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Optometrists put board certification program on hold; OD summit to be held
Delegates at the annual meeting of the American Optometric Association halted the plan to create a national board that they approved last year.
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LAS VEGAS — After months of debate, optometric board certification came to a standstill at the American Optometric Association (AOA) 103rd Congress here when the House of Delegates voted to halt the board certification process that they had started just a year ago.
At the 1999 House of Delegates meeting in San Antonio, a special committee introduced resolution 1935, on which an overwhelming majority voted to adopt board certification.
While the rest of the town talked about the NBA finals, the AOA delegates in the last week of June were focused on optometric board certification. A plan to establish an American Board of Optometric Practice (ABOP), the first national certification body for optometrists, had been proposed. The opponents seemed to be few but fierce.
The resolution stated that for an optometrist to become board-certified for a period of 10 years, practitioners would have to complete 10 hours of board-certified continuing education. Each course would be followed by an exam. To achieve recertification, a practitioner would need to complete and prove competency in 50 hours of board-certified continuing education over a 10-year period, which would include successfully passing the accompanying tests. A minimum of 20 hours of these continuing education courses needed to be completed within the 4 years preceding recertification. Additionally, applicants for recertification would have been required to obtain a passing score on an independent, open-book examination administered by ABOP. Board recertification would be granted for a period of 10 years beginning on the expiration date of the previous certificate.
In order to apply for board certification, optometrists needed to possess either a diagnostic certificate or a therapeutic license — credentials beyond the OD degree that authorize them to use diagnostic and therapeutic drugs, respectively, in their state of licensure. ABOP planned to phase in the requirement of a therapeutic license for all applicants.
For those ODs who enrolled in the first year of ABOP certification, the fee was to be $300; the second year, $400; and for the third year and beyond, the cost would have been $500. The graduated fee scale was designed to encourage early enrollment.
Why ABOP?
A national board certification program for optometry was advanced partly in response to the growth of managed care. Proponents of board certification felt that instituting a national program would assist in optometrists’ inclusion in managed care plans and enhance their status and that of the profession by exhibiting ongoing competency training.
“We don’t have to do this, but managed care and the way medicine is being changed in the marketplace right now calls for higher quality assessment and improvement in all areas,” said John A. McCall, Jr., OD, who was president of the AOA during the 1999 House of Delegates meeting and presented the ABOP proposal to the delegates. He told Primary Care Optometry News at that time that “This extra step, if optometrists choose to participate, will enable them to be certified by a national board that will have standards with ongoing competence training that nobody else has. We think that will benefit optometry in the marketplace.”
Those opposing the creation of ABOP argued that the goals of the program were already sufficiently covered at the state level and that optometrists had not been given enough time to evaluate the program proposed by the AOA’s Board Certification Project Team.
Missouri delegate Jack W. Bennett, OD, made a motion to postpone a vote on the matter until the following year’s meeting. One after another, board certification opponents made speeches supporting the postponement or abandonment of board certification. ABOP advocates made their own motion to halt discussion and put the proposal to an immediate vote. That motion was defeated, and the debate continued. Amendments to the board certification plan were proposed in order to delay the vote, but each one failed. Finally, after 3 hours of debate, a voice vote on the resolution was called. It passed overwhelmingly, and advocates of board certification cheered.
Opposition continued
Even as a Board of Trustees was being formed for ABOP, optometrists who saw no need for board certification continued their opposition. At state society meetings and in letters to optometric publications and the AOA itself, they said that ABOP was unnecessary or potentially harmful to the profession. Some critics even alleged a financial motive for the plan.
“Let’s recognize this for what it is: a way for the AOA to gain revenue without raising dues. Multiply 37,000 members by the $300 application fees, and you get $11.1,” wrote Norman M. Kahn, OD, in a letter published in the November 1999 issue of Primary Care Optometry News. (Primary Care Optometry News is published by SLACK Incorporated, the publisher of Ocular Surgery News).
On Feb. 15, 2000, the Board of Directors of the National Board of Examiners in Optometry (NBEO) released a position paper on the AOA’s board certification plan.
