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ASCO president says board certification case can be a learning opportunity

September 10, 2012

Editor’s note: Six optometric organizations (the AOA, American Optometric Student Association, Association of Schools and Colleges of Optometry, American Academy of Optometry, Association of Regulatory Boards of Optometry and National Board of Examiners in Optometry) originally formed the Joint Board Certification Project Team in 2007 to examine the issue of optometric board certification and propose a model for certification and maintenance of certification that is attainable, credible and defensible.

At the annual meeting of the AOA in 2009, the House of Delegates voted in favor of the AOA participating in the establishment and governance of the American Board of Optometry (ABO) as the entity to develop and implement the framework for board certification and maintenance of certification.

A lawsuit was brought against the ABO in 2010, and a federal judge ruled in favor of the ABO this year.

As part of the discussion moving forward on this topic, AOA News asked David Heath, O.D., president of the Association of Schools and Colleges of Optometry (ASCO), for his thoughts on the subject.

AOA News: Can you provide some background on ASCO’s involvement in establishing a board certification process?

Dr. Heath: ASCO is one of the founding organizations behind the ABO and nominates one representative to the ABO Board. Three years ago, when I was asked to represent ASCO as a founding member of the ABO Board, I accepted with a specific goal of assuring that the processes developed would be recognized and embraced by the broader health care community. Achieving that goal requires that the initial board certification process and the subsequent Maintenance of Certification (MOC) program comport with health care industry practices and standards. While I believe the ABO has done this every step of the way, including the conduct of a job/practice analysis, the delineation of exam content, the establishment of statistically valid, criterion-based scoring practices and the development of MOC educational programs, the true verdict will be in the acceptance/validation of the program by external agencies.

AOA News: Has the ABO accomplished its goal of offering a valid standard of board certification?

Dr. Heath: The ABO Board is committed to this goal of external review and has demonstrated this commitment through its application to the federal Centers for Medicare & Medicaid Services (CMS) for the recognition of its MOC program, which it has received, and its current efforts to become accredited by the National Commission on Certifying Agencies (NCCA). In both higher education and in health care, it is well-established that it is through external review that the quality or validity of a program or organization is established. The ABO is clearly not the only organization in optometry offering board certification, but it is the only group that has attained CMS recognition. I would hope that any organization offering a board certification and/or MOC program would similarly commit to undergo external review to demonstrate compliance with industry standards. As an aside, while gratifying, it is unfortunate that an additional independent entity to support the ABO had to be the courts.

AOA News: How should one view the court ruling in the ABO case?

Dr. Heath: In our academic programs, we emphasize to students the importance of evidence-based care and the critical analysis of the research that guides our treatment strategies. As optometrists review the ABO case, I would hope that similar intellectual rigor would be applied. The popular discussion of this case is tending to confuse AOS testimony with the conclusions of the court and assumes that testimony is fact. When reviewing the actual judgment and the court’s explanation, I believe you will find the discussion to date provides far more conjecture than evidence, opinion rather than fact, and in many cases fiction presented as fact. One example is in the Plaintiff’s Findings of Fact and Conclusions of Law (submitted to the court as document 209). It stated in reference to ophthalmologists/MDs, “Once they are licensed as a general medical practitioner they complete a 1-year internship followed by a 3-4 year residency program in which they are trained in the specialty….” The statement suggests that it is a fact that MDs are licensed upon graduation from medical school. In reality, MDs can’t take the last section of their national board exams until after a year of residency training, and there is no state in the U.S. that grants a physician a license sooner than after one year of post-graduate training. In fact, there are 11 states that require two years and two states (Nevada, New Jersey) that require three years of post-graduate training before licensure. Interestingly, for those states requiring three years, it appears that licensing as an “entry level” credential could occur at the same time that residency training is completed (for example, family practice), and board certification is granted. In this example, the statement of fact was simply wrong. Fiction was presented as fact, but it was also unfortunately used as a basic assumption to promote a simplified construct of medical education and training against which the profession of optometry and the ABO was to be compared.

AOA News: You attended the trial as a member of the ABO defense team. Can you offer some insight into what was actually ruled by the court?

Dr. Heath: Judge H. Howard Matz decisively ruled in favor of the ABO. There were no qualifications, there were no stipulations, and there was no hesitation. The blogs, the letters, the opinion pieces are all spinning the decision in many different ways. In reality, the case was quite focused and addressed the question of whether the ABO’s, not the ABCO’s or the ABCMO’s, use of the term “board certification” is “false, confusing, deceptive, misleading or tend[s] to be confusing or misleading to the public” in violation of the Lanham Act. The conclusion of the federal court is simply “no” – the ABO’s use of the term “board certification” is not “false, confusing, deceptive, misleading or tend[s] to be confusing or misleading to the public,” and thus the ABO is free to use the terminology. The court did not offer any conclusions on the ABO board certification process itself, in terms of its quality or its value. The court took no position on whether the board certification programs developed by different agencies within optometry are actually comparable or similar to that of the ABO. I would also note, that contrary to the misinformation being disseminated, the court’s judgment does not suggest that the ABO is wrong in claiming its diplomates have demonstrated competence beyond entry level.

AOA News: What is the impact of this ruling and does it affect the value of board certification?

Dr. Heath: As our optometric community considers and debates the impact of this litigation, I would suggest that the value of board certification is not going to be decided in blogs or newsletters. The value of any given board certification program in optometry will be decided by independent agencies, largely external to our profession: federal agencies, insurance companies, health care delivery systems, hospitals, and credentialing and privileging committees, among others. These groups will not accept a board certification credential simply because it is listed on an application, nor will a value be assumed simply because it is “verified.”   Those making appointment, credentialing and privileging decisions are intelligent individuals whose job it is to understand what is behind the credential and what is the value added to the review of a provider by that board certification credential – they will make those decisions and render judgment. At this juncture, from my personal perspective, our continuing internal debate has limited impact, other than intra-professional injury, and the broader health care industry will determine the value of any board certification/MOC process offered by optometry.

