The letters came from a young ophthalmologist in Kentucky. He was recruiting for an eye doctors’ rebellion.

“We won’t be trod upon,” he wrote, using the language of 1776. “You can’t promulgate injustice without consequences.”

(A letter from the National Board of Ophthalmology, the group that Rand Paul formed to issue its own certifications to ophthalmologists.)

The injustice he was talking about was a new rule, from the powerful group that deems American ophthalmologists to be “board-certified.” It required younger doctors to take a test that older doctors did not have to take.

The Kentucky doctor was so outraged that he seceded — and started his own Board of Ophthalmology, so he could certify himself.

“You can send a clear message to the establishment” by signing up to be certified by the new board, too, the letter said. “Check the appropriate box and return the card with your $500. Sincerely, Rand Paul, M.D.”

The letter, from about 2003, helps illuminate a little-understood (and mostly ridiculed) chapter of Paul’s life before politics: how he became a self-certified ophthalmologist.

The saga began in the 1990s, when Paul — now a senator representing Kentucky and a GOP presidential contender — hatched a plan to put his family’s free-market ideals into practice. He wouldn’t submit to the establishment. He would out-compete it by offering doctors an alternative with lower fees and fairer rules. His do-it-yourself medical board lasted more than a decade, becoming one of the most complex organizations Paul ever led on his own.

But it didn’t work. Indeed, in a life of successes, it became one of Paul’s biggest flops.

The board certified only 50 or 60 doctors, by Paul’s count, and was never accepted by the medical establishment. It failed partly because of resistance from the old guard — but also because Paul hurt his own cause with shortcuts and oversights that made his big effort seem small.

The other officers of his board, for instance, weren’t ophthalmologists. They were his wife and father-in-law. His Web site was mainly a mission statement, and his mission statement had grammatical errors. And, after Paul missed a filing deadline in 2000, the state legally dissolved his board. Although Paul kept it operating, it remained unrecognized by the state until he officially revived it in 2005.

“It was a good idea,” said Tim Conrad, an ophthalmologist in Louisville, who paid to be certified by Paul’s National Board of Ophthalmology. He eventually took the certificate off his wall. Now he can’t find it.

“It fell on its face,” Conrad said. “But I liked the idea.”

Rand Paul talks to a patient in Salama, Guatemala, where he provided free eye care. (Michael S. Williamson/The Washington Post)

Paul spent 17 years as an eye doctor in Bowling Green, Ky. He still has a license to practice in Kentucky — which doesn’t require doctors to be board-certified — and does free surgeries at home and abroad.

“He’s a very gifted, skilled surgeon, or I wouldn’t be working with him,” said Barbara Bowers, a Paducah doctor who has done surgeries with him since 2012. She said Paul had handled the most difficult kind of case she had: patients without insurance, whose untreated cataracts had hardened inside their eyes.

“It literally becomes kind of like a rock that you have to chisel out, and replace piece by piece,” Bowers said. “They’re kind of like Third-World-country cataracts.”

Paul declined to be interviewed for this report. A spokesman in Paul’s Senate office provided a brief statement from him: “I’m proud of my decade-long fight to have all ophthalmologists re-certify, regardless of age.”

Paul’s time as a doctor is a key part of his story, establishing him as more than just the son of libertarian icon Ron Paul. But, during the younger Paul’s run for the Senate in 2010, the Courier-Journal in Louisville put a dent in the tale, revealing that Paul’s only active “board certification” came from . . . himself.

“Tonight, I am getting certified by my newly formed ‘The USA Board of Ophthalmological Freedom,’” Stephen Colbert said on Comedy Central. Colbert was one of many to treat the board as a self-serving gimmick, set up by Paul to exempt himself from taking tests. “Here’s the application right there. Okay. It’s on a cocktail napkin.”

Back at the beginning, though, Paul’s breakaway board didn’t look like a joke.

To a generation of young ophthalmologists, in fact, it looked like something bold and noble. Maybe even something that would work.

“Dr. Paul was the one that organized us. Because he was the only one who really came out and said, ‘We should have our own board, and have our own tests,’” said Frank Burns, an eye doctor in Middletown, Ky. “We all felt the same way. He just, he had the voice.”

The fight began because the American Board of Ophthalmology — which had tested and certified new eye doctors since 1916 — had stopped making its certifications good for life. Instead, they would expire after 10 years. At that point, doctors had to take a test.

But there were exceptions. Doctors certified before 1992 were exempt.

“Once we had given a ‘lifetime certificate’ to somebody, legally, we couldn’t say, ‘We’re taking that away from you,” said Bruce Shields, who taught at Duke University and was on the American Board of Ophthalmology at the time.

Soon, however, the board heard from a mild-mannered former student of Shields’s at Duke. The professor remembered him — barely — as “Randy” Paul.

“If he hadn’t become famous, I would probably hardly remember him. He was very nondescript. Nothing negative. There were no issues that I recall. He did his job,” Shields said. “He was just, he was very quiet.”

No longer.

Paul wrote angry letters. He showed up at ophthalmologist conventions. He was demanding that the board test the older doctors, too. “He was pretty aggressive. And I was shocked, frankly,” Shields said.

Paul failed. The older doctors were the board. They weren’t changing.

So the revolution began.

“We mainly did it by e-mail. Basically, we just had to submit test questions. He kind of put it together,” said Burns, who helped Paul write his new board’s exams. “He did most of the legwork in terms of notifying physicians” that the test existed.

Paul established his board in 1997 and started giving exams in 2002. That didn’t solve the problem he was mad about: in the traditional system, the older doctors were still exempt. But Paul hoped to bleed the old board of people and money, and perhaps pressure it into changing the rules.

