Second Opinions
Accredited Fellowships: Getting our Priorities Straight
GEORGE A. WILLIAMS, MD

Over the past decade, the American Society of Retina Specialists, The Vitreous Society, The Retina Society, The Macula Society and other ophthalmic subspecialty societies have engaged the American Board of Ophthalmology (ABO) in a discussion on the status of ophthalmic subspecialty education in the United States. The reasons for this discussion are the lack of standardization of quality in fellowship programs, the lack of protection for fellows and ultimately the impact of the fellowship process on the quality of care.

In other words, what constitutes acceptable fellowship training? Since nearly 50% of residency graduates pursue some form of fellowship training, this is an important issue both for the profession of ophthalmology and for the public.

A PARADOX

The ABO, as the first specialty board in the United States and charter member of the American Board of Medical Specialties, has long recognized the value of accrediting residency training programs as a central tenet of the certification process. One of the key criteria in the accreditation of residency programs is the availability of subspecialty trained faculty in areas such as retina, cornea, pediatrics, glaucoma, plastics and pathology. The requirement for subspecialty ophthalmologists creates an interesting paradox. The accreditation of a residency depends on the presence of faculty who are the product of a nonaccredited training process. This raises the question by what criteria does the Residency Review Commission (RRC) of the American Council of Graduate Medical Education (ACGME) determine that a residency has fulfilled the requirement for subspecialty faculty? The reality is you are whatever specialist your chairperson says you are.

This status of self-declaration also holds outside of residency training programs. Individuals can declare themselves to be a specialist on the basis of minimal or no fellowship training. The implications to the public are obvious.

Although virtually no one, including the American Academy of Ophthalmology, (American Academy of Ophthalmology. The repair of rhegmatogenous retinal detachments. Ophthalmology 103:1313-1324, 1996.) accepts the concept that the completion of an ophthalmology residency alone is adequate training for the practice of modern vitreoretinal surgery, the reality is that there is at present no mechanism by which the public, hospitals, healthcare payers and even other ophthalmologists can evaluate the qualifications and training of individuals performing vitreoretinal surgery.

In response to these concerns, the ABO solicited input from the subspecialty societies concerning the fellowship training process. In retina, all three societies contributed to the process of developing retina specific standards for fellowship training with the goal of program accreditation without certification.

A committee of representatives of the three societies chaired by Travis Meredith, MD, developed training guidelines involving duration of training (2 years), number and mix of surgical cases, lasers, diagnostic studies and didactics. These guidelines were accepted by the ABO as being in the best interest of the public and forwarded to the ACGME for implementation via the RRC.

"UNINTENDED CONSEQUENCES"

However, the participation of the ACGME has created additional issues, which have been termed "unintended consequences." Everyone agrees that the ACGME is the gold standard for graduate medical education in this country. In fact, the ACGME is the only body recognized by the federal government and therein lies the problem of unintended consequences. If accreditation occurs via the ACGME, Medicare regulations are triggered that will preclude training programs from billing for services provided by the fellows. This includes surgical assistant fees and staffing clinics.

In addition, fellowship positions are then counted as residency positions. Since the number of residency positions is regulated, if an institution is at or over its cap, these new positions would not be reimbursed by Medicare. The net result is that some fellowship positions would be unfunded and some institutions would be forced to find other funding sources. Some training programs may not be able to continue.

It is a sad commentary on the state of our healthcare system when the pursuit of excellence in training the surgeons of tomorrow is hindered by such regulatory malfeasance.

Nonetheless, I believe that these financial considerations must remain secondary to a process that is recognized by all of medicine to be in the best interest of the public, the fellowship trainees and the profession. If ophthalmology does not establish an appropriate and recognized system of accreditation and certification for vitreoretinal surgery, we run the risk that others outside of ophthalmology and even outside of medicine will assume this responsibility.

The ABO now requires maintenance of certification (MOC) for its diplomates. For vitreoretinal surgeons, the MOC will involve a "practice emphasis" process in which vitreoretinal surgeons will be examined with an emphasis on retina in conjunction with a core ophthalmic knowledge base. It is inconsistent to allow MOC with a practice emphasis in retina without initial retina certification.

WE KNOW WHAT OUR PATIENTS DESERVE

In the end, our patients deserve the system that best assures the training and competence of their physician. This concept is eloquently described by the mission statement of the ABO: "The mission of the American Board of Ophthalmology is to serve the public by improving (emphasis added) the quality of ophthalmic practice through a process of certification and maintenance of certification that fosters excellence and encourages continued learning." (The American Board of Ophthalmology, Brochure, www.abop.org, 2004)

There has been a consensus since 1916 that an ABO-directed system of certification after residency training is in the public's best interest. I do not see how we can explain to our patients or ourselves that the same consensus does not exist for fellowship training.