Is it Time CE Changed?

From e-learning to costs, our panel of experts tackles the continuing education issues that have risen to the forefront of optometry.


  continuing education

Is It Time to Change CE?

From e-learning to costs, our panel of experts tackles the continuing education issues that have risen to the forefront of optometry.


Consider the great strides education has made through the past several decades. Anchored by the World Wide Web, technology has opened new paths to learning. Interactive hands-on experiences often replace lectures. When Stanford University’s Graduate School of Education asks the question “Can gaming transform communication?” it is clear the concept of how we learn is being fundamentally challenged. Yet by and large, optometric continuing education (CE) today remains unchanged, often utilizing a lecturer and PowerPoint slides only, much as it did 20 years ago.

This is one reason CE has been, is and continues to be a source of contention for many. The concerns are understandable: CE is big business. It is the source of our professional growth and expansion. And in many cases, it is how we are judged by those outside our industry.

This special report investigates how we in the optometric community should move forward with our CE efforts. It is the result of a project I began last year in which, as the chief optometric editor of Optometric Management magazine, I invited 52 people from across the industry to share their thoughts and ideas on CE. Through a series of eight conference calls, I asked colleagues from throughout North America the questions presented in this article.

The response was overwhelming. Lecturers, participants, CE coordinators, social and political leaders and, most importantly, our peers who practice optometry every day, offered a wide variety of answers that reflected variables, such as age, gender, region of the country or province, licensure requirements and, maybe even more importantly, the candidness of the responders. How we educate our profession through adult learning came to the forefront of the discussion.

After spending eight hours with this sampling of optometric professionals, we may not have answered all the questions, but we certainly came away with a clearer grasp of the educational issues that affect us all.

A change in “focus”: Should CE be formatted differently?

In our current system, we give a great deal of “focus” to one or more very specific aspects of the profession in any one class. For example, the learning may be focused on diabetic eye disease. Currently, a great deal of information is “taught” on how to identify the disease, manage the disease and maybe even deal with some of the systemic manifestations.

However, wouldn’t the course potentially be more effective if we were taught how to deal with every aspect of the diabetic patient’s exam, ranging from workflow changes within the clinic to technology needs, records and meaningful use compliance? Maybe even more critical is the education of our peers about how to assist our patients with the visual and ocular health issues that are present with any disease state, such as diabetic eye disease, as well as how to effectively discuss their options.

Should CE be presented differently?

Many of our panelists struggled with this question, as we discussed the pros and cons of increasing access to online virtual CE options. The challenge: Many states currently limit the number of CE credits an optometrist can acquire online. Interestingly, it was mentioned in numerous conversations that by capping online CE credits, we are one of the last professions that places limits on how we improve our knowledge.

Also, many discussed utilizing technology more advanced than a PowerPoint presentation and computer for enhancing information acquisition. Others, such as Blair Lonsberry, O.D., professor and clinic director of the Portland Vision Center, which is associated with Pacific University in Portland, Ore., and expert in adult learning, opined that the most successful adult learning format is more of an interactive, small group, case study-based approach. And that this approach has a facilitator rather than someone standing at the front of the room “lecturing” on how a clinical or practice-management-related process should be done. This free exchange of ideas and experiences within a mildly structured format is most likely to create long-term “useful” learning, says Michael Rothschild, O.D., Carrollton Ga.

Are small groups and a case study-based approach more effective?

Many optometrists were rigorously trained regarding the identification and treatment of various disease states. However, one area that is uniformly and overwhelmingly lacking is the effective communication of this information in a method that our patients can understand and effectively act on. For example, our current CE system lacks in concepts like healthcare reform, business operations, communication, HR management, generational care, political accountability, as well as general visual issues, such as convergence or accommodative issues. Aren’t these issues as prevalent and possibly more relevant than many of the disease states that we learn about in CE sessions?

“We need to spend a little more time talking about the basics.”

