Very few institutions and organizations have been spared from fundamental coronavirus 2019 (COVID-19) impact. This most certainly includes professional medical societies. Although some change has been wrought directly by the pandemic itself, much has been secondary to a dramatic acceleration of trends that were underway already.

Today's American Academy of Ophthalmology (AAO) first met in 1896 as the Western Ophthalmic and Oto-Laryngologic Society to serve "the interests of men who combined all three specialties in their practices."[@bib1] (At that time, otology and laryngology were considered separate practices.) In 1903, it was renamed the American Academy of Ophthalmology and Oto-Laryngology. The following year, the first woman was elected to membership and "men" became "men and women." Its interests were interpreted broadly. As early as 1903, the American Academy of Ophthalmology and Oto-Laryngology contacted public health authorities across the country regarding streetcars, noise pollution, and the latter's effects on hearing.[@bib2]

The member value proposition for major medical specialty societies such as the AAO diversified over ensuing generations. Although the primary value has always been education (as reflected in regular member surveys), advocacy and federal and state government relations have emerged a solid second in the value pantheon. Others include practice management resources, professional and public communications, quality-of-care initiatives (including clinical guidelines, outcomes measure development, clinical data registries, and health policy data analytics), web-based technology tools and software development, ethics programs, related public service programs, and others.

The mission of today's AAO is "to protect sight and empower lives by serving as an advocate for patients and the public, leading ophthalmic education, and advancing the profession of ophthalmology." The challenges emerging from the COVID-19 era have impacted each of these mission components---and much more.

Ophthalmic Education {#sec1}
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The last 50 years have seen the AAO offer a plethora of educational offerings. Society-sponsored peer-reviewed journals developed greater editorial sophistication and impact. Some societies nurtured substantive publishing enterprises with monographs, texts, and other printed materials. More recently, the AAO in particular has developed robust digital assets including novel simulation software. Audiences have expanded to include nonphysicians and physicians in training. All educational materials began to reflect increasing medical subspecialization.

At the same time, more and more educational material has become personalized and customizable according to specific clinical objectives linked to gaps in processes or outcomes of care. Similarly, more and more educational program design attention has been directed to preprogram and postprogram competency assessment.

COVID-19 notably impacted ophthalmic education. During the recent COVID-19--induced pause in ophthalmic nonurgent patient care, many ophthalmologists devoted more time to learning activities. Comparing the 3 months of March, April, and May of 2019 with March, April, and May of 2020, a 73% increase in AAO member Continuing Medical Education claims occurred in 2020. Others devoted time to contributing to science. The month of April 202 saw a 102% increase in submissions to *Ophthalmology* compared with the same period in 2019 (Fajardo D, Rapuano CJ, presentation to AAO Board of Trustees, June 20, 2020).

Social distancing and virtual events have mandated that ophthalmologists become increasingly comfortable with digital learning and virtual platforms. As a result, the AAO will move a growing percentage of educational resources from traditional, compliance-based delivery systems to more digital personalized learner experiences. These will use aggregated content that adapts to learner needs using artificial intelligence tools incorporating factors such as individual learning history, learner input, skills simulator results, and data from sources such as the Intelligent Research in Sight Clinical Data Registry and self-assessment programs.

Ophthalmic Education and the Annual Meeting {#sec2}
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For much of the 20th century, the AAO's annual meeting served as its principal educational vehicle. Some smaller societies retain this model even today, existing primarily to sponsor an annual meeting (with its accompanying camaraderie and professional networking). Throughout the 20th century, most of this annual meeting learning was accomplished via lectures in a face-to-face format. Particularly over the past 2 decades, the formats expanded to include practical skills transfer sessions and smaller interactive discussions (including so-called flipped classroom approaches).

The most substantive change in meetings wrought by the COVID-19 pandemic has been the forced widespread replacement of the face-to-face meeting by virtual meetings. Reactions to this change have been mixed, both in ophthalmology and throughout medicine. Some believe that digital technology can never replace direct contact and interactive networking in the context of a medical meeting and that virtual meetings remain sterile simulations. Some candidly appreciate the added bonus of tax-deductible travel and geographic separation from the demands of clinical practice. However, others relish the opportunity to learn asynchronously at a time, place, and frequency of their own choosing. They appreciate decreased time away from both clinical practice (with its loss of revenue) and from family. Regardless of individual preference, future meetings will need to accommodate different member learning style preferences.

The pragmatic consideration of cost deserves note. Some assume that the costs associated with designing and operating a virtual meeting are negligible and that registration pricing should reflect this. That assumption is inaccurate. Although a simple webinar is inexpensive, the technology and educational content costs for a large virtual meeting may run into the multiple millions of dollars. Exhibit and sponsorship revenue foregone in a virtual setting also negatively impacts funding for important programs that do not generate revenue, from quality of care to communications to advocacy to ethics.

