A petition from oculoplastics has brought a long-simmering debate to a boil. Your state and subspecialty societies are due to respond to a request for subspecialty certification from the American Society of Ophthalmic Plastic and Reconstructive Surgery—but they also want to hear your views. Know the pros and cons and get involved.

Oculoplastics has significant crossover in competition for surgical care with specialties outside ophthalmology. But when it comes to obtaining surgical privileges, ophthalmic plastic surgeons say that they’re at a disadvantage because—unlike oral surgeons, plastic surgeons and dermatologists—they don’t have subspecialty certification.

This prompted the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) to petition the American Board of Ophthalmology (ABO) for subspecialty certification in oculofacial plastic surgery. To be successful, the petition needs the support of first the ABO and then the approval of the American Board of Medical Specialties (ABMS). ASOPRS will only receive the ABO’s blessing if the profession as a whole approves, or at least doesn’t oppose, the petition. The ABO has asked the Academy—through its advisory body, the Council—to provide a forum for this debate. The Council will discuss this issue at both this month’s Fall 2003 meeting and its Spring 2004 meeting. (For more details on the process and the participating organizations, see the timeline “Debate Countdown” and “Who’s Who” below.)

To explore some of the ramifications of the debate, EyeNet posed 10 questions to two ophthalmologists with opposing viewpoints on the subject.

Representing the “pro” side of this point/counterpoint is John W. Shore, MD, president of ASOPRS and in private practice with Texas Oculoplastic Consultants in Austin. He is also affiliated with the M.D. Anderson Cancer Institute at the University of Texas, Houston, and is adjunct associate clinical professor in the department of plastic surgery.

Providing the “con” side of this discussion is Michael W. Belin, MD, professor of ophthalmology and director of cornea and refractive surgery at Albany Medical College in New York. He is on the Cornea Society’s board of directors and represents the Cornea Society on the Academy Council, though his answers to these questions represent his own opinion and aren’t necessarily those of the Cornea Society.

Would oculoplastic subspecialty certification be a unique solution for a unique subspecialty, or would it lead to widespread attempts by other ophthalmic subspecialties to obtain subspecialty certification?

Dr. Shore: Yes and no. Yes, it would be a good solution for a unique problem. And no, it would not necessarily lead to a domino effect.

Orthopaedics is the closest comparison to ophthalmology. Within orthopaedics there are eight subspecialties, including hand surgery, pediatrics, spine and sports medicine. Hand surgery is the only subspecialty that has a subspecialty board offering subspecialty certification, and it has been in existence for more than 20 years. The subspecialty of hand surgery was created to address the crossover with plastic surgery and general surgery, and subspecialty training and certification is now available to basic certificate holders in each of these specialties.

Dr. Belin: There is some misconception that ABO/ABMS is looking for “approval” by the profession via the Academy. This is more of a passive process where the ABO/ABMS can proceed without an active “No” vote. In my view , we are more likely to see a “No Opinion” from the Academy, which would give the ABO a further green light. The ABO has clearly stated that it does not require outside approval. I do not view other subspecialties seeking subspecialty certification as much as acquiescing to the ABO/ABMS. This is the start of a slippery slope, one with no return.

Ophthalmology is one of only six medical specialties on the ABMS without subspecialty certification. Why has ophthalmology historically been reluctant to adopt subspecialty certification?

Dr. Shore: In the past, there has been no overwhelming public need. Ophthalmology was a homogenous specialty with outstanding residency training programs. There was little outside competition from other medical specialties, with optometry the sole competitor for delivery of patient care. There was also a fear that subspecialty certification would cause the profession to fragment as it competed internally for resources, patients and contracts. Postgraduate training programs have functioned relatively well and supplied many qualified subspecialists. The problem in our area is that ophthalmologists completing fellowship training and even some completing ophthalmology residency are having hospital privileges challenged by nonophthalmologists, and in some cases privileges have been denied. We feel that subspecialty certification in oculofacial plastic surgery will preserve for all ophthalmologists the right to work in the midface, orbit and skull base. Finally, there has been no economic force driving the need to seek subspecialty certification.

Dr. Belin: It should be remembered that ophthalmology was the first specialty board to be incorporated in 1917 and was one of the founding boards of the ABMS. I do not think that ophthalmology has been historically reluctant. I think we have felt that subspecialty certification is not needed. Subspecialty certifications represent an unwanted solution to a fabricated problem. Ophthalmology has successfully taken different paths in the past. We are one of only five residencies that do not use the National Residents Matching Program. Our match, the SF matching program, was established by the Association of University Professors of Ophthalmology in 1977. This “different path” has served our needs very well. To quote Robert Frost, “Two roads diverged in a wood, and I took the one less traveled by, and that has made all the difference.”

We [the Cornea Society] feel a similar “alternate path” to fellowship approvals can be formulated to ensure quality training without the negatives associated with ACGME [the Accreditation Council for Graduate Medical Education] accreditation. It should be realized that the AUPO [Association of University Professors of Ophthalmology], which represents our premier educators, has almost unanimously come out against fellowship accreditation through the ACGME.

