Fellowship training in neuro-ophthalmology in the United States has slowly been evolving. Initially, fellowship programs across all of ophthalmology, including neuro-ophthalmology, were highly variable in quality and content and were not subject to external oversight, standardization, or regulation. Historically, an analogous lack of accreditation and standardization was a problem for residency training in ophthalmology as well. Since 1981, the Accreditation Council for Graduate Medical Education (ACGME) has accredited residency training in ophthalmology and recently 1 subspecialty fellowship area, orbit and oculoplastic surgery. Currently, there are 5 ACGME-approved orbit/oculoplastic fellowship programs. The ACGME does not accredit other subspecialty fellowships in ophthalmology including neuro-ophthalmology. Instead, neuro-ophthalmology fellowships follow the requirements developed by the Association of University Professors in Ophthalmology (AUPO) Fellowship Compliance Committee (FCC) and the North American Neuro-Ophthalmology Society (NANOS). The AUPO decided to develop a compliance process rather than following the ACGME requirements because of cost and administrative complexities. The AUPO FCC Limited Liability Corporation document was signed by Bartly Mondino, MD, Executive Vice President of the AUPO, on March 23, 2005. NANOS decided to use the AUPO FCC process to allow neuro-ophthalmology fellowship education to occur in both Ophthalmology and Neurology departments. The stated goals and objectives of the AUPO FCC are to provide a system that would enhance patient care for ophthalmologic diseases by promoting uniform standards for fellowship training and educational programs in the ophthalmic subspecialties (Cornea, External Disease, and Refractive Surgery; Glaucoma; Neuro-Ophthalmology; Oncology/Pathology; Pediatric Ophthalmology and Strabismus; Surgical Retina and Vitreous; and Uveitis).
There are 19 voting members in the AUPO FCC with 6 pairs of representatives from the respective participating subspecialties (Cornea, Glaucoma, Neuro-Ophthalmology, Oncology/Pathology, Pediatric Ophthalmology and Strabismus, and Uveitis); 3 representatives from Surgical Retina and Vitreous (because they have 3 participating subspecialty societies); and 4 members from the AUPO. There also are 2 nonvoting advisors. The current neuro-ophthalmology representatives to the AUPO FCC process are A. G. Lee, MD, and A. Arnold, MD. J. L. Keltner, MD, as the founding chair of the AUPO FCC, will retire from this position and be replaced as chair by Michael Belin, MD, on March 1, 2015.
Although the AUPO FCC compliance process is entirely voluntary, many national subspecialty organizations, including NANOS, strongly encourage, endorse, and support the AUPO process for neuro-ophthalmology fellowship programs. Each subspecialty, including neuro-ophthalmology, through the action of their subspecialty education committee (i.e., the NANOS Professional Standards Fellowship Committee) participates in all aspects of the graduate medical educational process for compliance. The Professional Standards Fellowship Committee along with the AUPO FCC developed a set of standard requirements for neuro-ophthalmology fellowship subspecialty training (including the curriculum requirements, qualifications for faculty and fellows participation in research and clinical experience). In addition to the subspecialty-specific process, the AUPO FCC also has developed general subspecialty requirements applicable to all ophthalmology fellowships in the United States.
The AUPO FCC determines the suitability of initial program applications. Programs admitted to the AUPO FCC compliance program are monitored on a triennial or quadrennial review basis to insure compliance (Table 1). All neuro-ophthalmology fellowship programs in compliance with the AUPO FCC are listed at the AUPO FCC Website at www.aupofcc.org. Although not all of the current neuro-ophthalmology programs in the United States participate in the AUPO FCC process, the majority of programs do and it is hoped that one day, all programs will participate. Some subspecialty organizations require completion of an AUPO FCC approved fellowship program to become a fellow in the subspecialty society, but NANOS has not chosen to pursue this requirement at this time. There are currently 19 AUPO FCC compliant fellowship programs in neuro-ophthalmology in the United States, and the full list of compliant programs can be accessed at http://www.aupofcc.org/programs_in_compliance.html?specialty=neuro.
In addition to the AUPO FCC process, a centralized application service for fellowship applicants is available through the San Francisco (SF) Match for all ophthalmology fellowship subspecialties except for Neuro-Ophthalmology and Pathology who do not participate in the process. Therefore, applicants applying for Neuro-Ophthalmology must interview, compete for, and ultimately accept or decline individual offers from fellowship programs without the match process. The reasons for neuro-ophthalmology not participating in the SF Match are complex. The Professional Standards Fellowship Committee of NANOS revisits this question annually and surveys the fellowship program directors to gauge interest in participating in the SF Match.
Ultimately, the role of the AUPO FCC is to monitor educational standards, to protect the public, institutions, and trainees, and to provide an infrastructure for accountability and enforcement. The AUPO, the parent organization with responsibility for planning, promoting, and delivering graduate medical education in ophthalmology, provides oversight to the AUPO FCC, but our specialty organization, NANOS, provides input, representatives, and direct communication to the AUPO FCC.
The NANOS Professional Standards Committee (a Fellowship Education Committee is a requirement to participate in the AUPO FCC) meets at the annual NANOS meeting. At that meeting, the AUPO FCC standards and requirements for neuro-ophthalmology fellowship training are discussed, and revisions are made and approved as needed. The committee discusses the ongoing issues of participation or nonparticipation in the SF Match and other questions related to the AUPO FCC process and professional standards.
Now that there are 19 AUPO FCC compliant fellowship programs in neuro-ophthalmology in the United States, 2 major issues will have to be dealt with by the NANOS Board of Directors: 1) Is it fair and appropriate for fellowship applicants to continue not to have NANOS participate in some type of formal matching process? 2) In the future, should full fellows in NANOS be required to be trained only by programs that are AUPO FCC compliant? These are difficult questions that merit continued discussion and debate.
We have had very positive feedback on the AUPO FCC process from participating fellows (through fellow exit surveys) and participating programs. We believe that the standardization and oversight offered by the AUPO FCC has improved graduate medical education in neuro-ophthalmology and has provided the intended protection for the trainees, the programs, and most importantly the patients.
We are delighted that this editorial is being published in March 2015, exactly 10 years since formal implementation of the AUPO FCC process!