The Post tracked down seven doctors, including Paul, who had completed Paul’s take-home, open-book exam. It appears that Paul took the same test everyone else did. Which he helped write. “[The] certifications process was the same for everyone,” an aide to Paul said.

The certificate signed by Rand Paul. (Courtesy of Mark Jones)

“The difficulty was probably harder, [and] it was more clinically relevant” than the old board’s exam, said Marc Jones, an eye doctor in Bedford, Ind. Jones was certified by the new board in 2003. As the years passed, he heard nothing from the board and wondered what happened.

“If you want to hold, I can go get my certification,” Jones said in a phone interview. A pause. “And it is signed by Rand Paul, M.D.! Hey, that is really cool. I’ve got to keep this! . . . I mean, he may be the next president.”

Although Paul put serious effort into writing letters and compiling tests, he also did things that detracted from the professional-medical-board image he was trying to project.

For one thing, he never named members who weren’t related to him.

Hilton Ashby, Paul’s father-in-law, was listed as the board’s secretary for much of its existence. Even he isn’t sure what he did.

“I never did go to any meetings,” Ashby said in a phone interview. “There was really nothing involved. It was more just a title than anything else, for me.”

An image from shows the organization’s mission statement. (Image supplied by

The digital face of Paul’s group,, also did not inspire confidence. “NBO formed as reaction to discriminatory recertification policy of the American Board of Ophthalmology,” it proclaimed on its front page (leaving out an “a” and a “the”), according to an archived copy from 2007.

Oddly, Paul also listed his address incorrectly in one filing with the state.

In 2009, he signed the board’s annual report that said he, his wife and father-in-law resided at a house in Portsmouth, Ohio. But Paul lived in Bowling Green, as he does now. The occupant of the Ohio house at that time — a local pro wrestler and wrestling promoter named Dirk “Extreme” Cunningham — said in a phone interview that he’d never met Paul, and had no connection to the board.

Is Cunningham an ophthalmologist?

“No,” said the wrestler. “Wish I was.”

A representative in Paul’s Senate office said he was unable to explain how this happened.

Most importantly, Paul never formally applied to have his board accepted by the American Board of Medical Specialties, the unofficial gatekeeper for new medical boards.Without its approval, Paul’s certification was close to useless. Many hospitals and insurance companies wouldn’t accept it as a valid credential.

Gregory P. Temas holds a certificate from the National Board of Ophthalmology. (Ted Richardson/For The Washington Post)

“Paul: I keep facing increasing rejection of NBO certification from hospitals and now even Blue Cross of NC,” a North Carolina doctor named Gregory P. Temas wrote Paul in an e-mail in 2007.

At the time, Temas was asking for advice. He'd been certified by Paul’s board and let his mainstream certification expire. Bad move. Now, the mainstream ophthalmology board had filed a complaint against him with the state, saying that Temas was calling himself “board-certified” when he had no right.

Temas asked Paul how many other people were in his shoes. “How many other ophthalmologists are NBO certified only?”

Paul wrote back, but he didn’t answer the question about numbers. Instead, he encouraged Temas to fight the old board in court and try to prove that Paul’s board was legitimate.

“NBO is happy to provide $500 toward any legal bills you may incur,” and maybe more, Paul wrote, according to a copy of the e-mail exchange provided by Temas. “I know it’s no fun to fight the establishment but if you beat them, imagine the letter we can send out detailing your victory.”

Temas didn’t try it.

“It would have taken much more than $500 to fight them,” he said. Instead, he caved. He paid $1,550 and got recertified by the mainstream board. Today, Temas says he admired Paul’s attempt to stand up against unfairness.

But the lesson he took away was the opposite of the one Paul intended: When you fight the power, you lose.

“It’s all about politics,” Temas said. “There’s good ol’ boys in the system, and they don’t listen to you.”

Sen. Rand Paul (R-Ky.) visits Guatemala on a medical mission trip. In this video, he checks the eyes of a patient and converses him via an interpreter. (Ed O'Keefe/The Washington Post)

Paul let his own American Board of Ophthalmology certificate expire in 2005 and kept only his own board’s certification. For him, it worked. The two hospitals Paul was affiliated with in Bowling Green didn’t require board certification. And he got paid to serve a number of patients by the federal Medicare and Medicaid programs, which don’t either.

Eventually, it became obvious that Paul’s effort was doomed. He had said at least 300 doctors had “agreed” to be certified by him. But the number of people who followed through fell far short of that.

“I was going to do it. But I’m very busy,” said James Huffman, an eye doctor and close friend of Paul’s in London, Ky. “Believe me, it’s hard enough to take one test.”

In 2008, Paul shut down the board’s Web site. In 2011, he failed to file its annual paperwork, and Kentucky legally dissolved the board again. This time, it stayed dissolved. In 2013, Paul donated the board’s last cash — $20,000 — to eye-care charity Orbis International. The rest of the board’s money had been spent on mailings and clerical expenses, a spokesman said. Paul was never paid by the group.

Today, Paul’s friends say his failed medical board demonstrated a key facet of his character.

"He never stopped trying. Real change is difficult. Standing up to the system is difficult. But never stop trying. Never give up,” said Jesse Benton, a longtime friend and adviser.

Paul seemed to have more mixed feelings about this part of his life. In 2010, when a Courier-Journal reporter first asked him about the National Board of Ophthalmology, Paul declined to talk about it.

So when did he want to talk about it? “Uh, you know, never,” Paul said at the time.

Alice Crites contributed to this report.