Will Retina Subspecialty Certification Ever Become a Reality?

A look at the obstacles and conflicting goals that have led to the current impasse.

Robert J. Murphy, Contributing Editor

The irony is lost on no one that the American Board of Ophthalmology (ABO) in 1916 was the first US board established to certify medical specialists, yet in 2011 remains among the last holdouts to grant subspecialty certification.

Advocates of retina fellowship accreditation as a pathway to ABO retina subspecialty certification cite numerous potential benefits for both providers and patients. They look to ABO certification as a way to indicate unequivocally to the public that a physician has received the requisite specialized training and education to perform retinal procedures that lie beyond the habitual scope of a comprehensive ophthalmologist's workflow.

Retina subspecialty proponents ultimately surpass that argument with public health and safety concerns in wishing to codify on a widespread basis that those who undergo major retinal surgery or other procedures receive the best possible care from physicians specially trained to provide them. They object to a current environment in which almost any ophthalmologist can claim to be a “retina specialist” following widely varying degrees of time and rigor in their retina fellowship training.

Many observers claim that the greatest obstacle to retina subspecialty certification comes from university department chairs and fellowship training program directors adhering to a status quo that falls short of ABO criteria. A central issue, according to knowledgeable sources, has to do with Medicare reimbursement of many procedures performed by “trainees” — as opposed to the classification of “junior faculty” — currently working in fellowship programs accredited under the auspices of the Association of University Professors of Ophthalmology (AUPO) Fellowship Compliance Committee.

University departments of ophthalmology and other sponsors of fellowship training risk losing their Medicare reimbursements if fellows working under Accreditation Council for Graduate Medical Education (ACGME) criteria are reclassified as “residents,” according to knowledgeable sources. In that capacity, they would be unable to bill Medicare for their work.

The university fellowship programs may then face sharply reduced funding for their training. And since the number of residents in university training programs is capped, reduced funding coupled with capping limits may lead to fewer accredited fellowship positions or resident slots in university training programs.

Not only that, retina fellows trained under any criteria besides the ACGME's cannot then take the next step in obtaining subspecialty certification through the ABO, one of the 24 subspecialty boards that comprise the American Board of Medical Specialties. “ABMS subspecialty certification requires that candidates complete an ACGME accredited training program,” says ABO Executive Director John Clarkson, MD, dean emeritus and professor of ophthalmology at the University of Miami School of Medicine's Bascom Palmer Eye Institute.

THE ROAD NOT TAKEN

The ABO professes to endorse retina and other ophthalmologic subspecialty certification yet is not in a position to initiate the process necessary to make this happen. “The American Board of Ophthalmology has on two different occasions officially endorsed fellowship accreditation and subspecialty certification, because we believe it will lead to improved training and improved patient care,” the ABO's Dr. Clarkson says.

Yet the road not taken is clearly mapped. “The first step in the process toward subspecialty certification would be to apply for fellowship accreditation through the ACGME,” Dr. Clarkson says. “Once there are accredited fellowship training programs, if the community of retina specialists seeks subspecialty certification, then the ABO could apply to the American Board of Medical Specialties for retina subspecialty certification.”

Alas, the best-laid plans of mice and men go oft awry. “The American Society of Retina Specialists recently submitted a formal petition to the ABO asking for its support of programs seeking subspecialty accreditation and certification,” according to a 2010 Retina editorial coauthored by Denis O'Day, MD, of Vanderbilt University's department of ophthalmology and Charles P. Wilkinson, MD, of the Johns Hopkins department of ophthalmology.

ABO's Dr. Clarkson “responded by noting that ACGME accreditation would be the required first step and that the ABO was on record as supporting this,” according to Dr. O'Day's and Dr. Wilkinson's editorial. The retina society and ACGME then initiated preliminary negotiations.

Those meetings apparently disbanded with no productive resolution and no plans to return to the negotiating table. “When I last spoke with the ACGME administrator for ophthalmology, there had been no action taken by the retina group,” the ABO's Dr. Clarkson says. “In short, there were no ongoing negotiations and no application submitted to ACGME as of September 2011 for any ophthalmology subspecialty other than ophthalmic plastic surgery.”

Until that happens, ABMS subspecialty certification of retina specialists will go nowhere, as long as ACGMEendorsed accreditation is a necessary first step. “To achieve subspecialty accreditation and certification in retina, the rules established by the ACGME and the ABMS must be followed,” Dr. O'Day and Dr. Wilkinson write.

MEANWHILE, BACK ON CAMPUS

The AUPO has pursued an independent, parallel pathway to adopt its own criteria separate from those of ACGME. In 2002 the group appointed a task force to explore the issue. One option was to petition the ACGME to establish an accreditation process, according to a 2007 Ophthalmology editorial by John L. Keltner, MD, et al., a past president of the AUPO and currently the co-director of the University of California, Davis, OCT Reading Center.

