Optometry and Prescriptions

Andrew_Doan · May 22, 2004

This was posted in the optometry forum.

http://forums.studentdoctor.net/showthread.php?t=123623
http://www.revoptom.com/drugguide.asp?show=view&articleid=2

I find it rather disturbing when an article "teaches" optometrists how to prescribe medications like prednisone without much emphasis on the systemic side effects.

"Optometric physicians and their patients are enjoying the huge benefits of topically applied medications. Now it's time to fully embrace a different route of administration: the orally administered medicines. So that we can put this subset of drugs in perspective, realize that the internist must master hundreds of medicines; we only need to master a baker's dozen (give or take) to treat the vast majority of ophthalmic diseases."

The term optometric physicians appears again. Way to blur the lines even more!

Richard_Hom · May 22, 2004

Andrew_Doan said:
This was posted in the optometry forum.

http://forums.studentdoctor.net/showthread.php?t=123623
http://www.revoptom.com/drugguide.asp?show=view&articleid=2

I find it rather disturbing when an article "teaches" optometrists how to prescribe medications like prednisone without much emphasis on the systemic side effects. ....

...The term optometric physicians appears again. Way to blur the lines even more!

Dr. Doan,

I believe that a characterization of this article and the guide might have been appropriate had this guide been the basis of a course much like a textbook. In reality, this article and the "guide" is what it is, simply a "pocket guide" that serves the same purpose as any other number of "pocket guides" one finds in healthcare. As such, it would be a disservice to the "professions" if you were to continue to characterize this guide as a textbook or as a foundation for a pharmacology course.

In addition, you're correct in optometry's unfortunate terminology of "optometric physician" I believe such use is defined in state law and only in a few states.

Richard_Hom

Andrew_Doan · May 22, 2004

Richard_Hom said:
Dr. Doan,

I believe that a characterization of this article and the guide might have been appropriate had this guide been the basis of a course much like a textbook. In reality, this article and the "guide" is what it is, simply a "pocket guide" that serves the same purpose as any other number of "pocket guides" one finds in healthcare. As such, it would be a disservice to the "professions" if you were to continue to characterize this guide as a textbook or as a foundation for a pharmacology course.

In addition, you're correct in optometry's unfortunate terminology of "optometric physician" I believe such use is defined in state law and only in a few states.

Richard_Hom

Dr. Hom,

Good points. However, even my "pocket guide" on my palm (Lexidrugs) lists side effects and contraindications.

If an article is written to discuss how to prescribe systemic medications, then some time should be spent to discuss the serious manifestations of a drug like prednisone. The article spends time listing contraindications with CAI, but treats prednisone like a "magic pill" for inflammation. I doubt few people remember all the side effects of steroids from a pharmacy class taken 2, 5, or 10 years previous.

OneStrongBro · May 22, 2004

Dr. Doan,
Who is the hottie in the picture? I think she is very pretty!!

Andrew_Doan said:
Dr. Hom,

Good points. However, even my "pocket guide" on my palm (Lexidrugs) lists side effects and contraindications.

If an article is written to discuss how to prescribe systemic medications, then some time should be spent to discuss the serious manifestations of a drug like prednisone. The article spends time listing contraindications with CAI, but treats prednisone like a "magic pill" for inflammation. I doubt few people remember all the side effects of steroids from a pharmacy class taken 2, 5, or 10 years previous.

Richard_Hom · May 22, 2004

Andrew_Doan said:
Dr. Hom,

Good points. However, even my "pocket guide" on my palm (Lexidrugs) lists side effects and contraindications.."

Dr. Doan,

Likewise good points.

One thing to remember. Let us criticize the authors rather than the profession as a whole. As you know the vehicle or venue for this pocket guide is an insert within a magazine and as such is constrained by editorial guidelines. In addition, pocket guides come in all sizes and shapes. This is a "throw away"and "free" pocket guide.

I'm sure that most practicing optometrists who prescribe frequently will have the hospital or medical plan formulary in one hand, Merck Manual or Merck Index in the other (or less so the PDR) and still in another hand the Wills Eye Manual.

As you may know, there many "eye" books, some will have significant value and others will have less so. We have reviews in our journals to guide the reader on their purchase or reading decisions. Your comments would have been more relevant, appropriate and less inflammatory had you reviewed the material rather than "demonizing" the profession from this singular publication.

I say this because in numerous other posts, you have sought the "reasonable" optometrist to offer their opinions on the possible expansion into surgery. Highly charged and one-sided comments and views may distract potentially "fence sitters".

In conclusion, I feel that many of your comments are about optometry are well-thought out and deserves attention. To ensure that may reach a wider audience (optometry include, I'm assuming that is your purpose), I'm hopeful that you will apply the journalist's paradigm of occasional objectivity.

Yours truly,
RIchard_Hom

marley · May 22, 2004

we took pharmacology with the dental students at uabso , in addition we took 2 other pharm classes, more specific to ocular pharmacology...we were absolutely taught about the systemic side effects and interactions of oral medications!....dr. doan, you do realize that we are taught VERY similer basic science courses compared to the medical students (same professors and books) at uab....in addition we take some classes physically with the md students...(like neuroscience!)...our first two years of classwork, concerning general knowledge about the body, are not a whole lot different from the md student's....we are very well competent to serve a primary eye care position....you know we had this argument in the 80's when we recieved the right to prescribe orals, and opthal. was defeated.....you really need to stop trying to find isolated (not representing the majority) articles to support your anti-optometry position...our healthcare system is more efficient with primary care gatekeepers (like optometry)....it seems to me you are either bitter because we are invading what has been opthal. turf, you guys aren't making as much as you used to, or your ego can't stand the fact another person will be recognized as an eye doctor that didn't go the md route....if you look back in history the osteo. docs had to go through this type of absurd argument.....from reading your posts you seem like a very insecure person?...even though you usually respond to criticism professionally, you just don't seem to get it...or you can't let yourself accept it..you keep talking about the difference b/t od's and omd's....why don't you just relax..we are competent and we can prescribe oral medications and there is a damn good chance we are going to be these procedures your calling surgery in the next 5-10 years (chalazion removal, lasik, yag, alt).. ..as for the optometrists who want to do more invasive procedures I don't agree with them....I wonder how this whole od vs. md thing is going to affect your health over your life time?....you don't seem to welcome change very well or accept it in a positive way.....this whole trend for od's is for better care for the patient's, not a better position for the omd's......now you go ahead and post your lame rebuttal....if anything you should apologize for your inappropriate comments!....and your disrespect for the optometry profession.....I'll go ahead and apologize for the od's in my profession who are trying to do real surgeries...they are wrong....let us all see if you are capable of recognizing that you are wrong in your above thoughts and posts...your criticizing a profession you only know on the surface....why don't you learn exactly what our training is before you open up your mouth again!

Andrew_Doan · May 23, 2004

I am aware of your training. I'm criticizing the article more than your profession. I do apologize if my post offends you Marley.

However, because you bring it up, I'll elaborate. I think it requires more experience than a few pharmacy courses to prescribe systemic medications like prednisone. Medical doctors go through more than pharmacology courses to learn how to prescribe. Some even go through 7 years of residency and fellowship (e.g., cardiology) to learn how to prescribe medications. As an ophthalmologist, I know enough to stay away from serious systemic medications (e.g. insulin) and defer management to the patient's primary care physician. For medications like prednisone and other immunosuppressives, ophthalmologists will often co-manage with an internist.

My posts have nothing to do with my ego. I don't care about money either because I'll either be a military physician or academic. Whether or not optometry gains more privileges, I am certain I will be a competent physician and financially secure. Good physicians will always make money in this society. I am more fearful about laws that suddenly grant non-physicians, e.g. optometry, psychologists, NP, ect..., full medical privileges without the necessary training. This is about protecting patients, and this is a cause worth fighting for.

