A majority of optometrists are content to describe themselves as primary eyecare providers, but over one quarter feel they also possess “subspecialty skills” in one or more specific niches — and they would like such capabilities to be recognized by others, too.

Jack Persico, Editor-in-Chief Review of Optometry

Excerpt from Review of Optometry: Optometrists Ready to Step up to Subspecialization

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For additional information about optometry specialties including current and proposed Specialty Boards, please see the American Board of Optometry Specialties.

Excerpt from Ophthalmology Workforce Expected to Decline 12% by 2035, Review of Optometry, September 22, 2023

“While projections show that the number of full-time ophthalmologists will decrease by 2,650 between 2020 and 2035, the demand for these doctors will increase to 5,150 representing a supply and demand mismatch of 30%“

Full Article: Ophthalmology Workforce Expected to Decline 12% by 2035

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Reflection

This supply and demand mismatch presents two options: 1) cutting eye care services or 2) expanding the Scope of Practice for other professions to cover the deficit. Which option is in the best interests of patients? Which option will the public support?

Introduction

In this editorial, which first appeared in the Portsmouth Herald, Dr. James Fieseher addresses the increased bureaucratization of the U.S. healthcare system.

We Need a Better Healthcare System

Our current model of healthcare was conceived in the late 1960s and launched during the Nixon administration as a not-for-profit, managed care system. Wealthy entrepreneurs saw an opportunity to make a fortune and by the Clinton administration, U.S. healthcare was managed by for-profit companies. The exceptions were the VA system, Medicare and Medicaid.

Read the Full Editorial

Introduction

Certification by ABCMO as a board-certified specialist in Medical Optometry requires three achievements beyond those required for licensing as a general practice optometrist. Those requirements are:

1. Completing a post-graduate, one-year clinical residency training in the recognition and treatment of diseases and functional disorders affecting human visual tracts. A one-year ACOE accredited residency at a Joint Commission accredited medical hospital is required.
2. Passage of the National Board of Examiners in Optometry specialty examination, Advanced Competence in Medical Optometry.
3. Submitting an application to ABCMO that documents having met all the requirements for ABCMO Board Certification as a specialist in Medical Optometry.

But, equally important as the clinical ability gained while meeting the above requirements, is having learned to practice within a medical facility where skills in professional interactions, referrals, patient reviews, and rounds are learned by working with different professionals in an environment where, as a medical staff member, one is regularly evaluated by peer review and expected to attend rounds and regular case reviews.

The ability to be credentialed in these skills first became possible when the Veterans Administration (VA) opened the first hospital residency program for graduate optometrists in 1975.

A Shift Towards Hospital-Based Health Care

A revolution in how health care is delivered began in 1980. Now, the majority of medical physicians no longer own independent private office practices and, increasingly, are employed by, or affiliated with, large hospitals and clinics.

Once, most pharmacists owned their retail pharmacy or worked in one owned by a pharmacist, but 5 of the largest big box store chains today employ fully 80% of all licensed pharmacists. Pharmacy reacted by adopting the Pharmacy doctoral degree and developing specialty residencies for those seeking to practice within medical facilities. Many of these are at VA medical facilities.

Another example, Audiologists no longer earn a Masters Degree but instead a Doctor of Audiology degree and prefer clinical practice rather than retail practice.

This transformation of health care into a commodity sold to the public by advertising emphasizing cost-savings and convenience accelerated when the Federal Trade Commission (FTC) claimed advertising by professionals lowered costs and should be permitted. This led the American Academy of Optometry (and many other professional societies) to remove restrictions on advertising by their memberships.

This transformation had a profound effect on retail optometrists especially after the FTC announced a study comparing advertising to non-advertising optometrists “showed” no difference in the accuracy of eyeglass prescriptions issued to FTC investigators. Unfortunately, the FTC did not reveal that its study had actually shown:

1. Advertising optometrists ranked last in the quality of the eye exams they performed.
2. Examinations by non-advertising optometrists ranked significantly higher.
3. Examinations by Fellows of the American Academy of Optometry ranked even higher in their quality.

Had the FTC merely read past issues of the leading national consumer-oriented publication at the time they would have learned through surveys of readers’ opinions about their optometry exams that optometrists who did not advertise were rated significantly higher in the quality and thoroughness of their examinations than those provided by retail advertising optometry stores.

