Charles F. Mullen

Opportunities and Challenges in Optometry and Optometric Education

Optometry – From Traditional Role to Medical Eye Care

The Primary Role of Optometrists Will Evolve Into Medical Eye Care

Over the next 15 years, the expanded use of technology and ancillary staff will change the traditional role of optometrists. Large corporations with advanced technology and sophisticated online marketing will dominate the multi-billion dollar eye care products market and the provision of eyewear and contact lenses will decline in traditional optometric practice.

However, with unmet medical eye care needs in most areas of the country, a new role for optometrists as primarily medical eye care practitioners will emerge. Recognizing the public health need for medical eye care, and the shortage of ophthalmologists, Federal and state agencies and legislatures will facilitate the transition of traditional optometry to primarily medical eye care.

The following are necessary to complete the transition to medical eye care, and to secure Federal funding for optometry’s postgraduate clinical training programs:

  1. Schools and colleges of optometry to revise their basic curriculum and adopt the medical postgraduate clinical training model. The Future of Optometric Education – Opportunities and Challenges
  2. Expansion of postgraduate/residency programs in medical eye care. ORMatch Participating Programs
  3. State optometry practice laws amended to authorize comprehensive medical treatment, clinical procedures and prescriptive authority for eye conditions.
  4. State Optometry Regulatory Boards to require one year of accredited postgraduate clinical training (residency) in medical eye care for licensure. Required Postgraduate Clinical Training for Optometry License
  5. A recognized and credible Specialty Certification Board in Medical Optometry established. American Board of Certification in Medical Optometry (ABCMO)
  6. Optometry specialties/subspecialties terminology and qualifications clarified. The State of Optometry Specialties and Subspecialties
  7. With a medical postgraduate clinical training model in place, optometry should qualify for inclusion in the Graduate Medical Education (GME) Program. Social Security Act amended to include optometry in GME. Changes Necessary to Include Optometry in the Graduate Medical Education Program (GME)
  8. Medical services provided by optometrist to be recognized by third party payers.

I present the above observations and suggestions as a blueprint for discussion. Thoughtful planning by optometry and optometric education is essential to the long term success of the Profession.

by Charles F. Mullen

Required Postgraduate Clinical Training for Optometry License

Expanded Practice Laws

Over the past 47 years, State optometric practice laws have been expanded to include more medical procedures, treatments and management of medical conditions. Individual State regulatory boards have reacted to expanded practice laws by requiring additional clinical training and/or instruction to perform the new clinical privileges granted. Thus, requirements for optometry practice can vary by State.

Optometry Four Year Curriculum

The entire optometry curriculum (academic and clinical) must be completed in just 4 years with no required postgraduate clinical training. Consequently, clinical training is limited, especially in the number of medical clinical teaching encounters, and in diversity of encounters to thoroughly prepare the graduate for the provision of current medical procedures, treatments and management. Also, not all optometry schools have access to sufficient numbers of patients with medical conditions necessary for clinical teaching.

Postgraduate Clinical Training

Medicine introduced postgraduate clinical training in 1930, as one year internships (now considered first year of residency), to compensate for the limited number of student clinical teaching encounters in the Medical School curriculum. One to three years postgraduate (residency) clinical training is now required for medical licensure. Overall, physicians spend an average of 4 years in postgraduate specialty clinical training.

Recommendation: Mandatory Postgraduate Clinical Training

It is time for optometry to follow medicine’s example by mandating a minimum of one year postgraduate clinical training (residency) in an accredited medical optometry postgraduate program or equivalent for licensure to compensate for limited student clinical encounters in medical procedures, treatments and management in the optometry school 4 year curriculum, and to ensure uniformity in clinical medical training among all states.

