i recently took my cat to a vet and was amazed by the personal attn given to her and the thoroughness spent talking with me about the issues surrounding her illness, and even related issues in health promotion.

a couple days later i went to my medical doctors office. i had what seemed like some sort of an eye infection. the entire visit breakdown was as follows:
5 min. with a nurse taking bp, history, etc
then a PA walks in (note: at the time i assumed he was an md - he didn't say anything otherwise). so he does the entire exam and appt. with me. even prescribes me tobramycin. i asked him a bunch of questions and it's funny i wasn't really satisfied with the answers i got.
on my drive to the pharmacy i took a closer look at the prescription pad and realized he was a PA. i felt seriously shortchanged. feel like charging the MD in charge with malpractice. there could've been some serious stuff wrong that could've slipped thru the cracks. now i'm wondering how common is this??? i am entering med school in '06 and my dream has always been to practice medicine, but not in this manner. what about spending chairside time. now i know that medicine has kinda gotten screwed by managed care, insurance, etc leading to a factory-like atmosphere in some instances. but c'mon couldn't a doctor come and spend a couple minutes with me.....any thoughts??? is this common now?? is this the future. will our pets have better health care than us???
why aren't other health care professional fields like this (i.e. dental, optometry?). will they become like this??

The vet was probably going to get cash from you and hence can charge his own fees. He knows he is going to get paid and can practice "boutique" medicine.

Doctors, facing cuts in reimbrusements must see more patients in the same time to make the same money they used to.

Dentistry? A general dentist sees most patients for only a short time just to check up on the hygenists work.

If you work for yourself you can practice how you like, but in group practice you will be expected to pull your load.

i felt seriously shortchanged. feel like charging the MD in charge with malpractice. there could've been some serious stuff wrong that could've slipped thru the cracks.
And there's part of your answer as to why medicine is getting worse. You were irritated by something so your reaction is to sue for malpractice. You can sue anyone for anything although you are unlikley to win unless you had a bad outcome that could have been found and prevented by your doctor.

although you are unlikley to win unless you had a bad outcome that could have been found and prevented by your doctor. ...and which furthermore would have been found and prevented by the MD, but not by the PA.

If you're not satisfied by the answers, keep asking questions. It's the provider's job to give you the info you need, but not even an MD/PhD who's been to vet school as well has the ability to read minds.

The vet was probably going to get cash from you and hence can charge his own fees. He knows he is going to get paid and can practice "boutique" medicine.

Doctors, facing cuts in reimbrusements must see more patients in the same time to make the same money they used to.

Dentistry? A general dentist sees most patients for only a short time just to check up on the hygenists work.

If you work for yourself you can practice how you like, but in group practice you will be expected to pull your load.


Agree with the vet statement. But you're off target with dentistry. No point in getting into the percentage of different types of procedures that a general dentist does throughout the course of his/her practice, but on average a dentist will spend at least 50% of the time with the patient. It depends if one is doing a filling, a root canal, a denture, an dental implant, etc etc. Ya hygiene we mostly take a look at the xrays and check up on things. But hygiene procedures make up a percentage (b/w 10-30%) of the days procedures.

Thankfully, with dentistry being a smaller community than our medical friends, we have been united enough (for the most part) in not accepting ridiculous insurance ploys (lowering reimbursements, capitation plans, etc). But it is getting tougher to work as a single practitioner in dentistry (due to rising overhead costs), not sure how it is for meds. I agree in any career, you can practice your own style - some careers it'll take longer than others.

I recently talked with an ER doc about medicine and his thoughts on becoming a doctor. He was a very nice man but obviously a little burnt, not by the work, but the system. As most of us know, this country is in a terrible medical crisis that only seems to be getting worse. The two biggest issues for doctors from what I've experienced is medical liability insurance and paying for healthcare.

Many people have told me that if I stay the course and become a physician, to stay with the more safe fields. And the ones you can make money in. I've worked for the American college of OB/GYN's in the medical liability department, so I know how bad it is in some fields, like OB which is the worst.