The NBEO is the national body that administers the examinations used by state boards of optometry in licensing optometrists. Their position paper stated that “any new national credentialing program to be introduced into the profession should be targeted at developing and documenting advanced competence only. Creating a new national credential with less credibility than existing credentials, or that competes with, or does not exceed, the standards required for obtaining and maintaining an optometric license would be a waste of time and resources or, worse, could reflect badly on all optometric credentials in the eyes of the public and other health care professions.”
Advanced certification or not?
In an interview NBEO president D.R. Gordon, OD, focused on the fact that ABOP was not proposing a higher-level certification than already existed.
“Through our conversations with the ABOP board we were told that this board certification program in no way intended to elevate the level of training for optometrists,” Dr. Gordon said. “It is simply a program aimed at maintaining clinical competency skills for the practice life. In the 10-page letter sent by ABOP to all of the AOA members, I don’t think it comes across loud and clear that there will be a lot of expense, paperwork, courses to attend and and tests to take in order to maintain nothing more than clinical competency, which is the job — by statute — of the state boards.”
“Board certification is aimed at advanced competency,” replied ABOP secretary-treasurer Thomas L. Lewis, OD, PhD. “That’s why it requires at least 2 years of practice experience before you can begin the process. It seems to me that it is clearly beyond entry level and clearly beyond what the national board tests for entry-level competencies as it relates to initial licensure.”
With continuing opposition to board certification coming from other optometry organizations, the AOA scheduled additional discussion and another vote on ABOP at their June 2000 Congress.
In the months leading up to the second vote, the debate was revisited at the state level.
Texas vs. Indiana
The Texas delegation to the 1999 AOA meeting voted in favor of board certification, hoping that it would help more Texas ODs get onto managed care panels.
“I’m not on a single managed care panel,” said Laurie L. Sorrenson, OD, who had just finished a term as president of the Texas Optometric Association (TOA). “I have been turned down over and over again.”
Dr. Sorrenson and her colleagues saw board certification as process familiar to managed care plans that would objectively establish education and competence.
“Third-party insurers fall into the medical model, and we as optometrists have always tried to say that we’re different. In reality, we need to recognize that there is a medical model, and we need to be a part of the system instead of standing outside it....”
But such a profound change was bound to cause optometry some strife, she admitted.
“Every time our profession has changed there has always been controversy, and there have always been people who thought we were going in the wrong direction. Fortunately, the nay-sayers did not prevent our profession from moving forward.”
When the AOA said that another board certification vote would be held, the TOA reviewed the issue and again decided to support the creation of ABOP.
“Fervor of the opposition”
The Indiana Optometric Association (IOA) also went back to the state’s 12 local societies and asked them to reconsider board certification.
“When they came to the state convention in April [2000] a resolution was presented asking us to vote against board certification,” said IOA president Marjorie Knotts, OD. “It was voted through our House of Delegates unanimously.
Indiana optometrists apparently do not need of board certification to gain access to managed care plans.
“We felt it was more a matter of whether they felt optometry was a good match with their panel rather than the fact that we were not board certified,” Dr. Knotts said. “Additionally, one of the major insurance companies in Indiana just informed us that board certification is not necessary for participation in any of their programs.”
When asked again how their AOA delegates should vote on the resolution to create ABOP, the answer of Indiana’s optometrists was clear.
“We were surprised by the fervor of the opposition,” Dr. Knotts said. “The members don’t feel there needs to be a new board certification process duplicating what our state board does, and there is no documented need for a new kind of certification that might lead to confusion among professionals, third-party payers and, most importantly, our patients.”
Board certification: round 2
By the time AOA delegates started arriving in Las Vegas, the consensus was clear. So many states had found their constituents opposed to the ABOP plan that there was a real possibility of it being killed outright. Optometry was not ready for board certification.
The Board of Trustees of AOA, which had invested its time and was about to invest a lot more of its money in ABOP, circulated a new amendment (Motion 6 on the order of business) a day before the House of Delegates was to discuss board certification.
Once again Dr. McCall addressed the House of Delegates, this time not as AOA president but as president of ABOP. He described the new resolution, which would put ABOP on what some ABOP supporters and AOA delegates were calling “life support.”