What can we learn from the experience of other medical specialties that have adopted subspecialty certification?

Dr. Shore: It has worked well, meeting the needs of both the profession and the public. And they haven’t reversed it. Additionally, I think that the cooperation among the specialties is a very good example of how competing boards work together. For example, cooperation among specialties has led to joint entry to subspecialty board certification in several areas, including hand surgery, pain medicine, dermatopathology and plastic surgery within the head and neck. And while many specialties such as orthopedic surgery and otolaryngology have selected only a few areas for subspecialty boards, other specialties identified many subspecialties for board certification—internal medicine has 16 subspecialty boards, and pathology has 10.

Dr. Belin: First, we can learn from our own experience that, at times, following or forging a new path proves to be the best for the profession. Second, other specialties have stated that subspecialty certification is divisive. According to the American Academy of Orthopaedic Surgeons, “A proliferation of subspecialty certification in orthopaedic surgery may result in fragmentation of our profession. In an effort to control costs, payers and institutions might even require an orthopaedic surgeon to possess a subspecialty certification in order to be reimbursed for commonly performed procedures. We need to focus our energy on activities that serve to unite us.” There also have been strong objections in HIV medicine, neuroimaging and sports medicine.

Will a subspecialty certification for oculoplastics change how the comprehensive ophthalmologist practices?

Dr. Shore: It should not. There is no desire on the part of ASOPRS, nor is there any intent, to limit or change how any ophthalmologist practices. We believe a subspecialty certification will lend credibility, visibility and respect among nonophthalmic surgeons and the public in general for all ophthalmologists who want to perform oculoplastic surgical procedures. We also believe subspecialty certification will enhance and strengthen the ability of the comprehensive ophthalmologist to perform oculoplastic surgery. It will raise awareness among others that ophthalmologists take ownership of the visual system and are qualified to provide comprehensive eye care, including the ocular adnexa. We also feel it will make it difficult for optometrists to claim surgical rights to the ocular adnexa, and this is important to our profession and to the American public.

Dr. Belin: Undoubtedly yes. While ASOPRS has stated that it would require as a condition of subspecialty certification that general ophthalmology continue to have access to certain lid and plastic procedures and that fellowship training would not be required to sit for the subspecialty certification, this historically has not been the case in other specialties even when such assurances have been initially made. As an example, in sports medicine, in the past both family physicians and internists were able to sit for the subspecialty certification in sports medicine. Since 1999, a fellowship is required to even be eligible for the examination.

Will the fellowships be affected by subspecialty certification? (Editor’s note: Subspecialty certification by ABO/ABMS would first require completion of an ACGME-accredited fellowship.)

Dr. Shore: I can’t speak for other subspecialties, but oculoplastic surgical fellowships would change over time. Some people would like to say it will change in a negative way, and that is a reason not to do it. I take the opposite tack. Our goal as a profession is to determine if standards are necessary. And if they are, then we must set the standards and utilize a mechanism to achieve the standards so that physicians who graduate have met these standards. If there is a need, then these programs will successfully compete for dollars, fundamentally changing the programs for the better. New programs will be integrated slowly as older programs drop off. Gradually all oculoplastic training programs will improve and meet the standards set by the profession. This will ensure thorough training for all graduates. In the long run the public will benefit.

Dr. Belin: My major goal is ensuring quality education, an adequate clinical and surgical experience and promoting research, and this is the area where I have the strongest concerns about pursuing fellowship accreditation following ACGME regulations. First, fellows would fall under the same regulations as residents. A fellow would become a PGY-5. There is currently, however, no funding for these positions, which have been capped per institution at the 1997 levels. Second, we would by nature of the process relinquish control over the content of our fellowship programs and lose the unique fellow/mentor relationship that has allowed our profession to academically flourish. Third, fellowships would be forced to affiliate with residency programs and be placed under the control of the department chairman. For most fellowships this would not represent a significant change, but there are some highly respected fellowships where this would represent a major and possibly detrimental change. Fourth, a fellow’s salary is currently augmented by assistant fees, call, etc. Under ACGME guidelines, this would not be allowed. Fifth, current ACGME fellowship guidelines neither support nor allow for fellow research. If anything, the rigid guidelines set by the ACGME stifle creativity and promote uniformity. This should not be the goal of subspecialty training. Finally, while I do feel that ACGME fellowship accreditation can offer assurances on the quality of the fellowship training experience, I think this can also be achieved through other channels that would not adversely affect the current fellow/mentor relationship or put additional strains on the sponsoring practices. Without a doubt, autonomy is fine as long as you can ensure quality. Our goal is to ensure quality, while maintaining autonomy.

Is oculoplastics trying to expand its scope of practice?