That physician actually told me to go with something like research or dentistry. Well, I have a real problem with sticking to the safe fields. We're in a war right now and it's the physicians with enough balls that stick with the fields they want, regardless of whether they play it safe or not.

I recently talked with an ER doc about medicine and his thoughts on becoming a doctor. He was a very nice man but obviously a little burnt, not by the work, but the system. As most of us know, this country is in a terrible medical crisis that only seems to be getting worse. The two biggest issues for doctors from what I've experienced is medical liability insurance and paying for healthcare.

Many people have told me that if I stay the course and become a physician, to stay with the more safe fields. And the ones you can make money in. I've worked for the American college of OB/GYN's in the medical liability department, so I know how bad it is in some fields, like OB which is the worst.

That physician actually told me to go with something like research or dentistry. Well, I have a real problem with sticking to the safe fields. We're in a war right now and it's the physicians with enough balls that stick with the fields they want, regardless of whether they play it safe or not.

90% of med student speak like you and me. however 1, 5, 10, 20 years down the line will you be singing the same tune when the stakes (family, time, $$, etc) are higher. and we're tempted to take part in capitation, PA doing our work, "selling out" to corporate, insurance etc. versus being on a soap box living the life off of student loans and med school dreams.

i recently took my cat to a vet and was amazed by the personal attn given to her and the thoroughness spent talking with me about the issues surrounding her illness, and even related issues in health promotion.

a couple days later i went to my medical doctors office. i had what seemed like some sort of an eye infection. the entire visit breakdown was as follows:
5 min. with a nurse taking bp, history, etc
then a PA walks in (note: at the time i assumed he was an md - he didn't say anything otherwise). so he does the entire exam and appt. with me. even prescribes me tobramycin. i asked him a bunch of questions and it's funny i wasn't really satisfied with the answers i got.
on my drive to the pharmacy i took a closer look at the prescription pad and realized he was a PA. i felt seriously shortchanged. feel like charging the MD in charge with malpractice. there could've been some serious stuff wrong that could've slipped thru the cracks. now i'm wondering how common is this??? i am entering med school in '06 and my dream has always been to practice medicine, but not in this manner. what about spending chairside time. now i know that medicine has kinda gotten screwed by managed care, insurance, etc leading to a factory-like atmosphere in some instances. but c'mon couldn't a doctor come and spend a couple minutes with me.....any thoughts??? is this common now?? is this the future. will our pets have better health care than us???
why aren't other health care professional fields like this (i.e. dental, optometry?). will they become like this??



Because for the most part, vets, dentists and optometrists are fee for service, with little if any insurance interference. Since the patient is the customer, customer service goes a very, very long way: Would you go to a vet who pissed you off, or a dentist that spent 30 seconds telling you to floss more often and left everything else to a dental hygeinist?

Hopefully medicine will return to a model where people are the customers, not insurance companies.

i recently took my cat to a vet and was amazed by the personal attn given to her and the thoroughness spent talking with me about the issues surrounding her illness, and even related issues in health promotion.

You also paid cash, in full, at the time of service.

Be careful what you ask for...you just might get it. ;)

why aren't other health care professional fields like this (i.e. dental, optometry?). will they become like this??

I cant speak for dentistry but optometry has more then its fair share of managed care woes. Pumping out exams in the most "efficient" way possible can affect the care rendered. This is really not the practitioners fault, or the patients fault. It is totally the fault of the insurance companies. Despite what you may hear on these forums, these ins. companies rake in dough hand over fist, while paying paltry fees to the provider panel. Can you believe that the ceo of united healthcare just retired with an 11 BILLION DOLLAR severence!!!!!!! HOLY F@#$ING SHIIT!!

I wont bother dropping a bigger pile of shiit on the fact that an eye rx was launched by a PA onto you!!! In the future see someone who deals solely with eyes. That would be an optometrist or ophthalmologist.

