In the following eloquently written article, Dr. Kenneth Myers discusses traditional board certification in allopathic medicine, osteopathy and dentistry and the emergence of board certification in optometry. He delineates the three levels of credentials recognized for physicians, dentists and optometrists at Joint Commission for Accreditation of Health Care Facilities (JCAHO). The article stresses the importance of residency training in achieving eligibility for board certification. And of particular significance to optometry, Dr. Myers thoroughly and precisely describes the difference between Specialty Board Certification and Board Certification of General Practice Optometrists. This is a very important and timely article for the profession of optometry and optometric education.
by Kenneth J. Myers, Ph.D.,O.D.
Medicine, osteopathy and dentistry have long had specialty certification boards that issue “board certifications” to those completing residency specialty training in defined specialty areas of each of these professions after licensing. Optometry has one specialty certification board and three boards that issue certifications to general practitioners.
The three boards for general optometry practitioners certify current licensing-level competency rather than specialty competency and differ considerably in their requirements.
All four types of certification are voluntary and not required for licensure, license renewal or the private practice of optometry.
Specialty certification is required, however, of a licensed optometrist seeking credentialing as a specialist at a Joint Commission accredited health care organization.
Specialist Board Certification
ABCMO is an optometry specialty board aligned with the credentialing process used for appointment and credentialing of allopathic and osteopathic physicians, dentists, optometrists and podiatrists practicing at Joint Commission accredited healthcare organizations. In this long-standing credentialing system, board certification recognizes achievement of advanced competency in a specific specialty within one of these professions; an advanced competency that requires completing accredited specialty residency training after licensing, passing a written examination testing competency in that specialty and meeting additional criteria of an appropriate specialty board. This process, termed “board certification” has been used for over 80 years to certify specialist-level competency; i.e. competency above that required for licensure in medicine, osteopathy, and dentistry.
With creation of ABCMO in 2009, there are 74 specialty boards recognized by credentialing committees at Joint Commission accredited health facilities which all require specialty residency training and passage of an examination testing specialty competency.
General Practice vs. Specialist Practice
Since 1986, the Joint Commission has recognized that optometrists, like dentists, qualify for appointment to the medical staff of an accredited healthcare organization for general practice optometry by holding the O.D. degree and state license. Additional professional credentials are also not required for private, general practice optometry by insurance panels or state and federal medical programs.
However, to apply for credentialing as a specialist at an accredited health care organization, physician, dental and optometry practitioners must document completion of residency training in a specialty, passage of an examination in that specialty, and provide the name of the recognized specialty board issuing their certification and its expiration date.
ABCMO formed in 2009 to permit residency trained O.D.s to meet requirements for credentialing as a specialist in medical optometry at accredited health care organizations and is incorporated as a nonprofit specialty board issuing a Level 2 credential.
Recognized Levels of Credentials for physicians, dentists and optometrists:
The three recognized credentialing levels for medical, osteopathic, dental and optometry practitioners at Joint Commission accredited facilities are:
- Level 1 – Credentialed as General Practitioner of licensed doctoral profession:
Degree + license required. Maintenance of license-level competency verified at license renewal as required by practitioner’s state licensing board. [Maintenance of License]
- Level 2 – Credentialed as Specialist in defined area of licensed doctoral profession:
Level 1 credentials plus residency training in specialty, passage of specialty examination and specialty board certification required. Specialists usually take part in maintenance of certificate programs to renew their specialty certifications every 10 years.
- Level 3 – Credentialed as Subspecialist
Level 1 and 2 credentials plus Fellowship training in a subspecialty required. Competency maintained as specified by subspecialty Society or College.
In this national 3-level credentialing system a licensed health profession is not considered a specialty itself.
Board certification is a Level 2 credential that certifies advanced competency in a specialty of a higher level than that required for licensing or license renewal as a general practitioner.
Types of Optometry Certification
ABCMO issues a Level 2 credential certifying competence in the specialty of medical optometry.
The three boards offering board certification in general practice optometry certify completion of additional, voluntary education and testing in general practice optometry. Such programs are considered additional, voluntary maintenance of license by medicine, osteopathy and dentistry because they are additional certifications of license-level competence and do not certify specialist competency.
Specialty Residency Programs in Optometry
Postgraduate optometry specialization via residency training is relatively new to optometry and began in 1985 within U.S. Department of Veterans Affairs medical centers which operate about one-half of US optometry residency programs. Non-VA residency programs at schools of optometry began in the 1980’s. Optometry residency programs are accredited by the Accreditation Council on Optometric Education. About 20% of newly licensed optometrists choose to serve a specialty residency of which about one-third are in medical optometry and based at VA medical centers.