I respect the ODs I work with. They've all completed fellowships and are extremely competent. If you all want to have full prescription rights and deal with dangerous systemic medications and eye drops, then perhaps optometry should require all their graduates to complete a one-year fellowship. Less than 15% of optometrists are F.A.A.O., which is rather pathetic. No physician graduates from medical school and receives prescription rights without first completing at least a one-year internship.

marley · May 23, 2004

please, don't act like you don't know what you are doing,...the article that you are making generalizations about is representing optometry,...don't you know we can all see what you are doing, and those who believe you are just as desperate as you are......o.k. dr. doan I know this is going to be hard for you to hear, but guess what, many of the drugs to treat primary eye care problems can be treated without doing a one year residency..I know this is different than what you have been told or experienced so try and take a deep breathe.....our four year program does prepare us to prescribe oral medicine for primary eye care problems...and of course you must be able to identify what is out of your league and what is not, or what is very serious and what is not....thanks for elaborating....guess what, od's will also often co-manage with an internist or pcp when treating eye problems with oral meds,...I'm fully aware some physcians do a 7 residency or fellowship to prescribe oral meds. (of course, a freaking cardiologist prescribes more serious meds!)......the fact that you are interested in academia makes perfect since to me, (academia is one gigantic circle jerk, perhaps you will fit in!...just from reading your fabricated comments I think you will..people like you know they are empowered by their knowledge and don't want to share it or they act like it is unattainable (i.e. refuse to allow od's to attend aao meetings etc. or give the empression you must be a genious to prescribe tobradex)..if you really wanted the people of america to be better off, you would try and educate as many people as possible!..I love to hear professors from all different areas of medicine boast about the miraculous knowledge they have and how ingenious they must be to treat disease....well that may very well be true for some cases (cardiology).....but for the most part, treating the common "primary care" diseases of the eye is not a miraculous procedure...) you are a little out of touch with the real world....there is a large group of people today that already know what their dr. is going to do for them before they get to the office....the internet is a wonderful resource...the drugs and treatments I'm referring to are extremely safe!....the monopoly md's have on health care is unconstitutional......the beauty of the optometrist is that he/she can treat the primary care problems or screen for and identify (diagnose) the major problems and take the appropriate steps, .....are you aware of the seven deadly sins?....think about vanity and then think about yourself....you need to back the hell up, check your ego.....and quite being naive about your postion on optometry, it is obvious....do you think there are idiots reading this page, or intelligent people, OR just freaking relax...you are the expert in eye care...it's o.k. nobody is going to take that from you, when I have my proliferative diabetic pt. in the chair, you (an omd)...will be the person I glorify and educate the pt. on your expertise....I must sleep know, I can't wait to here you comments though...........not

Andrew_Doan · May 23, 2004

You can attack me all you want personally, but your rhetoric is rather immature and unsupported.

Perhaps "you are a little out of touch with the real world" because patients do not "already know what their dr. is going to do for them before they get to the office". Most don't even know the difference between optometry and ophthalmology. Many will print material from the internet, but they have no clue what it means. I spend time everyday explaining the difference between the two fields. Many patients think their optometrists perform "surgeries" when in fact it's co-managing cataract and LASIK patients.

Your cavalier attitude about medications supports what I claim about optometry. Some of the drops and pills you prescribe will blind and kill people. These are NOT "extremely safe" medications. Indeed, when you prescribe something wrong, I am sure there is a physician who will cover your back and care for the patient. No malpractice suit will be charged. No report will ever be made. Why? Because ophthalmologists are afraid their referral base with disappear.

For instance, prescribe timolol or cosopt drops in a patient with asthma, COPD, or heart failure and you may kill them. Prescribe prednisone for pseudotumor in a diabetic with mucormycosis or a patient with orbital cellulitis and you may kill them. Prescribing prednisolone drops when you think it's "iritis" when it's endophthalmitis will blind the patient in 24 hours.

Let's look at how these medications are "extremely safe" by considering these true cases:

Case #1: Last week, a patient came in with "iritis" and increased IOP of 40. The patient was treated by their optometrist with Q1H prednisolone drops and cosopt for 2 weeks without improvement. The patient comes in for a second opinion, and he/she had "iritis" of only red blood cells. In fact, there was a small hyphema, and florid iris neovascularization of the iris from his/her diabetes. Unfortunately, there was no view to the back so PRP couldn't have been delivered. In this case, delay of treatment (PRP) because the patient was being treated for "iritis" may lead to the patient losing his/her eye. Why wasn't the patient referred sooner? Because the OD thought he/she was treating the "iritis".

Case #2: A patient was co-managed and then consulted for increased IOP after cataract extraction. The optometrist was "burping" the cataract wound during the post-operative care (for the whole week) and pouring anti-glaucoma medications on the eye to reduce the pressure without luck. He/she thought that the medications were "treating" the problem. Unfortunately, the "burping" of the cataract wound was the problem because the patient developed a suprachoroidal hemorrhage.

Case #3: A normal tension glaucoma patient was consulted for advanced glaucoma managed only by drops. A GVF demonstrated that the patient had a 20 degree central field left OU. Surgery was needed years previously, and delay of surgery resulted in severe visual loss. Again, prescription drops provided a false sense of security that "treatment" was delivered.

Case #4: A patient had an industrial accident with a sharp piece of metal. The patient felt some "jelly-like material" on his/her cheek and complained of floaters. The vision was 20/20 still. An optometrist saw the conjunctival laceration but missed the 0.5 mm scleral laceration and the vitreous that plugged the hole. The floaters were dismissed as a "migraine phenomenon resulting from trauma". The "jelly-like material" was dismissed as tears or mucous from the eye. The optometrist prescribed Vigamox for the conjunctival laceration and sent the patient home. Over the week, the patient then developed more floaters and decreased vision to 20/60 with an increased anterior chamber reaction. On day #5, steroid was added for "traumatic iritis". The patient dropped from 20/60 vision to hand motions vision in less than 12 hours. The patient developed traumatic endophthalmitis.

I see two problems with the use of drops here. First, the use of Vigamox initially provided the practitioner the belief that he/she was doing something for the patient, when in fact, the patient needed primary closure of the trauma wound. Second, the use of steroids was like pouring gas on a fire. Thus, to accept your argument that our arsenal of medications are ""extremely safe" is similar to saying that guns are available every where and are "safe" to use. Medications are only safe when used properly, so please stop your banter about how primary eye care is so safe and simple.

White arrow points to vitreous and gray arrow points to scleral laceration from a penetrating globe injury in Case #4

Marley, these examples are of "common "primary care" diseases of the eye". I will agree with you, however, that treating these diseases does not require a "miraculous procedure" if the caregiver knows what they are doing and respects the medications they are prescribing.

This is the art of medicine that you clearly dismiss and have little regard for when you use terms like "extremely safe", "common primary care diseases", and "not a miraculous procedure". Unfortunately, common primary care diseases will blind and kill people too.

marley · May 23, 2004

First, I really do want to apologize if you think I am attacking you personally, you obviously are a smart man and a good citizen of your community, I respect any person in our military, but somebody needs to keep you in check. The cases that you illustrate above are worthy of mention, but you see we are taught cases and scenario's like this, no **** people can go blind from wrongful use of these drugs!.......that is why we have four years of training..your reviewing some very similar situations we were taught about for od's and omd's, ..you can find isolated cases all day long about the improper handling of certain situations in eye care,...there are thousands of them....the fact is...there are good and bad od's and omd's....the public must and will recognize this....for some situations, second opinions are a must these days...and patient's really must be informed....I'm not sure were you are from, but this is America....our healthcare system and our culture are different, I know there is a large group of people that come to you with no clue, me too....but there is also a large group of people that are educated and can research what problems they are having before they go and see the doctor...primary care providers must screen for potentially dangerous situations and take the appropriate steps...I love to argue with you, and hear you boast about the "art of medicine"..I know there is some skill in it....and that there are primary eye care diseases out there that can blind and kill people...duh.....thank you "Daniel Son" ..when you say it like that, it sounds so untouchable....you know I could argue like yourself in a more "mature" manner....but to me, and I am sure many others, you sound pompous...I am only speaking frankly...of course, my god!...we are trained to know what we are doing and respect the medications we prescribe....I don't dismiss the wonderfull things we do for people when treating primary care problems of the visual system....I simply believe these primary care problems can be treated by an optometrist in this day and age, and there is absolutely no need for you to carry on about your expertise..........keep talking if you want, but you are only loosing face.....the best thing you can do at this point is agree with me, and move on....really, isn't your time more valuable?...

