Why Board Certification of Optometrists is Unnecessary

So, what are the problems, and what's so wrong with the AOA's proposal for Board Certification?

The AOA's Board Certification Proposal Harms Optometry

It all starts with how the AOA/ABO defines their Board Certification:

"A voluntary process that establishes standards that denotes that a doctor of optometry has exceeded the requirement(s) necessary for licensure. It provides the assurance that a doctor of optometry maintains the appropriate knowledge skills and experience needed to deliver quality patient care in optometry."

With that definition in mind it is easy to see the myriad problems with the AOA/ABO proposal:

 

The AOA's Definition of Board Certification Implies That Optometrists Are Not Competent

Breaking out the definition of board certification above, there are two "clauses" here that the AOA's BC represents:

  1. That the BC’d OD "has exceeded the requirements necessary for licensure"; and
  2. "Provides assurance that an [OD] maintains" the skill and knowledge to deliver quality care.

This says that by virtue of being AOA/ABO board certified, the doctor's knowledge, skills, and experience (e.g. his/her training) exceeds that required for licensure, and, therefore, it follows that he/she is likely to be more competent or a better doctor than an optometrist that is "merely" licensed. These suppositions are false and the definition puts the AOA in the position of having to contend to the world that BC’d docs are more qualified or better doctors than non-BC’d docs. If asked point blank, Mr. AOA, based on your definition of board certification, isn’t it true that a Board Certified Optometrist is a more qualified doc to provide eyecare than one that is not BC'd?, what do they say?

Second, the definition necessarily implies that if a doctor is not certified by the AOA/ABO there is no assurance that he/she has the knowledge, skills and experience to deliver quality patient care. That's patently false and profoundly demeans the entire profession, not to mention the National Boards and the optometric educators.

Both of the two statements, demean optometry and optometrists. They say that non-BC'd docs aren't as competent as BC'd ones (two classes of doctor?) and, more importantly, that without the AOA's certification, and the "extra knowledge, skills and training" that BC supposedly represents, there's no assurance your optometrist is competent.

 

Optometric Licensing = Medical Board Certification

The AOA compares board certification to medicine, however it really isn't comparable. Physicians are never licensed in their respective specialty. The only evidence that a physician is competent to practice his/her medical specialty is board certification. On the other hand, the completion of four years of post-graduate optometric education leading to Doctor of Optometry degree, the passing of extensive national board testing, obtaining state licensure and meeting state-mandated continuing education requirements to keep your license all work together to assure that optometrists are trained and competent to practice optometry. Quite simply, by virtue of obtaining your optometric license you are proven to be a competent optometrist in the same manner as an ophthalmologist’s obtainment of board certification proves he/she is a competent ophthalmologist. There is no evidence that third party payers do not understand this distinction between medicine and optometry and that they would require optometrists to prove competence beyond maintaining their license by meeting their state's continuing education requirements.

The AOA/ABO's Board Certification is Deceptive and Misleads the Public; Board Certified Does NOT Mean "Better"

The AOA's proposal declares that completing optometry school at an accredited college or university, passing all parts of the National Board examinations, and meeting the requirements to be licensed by your state are insufficient to prove that you are competent to practice optometry. Under the AOA's proposal only optometrists Board Certified by the AOA/ABO have actually proven ("assurance") they are competent. This is false and should offend every optometrist and optometric educator in the United States. The AOA's proposal claims further that optometrists Board Certified by the AOA/ABO have training and/or competence beyond that demonstrated by licensure. That too is false, demeans all optometrists, and misleads the public. Being in practice 30 years, for example, and passing a test does not prove you are more competent than any other optometrist. The AOA/ABO's board certification misleads the public into thinking that board certified optometrists are better trained and more competent than those that are not -- that they are "better" optometrists! This is simply not true.