AOA News: How do you see board certification and maintenance of certification fitting into the future of optometry?

Dr. Heath: Our schools and colleges of optometry have a responsibility to educate and to develop students into high-quality eye care providers with analytical minds, who demonstrate a high commitment to life-long learning and the ongoing enhancement of patient care. I personally believe that an effective board certification process with MOC can be an integral part of a life-long developmental process and that the ABO provides such a path. I also believe that the further integration of optometry into the health care delivery system and the inclusion of optometry as a member of an interdisciplinary health care team require that we commit to the same kind of quality assurance programs that other health professions have embraced, and board certification/MOC is one of those. Practitioners, our faculty, and indeed our students as future colleagues will need to make their own decisions – the pursuit of board certification is a voluntary process – but I would urge them to make the decision based on a first-hand assessment of the evidence and not based upon rhetoric. In the long term, I believe the ABO board certification and Maintenance of Certification programs will play a critical role toward achieving the profession’s goal of full inclusion in our health care system. As an aside to my colleagues in optometric education, I would suggest that this case can be a great teaching opportunity.

Dr. Heath serves as president of the State University of New York State College of Optometry. He is a professor and has a master’s in Education. He is active in the AOA and the New York State Optometric Association.

5 comments

  1. Yes, students now in training provide a fertile ground for indoctrination. New generations never know what it was really like in any field of endeavor.


  2. Every optometrist should read this interview two times. It hits the highlights of the board certification process which began in 2007. I applaud Dr. Heath and the other leaders who work so hard for our profession.

    Warmest Regards,
    Mark Herriott Kansas


  3. Please list those advantages board certification has over current licenceing and post-graduate options!


  4. Dr. Heath: This is Jim Studebaker, O.D. at Northwest Optometry in Englewood, Ohio. I hold a 1962 BS and and a 1963 MO in Optometry from I.U. and a 1977 O.D. from The Ohio State University and have been a senior examiner for the National Board of Optometry. I pasted all three parts of the National Board of Optometry in 1962 and 1963 and am entering my 50th year in practice here in Englewood.

    I practice with my two sons Joseph and Peter who also hold OD degrees from The Ohio State University. They have also been examiners for the National Board of Optometry and have also passed all three parts of the National Board. Joseph is a past president of Ohio State Optometric Association and a fellow of the American Academy of Optometry and Peter has been on the staff of the Dayton, Ohio VA for several years in the past.

    Needless to say we already feel very well “Board Certified” and deeply regret the divisiveness this subject has caused in our beloved profession of OPTOMETRY.

    The best piece of writing I have come across on this subject was written by Larry J Alexander, O.D. FAAO. If his advice on this subject were followed it might be possible to reign in some of the damage this movement has caused in OPTOMETRY. If you have not seen it and would like a copy of Dr. Alexander’s writing I would be glad to furnish a copy.


  5. This is yet another example of the tail wagging the dog. Insurance companies do NOT require us to have board certification, and I am sick and tired of my “leaders” telling us that we have to set up hoops to jump through because if we don’t, someone else will set up the hoops. Don’t give me that BS that we will lose access to patients. If you are a good doctor, you will have patients. And, let’s face it, ophthalmologists will not be willing to see “routine” exam patients for the pittance that is paid for them, nor will they have enough numbers to perform the job adequately if they wanted to do so. Patients will demand their eye care, and they will get it one way or another. Maybe if “independent stand-alone vision plans” aren’t invited to play in the new health care system, we might actually make enough per exam to take time to listen to the patient.

    You may call this a voluntary program. It is not. Once YOU put that box on the insurance credentialing form, we will all have to check the box. And what does that mean? Well, of course you respect us enough to tell us you know we’ve been keeping up with our journals and our seminars and webinars, and that our continuing education hours are worth something, and that we’re just being tested on our proficiency to prove it to….someone. So, this means I should be able to walk into one of those tests and pass it, right? So what’s the point?

    Oh, no. We have to have review seminars. Study sessions. Simulated tests. Who benefits? Follow the money. More for AOA, more for ASCO, and on and on. And for the speakers, the testers, the test-graders….and don’t forget that we’ll have to pay to become certified. Lather, rinse, repeat……

    All my journals tell me about all the equipment I need just to keep up with standard of care, like retinal imaging systems as just one example. And I’m told ICD-10 conversion will cost each one of us $100K. Not to mention all the costs associated with meaningful-use and office management software and constant hardware updates.

    All the while these organizations do nothing about our pitiful reimbursements while advertising to insurance companies that it’s better to involve ODs in their plan BECAUSE WE WORK CHEAPER.

    And you want me to pay all this money and time to avoid a totally imaginary crisis?

    Lastly, this plan severely penalizes those students you are “developing” into “high-quality eye care providers with analytical minds”, as they cannot become Board Certified for their first three years of practice, at exactly the time when they need unfiltered access to patients. If we all have to check the “Board Certified” box, these people will be intentionally out in the cold. Whose bright idea was that?

    I know you’re proud of the fact that you’re involving “independent agencies, largely external to our profession”. This is asking for the box, pure and simple. You remind me of the City Council in my hometown: they decide an issue, and then bring it up for “discussion” by the great unwashed. Then you count the votes the way you want to, and force your decision down the throats of the “little people”.

    I moved from my hometown for that reason. And, I’m leaving the AOA for the same reason.

    I read that less than 2% of the practicing optometrists has been willing to take the exam. Don’t flatter yourself into thinking that this will be a well-accepted program.



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