Andrew_Doan · May 23, 2004

marley said:
I'm not sure were you are from, but this is America....our healthcare system and our culture are different...

This statement illustrates your ignorance. Bigot comments like the one above gains little support from an intelligent crowd. If one can't support an argument, then the race card will be used. Good job, you convinced me that you are a bigot.

Because I am Asian you assume I am from another country? I grew up in the U.S., attended grade school, college, and medical school in the U.S.

Try picking one idea and stick with it. First you state medications are "extremely safe", and now you claim we must be careful in how we prescribe them?!

marley said:
the drugs and treatments I'm referring to are extremely safe!....

marley said:
no **** people can go blind from wrongful use of these drugs!.......
I know there is some skill in it....and that there are primary eye care diseases out there that can blind and kill people...duh.....

exmike · May 23, 2004

Marley, if you want such a wide scope of practice, why didn't you go to medical school and become an ophthalmologist?

mdkurt · May 23, 2004

Marley said:
people like you know they are empowered by their knowledge and don't want to share it or they act like it is unattainable (i.e. refuse to allow od's to attend aao meetings etc. or give the empression you must be a genious to prescribe tobradex

Funny. Just a couple weeks ago an OD referred a patient to me that he had kept on Tobradex for a year for his blepharitis. He had pressures of 28 and 30 and a brand-new disc hemorrhage. No, you don't have to be a genius. You just have to be properly trained.

shredhog65 · May 24, 2004

marley, you are the most ignorant sounding person i've ever seen post on this board. i realize that you are new, but insulting andrew in the way you just did is not acceptable.

it's people like you that make me hate your field. you are unprofessional, rude, and give you field a very bad image. i respect most optometrists (at least the ones that realize that they are optometrists, not ophthalmologists). you seem like you want to be one of those cavalier optometrists.

realize your boundaries and limitations for the well being of your patients. your clinical pharmacology courses are not enough to be competent at prescribing medication. all MD'd spend 2 years rotating through the various medical specialties, and another year as a medical or surgical resident. these three years of hands on medicine, plus three more years of ophthalmology residency, teach us how to prescribe. not just a simple lecture series.

i've seen far more neglegence in prescribing and treatment from OD's than ophthalmologists. it is true that there are bad ophthalmologists, but i'd rather have them prescibing medicine or performing surgery on me than a good OD.

JJMD · May 24, 2004

Obviously, there were not a classes about spelling or grammar at your optom school.... I guess you were too busy taking pharmacology. Bottom line, through his management of this forum and responses to posts, Andrew has demonstrated intelligence and professionalism.

Instead of defending your tenuous position, why don't you SHOW us that you know what you are talking about...visit the Grand Rounds Pages and try to figure them out. With your hubris and fearlessness, I see many law suits in your future.

marley · May 25, 2004

I'm afraid I have let my emotions get the best of me in the above comments, and perhaps in some previous posts.....dr. doan...I sincerely apologize and regret sounding like a bigot....I have worked very hard to feel competent providing my services to the American public, and unfortunately sometimes my passion for this profession fuels the fire for my emotions and anger at being questioned in my competence.....I have a huge amount of respect for omd's...there is no doubt about it, it is simply a fact, that the time you have invested in your training is longer than EVERY od....the environment is more competitive..etc....I understand how it would be frustrating to share the same title (doctor), with someone who hasn't put in the same amount of time, as you all have...I don't want to disrespect anyone...especially a group of people that I look up to and really do rely on....I honestly feel like I can help people with their sight....while in nursing school I wanted a profession that I felt was efficient and important, I felt that preserving or improving the function of the visual system was very important....in regards to the quality of a person's life........I don't want to argue with you guys, I just want to help people, and help preserve or improve the visual system of people...I know I can prescribe oral meds (with caution and respect for the side effects they may have)....I know I can do these non-surgical procedure if I had to (chalazion removal, lasik, yag)....I know that these non-surgical procedures are absolutely dangerous in the wrong hands.....and honestly I have no desire to do any of them....I am quiet happy prescribing contact lenses, glasses, treating glaucoma, and treating minor (but potentially major) eye inflammations or infections...etc....JJMD, shredhog65, mdkurt, exmike, and expecially Dr. Doan...PLEASE accept my apology if I offended you all. I will however, continue to stand my ground if you question my competence...

Andrew_Doan · May 25, 2004

Dear Marley,

Thank you for your apology.

I understand that the issues we discuss in this forum can be frustrating and emotionally charged for the parties involved. We are not alone, however, in regards to our feelings when discussing issues related to scope of practice, optometric surgery, and prescription rights. After attending the American Academy of Ophthalmology Mid-Year Forum in Washington D.C. last month, I realized that the leaders in ophthalmology and optometry face similar frustrations when dealing with the same controversial issues. I hope that this forum will allow discussion from both sides so that students, residents, optometrists, and physicians can discuss and think about these important issues that will affect our futures and patient care.

I respect your passion for optometry and understand your frustrations. I know that it requires years of hard work as an undergraduate and four years of doctoral training to achieve the O.D. degree. However, before the ink dries on your diploma, you have other parties telling you what you can and cannot do as a Doctor of Optometry. This has to be difficult when you love your profession, and you want to serve society as a primary eye care doctor.

I also agree with you that the 40,000 optometrists and 14,000 ophthalmologists in the U.S. play important and unique roles in the delivery of ocular care. It will be crucial for our professions to work together in the next several decades as the baby boomers age. There will be several fold increase in ocular diseases like ARMD, diabetic retinopathy, glaucoma, and cataracts. Without a doubt, optometry will play an important role because ophthalmologists will have less time to treat minor ocular problems and screen the population for disease. As an ophthalmologist, I trust that optometrists will do an outstanding job as a primary care eye doctor with excellent clinical acumen. As I trust my internal medicine colleagues to consult general ophthalmology when there are serious ocular issues, I hope that optometrists will continue to do the same instead of trying to replace the comprehensive ophthalmologist.

marley said:
honestly I have no desire to do any [surgeries]....I am quiet happy prescribing contact lenses, glasses, treating glaucoma, and treating minor (but potentially major) eye inflammations or infections.

I think you make an excellent point, and I think optometry, overall, does a great job screening for and treating the above problems. In fact, optometrists do a better job than ophthalmologists prescribing glasses and fitting contact lenses. I believe Dr. Hom made a good point previously about general ophthalmologists having a dispensary and how this is encroaching on optometry's territory. Perhaps general ophthalmologists should stop providing glasses in their office unless they are working with optometrists? One of my attendings no longer prescribes glasses. He refracts patients to determine their best-corrected visual acuities, and then returns the patient to the referring optometrist for the refraction and fitting of glasses. I have also adopted this philosophy if my patients regularly see an optometrist. As physicians, if we take a step back and give optometry the refractions and dispensing of glasses/contact lenses, then perhaps organized optometry will lessen their push for expansion of current scope of practice. Furthermore, I have no problems standing next to my optometry colleagues who are fighting to prevent opticians from being able to refract and dispense glasses. We can then concentrate on what we do best: the optometrist as a primary care eye doctor who prescribes contact lenses, glasses, treating minor ocular problems, treating early glaucoma, and treating minor eye inflammations or infections; and the ophthalmologist as the physician who treats serious ocular diseases and performs surgery.

I think the current balance in scope of practice determined for our professions is serving society well. There is no need for further expansion of scope of practice for optometry as observed in the State of Oklahoma. Because of the recent events in Oklahoma, I have established a firm and unyielding position in regards to legislation that allows optometrists, with a stroke of the pen, to perform ocular surgery and treat patients with dangerous oral medications.

JennyW · May 25, 2004

Andrew_Doan said:
I am aware of your training. I'm criticizing the article more than your profession. I do apologize if my post offends you Marley.

I respect the ODs I work with. They've all completed fellowships and are extremely competent. If you all want to have full prescription rights and deal with dangerous systemic medications and eye drops, then perhaps optometry should require all their graduates to complete a one-year fellowship. Less than 15% of optometrists are F.A.A.O., which is rather pathetic. No physician graduates from medical school and receives prescription rights without first completing at least a one-year internship.

FOr the record, residency training in optometry does not make someone FAAO, nor are all FAAO optometrists residency trained.