This year, because of uncertainties regarding the public health situation in November, the AAO staff and physician volunteers initially planned both an in-person meeting (with a virtual component for those unwilling or unable to attend) as well as a solely virtual meeting. However, in light of epidemiologic predictions, government regulations, and public health mandates---including social distancing and limited crowd sizes---it became impossible to deliver a safe in-person meeting. Accordingly, on July 13, the AAO was forced to cancel its in-person annual meeting and proceed with a solely virtual meeting. In 2021, the AAO anticipates returning to an in-person meeting, but with virtual components.

Public and Professional Advocacy and Its Health Policy Impact {#sec3}
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COVID-19 already has influenced public advocacy substantively. Congress and state legislators are spending less time on Capitol Hill or in statehouses and more in their districts and district offices. Face-to-face meetings between officials and constituents have been curtailed---but virtual meetings generally have become easier to arrange---particularly in the setting of pre-existing relationships. This, in turn, makes direct virtual interaction with elected officials, their staffs, and regulatory officials less disruptive for physicians either individually or as part of larger groups. To what extent these changes in public advocacy will lead to greater citizen engagement or will survive the COVID-19 era is difficult to predict.

The health policy impacts of COVID-19 are wide ranging. The pandemic has drawn attention to health disparities; access to care issues; surge capacity; domestic manufacturing of key molecules, equipment, and disposable supplies; supply chains; and emergency supply storage and distribution. These likely will be the subject of new legislation and regulation. The COVID-19 experience similarly will impact everything from public health infrastructure to scope of practice legislation, payment policy, and electronic health records data interoperability, exchange, and privacy.

The postpandemic years will be critical ones for the AAO to project its advocacy positions on these, as well as more traditional topics, during a time of competition for attention and funding in a setting of massively increased federal debt. The COVID-19 legacy will force reprioritization of certain issues. For example, telemedicine and issues impinging on practice efficiency that ensure patient access to care likely will be judged increasingly important. It also may be deemed not just appropriate, but essential, for the AAO as a responsible health care organization to lend its voice to policy issues critical to preparing for future public health emergencies.

Protecting and Advancing the Profession of Ophthalmology in the Postpandemic Era {#sec4}
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On March 18, the AAO, consistent with guidance from the Surgeon General and the Centers for Disease Control and Prevention, released the following language: "Due to the COVID-19 pandemic, the American Academy of Ophthalmology now finds it essential that all ophthalmologists cease providing any treatment other than urgent or emergent care immediately. . . . All other factors---business, finance, inconvenience, etc.---are remotely secondary. This is an existential crisis."[@bib3]

Never before in the AAO's history did it in effect recommend that protecting and advancing the profession of ophthalmology meant ceasing routine (i.e., nonurgent) care. Notably, the same announcement left judgment on individual circumstances to the individual physician. The recommendations were widely followed.[@bib4] All major subspecialty societies in ophthalmology endorsed it, other specialties issued similar guidance, and some states actually barred elective procedures. The profession faced a crisis of disease transmission to patients and staff, a crisis of disposable personal protective equipment availability, and an imperative to take public health responsibility. One immediate result was a loss of revenue to ophthalmologists, ophthalmic organizations, and patient care organizations. The price was steep in revenue lost, staff furloughed, and deferred care, but the viral transmission curve was flattened significantly in most areas, and therefore lives were saved.[@bib5] ^,^ [@bib6]

The AAO's responsibilities immediately shifted to providing trusted information for members on the science of COVID-19, ophthalmic practice and protection during an acute viral pandemic, balancing surgical procedures during a time of limited access, and navigating complex federal regulations governing federal stimulus and relief programs. Finally, members depended on AAO-supplied resources to assist in the operational and medical issues involved in the transition to care during an extended pandemic.

COVID-19 represents a unique communications challenge for the AAO and for our profession. Never before has ophthalmology faced a time-critical public health disaster of this magnitude. Ophthalmologists need up-to-date information and education about the science of COVID-19 and its unique ophthalmologic clinical challenges. Meeting these challenges has required assembling a team of experts (from both within and without ophthalmology) to examine and validate information and to identify clearly when the best available information has not yet been validated scientifically. The [www.aao.org/coronavirus](http://www.aao.org/coronavirus){#intref0010} website has grown from 1 page to 300 pages of content in 3 months, with more than 1 million page views in March alone! As relevant issues expand to include economic stimulus programs and evolving payment regulations, so does the scope of domain experts and content. However, clinical content has constituted 72% of all COVID-19--related AAO website traffic (Heinrich B, and Seldomridge DL, presentation to AAO Board of Trustees, June 20, 2020). By May, new information was pushed to members on a daily basis. Webinars frequently draw more than 500 attendees.