As with all things, when the service and the payment become disconnected, the quality suffers. I think flighterdoc hit the nail on the head. The real question is, as the next generation of physicians that is already moving forward with these sorts of models, comes of age, will the government allow them to provide service for a price? Will the social justice people come screaming about the inequity of it all, continuing a world where the middle class can get better care for a cat than themselves?

I for one dream of a day when we stop gearing our system towards the poorest people in the country. These sorts of schemes have simply put healthcare beyond the reach of the middle class. As the government tries to cover everyone, the quality progressively suffers. In the future, we should try to reconnect payment and serivce with an insurance overhaul and a return to catastrophic coverage. It is better to cover the poorest 1% with charity than to leave over 10% of the country without coverage. Besides, the idea of coverage through employment comes from the depression (A way around government wage controls). I think it is time to update our funding structure.

I wont bother dropping a bigger pile of shiit on the fact that an eye rx was launched by a PA onto you!!! In the future see someone who deals solely with eyes. That would be an optometrist or ophthalmologist.

True. The problem is I need a referral to see ophthalmologist, and that referral would have come from the family medical doctor I "saw". I didn't consider seeing an optometrist at the time, I guess that's an option. I take back my knee-jerk comment about feeling like suing the practice

True. The problem is I need a referral to see ophthalmologist, and that referral would have come from the family medical doctor I "saw". I didn't consider seeing an optometrist at the time, I guess that's an option. I take back my knee-jerk comment about feeling like suing the practice

so you wouldn't trust an fp , peds, or em md to treat conjunctivitis? in the real world specialists only see pts with difficult problems related to their specialty.....
trust me...any pa or np in fp can treat your problem.....

True. The problem is I need a referral to see ophthalmologist, and that referral would have come from the family medical doctor I "saw". I didn't consider seeing an optometrist at the time, I guess that's an option. I take back my knee-jerk comment about feeling like suing the practice

If you need a referral to see an ophthalmologist, then you would need a referral to see an optometrist as well. I've always found it perplexing that some people see their PCP for an ocular discomfort, I mean you wouldnt go to your PCP for dental discomfort, would you? (Just thinking out loud)

Yeah suing is the LAST thing you want to do here! You've got like zero percent probability of success. No harm, no foul right? Oh wait, their might be some pigment dispersion (you know glaucoma), or EBMD, or RCE, or iritis, or any number of other fairly common, intermittenly symptomatic, sight and life threatening, entities that your "doctor" would have missed. Like I said better to get your eyes checked by somebody who was trained to do so.

so you wouldn't trust an fp , peds, or em md to treat conjunctivitis? in the real world specialists only see pts with difficult problems related to their specialty.....
trust me...any pa or np in fp can treat your problem.....

First, I'll apologize by singling out PA's in my post. In my book, if you work in an emergency dept then in my mind you are practicing with an MD's responsibility. In an ER (I've worked "peripheral" to one) assessments are handed out in the best way possible, and I would personally justify the actions that occur there (w/o knowing this full implication). Hell, I once worked with an ER PA and he was responsible for many aspects of patient care, we were friends, and I respected him. Lots of things fall in the realm of "emergency care" and that's just the way it is. I dont have a problem with it. Thats my olive branch, and it is sincere, so take it.

However, there isn't a PA, PCP, FP, NP, CRN, or any other non-ophthalmic that can ever say that they have "examined" an eye. My practice is completely foreign to you, you may not think so, but it is. Hopefully, hopefully, you realize how limiting your thinking is.

If you need a referral to see an ophthalmologist, then you would need a referral to see an optometrist as well.

Not so. Optometrists typically do not file medical insurance claims, so they're not dealing with referrals. They may file vision claims (such as VSP), but these usually work like dental plans with a maximum annual benefit for a screening vision exam and/or corrective lenses. No referral is required. Ophthalmologists may also file claims under vision plans if they're simply doing a screening exam and prescribing corrective lenses, but they're usually going to come up with a medical diagnosis (there's an ICD-9 code for "change in vision," after all) and file a claim with the patient's medical insurance. HMOs will require a referral for this. If the patient is there with a medical problem, not simply for corrective lenses, that's the only option (aside from taking cash.)