This is an interesting thread, but I'm going to disagree with the tone of it.

The term "optometric physician" did not come about because optometrists suddenly wanted to by "physicians." It came about because many 3rd party payers would not recognize, nor provide reimbursement to "non physician" providers. Using the term "optometric physician" was merely a way to obtain reimbursement from 3rd party payers. It doesn't make sense that a pediatrician can see all the conjunctivits patients he wants to, while ODs are excluded simply because they are "not physicians."

I also disagree with the sentiment about "surgery." For people who obtain a medical license, they are basically given a "carte blanche" license as soon as the ink is dry. That means that you are "licensed" to do brain surgery as soon as you obtain your medical license.

I don't know of any doctors who would practice beyond the scope of what they are comfortable doing, regardless of whether they are "licensed" or not.
Why do people think that ODs would be any different?

Jen

Andrew_Doan · May 25, 2004

JennyW said:
FOr the record, residency training in optometry does not make someone FAAO, nor are all FAAO optometrists residency trained.

I also disagree with the sentiment about "surgery." For people who obtain a medical license, they are basically given a "carte blanche" license as soon as the ink is dry. That means that you are "licensed" to do brain surgery as soon as you obtain your medical license.

Jen,

Thanks for the clarification about the FAAO. Regardless, less than 10-15% of all optometrists complete a residency. People on Capital Hill believe that most optometrists complete a residency like ophthalmologists.

In regards to "carte blanche" license, your statement above is not completely true. A new medical graduate couldn't get a job anywhere. A graduated intern may be able to work at a few places (but these opportunities are fewer each year due to regulations). A physician is not legal to do anything until after completion of a residency. In fact, hospitals will not give physicians privileges to perform brain surgery without the proper neuro-surgical training. It's possible that a FP may perform brain surgery in his/her own ASC, but I am sure he/she will not be practicing very long after a couple complications. Perhaps the fear of lawsuits will prevent optometrists from operating.

When all fields of medicine are facing increasing regulations and stricter competency requirements, why is optometry becoming less regulated by laws like the one observed in Oklahoma? Why is optometry different?

JennyW · May 25, 2004

Andrew_Doan said:
Jen,

Thanks for the clarification about the FAAO. Regardless, less than 10-15% of all optometrists complete a residency. People on Capital Hill believe that most optometrists complete a residency like ophthalmologists.

In regards to "carte blanche" license, your statement above is not completely true. A new medical graduate couldn't get a job anywhere. A graduated intern may be able to work at a few places (but these opportunities are fewer each year due to regulations). A physician is not legal to do anything until after completion of a residency. In fact, hospitals will not give physicians privileges to perform brain surgery without the proper neuro-surgical training. It's possible that a FP may perform brain surgery in his/her own ASC, but I am sure he/she will not be practicing very long after a couple complications. Perhaps the fear of lawsuits will prevent optometrists from operating.

When all fields of medicine are facing increasing regulations and stricter competency requirements, why is optometry becoming less regulated by laws like the one observed in Oklahoma? Why is optometry different?

I completely understand your statements regarding licensure, and credentialing, and privileges. The point that I was making was that from a "licensure" standpoint, it's carte blanche under state law. (please correct me if I am wrong.)

So again, why would anyone think that an OD would do anything that they feel they could not handle just because they are "licensed." Physicians don't do it, so why would ODs be any different.

Also, your statement about ODs and residency is not entirely correct. As it stands, only 10-15% of ODs currently practicing have completely a residency. Approximately 40-50% of new graduates are now completing them.

Jen

doinkOD · May 25, 2004

Dear Dr. Doan,
Thank you for your insightful comments. It is always a pleasure to read such logical and thoughful comments and it proves to me that despite all the heated and often emotional debates that take place on this forum, we can stay professional and have meanigful conversations.
As an Optometrist who has an uncle and three cousines who are all practicing Ophthos in NY, all of whom are married to Opthomologists as well, I have the outmost respect for your profession. Being exposed to so much Ophthalmology growing up, I consiously decided to pursue my education in Optometry, because I didn't want to do surgery. I was very much fascinated with the field of vision science and wanted to be able to apply it in a clinical setting; thus, Optometry was the very logical career choice for me and I am very happy with my decision. And as a matter of fact, expanding on my knowledge of Optics, I am starting my masters in Astro-Physics on part-time basis this September, which I am very excited about. One of the key aspects of Optometry that I enjoy is patient care, which goes very much hand in hand with the fundemental consept of "do no harm" that I hold very dearly. Having said that, most of my colleagues and I, would never want to do anything to harm our patients. Even for something like a difficult Kerataconic RGP fitting, I try to refer my patient to an Optometrist who has special interest in CL and has done residency in this field, because I think that will be the best for my patient. By the same token, I get lots of referrals from other ODs and MDs for Low Vision patients, which is my area of special interest. My point being that for something as serious and invasive as surgery, I would never pretend to be an expert and I would never want to perform any procedure on my patients, if I don't have the proper training for it. As it has been already said many of times in this forum, we already have professionals who are specilized to do ocular surgeries and they are called Ophthalmologists, and I believe, it is only fair to the patient to be referred to a surgeon for surgery. The problem of underserviced areas, also exist here in Canada, and the governement tries to attract more young Ophthalmologists to these areas by offering attarctive tax relief, travel expenses, etc. I don't believe lowering the standards of care will solve the problem. Many of my colleagues and I have written to the Oklahoma Association of Optometrist Physicians expressing our concerns over the recent bill. We don't believe this is the directions our profession, Optometry, shoule take and I really do believe this is the feeling of most my collegues in North America. I think surgery should be were we draw the line. At the same time, Ophthalmologists should recognize the service that is provided to the public by Optometrists and stop fighting for the sake of fighting. Unfortunately, in some of the Canadian provinces, few Ophthos are working with Opticians and optical chains to assist Opticians gain privilages to refract independently. Some of those Ophthos are supproting this cause, just out of animosity they have towards Optometry, knowing that it is patients who will suffer at the end of the day. Providing primary care and dispensing by many ophthos in large urban centers in Canada is also another source of conflict that is slowly disappearing due to acute shortage of surgeons in Canada. If Ophthomologists and Optometrists work together and as you said support each other in providing the best care to their patients, I believe with the baby boomers there will be more than enough patients for both professions and each profession will get to practice what they are trained to do and what they love to do side by side.
I thank you once again for listening and thinking about the root of many of the so called "turf war" discussions. I hope I am making sense here. I need to get back to work.

Kindest Regards,
Dr. M.

Andrew_Doan · May 25, 2004

JennyW said:
The point that I was making was that from a "licensure" standpoint, it's carte blanche under state law. (please correct me if I am wrong.)

So again, why would anyone think that an OD would do anything that they feel they could not handle just because they are "licensed." Physicians don't do it, so why would ODs be any different.

Yes, a medical license is a kind of a carte blanche, but there have been established mechanisms to determine what physicians are able to do and not able to. In addition, medical graduates are educated in surgical and non-surgical medicine; thus, the medical degree includes these privileges.

On the other hand, optometrists are NOT surgeons and do not receive education in surgery nor extenstive training in systemic illnesses. Why should a law permit optometrists to have a license for something they are not trained for? In Oklahoma, for instance, a law instantly grants these privileges to a group of non-surgeons and non-physicians. I think the solution is simple. If you want to do surgery, then you should go to medical school and complete an ophthalmology residency.

JennyW said:
Also, your statement about ODs and residency is not entirely correct. As it stands, only 10-15% of ODs currently practicing have completely a residency. Approximately 40-50% of new graduates are now completing them.

I think you should do a little research before you assume 40-50% of new optometry graduates are completing residencies. Currently, there are only enough residency positions for 15% of the graduating class to complete a residency.

http://www.opted.org/residencies_faq.cfm

How many residency programs and positions presently exist?

Currently, there are 113 accredited optometric residency programs affiliated with a school or college of optometry. Other non-accredited residency programs also are available, and information on both accredited and non-accredited programs can be accessed through ASCO's Online Residency Program Directory at www.opted.org. Some residencies offer more than one position, so there are close to 200 total residency positions within both accredited and non-accredited residency programs. This number is contrasted with the more than 1,300 graduates of schools and colleges of optometry (current enrollment levels in the United States).

