaining to postgraduate clinical training, specialties, subspecialties and Certification Boards into four Optometry Specialty Certification Boards with their associated specialties and subspecialties.

ABO promotes advancement beyond the entry level, but does not promote nor certify specialization. The below guidance framework requires further development and refinements.

Optometry Specialty Board Currently Operating

American Board of Certification in Medical Optometry (ABCMO)

Medical optometrists diagnose, treat and manage a wide range of conditions of the eye. They prescribe medications, diagnostic tests, eyeglasses and contact lenses.

Specialty Certification in Medical Optometry Administered by the American Board of Certification in Medical Optometry (ABCMO) Requirements

Completion of a full-time, ACOE (or equivalent) accredited, postgraduate clinical residency training program having major emphasis on medical optometry.
Passage of the Advanced Competence in Medical Optometry (ACMO) exam offered by the National Board of Examiners in Optometry (NBEO).
Documented significant practice of medical optometry for a minimum of two years immediately prior to application for certification.

Subspecialty Certification Requirements

To become certified in a particular Subspecialty, an optometrist must

Receive certification by the parent Specialty Board such as the ABCMO.
Achieve Diplomate status in a relevant American Academy of Optometry Section or Membership in a Special Interest Group.
Complete two years of a subspecialty clinical fellowship or equivalent.
Passage of Subspecialty Examination offered by the NBEO.

Subspecialties of Medical Optometry (Under Consideration)

Cornea and External Disease

Subspecialty includes the diagnosis, treatment and management of diseases of the cornea, sclera, conjunctiva and eyelids.

Glaucoma

Subspecialty includes the diagnosis, treatment and management of glaucoma and other disorders usually associated with increased intraocular pressure.

Neuro-Ophthalmic Disorders

Subspecialty includes the relationship between neurologic and ophthalmic diseases. Manages local pathology affecting the optic nerve and visual pathways and the visual effects of traumatic brain injury. Includes the evaluation and management of problems that involve the afferent and efferent visual and visual-motor systems.

Vitreoretinal Diseases

Subspecialty includes the diagnosis and management of various diseases that affect the retina and vitreous.

For more information regarding the Specialty of Medical Optometry and associated subspecialties please visit ABCMO.org

The Following Specialties Require Further Development and Establishment of Certification Boards

See: Principles to Follow in Developing Specialties and Subspecialties.

Family Optometry

American Board of Certification in Family Optometry (ABCFO)

The Family Optometrist provides front line, primary eye care to all members of the family that is accessible and continuous over time for all ages and stages of life. When necessary, the Family Optometrist arranges for diagnostic tests and referrals to other health care providers and coordinates the care.

Specifically, the Family Optometrist diagnoses, treats and manages disorders of the eye including prescription of eyeglasses, contact lenses, optical aids and medications.

Certification Requirements

Residency training as required by ABCFO.
Practice as required by ABCFO.
Passage of an Examination in the Specialty of Family Optometry.
Passage of the Advanced Competence in Medical Optometry Exam or Residency Training in Medical Eye Care.

Subspecialties in Family Optometry (Require Further Development)

Adolescent Vision

Advanced Contact Lens Care

Geriatric Vision

Infant Vision

Sports Vision

Pediatric Optometry

American Board of Certification in Pediatric Optometry (ABCPO)

The management of ocular motility disorders, strabismus, amblyopia, developmental and perceptual abnormalities in children.

Certification Requirements

Achieve Diplomate status in the Binocular Vision, Perception and Pediatric Optometry Section of the American Academy of Optometry (AAO).
One year residency training or two years of pediatric practice.
Passage of an Examination in the Specialty of Pediatric Optometry.
Passage of the Advanced Competence in Medical Optometry Exam or Residency Training in Medical Eye Care.

Subspecialties in Pediatric Optometry

To Be Determined

Low Vision Optometry

American Board of Certification in Low Vision Optometry (ABCLVO)

Low Vision Optometry deals with the diagnosis and treatment of low vision. Management includes prescription of optical aids and other devices. Also, includes training and counseling of patients.

Certification Requirements

Achieve Diplomate status in the Low Vision Section of the American Academy of Optometry.
One year of residency training or two years of low vision practice.
Passage of an Examination in the Specialty of Low Vision Optometry.
Passage of the Advanced Competence in Medical Optometry Exam or Residency Training in Medical Eye Care.

Subspecialties in Low Vision Optometry

To Be Determined

Criteria for the Establishment of an Optometry Specialty Board

The specialty board issuing certifications in a specialty shall be an independent, not-for-profit entity with a board of directors and officers of up to 7 individuals of which the majority of voting members are licensed practitioners of the specialty and two non-voting members who will represent the public interest.

The board may have ex officio members representing the Accreditation Council on Optometric Education (ACOE), the Association of Schools and Colleges of Optometry (ASCO) and the independent entity preparing and administering its national written specialty examination testing competence in the specialty required to apply for specialty certification.

American Board of Optometry Specialties (ABOS)

The development and administration of all Specialty Boards is overseen and assisted by the American Board of Optometry Specialties (ABOS).

Principles for Optometry to Follow in Developing Specialties and Subspecialties

The following principles have proven to be effective by Medicine in the administration of Specialties and Subspecialties. The principles are widely recognized by accrediting groups, insurance carriers, health care institutions and providers:

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).