I've always found it perplexing that some people see their PCP for an ocular discomfort, I mean you wouldnt go to your PCP for dental discomfort, would you? (Just thinking out loud)

Dentists are pretty much the exception, although why this has happened is anyone's guess. Taking your suggestion to its logical conclusion, everyone should just make an appointment with a dermatologist for their rash, a cardiologist for their chest pain, an orthopedist for their sore knee, an ENT for their sore throat, etc. The impracticality of this aside, do you really want to spend your time as a specialist treating case after case of viral and allergic conjunctivitis, to the point where you can't even squeeze in the patients with serious pathology? I would hope not. Every simple ocular problem does not require a dilated slit-lamp exam. Provided red flags are not present, the likelihood that a clinician will miss serious underlying pathology is pretty small, and most non-ophthalmologists are quick to refer if they suspect something serious is going on.

"However, there isn't a PA, PCP, FP, NP, CRN, or any other non-ophthalmic that can ever say that they have "examined" an eye. My practice is completely foreign to you, you may not think so, but it is. Hopefully, hopefully, you realize how limiting your thinking is."

I respect and understand what you are saying here and I appreciate your tact. I know your exam is much better than mine.
I think other providers, however can perform a reasonable screening exam and refer more serious problems on to you folks.
do you really want to see every 5 year old with conjunctivitis or every mom with a corneal abrasion from her 4 yr olds fingernail or every tiny metallic corneal fb after using a grinder? of course not.you would get 20 pages a day from the er.
but when I get the elderly htn/dm pt with increased IOP you bet I'll call you....or the guy with an arrow ticking out of his eye......or the pt with strange field cuts....

Not so. Optometrists typically do not file medical insurance claims, so they're not dealing with referrals. They may file vision claims (such as VSP), but these usually work like dental plans with a maximum annual benefit amount for a screening vision exam and corrective lenses. No referral is required. Ophthalmologists may also file claims under vision plans if they're simply doing a screening exam and prescribing corrective lenses, but they're usually going to come up with a medical diagnosis (there's an ICD-9 code for "change in vision," after all) and file a claim with the patient's medical insurance. HMOs will require a referral in order for this to happen. If the patient is there with a medical problem, not simply for corrective lenses, they won't have any choice (aside from taking cash.)

Only partially true. I file medical insurance claims, and deal with referrals on an everyday basis. ~50% of my office visits are filed under medical insurance with a large portion of them HMO based and so have refferals as a necessity to see me (exactly the same format as an ophth., derm, etc.,.) I am not an exception, while many (most?) OD's deal solely with vision plans, I would estimate that OD's bill medical much more commonly then you suggest. If some other OD's in this forum chime in here, you will quickly see I am not mistaken.


Dentists are pretty much the exception, although why this has happened is anyone's guess. Taking your suggestion to its logical conclusion, everyone should just make an appointment with a dermatologist for their rash, a cardiologist for their chest pain, an orthopedist for their sore knee, an ENT for their sore throat, etc. The impossible impracticality of this aside, do you really want to spend your time as a specialist treating case after case of viral and allergic conjunctivitis, to the point where you can't even squeeze in the patients with serious pathology? I would hope not. Regardless of your opinion, every simple ocular problem does not require a dilated slit-lamp exam. Provided red flags are not present, the likelihood that a clinician will miss serious underlying pathology is pretty small, and most PCPs are quick to involve ophthalmology if we suspect something serious is going on.