“Every disease, from retinal issues to simple concerns, such as uncorrected myopia or vergence issues, has an impact on every part of the practice, and sometimes we get too focused on just the disease management part and forget about how it affects the patient, the practice, the flow, etc.,” explains Michael Rothschild, O.D., of West Georgia Eye Care in Carrollton, Ga. “When was the last time we talked about [the] accommodation or convergence issue? We have yet to find a balance. We are supposed to take care of these things, and, in some instances, vision abnormalities cause just as many problems as diseases like diabetes.”

CE might also impact the business side of the practice, said several panelists. For example, a CE course may explain the clinical value of a corneal topographer, “but I need to figure out how to afford it, how to train my staff, implement [it], etc.,” says Dr. Rothschild.

It’s time we get back to the basics of what our profession does, says Mark Dunbar, O.D., F.A.A.O., of Bascom Palmer Eye Institute in Miami, Fla. and chairman of CE for Vision Expo.

“There is a lot of truth to the fact that we need to spend a little more time talking about the basics, such as what a disease state is,” Dr. Dunbar explains. “On the other hand, there is an assumption that everyone has baseline knowledge. We would assume they have a baseline understanding, but we still need some baseline in a two-hour course. Maybe in a 15-minute course, we can focus directly on advanced topics.”

John Rumpakis O.D., M.B.A., founder, president and CEO of Practice Resource Management, concurs. “The curriculum should be a mixture or review of common pathologies with an emphasis on new and upcoming trends,” he says. “We often don’t review enough to keep everyone at a specific level. We should have a foundational approach that includes a baseline review of the pathology state, as well as where we are and where we are heading. For example, vitreomacular traction (VMT) — we can talk about the new drugs and lose many people who are not up to date with what VMT is and what it can cause or look like.”

Should CE focus more on outcomes vs. credits?

What if our CE was something we attended because we wanted to, or it was crucial for our survival? In most related professions, and most predominantly in our ophthalmology counterparts, CE is not a credit-based system, but rather a true learning system with the focus on learning. Currently in optometry, a much greater emphasis is placed on “credit” education by the various state boards and licensing organizations.

How can education be monitored?

Panelists universally agreed that adult learning should not require a “monitor.” We always have people who do not want to learn, and they attend CE to get their credits. Of course, if we create different criteria for earning credits, we will create a different need and, thus, different expectations for all education and all the generations to come. Our problem is inertia, says Mark Dunbar, O.D., Miami, Fla.

“We have done things one way, and no one feels that we need to change behavior to make things better,” he explains.

Also, monitoring takes another form, says Jill Autry, O.D., R.Ph., of the Eye Center of Texas in Houston, Texas. “We don’t see the type of hand-holding in ophthalmology that we see in optometry,” she explains. “It is ‘come and go,’ and they go to courses they want without having to turn in evaluation forms, have badges scanned, keep track of CE hours. Why are we even having this situation? Why should we be policed when our colleagues aren’t?”

It was universally agreed that adult learning should not require a “monitor.”

“What if at end of the course, instead of an evaluation, we followed up in three to four months to see whether the attendees actually learned something?”

“Many people come and listen but don’t take anything back and implement change,” Dr. Rumpakis says. “If our CE was more focused not just on the knowledge but also on the tools and providing a comfort level or understanding of the changes that need to be made to create positive meaningful change, then we would really be providing an outcome-based education.”

After all, learning something for 60 minutes in a class just so we can “get our credits” doesn’t create positive meaningful change, nor does it guarantee better and more compliant patient care.

“Outcomes measures have been kicked around for a while but have never come to a conclusion,” explains Leo Semes, O.D., F.A.A.O., associate professor and director of CE at the University of Alabama, Birmingham School of Optometry. “For example, what if at end of the course, instead of an evaluation, we followed up in three to four months to see whether the attendees actually learned something and the educators accomplished the goals and objectives set forth at the beginning of the course? Maybe then six months later you go back and look at outcomes from a clinical perspective.”