The Rise of Hospital Specialties in Optometry, Pharmacy, Audiology, and Podiatry

The majority of those entering training in health care professions do not expect, nor plan to practice, in a retail setting as they anticipate their clinical skills will erode from underutilization. Pharmacy is a prime example and while the majority of pharmacy graduates still practice at the retail level, an impressive number of hospital specialty residencies for pharmacy graduates have been created in the last 25 years and entry into them is highly competitive. Podiatry and audiology have also followed the same path.

In 1975 the first hospital optometry residency was established at a VA hospital. Funded by the VA Office of Academic Affiliations in Washington, it was a start towards creating a cadre of optometrists trained to practice in VA hospitals because at that time the VA’s 172 hospitals had but a total of 6 optometrists on their combined medical staffs. By contrast, military hospitals and HMOs at that time had over 1,000 optometrists on their medical staffs.

Today some 220 VA residencies in medical optometry exist and over 1,400 4th year optometry students serve one or more VA rotations prior to graduation. Overall, about 28% of optometry graduates choose to enter a residency of which the majority are based at VA medical facilities and center around the specialty of Medical Optometry.

The current Optometry Residency Matching System (ORMS) was created and first operated by Dr. Charles Haines, a former VA clinical optometrist. After he retired he donated it to the Association of Schools and Colleges of Optometry which now makes residency matches.

Closing Thoughts

It is hoped this Reflection will assist optometry students considering whether a residency in Medical Optometry is for them by highlighting how it is primarily designed to train those seeking to practice within an accredited medical facility, or as a faculty member, rather than in a retail facility.

Currently, Medical Optometry is the only optometry specialty aligned with the three steps of board certification described above that is also recognized by credentialing committees at over 130 Joint Commission accredited medical facilities across the nation.

To learn more about Pharmacy, the split between “Retail” and “Clinical” career paths, the role of Residencies in education and training, and the development of Clinical Pharmacy Specialists please review Retail and Clinical Pharmacy

For more information about Optometry within the VA please review the resources here at ABCMO.org or at VA Optometry or the VA Office of Academic Affiliations.

 

Note: This first appeared in Optimum VA, The Official Newsletter of the National Association of VA Optometrists, January/February 2022.

The Accreditation Council on Optometric Education (ACOE) is requiring each optometry residency program to list the advanced competencies their residents are expected to attain. The National Board of Examiners in Optometry’s (NBEO) Advanced Competence in Medical Optometry (ACMO) exam is a nationally recognized test that validates these competencies and is already a metric being used by many VA residencies.

Once a residency-trained optometrist passes the ACMO examination, they may apply for Board Certification with the American Board of Certification in Medical Optometry (ABCMO). Both the ACMO exam and Board Certification through ABCMO offer residents an opportunity to create a distinction for themselves consistent with the medical model that incorporates specialty residency training and national testing. This is an idea we all try to encourage in them and often is the main reason why they elected to do a VA residency.

As you probably know, if a resident chooses VA employment after finishing residency there are employee recognition awards, in particular, the Special Advancement for Achievement (SAA), that the ACMO exam alone used to satisfy. However, with 2019 updates to the VA Handbook 5017, SAAs are no longer given for passing the testing component, but now ONLY for the attainment of Board Certification.

While it was previously advantageous for a resident to wait to take the ACMO until federally employed, they are now financially incentivized to take the ACMO exam during residency as the exam fee is discounted by $300 for residents. Further, the old notion that an SAA opportunity will be lost no longer applies. The passage of ACMO as a resident moves VA employees one step closer toward ABCMO Certification eligibility to meet that SAA criteria.

Requiring VA optometry residents to take the ACMO exam during their residency will also help with the following:

1. Satisfy the ACOE’s updated Optometric Residency Standards 2.1 and 2.4 that address residents’ attainment of advanced competencies upon completion of the program
2. Advance residency-trained optometrists toward ABCMO Board Certification eligibility
3. Save money by taking advantage of NBEO’s discounted ACMO fee for residents
4. Position future VA optometrists for SAA opportunities early in their career

The ACMO exam is offered annually. To register for the test or for more information, please visit

https://www.optometry.org/exams/acmo

The message is simple: Times have changed. With the updates to the VA Handbook 5017, it is in the best interest of residents to take the ACMO examination during residency. Likewise, programs will be in compliance with updated ACOE standards.

-Richard Zimbalist O.D., FAAO, Truman VA Hospital, Vice President ABCMO
-Douglas Rett O.D., FAAO, Chief Boston VA, Board of Directors ABCMO