Therefore, only 15% of all optometrists (new graduates too) can complete a one-year "residency" program.

Andrew_Doan · May 25, 2004

doinkOD said:
Dear Dr. Doan,
Thank you for your insightful comments. It is always a pleasure to read such logical and thoughful comments and it proves to me that despite all the heated and often emotional debates that take place on this forum, we can stay professional and have meanigful conversations.
As an Optometrist who has an uncle and three cousines who are all practicing Ophthos in NY, all of whom are married to Opthomologists as well, I have the outmost respect for your profession. Being exposed to so much Ophthalmology growing up, I consiously decided to pursue my education in Optometry, because I didn't want to do surgery. I was very much fascinated with the field of vision science and wanted to be able to apply it in a clinical setting; thus, Optometry was the very logical career choice for me and I am very happy with my decision. And as a matter of fact, expanding on my knowledge of Optics, I am starting my masters in Astro-Physics on part-time basis this September, which I am very excited about. One of the key aspects of Optometry that I enjoy is patient care, which goes very much hand in hand with the fundemental consept of "do no harm" that I hold very dearly. Having said that, most of my colleagues and I, would never want to do anything to harm our patients. Even for something like a difficult Kerataconic RGP fitting, I try to refer my patient to an Optometrist who has special interest in CL and has done residency in this field, because I think that will be the best for my patient. By the same token, I get lots of referrals from other ODs and MDs for Low Vision patients, which is my area of special interest. My point being that for something as serious and invasive as surgery, I would never pretend to be an expert and I would never want to perform any procedure on my patients, if I don't have the proper training for it. As it has been already said many of times in this forum, we already have professionals who are specilized to do ocular surgeries and they are called Ophthalmologists, and I believe, it is only fair to the patient to be referred to a surgeon for surgery. The problem of underserviced areas, also exist here in Canada, and the governement tries to attract more young Ophthalmologists to these areas by offering attarctive tax relief, travel expenses, etc. I don't believe lowering the standards of care will solve the problem. Many of my colleagues and I have written to the Oklahoma Association of Optometrist Physicians expressing our concerns over the recent bill. We don't believe this is the directions our profession, Optometry, shoule take and I really do believe this is the feeling of most my collegues in North America. I think surgery should be were we draw the line. At the same time, Ophthalmologists should recognize the service that is provided to the public by Optometrists and stop fighting for the sake of fighting. Unfortunately, in some of the Canadian provinces, few Ophthos are working with Opticians and optical chains to assist Opticians gain privilages to refract independently. Some of those Ophthos are supproting this cause, just out of animosity they have towards Optometry, knowing that it is patients who will suffer at the end of the day. Providing primary care and dispensing by many ophthos in large urban centers in Canada is also another source of conflict that is slowly disappearing due to acute shortage of surgeons in Canada. If Ophthomologists and Optometrists work together and as you said support each other in providing the best care to their patients, I believe with the baby boomers there will be more than enough patients for both professions and each profession will get to practice what they are trained to do and what they love to do side by side.
I thank you once again for listening and thinking about the root of many of the so called "turf war" discussions. I hope I am making sense here. I need to get back to work.

Kindest Regards,
Dr. M.

Dr. M,

Thank you for your opinion. I value your experience and wisdom. Ophthalmology and optometry need to unite and work together, instead of fighting over for "turf".

JennyW · May 25, 2004

Andrew_Doan said:
If you want to do surgery, then you should go to medical school and complete an ophthalmology residency.

I think you should do a little research before you assume 40-50% of new optometry graduates are completing residencies. Currently, there are only enough residency positions for 15% of the graduating class to complete a residency.

http://www.opted.org/residencies_faq.cfm

How many residency programs and positions presently exist?

Currently, there are 113 accredited optometric residency programs affiliated with a school or college of optometry. Other non-accredited residency programs also are available, and information on both accredited and non-accredited programs can be accessed through ASCO's Online Residency Program Directory at www.opted.org. Some residencies offer more than one position, so there are close to 200 total residency positions within both accredited and non-accredited residency programs. This number is contrasted with the more than 1,300 graduates of schools and colleges of optometry (current enrollment levels in the United States).

Therefore, only 15% of all optometrists (new graduates too) can complete a one-year "residency" program.

Don't take everything you read on the internet at face value.

That page that you are quoting was last updated in 2001. Just by doing a simple search, I found over 140 "residencies" many of which have multiple residency positions. That's obviously much more than the 113 quoted. There are over 30 positions with the IHS in Arizona alone. And ASCO is only going to post residencies that THEY accredit. In fact, many of the non accredited ones are under the supervision of ophthalmologists, and this is often times the reason that they are not accredited.

And I don't agree that ONLY medical school can be a place to become a surgeon. Even a competent eye surgeon. If that were the case, then we better start sending all those DDSs to medical school to learn how to do surgery. All those extractions and root canals could kill someone. Clearly, dental school is completely inadequate training for "tooth surgery."

Jen

Andrew_Doan · May 25, 2004

JennyW said:
Don't take everything you read on the internet at face value.

That page that you are quoting was last updated in 2001. Just by doing a simple search, I found over 140 "residencies" many of which have multiple residency positions. That's obviously much more than the 113 quoted. There are over 30 positions with the IHS in Arizona alone. And ASCO is only going to post residencies that THEY accredit. In fact, many of the non accredited ones are under the supervision of ophthalmologists, and this is often times the reason that they are not accredited.

And I don't agree that ONLY medical school can be a place to become a surgeon. Even a competent eye surgeon. If that were the case, then we better start sending all those DDSs to medical school to learn how to do surgery. All those extractions and root canals could kill someone. Clearly, dental school is completely inadequate training for "tooth surgery."

Jen

Jen,

Please show me the data that 40-50% of optometry graduates pursue residency training. I highly doubt this from speaking with recent graduates. In addition, if you increase the number of optometric residents from 200 yearly to 600 yearly, then 400 residents are likely working for free, which makes it less likely that there are 600 optometric residents per year. Some of the 200 positions indicated above are already unfunded positions, and funding for residencies is tough to come by. Also, I doubt that there are 400 new optometric residencies developed since 2001 that are accredited. What kind of standards and quality are you subjecting graduates in an un-accredited program? The public would never tolerate un-accredited ophthalmology programs for eye surgeons. In addition, I think "residencies" at a private, un-accredited clinic may not provide the breadth and diversity of pathology needed to train competent clinicians.

Please spare me the argument that DDS are not surgeons. Their curriculum prepares them to perform oral surgery, and dentistry has been established as a surgical subspecialty for over 200 years. DDSs are trained by faculty who are oral surgeons. Furthermore, OMFS surgeons also complete a comprehensive medical internship and surgical residency at ACGME credited institutions. The same argument can be made for osteopathic graduates.

How long as optometry been training surgeons or preparing optometric graduates for surgery? The answer is simple: never.

If optometry education does not provide the necessary fundamentals to pursue a surgical and comprehensive medical career, then what makes you think optometrists should be allowed to perform surgeries?

aphistis · May 25, 2004

JennyW said:
And I don't agree that ONLY medical school can be a place to become a surgeon. Even a competent eye surgeon. If that were the case, then we better start sending all those DDSs to medical school to learn how to do surgery. All those extractions and root canals could kill someone. Clearly, dental school is completely inadequate training for "tooth surgery."

A general dentist spends four years learning & practicing the various aspects of dentistry, including both invasive & noninvasive treatments. We're also required to perform a variety of direct & indirect operative treatments on patients as part of our licensure examinations. Oral & maxillofacial surgeons receive a *minimum* of four further years of residency training to receive their OMS certifications, and furthermore dual-degree OMS complete a medical degree in addition to their postdoctoral surgery training. We're fully competent to diagnose, perform, and postoperatively manage the procedures we perform on patients.

Dr. Doan already mentioned this, but I'm chipping in since you're trying to drag my profession into the mire--research twice, argue once.