Dr. Semes acknowledges that such a system would create “all kinds of logistics issues” for the educators, CE sponsors, course approval body and CE host. “But creating behavioral change in the profession that positively impacts our patient base is the real outcome that we should all focus on,” he says.

Who should approve CE, and how should it qualify (considering the many different categories of diseases and subspecialties)?

Fundamental change likely needs to start with “how,” “what” and “why” education is deemed necessary. This begins with the state boards regarding how and what they deem necessary for constructive education, as well as the legal landscape of the individual state. Though most panelists agree that one set of national criteria for the necessary number of CE hours would be ideal, it was also a consensus that this was not likely to be accomplished anytime in the near future for political and financial reasons.

Where should CE be held?

Which is better: live CE, online interactive CE or distance learning that includes an article followed by a short test? Your answer depends greatly upon your personal situation.

Many eyecare professionals prefer to attend a big meeting with a diversity of educational opportunities tied in with various local events and a great learning environment. Others simply do not have the time or financial means to travel to all the major meetings, so they utilize online media for some of their hours.

As you are probably aware, many state boards limit how many hours you can acquire through online media. Those interviewed saw no reasonable or logical rationale behind this decision, because there is no guarantee that someone learns more in a live event than an online event. The same discussion holds true for distance learning CE with a post-test vs. live CE opportunities. There must be another reason (financial, for example) that some forms of CE are limited.

There is no guarantee that someone learns more in a live event than an online event.

Instead, why don’t we focus on how CE is qualified. Through the last few years, the qualifications and classifications have become somewhat mind numbing with so many different categories of disease and vision subspecialties. Why are they being made so complicated?

“It would be ideal if there was one set of national criteria for how many CE hours are needed.”

During our conversations, many agreed with Dr. Rumpakis’ idea that we should have two categories: clinical care and business management. Personally, I could not agree more. If you add these two categories together, you have practice management. That is what you do — manage a practice.

“No more of the coding classes, which are a completion of care anyway and not some separate entity from the rest of the medical record,” Dr. Rumpakis says. “It is completion of the clinical care cycle.”

This brought up a subsequent question, namely, who should actually determine the quantity of CE? Are the state boards, academic institutions, sociopolitical organizations or for-profit groups more qualified to make those decisions? The answer is simply not clear — too many financial, political and legal factors come into play to fully answer that question.

What is technology’s role in CE?

The non-traditional methods of CE (online and distance learning) are gaining in popularity, as demographics within the industry and the personal priorities of the various generations change. Undoubtedly, the availability of technology will continue to have far reaching effects on how education is provided in the future.

“We need to look at advancing technology to keep people interested and interactive with the CE process,” says Dr. Dunbar.

“With smart phone technology, there has to be a better option to engage the audience and keep them interactive and actually learning,” adds Marc Bloomenstein, O.D., F.A.A.O., of Schwartz Laser Center in Phoenix, Ariz. “It is relatively inexpensive since most people have one…and most of them are on the phone during the sessions anyway.”

Similarly, Justin Bazan, O.D., of Vision Source Park Slope Eye in Park Slope, N.Y., says that as technology continues to advance, there will also likely be new apps, and learning modules will likely be able to test for the outcomes in a live, interactive environment instead of static tests graded by academic institutions. Our current methods are easy for CE hosts, because they can delegate all risk, challenge and workload to an academic institution. Once these interactive computer-based algorithms for successful adult learning start to appear, CE will potentially shift from the current credentialing bodies into a privatized setting, much like many of the adult and child learning centers of today have risen in popularity and utilization.

“Online is the way of the future for all education regardless of format and place,” Dr. Semes explains. “This is the way education is going across all educational divisions, whether it is a large university, a not-for-profit or a for-profit.”

“Online is the way of the future for all education regardless of format and place.”