But the AUPO dismissed this option, instead favoring an accreditation process designed by the American Association for Pediatric Ophthalmology and Strabismus (AAPOS). It consists of an 11-point plan endorsed by the AUPO's Fellowship Compliance Committee setting out criteria for ophthalmologic fellowship accreditation modeled after the AAPOS's criteria.

However, nowhere in that 11-point plan does the AUPO mention certification, suggesting that the process described there has to do only with accreditation but not certification. Also, nowhere in the AUPO's 11-point plan, or in the 2007 Ophthalmology editorial in which it was described, does it mention ACGME criteria.

“In [the editorial], our position is put forward as well as our solution to the problem, which does not involve accreditation and certification by the ACGME and ABO,” AUPO Executive Vice President Bartly Mondino, MD, chairman of the UCLA department of ophthalmology and director of the Jules Stein Eye Institute, said in an e-mail exchange.

Asked to clarify why AUPO appears to have rejected the ACGME accreditation criteria — the very guidelines that the ABO's Dr. Clarkson stipulates must be met for board-sanctioned subspecialty certification — Dr. Mondino replied, “AUPO chose the AAPOS model, which we understood and find to be simple, efficient, and economical. This choice does not imply a rejection of ACGME.”

On the matter of retina subspecialty certification, Dr. Mondino said, “AUPO is not blocking and cannot block retina surgeons from obtaining accreditation or certification for their subspecialty. We are interested in certification following completion of our programs at some point.” Such a position provides little encouragement for retina specialists wishing to obtain certification any time soon.

Given the current impasse and present circumstances, is it reasonable to expect ACGME-sanctioned retina fellowship accreditation and ABO subspecialty certification to be attainable, say, within the next five to 10 years? “Unless there's a dramatic change in the outlook of the program directors and department chairs, I think it's highly unlikely,” the ABO's Dr. Clarkson says.

WHAT'S WRONG WITH THE STATUS QUO?

Since no one involved in this matter appears to be undertaking any practical action to move it forward — besides writing journal editorials stating their group's nonnegotiable positions — a reasonable question might be: Why not just stay with the present circumstances?

From the perspective of university professors and fellowship program directors, the status quo appears to suit them fine, particularly from a financial standpoint. Why risk the present Medicare reimbursement — a large segment of a university ophthalmology department's funding — for the unpredictable vicissitudes that may follow a reclassification of fellows and that may well jeopardize that reimbursement? Private practice fellowship directors, meanwhile, can pay a fellow in training a nominal salary and pocket the greater sums deriving from Medicare reimbursement for eligible procedures. Why derail that revenue train?

Meantime, advocates for ACGME-stipulated retina fellowship training and subsequent ABO certification point to what they view as flaws in the current system. “The public is being deceived, for one thing,” Paul Tornambe, MD, a past president of the American Society of Retinal Specialists and a voluntary clinical faculty member at the University of California, San Diego, said in a recent phone interview. “When you go through the Yellow Pages, you have ophthalmologists who advertise cataract, refractive surgery, glaucoma and retina,” Dr. Tornambe says. “There are no boards; there's no verification of training. So we need to prove at certain milestones that you are trained to be a retina specialist.”

But what about the AUPO's accreditation plan and the group's stated priority of providing the best possible medical education and training leading to optimal patient care? The AUPO has developed what it believes to be rigorous and comprehensive guidelines for retina fellowship training and accreditation. Yet Dr. Tornambe sees flaws there as well. On the one hand, he applauds the university professors for having “recently acknowledged that there is a problem by establishing minimal criteria for specialty training.”

On the other hand, some factors give him pause. “Unfortunately, the AUPO plan is voluntary, has no authority to sanction programs that do not meet its criteria, has no oversight board and does not address the very important issue of certification,” Dr. Tornambe says. “So what they have is a much more watered-down thing [compared with ACGME accreditation], and they basically say they do accreditation but not certification.”

AN AUSPICIOUS ANNIVERSARY LOOMS

As long as Medicare funding is available for trainees in current university-based fellowship accreditation programs and as long as that funding comprises a significant part of an ophthalmology department's budget for performing this training, AUPO is unlikely to spearhead any initiatives for change.

That will have to come from negotiations between the American Society of Retina Specialists and the Accreditation Council for Graduate Medical Education. Alas, there appears to be nothing happening on that front, at least nothing either party wishes to divulge.

Meanwhile, amidst the multiple power plays from numerous interested parties and universal recognition that financial issues remain at the heart of the matter, the fallback position is to advance claims to be acting in the patient's best interest. Clearly, no matter what your position on this issue, who can deny that the patient's interest stands paramount? If only patients could receive assurance of their physicians' credentials in a more transparent manner. Patient-advocacy proponents will be chagrined if the 100th anniversary of ophthalmology certification should come and go in 2016 with still no forward momentum on a matter that serves the public good. RP