JennyW · May 25, 2004

aphistis said:
A general dentist spends four years learning & practicing the various aspects of dentistry, including both invasive & noninvasive treatments. We're also required to perform a variety of direct & indirect operative treatments on patients as part of our licensure examinations. Oral & maxillofacial surgeons receive a *minimum* of four further years of residency training to receive their OMS certifications, and furthermore dual-degree OMS complete a medical degree in addition to their postdoctoral surgery training. We're fully competent to diagnose, perform, and postoperatively manage the procedures we perform on patients.

Dr. Doan already mentioned this, but I'm chipping in since you're trying to drag my profession into the mire--research twice, argue once.

I think you missed the sarcasm. I'm not dragging your profession into the mire at all. In fact, I'm pointing out that there are many professionals out there performing very competent "surgery" without having done to medical school.

And that's the point. Too many people on these boards blather on and on about how MEDICAL SCHOOL is the ONLY WAY to become ANY SORT of competent surgeon, and dentists prove that wrong every day that they practice.

Jen

aphistis · May 25, 2004

JennyW said:
I think you missed the sarcasm. I'm not dragging your profession into the mire at all. In fact, I'm pointing out that there are many professionals out there performing very competent "surgery" without having done to medical school.

And that's the point. Too many people on these boards blather on and on about how MEDICAL SCHOOL is the ONLY WAY to become ANY SORT of competent surgeon, and dentists prove that wrong every day that they practice.

Jen

OK, but before you start proclaiming that you're every bit as "entitled" to perform ocular surgery as dentists are to perform oral surgery, you have a lot of explaining left to do. I can justify the dental profession's competency by summarizing its surgical/operative curriculum for you. If you're going to make the same claim for optometry, you need to be able to present equal justification. Ante up.

Richard_Hom · May 25, 2004

Dear Forum,

I believe that optometric residencies were originally designed to supplement and complement the pre-existing scope of practice of optometry, namely, traditional optometric skills such as contact lenses, binocular vision and low vision. Admittedly, the majority of optometric residencies do not concentrate on diseases management and detection. Only in the past 20 years, it seems that optometric residencies have started to focus on disease detection, "disease management", and advanced procedures. Still, residencies abound but emphasize the separate discplines of optometry.

This lack of uniformity in residency education and experience is a reflection to the dichotomy facing the optometric profession, namely traditional optometric skills vs. newly-defined medical scope of practice. This is unfortunate. Ophthalmologic residencies are uniform to a large extent and may reflect strengths or research interests of its clinical and basic science faculty.

That is not to day that there isn't any value to optometric residencies. They provide valuable experience that broadens the viewpoint of the optometric graduate and exposes the individual to a more varied faculty and patient mix.

This discourse is not a justification for any of the discussions of the current threads on this forum nor an excuse. It is just an explanation. Neither is the post meant to support or refute the merits of whether optometrists should or should not have expanded scope of practice.

Richard_Hom

mdkurt · May 25, 2004

JennyW said:
I'm pointing out that there are many professionals out there performing very competent "surgery" without having done to medical school.

And that's the point. Too many people on these boards blather on and on about how MEDICAL SCHOOL is the ONLY WAY to become ANY SORT of competent surgeon
Jen

In my ophthalmology residency, I had the opportunity to work with OMFS residents and optometry students. I'd like to know what part of your optometric schooling has prepared you for, or even laid the groundwork for, surgery. I do think that anyone can learn surgery given the proper training. This theoretically wouldn't have to entail medical school, but right now this is the only avenue for safely training large groups of people how to do surgery. I don't know where you trained/are training, but what modifications do you think you'd need to learn surgery? What would you propose to teach optometrists the skills necessary to do surgery? An extra 40 hours of CME? 40 days? 4 years? It would require an entire overhaul of optometric education. It's tempting to look at a video and say "that's easy". Just remember that first you need to learn how to scrub.

Andrew_Doan · May 26, 2004

In a previous discussion, it was brought up that nurses perform invasive procedures all the time. It is true that while a nurse may know how to perform these procedures, non-physician groups often dismiss the decision making process that leads to the ordering of a procedure. For instance, I was discussing this issue with a colleague, and she mentioned how some residents don't consider risks enough. In the case of central lines, while these are "easy" to place, they carry significant risks of sepsis and even death. I've seen patients who have died or became extremely ill because of an infected line.

All medical procedures and medications have associated risks. These risks are never truly appreciated until a practitioner sees enough and manages a large number of cases. I agree that residents don't consider these risks to the degree as their attendings, but I can guarantee you that residents will think twice before ordering a central line again after seeing patients die. The training physician will consider if the patient really needs IV access before consenting the patient or family. After seeing one patient die or severely injured under their care or one of their colleagues, I guarantee you that physicians will NEVER forget about the risks and complications associated with medications, procedures, or surgeries. This lesson cannot be learned from books, lectures, videos, or ?pocket guides?.

I was scrubbing into a case last night for a patient with severe endogenous endophthalmitis (infection of the eye) not responsive to a tap and inject of antibiotics on Monday. Our plan was for a diagnostic vitrectomy and injection of additional antibiotics with an antifungal. At this point, we do not know why this young patient has developed severe inflammation of her eye; however, my attending was teaching me how it is important to act quickly in the setting of an endophthalmitis. He emphasized that prompt action may not save sight, but it will help prevent the patient from dying by removing the source of infection. I was concentrating on saving vision in this woman that I almost forgot that she could die if I think too long. Nothing is a better teacher than humility while experiencing death and severe illness.

This is why we have implemented standardized training programs for training physicians and surgeons. People who haven't participated in the training as physicians will have difficulty understanding the importance of completing a residency and possibly fellowship. For ophthalmology, I will spend more than 4 years of post-graduate training after completing my residency. I will have managed over 10,000 patients medically and surgically. Over 95% of my patients have multiple ocular pathologies. While I can probably teach my kids to perform surgery, the decision making process and analysis before a medical or surgical treatment is delivered can only be taught in medical school, internship, residency, and for some, fellowship.

In the US, the training of medical doctors (MD and DO) and surgeons begin on day one of medical school and finishes on day 2920 for ophthalmologists, day 2555 for internists, and day 3285 for general surgeons. The training to become a physician and surgeon has been tested, strengthened, and proven for over one hundred years.

shredhog65 · May 27, 2004

JennyW,

it is obvious that you are ignorant to the training of dentists. their curriculum is much more like an MD's than is your's. dental students are trained in the correct way to dispense systemic medication and to perform surgical proceedures. OD's are not - and no, your pharmacology course is not enough. this argument is an ongoing issue and many missinformed optometry students keep chiming in with their opinions. learn the facts before you make a point. when treating a patient, i hope you realize the difference between when you think you know something and when you really do know something.

JennyW · May 27, 2004

shredhog65 said:
JennyW,

it is obvious that you are ignorant to the training of dentists. their curriculum is much more like an MD's than is your's. dental students are trained in the correct way to dispense systemic medication and to perform surgical proceedures. OD's are not - and no, your pharmacology course is not enough. this argument is an ongoing issue and many missinformed optometry students keep chiming in with their opinions. learn the facts before you make a point. when treating a patient, i hope you realize the difference between when you think you know something and when you really do know something.

That's very interesting.

What exactly is "the correct way to dispense systemic medications?"

And what makes you think that OD schools are incapable of achieving the same goal?

Jen

JennyW · May 27, 2004

Andrew_Doan said:
In a previous discussion, it was brought up that nurses perform invasive procedures all the time. It is true that while a nurse may know how to perform these procedures, non-physician groups often dismiss the decision making process that leads to the ordering of a procedure. For instance, I was discussing this issue with a colleague, and she mentioned how some residents don't consider risks enough. In the case of central lines, while these are "easy" to place, they carry significant risks of sepsis and even death. I've seen patients who have died or became extremely ill because of an infected line.

All medical procedures and medications have associated risks. These risks are never truly appreciated until a practitioner sees enough and manages a large number of cases. I agree that residents don't consider these risks to the degree as their attendings, but I can guarantee you that residents will think twice before ordering a central line again after seeing patients die. The training physician will consider if the patient really needs IV access before consenting the patient or family. After seeing one patient die or severely injured under their care or one of their colleagues, I guarantee you that physicians will NEVER forget about the risks and complications associated with medications, procedures, or surgeries. This lesson cannot be learned from books, lectures, videos, or ?pocket guides?.

