Board certification in optometry: a former insider's view from the outside

It's been 7 years since I retired after 25 years as executive director of National Board of Examiners in Optometry (NBEO), prior to which I was president of Pennsylvania College of Optometry (PCO). Since then I have been active in the management of several national professional societies in specialties of medicine, dentistry, and podiatry. So I have become quite familiar with what board certification means in these professions, which clearly is much different than what it now means in optometry. While I have had no contact with optometry since mid-2005, I was asked to be an “expert witness” for the American Optometric Society (AOS) in its lawsuit against the American Board of Optometry (ABO). But my multi-page written report, a 2-hour deposition, and a few minutes on the stand at the trial recently had absolutely no impact.

The reason? The trial, in a Federal court, really turned on whether an OD who is board-certified by ABO would have a competitive advantage over an equally qualified OD who is not board certified by ABO. It ultimately had nothing to do with whether the ABO program of board certification is credible when compared with board certification as it exists for other doctoral level health professionals also identified with optometrists as “physicians” by CMS for Medicare reimbursement, that is, doctors of medicine, osteopathy, dentistry, podiatry, and chiropractic. And since AOS was not able to convince the judge that this competitive advantage exists (or is likely to exist in the future when the AOA promotes ABO certification for inclusion on insurance panels and hospital staffs), he had no choice but to rule in favor of ABO. But the big winner is not ABO; it's the American Board of Clinical Optometry (ABCO), the certifying board endorsed by AOS, which simply requires an OD to be licensed to be also “board certified.” And maybe that was the reason for the lawsuit in the first place.

However, my interpretation of the court's decision is that any OD who holds any “certificate” that was issued by any corporation called a “board” can now, with the acquiescence of a Federal court, use the term “board certified.” So I assume this applies also to every OD who has passed the “National Boards”; after all, NBEO is a national “board” that issues “certificates” (diplomas), and since its inception in 1951 has identified those who pass all three parts of its examination sequence as Diplomates.

In 1998 NBEO adopted a policy I had proposed, which states "Passing any current National Board examination, including the Treatment and Management of Ocular Disease (TMOD) examination, or any combination of current National Board examinations, is not equivalent to “board certification." That was adopted as NBEO wanted to make it clear at that time that it recognized the difference in the levels of credentialing between licensure and board certification.

Clearly things have changed since then, and the profession, led by its national association (AOA) with the support of all the academic deans and presidents (ASCO) and the most prestigious optometric professional society (AAO), now accepts the premise that board certification in optometry has nothing to do with a specialty area of the profession based on advanced (post-doctoral) and rigorously supervised education and clinical training as exists with all other recognized “medical” professions. So given this consensus by the optometric political, academic, and scientific organizations, it seems reasonable that NBEO Diplomates now have as much right as ABO and ABCO Diplomates to claim to be “board certified in optometry.” The judge in AOS vs. ABO essentially gave his blessing to this unwitting change in NBEO policy, based on the evidence presented to him. It will be interesting to see if the NBEO addresses this obvious, and legitimate, opportunity to re-level the playing field for the vast majority of ODs by supporting this use of the term “board certified” by its Diplomates.

Independent of how the NBEO responds, the debate was never about potential competition; it was always about the credibility of optometric credentials. I worked for 4 decades, first as an optometric educator at PCO, Indiana University, Illinois College of Optometry, University of Houston, and New England College of Optometry, then as executive director of the NBEO, to raise the level of optometric education and its national credentials to be on a par with those of the other major “medical” professions. I was even elected as the only non-MD health professional to serve on the board of directors of the National Board of Medical Examiners (NBME) for two 4-year terms because of the respect that sister national board had for what optometry’s national board was doing in setting standards for initial licensure, not because I was somehow special.

I testified in numerous state legislatures in the 1970s, ‘80s, and ‘90s to help secure broad drug legislation for optometry, including WV and NC that led the way for the therapeutic use of drugs), because I believed that the profession's educational institutions, national credentials, and licensing system were credible and this development in the profession was in the best interest of the public.

More than a decade ago when the American Board of Optometric Practice (ABOP), a similar AOA-inspired board certification program, was introduced, I opposed that as a false credential, and wrote a lengthy white paper that was adopted by the NBEO board of directors that helped end the short life of that organization.

Now we have ABOP redux, and other than the surprisingly (to me) enthusiastic support by two key national organizations (ASCO and AAO), there really is no significant difference between ABOP and ABO. While there are some additional bells and whistles (spend 3 years in practice, take some CE courses, and pass a 240-item exam), optometric board certification is still in-optometry! I can only conclude that the concerns about the credibility of optometry's credentials that I shared with many other academic and licensing leaders for decades are no longer relevant.

What may not have been considered in the formation of ABO is the potential harm of this new credential to optometry's standing in the eyes of its sister health professions and the credibility of its most important existing credentials-the OD degree and the national board exams required for licensure. Perhaps the comments of a current colleague who is actively involved in the board certification process of a medical specialty are relevant here. While this is only one person’s opinion, and thus a limited sample, coming from his position in the active assessment of advanced competence in an area of medical practice he has a broad perspective and speaks with significant authority about “board certification.” I had discussed the ABO program with him when I was considering whether to invest the time needed to be an expert witness for AOS. While he thought the ABO board certification program was weak and not credible, he also argued in support of ABO's rights in the case, that is, board certification is whatever a board says it is. His parting comment was, "if optometry wants to look inferior to the other medical professions it has every right to do so."

That sums it up concisely. After decades of work by many leaders to earn respect for optometry's education and credentials, the profession has regressed 50 years. Only time will tell if this new self-aggrandizing optometric “credential” does anything to help optometry and its patients or, instead, raises issues of trust that will damage the profession irreparably.ODT