Additional Benefits of Mandatory Postgraduate Clinical Training

  • Mandated postgraduate medical clinical training would place the graduate on an expeditious path to Specialty Board Certification.
  • The Federal Government supports postgraduate training through the Graduate Medical Education (GME) Program. States’ enactment of optometry’s postgraduate requirement for licensure would be another step toward optometry’s inclusion in the Graduate Medical Education (GME) Program.

by Charles F. Mullen

The State of Optometry Specialties and Subspecialties

Background

Board certified specialists in over 40 medical and dental specialties along with 136 associated subspecialties are readily recognized by hospital credentialing committees and boards. By comparison, optometry has just 1 specialty and 0 subspecialties. And only optometrists who are board certified in Medical Optometry by the American Board of Certification in Medical Optometry (ABCMO) are recognized as specialists by Federal facilities, state licensed hospitals, teaching facilities, group practices and credentialing networks.

The recognition of the Specialty of Medical Optometry is a significant achievement for the profession of optometry, and a step closer to inclusion in the Graduate Medical Education (GME) Program. However, augmentation of Medical Optometry subspecialties still needs to be accomplished. Furthermore, the specialties of Pediatric and Low Vision Optometry need to be further developed along with the creation of their respective certification boards. 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) needs to be implemented. ABOS is the optometric analog of the American Board of Medical Specialties (ABMS).

The following outline is presented to facilitate further development of optometry specialties and subspecialties.

Recognized Optometry Specialty and Certification Board

Medical Optometry

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 American Board of Certification in Medical Optometry (ABCMO) Requirements

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

Subspecialties of Medical Optometry (Need to be Augmented)

Cornea and External Disease

Subspecialty includes the diagnosis, treatment and management of diseases of the cornea, sclera, conjunctiva and eyelids. Includes the management of complex contact lenses cases.

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.

Subspecialty Certification Requirements

To become certified in a particular Subspecialty, an optometrist must

  1. Receive certification by the parent Specialty Board such as the ABCMO
  2. Achieve Diplomate status in a relevant American Academy of Optometry Section or Special Interest Group
  3. Complete two years of a subspecialty clinical fellowship or equivalent

The Following Specialties Require Further Development and Establishment of Certification Boards

For consideration – the specialties below (Pediatric Optometry and Low Vision Optometry) could be created as Subspecialties of Medical Optometry instead of independent specialties.

Pediatric Optometry

American Board of Certification in Pediatric Optometry (ABCPO)

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

Certification Requirements

  1. Achieve Diplomate status in the Binocular Vision, Perception and Pediatric Optometry Section of the American Academy of Optometry (AAO)
  2. One year residency training or two years of pediatric practice
  3. Examination as prescribed by the Specialty Board

Subspecialties in Pediatric Optometry

They are to be augmented later after the Specialty Board is formed.

Low Vision Optometry

American Board of Certification in Low Vision Optometry (ABCLVO)

(Draft Description) 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

  1. Achieve Diplomate status in the Low Vision Section of the American Academy of Optometry
  2. One year of residency training or two years of low vision practice
  3. Examination as prescribed by the Specialty Board

Subspecialties in Low Vision Optometry

They are to be augmented later after the Specialty Board is formed.

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.

The specialty may be a blend, mixture or concentration of one or more ASCO listed residencies, but preferentially have a major emphasis within one of the 11 ASCO listed residencies.

American Board of Optometry Specialties (ABOS)

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

by Charles F. Mullen

Why Optometry Needs the American Board of Optometry Specialties (ABOS)

Background

Optometry residency training began 40 years ago and has grown such that today 25% of graduates, prior to entering practice, elect to serve a postgraduate residency (PG-1) in an optometry specialty of which the most popular is medical optometry. This is a significant shift towards postgraduate residency training and a sign the O.D. degree and license, while adequate to insure competence in general practice, can no longer insure competence in all areas of optometry practice. The profession of dentistry began to train and certify dental specialists prior to optometry. Medicine began to develop specialist residencies even earlier, about 90 years ago.