The AOA/ABO's Definition of Board Certification Does Not Need to Be Misleading to Prove Continued Competence

The AOA acknowledges that Board Certification itself is not necessary, what's needed is to demonstrate continuing competence. The AOA's proposal is premised on the assumption that the only way to demonstrate continuing competency is through maintenance of certification (MOC), and MOC requires something to maintain, namely, board certification, since this is consistent with the medical model with which third party payers are familiar. The AOA further assumes that, to be credible, board certification needed to represent something more than entry level competence. Herein lies the fallacy of the AOA's proposal (see the bullet points above!). Continued competency in optometry can be demonstrated without the deceptions inherent in the AOA's definition of board certification. Instead of suggesting licensed doctors are not competent the AOA/ABO could just as validly, more honestly, and far more easily assume competency via licensing as the starting point, and from there develop a national program for certifying demonstrated continued competency. The point is simple: the AOA/ABO's Board Certification proposal is not only misleading, but carries a lot of baggage and cost that is not necessary to achieve the AOA's goals.

The AOA/ABO's Board Certification Will Not Be Voluntary For Private Practice Optometrists

Currently there is no such thing as board certification for optometrists. If a third party plan made board certification or maintenance of certification a requirement ALL of optometry would be eliminated, which clearly they will not do since it would leave many of their beneficiaries without accessible eye care, glasses, or contact lenses. If the AOA rejected board certification the third party plans would also reject it as a criteria for optometric participation. But, create board certification, and they can (and will) adopt it as a requirement. Consider how VSP approached TPA's. It was only a matter of time before VSP made TPA certification a requirement to be a VSP provider. But nobody can require board certification if there is no program of board certification. Create one and, no matter how "voluntary" the AOA/ABO may say their program is, it may well become a practical necessity to private practice, bringing with it substantial additional expense, additional CE over and above what your state license requires, burdensome testing every 10 years, and the risk of losing your ability to accept VSP or other third party plans if you don't pass that test! Will you lose your license if you fail the test? No. Will you lose your ability to make a living in private practice? Quite possibly.  

The AOA/ABO's Board Certification Proposal Divides and Weakens Optometry and the AOA Itself

Through its definition of board certification the AOA's proposal divides optometrists into two classes. The first, those Board Certified by the AOA/ABO, the AOA claims are optometrists that have proven ("assurance") they are competent and/or trained beyond licensure/entry level. The second, notwithstanding that they are fully trained and licensed to practice optometry, the AOA considers to have not proven ("no assurance") that they are competent!

This separation of optometrists into two groups harms and weakens optometry, and is an affront to all optometrists, colleges, universities, and National Boards, and to all regulatory authorities that license optometrists. There is no reason for competent optometrists (full time educators and doctors that don't accept insurance, for instance) that do not participate in third party plans to obtain the AOA's board certification or MOC since it's only functional purpose is to avoid exclusion from third party payer plans, yet the AOA will, if not expressly, then implicitly be telling the public and government and third party payer plans that this latter group of doctors are not necessarily ("no assurance") competent. This is repugnant to the long established practice of the AOA and will harm both optometry and the AOA itself.

The AOA's Proposal Usurps the Authority of Optometric Licensing Boards and Confuses the Public

Every state licensing authority (e.g. Board of Optometry/regulatory board) has among it's legal obligations to its respective State and the citizens of the State to assure "that a doctor of optometry maintains the appropriate knowledge skills and experience needed to deliver quality patient care in optometry." A primary function of a state board is to protect the public from incompetent doctors. That is why, for instance, every state requires continuing education as part of the license renewal process. By purporting to do the same thing, assuring competence, the AOA/ABO proposal appears to take on a state regulatory function and creates confusion and uncertainty in the public's mind -- what exactly does it mean if a doctor is licensed but not board certified? Can one assume he/she has maintained the appropriate knowledge and skills to deliver quality patient care, or not? The State says yes, the AOA/ABO says no. As to a non-board certified doctor, the AOA/ABO is essentially telling the public that you cannot be sure this doctor has maintained the knowledge and skills needed to deliver quality care, whereas the State says that the doctor has!

The AOA's Proposal Gives Organized Ophthalmology Ammunition to Attack Optometry

Our MD/physician colleagues will seize on the premise of the AOA's proposal -- that graduating an accredited college or university, passing national boards, and obtaining a license, taken together, is insufficient proof that an optometrist is competent to practice optometry -- to buttress their arguments that optometrists are not well trained, that allowing us to prescribe is dangerous, and that our scope of practice laws therefore should not be amplified!  The truth is, that's exactly what the AOA's proposal and definition of board certification says -- being licensed does not assure that a doctor is competent. According to the AOA optometrists must do more than be licensed to prove they are competent. So, medicine will argue that legislatures should not be giving optometry more prescribing authority if even their own AOA doubts the optometric competence based merely on being licensed! Did the AOA think about this? What exactly were they thinking?