Advancing the profession of ophthalmology in the postpandemic era will involve careful attention and devotion of human and fiscal resources to policy issues that are particular or unique to ophthalmology and for which generally no other organizational champion exists. These may pertain to regulations (such as advanced alternative payment models), payment for ophthalmology Current Procedural Terminology codes, regulatory telemedicine in ophthalmology, ophthalmic care in the Veterans Administration Health System, hospital-based ophthalmic services, residency training programs, other medical societies, development of ophthalmology-relevant federal legislation, and much more. They also may be scientific, including support for National Eye Institute programs, interface with the Centers for Disease Control and Prevention, and providing assistance to the ophthalmic pharmaceutical and device industry in the approval process for new drugs and devices. The practice of ophthalmology likely will never be quite the same. The AAO must help to provide the scientific and clinical resources, the practice management tools, and the healthcare delivery environment not only to support the "normal" practice of ophthalmology, but also to recognize our special role in supporting the profession of ophthalmology in any future public health emergencies.

We also all now recognize the community economic and social disruptions that accompanied the COVID-19 pandemic. They frayed social institutions and human behavior. On May 31, the AAO released a statement entitled "Statement on Death of George Floyd and Its Aftermath" that concluded, "There is no place for racism."[@bib7] On June 4, after reports by numerous ophthalmologists of blinding injuries secondary to kinetic impact projectiles (so-called rubber bullets), the AAO issued a statement calling for a halt to their use "to control or disperse crowds of protesters."[@bib8] It later noted that a large published study demonstrated these so-called less lethal projectiles result in death in 3% of cases and debilitating injury or disfigurement in more than 15%.[@bib9] These policy statements were the indirect result of COVID-19 and the societal disruptions that accompanied it. They address societal and public health issues with a direct impact on membership and a less obvious, but very real, impact on our profession.

These actions of the AAO leadership constitute part of the legacy of our profession during the COVID-19 era. They also signal an increasing recognition that ophthalmology does not exist completely distinct from broader social issues of economics, health policy, public health, and social justice. Although professionally we are ophthalmologists first, we also share a civic responsibility.

The American Academy of Ophthalmology's Future {#sec5}
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The AAO is an organization of considerable scope and complexity. Although the AAO counts approximately 93% of practicing American ophthalmologists as members, it has a global professional impact. Recently, more than 30% of the AAO's 32 000 members practiced outside the United States, as did a similar percentage of professional attendees at its annual meeting. From an operational perspective, most of its noneducational programs have no or little associated revenue, and therefore are funded largely out of educationally related revenue and dues. To execute this increasing scope of responsibilities, major medical society budgets not infrequently exceed \$30 million, and some exceed \$100 million. (The AAO budget is approximately \$60 million.)

In recent years (but before COVID-19), medical societies have faced a number of strategic and tactical challenges. These have included, but have not been limited to, changing educational objectives, technologies, and appetites; physician payments that do not keep up with rising operational costs; changing annual meeting value proposition, competition, costs, and logistics; changing member priorities in advocacy and healthcare reform; changing member demographics; competition for dues dollars by a burgeoning number of medical societies; increasing operational costs; and a widening spectrum of member preference for engagement in more socially focused issues.

The COVID-19 pandemic has exacerbated some of these issues and unearthed further some new ones, including conduct of society business in a virtual business world; transition of major meetings from in-person to virtual; enhanced member practice economic challenges; the need for pandemic-focused, member-relevant, and timely clinical information and practice-specific recommendations; member-specific distillations of and recommendations regarding federal economic recovery and stimulus legislation and regulations; and sudden disruptions to budget and operations.

What Does All of This Mean for the American Academy of Ophthalmology Going Forward? {#sec6}
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The lessons learned from the COVID-19 era already have had ramifications on most of its major activities. The AAO leadership recently conducted a multiday virtual meeting looking beyond COVID-19 and reprioritizing major operational initiatives, programs, and resources. It also has caused the AAO to re-examine how professional principles and activities are embedded into the fabric of our communities.

Certain initiatives that have been critical during COVID-19 (such as member communications) will be enhanced further in the postpandemic era. Members use and trust the AAO content, and the AAO must take care to continue to earn and retain that trust. That means allocating resources not only for assembling and producing content, but also for scientifically examining and validating it, incorporating adjunctive digital assets in multiple communication channels, and doing so with alacrity, for multiple audiences and in multiple languages. However, certain long-standing programs have seen their audience or relevance dwindle and will be phased out, making room for new initiatives. In short, the AAO is redesigning its activities proactively for a rapidly changing environment.

The AAO is well positioned to continue delivering strong value to its members. It has no long-term debt and slowly over decades has accumulated operating reserves sufficient to withstand the pandemic-induced loss of annual meeting revenue and novel operational challenges. The AAO is fortunate to have a rich heritage, a strong governance culture, talented staff, and hundreds of dedicated physician volunteers. Whether considering legislative or regulatory advocacy, web-based education, or big dataset analytics, ophthalmology must have a national, powerful presence. The AAO should provide the leadership and the resources required to represent the needs of our profession and our patients as we advance into the postpandemic world.

Financial Disclosure(s): The author(s) have made the following disclosure(s): D.P.: Employee --- American Academy of Ophthalmology