I was scrubbing into a case last night for a patient with severe endogenous endophthalmitis (infection of the eye) not responsive to a tap and inject of antibiotics on Monday. Our plan was for a diagnostic vitrectomy and injection of additional antibiotics with an antifungal. At this point, we do not know why this young patient has developed severe inflammation of her eye; however, my attending was teaching me how it is important to act quickly in the setting of an endophthalmitis. He emphasized that prompt action may not save sight, but it will help prevent the patient from dying by removing the source of infection. I was concentrating on saving vision in this woman that I almost forgot that she could die if I think too long. Nothing is a better teacher than humility while experiencing death and severe illness.

This is why we have implemented standardized training programs for training physicians and surgeons. People who haven't participated in the training as physicians will have difficulty understanding the importance of completing a residency and possibly fellowship. For ophthalmology, I will spend more than 4 years of post-graduate training after completing my residency. I will have managed over 10,000 patients medically and surgically. Over 95% of my patients have multiple ocular pathologies. While I can probably teach my kids to perform surgery, the decision making process and analysis before a medical or surgical treatment is delivered can only be taught in medical school, internship, residency, and for some, fellowship.

In the US, the training of medical doctors (MD and DO) and surgeons begin on day one of medical school and finishes on day 2920 for ophthalmologists, day 2555 for internists, and day 3285 for general surgeons. The training to become a physician and surgeon has been tested, strengthened, and proven for over one hundred years.

That story is fair enough Dr. Doan and your point is well taken, but there is a huge difference between that and removing a chalazion.

Jen

aphistis · May 27, 2004

JennyW said:
That's very interesting.

What exactly is "the correct way to dispense systemic medications?"

And what makes you think that OD schools are incapable of achieving the same goal?

Jen

The correct way to dispense systemic medications is with full awareness of their effects, indications, contraindications, mechanisms, etc. There's absolutely no reason why optometry schools *can't* do it, but that doesn't change the fact that they currently *don't*.

Furthermore, you haven't responded to the challenge, posed to you by myself and several others, to explain how optometry school prepares you to perform surgery.

maxwellfish · May 27, 2004

shredhog65 said:
JennyW,

it is obvious that you are ignorant to the training of dentists. their curriculum is much more like an MD's than is your's. dental students are trained in the correct way to dispense systemic medication and to perform surgical proceedures. OD's are not - and no, your pharmacology course is not enough. this argument is an ongoing issue and many missinformed optometry students keep chiming in with their opinions. learn the facts before you make a point. when treating a patient, i hope you realize the difference between when you think you know something and when you really do know something.

Hello all,

I'm not looking for arguments today... I just have a quick follow up question posed to anybody. Concerning the above statement, how are dentists trained to correctly dispense systemic medication? I think someone just answered how to correctly dispense it, I'm curious as to the training.

thanks

JennyW · May 27, 2004

aphistis said:
The correct way to dispense systemic medications is with full awareness of their effects, indications, contraindications, mechanisms, etc. There's absolutely no reason why optometry schools *can't* do it, but that doesn't change the fact that they currently *don't*.

QUOTE]

And you're making that statement based on what....??

Jen

Andrew_Doan · May 27, 2004

JennyW said:
And what makes you think that OD schools are incapable of achieving the same goal?

If you read my story above, then you will understand that it's the lack of standardized residency training and contact with ill patients in a hospital setting that makes OD less capable of prescribing systemic medications.

Have you medically managed any patients with: heart failure, severe asthma, hyperglycemia, hypoglycemia, severe hypertension, sepsis, immunosuppression, adrenal insufficiency, or hypotension? The medications OD and non-physicians seek to prescribe can have severe consequences. Without a medical internship and ophthalmology residency, it is difficult to learn how to master these medications, e.g. prednisone, diamox, and antibiotics. I'll reiterate again that one cannot learn how to prescribe systemic medications without a medical education, internship, and residency. I can teach you how to write: prednisone 80 mg PO QD; however, knowing when to prescribe and when to watch is part of the art of medicine that non-physicians quickly and wrongly dismiss as "trivial". The art of medicine can only be learned by managing thousands of patients with different problems.

JennyW said:
That story is fair enough Dr. Doan and your point is well taken, but there is a huge difference between that and removing a chalazion.

Yes, I agree that removing a chalazion is different than doing intraocular, orbital, or periorbital surgery. If optometrists would like to expand their scope of practice, then I think it may be reasonable to form a joint board consisting of MDs, DOs, and ODs to determine what procedures and by what mechanisms these procedures will be taught to optometry. To date, there is no such board; thus, all surgical procedures, minor and major, should be reserved for physicians and surgeons trained to perform them.

What angers me and my colleagues is instead of forming a working relationship with ophthalmologists, optometry will aggressively lobby for legislation that grants them privileges. Read the new optometry law in Oklahoma. It's more than just chalazions the Oklahoma optometrists are seeking.

The law makers care about two things: votes and money. Optometry knows how to win the votes and gives a lot of money to law makers. In 1998, the Oklahoma optometrists were extremely organized. Many arranged closing of their offices and used portable exam lanes to provide free refractions for contact lenses and glasses for the law makers and their family members on the day the Oklahoma optometry laser bill passed. Each law maker also received checks and laser pointers too. I'm sure the law makers were thinking of the people of Oklahoma when they passed the law that allowed optometry to perform PRK refractive surgery. If access to care was their concern, then they achieved little because if patients couldn't afford to drive 3 hours to see an ophthalmologist, then they sure can't pay the thousands of dollars for refractive surgery.

If you're so passionate about performing chalazions, then I encourage you to work with the leadership of organized optometry and arrange a mechanism where MDs, DOs, and ODs can regulate the scope of practice. This would be a much better solution than turning to law makers to decide scope of practice decisions.

Richard_Hom · May 27, 2004

"... What angers me and my colleagues is instead of forming a working relationship with ophthalmologists, optometry will aggressively lobby for legislation that grants them privileges. Read the new optometry law in Oklahoma. It's more than just chalazions the Oklahoma optometrists are seeking. .."

Richard_Hom · May 27, 2004

"... What angers me and my colleagues is instead of forming a working relationship with ophthalmologists, optometry will aggressively lobby for legislation that grants them privileges. Read the new optometry law in Oklahoma. It's more than just chalazions the Oklahoma optometrists are seeking. .."

As always, your comments are cogent and relevant.

One notion is that there has been little negotiating with the various professional organizations at the pre legislative level and therefore there would seem to be little cooperation in a joint regulatory board. If only joint regulatory boards were truly cooperative, then this morass would not be upon us. Again, I predict that the only people who benefit from this fight are the legislators who are receiving a tremednous amount of PAC funds.

Richard_Hom

shredhog65 · May 27, 2004

JennyW said:
aphistis said:

The correct way to dispense systemic medications is with full awareness of their effects, indications, contraindications, mechanisms, etc. There's absolutely no reason why optometry schools *can't* do it, but that doesn't change the fact that they currently *don't*.

QUOTE]

And you're making that statement based on what....??

Jen

Click to expand...

many previous posts here by OD's describing how you are trained. what aphistis said pretty much sums it up.

aphistis · May 27, 2004

maxwellfish said:
Hello all,

I'm not looking for arguments today... I just have a quick follow up question posed to anybody. Concerning the above statement, how are dentists trained to correctly dispense systemic medication? I think someone just answered how to correctly dispense it, I'm curious as to the training.

thanks

Hi there,

To answer your question, dental students spend the latter half of dental school in clinic treating patients under the supervision of licensed faculty, similar (but not identical) to the relationship between resident & attending physicians. Restorative procedures obviously comprise a large percentage of treatment plans, but some patients require medication as part of their regimen. Commonly prescribed dental medications include narcotic & non-narcotic analgesics, anti-inflammatories, antibiotics, antifungals, anxiolytics, fluoride, and others I'm sure I'm forgetting. Students are responsible for devising treatment plans, with faculty signature approval (and countersignatures on prescriptions) as a regulatory mechanism.

Hope that helps!