I see your point, what with pts self referring to specialists, but remember HMOs are not the only game in town, and a refferal is often not required (these are typically considered better plans then HMOs in the marketplace), so pts frequently self refer to me for their eye problems. Obviously not an "impossible impracticality". You are right in that every eye problem does not require a slitlamp DFE, but IMHO, the only way to definitively determine that fact is by.....you guessed it, by actually doing that slit lamp/DFE. Your last statement is where I take exception, "...the likelihood that a clinician will miss serious underlying pathology is pretty small.." I understand the statistical relevance of a PCP's approach to patient care, I may not agree with it totally, but I think it has its place. However, you will probably be unable to ever convince me that a PCP can render directed examination or treatment to the eye. Lets face facts here, history and cursory physical eye exam isn't exactly they way we do it, you know I mean? Those "allergic/viral" red eyes are approached in exactly the same way as floaters and blurred vision. Trust me you dont have the time, skill, or equipment to accurately assess these individuals, and while incidence numbers may save your behind, dont confuse this with a true SOAP eye exam. Your comments in this regard reflect what I've been whining about in other threads. Dont get me wrong, I'm staggered (and impressed) by the ddx you guys/gals (PCPs) must consider with any given pt, but I'm biased in regards to the eye, and will always point it out as a shortcoming of the current standard of care.

FYI- typical er workup for eye complaint in my dept:
visual acuity done by rn staff
gross exam/perrl/eomi's/field cuts
ophthalmoscope exam
slit lamp with/without fluorescein
IOP via tonometer

I feel like this is a reasonable screening exam and catches most urgent/emergent problems(infections, fb's, iritis, glaucoma, burns, hsv, etc)

I don't do dilated exams.
I don't write for ophthalmic steroids without a consult.

FYI- typical er workup for eye complaint in my dept:
visual acuity done by rn staff
gross exam/perrl/eomi's/field cuts
ophthalmoscope exam
slit lamp with/without fluorescein
IOP via tonometer

I feel like this is a reasonable screening exam and catches most urgent/emergent problems(infections, fb's, iritis, glaucoma, burns, hsv, etc)

I don't do dilated exams.
I don't write for ophthalmic steroids without a consult.


You know what that looks like to me. It looks like you opened the book and looked it up and wrote it in here.

By the way you need a fluorecein exam. and not every patient needs an IOP.

You know what that looks like to me. It looks like you opened the book and looked it up and wrote it in here.

By the way you need a fluorecein exam. and not every patient needs an IOP.

no, I didn't get it from a book.that's how I have done it for years. notice slit lamp exam with/without fluorescein in my 1st post.I'm fairly certain I do this a lot more than you do.....I probably do at least 5 screening eye exams/day.....I work in a 100k pt/yr trauma ctr, remember.....

I respect and understand what you are saying here and I appreciate your tact. I know your exam is much better than mine.
I think other providers, however can perform a reasonable screening exam and refer more serious problems on to you folks.
do you really want to see every 5 year old with conjunctivitis or every mom with a corneal abrasion from her 4 yr olds fingernail or every tiny metallic corneal fb after using a grinder? of course not.you would get 20 pages a day from the er.
but when I get the elderly htn/dm pt with increased IOP you bet I'll call you....or the guy with an arrow ticking out of his eye......or the pt with strange field cuts....


Thank you, I meant every word.

Unfortunately, I find fault with "screenings". They lead to a false sense of security for the unsuspecting pt and unsuspecting provider. The Lions club near me is always doing friggin "glaucoma" screenings at the firehouse, and I once had a pt come in saying "their glaucoma is better!" so they have stopped their medication. I know thats different then what you are doing, but you get my point.

I don't necessarily "want" to see simple cases, I just happen to think that there is little choice in the matter (see my above post for why). I dont mean any disrespect, but I shudder at the thought of you examining or treating any of the above. The eye can be pretty durable, but it has a whole herd of zebras waiting to ruin your day. The biggest thing you have going for you is incidence data (when you examine the eye) and while this is a huge factor, and ultimately the cause for the current standard of care, I see it as misleading the patients you serve.

pbea- are you an md or an od?