Should speaker disclosure and formal credentialing be required?

Currently, educators face various issues, as do the people in attendance. We still have a lack of clear disclosure, as well as levels of performance and expertise. It is obvious when certain educators are paid by a company and “give a commercial,” says Jenny Kiernan, O.D., of Eye Consultants of Colorado in Conifer, Colo. “With most of them, it is so transparent,” she said.

In an ideal world, the Sunshine Act will act as a de facto disclosure, but that may take many years (if ever). In the interim, most interviewed for this article agree that it comes down to the personal responsibility of the educator to be up front with the audience about their business relationships. Many interviewed for this article report that it is not wrong that the educators have financial interests, as long as they are disclosed and the educators are not trying to incite attendees to behave in a certain way without full disclosure.

In addition, as the avenues for education continue to be modified, educators will have to expand their teaching styles and methods and be more versatile with the utilization of technology. There was ever-mounting discussion about elevating how the educators are enabled to create behavioral change in the attendees, regardless of media.

How do finances affect potential CE changes?

Another point of the discussion revolved around the financial aspects of education.

Education is big business and involves the transfer of millions of dollars in the eyecare space alone every year.

“There is an ever-increasing pressure amongst industry to support an educational process that can demonstrate positive and meaningful change,” explains Howard Purcell, O.D., F.A.A.O., vice president, Customer Development Group, Essilor of America. “When events do this, it is much easier to fund them.”

Still, let us make no false claims that the financial aspects of education continue to change.

Our CE is still very inexpensive compared with most other professions largely because of industry sponsorship. However, with the changes in the legal landscape our profession may be asked to foot a large part of the bill in the future. Maybe this will in some way help facilitate change, as eyecare providers who need more education will be more selective in what courses they take or what educators they choose to invest their time, money and effort.

Though competition for attendees will continue to keep prices down as an element of our free market economy, the best venues, live or online, will continue to thrive.

This competition will ultimately be the driving force of which live meetings survive and which online or distance-learning avenues grow.

Of course, this education creates new challenges. The states, or small local meetings, may find it more difficult to draw attendees if they cannot find financial support from their attendees. This may create opportunities for new educators who are willing to work for less than some of the more experienced educators. Also, this competition may drive more online CE venues that are recorded or less interactive.

“Ultimately, the people responsible for the profitability of the conference or virtual event are those who will decide how these changes will impact CE and, subsequently, how much it will cost to the attendee,” says Dr. Bazan.

Also, this can create some legal issues, as many times the material presented by the educators has information that is very time sensitive.

Though competition for attendees will continue to keep prices down… the best venues, live or online, will continue to thrive.

“There needs to be a balance. I want to know what everyone’s personal experience is, but it needs to be rooted in clinical research.”

Those interviewed offered no clear consensus about the need for formal credentialing. However, discussion included the need for the speakers to receive training on presentation and motivational skills. The other part of the evolving discussion was how the educators presented data. Among those questioned, the relevance of evidence-based medicine that is rooted in clinical research vs. the transfer of clinical experience seemed unclear. However, the need exists for the educator to be very clear about opinion and experience vs. clinical fact, says Dr. Rumpakis.

“I think there needs to be a balance,” he explains. “I want to know what everyone’s personal experience is, but it needs to be rooted in clinical research. I want to learn what they have learned in terms of shortcuts.”

Navigating CE

Ultimately, each of you will be an educational consumer and have to make a decision about the cost of learning for every event or educational opportunity: What are the benefits, and what is the ROI? You will determine not only the cost, but also the cost of implementing (or not implementing) what you learned.

It is my hope that this discussion creates a positive meaningful change and arms you with the points of discussion for the future of eyecare education. OM

What are your thoughts? Please contact us, and share your thoughts at optometric

Dr. Morris is the director of Eye Consultants of Colorado and Morris Education & Consulting Associates. E-mail him at