Ophthalmic subspecialty fellowship accreditation and ophthalmic subspecialty certification: still hot issues.

Abstract

The debate over accreditation of fellowships in ophthalmic subspecialties and the issuing of subspecialty certificates in ophthalmology has heated up again. Although accrediting ophthalmic fellowships had been previously dismissed as financially unworkable, the issue came up again in the fall of 2003 when the American Society for Oculoplastic and Reconstructive Surgery made a formal request to the American Board of Ophthalmology to issue a “Certificate of Added Qualification” (CAQ) in oculoplastics. The impetus for this move was that some oculoplastic surgeons had encountered difficulties obtaining surgical privileges for procedures that they considered themselves qualified to perform. Other specialists, entrenched in credentialing committees, were denied their right to perform these procedures without evidence of specific training. The oculoplastic surgeons decided that a CAQ would alleviate this problem. The American Board of Ophthalmology turned to the American Academy of Ophthalmology (AAO) for advice. In the meantime, the Accreditation Council for Graduate Medical Education (ACGME), responding to pressure for higher quality assurance, proposed accreditation of all fellowships in ophthalmic subspecialties and issued a request for comment from individual subspecialty societies. At the North American Neuro-Ophthalmology Society (NANOS), an Accreditation and Certification Committee, co-chaired by John L. Keltner, MD (Davis, CA), and Ralph Sawyer, MD (North Potomac, MD), had been studying this issue. Acknowledging the need for assuring quality training at the fellowship level, this committee also recognized that fellowship accreditation, as proposed by the ACGME, would mean: That independent clinical activity of the fellow could not be billed. This would include assisting residents in surgery. Fellowship positions would be counted as part of the allocation of residency positions in some parent institutions, as determined by the federal agency whose funds underwrite house officer salaries. Fellowship positions at academic medical centers that are considered less remunerative to the medical centers might be dropped.Private practice-supported fellowship programs, which do not depend on federal support, might be the only ones to survive. It is possible that these programs would not be as observant of the ACGME guidelines concerning continuous quality improvement, or as nurturing for research as those based in academic institutions.Duty work hours would apply to fellows as they do to residents. This would create havoc for patient care staffing mandates in the significant number of neuro-ophthalmic training programs that have but one trainee. NANOS also expressed the concern that CAQs for all ophthalmic subspecialties might lead to the pitting of one subspecialty against another. Each subspecialty might then lay claim to a domain of practice that would exclude other subspecialists and general ophthalmologists. Furthermore, NANOS doubted that holding a CAQ would solve the American Society for Oculoplastic and Reconstructive Surgery’s problem. Given these problems, NANOS, as well as other members of the AAO Council, opposed the ACGME plan and the call for the CAQ. So did the Association of University Professors in Ophthalmology (AUPO), which proposed developing an alternative pathway for fellowship accreditation. At the same time, the Association of University Professors in Neurology established the United Council for Neurologic Subspecialties, made up of members of the American Academy of Neurology, American Neurologic Association, and the Society for Child Neurology to develop its own pathway for neurologic fellowship approval. NANOS named Dr. Keltner and Steven E. Feldon, MD (Rochester, NY), to be its representatives on the AUPO task force. They began reviewing the United Council for Neurologic Subspecialties proposal and updating its fellowship guidelines published on the NANOS Web site (www.nanosweb.org). The AAO Council, responding to these negative feelings, informed the ACGME in November 2003 that there was a consensus against ophthalmology subspecialty accreditation and asked for a delay. In December 2003, Susan Day, MD (San Francisco, CA), chair of the Ophthalmology Residency Review Committee of the ACGME, wrote to Stephen Podos, MD (New York, NY), executive vice president of the AUPO, to inform him that the process for seeking ACGME accreditation of fellowship training programs would be on hold.