"I don't necessarily "want" to see simple cases, I just happen to think that there is little choice in the matter (see my above post for why). I dont mean any disrespect, but I shudder at the thought of you examining or treating any of the above. The eye can be pretty durable, but it has a whole herd of zebras waiting to ruin your day. The biggest thing you have going for you is incidence data (when you examine the eye) and while this is a huge factor, and ultimately the cause for the current standard of care, I see it as misleading the patients you serve."

I understand your take on this but realistically if you wanted to have an md ophtlamologist or od see all of these there would need to be one stationed 24/7 in every emergency dept in the country. all the cases I mentioned above are triaged as "fast track" cases where I work. we see LOTS of these every day.

pbea- are you an md or an od?

"I don't necessarily "want" to see simple cases, I just happen to think that there is little choice in the matter (see my above post for why). I dont mean any disrespect, but I shudder at the thought of you examining or treating any of the above. The eye can be pretty durable, but it has a whole herd of zebras waiting to ruin your day. The biggest thing you have going for you is incidence data (when you examine the eye) and while this is a huge factor, and ultimately the cause for the current standard of care, I see it as misleading the patients you serve."

I understand your take on this but realistically if you wanted to have an md ophtlamologist or od see all of these there would need to be one stationed 24/7 in every emergency dept in the country. all the cases I mentioned above are triaged as "fast track" cases where I work. we see LOTS of these every day.

OD

I realize the ER sees quite a bit of these, and I've already stated my feelings regarding the ER and eyecare (that ER providers do what they must, justifiably so). Furthermore, I am impressed that you use a slit lamp. My experience with any non-ophthalmic provider (I have worked with several, and I currently work partime in an ED) has been one of incredulity, when confronted with an eye condition, anything beyond rudimentary exam is often not even attempted. The provider either "diagnosis" them based on history and limited findings, or refers them. With the former being far more common. The OP illustrates this clearly. I guess my real problem with all of this lies with private office docs "playing the numbers", not with ER medicine.

pbea- are you an md or an od?

He's an optometrist (OD).

The issue of referrals to optometry is pretty much a moot point as far as I'm concerned, as I never refer patients with medical eye problems to ODs...they all go to an ophthalmologist (MD). I've never been asked for a referral to an optometrist.

I don't necessarily "want" to see simple cases, I just happen to think that there is little choice in the matter (see my above post for why). I dont mean any disrespect, but I shudder at the thought of you examining or treating any of the above. The eye can be pretty durable, but it has a whole herd of zebras waiting to ruin your day. The biggest thing you have going for you is incidence data (when you examine the eye) and while this is a huge factor, and ultimately the cause for the current standard of care, I see it as misleading the patients you serve.

Really, you "shudder" at the thought of me treating these? Great. Take your concerns to the ABMS while I begin calling you every single night - 5 - 10 times a day. I am an emergency physician. I am facile with a slit lamp and have spent a month rotating with retinal surgery. I can perform a dilated eye exam, I can accurately measure intraoccular pressure, I am decent with the fundoscope, I am skilled at FB removal and I see lots of eye pathology everyday (more than enough to maintain my skill). BUT, since you are so superior (I assume you are an OD with all that swagger), please feel free to pm me your number. I'd be happy to wake you personally to guide me in every eye exam I do... Of course that would be the first time I would EVER have consulted an OD. IRL - I can not imagine referring a patient to an OD - and that includes the patients seen by the PAs working with me.

arrogant *****

- H

He's an optometrist (OD).

The issue of referrals to optometry is pretty much a moot point as far as I'm concerned, as I never refer patients with medical eye problems to ODs...they all go to an ophthalmologist (MD). I've never been asked for a referral to an optometrist.

I'd never refer to an OD either... I'd refer to an ophthalmologist and if they feel they need to refer to an OD then that's their business (and their loss in my opinion)... of course I am of the opinion that opthalmologists should increase their numbers and split focus more equally between clinic and OR instead of full blast OR (like ENT and OBGYN)... It's my opinion of course and I am sure many ODs will be unhappy with that opinion.