The resolution stated:
“1) That all implementation of the board certification process shall cease immediately, and that there be no new expenditures of AOA funds for the activities of the American Board of Optometric Practice (ABOP) unless approved by the House of Delegates; and
“2) That the AOA shall convene a summit on board certification and continued competency; and that such a summit shall be facilitated by an outside party, and include, but not be limited to, representatives – of their own choosing – of the following national optometric organizations: the American Academy of Optometry (AAO), Association of Regulatory Boards of Optometry (ARBO), Association of Schools and Colleges of Optometry (ASCO), National Board of Examiners in Optometry (NBEO), American Optometric Student Association (AOSA), Neuro-optometric Rehabilitation Association (NORA), College of Vision Development (COVD) and the Optometric Extension Program Foundation (OEPF), as well as representatives from affiliated associations at a time and location to be selected by the AOA which shall make a report on the conference to the House of Delegates in Boston at the 104th annual Congress in June 2001.”
First to comment were representatives of organized optometry.
The Association of Schools and Colleges of Optometry was unenthusiastic about board certification, the National Board of Examiners in Optometry called for a national summit and “a clean slate” before any additional certification is imposed on optometrists, Association of Regulatory Boards of Optometry said only that they declined to be represented on the ABOP board of trustees and the American Optometric Student Association said flatly that it does not support board certification.
The floor was then opened for general comment.
Speaking out on board certification
The original ABOP plan still had its advocates, and they did reiterate their support. Ironically, however, the creation of a national board was seen by many ODs to be dividing optometry against itself.
Charles B. Brownlow, OD, FAAO, executive director of the Wisconsin Optometric Association, urged the House to vote in favor of the motion to halt board certification, allowing ABOP to stand as an inactive corporation with the work that has already been completed. “The profession is constantly being threatened from without,” he said. “We can withstand threats from without. We cannot withstand threats from within.”
W. David Sullins Jr., OD, of Athens, Tenn., a former president of the AOA, said that while evaluating continued competency is necessary, this program has divided the profession. “I have no doubt that the ABOP board of trustees did what they were charged to do in San Antonio and that they did it well,” he said. “However, I have never seen anything be as divisive to this profession as this issue.”
While A. Norman Haffner, OD, president of the State University of New York College of Optometry, agreed that the issue is divisive, he questioned the credibility and competency of the program. “The closeness of ABOP to the AOA has not yet been raised, and it should,” he said. “Isn’t it strange that ophthalmology hasn’t uttered a word about this? I urge the house to get rid of it. It is not appropriate. It is flawed and we can do, and have done, much better.”
In a 971 to 674 vote, the House passed Motion 6. Optometric board certification is now on hold.
A fair discussion of board certification
Many who attended this year’s Congress said they thought that the discussion that took place prior to the vote on board certification provided both sides with a relatively open forum in which to present their views. “My overall impression was that it was handled much better than it had been the year before,” said Dr. Knotts, the Indiana Optometric Association president whose state’s House of Delegates had voted against board certification. “There was a real effort by [immediate past president of the AOA] Dr. [Harvey] Hanlen, I felt, to make it an inclusive and fair discussion in general. I was very pleased by that. The only comment I would make in the negative is that when we got down to actually voting for the important vote, the question was called very quickly and there wasn’t time to really pull things together. But I thought he gave a very fair shake to most of the discussion.”
Linda Casser, OD, member of the board of directors of the NBEO who spoke to the House of Delegates about the incredibility and indefensibility of the process, agreed that the meeting proceeded relatively fairly. “Given how processes of this nature tend to unfold, I would say that the process was a reasonably fair and open-ended one,” she said. “I believe the preference would have been for the plan to unfold as it had been originally proposed, and that was to have a vote solely on the motion to continue Resolution 1935 rather than amend it; that added a dimension to the process that wasn’t projected initially. But given how these things tend to unfold, perhaps it wasn’t a surprising approach, and I feel reasonably comfortable with the process as it was conducted on-site.”
Dr. Casser said that the NBEO is waiting for word on the upcoming summit, which comes close to what it had suggested in its position paper on board certification. “It certainly speaks in good measure to the concerns that we had, and that bringing everyone together is going to be an important process,” she said. “It doesn’t meet the issue 100%, but it certainly is a solid step in that direction.”