And consider these other "unintended consequences" of and problems with the AOA's proposal:

  • Whereas physicians obtain Board Certification to prove that they are trained and competent in their medical specialty, the sole reason for obtaining the AOA's Board Certification is to participate in third party insurance plans. Thus, optometrists that do not participate in third party plans (for instance, optometrists employed by HMO's, so-called "commercial" optometrists, full time optometric educators, optometrists in research and private industry) have no reason to obtain Board Certification, though if they don't they will be viewed by the AOA, and as a result the public, as having failed to prove they are competent! Competency and whether or not you accept third party payment plans are completely unrelated, yet will be linked to together through the AOA/ABO's proposal for board certification.
  • The AOA's proposal undermines the authority of individual States to determine who is qualified and competent to practice optometry and who is not, and what is necessary and sufficient to remain up to date with changes in the profession.
  • The AOA acknowledges that Board Certification itself is not likely to ever be necessary for participation on third party payer plans.
  • According to the AOA, the only reason for Board Certification is so that maintenance of certification can be used to show continuing competence. However, there are far less expensive, less controversial, and more compelling ways to demonstrate continued competence without the AOA's proposal for Board Certification, but the AOA refused to consider any approach other than board certification and MOC.
  • The AOA's Board Certification process is expensive and time consuming, and no third party payer has so much as intimated that it is either necessary or sufficient to satisfy their requirements (indeed, they haven't even developed their requirements as health care reform is in its infancy).
  • The AOA's proposal was overwhelmingly unwanted by optometrists, but was narrowly approved because states, like California, voted "yes" even after their own survey showed that COA members expressing an opinion were against the AOA's proposal by a ratio of 3 to 1!
  • Because the AOA will seek to advance the interests of their Board Certified doctors over those of doctors that choose not to become AOA/ABO Board Certified, the AOA will cease representing optometry as a whole and will lose members who see no reason to support an organization that isn't supporting them, profoundly weakening its effectiveness in doing what the AOA has traditionally done best -- protecting optometry in National legislative issues.
  • Only continuing education courses approved by the American Board of Optometry -- a new entity with unknown agenda or criteria -- count toward the AOA's Board Certification, so there is the potential that the ABO will become a self-serving CE monopoly, forcing doctors into their programs in order to remain Board Certified and thereby eligible for full participation in third party payer plans.
  • The AOA says optometry is the only "prescribing" doctoral level profession without board certification (dentists have it, but less than 1% of general dentists are board certified), but that ignores that an optometric education is the functional equivalent to a physician's specialty training. An ophthalmology residency is "ophthalmology school." Optometry school is our specialty training, and licensure is our proof of competence to practice our specialty. Once again, the AOA is claiming that optometric education is inadequate and we don't graduate as capable of practicing our profession as physicians that complete their education!
  • Optometric Physician's survey, with some 1300 votes recorded, found that 87% of optometrists were against the AOA's proposal and only 7% were in favor. In California, COA members that voiced an opinion in a COA sponsored poll were against the AOA's proposal by a margin of 3 to 1. Nonetheless, the COA voted all its delegates for board certification and the AOA passed it's proposal. This reflects that some state organizations and the AOA as a whole no longer feel they have a duty or ethical obligation to represent their members.


Here are a few quotes from the AOA's PowerPoint Presentation and other AOA sources on their Board Certification Proposal. These quotes and the related materials published by the AOA support the statements and conclusions above.

  • All doctors, all procedures, all medications and all treatments are not equally effective. Some are more effective than others. Some are not effective at all.
  • Using state boards to prove or demonstrate continued competence won’t work.
  • The need for MOC is the reason to pursue Board Certification.
  • It is the maintenance of certification that is the real thrust of BC
  • The 150 points may include those continuing education requirements needed for license renewal, as long as they receive the approval of the American Board of Optometry.
  • The fees for application and the examination will be set by the American Board of Optometry. However, in the projected model, the application fee would likely cost $200-250, while the examination would cost between $450 and $1,000. Additional expenses will vary depending on which Post Graduate Educational Requirements are used to become eligible for the examination.