I knew I should have kept my big mouth shut. Having frequented these forums I should have realized that many of you will only hear what you want to. Then you will proceed to fire off some knee-JERK reply without so much as an afterthought. I reread my posts to make sure I wasnt crazy, but I do believe I was talking about referring to optometrists OR ophthalmologists. Who you decide to refer to is your (biased) prerogative, as long as you make the referral, get it?!?. I also seem to recall specifically excluding doctors in the ER as well from my rant. All of you fail reading comprehension. I'm so very happy to hear that you are so skilled with eye examination, but my anecdotal experience with some of your colleagues, tells me otherwise. Hell, thats what the OP partially alluded to, but I'm sure you didnt bother to actually read that post either. I would NEVER have an ED anybody go "drilling" for oil in my cornea, you can be damn sure of that. I see no reason to change this opinion , just because you dont like it. I guess we all have a bias, DONT WE. Since you all seem to be able to act as optometrists or medical ophthalmologists, I'd just like to add, while we are at it, that I wouldnt trust your simple visual acuity, let alone your.. Oh nevermind this is ridiculous. You were calling me arrogant, some nerve. Now this is arrogant, your ocular skills cant hold a candle to my flame, so how do you like dem apples.

You were calling me arrogant, some nerve. Now this is arrogant, your ocular skills cant hold a candle to my flame, so how do you like dem apples.

Again sir, take your concerns to the American Board of Medical Specialties. The care and treatment of emergency eye pathology is well within the scope of practice of the emergency physician. Period. And I would not even want to imagine the liability I would incur sending an ED patient to my local Wal-Mart to see an OD instead of following up with an MD(/DO). I not even sure I can legally refer to an OD as that would likely be seen as a "lower level of care". but hey, if you ever have a problem, feel free to go to whatever provider you choose. We will leave the light on for you in the ED, even though we failed reading comprehension and all.

- H

this is ridiculous.

Indeed... :rolleyes:

Really, you "shudder" at the thought of me treating these? Great. Take your concerns to the ABMS while I begin calling you every single night - 5 - 10 times a day. I am an emergency physician. I am facile with a slit lamp and have spent a month rotating with retinal surgery. I can perform a dilated eye exam, I can accurately measure intraoccular pressure, I am decent with the fundoscope, I am skilled at FB removal and I see lots of eye pathology everyday (more than enough to maintain my skill). BUT, since you are so superior (I assume you are an OD with all that swagger), please feel free to pm me your number. I'd be happy to wake you personally to guide me in every eye exam I do... Of course that would be the first time I would EVER have consulted an OD. IRL - I can not imagine referring a patient to an OD - and that includes the patients seen by the PAs working with me.

arrogant *****

- H


I was completely unaware that EM docs were that well trained at dealing with eyes.

Learn something new everyday.

I knew I should have kept my big mouth shut. Having frequented these forums I should have realized that many of you will only hear what you want to. Then you will proceed to fire off some knee-JERK reply without so much as an afterthought. I reread my posts to make sure I wasnt crazy, but I do believe I was talking about referring to optometrists OR ophthalmologists. Who you decide to refer to is your (biased) prerogative, as long as you make the referral, get it?!?. I also seem to recall specifically excluding doctors in the ER as well from my rant. All of you fail reading comprehension. I'm so very happy to hear that you are so skilled with eye examination, but my anecdotal experience with some of your colleagues, tells me otherwise. Hell, thats what the OP partially alluded to, but I'm sure you didnt bother to actually read that post either. I would NEVER have an ED anybody go "drilling" for oil in my cornea, you can be damn sure of that. I see no reason to change this opinion , just because you dont like it. I guess we all have a bias, DONT WE. Since you all seem to be able to act as optometrists or medical ophthalmologists, I'd just like to add, while we are at it, that I wouldnt trust your simple visual acuity, let alone your.. Oh nevermind this is ridiculous. You were calling me arrogant, some nerve. Now this is arrogant, your ocular skills cant hold a candle to my flame, so how do you like dem apples.