Dr. McCall, former president of the AOA and driving force behind the board certification process, said he was glad to see the work that has been accomplished in the formulation of the program retained. “I was proud of the House of Delegates rejecting the call from the ASCO and the NBEO to dissolve the process and start over with a clean slate,” he said. “To start over would mean to dissolve ABOP and throw away the document that has already been produced. That document has 34 months of work put into it, countless hours, and it is a very credible and defensible document. That suggestion, alone, would not be a prudent one. I was glad to see the House reject it.”
ABOP president resigns
The meeting also witnessed Dr. McCall resign from his post as president of ABOP, a measure taken in order to protect the future of board certification, he told Primary Care Optometry News. “By pushing this and meeting with individuals, states, regions and national organizations and explaining very passionately the position of the AOA and ABOP, if some group happens to have an opposing view, my passion tended to polarize them,” he said. “I realized after a while that some of the opposition was directed at the concept, which is OK, because a differing of opinion is healthy for a profession, especially when it’s trying to advance. But some of that was directed at me — it became personal for a lot of people and a lot of organizations. I finally came to the conclusion that if we’re going to move toward a national summit, and try to get national groups together on this with more input, then my polarization effect needed to go away. I believe the process is too important to let me be a factor in that not going forward.”
Dr. McCall said that while ABOP currently is not being funded by the AOA, the organization still remains an entity. His resignation, however, is permanent. “We have excellent leaders and educators who are on ABOP right now that have done a huge amount of the work,” he said. “Those people need to rise up and be seen and heard from right now, because they are a tremendously talented group, and too much focus has been on me.”
Has certification divided optometry?
Dr. McCall agreed that board certification has divided optometry, but it has not been the only issue to do so. “I do believe it has been divisive,” he said. “So were diagnostics and, especially, so were therapeutics. If we’d had a national summit on therapeutics in 1976, the majority of the states wouldn’t have bought in. Looking back, as a therapeutic profession with all 50 states and the District of Columbia, obviously this was the natural maturation of the profession that needed to go there. This is going to be the same way. The key difference here is that this profession is not used to being led from the national level.”
Recognizing the urgent need for board certification, Dr. McCall said, is what prompted starting nationally with the AOA. “We looked at this saying that this is too big of an issue to start at the ground level and move up, since we already know from past experience that it is a 25- to 30-year process for that to happen,” he said. “Do we have 25 or 30 years to wait for board certification to be integrated into optometry? We think no. We think that within the next 3 to 5 years, this will happen, and this must happen, because of the way the health care system is maturing in the United States today.”
For Your Information:
- Charles B. Brownlow, OD, FAAO, is executive director of the Wisconsin Optometric Association. He can be reached at 5721 Odana Road, Ste. 102, Madison, WI 53719; (800) 827-1945 or (608) 274-5044/4322; fax: (800) 308-7189 or (608) 274-2674/8646; e-mail: Brownlowod@aol.com.
- Linda Casser, OD, is a member of the board of directors of the National Board of Examiners of Optometry. She can be reached at Pacific University College of Optometry, 2043 College Way, Forest Grove, OR 97116; (503) 359-2766; fax: (503) 359-2929; e-mail: casserl@pacificu.edu.
- A. Norman Haffner, OD, is president of the State University of New York College of Optometry. He can be reached at 33 W. 42nd St., New York, NY 10036-8003; (212) 780-5050; fax: (212) 780-4949; e-mail: anhaffner@sunyopt.edu.
- Marjorie Knotts, OD, can be reached at 6326 Rucker Road, Ste. C, Indianapolis, IN 46220; (317) 259-4234; fax: (317) 259-1538.
- John A. McCall Jr., OD, is past president of the American Optometric Association. He can be reached at 711 E. Goliad, Crockett, TX 75835; (409) 544-3763; fax: (409) 544-7894.
- W. David Sullins Jr., OD, can be reached at 417 N. Jackson St., Athens, TN 37303; (423) 745-4910; fax: (423) 745-2230.