About 93% of practicing optometrists have not served residencies, are not eligible for ABCMO certification and are in private general practice. The majority of ABCMO applicants practice within, or plan to practice within, accredited health care facilities or private medical practices.
Purpose of Board Certification of General Practice Optometrists
The credentials awarded by the organizations issuing “board certifications” to general practice optometrists require additional education and testing in general practice compared to that required by state licensing boards for renewal of optometry licenses. Optometrists taking these additional steps to ensure their competency in general practice are to be commended.
Confusion Can Exist
The existence of four types of “board certification” for optometrists, however, can produce confusion for credentialing bodies since three certify license-level competency and one certifies specialist-level competency.
- The meaning of “board certification”, as subscribed to by credentialing committees at accredited medical facilities, and ABCMO, recognizes attainment of specialist status from successful completion of an accredited post-licensure specialty residency, passage of a national specialty examination, meeting requirements of practice of the specialty in a suitable setting for a specified period of time and engaging in a maintenance of specialty competency program.
- There are significant differences between board certification as a specialist in medical optometry and “board certification in general practice optometry”.
- ABCMO believes optometrists voluntarily exceeding state requirements for license renewal are to be commended for doing so. But such achievement does not confer specialist status and is not to be confused with the meaning of “board certification” as used in medicine, osteopathy, dentistry and ABCMO.
Development of Specialists and Board Certification
Until the 1940’s, medical (MD) and osteopathic (DO} physicians and dentists frequently entered practice with degree and license.
With time, the increasing complexity of healthcare led to residency training of 3-5 years in medical-osteopathic specialties after licensure, that accelerated with the concentration of advanced procedures at hospitals which began to prefer, and often require, residency-trained specialists. Today, the 24 American Board of Medical Specialties recognized specialty boards for MDs all require specialty residency training and written specialty examinations for board certification and osteopaths and dentists have similar specialty boards. Altogether, including ABCMO, there are 74 recognized specialty boards for physicians, dentists, optometrists and podiatrists.
About 80% of medical-osteopathic physicians are board certified in a recognized specialty and Joint Commission accredited medical facilities require specialists be residency trained and certified by a specialty board. There is no requirement to be board certified for private practice.
Board certification is therefore synonymous with specialization via residency training and with the clinical privileging of specialists at accredited medical facilities.
Defined-license doctoral prescribing practitioners like dentists, optometrists and podiatrists were slower to develop specialties as their training, degrees and licenses prepare them for general practice without additional training or certification.
Dentistry was the first defined-license doctoral profession to establish specialties and now has 8 dental specialties for which residency training and board certification are required. The great majority of licensed dentists remain in general practice however and virtually all of the 377,000 general practice U.S. dentists practice on the basis of degree and license since the American Dental Association (ADA), state dental boards and credentialing committees accept licensure as fully documenting competency in general dentistry. A board exists to offer board certification in general practice dentistry but it is not recognized by the ADA and has certified less than 1% of general practice optometrists.
Optometry began to move to residency training when the Department of Veterans Affairs established optometry hospital residency training programs in 1975. Optometry since then has designated ten specialties for which residency training is appropriate and the Accreditation Council on Optometric Education (ACOE) accredits optometry residency programs. The Advanced Competence in Medical Optometry examination (ACMO) is administered annually by the National Board of Examiners in Optometry (NBEO) since 2005 and the American Board of Certification in Medical Optometry (ABCMO) incorporated in 2009 to offer board certification in the specialty of medical optometry with a maintenance of certification requirement.
There remain, however, non-recognized boards that grant board certification not requiring residency training, to physicians. These “board certifications” are not accepted at accredited medical facilities, nor recognized by the ABMS or the medical credentialing community. Some state medical licensing boards will not permit holders of these credentials to state they are “board certified” [See NC state medical board “Who may claim to be board certified”.]
While in private practice a licensed practitioner may claim to be a specialist from holding a certificate from a “board”, such specialist claim will be disallowed by credentialing committees at accredited health facilities unless issued by a recognized specialty board. This underlines the chief purpose of board certification which is to grant privileges as a specialist to appropriately trained specialists within a licensed health care profession.
Dr. Myers was founding Director of the VA Optometry Service, dean of an optometry school and currently president of the American Board of Certification in Medical Optometry.