Animosity is always the result when you give two people or two groups overlapping tasks. My theory of management.

Optometry is intended to be primary care for the eye.

Optholmology is intended to be referral/surgical care.

We should leave it at that, but what screws it up is the screwed up way in which insurance covers services from some providers and not others and then potentially only with a referal. If their was no cost to patient difference, a patient with conjunctivitis could easily have seen an optometrist for primary care instead of an FP; whether they would or not depends on popular notions.


Don't flame me, I have no bias in this matter as neither profession will ever be my own.

I'd never refer to an OD either... I'd refer to an ophthalmologist and if they feel they need to refer to an OD then that's their business (and their loss in my opinion)... of course I am of the opinion that opthalmologists should increase their numbers and split focus more equally between clinic and OR instead of full blast OR (like ENT and OBGYN)... It's my opinion of course and I am sure many ODs will be unhappy with that opinion.

Many MDs are shying away from clinic because ophthalmic exams reimburse quite badly. I worked for a doc back in undergrad. He had to see around 80 patients in a day to pay the bills (his salary came completely from surgical revenue). Surgery, given his speed at cataract work, made for a much more lucrative day.

On a personal note, its a shame y'all are so reluctant to refer to ODs. They can manage probably 95% of what you'd refer out anyway. But, you have to go with what you're comfortable with. No one can fault that.

We have a group in town called "xyz" eye care the has both md's and od's. they do most of our outpt f/u's although only the md's take call for pts seen same day in the dept. someone there screens the cases and od's do end up seeing many of them. I have never had complaints about their f/u care. they even recently sent a young lady into the ed who came to see them because she though she needed glasses and actually was having an atypical cva ( 30 yr old fe on birth control with some wild field cuts) so great pick up.

I see your point, what with pts self referring to specialists, but remember HMOs are not the only game in town, and a refferal is often not required (these are typically considered better plans then HMOs in the marketplace), so pts frequently self refer to me for their eye problems. Obviously not an "impossible impracticality". You are right in that every eye problem does not require a slitlamp DFE, but IMHO, the only way to definitively determine that fact is by.....you guessed it, by actually doing that slit lamp/DFE. Your last statement is where I take exception, "...the likelihood that a clinician will miss serious underlying pathology is pretty small.." I understand the statistical relevance of a PCP's approach to patient care, I may not agree with it totally, but I think it has its place. However, you will probably be unable to ever convince me that a PCP can render directed examination or treatment to the eye. Lets face facts here, history and cursory physical eye exam isn't exactly they way we do it, you know I mean? Those "allergic/viral" red eyes are approached in exactly the same way as floaters and blurred vision. Trust me you dont have the time, skill, or equipment to accurately assess these individuals, and while incidence numbers may save your behind, dont confuse this with a true SOAP eye exam. Your comments in this regard reflect what I've been whining about in other threads. Dont get me wrong, I'm staggered (and impressed) by the ddx you guys/gals (PCPs) must consider with any given pt, but I'm biased in regards to the eye, and will always point it out as a shortcoming of the current standard of care.


arggggh blue type...my frigging eyes...who should I see!

Many MDs are shying away from clinic because ophthalmic exams reimburse quite badly. I worked for a doc back in undergrad. He had to see around 80 patients in a day to pay the bills (his salary came completely from surgical revenue). Surgery, given his speed at cataract work, made for a much more lucrative day.

On a personal note, its a shame y'all are so reluctant to refer to ODs. They can manage probably 95% of what you'd refer out anyway. But, you have to go with what you're comfortable with. No one can fault that.

We are all well aware of that story.... greed can conquere the future of the practice... and ruin it... but who am I tell them how to run their business..

Maybe if primary care starts getting fixed in the future....

I guess we can judge from this thread that the next generation of healthcare will deliver medicine by arguing a lot about eye exams ;) .

arggggh blue type...my frigging eyes...who should I see!

just stop the viagra...it's a common side effect....:)

So much for constructive debate, eh?