Dr. Shore: The answer is an emphatic no. We are trying to seek acceptance externally, from the rest of medicine, for the surgical skills and techniques we have already developed through our research, education and training. This is not about becoming face-lift doctors or doing breast implants. Instead, it is about recognizing our expertise. Over the past 30 years, there has been an expansion of this expertise such as our role in performing such sophisticated procedures as skull base surgery. As we compete for resources in the hospital or university setting, we simply want to be on a level playing field with other subspecialties. Trying to do that without the ABMS board certification puts us at a distinct disadvantage. Our hospital credentials are not even recognized. With subspecialty certification, no one will be able to argue about our qualifications or the qualifications of the comprehensive ophthalmologist.

Dr. Belin: By its [ASOPRS’] own presentation at the Academy’s Council meeting in April, the answer is yes. I have no problem with recognizing its expanded scope within reason. It is that I do not feel subspecialty certification is the only, nor the best, way for ophthalmology to recognize it.

What are the potential advantages/disadvantages of subspecialty certification for the profession of ophthalmology?

Dr. Shore: Potential advantages include standardization of training and well-defined training goals. Also, a wide consensus and input from all aspects that set up the process of subspecialty certification help ensure that the public’s needs are being served. Additionally, ophthalmologists who are subspecialty certified will be able to demonstrate that they have met a specific set of standards. Subspecialty certification raises the bar for the entire profession. The disadvantages include the fact that this is a painful process to go through, it is expensive to put into practice, it will disrupt current training programs and there will be some impact on residency training in terms of money. However, in my opinion, none of the disadvantages outweigh the advantages, and in the long run, the public will be well served.

Dr. Belin: The real problem is not going to be solved by ASOPRS getting subspecialty certification. The problem stems from ophthalmology’s lack of departmental presence in some hospitals and/or ambulatory surgery centers. I understand that the difficulty arises when ophthalmology is not its own department, but is under the whim of a department of surgery. My problem with this entire argument is that if board certification for ophthalmology has not been adequate in these hospitals for ophthalmology to achieve departmental status, why would we think that an ophthalmic plastic subspecialty certification would have any better result. Subspecialty certifications will have an effect to weaken the comprehensive ophthalmologist and make us appear more interested in subspecialty ophthalmology than comprehensive eye care. We could do more for our profession by strengthening ophthalmology’s presence as a whole rather than attacking the problem piecemeal.

What are the potential advantages/disadvantages of subspecialty certification for the quality of patient care?

Dr. Shore: The public can look with trust at the subspecialists who have been subspecialty certified. Additionally, there will be increased visibility within academic institutions, which will inevitably attract more research and education dollars. This will be an advantage to the public, who will benefit from the higher standards that will be required. A disadvantage is that it may lead to further fragmentation of patient care, as patients continue to self-refer to specialists, which is the trend in medicine today. In addition, not everybody needs specialty care, but those who demand it will find a way to get it, which in turn drives up costs.

Dr. Belin: I really do not feel that subspecialty certification by the ABO or fellowship accreditation through the ACGME ensures any better patient care than a similar process through a joint subspecialty/AUPO organization. If anything, the excessive amount of time typically associated with ACGME compliance would distract from patient care. As a past program director I can attest to that.

Would subspecialty certification protect the public as ophthalmology certification has?

Dr. Shore: Absolutely. It protects the public in terms of the profession. Over time, as you set the standards and test the standards, the standards will be recognized, and the public can look to that with the same degree of confidence as it does board certification in ophthalmology, which has the highest respect. It is tremendous what the Academy has done and what ophthalmology has done in the public interest.

Dr. Belin: I am chairman of the Academy Ophthalmic Technology Assessment Committee’s cornea panel; the Academy mandates that all conclusions we draw are supported by Level 1 data. I would love to see Level 1 data to support the above statement [that subspecialty certification protects the public as ophthalmology certification has]. We have blindly accepted that fellowship accreditation would result in superior training. In truth, the rigid regulations promulgated by the ACGME distract from the unique fellow learning experience. While I wholeheartedly support the ABO and feel it does a tremendous job on certification following residency, fellowship is fundamentally different. I do not see that the current situation is putting the public at risk.

Would subspecialty certification affect the public’s perception of ophthalmologists?

Dr. Shore: I think the public will look to this subspecialty certification in ophthalmology and say it is a good thing—especially in light of the fact that the public looks to subspecialists in other areas of medicine to care for their medical concerns. The public will recognize that ophthalmology has gone through a process and met certain criteria. This will provide a positive perception among the public.

Dr. Belin: With more than 80 “board certifications,” there already are too many for anyone in the general public to fully understand. The public still does not fully understand the difference between an ophthalmologist, an optometrist and an optician. We have seen a proliferation of non-ABO certifications for things like cataract surgery and refractive surgery. Adding more subspecialty certifications will not clear the air, will not make things easier for patients to understand and probably would not affect the public’s perception or our profession. What it will do, however, is give further ammunition to others who view us as a narrow profession interested only in subspecialty care. This is not the path our profession should be taking.