Andrew_Doan · May 27, 2004

aphistis said:
To answer your question, dental students spend half of dental school in clinic treating patients under the supervision of licensed faculty, similar (but not identical) to the relationship between resident & attending physicians. Operative therapy obviously comprises a substantial fraction of treatments, but some patients require medication as part of their treatment regimen. Commonly prescribed dental medications include narcotic & non-narcotic analgesics, anti-inflammatories, antibiotics, antifungals, anxiolytics, fluoride, and others I'm sure I'm forgetting. Students are responsible for devising treatment plans, with faculty signature approval (and countersignatures on prescriptions) as a regulatory mechanism.

The supervision in dental school is similar to the relationship between medical students and attending physicians, not residents and attending physicians.

Medical residents can write orders and prescriptions without attending approval but under attending supervision.

I'm curious. Do dentists manage any systemic illnesses?

I think the main point is that dentists are trained for a surgical career with limited medical privileges. Similar to medicine, this training has been tested, strengthened, and proven for over 100 years. In addition, if dental graduates desire to perform more invasive surgeries then there are dental surgical fellowships and OMFS residencies. The OMFS residents complete a transitional year and work with medical residents. I worked with OMFS residents on the cardiology service. They also take call with us and manage patients.

aphistis · May 27, 2004

Andrew_Doan said:
The supervision in dental school is similar to the relationship between medical students and attending physicians, not residents and attending physicians.

Medical residents can write orders and prescriptions without attending approval but under attending supervision.

My mistake. I didn't realize med students became involved in patient care to that extent. Are students typically required to be primary caregiver on any of their rotations?

I'm curious. Do dentists manage any systemic illnesses?

To the extent that they present within our realm of expertise, yes, but not in the traditional see-your-internist-once-a-month sense. A number of diseases routinely present with oral manifestations, and we'll obviously address these in treatment. Further, systemic disease can obviously make a big impact in our treatment planning (med dosages for liver/kidney, premeds for some cardiac, inhalation sedation for lungs, hemostasis for anticoagulants, etc). But I can't think of a circumstance where a patient wouldn't be referred to physician for diagnosis & treatment if the dentist suspects an undiagnosed systemic condition.

With the notable exceptions of fluoride & periodontal maintenance treatment, most of our treatments are intended to be once-and-done, definitive treatments. We're not qualified to manage a patient's sarcoidosis any more than her rheumatologist could do a root canal.

I think the main point is that dentists are trained for a surgical career with limited medical privileges. Similar to medicine, this training has been tested, strengthened, and proven for over 100 years. In addition, if dental graduates desire to perform more invasive surgeries then there are dental surgical fellowships and OMFS residencies. The OMFS residents complete a transitional year and work with medical residents. I worked with OMFS residents on the cardiology service. They also take call with us and manage patients.

All true enough.

maxwellfish · May 27, 2004

Thank you aphistis, your reply to my question is appreciated.

My question is, what makes optometry any less qualified than dentistry to prescribe medication, especially that which pertains to the eye and visual system? I mean, the statement earlier was that the dental education is way more like MDs and they are trained to correctly dispense.

No, one pharmacology course is not enough, but OD students spend at least their last year on rotations handling patients with supervision in much the same manner as dental students. Just like dentistry, some of that time is spent handling cases which require medication and sometimes those patients may have underlying (or obvious) systemic conditions. So what makes the OD education so inferior?

No, all curriculums are not the same between professions; why should they be, but that doesn?t mean the end result in some aspects are not the same. Hell even curriculums between medical schools differ-they have to, the same person isn?t teaching everywhere!

Like mentioned earlier if there is a problem in end-result competency, then we should work together to fix it-instead of pointing fingers and saying "they'll never get it right."

out for now

aphistis · May 27, 2004

maxwellfish said:
Thank you aphistis, your reply to my question is appreciated.

My question is, what makes optometry any less qualified than dentistry to prescribe medication, especially that which pertains to the eye and visual system? I mean, the statement earlier was that the dental education is way more like MDs and they are trained to correctly dispense.

No, one pharmacology course is not enough, but OD students spend at least their last year on rotations handling patients with supervision in much the same manner as dental students. Just like dentistry, some of that time is spent handling cases which require medication and sometimes those patients may have underlying (or obvious) systemic conditions. So what makes the OD education so inferior?

No, all curriculums are not the same between professions; why should they be, but that doesn?t mean the end result in some aspects are not the same. Hell even curriculums between medical schools differ-they have to, the same person isn?t teaching everywhere!

Like mentioned earlier if there is a problem in end-result competency, then we should work together to fix it-instead of pointing fingers and saying "they'll never get it right."

out for now

Before anything else, I want to emphasize here that I'm not trying to step on optometry as a profession. Also, the "a dentist's training is more like an MD's than an optometrist's" remark came from someone else, not me. I'm inclined to defer most of the rest to Dr. Doan, since he's much more familiar with this discussion than I am.

The question you raise at the end of your post, proper scope of practice, is what frames this entire debate. Does optometry education result in professional incomptency? That depends on how an optometrist's responsibilities to his/her patients are defined, and that in turn will depend primarily on whose definition is being used. There's no hope for a permanent, mutually agreeable solution to the problem unless or until that question can first be resolved to everyone's satisfaction, and I don't see that happening anytime soon.

maxwellfish · May 27, 2004

aphistis said:
Before anything else, I want to emphasize here that I'm not trying to step on optometry as a profession. Also, the "a dentist's training is more like an MD's than an optometrist's" remark came from someone else, not me.

I'm sorry--totally not directed towards you, sorry for the confusion.

Richard_Hom · May 27, 2004

"...Does optometry education result in professional incomptency? That depends on how an optometrist's responsibilities to his/her patients are defined, and that in turn will depend primarily on whose definition is being used..."

Dear aphistis,

I'm hoping that your statement was taken out of context. I don't believe that the education itself promotes incompetency. I believe that sufficient expereince in attained in well -defined roles and procedures and personal ethics are better gauges of competency than education itself. I don't wish to debate the majority of your comments except for the above. I'm sure that in the heat of the post our journalistic ethics may get the better of ones' self.

Of course my post does not support or refute the notion that optometrists should or should not have surgical privileges.

Richard_Hom

aphistis · May 27, 2004

Richard_Hom said:
"...Does optometry education result in professional incomptency? That depends on how an optometrist's responsibilities to his/her patients are defined, and that in turn will depend primarily on whose definition is being used..."

Dear aphistis,

I'm hoping that your statement was taken out of context. I don't believe that the education itself promotes incompetency. I believe that sufficient expereince in attained in well -defined roles and procedures and personal ethics are better gauges of competency than education itself. I don't wish to debate the majority of your comments except for the above. I'm sure that in the heat of the post our journalistic ethics may get the better of ones' self.

Of course my post does not support or refute the notion that optometrists should or should not have surgical privileges.

Richard_Hom

Dr. Hom,

My intent in writing the excerpt you quoted was simply to illustrate that optometrists and opthalmologists don't always seem to agree on where the boundaries lie separating optometry from ophthalmology. I didn't intend to endorse or criticize either position. I hope this clears up any confusion.

JennyW · May 28, 2004

aphistis said:
Hi there,

To answer your question, dental students spend the latter half of dental school in clinic treating patients under the supervision of licensed faculty, similar (but not identical) to the relationship between resident & attending physicians. Restorative procedures obviously comprise a large percentage of treatment plans, but some patients require medication as part of their regimen. Commonly prescribed dental medications include narcotic & non-narcotic analgesics, anti-inflammatories, antibiotics, antifungals, anxiolytics, fluoride, and others I'm sure I'm forgetting. Students are responsible for devising treatment plans, with faculty signature approval (and countersignatures on prescriptions) as a regulatory mechanism.

Hope that helps!

Ok Bill.

If you substitute the word "dental" for the word "optometry" in your post, then your post would pretty much describe optometric training.

And I never meant to give the impression that optometric training allows for massively invasive procedures like the one Dr. Doan described earlier in this thread.

But it certainly provides for the removal of chalazions, foreign bodies, dialation and irrigation, and even *gasp* PIs and YAGs. These are procedures that have historically been considered "surgical."

How? Likely in the same way that dental is done. Through didactic training, clinical observation, and clinical performance under the supervision of experienced licensed faculty members, many of whom are ophthalmologists.

Jen

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