The movement towards optometry specialization began within the U.S. Department of Veterans Affairs in 1975 as an effort to prepare optometrists via residency training for practice within medical facilities in which they would encounter chiefly medical eye conditions, rather than refractive errors, and be trained to make appropriate referrals as required for surgical treatments while providing primary medical eye care.

The Association of Schools and Colleges of Optometry (ASCO) now lists 11 types of optometry specialty residency programs as well as a residency matching service and the Accreditation Council on Optometry Education accredits most optometry specialty residency programs.

At this time only the specialty of medical optometry has in place the accepted 3-step process to certify competence as a specialist required by Joint Commission accredited health care facilities and their credentialing committees. This recognition permits their credentialing as a specialist in medical optometry at accredited health care facilities and is the same as that required for medicine, osteopathy, dentistry, and podiatry specialists by credentialing committees at Joint Commission accredited health care facilities.

Such credentialing of specialists must be utilized for optometry specialists since optometrists are classified by the Centers for Medicare and Medicaid (CMS) as “physicians” for credentialing purposes and the Joint Commission requires this form of credentialing of all independently prescribing members of the medical staff which includes optometrists following a 1986 policy statement by the Joint Commission that authorized placing optometrists on the medical staff of accredited facilities and granting them clinical privileges.

Medicine, osteopathy, dentistry and podiatry have coordinating boards or committees that set the standards and requirements through which defined areas in their professions are recognized as specialties and by which its practitioners can become board certified specialists.

A key requirement of any profession’s specialty coordinating board is that it be free of real or apparent conflicts of interests with trade associations and all bodies responsible for accrediting residencies or preparing and administering specialty written examinations, in order to avoid “regulatory capture” and ensure autonomy of its actions. Such boards must also operate as a nonprofit corporation and have governance that includes representatives of the public.

Optometry has had no such coordinating board for optometry specialties to set the standards by which an optometry specialty is recognized and its practitioners are certified other than for the specialty of medical optometry whose specialty board is now recognized by credentialing committees at Joint Commission accredited health facilities and private practices. Specialty boards for the other optometry specialties have yet to be formed.

The US credentialing system of health care providers recognizes as specialists those practitioners of medicine, osteopathy, dentistry, optometry and podiatry who meet three requirements for recognition by credentialing committees at Joint Commission accredited health care facilities. These requirements are below:

Accepted Specialty Training, Testing and Certification Standards

  1. Satisfactory completion of a postgraduate, accredited full-time clinical residency training program in a recognized specialty of the licensed profession
  2. Passage of the standardized, national written examination in the specialty required by a specialty board of certification.
  3. Certification of competence by a recognized specialty board.

This recognized, national 3-step process is commonly termed “board certification” and those holding such certifications are credentialed as board certified specialists within defined areas of their licensed profession by credentialing-licensing committees at Joint Commission health care facilities. Those completing the 3-step process may refer to themselves as “board certified” in their specialty.

Since specialists often practice within accredited health care organizations and private group practices having credentialing committees, it is highly advantageous to be board certified in one’s specialty.

The incorporators of ABOS believe all optometry specialties should have the same credentialing opportunities now available only to those completing residencies in medical optometry.

Purpose of ABOS

The current inequality of career opportunities to pursue one’s chosen specialty requires the establishment of additional specialty boards and written specialty examinations that meet the same high standards required of medical optometry specialists and those of recognized credentialing committees.

The American Board of Optometry Specialties (ABOS) has as its main mission, the encouragement, support and further development of optometry specialty boards and specialty examinations that meet, or exceed, the standards and expectations for acceptance recognition by credentialing committees at Joint Commission accredited health care systems as specialty boards.

To address the lack of specialty boards and written examinations for other optometry specialties ABOS will establish standards to be met by which ABOS will recognize a specialty, its residency programs and written specialty examination.

In addition, ABOS will, upon request, provide counsel, advice, and fiscal support to nascent optometry specialty boards and work with them to acquire ABOS recognition.

by Charles F. Mullen